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Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Aspirin / Ace Inhibitors / Norvasc Attending: ___. Chief Complaint: Blood in stool and urine Major Surgical or Invasive Procedure: ___ y.o woman with h.o CKD3, HTN, hypothyroidism who presents with reports of bloody bms and abdominal pain starting on ___. Pt reports that she's had a few "medium sized" episodes of brbpr not mixed with stool. She noticed this after having "a lot of diarrhea" History difficult to ascertain given hard of hearing and somewhat conflicting history. She reports diffuse ___ periumbilical cramping pain since onset of symptoms but that this had resolved in the ER. Denies new foods, sick contacts, fever, n/v but does report recent use of antibiotics (___nded last wed). Some report of possible hematuria,but pt denies on further questioning and denies dysuria, urinary frequency. Has never had these episodes before. Otherwise denies headache, dizziness, CP, sob, cough. In the ED, she was noted to have small amount of red blood on rectal exam, no external hemorrhoids, no anal fissues., CT with distal proctitis, colitis and she was given cipro/flagyl. 10pt ROS reviewed and otherwise negative History of Present Illness: Blood in urine and stool Past Medical History: 1. Overactive bladder 2. End-stage renal disease 3. Gastroesophageal reflux disease 4. Borderline hyperglycemia 5. Hyperlipidemia 6. Hypertension 7. Hypothyroidism 8. Osteoporosis 9. Status post total abdominal hysterectomy 10. Status post cervical spine fusion. Social History: ___ Family History: CAD, CVA Physical Exam: Gen:well appearing, lying in bed. Hard of hearing vitals:98.9 PO 155 / 63 70 18 97 Ra head: ncat ENT:EOMI anicteric MMM neck:supple respiratory:b/l ae no w/c/r cardiac:s1s2 rr no m/r/g gastrointestinal: +bs, soft, +TTP periumbical area, no guarding or rebound extremities: no cce 2+pulses neurologic:AAOx3, CN ___ intact, motor ___ x4, no tremor psych:calm, cooperative skin:no obvious rash Pertinent Results: ___ 02:05PM BLOOD WBC-12.9* RBC-3.29*# Hgb-10.1*# Hct-31.7* MCV-96# MCH-30.7 MCHC-31.9* RDW-15.2 RDWSD-53.4* Plt ___ ___ 06:20AM BLOOD WBC-13.8* RBC-3.14* Hgb-9.4* Hct-29.9* MCV-95 MCH-29.9 MCHC-31.4* RDW-15.1 RDWSD-51.6* Plt ___ ___ 09:05AM BLOOD WBC-9.4 RBC-3.37* Hgb-10.0* Hct-31.4* MCV-93 MCH-29.7 MCHC-31.8* RDW-14.7 RDWSD-49.8* Plt ___ ___ 02:05PM BLOOD Glucose-141* UreaN-73* Creat-2.7* Na-138 K-5.0 Cl-110* HCO3-13* AnGap-19 ___ 06:20AM BLOOD Glucose-83 UreaN-57* Creat-2.3* Na-142 K-5.0 Cl-113* HCO3-13* AnGap-20 ___ 09:05AM BLOOD Glucose-93 UreaN-42* Creat-2.0* Na-138 K-4.9 Cl-110* HCO3-18* AnGap-15 Urine Cx Prelim Greater than 100,000 CFU E Coli Sensitivities pending LOWER CHEST: Bibasilar ground-glass opacities are most consistent with atelectasis. There is mild traction bronchiectasis at in the lingula. Minimal pleural thickening is noted posteriorly. Small to moderate pericardial effusion is mostly simple in density. Aortic valvular and mitral annular calcifications are moderate. ABDOMEN: HEPATOBILIARY: The right hemidiaphragm is mildly elevated. 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 is atrophic. No focal lesion is seen within the limits of a noncontrast 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 gland is normal in size and shape. The left adrenal gland is mildly diffusely thickened. URINARY: Bilateral kidneys are mildly atrophic, left smaller than right. There is a 2.8 cm hypodensity in the lower pole of the left kidney, likely representing a simple cyst. Otherwise, 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. Redundant sigmoid colon in the presacral space, posterior to the bladder demonstrate adjacent fat stranding. The involved loop are not dilated. There is mild stranding around the anterior aspect of the rectum. However the rectal wall does not appear dilated. Air-fluid level is seen within the rectal vault. The appendix is not visualized. 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. Extensive atherosclerotic disease is noted. BONES: There is rightward curvature of the spine with moderate to severe degenerative changes of the lumbar spine. There is no evidence of worrisome osseous lesions or acute fracture. Patient is status post gamma nail placement in the left femur. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: -Fat stranding around redundant sigmoid colon in the presacral space. The loops of bowel are not distended. The findings may represent distal colitis/proctitis. -Mild to moderate pericardial effusion. Please correlate with cardiac history and function. -Atrophic left kidney. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Detrol LA (tolterodine) 4 mg oral DAILY 2. Vitamin D 1000 UNIT PO DAILY 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 4. amLODIPine 10 mg PO DAILY 5. Calcium Carbonate 1250 mg PO DAILY 6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 7. Nitroglycerin SR 2.5 mg PO Frequency is Unknown 8. ofloxacin 0.3 % ophthalmic R. eye daily 9. Omeprazole 20 mg PO DAILY 10. Levothyroxine Sodium 50 mcg PO DAILY 11. Fluticasone Propionate 110mcg 2 PUFF IH BID 12. melatonin 1 mg oral QHS 13. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150 mg-unit-mg-mg oral DAILY Discharge Medications: 1. Sodium Bicarbonate 650 mg PO BID RX *sodium bicarbonate 650 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 2. Nitroglycerin SR 2.5 mg PO Q12H:PRN chest pain 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 4. amLODIPine 10 mg PO DAILY 5. Calcium Carbonate 1250 mg PO DAILY 6. Detrol LA (tolterodine) 4 mg oral DAILY 7. Fluticasone Propionate 110mcg 2 PUFF IH BID 8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 9. Levothyroxine Sodium 50 mcg PO DAILY 10. melatonin 1 mg oral QHS 11. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150 mg-unit-mg-mg oral DAILY 12. ofloxacin 0.3 % ophthalmic R. EYE DAILY 13. Omeprazole 20 mg PO DAILY 14. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: 1. Blood in stool - ? due to stercoral colitis vs infectious colitis 2. Hematuria - due to presumed UTi 3. Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Followup Instructions: ___ Radiology Report EXAMINATION: CT abdomen pelvis without contrast INDICATION: NO_PO contrast; History: ___ with abd pain, distension, bloody stool.NO_PO contrast// ? colon mass, less likely colitis 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 4.4 s, 47.9 cm; CTDIvol = 5.8 mGy (Body) DLP = 275.3 mGy-cm. 2) Spiral Acquisition 0.9 s, 10.0 cm; CTDIvol = 4.8 mGy (Body) DLP = 47.9 mGy-cm. Total DLP (Body) = 323 mGy-cm. COMPARISON: None. CT abdomen pelvis from ___ is not available for review at the time of this dictation. FINDINGS: LOWER CHEST: Bibasilar ground-glass opacities are most consistent with atelectasis. There is mild traction bronchiectasis at in the lingula. Minimal pleural thickening is noted posteriorly. Small to moderate pericardial effusion is mostly simple in density. Aortic valvular and mitral annular calcifications are moderate. ABDOMEN: HEPATOBILIARY: The right hemidiaphragm is mildly elevated. 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 is atrophic. No focal lesion is seen within the limits of a noncontrast 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 gland is normal in size and shape. The left adrenal gland is mildly diffusely thickened. URINARY: Bilateral kidneys are mildly atrophic, left smaller than right. There is a 2.8 cm hypodensity in the lower pole of the left kidney, likely representing a simple cyst. Otherwise, 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. Redundant sigmoid colon in the presacral space, posterior to the bladder demonstrate adjacent fat stranding. The involved loop are not dilated. There is mild stranding around the anterior aspect of the rectum. However the rectal wall does not appear dilated. Air-fluid level is seen within the rectal vault. The appendix is not visualized. 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. Extensive atherosclerotic disease is noted. BONES: There is rightward curvature of the spine with moderate to severe degenerative changes of the lumbar spine. There is no evidence of worrisome osseous lesions or acute fracture. Patient is status post gamma nail placement in the left femur. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: -Fat stranding around redundant sigmoid colon in the presacral space. The loops of bowel are not distended. The findings may represent distal colitis/proctitis. -Mild to moderate pericardial effusion. Please correlate with cardiac history and function. -Atrophic left kidney. Radiology Report INDICATION: History: ___ with ?pleural effusion// ?cpd TECHNIQUE: Chest PA and lateral COMPARISON: ___ and CT scan of the abdomen and pelvis from earlier today FINDINGS: The size of the cardiac silhouette is enlarged. Opacities around the lingula likely reflect atelectasis. No pleural effusion or pneumothorax. The bones appear diffusely osteopenic however no overt compression deformities are identified. IMPRESSION: No pleural effusion or acute cardiopulmonary abnormality. Marked cardiomegaly. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Abd pain, Hematuria Diagnosed with Diarrhea, unspecified temperature: 98.1 heartrate: 80.0 resprate: 20.0 o2sat: 98.0 sbp: 140.0 dbp: 49.0 level of pain: 5 level of acuity: 3.0

/P: Pt is a ___ y.o woman with h.o CKD, HTN, hypothyroidism, GERD, spinal stenosis who presents with 2 days of abdominal pain and bloody diarrhea. #gastrointestinal bleeding #abdominal pain Patient was started on cipro/flagyl out of concern for colitis. She had NO additional bowel movements during hospitalization. She tells me that blood from rectum started after having a "lot of diarrhea". ? if her symptoms are from a stercoral colitis. Given that she had NO bowel movements over hospitalzation, no findings consistent with megacolon, it was not felt that her symptoms were from C diff infection, nor from a bacterial colitis. Rather, it seems that she may have have had a more self limited process such as a viral one. # Hematuria: Noted by patient, and seen on UA. Ucx growing out E coli, sensitivities pending. She received a treatment course of 3 days of ciprofloxacin, and I will f/u sensitivity results. Patient noted resolution of hematuria during hospitalization. #CKD3-4-appears to be at recent baseline # Acidosis: Appears secondary to CKD, but bicarbonate quite low at 13. Persisted even after cessation of diarrhea, so unlikely to be due to GI losses. Started on sodium bicarbonate 650 mg po bid. #hypothyroidism-continue home meds #GERD-PPI # ? Pericardial effusion incidentally noted on CT scan. Patient WITHOUT signs or symptoms of dyspnea, chest pain, lightheadedness. Inpatient ECHO not pursued given lack of symmptoms, insensitivity of CT scan for picking up this finding, and that CXR not suggestive of pericardial effusion. Outpatient providers can consider pursuing outpatient echo. Greater than ___ hour spent on care on day of discharge.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ ___ Complaint: Found down at home by family. Major Surgical or Invasive Procedure: ___ - Placement of a gastrostomy tube placement. History of Present Illness: This is a ___ year old male with known seizure disorder, HTN, CVA unknown seizures medications who was found down by family. The patient was unresponsive. The patient was last seen normal by family at 1100. He was taken by ems to this ED and intubated for airway protection. On arrival the patients GCS was 6. A head Ct was performed which was consistent with scattered scant SAH on the right. There were no other traumatic injuries noted on imaging. There is no family at the bedside. Past Medical History: - B12 deficiency, on monthly injections - depressive disorder, - gastric cancer - s/p total gastrectomy -Massive LGIB ___ though source was not determined - prostate cancer(s/p implant for prostate cancer in ___, PSA has been undetectable and stable) - SDH- acute R frontal SDH ___ s/p fall. He was admitted to the neurosurgical service for Q4 neuro checks and repeat imaging. on ___ patient's exam was stable. A repeat head CT was stable. -history of gastrointestinal bleeding from diverticulosis -tophaceous gout, -systemic hypertension, -chronic kidney disease( GFR--CR--) -vitamin D deficiency -avascular necrosis in both hips and right distal femur, sciatica, bilateral hip osteoarthritis, -paroxysmal supraventricular tachycardia, on beta-blocker -R DVT in ___ ivc filter, -septic shock from infectious liver cyst in ___. -Macular degeneration Social History: ___ Family History: Non-contributory Physical Exam: =================== EXAM ON ADMISSION =================== Vitals: 98.1 90 150/67 16 100% General: Critically ill-appearing, frail, elderly HEENT: +ETT, +edematous orbits bilaterally, +left conjunctival hemorrhage with significant conjunctival edema, +laceration R frontal areas ___: RRR Pulmonary: No incr WOB Abdomen: Soft, NT, ND, +BS, no guarding Extremities: Warm, no edema Skin: No rashes or lesions Neurologic Examination: - Mental Status - Eyes closed. Will scrunch eyelids to voice but not open eyes. Does not follow commands or track. - Cranial Nerves - R pupil 2 and sluggishly minimally reactive. L pupil unable to be visualized ___ conjunctival hemorrhage and edema. Symmetric grimace. +cough/gag. - Sensori-motor - Decreased bulk. Normal tone. Will move hands and feet spontaneously symmetrically. Does not withdraw anti-gravity to noxious. -DTRs: Bi Tri ___ Pat Ach L 1 1 1 1 0 R 1 1 1 1 0 Plantar response mute bilaterally. - Coordination - Deferred. - Gait - Deferred. =================== EXAM ON DISCHARGE =================== Vitals: T: 97.5 HR 82 BP 115/56 RR 16 O2 97% RA General: Emaciated, Alert, oriented x3, appears uncomfortable, in some pain. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: J-tube in place on left. Tenderness to mild palpation at site Ext: Warm, well perfused. Erythema and tenderness around R wrist Pertinent Results: ======================= LABS ON ADMISSION ======================= ___ 01:42PM BLOOD WBC-7.1 RBC-3.72* Hgb-10.9* Hct-33.6* MCV-90 MCH-29.3 MCHC-32.4 RDW-19.5* RDWSD-64.2* Plt ___ ___ 02:00PM BLOOD ___ ___ 12:15AM BLOOD Glucose-105* UreaN-39* Creat-2.0* Na-139 K-4.6 Cl-105 HCO3-16* AnGap-23* ___ 12:15AM BLOOD Calcium-8.9 Phos-5.0*# Mg-2.4 ___ 01:42PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 03:21PM BLOOD Type-ART Tidal V-430 PEEP-5 FiO2-100 pO2-548* pCO2-36 pH-7.37 calTCO2-22 Base XS--3 AADO2-122 REQ O2-31 -ASSIST/CON Intubat-INTUBATED ___ 01:50PM BLOOD Glucose-132* Lactate-1.9 Na-140 K-4.5 Cl-105 calHCO3-21 ======================= PERTINENT INTERVAL LABS ======================= ___ 02:37AM BLOOD ALT-28 AST-56* AlkPhos-64 TotBili-0.5 ___ 12:15AM BLOOD CK-MB-9 cTropnT-0.03* ___ 02:22AM BLOOD Phenyto-19.5 ___ 01:45PM BLOOD Phenyto-14.9 ======================= LABS ON DISCHARGE ======================= ___ 07:30AM BLOOD WBC-7.9 RBC-3.08* Hgb-8.9* Hct-28.6* MCV-93 MCH-28.9 MCHC-31.1* RDW-17.3* RDWSD-59.4* Plt ___ ___ 07:30AM BLOOD Glucose-131* UreaN-30* Creat-1.3* Na-136 K-4.8 Cl-104 HCO3-22 AnGap-15 ___ 07:30AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.1 ======================= MICROBIOLOGY ======================= ___ Sputum: KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ___ Urine - Mixed bacterial flora ___ Blood culture x3 - No growth ======================= IMAGING ======================= ___ CT head without contrast: 1. Likely right frontal lobe contusion with adjacent subarachnoid hemorrhage and small right frontotemporal subdural hematoma. 2. Large right frontal subgaleal hematoma. 3. Right parietal, occipital and bilateral periorbital soft tissue swelling. 4. Please see concurrently obtained facial bone CT for description of maxillofacial structures. 5. No definite calvarial fracture identified. ___ CT C spine without contrast 1. Multilevel degenerative changes as described. The degree of degenerative changes lowers the threshold for spinal cord injury in the setting of trauma. If there is neurological symptomatology, MRI can be obtained for further evaluation. ___ CT mandible, maxilla 1. Large left frontal subgaleal hematoma left greater than right preseptal periorbital soft tissue swelling. 2. Compression of the nasal bone with increased sclerosis may indicate chronic injury first is acute fracture. Recommend clinical correlation. 3. No other facial bone fractures identified. 4. Please see concurrently obtained noncontrast head CT and cervical spine CT studies for description of cranial and cervical spine structures ___ CT chest, abdomen, pelvis: 1. No evidence of traumatic injury in the chest, abdomen, or pelvis. 2. Scarring and/or atelectasis at the left lung base. Small focus of ground-glass centrilobular nodular opacity in right upper lobe may represent atypical infection or inflammatory change. Right upper lobe granuloma. 3. Multiple hepatic hypodensities compatible with cysts or biliary hamartomas. Right lobe of hyperenhancing focus in the liver is indeterminate. 4. Diffuse intra and extrahepatic biliary dilation as well as pancreatic duct prominence, with smooth tapering at the level of the ampulla. No obstructing masses identified. This may represent ampullary stenosis, and significance is uncertain as an incidental finding. If there are lab abnormalities or other clinical features warranting further evaluation, MRCP can be obtained. 5. Infrarenal IVC filter with a single strut within the abdominal aorta. 6. Renal cortical thinning bilaterally indicative of scarring from prior infection or ischemia. ___ CT head without contrast: 1. Right-sided subarachnoid hemorrhage and subdural hemorrhage as described. 2. No evidence of herniation or mass effect. 3. Evolving left frontal and parietal soft tissue swelling and subgaleal hematoma. Grossly stable bilateral periorbital soft tissue swelling. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 12.5 mg PO DAILY 2. Allopurinol ___ mg PO DAILY 3. Colchicine 0.6 mg PO EVERY OTHER DAY 4. Mirtazapine 15 mg PO QHS 5. Allopurinol ___ mg PO DAILY 6. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H Pain 7. Lidocaine 5% Patch 1 PTCH TD DAILY 8. Furosemide 20 mg PO DAILY Edema Discharge Medications: 1. Allopurinol ___ mg PO DAILY 2. Atenolol 12.5 mg PO DAILY 3. Colchicine 0.6 mg PO DAILY 4. Lidocaine 5% Patch 1 PTCH TD DAILY 5. Mirtazapine 15 mg PO QHS 6. LeVETiracetam 500 mg PO BID 7. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain RX *oxycodone [Oxecta] 5 mg 0.5 (One half) tablet(s) by mouth every four (4) hours Disp #*24 Tablet Refills:*0 8. Acetaminophen 650 mg PO Q8H Discharge Disposition: Extended Care Facility: ___ ___ Rehabilitation and Sub-Acute Care) Discharge Diagnosis: Primary Diagnoses: - Subarachnoid hemorrhage - Delirium - Malnutrition Secondary Diagnoses: - gout - osteoarthritis Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Q116 CT HEADSINUS INDICATION: ___ male status post unwitnessed fall. Evaluate for facial bone fractures. TECHNIQUE: Helically-acquired multidetector CT axial images were obtained through the maxillofacial bones and mandible. Intravenous contrast was not administered. Axial images reconstructed with soft tissue and bone algorithm to display images with 1.25 mm slice. Coronal and sagittal reformations were also constructed. All produced images were evaluated in production of this report. DOSE: This study involved 3 CT acquisition phases with dose indices as follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Spiral Acquisition 2.7 s, 21.5 cm; CTDIvol = 25.7 mGy (Head) DLP = 552.4 mGy-cm. Total DLP (Head) = 552 mGy-cm. COMPARISON: None. FINDINGS: SOFT TISSUES: Again is noted a left frontal subgaleal hematoma with soft tissue swelling. MAXILLOFACIAL BONES: The maxillofacial bones are intact, without fracture. The zygomatico-maxillary complex is intact. The lateral pterygoid plates are intact. MANDIBLE: The mandible is without fracture or temporomandibular joint dislocation. The temporomandibular joints are symmetric, without significant degenerative change. DENTITION: There are no dental fractures. There is no remarkable periodontal disease, periapical lucency, or odontogenic abscess. SINUSES: The paranasal sinuses are intact and clear. The ostiomeatal units are patent. The mastoid air cells and middle ear cavities are clear. NOSE: There is depression of the nasal bone with increased sclerosis which may represent a chronic injury. There is no nasal septal hematoma. There is rightward nasal septal deviation with bony spur. ORBITS: The orbits, including the laminae papyracea, are intact. The globes are intact with non-displaced lenses and no intraocular hematoma. There is no retrobulbar hematoma or fat stranding. Bilateral, left greater than right, periorbital preseptal soft tissue swelling is present. Endotracheal and enteric tubes are noted in the airway and esophagus respectively. There is fluid in aerosolized secretions in the nasal cavity and posterior nasopharynx, which may be related intubation status. IMPRESSION: 1. Large left frontal subgaleal hematoma left greater than right preseptal periorbital soft tissue swelling. 2. Compression of the nasal bone with increased sclerosis may indicate chronic injury first is acute fracture. Recommend clinical correlation. 3. No other facial bone fractures identified. 4. Please see concurrently obtained noncontrast head CT and cervical spine CT studies for description of cranial and cervical spine structures. RECOMMENDATION(S): 1. Compression of the nasal bone with increased sclerosis may indicate chronic injury first is acute fracture. Recommend clinical correlation. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE INDICATION: ___ male status post unwitnessed fall. Evaluate for cervical spine fracture. 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: This study involved 3 CT acquisition phases with dose indices as follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Spiral Acquisition 5.3 s, 20.6 cm; CTDIvol = 36.7 mGy (Body) DLP = 755.2 mGy-cm. Total DLP (Body) = 755 mGy-cm. COMPARISON: None. FINDINGS: There is mild reversal of the cervical lordosis. There is no evidence of fracture. Patient's intubation status limits evaluation for prevertebral soft tissue swelling. There are multilevel degenerative changes of the cervical spine with endplate osteophytes and disc space narrowing. Facet arthropathy is worst at C7-T1 on the left. Degenerative changes result in mild-to-moderate central canal narrowing throughout the cervical spine. Streak artifact limits evaluation of thyroid gland. Atherosclerotic vascular calcifications are seen in bilateral carotid bifurcations. IMPRESSION: 1. No definite fracture identified. 2. Multilevel degenerative changes as described. The degree of degenerative changes lowers the threshold for spinal cord injury in the setting of trauma. If there is neurological symptomatology, MRI can be obtained for further evaluation. 3. Please see concurrently obtained CT of the chest abdomen and pelvis for description of thoracic structures. 4. Please see concurrently obtained CT of the head and facial bone studies for description of cranial and facial bone structures. RECOMMENDATION(S): 1. Multilevel degenerative changes as described. The degree of degenerative changes lowers the threshold for spinal cord injury in the setting of trauma. If there is neurological symptomatology, MRI can be obtained for further evaluation. Radiology Report EXAMINATION: CT CHEST/ABD/PELVIS W/CONTRAST AND CORONAL/SAGITAL RECONS INDICATION: ___ with head trauma. Evaluate for injuries. TECHNIQUE: MDCT acquired axial images of the chest, abdomen, and pelvis were obtained after administration of 130 mL Omnipaque intravenous contrast. Enteric contrast was not given. Coronal and sagittal reformats were prepared and reviewed. DOSE: This study involved 3 CT acquisition phases with dose indices as follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Spiral Acquisition 8.1 s, 63.4 cm; CTDIvol = 5.0 mGy (Body) DLP = 314.4 mGy-cm. Total DLP (Body) = 314 mGy-cm. COMPARISON: None. FINDINGS: CHEST: The thyroid gland is homogeneous. The great vessels enhance normally and are normal caliber. Heart size is normal and there is mild coronary artery calcification. No mediastinal hematoma. Endotracheal tube terminates in the mid thoracic trachea and there are secretions around the tip of the endotracheal tube. Enteric tube is noted in the esophagus and terminates at the gastroesophageal junction. Mild ground-glass centrilobular peribronchial nodules in the right upper lobe may correspond to small focus of atypical infection/inflammatory change (02:28). Right upper lobe granuloma noted. There is a mild amount of subpleural scarring and atelectasis at the left lung base. No evidence of pulmonary contusion. No pleural effusion or pneumothorax. ABDOMEN: The liver is intact and homogeneous in attenuation. Hyperenhancing focus in the right lobe of the liver superiorly (2:89) is indeterminate, possibly an FNH, hemangioma, or perfusion abnormality. There are multiple hepatic hypodensities compatible with cysts or biliary hamartomas. There is diffuse intra and extrahepatic biliary dilation, as well as prominence of the pancreatic duct. Biliary and pancreatic ducts taper smoothly to the ampulla with no obstructing mass identified. The gallbladder is distended but does not demonstrate wall thickening or pericholecystic fluid. The pancreas is normal in attenuation. The spleen is intact. The adrenal glands are normal bilaterally. The kidneys enhance and excrete contrast symmetrically. Bilateral areas of renal cortical thinning are indicative of scarring from prior infection or ischemia. Cortical hypodensities bilaterally likely represent cysts. The patient is status post partial gastrectomy with gastrojejunostomy. There is transient intussusception at the jejunojejunal anastomosis, of no clinical significance. There is no evidence of bowel obstruction. The appendix is normal. No free air or free fluid in the abdomen. The large bowel is normal in caliber. No mesenteric or retroperitoneal lymphadenopathy. VESSELS: There is a moderate atherosclerotic calcification of the abdominal aorta and iliac vessels without aneurysmal dilatation. Intrarenal IVC filter is noted with a single strut of the filter penetrating the abdominal aorta (2:147). PELVIS: The urinary bladder contains a Foley catheter and is thin walled. The prostate gland demonstrates numerous brachytherapy seeds. Penile prosthesis is partially imaged. No pelvic free fluid or lymphadenopathy. BONES: Right total hip arthroplasty appears well seated without hardware related complication. There are moderate degenerative changes of the right glenohumeral joint, and along the thoracic and lumbar spine. No acute fractures appreciated. Old left lateral rib deformity (2:81) is indicative of remote injury. IMPRESSION: 1. No evidence of traumatic injury in the chest, abdomen, or pelvis. 2. Scarring and/or atelectasis at the left lung base. Small focus of ground-glass centrilobular nodular opacity in right upper lobe may represent atypical infection or inflammatory change. Right upper lobe granuloma. 3. Multiple hepatic hypodensities compatible with cysts or biliary hamartomas. Right lobe of hyperenhancing focus in the liver is indeterminate. 4. Diffuse intra and extrahepatic biliary dilation as well as pancreatic duct prominence, with smooth tapering at the level of the ampulla. No obstructing masses identified. This may represent ampullary stenosis, and significance is uncertain as an incidental finding. If there are lab abnormalities or other clinical features warranting further evaluation, MRCP can be obtained. 5. Infrarenal IVC filter with a single strut within the abdominal aorta. 6. Renal cortical thinning bilaterally indicative of scarring from prior infection or ischemia. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man s/p fall now intubated // eval OGT placement COMPARISON: ___. IMPRESSION: As compared to the previous radiograph, the patient is now intubated. The tip of the endotracheal tube is relatively high, projecting approximately 7 cm above the carina. The nasogastric tube shows a normal course, the tip projects over the middle parts of the stomach. No evidence of complications, notably no pneumothorax. No new focal parenchymal opacity. Massive overinflation persists. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with SAH. Evaluate for stability of hemorrhage. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: This study involved 3 CT acquisition phases with dose indices as follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced Acquisition 16.0 s, 16.6 cm; CTDIvol = 53.7 mGy (Head) DLP = 891.9 mGy-cm. Total DLP (Head) = 892 mGy-cm. COMPARISON: ___ noncontrast head CT studies. FINDINGS: There is a right-sided subdural hematoma measuring 5 mm at its widest diameter seen predominantly along the vertex. There is also moderate subarachnoid blood seen along the right cerebral hemisphere. There is subdural hemorrhage along the right tentorium. The ventricles and sulci are stable. There is continued left frontal and parietal soft tissue swelling and subgaleal hematoma. There is stable bilateral periorbital soft tissue swelling. There is marked swelling of the left side of the face and a large left-sided subgaleal hematoma along the left fronto parietal convexity. There is no evidence of herniation. There is no evidence of fracture. There is mild mucosal thickening of the ethmoid air cells. There is a small air-fluid level in the sphenoid sinus as well as some aerosolized secretions. The visualized maxillary sinuses are clear. The mastoid air cells are well aerated. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. Right-sided subarachnoid hemorrhage and subdural hemorrhage as described. 2. No evidence of herniation or mass effect. 3. Evolving left frontal and parietal soft tissue swelling and subgaleal hematoma. Grossly stable bilateral periorbital soft tissue swelling. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with Please evaluate // intubated IMPRESSION: As compared to ___ chest radiograph, nonspecific left lower lobe opacities have decreased in extent. Remainder of lungs are grossly clear. Radiology Report INDICATION: ___ year old man with dobhoff placement // placement COMPARISON: No comparison FINDINGS: On image 1 series 6, the newly inserted top of catheter is visualized in the middle parts of the stomach, approximately at the level of the ___ inserted feeding tube. No complications. IMPRESSION: On image 1 series 6, the newly inserted top of catheter is visualized in the middle parts of the stomach, approximately at the level of the ___ inserted feeding tube. No complications. Radiology Report EXAMINATION: MR CERVICAL SPINE W/O CONTRAST INDICATION: ___ year old man hx of fall, intubated with c-collar, hx of MRI compatible penile prosthesis, eval for c-spine clearance. // c-spine clearance TECHNIQUE: Sagittal T1, T2 and sagittal IDEAL sequences were obtained through the cervical spine, axial T2 and gradient echo sequences were also obtained. COMPARISON: CT of the cervical spine dated ___, and ___. Prior head CT dated ___. FINDINGS: Fluid level is identified in the sphenoid sinus, previously demonstrated by head CT in ___. The visualized elements of the posterior fossa on the craniocervical junction are unremarkable. The patient is intubated with endotracheal tube and orogastric tubes. There is significant amount secretions layering in the nasopharyngeal space. The signal intensity throughout the cervical spinal cord is normal with no evidence of focal or diffuse lesions to indicate spinal cord edema or cord expansion. At C2/C3 level, there is disc desiccation and mild disc bulging, causing mild anterior thecal sac deformity with no evidence of spinal canal stenosis or nerve root compression.. At C3/C4 level, anterior posterior spondylosis are present, unchanged since the prior CT examination, bilateral uncovertebral hypertrophy are causing mild to moderate bilateral neural foraminal narrowing, there is no evidence of spinal canal stenosis.. At C4/C5 level, there is disc bulging and bilateral uncovertebral hypertrophy producing moderate right and moderate to severe left neural foraminal narrowing, there is no evidence of spinal canal stenosis. At C5/C6 level, diffuse disc bulge, spondylosis and bilateral uncovertebral hypertrophy are causing mild left and moderate right neural foraminal narrowing, there is no evidence of spinal canal stenosis. At C6/C7 level, there is diffuse disc bulge, spondylosis, causing anterior thecal sac deformity and moderate left-sided neural foraminal narrowing, there is no evidence of spinal canal stenosis. The visualized paravertebral structures are grossly unremarkable. IMPRESSION 1. Multilevel multifactorial degenerative changes throughout the cervical spine, with no significant change since the prior CT examination, there is no evidence of bone edema or ligamentous injury. 2. There is no evidence of focal or diffuse lesions throughout the cervical spinal cord to indicate spinal cord edema or cord expansion.. NOTIFICATION: . Radiology Report EXAMINATION: Video oropharyngeal swallow. INDICATION: ___ man status post fall, now with aspiration on bedside swallow evaluation. TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in conjunction with the speech and swallow division. Multiple consistencies of barium were administered. DOSE: Fluoro time: 2.9 min. COMPARISON: No prior studies. FINDINGS: Barium passes freely through the oropharynx and esophagus without evidence of obstruction. Laryngeal penetration with thin liquid. No aspiration. IMPRESSION: Laryngeal penetration with thin liquid without evidence of aspiration. Please refer to the speech and swallow division note in OMR for full details, assessment, and recommendations. Radiology Report INDICATION: ___ year old man s/p gastrectomy requiring tube feeds; s/p placement of dobhoff tube // 2-step placement of dobhoff tube TECHNIQUE: 2 portable AP views of the chest. COMPARISON: Chest radiograph ___ FINDINGS: The initial images demonstrates a dobhoff tube positioned in the distal esophagus, above the level the gastroesophageal junction. The subsequent image shows the radiopaque tip of the Dobhoff tube just below the diaphragm, just distal to the expected location of the gastroesophageal junction. Radio-opaque contrast material is seen within the transverse colon with diverticular disease evident. The lung volumes are within normal limits. No consolidation or pneumothorax seen. No pleural effusions seen. Radiology Report INDICATION: ___ year old man with total gastrectomy, malnutrition. Failed surgical attempt at placement ___. // ? J tube placement COMPARISON: Comparison is made to prior CT from ___. TECHNIQUE: OPERATORS: Dr. ___, Dr. ___ ___ imaging fellow), and Dr. ___ radiologist performed the procedure. Dr. ___ supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 50 mcg of fentanyl and 1 mg of midazolam throughout the total intra-service time of 25 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. No intravenous contrast was used. PROCEDURE: 1. Placement of a gastrostomy 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 CT 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 pre-procedure CT of the abdomen was obtained. Using a marker, the skin was marked and draped using sterile technique. Under CT guidance, 3 T-fastener buttons were sequentially deployed in a triangular position elevating the neo-stomach to the left anterior abdominal wall. Position was confirmed with CT and aspiration of gastric contents. A 19 gauge needle was introduced under CT guidance and position confirmed. A ___ wire was introduced into the neo-stomach. After sequential dilation using 12 ___ dilators, a gastrostomy catheter was advanced over the wire into position. The catheter was secured by forming the retaining loop in the stomach after confirming the position on CT. The catheter was then flushed, capped and secured to the skin with 0-silk sutures. Sterile dressings were applied. The patient tolerated the procedure well and there were no immediate complications. FINDINGS: 1. Successful placement of a gastrostomy tube into the neostomach. IMPRESSION: Successful placement of a gastrostomy tube. The catheter should not be used for 24 hours. Radiology Report EXAMINATION: Portable chest radiograph. INDICATION: ___ male status post trauma. TECHNIQUE: Single portable AP chest radiograph. COMPARISON: None available. FINDINGS: Single portable AP chest radiograph demonstrates an endotracheal tube, its tip which projects over the mid trachea approximately 4 cm from the level of the carina. An enteric tube descends the thorax in uncomplicated course, its tip which projects just below or at the level of the gastroesophageal junction for which advancement approximately 8 cm is advised. Surgical sutures project over the left upper quadrant. Surgical clips are additionally noted which project over the left upper quadrant. Lungs are clear without a focal consolidation. Cardiomediastinal silhouette is within normal limits. There is no pneumothorax or large pleural effusion. The right costophrenic angle is not imaged. Osseous structures demonstrates no acute fracture. Imaged upper abdomen is without an acute abnormality. IMPRESSION: 1. No acute intrathoracic abnormality. 2. Endotracheal tube appears appropriately positioned. Advancement of the enteric tube approximately 8 cm is advised for more appropriate positioning. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ male status post unwitnessed fall. Evaluate foracute intracranial hemorrhage or fracture. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal as well as bone algorithm reformatted images were obtained. DOSE: This study involved 3 CT acquisition phases with dose indices as follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced Acquisition 8.0 s, 17.7 cm; CTDIvol = 50.5 mGy (Head) DLP = 891.9 mGy-cm. Total DLP (Head) = 892 mGy-cm. COMPARISON: None. FINDINGS: There is a large left frontal subgaleal hematoma without associated fracture. There is a right parieto-occipital scalp soft tissue swelling. There is also left greater than right periorbital soft tissue swelling, with no definite preseptal extension. Hyperdense area of the right frontal lobe corresponds to subarachnoid hemorrhage and parenchymal contusion. Additionally, there is thin extra-axial fluid along the right frontal and temporal convexities, compatible with subdural hemorrhage. Bilateral basal ganglia calcifications are noted. There is no mass effect or midline shift. There is nonspecific fluid in the nasal cavity and nasopharynx, which may be related to intubation status. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. IMPRESSION: 1. Likely right frontal lobe contusion with adjacent subarachnoid hemorrhage and small right frontotemporal subdural hematoma. 2. Large right frontal subgaleal hematoma. 3. Right parietal, occipital and bilateral periorbital soft tissue swelling. 4. Please see concurrently obtained facial bone CT for description of maxillofacial structures. 5. No definite calvarial fracture identified. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: S/P FALL Diagnosed with TRAUM SUBARACHNOID HEM, TRAUMATIC SUBDURAL HEM, UNSPECIFIED FALL, ALTERED MENTAL STATUS temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: nan

___ year old male with a history of subdural hematoma, gastrointestinal bleeding from diverticulosis, gastrointestinal cancer, prostate cancer, hypertension and significant weight loss due to malnutrition he is presenting now s/p fall, pain with chewing food, right SAH/SDH and left sided subgleal hematoma. # Mental Status Change At time of presentation to the ED, GCS was 6 and pt was emergently intubated. Pt was given ___ Fentanyl and started on propofol following intubation. A non-contrast head CT showed a large right frontal subgaleal hematoma with right frontal lobe contusion with adjacent subarachnoid hemorrhage as well as a small right frontotemporal subdural hematoma. Neurosurgery was consulted who deferred any surgical management. Other labs and imaging were unremarkable. Cardiac enzymes and EKG were unremarkable. The patient was started on a nicardipine drip to maintain a systolic blood pressure of 140-170. The patient was started on 1g Keppra IV BID, and neurology was consulted due to concerns for seizures and possible CVA. An EEG was ordered and showed runs of lateral periodic discharges, maximal in the right frontal region, initially occurring in long runs at ___ Hz consistent with significant focal cortical irritability. The patient was loaded with 20 mg/kg IV Phenytoin and started on Phenytoin 100 mg TID for EEG abnormalities. The following morning, the level was found to be elevated at 19.5 uncorrected (corrects to 24.4 for an albumin of 3.5). Keppra dose decreased appropriately for CrCl<30 (from 1000 mg BID to ___ mg BID). His blood pressure was liberalized to keep his systolic blood pressure less than 160. On ___, Neurology recommended that the patients phenytoin be weaned off over the next three days and that his LFTs be checked. His Keppra was continued at 500mg BID. His EEG showed no evidence of seizures but had right PLEDs, which were improving. During this time, the patient remained in a cervical collar. Attempts were made to obtain a MRI of the cervical spine to clear the collar, but because the patient had a penile implant (of unknown type), an MRI could not be completed. On ___, the patient's exam was improving with sedation holidays. He remained intubated with the hopes of getting a MRI, but this was abandoned, an attempt was made to extubate the patient. He was found to have increased secretions, so he remained intubated an additional day, and was successfully extubated on ___ and transferred to the floor. A spot routine EEG ___ without any evidence of PLEDs or epileptiform discharges. His level of alertness slowly improved throughout his admission. On discharge, he continued to have some confusion without agitation. # Malnutrition He has lost 40 pounds over the past year and a half with a negative malignancy workup including colonoscopy, EGD, and CTAP. He has had several admissions for weakness. He has tried Remeron, Megace, and recently Marinol without significant improvement, and in ___ he had a dobhoff placed for home tube feeds. At one point his home nurse removed this as he felt it was impairing his ability to eat but he was not able to keep up with tube feeds and had it replaced. He has also been referred to a maxillfacial surgeon for removal of a torus ___ that interferes with eating. On this hospitalization, the patient was initially fed though a dobhoff tube with Jevity 1.2 @ 50 mL/hr for 100% estimated needs. In addition, the patient has failed bedside speech and swallow evaluation. His video swallow evaluation demonstrated a delay in the oropharynx secondary to his recent neurological insults and aggravating his PO intake. Due to ongoing concerns for poor nutrition, ACS was consulted for J-tube placement. On ___, an attempt at placement was made. However, given patient's previous gastrectomy and distorted anatomy, the procedure could not be completed. ___ was consulted for CT-guided placement, which was successfully completed on ___. On ___ tube feeds were started without complications. He was discharged at his goal of Jevity 1.2 @ 50mL/hr. The patient also was able to take in small amounts PO. Per speech and swallow, he was given a pureed (dysphagia) diet with nectar-thick liquids. # Home situation concerns: It was noted from a previous hospitalization that Elder Services had been contact regarding concern for elder neglect. Further concerns were brought to the team during this hospitalization from the patient's daughter, ___, who was concerned that ___, the patient's HCP, was working toward secondary gain at the expense of the patient's well-being. An ethics consult was called, and a meeting was held with ethics and social work. Upon further investigation, it was discovered that nothing had been filed with protective services during the previous hospitalization. A decision was made to file a report with ETHOS at this time, and the daughter was encouraged to do so as well. # Klebsiella in sputum: Sputum was collected on ___ after the patient was extubated, and found to be growing Klebsiella. However, the patient exhibited no signs of pneumonia. He remained afebrile, satting well on room air, and with no leukocytosis, and so it was decided to not treat with antibiotics. The patient showed no clinical signs of pneumonia throughout the remainder of his hospital course. #Arthritis/gout: As the patient's mental status improved, he began endorsing pain in both hands and his shoulder. He was covered on OxycoDONE (immediate release) 2.5mg PO/NG Q4H: PRN pain and acetaminophen 325-650 mg PO Q6H:PRN pain/fever. A lidocaine patch was given for his shoulder. # Depression: The patient has a history of depression and this could be contributing to his delirium. He was continued on Mirtazapine 15 mg PO/NG QHS for depression. # Normocytic Anemia: The patient has decreased his H/H from 10.9 to 9.4 over the course of his hospital stay. The patient has a known B12 deficiency. There was never any evidence of active bleeding, and the patient remained hemodynamically stable. He received Ferrous Sulfate 325 mg PO/NG Daily. # Hypertension: Patient continued on home Atenolol 12.5mg. # ___ on Chronic Kidney Disease: Patient's initial creatinine was found to be 2.0, above his baseline of 1.2. It slowly came down throughout his hospitalization and was 1.2 on ___. However, it then began to slowly increase to 1.4. # Gout: The patient has a history of tophaceous gout controlled with medication. He was given Colchicine 0.6 mg daily and Allopurinol ___ mg daily. # Edema: Held home lasix as patient had no signs of edema and had likely prerenal ___ with creatinine of 2.0 on admission. # Glaucoma: Patient has diagnosed in past with open-angle glaucoma. Continued Latanoprost 0.005% Opth. Soln. 1 Drop both eyes QHS. # Vitamin D deficiency: Continued vitamin D supplementation 1000 Unit PO/NG Daily ============================== TRANSITIONAL ISSUES ============================== - The patient is on Keppra 500 mg PO BID, which he should continue until his appointment with Dr. ___ in neurosurgery. - The patient should have a non-contrast head CT before his appointment with neurosurgery. This is already ordered for ___. - The ___ rehab facility should confirm that the patient has an appointment scheduled with neurosurgery in ___ weeks. The office number is ___. - The patient's colchicine was increased from 0.6mg every other day to 0.6mg daily, which is the recommended dosing for his GFR. - The patinet was started on Acetaminophen 650 mg PO Q8H for pain. - The patient's pain regimen was changed from oxycontin 10mg BID to oxycodone 2.5mg Q4H prn pain, to allow for better titration of pain medication. - The patient's furosemide was stopped as he was not having symptoms and at times had low blood pressures of ___. This can be restarted at the discretion of his primary care doctor. - The patient is receiving tube feeds through his J-tube: Jevity 1.2 @ 50cc/hr. # CODE: FULL # CONTACT: Wife ___ - phone ___ ___

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/Vomiting Major Surgical or Invasive Procedure: ERCP ___ with duodenal stent History of Present Illness: Mr. ___ is a ___ year old male with recently diagnosed pancreatic mass (s/p biopsy on ___ with results pending) with suspected peritoneal carcinomatosis, liver and iliac possibly metastatic lesions, and past medical history of type 2 diabetes and chronic anemia who presents with recurrent abdominal pain associated with distension and nausea/vomiting immediately after po intake. Patient was discharged on ___ and states that soon after returning home he had recurrence of his nausea vomiting including green / bilious vomiting earlier today. He has been unable to tolerate p.o. and reports abdominal distension but denies fever/chills. Patient has had chronic abdominal pain since the onset of his pain approximately 3 weeks ago but has not had any acute worsening. He has had normal bowel movements. He denies back pain, dysuria. Patient had EUS on ___ by ERCP service with biopsies pending. Due to inability to tolerate oral intake, he presented to ___ earlier today and was noted to have ___ with Cr 2.6 up from baseline of 0.8. Since he recently underwent EUS and biopsy of pancreatic mass here at ___, he was transferred to our ED for further workup and care. Prior to transfer from ___ he received 1L NS bolus. Past Medical History: - Diabetes, non-insulin-dependent - Anemia, of unclear etiology. On oral iron supplementation. Social History: ___ Family History: Fam Hx: Has a cousin who died of "stomach cancer" in 2 other cousins who died of cancer, 1 of whom had brain cancer. Mother and brother with diabetes. Father had ___ disease and died of complications from this. Physical Exam: Discharge Exam: Vitals: 97.9 PO 134 / 62 R Lying 80 18 96 Ra Gen: sitting up in bed in no apparent distress, awake and alert HEENT: AT, NC, PERRL, EOMI, MMM, hearing grossly intact CV: S1, S2, RRR no M/R/G Pulm: CTA b/l, no wheeze, rhonchi, or rales GI: (+) BS, soft, NT, ND, no HSM MSK: No edema Skin: No rashes or ulcerations evident Neuro: A+O x4, speech fluent, face symmetric, moving all extremities Psych: calm mood, appropriate affect Pertinent Results: CT A/P, OSH, ___: - Aggressive-appearing ill-defined soft tissue mass involving the uncinate process of the pancreas with circumferential involvement of the wall of the adjacent C3 segment of the duodenum and further extension to encase the superior mesenteric artery by 360 degrees. Mass abuts and deforms the posterior margin SMV. Adjacent borderline enlarged central mesenteric LNs. -Confluent soft tissue nodularity along peritoneal surfaces in the right upper quadrant adjacent to the colonic flexion loops of small bowel and along the right paracolic gutter suggesting peritoneal carcinomatosis. There is soft tissue nodularity inseparable from the thickened appendix which is likely secondary involved with metastatic disease. A small amount of free fluid is present in the pelvis. - Subtle lytic lesion with aggressive appearance and cortical disruption medial left iliac bone. - subtle poorly defined 2.7cm focus of decreased attenuation in subcapsular lateral liver, could be related to underlying hepatic mass, possibly metastatic disease - Scattered bibasilar pulm nodules LLL RLL measure up to 3mm in size and are stable. - Rounded lucent lesions in T11, T12, L2, L3, and L5 vertebral bodies, possibly osseous hemangiomas - 1.4cm left adrenal nodule, not significantly enlarged compared to prior study ___, likely an adenoma CT Abdomen/Pelvis ___ IMPRESSION: 1. 4.7 cm pancreatic uncinate process mass compatible with known pancreatic cancer invades and obstructs the third portion of the duodenum with distended proximal duodenum and stomach. 2. Small volume ascites and omental thickening concerning for carcinomatosis. 3. Lytic lesion left iliac bone and lower thoracic spine suggestive of metastasis. 4. No pathologic fracture. 5. Please refer to report from CT chest for intrathoracic findings. CT Chest ___ IMPRESSION: No definitive evidence of intrathoracic metastatic disease but solid pulmonary nodule in the left lower lobe should be reassessed in 3 months for documentation of stability ERCP with duodenal stent on ___ Impression: A ERCP was used for the procedure. A malignant appearing stricture was seen at the third part of the duodenum measuring 5cm. The scope did not traverse the lesion. Under fluoroscopic guidance, a standard biliary extraction balloon preloaded with a 0.35in guidewire was passed into the duodenum traversing the stenosis. As contrast was injected a tight stenosis was seen, as well as, an unobstructed bowel loop distal to the stenosis. The balloon catheter was removed and the guidewire was left in place within the proximal jejunum. A 22 mm x ___ mm uncovered duodenal metal stent (WallFlex duodenal stent Ref ___ was slowly advanced over the guidewire through the stenosis under fluoroscopic visualization. Final deployment position of the stent was from the second part of the duodenum to the distal duodenum. Final fluoroscopic views showed adequate luminal patency. The scout film was normal. The bile duct was deeply cannulated with the sphincterotome. Contrast was injected and there was brisk flow through the ducts. Contrast extended to the entire biliary tree. Cholangiogram didnot reveal any filling defects. CBD, CHD and IHD were not dilated and hence no stent was placed. Excellent bile and contrast drainage was seen endoscopically and fluoroscopically. I supervised the acquisition and interpretation of the fluoroscopic images. The quality of the fluoroscopic images was good. ___ 08:30AM BLOOD WBC-3.6* RBC-3.29* Hgb-9.3* Hct-25.9* MCV-79* MCH-28.3 MCHC-35.9 RDW-12.4 RDWSD-35.3 Plt ___ ___ 08:17PM BLOOD WBC-5.3 RBC-3.77* Hgb-10.3* Hct-30.9* MCV-82 MCH-27.3 MCHC-33.3 RDW-12.6 RDWSD-37.4 Plt ___ ___ 07:40AM BLOOD Glucose-166* UreaN-5* Creat-0.7 Na-143 K-3.2* Cl-103 HCO3-25 AnGap-15 ___ 07:40AM BLOOD Calcium-8.3* Phos-2.8 Mg-1.4* ___ 12:55PM BLOOD WBC-4.2 RBC-3.46* Hgb-9.7* Hct-27.9* MCV-81* MCH-28.0 MCHC-34.8 RDW-12.7 RDWSD-36.3 Plt ___ ___ 12:55PM BLOOD Neuts-71.8* Lymphs-15.0* Monos-7.4 Eos-4.8 Baso-0.5 Im ___ AbsNeut-3.01 AbsLymp-0.63* AbsMono-0.31 AbsEos-0.20 AbsBaso-0.02 ___ 12:55PM BLOOD Plt ___ ___ 07:50AM BLOOD K-3.8 ___ 07:50AM BLOOD Mg-1.9 Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Pantoprazole 40 mg PO BID 2. Ferrous Sulfate 325 mg PO DAILY 3. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Ferrous Sulfate 325 mg PO DAILY 3. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 4. Pantoprazole 40 mg PO BID Discharge Disposition: Home Discharge Diagnosis: # Abdominal pain: # Nausea / vomiting # Anorexia # Pancreatic adenocarcinoma # Duodenal obstruction # Acute kidney injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: Chest: Frontal and lateral views INDICATION: History: ___ with abdominal pain and persistent vomiting// eval for borhaaves or evidence of perforation in the setting of recent endoscopy TECHNIQUE: Chest: Frontal and Lateral COMPARISON: None. FINDINGS: The lungs are clear without focal consolidation. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are unremarkable. No evidence of free air is seen beneath the diaphragm. No pneumomediastinum is seen. IMPRESSION: No acute cardiopulmonary process. No evidence of free air beneath the diaphragm. Radiology Report INDICATION: History: ___ with pancreatic mass with complaint of persistent nausea.vomiting// eval for evidence of SBO TECHNIQUE: Supine and upright abdominal radiographs were obtained. COMPARISON: ___ FINDINGS: There is relative paucity of small bowel gas. There is also lack of gastric air, with possible small focus seen non dependently. Opacity over the upper abdomen long the course of a probably dilated stomach is concerning for a stomach distended with fluid. No large air-fluid levels are seen. There is no evidence of free air. IMPRESSION: Paucity of small bowel gas; dilated loops of fluid-filled small bowel are not excluded. No air-fluid levels are seen. Small amount of stool seen throughout the colon, the colon itself does not appear obstructed. Concern that the stomach is quite distended and fluid-filled. Radiology Report EXAMINATION: CTA ABD AND PELVIS INDICATION: ___ year old man with metastatic pancreatic CA would like staging scan// pancreas protocol TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast images were acquired through the abdomen and pelvis. Oral contrast was not administered. MIP reconstructions were performed on independent workstation and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 2.7 s, 30.1 cm; CTDIvol = 9.9 mGy (Body) DLP = 290.5 mGy-cm. 2) Spiral Acquisition 9.6 s, 62.5 cm; CTDIvol = 7.7 mGy (Body) DLP = 476.1 mGy-cm. Total DLP (Body) = 767 mGy-cm. COMPARISON: CT of the abdomen and pelvis performed at an outside institution without contrast on ___. FINDINGS: PANCREATIC CANCER STAGING: Morphologic Evaluation Appearance (in the pancreatic parenchymal phase): hypoattenuating Size (maximal axial dimension in cm): 4.7 x 3.3 x 4.7 cm Location (head right of SMV, body left of SMV): uncinate Pancreatic duct narrowing/abrupt cutoff with or without upstream dilatation: absent Biliary tree abrupt cutoff with or without upstream dilatation: absent The mass infiltrates and obstructs the third portion of the duodenum. No peripancreatic stranding. Arterial evaluation SMA involvement: present Solid soft-tissue contact: 360 degrees Focal vessel narrowing or contour irregularity: present Extension to first SMA branch: present Celiac Axis involvement: absent Common hepatic artery involvement: absent Venous evaluation MPV involvement: absent Degree of solid soft-tissue contact: <=180° Degree of increased hazy attenuation/stranding contact: <=180° Focal vessel narrowing or contour irregularity (tethering or tear drop): absent SMV involvement: present Degree of solid soft-tissue contact: <=180° Focal vessel narrowing or contour irregularity (tethering or tear drop): present Extension to first draining vein: present Thrombus within vein: absent; type of thrombus: None Venous collaterals: absent Extrapancreatic evaluation Liver lesions: absent Peritoneal or omental nodules: present Ascites: present, small volume Suspicious lymph nodes: porta hepatis, measuring up to 17 mm in short axis (6:88) Other extrapancreatic disease (invasion of adjacent structures): present (duodenum). LOWER CHEST: Please refer to the separate report of CT chest performed on the same day for description of the thoracic findings. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits, without stones or gallbladder wall thickening. 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. The left adrenal gland demonstrates a nodule which demonstrate fat density most likely representing an adenoma. 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 massively dilated with fluid and air-fluid level. The proximal duodenum is dilated and filled with fluid to the level of the infiltrating mass which causes obstruction in the third portion the duodenum (6: 103). The distal duodenum to this level is decompressed. Colon and rectum are within normal limits. Normal appendix. RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no evidence of pelvic or inguinal lymphadenopathy. REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable. VASCULAR: There is no abdominal aortic aneurysm. There is mild calcium burden in the abdominal aorta and great abdominal arteries. BONES: A lytic lesion in the left iliac bone adjacent to the sacroiliac joint is concerning for metastasis with cortical irregularity and thinning but no frank pathologic fracture. Other ill-defined thoracic vertebral body lytic lesions are noted. Please refer to report from CT chest for details. No acute fracture identified. SOFT TISSUES: Small volume ascites prominent omental thickening concerning for carcinomatosis (6: 105). The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. 4.7 cm pancreatic uncinate process mass compatible with known pancreatic cancer invades and obstructs the third portion of the duodenum with distended proximal duodenum and stomach. 2. Small volume ascites and omental thickening concerning for carcinomatosis. 3. Lytic lesion left iliac bone and lower thoracic spine suggestive of metastasis. 4. No pathologic fracture. 5. Please refer to report from CT chest for intrathoracic findings. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 5:09 pm, 4 minutes after discovery of the findings. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ year old man with metastatic pancreatic CA would like staging scan// Pancreatic CA staging TECHNIQUE: MDCT of the chest was obtained from thoracic inlet to upper abdomen. Axial images were reviewed in conjunction with coronal and sagittal reformats COMPARISON: None FINDINGS: Aorta and pulmonary arteries are unremarkable. Heart size is normal. No mediastinal, hilar or axillary lymphadenopathy is present. No pericardial pleural effusion is seen. Image portion of the upper abdomen will be reviewed separately as part of the CT abdomen and pelvis in corresponding report will be issued Airways are patent to the subsegmental level bilaterally. Lungs are clear except for 4.5 mm nodule in the left lower lobe, series 7, image 190. Its etiology is unclear and it might represent solitary metastatic disease (unlikely) versus other etiology. No lytic or sclerotic lesions worrisome for infection or neoplasm demonstrated. IMPRESSION: No definitive evidence of intrathoracic metastatic disease but solid pulmonary nodule in the left lower lobe should be reassessed in 3 months for documentation of stability Please review CT abdomen and pelvis in the corresponding report for assessment of the findings in the upper abdomen. Gender: M Race: PORTUGUESE Arrive by AMBULANCE Chief complaint: Vomiting, Transfer Diagnosed with Vomiting without nausea, Other specified diseases of pancreas temperature: 98.0 heartrate: 82.0 resprate: 16.0 o2sat: 100.0 sbp: 124.0 dbp: 75.0 level of pain: 0 level of acuity: 3.0

Mr. ___ is a ___ year old male with recently diagnosed pancreatic mass and past medical history of type 2 diabetes and anemia who presents with abdominal pain associated with postprandial abdominal distension and nausea/vomiting due to a duodenal obstruction. # Abdominal pain # Nausea / vomiting, inability to tolerate oral intake # Metastatic pancreatic adenocarcinoma # Duodenal obstruction During his last admission, imaging showed an aggressive-appearing ill-defined soft tissue mass involving the uncinate process of the pancreas with circumferential involvement of the wall of the adjacent C3 segment of the duodenum. He underwent EUS for biopsy on ___ with results positive for ductal adenocarcinoma. He then represented this admission with recurrent abdominal pain, persistent bilious emesis and minimal po intake ___ duodenal obstruction. Given mass intrusion into the duodenum, pt underwent ERCP ___ which confirmed the presence of a malignant stricture in the third part of the duodenum. Duodenal stent placed with good results. No reported abdominal pain. Tolerating a regular diet on day of discharge. Oncology was consulted and are discussing palliative chemo options and possible clinical trials but are awaiting genomic testing. He underwent staging with a CTA abdomen/pelvis and CT chest. # LLL nodule # Possible peritoneal carcinomatosis # Possible iliac metastases CT staging findings: No definitive evidence of intrathoracic metastatic disease but solid pulmonary nodule in the left lower lobe should be reassessed in 3 months for documentation of stability. Small volume ascites and omental thickening concerning for carcinomatosis. Lytic lesion left iliac bone and lower thoracic spine suggestive of metastasis. # Acute kidney injury # Prerenal azotemia Cr peaked at 2.8. Returned to baseline with IV hydration. Transitional issues: - f/u with ___ in one week

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Gentamicin / vancomycin Attending: ___. Chief Complaint: right rest pain Major Surgical or Invasive Procedure: diagnostic right lower extremity angiogram History of Present Illness: ___ PMH ___, ESRD on HD, s/p failed DDRT ___, PVD s/p L recanalyzed AKpop-DP bypass, L ___ toe amps, R PTA of R peroneal on ___ p/w rest pain of right foot. Patient reports he has had pain for 2 weeks. Denies ulcers. Numbness of foot baseline. Difficulty walking on foot. Past Medical History: Atrial Fibrillation Deep Vein Thrombosis Depression Diabetes Mellitus Type II End-Stage Renal Disease on PD GI Bleed H. Pylori Hepatitis C treated with Zepatier Hyperparathyrodism Hypertension Idiopathic Thrombocytopenia IVC Filter Left hallux amputation ___ Osteomyelitis s/p left third toe amputation ___ Peripheral Vascular Disease with multiple revascularization procedures Prostate Cancer treated with radiation Radiation Proctitis Transient Ischemic Attack Social History: ___ Family History: Father - CHF, died age ___ Mother - diagnosed with diabetes mellitus at age ___. Paternal aunt and two sisters with ___ and a sister with juvenile diabetes died at ___. Siblings - 6 of 9 siblings with hypertension. Physical Exam: Neuro/Psych: Oriented x3, Affect Normal, NAD. Neck: Thyroid normal size, non-tender, no masses or nodules. Nodes: No clavicular/cervical adenopathy, No inguinal adenopathy. Heart: Regular rate and rhythm. Lungs: Clear, Normal respiratory effort. Gastrointestinal: Non distended, Guarding or rebound, No hernia. Extremities: Abnormal: L partial TMA site c/d/i. R foot with no ulcers, callous on ___ toe. chronic changes of PVD. . Pulse Exam (P=Palpation, D=Dopplerable, N=None) RLE DP: N. ___: N. LLE DP: D. ___: D. Pertinent Results: ___ 11:45AM BLOOD WBC-7.2 RBC-4.17* Hgb-10.5* Hct-34.3* MCV-82 MCH-25.2* MCHC-30.6* RDW-17.4* RDWSD-51.8* Plt ___ ___ 11:45AM BLOOD Plt ___ ___ 11:45AM BLOOD Glucose-91 UreaN-66* Creat-15.6* Na-136 K-4.3 Cl-92* HCO3-22 AnGap-26* ___ 11:45AM BLOOD Calcium-8.0* Phos-7.9* Mg-2.5 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Ascorbic Acid ___ mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Calcitriol 0.5 mcg PO DAILY 6. Cinacalcet 30 mg PO DAILY 7. Digoxin 0.125 mg PO 2X/WEEK (MO,TH) 8. Epoetin Alfa 6000 units SC TUES, THURS, SAT 9. Glargine 10 Units Dinner Insulin SC Sliding Scale using HUM Insulin 10. Lactulose 15 mL PO BID:PRN 2 loose BM per day 11. Metoprolol Tartrate 100 mg PO BID 12. PARoxetine 20 mg PO DAILY 13. sevelamer CARBONATE 2400 mg PO TID W/MEALS Discharge Medications: 1. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate RX *hydromorphone 2 mg 1 tablet(s) by mouth Twice a Day Disp #*9 Tablet Refills:*0 2. lidocaine 5 % topical BID:PRN 3. Glargine 10 Units Dinner Insulin SC Sliding Scale using HUM Insulin 4. amLODIPine 10 mg PO DAILY 5. Ascorbic Acid ___ mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 40 mg PO QPM 8. Calcitriol 0.5 mcg PO DAILY 9. Digoxin 0.125 mg PO 2X/WEEK (MO,TH) 10. Epoetin Alfa 6000 units SC TUES, THURS, SAT 11. Lactulose 15 mL PO BID:PRN 2 loose BM per day 12. Metoprolol Tartrate 100 mg PO BID 13. PARoxetine 20 mg PO DAILY 14. sevelamer CARBONATE 2400 mg PO TID W/MEALS 15. HELD- Cinacalcet 30 mg PO DAILY This medication was held. Do not restart Cinacalcet until renal gives you permission to Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: lower extremity ischemia secondary to peripheral vascular disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: DX ANKLE AND FOOT INDICATION: ___ with ankle fracture with hardware and screws placed with increasing pain and known Charcot foot.// Fracture? Osteo? Hardware placement Fracture? Osteo? Hardware placement Fracture? Osteo? Hardware placement TECHNIQUE: Frontal, oblique, and lateral view radiographs of the right ankle. AP, lateral, oblique views of the right foot. COMPARISON: ___ right ankle radiograph FINDINGS: When compared to ___ right ankle radiograph, there is no significant change in alignment. Patient is status post surgical repair of trimalleolar fracture. There is no perihardware lucency or hardware related fractures. Ghost tract projecting over the distal tibial diaphysis is consistent with prior removal of surgical hardware. Minimal lucency surrounding the syndesmotic screws is unchanged from prior. Malalignment of the tibiotalar joint with lateral talar tilt is again seen. The surrounding soft tissue swelling is improved. Bones of the foot are demineralized. There is no fracture or focal erosion. Extensive vascular calcifications are again noted. IMPRESSION: Status post surgical repair of trimalleolar fracture, there is no significant change in alignment when compared to ___ right ankle radiograph. Radiology Report EXAMINATION: ART DUP EXT LO UNI;F/U RIGHT INDICATION: ___ year old man with lower ext PVD// R lower extremity rest pain TECHNIQUE: Grayscale, color Doppler and pulse Doppler evaluation of the right lower extremity arteries was performed. COMPARISON: None FINDINGS: There is a monophasic waveform in the right common femoral artery with a velocity 115 cm/sec. There is acceleration of velocities in the right profunda femoris artery to 268 cm/sec. There is a monophasic waveform in the profunda femoris artery. There are monophasic waveforms in the right SFA. There is a monophasic waveform in the right popliteal artery. There is no flow identified in the right posterior tibial artery at the level of the mid calf. No flow could be identified in the right peroneal artery. IMPRESSION: 1. Significant calcified plaque throughout the visualized arteries. Monophasic waveforms from the SFA to the popliteal artery, in keeping with significant peripheral vascular disease. 2. No flow was identified in the peroneal and posterior tibial arteries, which are likely occluded. 3. Acceleration of velocities in the proximal profunda femoris artery, likely representing stenosis. Radiology Report EXAMINATION: ART EXT (REST ONLY) INDICATION: ___ year old man with lower ext PVD// PVD TECHNIQUE: Noninvasive evaluation of the arterial system of the lower extremities was performed with Doppler signal recordings, pulse volume recordings and segmental limb the pressure measurements. COMPARISON: ABI dated ___ FINDINGS: A monophasic waveform was identified in the femoral artery with a monophasic waveform also noted in the popliteal artery. No waveform was identified in the dorsalis pedis or posterior tibial arteries. Ankle brachial indices could not be calculated. On the left side, monophasic waveforms are noted in the femoral, popliteal, posterior tibial and dorsalis pedis arteries. The arteries were noncompressible and so an ABI could not be calculated. Pulse volume recordings are diminished in amplitude bilaterally, right worse than left. A post stress examination was not performed. IMPRESSION: Nondiagnostic ABI examination with the no waveform identified in the posterior tibial or peroneal arteries on the right, which may suggest occlusion. An ABI on the left could not be determined due to noncompressibility of the vasculature. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: R Foot pain Diagnosed with Other disorder of circulatory system temperature: 98.8 heartrate: 61.0 resprate: 18.0 o2sat: 100.0 sbp: 147.0 dbp: 74.0 level of pain: 7 level of acuity: 3.0

Mr. ___ is a ___ year old male with right rest pain who was admitted to the ___ on ___. The patient was taken to the endovascular suite and underwent right lower extremity diagnostic angiogram. For details of the procedure, please see the surgeon's operative note. The patient tolerated the procedure well without complications and was brought to the post-anesthesia care unit in stable condition. After a brief stay, the patient was transferred to the vascular surgery floor where he remained through the rest of the hospitalization. Post-operatively, he did well without any groin swelling. He was able to tolerate a regular diet, get out of bed and ambulate without assistance, void without issues, and pain was controlled on oral medications alone. He was deemed ready for discharge, and was given the appropriate discharge and follow-up instructions.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Codeine / Zosyn / Penicillins / Indomethacin / epinephrine / Versed Attending: ___ Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Abdominal catheter placement History of Present Illness: Mr. ___ is a ___ year old male with NASH cirrhosis complicated by portal hypertension and hepatic encephalopathy, CF complicated by bronchiectasis, chronic MAC pulmonary infection, HFpEF, CAD, SVT s/p ablation in ___, and L temporal lobe epilepsy, who was discharged from ___ on ___ with readmission for AMS/fall, and discharged again on ___, re-presenting on day of discharge from rehab because of worsening abdominal pain. He reports diffuse abdominal pain and nausea with frequent dry heaving and diarrhea; however, he reports that his diarrhea is at baseline. He denies fever, chest pain, cough, or dyspnea. He reports left>right lower leg edema and tenderness that is chronic and also at baseline. On arrival to the ED, initial vitals T 98.9 HR 90 BP 115/45 RR 18 O2 94% RA. Exam notable for: - Jaundiced, in no acute distress - Abdomen moderately distended, diffusely tender, +fluid wave - Extremities: L>R lower extremity edema, mild tenderness - Neuro: +Asterixis Labs notable for: - WBC 4.4, Hgb 7.5, Plt 52, INR 2.6 - ALT 15, AST 52, AP 122, Tbili 16.6, Alb 2.8, Lip 29 - Na 135, Cl 92, HCO3 35, BUN 27, Cr 0.8 - UA negative - Peritoneal fluid cell counts: 181 WBCs, 627 RBCs, 5% poly, 42% lymph, 5% meso, 45% macro, 3% other - Peritoneal fluid chemistry: Protein 1.1, glucose 139 Imaging notable for: - RUQUS: 1. Cirrhotic liver, without evidence of focal lesion or splenomegaly. 2. Moderate amount of ascites and umbilical vein recanalization. 3. Gallbladder wall edema likely secondary to third spacing. Patient received: - IV zofran 4mg x1 While in the ED, patient desaturated to 80% on RA and was placed on 3L NC. Transfer vitals: T 99.1 HR 92 BP 119/60 RR 18 O2 96% 3LNC On arrival to the floor, patient endorses the above history and adds that his pain was ___ on day of discharge and worsened while at rehab. He believes certain medications exacerbate his pain but is not sure which ones, possibly his pain and nausea medications. He denies vomiting but continues to have intermittent nausea. Past Medical History: NASH/CF cirrhosis c/b ascites, portal hypertension Cystic fibrosis (hetrozygote) c/b bronchiectasis Chronic ___ pulmonary infection Chronic diastolic heart failure Non-obstructive CAD Bilateral carotid stenosis SVT s/p ablation ___ Left temporal lobe epilepsy (___) -- followed by Dr. ___ GERD, esophageal spasm s/p fundoplication (___) BPH s/p TURP (___) Primary nocturnal enuresis (___) Eczema Strabismus Social History: ___ Family History: - Siblings heterozygous for cystic fibrosis gene (Delta 508) - Father died of esophageal cancer. h/o alcoholism - 2 sisters with lung cancer (both smokers) - Paternal aunt with cystic fibrosis, died at age ___ Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: T 98.3 BP 120/54 HR 80 RR 16 O2 97% RA GENERAL: Chronically ill-appearing, jaundiced, in NAD HEENT: NC/AT, EOMI, pupils reactive bilaterally with anisicoria R>L, scleral icterus, MMM NECK: Supple, no appreciable JVD at 90 degrees HEART: RRR, normal S1/S2, no m/r/g LUNGS: Fine bibasilar crackles, otherwise CTAB, breathing comfortably on RA ABDOMEN: Soft, diffusely tender to palpation with exaggerated voluntary guarding, no rebound, active bowel sounds, +fluid wave EXTREMITIES: 1+ pitting edema in RLE, 2+ pitting edema in LLE (chronic) SKIN: Diffuse ecchymosis on bilateral upper extremities NEURO: Alert, oriented x3, +asterixis, moving all extremities with purpose DISCHARGE PHYSICAL EXAM: ======================== Gen: Cachectic, temporal wasting, calm, NAD CV: RRR, no murmurs PULM: mild LLB crackles, otherwise CTAB ABD: distended but soft, R side with bandage covering abdominal catheter with yellow fluid on gauze EXT: no ___ edema, wwp Neuro: A&O x3 Pertinent Results: ADMISSION LABS: =============== ___ 05:18PM BLOOD WBC-4.4 RBC-1.98* Hgb-7.5* Hct-23.0* MCV-116* MCH-37.9* MCHC-32.6 RDW-24.7* RDWSD-101.6* Plt Ct-52* ___ 05:18PM BLOOD ___ PTT-41.1* ___ ___ 05:18PM BLOOD Glucose-139* UreaN-27* Creat-0.8 Na-135 K-4.3 Cl-92* HCO3-35* AnGap-8* ___ 05:18PM BLOOD ALT-15 AST-52* AlkPhos-122 TotBili-16.6* ___ 05:18PM BLOOD Albumin-2.8* ___ 09:10PM ASCITES TNC-181* RBC-627* Polys-5* Lymphs-42* ___ Mesothe-5* Macroph-45* Other-3* ___ 09:10PM ASCITES TotPro-1.1 Glucose-139 IMAGING/STUDIES: ================ LIVER US ___: 1. Cirrhotic liver, without evidence of focal lesion or splenomegaly. 2. Moderate amount of ascites and umbilical vein recanalization. 3. Gallbladder wall edema likely secondary to third spacing. CXR ___: Lungs are low volume with improving pulmonary edema. Bilateral effusions have also improved. Cardiomediastinal silhouette is stable. No pneumothorax is seen. DISCHARGE LABS: =============== ___ 06:09AM BLOOD WBC-5.7 RBC-1.98* Hgb-7.2* Hct-21.5* MCV-109* MCH-36.4* MCHC-33.5 RDW-UNABLE TO RDWSD-UNABLE TO Plt Ct-45* ___ 06:09AM BLOOD ___ ___ 06:09AM BLOOD Glucose-138* UreaN-28* Creat-1.0 Na-132* K-4.8 Cl-90* HCO3-37* AnGap-5* ___ 06:09AM BLOOD ALT-16 AST-51* AlkPhos-162* TotBili-13.2* ___ 06:09AM BLOOD Calcium-9.0 Phos-3.5 Mg-1.5* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ketorolac 0.5% Ophth Soln 1 DROP RIGHT EYE BID 2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 3. Azithromycin 250 mg PO DAILY 4. Bisacodyl 10 mg PO DAILY:PRN Constipation - Third Line 5. Ciprofloxacin HCl 500 mg PO DAILY 6. Cyanocobalamin 1000 mcg PO DAILY 7. Desmopressin Acetate 0.6 mg PO QHS 8. Finasteride 5 mg PO DAILY 9. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 10. FoLIC Acid 1 mg PO DAILY 11. Levalbuterol Neb 0.63 mg NEB TID:PRN SOB 12. Multivitamins 1 TAB PO DAILY 13. Pantoprazole 40 mg PO Q24H 14. Rifaximin 550 mg PO BID 15. Torsemide 20 mg PO DAILY 16. Vitamin D 1000 UNIT PO DAILY 17. Zinc Sulfate 220 mg PO DAILY 18. Calcium Carbonate 500 mg PO QID:PRN indigestion 19. Pulmozyme (dornase alfa) 1 neb inhalation BID:PRN SOB 20. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE BID 21. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 22. Lidocaine 5% Patch 1 PTCH TD QPM 23. Lactulose 30 mL PO TID Discharge Medications: 1. Ondansetron ODT 4 mg PO Q8H:PRN Nausea 2. TraMADol ___ mg PO Q6H:PRN Pain - Moderate RX *tramadol 50 mg ___ tablet(s) by mouth every four (4) hours Disp #*18 Tablet Refills:*0 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 4. Lidocaine 5% Patch 2 PTCH TD QPM 5. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 6. Azithromycin 250 mg PO DAILY 7. Bisacodyl 10 mg PO DAILY:PRN Constipation - Third Line 8. Calcium Carbonate 500 mg PO QID:PRN indigestion 9. Ciprofloxacin HCl 500 mg PO DAILY 10. Cyanocobalamin 1000 mcg PO DAILY 11. Desmopressin Acetate 0.6 mg PO QHS 12. Finasteride 5 mg PO DAILY 13. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 14. FoLIC Acid 1 mg PO DAILY 15. Ketorolac 0.5% Ophth Soln 1 DROP RIGHT EYE BID 16. Lactulose 30 mL PO TID 17. Levalbuterol Neb 0.63 mg NEB TID:PRN SOB 18. Multivitamins 1 TAB PO DAILY 19. Pantoprazole 40 mg PO Q24H 20. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE BID 21. Pulmozyme (dornase alfa) 1 neb inhalation BID:PRN SOB 22. Rifaximin 550 mg PO BID 23. Torsemide 20 mg PO DAILY 24. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Abdominal pain ___ Cirrhosis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ with NASH cirrhosis, worsening abd pain.// portal venous flow. other pathology TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: Abdominal ultrasound from ___ 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. The main portal vein is patent with hepatofugal flow. There is moderate ascites. There is recanalization of the umbilical vein. BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 4 mm GALLBLADDER: There is wall edema, likely due to underlying liver disease. The gallbladder is relatively decompressed. Sludge seen within the gallbladder. No visualized cholelithiasis. 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: 11.4 cm KIDNEYS: Limited views of the kidneys show no hydronephrosis. Right kidney: 10.0 cm Left kidney: 11.0 cm RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. Cirrhotic liver, without evidence of focal lesion or splenomegaly. 2. Moderate amount of ascites and umbilical vein recanalization. 3. Gallbladder wall edema likely secondary to third spacing. Radiology Report INDICATION: ___ year old man with nash cirrhosis, here with encephalopathy and abdominal pain, c/f infection// pneumonia TECHNIQUE: Chest AP view COMPARISON: ___ IMPRESSION: Lungs are low volume with improving pulmonary edema. Bilateral effusions have also improved. Cardiomediastinal silhouette is stable. No pneumothorax is seen. Radiology Report EXAMINATION: SHOULDER (AP, NEUTRAL AND AXILLARY) TRAUMA LEFT INDICATION: s/p unwitnessed fall complaining of left shouler pain fracture s/p unwitnessed fall complaining of left shoulder pain TECHNIQUE: Four views of the left shoulder were obtained COMPARISON: ___ FINDINGS: There is no fracture or dislocation involving the glenohumeral or AC joint. There is mild acromioclavicular joint narrowing as well as narrowing of the left glenohumeral joint. No suspicious lytic or sclerotic lesions are identified. No periarticular calcification or radio-opaque foreign body is seen. IMPRESSION: No acute fracture or dislocation of the left shoulder. Mild and unchanged degenerative changes as described above. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old man with ___ year old male with NASH cirrhosis complicatedby portal hypertension and hepatic encephalopathy, CF complicatedby bronchiectasis, chronic MAC pulmonary infection, HFpEF, CAD,SVT s/p ablation in ___, and L temporal lobe epilepsy, whowas discharged from ___ on ___ with readmission for AMS/fall,and discharged again on ___, re-presenting on day of ___ rehab because of worsening abdominal pain.// ?bleed after unwitnessed fall with reported head strike 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 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 747.4 mGy-cm. 2) Sequenced Acquisition 1.0 s, 4.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 186.9 mGy-cm. Total DLP (Head) = 934 mGy-cm. COMPARISON: ___ FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles and sulci are prominent in keeping with generalized parenchymal volume loss. Bilateral periventricular and subcortical white matter hypodensities are nonspecific but likely reflect chronic microvascular ischemic change. No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are unremarkable apart from bilateral lens replacements.. IMPRESSION: No acute intracranial abnormality. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE INDICATION: ___ year old man with ___ year old male with NASH cirrhosis complicated by portal hypertension and hepatic encephalopathy, CF complicated by bronchiectasis, chronic MAC pulmonary infection, HFpEF, CAD,SVT s/p ablation in ___, and L temporal lobe epilepsy, who was discharged from ___ on ___ with readmission for AMS/fall,and discharged again on ___, re-presenting on day of discharge from rehab because of worsening abdominal pain.// Unwitnessed fall w/ head strike noting some C-spine pain though has had in past Unwitnessed fall w/ head strike noting some C-spine pain though has had in past 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 5.1 s, 20.2 cm; CTDIvol = 25.1 mGy (Body) DLP = 505.9 mGy-cm. Total DLP (Body) = 506 mGy-cm. COMPARISON: ___ FINDINGS: The patient is status post C2 through C6 posterior fusion and C3-C5 laminectomies. The alignment is unchanged when compared to prior with persisting mild anterolisthesis of C4 on C5. Perihardware lucencies of the bilateral lateral mass screws of C2 and of C6 are unchanged. No acute fractures identified. The vertebral body heights are preserved. Mild disc height loss at C5-C6, C6-C7 and C7-T1. Mild central canal narrowing at C6-C7 is due to posterior osteophytes. Uncovertebral and facet osteophytes cause moderate right neural foraminal narrowing at C3-C4, moderate left neural foraminal narrowing at C4-C5 and mild left neural foraminal narrowing at C6-C7, all unchanged. There is no prevertebral soft tissue swelling. The thyroid is unremarkable. A large right pleural effusion is not significantly changed since prior IMPRESSION: 1. No acute fracture or traumatic malalignment. 2. Unchanged lucencies around the C2 and C6 screws. 3. Unchanged but incompletely evaluated large right pleural effusion. Radiology Report INDICATION: ___ year old man with NASH cirrhosis and recurrent abdominal ascites, planning for discharge to hospice// Pleurx catheter placement for drainage of ascites w/ hospice TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ performed the procedure. ANESTHESIA: Sedation was provided by administrating divided doses of 50 mcg of fentanyl while the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: CONTRAST: none FLUOROSCOPY TIME AND DOSE: 0.8, 7 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 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 ___ 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 was secured to the skin with 0 silk suture. The ___ catheter site was closed with ___ Vicryl subcuticular suture and Steri-Strips. The patient tolerated the procedure well without any immediate postprocedure complications. FINDINGS: Limited grayscale ultrasound imaging of the abdomen demonstrated moderateascites. A suitable target in the deepest pocket in the right lower quadrant was selected for PleurX catheter placement. IMPRESSION: Successful peritoneal PleurX catheter placement 2.5 L paracentesis Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abd pain, Jaundice Diagnosed with Unspecified abdominal pain temperature: 98.9 heartrate: 90.0 resprate: 18.0 o2sat: 94.0 sbp: 115.0 dbp: 45.0 level of pain: 8 level of acuity: 3.0

PATIENT SUMMARY: ================ ___ year old male with NASH cirrhosis complicated by portal hypertension and hepatic encephalopathy, CF complicated by bronchiectasis, chronic MAC pulmonary infection, HFpEF, CAD, SVT s/p ablation in ___, and L temporal lobe epilepsy, who was discharged from ___ on ___ with readmission for AMS/fall, and discharged again on ___, re-presenting on day of discharge from rehab because of worsening abdominal pain, ultimately had pleurx catheter placed and discharged to nursing facility with plans to begin hospice care.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Bactrim / vancomycin / Penicillins / morphine / ampicillin Attending: ___. Chief Complaint: Flank pain, fevers, n/v Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a ___ y/o male with a h/o spina bifida (wheelchair dependent, can pivot to wheelchair), UE DVT (dx ___, Chronic flank pain, h/o ileal conduit secondary to neurogenic bladder, h/o ESBL E coli UTI ___ here at ___ at ___, presents with one day of feeling unwell. He went to ___ on day prior to admission and felt unwell and returned home. He had one loose bm that day but had taken his bowel medications. Today, he developed temperature to 101, n/v x 1, and marked worsening of his right flank pain so he came to ___ ED. UA appears infected so he received antibiotics in the ED. His right flank pain is severe, ___ as if he has a "kidney infection" Denies sick contacts, no cough, no oral pain. Past Medical History: 1. Spina bifida 2. Nephrolithiasis 3. Chronic UTI 4 Ileal conduit for neurogenic bladder 5 hypertension 6 Ileal loop stomatitis 7 Back pain 8. VP shunt 9. Cellulitis of left lower extremity (___) 10. Bilateral Flank Pain (___) Social History: ___ Family History: Mother ___ Comment: CAD, MI and CHF Father: ___ cancer at age ___ Sister with kidney stones Physical Exam: ADMISSION AF 110/70 102 Gen: Very pleasant, NAD Lung: CTA B CV: RRR Abd: Nabs, soft, + ileal conduit Ext: + ulcer on left popliteal fossa, + ulcer on left ankle, both without signs of infection. Skin: + well healed surgical scar over sacrum. ++ skin breakdown and foul odor in between all toes. MSK: + tenderness to light palpation right flank, right paraspinal muscles to above sacrum. No rash or swelling or palpable muscle spasm. DISCHARGE VS: 98.1 123/70 90 16 95%RA Gen - sitting up in bed, comfortable appearing Eyes - EOMI ENT - OP clear, MMM Heart - RRR no mrg Lungs - CTA bilaterally Abd - soft nontender much improved from prior, urostomy c/d/i; normoactive bowel sounds Ext - 1+ nonpitting edema bilaterally (he reports chronic) Skin - L lower extremity with two ulcers, clean based, improved in appearance from prior exam Vasc - 2+ DP/radial pulses Neuro - AOx3, ___ upper extremities Psych - appropriate Pertinent Results: ADMISSION ___ 07:30AM BLOOD WBC-6.8 RBC-4.89 Hgb-14.0 Hct-41.6 MCV-85 MCH-28.6 MCHC-33.7 RDW-12.8 RDWSD-39.2 Plt ___ ___ 07:30AM BLOOD Glucose-117* UreaN-15 Creat-0.9 Na-134 K-4.2 Cl-100 HCO3-20* AnGap-18 ___ 07:30AM BLOOD ___ PTT-42.5* ___ DISCHARGE ___ 06:57AM BLOOD WBC-5.9 RBC-3.99* Hgb-11.2* Hct-34.2* MCV-86 MCH-28.1 MCHC-32.7 RDW-12.6 RDWSD-39.3 Plt ___ ___ 06:57AM BLOOD Glucose-103* UreaN-23* Creat-0.7 Na-138 K-4.3 Cl-107 HCO3-22 AnGap-13 ___ 06:20AM BLOOD ___ PTT-44.7* ___ CT Abd/Pelvis 1. No acute abnormality to account for the patient's right sided abdominal pain. 2. New mild hydronephrosis and hydroureter on the left compared to the CT from ___. Unchanged moderate right hydronephrosis and hydroureter. 3. 4 mm nonobstructing right lower pole calculus. 4. Resolution of previously noted enteritis. Testicular U/S No evidence of testicular torsion. Stable appearance of complex cystic lesions surrounding the testes bilaterally. These may represent lymphatic malformation. Renal U/S Severe hydronephrosis of the right kidney, difficult compared to prior CT due to differences in imaging modality, but likely unchanged. No evidence of perinephric fluid collection. ___ 7:48 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. WORK UP PER ___. ___ (___) ___. ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. KLEBSIELLA OXYTOCA. >100,000 ORGANISMS/ML.. ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. PRESUMPTIVE STREPTOCOCCUS BOVIS. 10,000-100,000 ORGANISMS/ML.. GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | KLEBSIELLA OXYTOCA | | ENTEROCOCCUS SP. | | | AMPICILLIN------------ =>32 R <=2 S AMPICILLIN/SULBACTAM-- =>32 R 8 S CEFAZOLIN------------- =>64 R 8 R CEFEPIME-------------- =>64 R <=1 S CEFTAZIDIME----------- =>64 R <=1 S CEFTRIAXONE----------- =>64 R <=1 S CIPROFLOXACIN--------- =>4 R 0.5 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- 64 I <=16 S <=16 S PIPERACILLIN/TAZO----- <=4 S TETRACYCLINE---------- =>16 R TOBRAMYCIN------------ 8 I <=1 S TRIMETHOPRIM/SULFA---- =>16 R <=1 S VANCOMYCIN------------ 2 S Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 25 mg PO DAILY 2. Lactulose 30 mL PO Q8H:PRN constipation 3. Polyethylene Glycol 17 g PO DAILY 4. Warfarin 5 mg PO DAILY16 DVT 5. Enoxaparin Sodium 100 mg SC BID DVT 6. Tizanidine 4 mg PO QHS pain 7. Docusate Sodium 100 mg PO DAILY 8. Gabapentin 600 mg PO QHS 9. Gabapentin 300 mg PO QAM 10. Gabapentin 300 mg PO NOON 11. Famotidine 20 mg PO DAILY 12. Acetaminophen 1000 mg PO Q8H:PRN fever, pain 13. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain Discharge Medications: 1. Docusate Sodium 100 mg PO DAILY 2. Enoxaparin Sodium 100 mg SC Q12H Start: Today - ___, First Dose: Next Routine Administration Time 3. Famotidine 20 mg PO DAILY 4. Gabapentin 600 mg PO QHS 5. Gabapentin 300 mg PO QAM 6. Gabapentin 300 mg PO NOON 7. Lactulose 30 mL PO Q8H:PRN constipation 8. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain 9. Polyethylene Glycol 17 g PO DAILY 10. Tizanidine 4 mg PO QHS pain 11. Warfarin 10 mg PO DAILY16 12. Acetaminophen 1000 mg PO Q8H:PRN fever, pain 13. Atenolol 25 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ ___: Urinary Tract Infection Chronic Upper Extremity DVT Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report INDICATION: ___ with right flank pain, right lower quadrant pain, dysuria, fevers TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis without and following intravenous contrast administration with split bolus technique. Coronal and sagittal reformations were performed and reviewed on PACS. Oral contrast was not administered. DOSE: This study involved 5 CT acquisition phases with dose indices as follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Spiral Acquisition 5.0 s, 54.0 cm; CTDIvol = 16.8 mGy (Body) DLP = 908.4 mGy-cm. 4) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 26.5 mGy (Body) DLP = 13.2 mGy-cm. 5) Spiral Acquisition 5.0 s, 54.0 cm; CTDIvol = 16.9 mGy (Body) DLP = 909.3 mGy-cm. Total DLP (Body) = 1,831 mGy-cm. COMPARISON: CTU exams from ___ and ___ FINDINGS: LOWER CHEST: Lung bases are clear. Small fat containing left Bochdalek hernia is 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: 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: Patient is status post cystectomy with quadrant ileal conduit. Atrophic right kidney with cortical thinning is again seen. 4 mm nonobstructing right lower pole kidney stone is seen (02:30). There is no perinephric abnormality. Moderate hydronephrosis and hydroureter on the right appears unchanged since ___. Mild hydronephrosis and hydroureter on the left is new compared to the recent CT examination. There is symmetric enhancement and normal excretion of contrast. GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness and enhancement throughout. Previously noted enteritis appears resolved. Parastomal hernia containing small bowel is unchanged, without evidence of obstruction. Colon and rectum are within normal limits. Appendix is not visualized. There is no evidence of mesenteric lymphadenopathy. No free air free fluid is demonstrated. RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. There is no calcium burden in the abdominal aorta and great abdominal arteries. There is a replaced common hepatic artery arising from the SMA. PELVIS: There is no evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: Prostate contains coarse calcifications, likely the sequela of prior inflammation. The seminal vesicles are unremarkable. BONES AND SOFT TISSUES: There is no evidence of worrisome osseous lesions. There is no fracture. VP shunt is partially imaged with distal ossified terminating adjacent to the liver dome. Dysmorphic pelvis and spinal bifida with myelomeningocele are again seen. There is some skin thickening and stranding in the left gluteal region. IMPRESSION: 1. No acute abnormality to account for the patient's right sided abdominal pain. 2. New mild hydronephrosis and hydroureter on the left compared to the CT from ___. Unchanged moderate right hydronephrosis and hydroureter. 3. 4 mm nonobstructing right lower pole calculus. 4. Resolution of previously noted enteritis. Radiology Report EXAMINATION: SCROTAL U.S. INDICATION: ___ year old man with R testicular pain // anatomic abnormality, doppler for signs of torsion TECHNIQUE: Greyscale with color and spectral Doppler ultrasound of the scrotum was performed with a linear transducer. COMPARISON: Scrotal ultrasound ___ FINDINGS: The right testicle measures: 2.5 x 1.3 x 2.9 cm. The left testicle measures: 2.2 x 1.3 x 2.3 cm. There are numerous complex cystic lesions surrounding bilateral testes, similar as before. The testicular echogenicity is normal, without focal abnormalities. The right epididymis is normal. Left epididymis was not well visualized. Vascularity is normal and symmetric in the testes. IMPRESSION: No evidence of testicular torsion. Stable appearance of complex cystic lesions surrounding the testes bilaterally. These may represent lymphatic malformation. Radiology Report EXAMINATION: RENAL U.S. INDICATION: Evaluate for new hydronephrosis or renal abscess, evidence of pyelonephritis, in a patient with urostomy presenting with right flank pain, UTI, persistent pain. TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: None. FINDINGS: The right kidney measures 9.5 cm. The left kidney measures 11.9 cm. No perinephric fluid collection is identified. There is severe hydronephrosis in the right kidney, difficult compared to CT due to differences in imaging modality but likely unchanged. In the interpolar region of the right kidney is an area of twinkle artifact, consistent with a known stone. The left kidney demonstrates mild pelvic fullness, without frank hydronephrosis. IMPRESSION: Severe hydronephrosis of the right kidney, difficult compared to prior CT due to differences in imaging modality, but likely unchanged. No evidence of perinephric fluid collection. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: R Flank pain Diagnosed with URIN TRACT INFECTION NOS, PYELONEPHRITIS NOS temperature: 97.9 heartrate: 100.0 resprate: 18.0 o2sat: 100.0 sbp: 125.0 dbp: 70.0 level of pain: 10 level of acuity: 3.0

This is a ___ year old male with past medical history of spina bifida, neurogenic bladder s/p ileal conduit c/b prior ESBL Ecoli UTI, admitted ___ with fevers and acute on chronic R flank pain, concern for UTI, started on IV antibiotics with clinical improvement, completing a course of antibiotics in the hospital and able to be discharged home. # Urinary Tract Infection / Acute on Chronic R flank pain - patient with a curious history of chronic R flank pain with intermittent exacerbations of this pain without clear etiology; please see prior discharge summary regarding records obtained from ___ regarding his recurrent presentations; on this particular admission, patient reported fevers at home and acute onset R flank pain; patient afebrile and without leukocytosis, but given report of fevers and nausea at home, there was concern for pyelonephritis and UTI, so he was started on broad spectrum coverage with meropenem and linezolid given prior resistance profiles. Urine cultures subsequently grew out Ecoli, Klebsiella, Enterococcus. Patient rapidly improved after initiation of antibiotics. Given uncertainty of infection (versus another exacerbation of his chronic R flank pain for which an etiology has not been identified) and rapid clinical improvement, decision was made to have patient complete a limited 5-day course of antibiotics. He resolved to baseline and was able to be discharged home without opiate pain medications. # Chronic Upper Extremity DVT - Admission INR was 1.4 despite his being on Coumadin 5mg (INR goal ___ for upper extremity DVT. Continued him on lovenox bridge he had been on at home, and increased coumadin dosing to 10mg. INR 1.9 by time of discharge. Patient discharged on lovenox bridge and Coumadin with plan for INR check 2 days following discharge (___). # Chronic Lower Extremity Ulcers / Acute lower extremity cellulitis - patient with 2 chronic ulcers of his L lower extremity; seen by wound care consult and thought to have mild cellulitis; he was treated with above antibiotics with rapid improvement; completed ___s above. Discharged with home services for help with wound care. # Hypertension - continued home atenolol # Chronic Pain - continued home tizanidine, gabapentin and oxycodone # Tinea Pedis - continued home clotrimazole # GERD - continued famotidine Transitional Issues - Discharged home with reactivation of prior services - To follow-up for INR check on ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: gluten Attending: ___ Chief Complaint: Lower extremity edema and abdominal distension Major Surgical or Invasive Procedure: 1.6 L paracentesis History of Present Illness: ___ female w/ EtOH Cirrhosis c/b varices, HTN who presents with ___ week of worsening bilateral leg swelling and abdominal swelling. She states the symptoms started 3 weeks ago with her L leg becoming more swollen. This has increased over the last 3 weeks and is now bilateral. She endorses her L leg has a redness for 5 days. She also endorses increasing abdominal distention and ~12lb weight gain. (dry weight 124lbs) She has not really been adherent to a low salt diet or medications in past per OMR notes, but states she has been taking her two diuretics for the last 3 weeks as prescribed. In the ED: Initial Vitals were:99.6 100 123/55 18 100% RA. Labs were significant for: Na 136, Cr 0.6, WBC 5.8, Hgb 9.4, Plt 179. She had ___ US to r/o DVT and RUQ US. Patient was given no medicines. On the floor she was doing well on RA with no complaints. ROS: per HPI, (+) Diarrhea, denies fever, chills, night sweats, headache, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, constipation, BRBPR, melena, Past Medical History: EtoH cirrhosis - admitted to ___ in ___ with liver decompensation Portal gastropathy ___ EGD Grade II varices ___ Anxiety Hyperlipidemia. Hypertension. Obesity. Alcohol dependence sober since ___ Social History: ___ Family History: Positive for CAD and diabetes. No colon cancer. No liver cancer. Physical Exam: ADMISSION PHYSICAL EXAMINATION: GENERAL: Pleasant, ___, in no apparent distress. HEENT - normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear, temporal wasting NECK: Supple, JVP flat. CARDIAC: RRR, ___ systolic ejection murmur PULMONARY: CTA b/l no w/r/r ABDOMEN: (+) BS, abdominal distention, (+) fluid wave EXTREMITIES: Warm, ___, 3+ edema b/l up to thigh, erythema of lower legs, L>R NEUROLOGIC: A&Ox3, CN ___ grossly normal, normal sensation DISCHARGE PHYSICAL EXAMINATION: VS: 98.4 ___ 18 100%RA GENERAL: Pleasant, thin, ___, in no apparent distress. HEENT: normocephalic, atraumatic, no conjunctival pallor or scleral icterus NECK: Supple CARDIAC: RRR + murmur PULMONARY: CTAB ABDOMEN: + abdominal distention, nontender EXTREMITIES: Warm, ___, 1+ edema. 12cm rash on LLE that is improved. NEUROLOGIC: A&Ox3, grossly normal, no asterixis Pertinent Results: ADMISSION LABS: ___ 04:42PM BLOOD ___ ___ Plt ___ ___ 04:42PM BLOOD ___ ___ Im ___ ___ ___ 06:06PM BLOOD ___ ___ ___ 04:42PM BLOOD ___ ___ ___ 04:42PM BLOOD ___ ___ 05:15AM BLOOD ___ DISCHARGE LABS: ___ 05:10AM BLOOD ___ ___ Plt ___ ___ 05:10AM BLOOD ___ ___ ___ 05:05PM BLOOD ___ ___ ___ 05:05PM BLOOD ___ ___ 05:05PM BLOOD ___ PARACENTESIS: ___ 03:01PM ASCITES ___ ___ ___ 03:01PM ASCITES ___ LD(___)-49 ___ STUDIES: ___ CXR: IMPRESSION: No previous images. The cardiac silhouette is within normal limits and there is no evidence of vascular congestion, pleural effusion, or acute focal pneumonia. ___ RUQ US: IMPRESSION: 1. No portal vein or IVC thrombus. 2. Cirrhotic liver, mild splenomegaly, and moderate ascites are again seen. ___ ___ IMPRESSION: No evidence of deep venous thrombosis in the right or left lower extremity veins. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Escitalopram Oxalate 10 mg PO DAILY 2. Furosemide 20 mg PO DAILY 3. Nadolol 40 mg PO DAILY 4. Spironolactone 25 mg PO DAILY 5. Omeprazole 20 mg PO DAILY Discharge Medications: 1. Escitalopram Oxalate 10 mg PO DAILY 2. Furosemide 40 mg PO DAILY RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Spironolactone 25 mg PO DAILY RX *spironolactone 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Omeprazole 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Alcohol cirrhosis Volume overload ascites Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: History: ___ with b/l ___ edema and abd distension // portal vein thrombus or IVC thrombus TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen was performed. COMPARISON: Ultrasound from ___. FINDINGS: Liver: The hepatic parenchyma is coarsened and nodular. No focal liver lesions are identified. There is a moderate amount of ascites. Bile ducts: There is no intrahepatic biliary ductal dilation. The common hepatic duct measures 4 mm. Gallbladder: The gallbladder appears within normal limits, without stones, abnormal wall thickening, or edema. Adenomyomatosis is similar to prior. Pancreas: The imaged portion of the pancreas appears within normal limits, with portions of the pancreatic tail obscured by overlying bowel gas. Spleen: The spleen demonstrates normal echotexture, and measures 14.9 cm. Kidneys: The right kidney measures 10.4 cm. The left kidney measures 9.8 cm. Doppler evaluation: The main portal vein is patent, with flow in the appropriate direction. Main portal vein velocity is approximately 35 cm/sec. Right and left portal veins are patent, with antegrade flow. Right, middle and left hepatic veins are patent, with appropriate waveforms. Splenic vein and superior mesenteric vein are patent, with antegrade flow. The IVC is patent. IMPRESSION: 1. No portal vein or IVC thrombus. 2. Cirrhotic liver, mild splenomegaly, and moderate ascites are again seen. Radiology Report INDICATION: ___ year old woman with b/l ___ edema L>R // DVT? TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: None available. FINDINGS: There is normal compressibility, flow, and augmentation of the bilateral common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. There is extensive subcutaneous edema. IMPRESSION: No evidence of deep venous thrombosis in the right or left lower extremity veins. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with cirrhosis, volume overload // assess for pulm edema, acute process assess for pulm edema, acute process IMPRESSION: No previous images. The cardiac silhouette is within normal limits and there is no evidence of vascular congestion, pleural effusion, or acute focal pneumonia. Radiology Report INDICATION: ___ year old woman with EtoH cirrhosis now presenting with new ascites // Eval for causes of new ascites TECHNIQUE: Ultrasound guided diagnostic and therapeutic paracentesis COMPARISON: Abdominal ultrasound dated ___ FINDINGS: Limited grayscale ultrasound imaging of the abdomen demonstrated moderate ascites. A suitable target in the deepest pocket in the suprapubic region was selected for paracentesis. PROCEDURE: The procedure, risks, benefits and alternatives were discussed with the patient and written informed consent was obtained. A preprocedure time-out was performed discussing the planned procedure, confirming the patient's identity with 3 identifiers, and reviewing a checklist per ___ protocol. Under ultrasound guidance, an entrance site was selected and the skin was prepped and draped in the usual sterile fashion. 1% lidocaine was instilled for local anesthesia. A 5 ___ catheter was advanced into the largest fluid pocket in the suprapubic region and 1.6 L of clear, straw-colored fluid was removed. Fluid samples were submitted to the laboratory for cell count, differential, culture, and cytology. 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: Technically successful ultrasound-guided diagnostic and therapeutic paracentesis yielding 1.6 L of clear yellow fluid from the suprapubic region. Gender: F Race: WHITE Arrive by UNKNOWN Chief complaint: Leg swelling Diagnosed with Localized edema temperature: 99.6 heartrate: 100.0 resprate: 18.0 o2sat: 100.0 sbp: 123.0 dbp: 55.0 level of pain: 0 level of acuity: 3.0

Ms. ___ is a ___ w/ EtOH cirrhosis Childs class B, c/b by varices s/p banding ___, presenting with edema and weight gain found to have new ascites. # ASCITES: Patient w/ new ascites, never had paracentesis before, no abdominal pain or leukocytosis to suggest SBP. RUQ ultrasound negative for portal vein thrombus. Possibly in setting of medication noncompliance and dietary indiscretion. Patient reports drinking a lot of water. She underwent fluid restriction/ low salt diet education. S/p 1.6L para ___. SAAG and total protein c/w liver etiology. She underwent therapeutic/diag tap for 1.6 L that was negative for SBP and malignant cells. Her Lasix was increased to 40 PO daily. #Hypotension: Asymptomatic, down to systolic 88. Likely in setting of starting nadolol 40 but persisted despite decreased nadolol to 20. Nadolol was discontinued. # GIB/VARICES: Grade II varices per ___ EGD. Patient states she has not taken nadolol given outpatient hypotension. Trial of Nadolol for bleeding prophylaxis resulted in hypotension to 88 systolic and was discontinued. # EtOH CIRRHOSIS: Childs ___ B, sober since ___. MELDNa was 13 on ___. S/p 1.6L para ___. She was given 25g Albumin x 1. # LLE erythema: Patient with erythema of lower extremity, over 3 weeks in setting of edema. Nonblanching, non warm, so likely due to edema and not cellulitis as bilateral color changes. Improved without intervention. # COAGULOPATHY: INR 1.4, PTT 40 on admission.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Pradaxa / OxyContin Attending: ___ Chief Complaint: Initially admitted to Orthopedics for Septic Arthritis transferred to medicine for management on confusion, dysarthria, acute on chronic renal failure and supra-therapeutic INR Major Surgical or Invasive Procedure: ___ Irrigation and debridement, liner exchange of left knee ___ endoscopic retrograde cholangiopancreatography History of Present Illness: Mr. ___ is an ___ year old male with a history of valvular atrial fibrillation (on coumadin), EtOH Cirrhosis complicated by portal hypertension, TIAs and s/p TKA in LLE who was initially admitted to the orthopedics service for management of septic arthritis. Patient had a podiatric procedure 3 days prior to admission for an ingrown toenail and was given Amoxicillin prophylaxis. He presented to the ED on ___ with a hot, erythematous, painful right knee, joint aspiration in the ED revealed septic arthritis, initially started on Vancomycin but discontinued in hopes for better culture data in the OR. On ___, he underwent left knee incision and drainage and liner exchange. Culture grew STAPHYLOCOCCUS LUGDUNENSIS, ID consulted and patient was started on Nafcillin with plan to add Rifampin for additional coverage. Overnight ___ the patient's daughter noted patient to be more confused and with garbled speech during a phone conversation. Medicine was consulted this morning for evaluation. His neurological exam was in tact per medicine consult service note and they had low suspicion for stoke given therapeutic INR on Coumadin and without focal neurologic deficits. Vital Signs on evaluation at 11am: T 97.6, 119/73, hr 88, rr 16, saturation 100% RA On transfer to medicine service patient found to be confused at times, answering questions inappropriately and with slurred speech. Patient lethargic but alert, oriented to person, place and time though questions had to be asked a few times since he answered inappropriately. He is unable to give a good history and cannot recall many of his medical problems. He denies headache, confusion, weakness, loss of sensation, changes in vision, lightheadedness or dizziness. 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: - TIA ___ - Atrial Fibrillation (valvular) on Coumadin - C.Cath for STEMI found to have non-occlusive CAD - Alcoholic cirrhosis s/p portal shunt in ___ (TIPS?) - CKD - baseline Cr of 1.5-2.3 - Gout/high uric acid - prior etoh abuse, sober for ___ years - ___ ___ Social History: ___ Family History: - Non-contributory to acute presentation - Brother had TIAs is ___, mother and father both lived to old age. Physical Exam: Medicine Transfer Exam: VS - 98.5 98.2 98/62 88 16 98%RA General: Pleasant but confused occasaionally, elderly male seated in bed in NAD. He answers questions inappropriately at times and exhibits slurred speech. HEENT: NCAT, EOMI, sclerae anicteric, neck supple, moist mucous membranes, OP WNL CV: RRR, S1S2 clear and of good quality, ___ holosystolic murmur heard best at the LUSB PULM: Lungs clear to auscultation bilaterally, moving air well and symmetrically ABDOMEN: NABS, soft, non-tender, non-distended, no hepatosplenomegaly MSK: Left knee dressings in place, did not take down dressing. EXTREMETIES: warm and well perfused, 1+ LLEE, palpable distal pulses. Flexion and extension of L foot intact, diminished motor function of right foot. Toes edematous. +Asterixis LYMPH: no cervical lymphadenopathy SKIN: no rashes, no jaundice NEURO: Lethargic but alert, confused at times answering questions inappropriately. Oriented to person, place and time with repeated questioning, CN ___ grossly intact. Motor strength intact in UE bilaterally. Motor and sensory function intact in major joints of LLE. ___ strength with flexion of L foot and ___ with extension of L foot, sensation intact. Limited LLE exam given recent surgery to left knee. Asterixis On discharge, he was afebrile with BP 140/80, HR ___, O2 sats 99% RA. He was alert and oriented x3, no asterixis. Lungs clear to auscultation. Pertinent Results: Admission to medicine labs: ___ 05:40AM BLOOD WBC-6.2 RBC-2.77* Hgb-9.1* Hct-28.8* MCV-104*# MCH-32.9* MCHC-31.6 RDW-16.4* Plt ___ ___ 05:40AM BLOOD Glucose-125* UreaN-47* Creat-2.2* Na-133 K-4.7 Cl-106 HCO3-20* AnGap-12 ___ 05:40AM BLOOD ___ PTT-49.1* ___ ___ 01:21PM BLOOD ALT-21 AST-32 LD(LDH)-283* AlkPhos-130 TotBili-2.6* INR trend: ___ 09:35AM BLOOD ___ ___ 05:40AM BLOOD ___ PTT-49.1* ___ ___ 01:21PM BLOOD ___ PTT-51.4* ___ ___ 05:42AM BLOOD ___ ARF trend: ___ 05:40AM BLOOD Glucose-125* UreaN-47* Creat-2.2* Na-133 K-4.7 Cl-106 HCO3-20* AnGap-12 ___ 05:42AM BLOOD Glucose-113* UreaN-53* Creat-2.7* Na-134 K-4.6 Cl-104 HCO3-21* AnGap-14 ___ 04:57AM BLOOD Glucose-116* UreaN-52* Creat-2.5* Na-137 K-3.9 Cl-108 HCO3-18* AnGap-15 ___ 04:52AM BLOOD Glucose-120* UreaN-64* Creat-2.2* Na-140 K-4.0 Cl-110* HCO3-19* AnGap-15 ___ 06:40AM BLOOD Glucose-119* UreaN-58* Creat-1.9* Na-141 K-3.6 Cl-111* HCO3-20* AnGap-14 ___ 05:16AM BLOOD Glucose-109* UreaN-33* Creat-1.5* Na-138 K-4.1 Cl-110* HCO3-21* AnGap-11 LFTs: ___ 06:00PM BLOOD ALT-32 AST-41* AlkPhos-109 TotBili-1.5 ___ 01:21PM BLOOD ALT-21 AST-32 LD(LDH)-283* AlkPhos-130 TotBili-2.6* ___ 05:42AM BLOOD ALT-19 AST-31 LD(LDH)-244 AlkPhos-125 TotBili-3.6* DirBili-3.0* IndBili-0.6 ___ 06:40AM BLOOD ALT-24 AST-52* AlkPhos-122 TotBili-6.2* DirBili-1.7* IndBili-4.5 ___ 05:40AM BLOOD ALT-24 AST-55* LD(___)-571* AlkPhos-104 TotBili-7.6* DirBili-2.5* IndBili-5.1 ___ 05:40AM BLOOD ALT-21 AST-50* LD(LDH)-577* AlkPhos-94 TotBili-5.3* DirBili-2.0* IndBili-3.3 ___ 05:03AM BLOOD ALT-21 AST-38 LD(LDH)-476* AlkPhos-93 TotBili-3.6* ___ 09:01AM BLOOD ALT-22 AST-36 LD(___)-469* AlkPhos-119 TotBili-3.2* Discharge Labs: Microbiology: TISSUE (Final ___: STAPHYLOCOCCUS ___. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS ___ | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S OXACILLIN------------- 0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 1 S Reports: - CT Head ___ without acute evicence of bleed. - RUQ US with dopplers ___ 1. Cirrhotic liver with apparent portal vein thrombosis and markedly increased arterial blood supply. No focal liver masses are seen. 2. Several liver cysts, possibly peribiliary cysts as well as some mild intrahepatic bile duct dilatation is noted. 3. Doppler shows portal vein thrombosis and patent hepatic veins and IVC. 4. Soft tissue mass in the region of the pancreatic tail, slightly increased compared to CT of ___. EGD report ___: The biliary tree, cystic duct, and gallbladder were opacified. The CBD measured 8 mm. The cystic duct and CBD overlapped making delineation difficult. There appeared to be several filling defects in the cystic duct and a large 18 mm stone in the gallbladder. There were no definitive filling defects in the CBD. The intra-hepatic bile ducts demonstrated diffuse pruning likely secondary to patients known cirrhosis. A limited sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. Balloon sweep x3 was performed with extraction of a small amount of debris. Medications on Admission: - Furosemide 40 mg PO DAILY - simvastatin 20 mg Daily - Metoprolol tartrate 25 mg PO BID - Allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY - aspirin 81 mg Tablet, PO DAILY (Daily). - warfarin 2 mg Tablet Daily: Goal INR of ___ Discharge Medications: 1. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 6. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 7. tramadol 50 mg Tablet Sig: ___ Tablet PO Q6H (every 6 hours) as needed for pain. 8. lactulose 10 gram/15 mL (15 mL) Solution Sig: Fifteen (15) mL PO three times a day: Titrate to ___ bowel movements daily, hold if pt having >4 bowel movements daily. 9. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 ___. 10. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: Not to exceed 2g daily. 11. vancomycin 500 mg Recon Soln Sig: 1250 (1250) mg Intravenous Q48H (every 48 hours): Received on ___, next dose starts ___. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: primary: Left knee infection, hepatic encephalopathy, acute renal failure. secondary: atrial fibrilation, liver cirrhosis, congestive heart failure, hypertension 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 RIGHT KNEE FILMS, ___ HISTORY: ___ male with pain, question joint infection. FINDINGS: AP, lateral, and oblique views of the left knee. No prior plain film available for comparison. Postoperative changes of left total knee arthroplasty are seen, which is in anatomic alignment. Joint space is maintained. Subtle lucency seen at the anterior apect of the intramedullary aspect of the tibial component is seen, nonspecific but correlation with priors may be useful. There is no evidence of fracture or definite hardware complication. Possible small suprapatellar joint effusion is seen. Radiology Report AP CHEST, 9:00 A.M., ___ HISTORY: New left PICC line. IMPRESSION: AP chest compared to ___: The tip of the wire in the new left PIC line is by report 5 mm back from the tip of the catheter, which ends in the right atrium. As discussed with the IV nurse, ___, if the system is withdrawn 4 cm it will end in the low SVC. Small left pleural effusion is new since ___. Heart size is normal. There is no pneumothorax. Band of atelectasis crossing the right hilus in to the lower lobe is new as well. Lungs are otherwise grossly clear of any acute abnormality, but the pattern of vasculature, particularly in the right upper lobe suggests emphysema. Radiology Report INDICATION: ___ male with history of TIAs and atrial fibrillation, presents with dysarthria and supratherapeutic INR. Question acute stroke. ___. TECHNIQUE: Contiguous non-contrast axial images were acquired through the brain. FINDINGS: There is no intracranial hemorrhage, mass effect, edema, or shift of normally midline structures. The gray-white matter differentiation is preserved. There are foci of discrete and confluent periventricular white matter hypoattenuation, compatible with small vessel ischemic disease. Ventricles and sulci are prominent, consistent with age-related involution. Suprasellar and basilar cisterns are patent. Paranasal sinuses and mastoid air cells are well aerated. Concave right maxillary walls appear longstanding. Vascular calcifications are seen in the cavernous carotid arteries. Globes and orbits are intact. IMPRESSION: 1. No acute intracranial process such as hemorrhage or major vascular territorial infarct. MRI is, however, more sensitive for early ischemic disease if not contraindicated. 2. Age-related involution and small vessel ischemic disease. Radiology Report LIVER ULTRASOUND AND LIVER DOPPLER CLINICAL INDICATION: ___ male with cirrhosis. The history states prior TIPS in ___ but TIPS were not performed until the ___. Previous scan suggests the patient may have had a portocaval surgical shunt. COMPARISON SCAN: ___. The liver is coarse and heterogeneous in echotexture and relatively small in size. No discrete liver lesions are identified. There are several peribiliary cysts, and there are some areas which appear to suggest mild intrahepatic bile duct dilatation. The gallbladder is normal in size with several stones and some sludge noted. The spleen is normal in size at 11 cm, and a 3.2 cm soft tissue mass is seen in the region of the pancreatic tail. This has been previously noted on CT scan of ___ and is minimally increased in size. Both kidneys are small and somewhat atrophic appearing. The right kidney measures 8.8 cm in length and the left kidney 8.4 cm. There is no hydronephrosis, although there may be some calculi present in the right kidney, nonobstructive. Color flow and pulse Doppler waveform analysis was performed. The portal vein appears to be occluded with markedly increased and tortuous hepatic arterial flow noted both in the porta hepatis and well within the liver itself. The hepatic veins are patent as is the inferior vena cava. There does appear to be some flow in the splenic vein, but the portacaval anastomosis could not be identified. CONCLUSION: 1. Cirrhotic liver with apparent portal vein thrombosis and markedly increased arterial blood supply. No focal liver masses are seen. 2. Several liver cysts, possibly peribiliary cysts as well as some mild intrahepatic bile duct dilatation is noted. 3. Doppler shows portal vein thrombosis and patent hepatic veins and IVC. 4. Soft tissue mass in the region of the pancreatic tail, slightly increased compared to CT of ___. Radiology Report HISTORY: Left knee septic arthritis, washout ___, now worsening swelling and hematocrit drop, question septic arthritis. LEFT KNEE, THREE VIEWS. A three-component knee prosthesis is in place. There appears to be a large joint effusion as well as some surrounding soft tissue swelling. No fracture or focal osteolysis is identified. Diffuse osteopenia present. Faint vascular calcification noted. Compared with ___, the degree of distension of the suprapatellar recess appears greater. Radiology Report INDICATION: Leukocytosis, shortness of breath. TECHNIQUE: AP and lateral chest radiograph. COMPARISONS: ___. FINDINGS: The left PICC is barely visible but appears to be terminate in the low SVC. There is mild cardiomegaly. Hyperexpansion and diaphragmatic flattening suggests emphysema. Surgical clips are overlying the upper abdomen. There is no focal consolidation or pneumothorax. There are small bilateral pleural effusions. There is no pulmonary vascular congestion. IMPRESSION: No evidence of pneumonia. Small bilateral pleural effusions. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: R/O SEPTIC JOINT Diagnosed with PYOGEN ARTHRITIS-LOWER LEG, CELLULITIS OF LEG, ALCOHOL CIRRHOSIS LIVER, LONG TERM USE ANTIGOAGULANT temperature: 99.2 heartrate: 88.0 resprate: 18.0 o2sat: 100.0 sbp: 130.0 dbp: 69.0 level of pain: 0 level of acuity: 3.0

Primary Reason for Hospitalization: ___ year old male with a history of valvular atrial fibrillation on coumadin, EtOH Cirrhosis complicated by portal hypertension, TIAs and s/p TKA of LLE, initially admitted to the orthopedics service for management of septic arthritis then transferred to medicine service for management of confusion, dysarthria, ARF and supratherapeutic INR. # Hepatic Encephalopathy: On transfer pt had worsening confusion with hallucinations. History of TIAs and A.fib was concerning for additional TIA but he was therapeutic on coumadin and head CT showed no acute change. Given his concurrent rise in bilirubin and new asterixis on exam, his AMS was felt most c/w hepatic encephalopathy, likely exacerbated by narcotic pain medications and infection. RUQ U/S showed no portal vein thrombus or ascites. Narcotic medications were discontinued and he was started on aggressive lactulose. His encephalopathy gradually resolved and on discharge he was AAOX3 and had no asterixis. # Cirrhosis: C/b by encephalopathy during hospitalization. Pt has h/o EtOH cirrhosis s/p portocaval shunting in 1970s. No known h/o SBP or prior h/o hepatic encephalopathy, was not on lactulose as an outpatient. Acute decompensation felt most likely ___ infection, recent surgery and narcotic pain medication with TIPS predisposes patient to developing HE. RUQ US completed as above. Hepatology was consulted for further management, and there was initial concern that biliary obstruction could be contributing to his acute decompensation since ERCP from ___ showed CBD stone that was never removed. However he had no abdominal pain to suggest acute cholangitis. His liver function and encephalopathy gradually improved withlactulose, treatment of infection, and discontinuation of narcotic medications. # Acute on chronic renal failure: Pt developed acute on chronic renal failure with creat gradually increasing to 2.8 from baseline 1.8-2.0. Initially concerning for HRS in setting of worsening LFTs, however FeUrea suggested intrinsic renal failure. He also developed a peripheral eosinophilia, which was felt most c/w acute interstitial nephritis. IV nafcillin was switched to IV vancomycin, and his creat gradually improved without steroids. On discharge his creat had improved to 1.5. # L Knee Septic Arthritis: Stable s/p washout on ___, wound cultures grew STAPHYLOCOCCUS LUGDUNENSIS, thought likely bacteremic seeding s/p podiatric procedure. Was initially on IV nafcillin, switched to IV vancomycin due to concern for AIN as above. He should complete a 6 week course of antibiotics (will be completed on ___. He is scheduled to f/u in the Infectious Disease ___ clinic. Weekly labs including CBC w/diff, BUN/Creat, ESR, CRP, and Vanco Trough should be drawn with results faxed to Infectious disease R.Ns. at ___. All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at ___ or to on call MD in when clinic is closed. He should also follow up in ___ clinic for surgical wound check one week after d/c. # L Knee Hemarthrosis: Pt's Hct gradually downtrended and he required RBC transfusion (5 units total). He was noted to have worsening L knee effusion and ecchymoses, felt most likely to be source of bleed. He was guaiac negative. His knee was wrapped with ACE bandage and ice was applied TID. His Hct stabilized and L knee effusion improved. # Atrial Fibrillation: Chronic, stable on Coumadin, rate controlled with home Metoprolol. CHADS2 score of 5 extremely high risk for stroke, particularly given recent TIA in ___. He was switched from coumadin to IV heparin sliding scale due to need for procedures including knee washout and ERCP. He was restarted on coumadin on ___, INR on discharge was 1.9 so heparin drip discontinued. He will need continued monitoring of his INR with goal ___. If he is subtherapeutic, he should be bridged with IV heparin. # Urinary retention: The patient developed urinary retention with 1000cc of retained urine and had a foley placed. The patient underwent voiding trial, but failed with 600cc of urine in the bladder so the foley was replaced on ___. Subsequent voiding trial should be attempted ___. If repeat voiding trial fails the patient may need to be referred to urology. # CAD: Recent cath with non-occlusive CAD to 40-50% stenosis. Continued Aspirin 81 mg PO/NG DAILY, Metoprolol Tartrate 25 mg PO/NG BID, Simvastatin 20 mg PO/NG QHS. # HTN: Chronic, stable on home Metoprolol Tartrate 25 mg PO/NG BID. Would benefit from ACE inhibitor therapy given his chronic systolic CHF, but this was deferred during hospitalization due to acute renal failure. # CHF: Chronic, Systolic CHF with LVEF 35-40%, ischemic related, well compensated currently ___ Class I based on history prior to surgery. Continued Metoprolol as above. Patient would benefit from an ACE-I and should be started after resolution of ARF.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Indocin / Codeine Attending: ___ Chief Complaint: fever Major Surgical or Invasive Procedure: n/a History of Present Illness: Ms. ___ is an ___ woman with history of diverticulitis c/b perirectal abscesss with recent admission to colorectal surgery (___) s/p CT guided drainage ___, pigtail cath later removed) and lap assisted sigmoid colectomy on ___, CML on gleevec, paroxysmal afib (not on ac due to bleeding hx, HTN, CKD (b/l cr 1.3-1.6), HFpEF, who presented with fever 100.3, lethargy x 2 days. Also found to have ___. In the ED, she was given 500 cc's of normal saline. CT abdomen ___ showed perirectal fluid collection decreased in size. She was seen by colorectal surgery in the ED and no acute surgical intervention per colorectal surgery. Pt stated that she has felt lethargic for 2 days now. her caretaker ___ who takes care of her at home sent her to the hospital for a number of reasons including a temperature that was recorded at 100.3, watery stoma output. Also the patient has generally felt "out of sorts" ever since her recent discharge as well but she cannot specify further. She also vomited a scant amount this morning (no blood) and developed a fever, which prompted her to come to the hospital. She denies ab pain. Her ostomy output has been watery, then more "pasty" and is now watery again. Her urine output she says is lower than usual. She also endorses small amounts of mucous from her rectum (no bleeding). Noted trouble "pushing the urine out" but notes that this is a chronic issue for her and usually worse when she is in bed for long periods of time. Typically ambulates with a walker which has not changed recently. She also endorsed not eating or drinking very much at all lately due to poor appetite. Remainder of comprehensive 10 point ROS is otherwise negative. Past Medical History: - CLL/ CML: developed in ___, s/p rituxan (kidney failure with this) and campath (nausea and dysentery symptoms with this), s/p 12 doses of alemtuzumab. ___ started on ibrutinib. Hematology ___: on Gleevec 200mg am, 100mg pm. bone marrow aspirate and bx shows minimal residual CLL. CML under good control -HFpEF: ___ had complains of lower extremity weakness limiting mobility; EKG NSR, LAE, nonspecific T wave changes. - paroxysmal AFib: in NSR on amiodarone, opted against anticoag given bleeding history, yearly CXR no evidence of interstitsial changes to suggest amiodarone toxicity, LFTs elevated - Anemia: ___ CML and CLL - Hypertension - HLD - Insomnia - Osteoarthritis - Colitis - CKD - SIBO - fructose and lactose intolerance - pelvic floor dysfuntion - left shoulder arthritis - hearing loss - s/p NSTEMI i/s/o GI bleeding PAST SURGICAL HISTORY: - Tonsillectomy ___ - Thoracentesis ___ - Cataract surgeries - lap assisted sigmoid colectomy and end colostomy by colorectal surgery on ___ Social History: ___ Family History: Mother, heart attack. Father, hypertension. Paternal grandfather may have had "stomach cancer," grandmother with ___ disease. Physical Exam: ADMISSION EXAM: Vitals: 98.2 PO 123 / 67 79 16 98 RA Consitutional: NAD, lying in bed comfortably Eyes: EOMI, sclerae anicteric ENT: MMM, OP clear Cardiovasc: RRR, no MRG, no edema Resp: normal effort, no accessory muscle use, lungs CTA ___. GI: ostomy draining light brown stool that is slightly thick in consistency, no blood. Pain with deep palpation in the epigastrum but otherwise nontender to palpation in all 4 quads. MSK: No significant kyphosis. No palpable synovitis. Skin: No visible rash. No jaundice. Neuro: AAOx3. CNs II-XII intact. MAEE. Psych: Full range of affect =================== DISCHARGE EXAM: Vitals: 98.0 124/74 68 18 97%Ra Consitutional: NAD, lying in bed comfortably Cardiovasc: RRR, no MRG, no edema Resp: normal effort, no accessory muscle use, lungs CTA ___. GI: ostomy draining light brown stool that is slightly thick in consistency, no blood. Ostomy itself is pink and moist. Neuro: AAOx3. CNs II-XII intact Pertinent Results: ___ 08:45PM BLOOD WBC-11.2* RBC-3.08* Hgb-10.3* Hct-30.8* MCV-100* MCH-33.4* MCHC-33.4 RDW-17.4* RDWSD-63.5* Plt ___ ___ 08:45PM BLOOD Neuts-86.9* Lymphs-9.3* Monos-2.3* Eos-0.1* Baso-0.2 Im ___ AbsNeut-9.73* AbsLymp-1.04* AbsMono-0.26 AbsEos-0.01* AbsBaso-0.02 ___ 08:45PM BLOOD Glucose-97 UreaN-32* Creat-1.8* Na-134 K-3.9 Cl-94* HCO3-20* AnGap-24* ___ 08:45PM BLOOD ALT-12 AST-28 AlkPhos-94 TotBili-0.4 ___ 08:45PM BLOOD Albumin-2.8* ___ 08:55PM BLOOD Comment-GREEN TOP ___ 08:55PM BLOOD Lactate-0.9 Imaging: CT ABD/PELV ___: 1. Perirectal collection appears to have been present on examination dated ___, while slightly decreased in size, remains concerning for abscessor phlegmonous changes. Note is made of small foci of air which extend superiorly, apparently extra luminal. 2. Status post left lower quadrant and colostomy without evidence of obstruction. 3. Enlarged retroperitoneal nodes are stable in size and number, may be reactive. 4. Hyperdense liver again noted, can be seen in the setting of hemochromatosis or amiodarone administration. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amiodarone 200 mg PO DAILY 2. Polyethylene Glycol 8.5 g PO DAILY 3. Simvastatin 20 mg PO QPM 4. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 5. TraMADol 25 mg PO Q6H:PRN pain 6. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia 7. IMatinib Mesylate 200 mg PO QAM 8. IMatinib Mesylate 100 mg PO QHS Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 2. TraMADol 25 mg PO Q6H:PRN pain 3. Vancomycin Oral Liquid ___ mg PO Q6H last day of antibiotics ___ RX *vancomycin 125 mg 1 capsule(s) by mouth every 6 hours Disp #*56 Capsule Refills:*0 4. Amiodarone 200 mg PO DAILY 5. IMatinib Mesylate 200 mg PO QAM 6. IMatinib Mesylate 100 mg PO QHS 7. Simvastatin 20 mg PO QPM 8. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: severe cdiff infection dehydration acute renal failure on CKD III 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: +PO contrast; History: ___ with s/p recent colectomy, p/w fever, please eval for colitis, other post-operative complication+PO contrast// ___ with s/p recent colectomy, p/w fever, please eval for colitis, other post-operative 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 administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.6 s, 50.0 cm; CTDIvol = 10.1 mGy (Body) DLP = 505.7 mGy-cm. Total DLP (Body) = 506 mGy-cm. COMPARISON: CT abdomen and pelvis dated ___. CT abdomen pelvis ___. FINDINGS: LOWER CHEST: Atherosclerotic coronary artery calcifications and aortic valvular calcifications are partially imaged. There is no pericardial effusion. Subsegmental atelectasis involves the lower lobes bilaterally. There is no pleural effusion. ABDOMEN: HEPATOBILIARY: The liver is hyperdense in 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. A left renal cyst measuring 5.1 x 4.7 cm extends from the inferior pole. There is no nephrolithiasis or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: Aside from a small hiatal hernia, the stomach is unremarkable. Small bowel diameter is at the upper limits of normal measuring 2.8 cm which could reflect a mild small bowel ileus. There is no abrupt transition point. The appendix is normal. Patient is status post left lower quadrant end colostomy. Similar to prior examination dated ___, there appears to be a 2.2 x 3.3 cm rim enhancing fluid collection adjacent to the rectum (2:65) which extends superiorly where there are apparent extraluminal foci of air. Ill-defined fluid is present anteriorly at this level. There is circumferential thickening of the wall of the cecum and ascending colon, slightly more prominent than prior exam. The descending colon is somewhat collapsed but there may be some mild wall thickening of this also (series 2, image 28). PELVIS: Foci of air within the bladder lumen is presumably iatrogenic. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable. LYMPH NODES: Multiple enlarged retroperitoneal nodes are not appreciably changed, the largest measuring 9 mm in short axis (02:30), left periaortic in location.. 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. Multilevel degenerative changes are present throughout the lumbar spine with severe loss of intervertebral disc space and endplate sclerosis. SOFT TISSUES: Stranding within the soft tissues posterior to the bilateral ischial tuberosities is noted. There is mild diffuse anasarca. IMPRESSION: 1. Status post left lower quadrant end colostomy without evidence of obstruction. Thickening of the cecum and ascending colon, with possible mild thickening of the descending colon compatible with colitis with differential considerations including inflammatory, infectious or ischemic etiology. 2. Perirectal collection appears to have been present on examination dated ___, while slightly decreased in size, remains concerning for abscess or phlegmonous changes. Note is made of small foci of air which extend superiorly, apparently extra luminal. Of note, this appears to be a chronic or recurrent process, with similar changes on previous imaging including ___ CT. 3. Enlarged retroperitoneal nodes are stable in size and number, may be reactive. 4. Hyperdense liver again noted, can be seen in the setting of hemochromatosis or amiodarone administration. 5. Mild prominence of small bowel loops could reflect early ileus. NOTIFICATION: The findings were discussed with Dr. ___. by ___ ___, M.D. on the telephone on ___ at 2:51 am, 1 minutes after discovery of the findings. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman recently s/p colostomy for diverticulitis. Now with fever of unclear source. CT abdomen showed no definitive worsening of recent perirectal abscess.// Rule out pneumonia. Rule out pneumonia. IMPRESSION: Heart size and mediastinum are unchanged. Left basal consolidation is unchanged. No pulmonary edema is present. Significant degenerative changes most likely due to osteonecrosis of bilateral shoulders are present. Gender: F Race: WHITE - OTHER EUROPEAN Arrive by AMBULANCE Chief complaint: Fever, Vomiting Diagnosed with Fever, unspecified, Weakness temperature: 100.9 heartrate: 74.0 resprate: 18.0 o2sat: 97.0 sbp: 122.0 dbp: 60.0 level of pain: Unable level of acuity: 2.0

Summary: Ms. ___ is an ___ woman with history of diverticulitis c/b perirectal abscesss with recent admission to colorectal surgery (___) s/p CT guided drainage ___, pigtail cath later removed) and lap assisted sigmoid colectomy on ___, CML on gleevec, paroxysmal afib (not on ac due to bleeding hx, HTN, CKD (b/l cr 1.3-1.6), HFpEF, who presented with fever 100.3, lethargy x 2 days; found to be cdiff positive. Also found to have ___, now improved. PO intake has remained poor however and I decided to watch her another day to ensure further improvement in intake and also await her ostomy output to decrease as well. Rest of hospital course and plan are outlined below by issue: #Fever, Leukocytosis: #Severe Cdiff infection: discussed CT images with radiology and notably, there was thickening of the cecum and ascending colon which were present on prior CT abdomen however with some slight interval worsening, suggestive of colitis (feel most likely) and indeed cdiff became positive, likely relating to antibiotics given during prior admission. Perirectal fluid collection is chronic issue (at least since ___ and smaller on CT abdomen after drainage earlier this month, so unlikely to be a source. Leukocytosis has now resolved after initiating PO vancomycin. Hemodynamically stable and has remained afebrile since admission. UA negative. CXR was unchanged from prior. #Acute renal failure on CKD: cr on admission 1.8 up from baseline 1.3-1.6. Pt admitted to poor po intake plus diarrhea with high BUN, likely prerenal azotemia. S/p ___ cc's in ED followed by another gentle 500 cc's on the floor. Renal function now back to baseline. #AFib: not on ac due to hx of bleeding. On amio for rhythm control. Hyperdense liver noted on exam and she does have a history of abnormal LFTs which are monitored as an outpatient. Continuing amio. LFTs normal this admission #HFpEF: euvolemic to dry on exam, monitoring carefully with IV fluids. #CML: outside oncologist Dr. ___ at ___ follows her every 2 weeks as outpatient. To resume imatinib upon discharge #Contacts: hc proxy ___ ___ (alternate: ___ ___ (son) ___ -___: attempted to call ___ to update (no answer) so called alternate ___ but again no answer. -___: I was able to get in contact with the patient's hc proxy ___ over the phone and updated her on the plan. #Transitional Issues: -PO vancomycin x 14 days (last day ___ -f/u with surgery and PCP -___ has ___ f/u appointment with Dr. ___ oncologist in the next 2 weeks Consults: Colorectal surgery Dispo: was at home living at ___ with 24h aid and ___ to help with ostomy. Has been ambulating as usual with a cane. Discharge ___ back home to resume service, pending improvement in po intake, stable creatinine.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: Penicillins Attending: ___. Chief Complaint: sudden onset of left hand clumsiness and weakness with left facial droop and minimal responsiveness. Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year old man with a history of CAD, right parietal glioma s/p resection in ___ who presents with sudden onset of left hand clumsiness and weakness with left facial droop and minimal responsiveness. The patient spent the morning doing strenuous yardwork but otherwise felt fine. He had dinner as usual with his wife at 5pm and at 6pm she heard him dropping his pill bottle on the floor. She saw him sitting on the couch a few minutes later and said he appeared "off". He was only intermittently responding to her questions (but when he did, he gave appropriate answers) and his head was turned all the way to the left. The patient reports remembering being in the bathroom and he couldn't use his left hand to do anything. He said it felt like he couldn't control the hand. He denies seeing it shake. He had some difficulty walking and kept walking into walls. He says he remembers everything but he is likely not reliable at the time of interview. He vomited twice prior to EMS arrival. He arrived in the ED and intially had a dense left neglect with left facial droop and left arm paresis. A CODE STROKE was called. In the CT scanner he had rhythmic shaking of the left arm with eyes open but not responding to questions. He responded after about 2 minutes but the shaking continued for several minutes after. Over a period of 20minutes his left arm strength returned and he was able to give a history. He says he forgot his keppra this morning, which is very unusual for him. With regard to his brain tumor, he is followed at ___ and had a follow up MRI 1 month ago that he reports as normal. He denies any recent illness, fever, diarrhea or vomiting before tonight. No urinary symptoms or cough. Has had left chest/arm discomfort, no with exertion the past 2 weeks but no chest pain or palpiations tonight. On neuro ROS, the pt loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies numbness, parasthesiae. No bowel or bladder incontinence or retention. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies nausea, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: -Glioma p/w GTC seizure ___, s/p resection ___ at ___ (grade II or III mixed astro/oligo histology), s/p Temodar ___ c/b diabetes insipidus, now with stable findings on MRI and stable f/u with a Neuro-Oncologist at ___ Dr. ___. - h/o DVT - Right calf in ___ during his postoperative course, treated with Lovenox for several weeks. Has had intermittent right lower extremity swelling since then. - CAD s/p BMS to proxLAD ___ - h/o bowel surgery in ___, s/p surgery for lysis of adhesions in ___ and ___ SBO medically managed at ___ (___). - GERD/PUD/Barrett's esophagitis (___) now asx on PPI - Diabetes - Dyslipidemia - Hypertension - BPH - Rosacea - L ureteral stone s/p extraction in ___. - BPH, untreated - Left shoulder surgery (torn labrum repair) in ___. Social History: ___ Family History: CAD in his father in his ___. ___ cancer in his ___ cancer in maternal uncle in his ___. ___ ulcers in his father. ___ abuse in his father. No history of diabetes, hypertension, CVA, or prostate cancer. ?DM in grandfather, ?CAD in grandmother. Physical Exam: Vitals: HR 66 BP 146/86 RR16 100 RA General: Awake, cooperative, slow to respond HEENT: NC/AT Neck: Supple Pulmonary: CTABL Cardiac: RRR, no murmurs Extremities: some echymosis around both ankles Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history about 20 minutes after seizure but still odd affect. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Able to read without difficulty but did not read far left word on all sentences. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt. was able to register 3 objects and recall ___ at 5 minutes despite prompts. There was evidence of a dense left neglect to both visual, sensory input. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VF likely full to confrontation though neglect on the left. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: Lower left facial droop 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 on right Both rhythmic and nonrhythmic shaking of left arm, sometimes right hand tremor and sometimes left foot tremor. Delt Bic Tri WrE FFl FE IP Quad Ham TA ___ L 0 0 0 0 0 0 5 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 ** left arm recovered to 4 at delt, 4+ at bic 4+ at tri and 5 FFL 20 minute after witnessed sz -Sensory: no senory deficit on the right, extinction to DSS on the left. -DTRs: Bi Tri ___ Pat Ach L 2+ 2+ 2+ 2+ 1 R 2+ 2+ 2+ 2+ 1 Plantar response was flexor bilaterally. -Coordination: intention tremor on the left on FTN. No dysmetria on FNF or HKS on the right. -Gait: deferred PHYSICAL EXAM ON DISCHARGE: - Neuro: possible subtle left lower quadrantanopia. Otherwise, completely nonfocal with complete resolution of left arm weakness and complete resolution of left visual and sensory neglect. Pertinent Results: ADMISSION LABS: ___ 07:29PM BLOOD WBC-7.7# RBC-4.45* Hgb-13.5* Hct-40.5 MCV-91 MCH-30.4 MCHC-33.3 RDW-13.2 Plt ___ ___ 07:29PM BLOOD ___ PTT-27.1 ___ ___ 07:29PM BLOOD Glucose-122* UreaN-19 Creat-1.2 Na-141 K-4.1 Cl-105 HCO3-27 AnGap-13 ___ 07:29PM BLOOD CK(CPK)-193 ___ 07:29PM BLOOD CK-MB-3 cTropnT-<0.01 ___ 06:47AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.9 ___ 06:47AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 08:01PM BLOOD Glucose-104 Na-137 K-4.5 Cl-102 calHCO3-26 ___ 08:26AM URINE Color-Straw Appear-Clear Sp ___ ___ 08:26AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 08:26AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG EKG (___): Sinus rhythm. Compared to the previous tracing of ___ the rate has increased. NCHCT/CTA/CTP (___): 1. No acute intracranial hemorrhage and no thromboembolic vascular filling defect. 2. Increased left temporal lobe mean transit time, with corresponding blood flow and volume abnormalities. Given the distribution, and the known history of seizure, these are most likely seizure related perfusion changes rather than infarction. If concern persists for the latter, and the patient is able, would recommend MRI. MRI HEAD WITH/WITHOUT CONTRAST (___): 1. No acute intracranial hemorrhage and no thromboembolic vascular filling defect. 2. Increased left temporal lobe mean transit time, with corresponding blood flow and volume abnormalities. Given the distribution, and the known history of seizure, these are most likely seizure related perfusion changes rather than infarction. If concern persists for the latter, and the patient is able, would recommend MRI. Medications on Admission: 1. Fluoxetine 20 mg PO DAILY 2. Aspirin 325 mg PO DAILY 3. LeVETiracetam 1000 mg PO QAM 4. LeVETiracetam 500 mg PO QPM 5. Pantoprazole 40 mg PO Q24H 6. Tamsulosin 0.4 mg PO HS Discharge Medications: 1. Fluoxetine 20 mg PO DAILY 2. Aspirin 325 mg PO DAILY 3. LeVETiracetam 1000 mg PO QAM 4. LeVETiracetam 500 mg PO QPM 5. Pantoprazole 40 mg PO Q24H 6. Tamsulosin 0.4 mg PO HS Discharge Disposition: Home Discharge Diagnosis: Breakthrough seizure (caused by missing dose of Keppra) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Right headache and left upper extremity weakness with question of stroke. COMPARISON: Head CT from ___. TECHNIQUE: Axial CT images were acquired through the head without intravenous contrast. Thereafter, images were acquired through the head and neck following the uneventful intravenous administration of iodine-based contrast. In addition, CT perfusion imaging is performed. With the angiographic images, dedicated three-dimensional angiographic reconstructions are created. FINDINGS: CT HEAD WITHOUT CONTRAST: There is no intracranial hemorrhage, edema, or vascular territorial infarction. The patient is status post right parietal craniotomy, and note is made of a resection defect in the right parietal lobe (history notable for prior glioma resection in ___, yielding mixed astro and oligo histology). Aside from the surgical defects, ventricles and sulci are normal in size and in configuration. There are small mucus retention cysts in the maxillary sinuses bilaterally and paranasal sinuses are otherwise clear. CT ANGIOGRAM OF THE NECK: The aorta demonstrates a normal three-vessel branching pattern. The origins of both vertebral arteries and common carotid arteries are normal. Note is made of a right dominant vertebral arterial system. Both carotid bifurcations are normal, specifically without evidence of hemodynamically significant atherosclerotic plaques. Overall, the common carotid, internal carotid and vertebral arteries show no luminal caliber irregularities on either side, to suggest pseudoaneurysm, dissection or thromboembolic filling defect. Imaged portions of the lungs reveal multiple right upper lobe calcified granulomata. There is no space-occupying mass in the neck, abnormal focus of enhancement or lymphadenopathy by size criteria. Bony structures reveal mild degenerative changes, and no suspicious sclerotic or lytic lesion. CT ANGIOGRAM OF THE HEAD: Primary arterial structures opacify normally with contrast. As noted previously, there is a right dominant vertebral system. There are no luminal caliber irregularities to suggest thromboembolic filling defects, aneurysm or dissection. Anatomy is conventional in orientation. Venous structures are notable for a diminutive left transverse sinus, through which only scant flow is visualized. Additionally, note is made of a prominent right inferior vermian vein. CT PERFUSION: Note is made of increased mean transit time corresponding to the left temporal lobe. Corresponding defects are also present on blood flow and volume maps. IMPRESSION: 1. No acute intracranial hemorrhage and no thromboembolic vascular filling defect. 2. Increased left temporal lobe mean transit time, with corresponding blood flow and volume abnormalities. Given the distribution, and the known history of seizure, these are most likely seizure related perfusion changes rather than infarction. If concern persists for the latter, and the patient is able, would recommend MRI. Radiology Report INDICATION: Partial seizure.? pneumonia. COMPARISONS: Multiple prior radiographs of the chest, most recent ___. TECHNIQUE: PA and lateral upright radiographs of the chest. FINDINGS: The lungs are well expanded and clear. The cardiomediastinal silhouette, hilar contours, and pleural surfaces are normal. There is no pleural effusion or pneumothorax. Healed fractures of the posterior right fourth, fifth and sixth ribs are unchanged. IMPRESSION: Multiple healed rib fractures, otherwise, normal chest radiograph without evidence of pneumonia. Radiology Report HISTORY: ___ man with left arm seizure and weakness; ? recurrence of right-sided mass or stroke. TECHNIQUE: Multi sequence multiplanar MR images were acquired of the brain before and after the administration of contrast according to department protocol. COMPARISON: CTA head and neck ___, CT head ___. FINDINGS: Right parietal resection cavity, and associated post-surgical changes are noted. Tubular enhancement along the resection cavity represents a traversing vessel, best shown on the thin-section MP-RAGE images. There is no mass or mass effect. There is no acute infarct. The global left temporal abnormality seen on the recent CT-perfusion study now shows no abnormal FLAIR-signal, diffusion abnormality or enhancement. Hypointense signal within the subcortical white matter of the left medial frontal gyrus on T2-weighted sequences demonstrates "blooming" on susceptibility sequences and thin rim of T1 hyperintensity, likely reflecting prior hemorrhage and focal hemosiderin deposition. There is no acute intracranial hemorrhage. The ventricles and sulci remain normal in size and configuration, with incidental note made of ex vacuo dilatation of the occipital horn of the right lateral ventricle. There is no abnormal enhancement. The prinicipal intracranial flow-voids are normal in appearance. The dural venous sinuses are patent. The maxillary sinuses demonstrate mucus-retention cysts, bilaterally. Small amount of fluid is seen within the posterior right mastoid air cells, unchanged from ___ CT. The orbits are unremarkable. IMPRESSION: 1. No acute infarct. 2. Focal hemosiderin in the left frontal lobe may reflect prior hemorrhagic infarct, and in addition to the resection cavity, could provide a gliotic seizure focus. Comparison with recent outside imaging is recommended, and when this is uploaded to PACS, an addendum can be issued. 3. No change in a right parietal resection cavity, without evidence of residual or recurrent neoplastic disease. Tubular enhancement along the resection cavity represents a traversing vessel. Gender: M Race: WHITE Arrive by UNKNOWN Chief complaint: LEFT HAND FLACID Diagnosed with CEREBRAL ART OCCLUS W/INFARCT temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: 1.0

Mr. ___ is a ___ year old man with a history of CAD, right parietal glioma s/p resection in ___ who presented with sudden onset of left hand clumsiness and weakness with left facial droop and minimal responsiveness and subsquent witnessed partial onset complex seizure while in the CT scan This is in the context of missing his keppra dose this morning. # NEURO: In the ED, patient's exam has continued to improve over the course of an hour with nearly resolved left arm strength (still clumsy hand), improved facial droop and less dramatic left side neglect and increased alertness. Overnight on HD #1, his exam normalized completely. He had a NCHCT/CTA/CTP which did not show evidence of hemorrhage, aneurysm or flow-limiting stenosis. CT perfusion showed increased left temporal lobe mean transit time, with corresponding blood flow and volume abnormalities, supporting diagnosis of seizure. Patient's neuro deficits were felt to represent a ___ paralysis following the seizure. To rule out stroke or recurrence of his oligo-astrocytoma, he underwent MRI on HD #2 which showed no stroke and no tumor recurrence compared with images from ___ from ___. It also showed evidence of his prior ___ cavity hemorrhage which could provide a gliotic seizure focus. Patient was seen by Neuro-Oncology while at ___ who agreed that his imaging did not support tumor recurrence. He underwent toxic-metabolic workup as well which was all negative. Ultimately his seizure was felt to be likely caused by his missed Keppra dose. We did suggest increasing his keppra to 100mg po bid, but he was reluctant. A Keppra level was checked and is pending. He was discharged on his home AED dosing (Keppra 1000mg qAM + 500mg qPM) and will follow up with his ___ neuro-oncologist. ============================

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Tramadol / Abacavir Attending: ___. Chief Complaint: symptomatic anemia Major Surgical or Invasive Procedure: none History of Present Illness: HISTORY OF PRESENT ILLNESS: ___ with a PMH of HIV, ESRD ___ PKD on HD, HCV, chronic abdominal pain, who presented with worsening anemia. Routine labs from ___ dialysis over last two weeks have showed a steady decline of Hg. Was above 11, and epogen appropriately held approximately two weeks ago, but then resumed last week at low dose (2500 units per treatment). Hg over last ten days has been steadily declining...8 last week, to 6 on ___ (both drawn at ___), and now 5. Patient feels fatiqued, but denies fevers or black/bloody stools. Blood cultures drawn from HD catheter over the weekend are negative so far. Patient was recently hospitalized at OSH for c.diff colitis, but getting better. In the ED, initial vitals were: 99.9 90 131/57 16 100% RA - Labs were significant for leukocytosis to 17.3, Hg 5.4 - Imaging revealed: CXR with mild pulmonary vascular congestion - The patient was given 80mg IV pantoprazole, 2mg IV morphine, 1g tylenol Vitals prior to transfer were: 98.6 88 135/63 18 100% RA Upon arrival to the floor, initial vitals were 98.3 140/62 74 18 100% RA. She denied any chest pain or shortness of breath. She did report feeling fatigued and lightheaded. She also denied diarrhea - reports constipation at home. Last bowel movement was ___ days ago. Past Medical History: HIV (CD4 270 ___ ESRD (on HD 3x per week. Tunneled catheter) Hepatitis C (grade 1 inflammation and stage I fibrosis) Hypertension Anxiety Depression Hyperparathyroidism ITP Right Subclavian Thrombosis History of staph epi bacteremia ___ Diverticulosis Laxity of the right knee Colon polyp/adenoma w/ high-grade dysplasia ___ attempts at colonoscopy have been unsuccessful due to stricture or angulation of colon) ___ R retroperitoneal hematoma from rutured renal cyst Past Surgical History Subtotal parathyroidectomy due to secondary hyperparathyroidism PD Catheter placements Multiple C-sections Right upper arm atrioventricular graft ___ c/b significant extremity swelling s/p Ligation / AVG infection s/p graft removal Social History: ___ Family History: Father died of throat cancer and he was a smoker Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: tm 98.3 tc 98.1 130s-140s/60s-70s 18 100 RA General: Alert, oriented, but poor historian. No acute distress. HEENT: Sclera mildly icteric, PERRL, +cataracts bilaterally. EOMI. Dry MM. CV: Regular rate and rhythm, III/VI systolic murmur loudest at ___ w/+radiation to the carotids. Soft ___ murmur at apex. Tunneled line in palce w/o surrounding erythema or tenderness. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, mildly diffusely tender, non-distended, multiple scars GU: No foley Ext: Warm, well perfused, no clubbing, cyanosis or edema Neuro: CNII-XII grossly intact DISCHARGE PHYSICAL EXAM: Vitals: T 98.3 BP 110/72 HR 79 RR 20 100%RA General: Alert, oriented. No acute distress HEENT: Sclera anicteric, EOM grossly intact. CV: Regular rate and rhythm, III/VI systolic murmur loudest at ___ Tunneled line in place w/o surrounding erythema or tenderness. Lungs: CTAB Abdomen: Soft, non-tender, non-distended, no rebound or guarding GU: No foley Ext: Warm, well perfused, no clubbing, cyanosis or edema Neuro: no focal deficits, moving all extremities with purpose Pertinent Results: ADMISSION LABS: ___ 10:30AM HGB-5.5*# HCT-17.9*# ___ 05:00PM RET AUT-8.9* ABS RET-0.14* ___ 05:00PM ___ PTT-34.2 ___ ___ 05:00PM PLT COUNT-366# ___ 05:00PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-3+ MICROCYT-OCCASIONAL POLYCHROM-1+ OVALOCYT-1+ SCHISTOCY-OCCASIONAL TEARDROP-OCCASIONAL ___ 05:00PM HOS-AVAILABLE ___ 05:00PM NEUTS-82.0* LYMPHS-11.7* MONOS-5.1 EOS-0.2* BASOS-0.1 NUC RBCS-0.1* IM ___ AbsNeut-14.18* AbsLymp-2.03 AbsMono-0.88* AbsEos-0.03* AbsBaso-0.01 ___ 05:00PM WBC-17.3*# RBC-1.54*# HGB-5.4* HCT-17.3* MCV-114* MCH-35.1* MCHC-30.9* RDW-19.4* RDWSD-76.1* ___ 05:00PM calTIBC-147* VIT ___ FOLATE->20.0 ___ FERRITIN-3071* TRF-113* ___ 05:00PM IRON-50 ___ 05:00PM ALT(SGPT)-18 AST(SGOT)-64* LD(LDH)-456* ALK PHOS-129* TOT BILI-3.3* DIR BILI-0.2 INDIR BIL-3.1 ___ 05:00PM estGFR-Using this ___ 05:00PM GLUCOSE-87 UREA N-21* CREAT-3.8*# SODIUM-133 POTASSIUM-4.4 CHLORIDE-93* TOTAL CO2-26 ANION GAP-18 ___ 06:36PM LACTATE-1.0 PERTINENT LABS: ___ 07:23AM BLOOD TSH-4.6* ___ 06:20AM BLOOD Free T4-1.2 ___: HIV not detected ___: HCV viral load 17,800,000 IU/mL. DISCHARGE LABS: ___ 03:00PM BLOOD Hgb-7.1* Hct-22.6* ___ 06:10AM BLOOD ___ PTT-39.6* ___ ___ 06:10AM BLOOD Glucose-69* UreaN-51* Creat-5.6* Na-131* K-4.9 Cl-92* HCO3-24 AnGap-20 ___ 06:10AM BLOOD ALT-8 AST-18 LD(LDH)-216 AlkPhos-102 TotBili-4.4* ___ 06:10AM BLOOD Albumin-3.1* Calcium-8.6 Phos-2.1* Mg-2.1 BLOOD BANK: DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Ms. ___ has a new diagnosis of an anti-Fya antibody. Ms. ___ received three RBC units on ___, and ___, respectively. All of those units were retrospectively determined to be positive for the Fya-antigen. She was then transfused a fourth unit of RBCs on ___ (before the results of her antibody evaluation were complete) that was Fya-antigen positive. The Fya-antigen is a member of the ___ blood group system. Anti-Fya antibodies are clinically significant and capable of causing acute and delayed hemolytic transfusion reactions. Since the Fya antibody is currently coating the transfused red cells (DAT+ with IgG, eluate has anti-Fya), she is at risk for a delayed hemolytic transfusion reaction. Her current team should look for signs of hemolysis, including an unexplained fever, an unexplained decrease in hematocrit, rise in bilirubin, rise in LDH and decrease in haptoglobin. Treatment for delayed hemolytic transfusion reactions is symptomatic with transfusion of antigen negative RBCs for symptomatic anemia. In the future the patient should receive Fya-negative products for red blood cell transfusions. Approximately 34% of ABO compatible units will be Fya-antigen negative. A wallet card and letter stating the above will be sent to the patient. MICRO: ___ EBV IgG positive ___ Blood Culture negative final IMAGING: ___ MRI abdomen/pelvis Collection abutting the distal sigmoid as described above, communicating with the sigmoid along its superior aspect. The findings are suggestive of a large semi-collapsed pseudodiverticulum containing a small amount of fluid, and draining into the sigmoid. There is abutment against the left ovary, which does not appear to be involved. No separate isolated fluid collections. CT abdomen/pelvis ___. Fluid pocket, 3.5 x 2.6 cm, in the right perirectal region, may be intramural. Findings consistent with a small abscess. Repeat imaging with rectal contrast could be obtained. 2. Polycystic kidney disease and renal osteodystrophy. 3. Normal size spleen. ___ KUB Nonobstructive bowel gas pattern. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Atazanavir 300 mg PO DAILY 2. Docusate Sodium 100 mg PO DAILY:PRN constipation 3. Lactulose 30 mL PO DAILY:PRN constipation 4. Metoprolol Tartrate 100 mg PO BID 5. Nephrocaps 1 CAP PO DAILY 6. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO Q8H:PRN pain 7. Polyethylene Glycol 17 g PO DAILY 8. Raltegravir 400 mg PO BID 9. RiTONAvir 100 mg PO DAILY 10. Senna 8.6 mg PO BID:PRN constipation 11. Calcium Carbonate 500 mg PO FIVE TIMES PER DAY 12. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN wheeze 13. Sulfameth/Trimethoprim SS 1 TAB PO 3X/WEEK (___) Discharge Medications: 1. Atazanavir 300 mg PO DAILY 2. Calcium Carbonate 500 mg PO FIVE TIMES PER DAY 3. Docusate Sodium 100 mg PO DAILY:PRN constipation RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth daily prn Disp #*28 Capsule Refills:*0 4. Lactulose 30 mL PO DAILY:PRN constipation 5. Nephrocaps 1 CAP PO DAILY 6. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 [ClearLax] 17 gram/dose 1 powder(s) by mouth daily prn Refills:*0 7. Raltegravir 400 mg PO BID 8. RiTONAvir 100 mg PO DAILY 9. Senna 8.6 mg PO BID:PRN constipation RX *sennosides [senna] 8.6 mg 1 capsule by mouth BID PRN Disp #*52 Capsule Refills:*0 10. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO Q8H:PRN pain 11. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN wheeze 12. Emtricitabine Oral Solution 60 mg PO Q24H RX *emtricitabine [Emtriva] 10 mg/mL 60 mg by mouth daily Refills:*0 13. FoLIC Acid 5 mg PO DAILY RX *folic acid 1 mg 5 tablet(s) by mouth daily Disp #*70 Tablet Refills:*0 14. Ciprofloxacin HCl 250 mg PO Q24H RX *ciprofloxacin HCl [Cipro] 250 mg 1 tablet(s) by mouth daily Disp #*2 Tablet Refills:*0 15. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth q8hr Disp #*6 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: Acute on chronic anemia Anti-Fya antibody constipation SECONDARY DIAGNOSES: end stage renal disease hypertension 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 shortness of breath // acute process? COMPARISON: ___ FINDINGS: PA and lateral views of the chest provided. Left subclavian access dialysis catheter is noted with tip in the low SVC. There is no focal consolidation, large effusion or pneumothorax. There is mild pulmonary vascular congestion. No frank edema. Cardiomediastinal silhouette is unchanged. Bony structures appear intact. There is a chronic appearing deformity of the right humeral head. IMPRESSION: As above. Radiology Report INDICATION: ___ year old woman with h/o c diff, now w/1 week of constipation. // ileus? TECHNIQUE: Supine and upright abdominal radiographs were obtained. COMPARISON: CT abdomen pelvis from ___. FINDINGS: The bowel gas pattern is nonspecific, with multiple air-filled loops of large and small bowel, and air and stool noted throughout the descending and sigmoid colon, with air at the level of the rectum. Densely calcified distal aorta and bilateral common iliac arteries are noted, along with hepatic and splenic capsular calicifactions, as seen on the prior CT. A partially visualized dual lumen central venous port is also present. There is no free intraperitoneal air. IMPRESSION: Nonobstructive bowel gas pattern. Radiology Report EXAMINATION: CT SCAN OF THE ABDOMEN AND PELVIS WITH INDICATION: ___ year old woman with hx of HIV and hep c, hx of diverticulosis, p/w abdominal pain and possible hemolytic anemia. // any diverticulitis? any splenomegaly, liver abnormalities, ascites? 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. Coronal and sagittal reformations were performed and reviewed on PACS. Oral contrast was administered. DOSE: Acquisition sequence: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 1.1 mGy (Body) DLP = 1.1 mGy-cm. 4) Stationary Acquisition 7.0 s, 1.0 cm; CTDIvol = 15.8 mGy (Body) DLP = 15.8 mGy-cm. 5) Spiral Acquisition 12.6 s, 43.3 cm; CTDIvol = 7.1 mGy (Body) DLP = 298.6 mGy-cm. Total DLP (Body) = 329 mGy-cm. COMPARISON: ___. FINDINGS: LOWER CHEST: Minimal scarring/ atelectasis noted at the lung bases, right slightly more prominent than left. ABDOMEN: Calcifications/high density material, linear in nature are noted the in the perihepatic region, perisplenic as well as in the pelvis. No associated mass. Differential includes prior hemorrhage. 1.3 cm calcification is also noted in the anterior abdominal wall close to the umbilicus. These are without change from ___ and of no current clinical significance. HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. Few tiny, less than 1 cm hypodensities noted, difficult to characterize but may represent small cysts. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder contains multiple small calcified gallstones. . No evidence for acute cholecystitis. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions. There is prominence of the pancreatic duct without definite dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. It measures 10.5 cm in its long axis. Very splenic linear calcifications as noted above. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: Polycystic kidney disease with multiple cysts replacing the and tightening kidney on both sides. Cyst wall calcifications noted. No definite enhancing nodule seen. 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. Fluid-filled colon. Few diverticulae are on the left side but no adjacent inflammatory changes near the diverticula. There is a 3.5 x 2.6 cm fluid pocket just to the right of the midline, in the lower pelvis, this may represent a perirectal fluid collection or intramural fluid pocket. The wall of the rectum shows thickening in this area. A small amount of fluid is noted in the presacral space. The appendix is normal. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: Uterine survey shows calcifications are seen around the liver and spleen. In addition there is also intramural calcification within the uterus indicating lie a myomatous change. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Considerable atherosclerotic disease is noted. BONES: There are changes of renal osteodystrophy throughout the lumbar spine, (___ spine and erosive change), and pelvic bones. SOFT TISSUES: As described in the first paragraph above. IMPRESSION: 1. Fluid pocket, 3.5 x 2.6 cm, in the right perirectal region, may be intramural. Findings consistent with a small abscess. Repeat imaging with rectal contrast could be obtained. 2. Polycystic kidney disease and renal osteodystrophy. 3. Normal size spleen. NOTIFICATION: Repeat Page placed to referring physician on the CT requisition form. No response. Radiology Report EXAMINATION: MRI of the Pelvis INDICATION: ___ year old woman with ESRD, HCV, anemia chronic abdominal pain with a perirectal fluid collection. TECHNIQUE: Non-contrast T1- and T2-weighted multiplanar images of the pelvis were acquired in a 1.5 T magnet. COMPARISON: CT examination from ___. FINDINGS: There is a moderate amount of stool throughout the sigmoid colon and rectum, limiting evaluation. There is a pouch-like biobed collection arising from the distal sigmoid. The inferior portion measures approximately 2.6 x 5.9 x 3.5 cm (06:32). The wall has an slightly increased signal intensity in comparison to the adjacent bowel wall on T2 weighted sequences. The collection extends superiorly and leftward to abut the left ovary, with this portion measuring approximately 2.6 x 4.0 x 2.8 cm (series 3 image 12). A small amount of enteric contrast extends into this superior component from the sigmoid (series 8 image 24), and fills the midportion of this collection (series 8, image 27). The inferior component does not fill with contrast, but appears to be communicating with the upper portions (series 2, image 15, series 8, image 35). This has the appearance of a large collapsed diverticulum/pseudodiverticulum which drains into the sigmoid. UTERUS AND ADNEXA: The uterus is anteverted and measures 5.6 x 3.2 x 5.5 cm. There is a 2.4 x 2.6 cm T1 and T2 hypointense calcified fibroid near the cervix. The endometrium is normal in thickness for age and measures 1 mm. The junctional zone is not thickened. The right ovary is visualized and appears within normal limits. The left ovary is visualized and appears within normal limits. Trace pelvic free fluid is within physiologic limits. LYMPH NODES: No significant pelvic sidewall or inguinal adenopathy by size criteria. BLADDER AND DISTAL URETERS: Unremarkable. VASCULATURE: The visualized intrapelvic vessels appear patent without any significant areas of narrowing or dilatation. OSSEOUS STRUCTURES AND SOFT TISSUES: The bones are heterogeneous in signal characteristics which may be the a reflection of anemia, smoking or obesity. No concerning lesions are identified. IMPRESSION: Collection abutting the distal sigmoid as described above, communicating with the sigmoid along its superior aspect. The findings are suggestive of a large semi-collapsed pseudodiverticulum containing a small amount of fluid, and draining into the sigmoid. There is abutment against the left ovary, which does not appear to be involved. No separate isolated fluid collections. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with HCV, ESRD, and pseudodiverticulum presenting with abdominal pain and now with bump in WBC. any acute infectious intrathoracic process? // any acute infectious process? any acute infectious process? COMPARISON: Prior chest radiographs since ___ most recently ___. IMPRESSION: Lungs fully expanded and clear. Normal cardiomediastinal and hilar silhouettes and pleural surfaces. Dual channel left subclavian central venous catheter ends in the SVC. Incidental note made of subdiaphragmatic calcifications and sclerotic osteodystrophy in the thoracic spine. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Anemia Diagnosed with Anemia, unspecified temperature: 99.9 heartrate: 90.0 resprate: 16.0 o2sat: 100.0 sbp: 131.0 dbp: 57.0 level of pain: 8 level of acuity: 2.0

___ with a PMH of HIV, ESRD ___ PKD on HD, HCV, chronic abdominal pain, who presented with acute on chronic anemia and abdominal pain.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abd pain LLQ Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ with DM, depression, insomnia, epigastric pain/dyspepsia undergoing workup, arthritis, diverticulosis, who presents with 3 days of worsening LLQ abdominal pain and bloody/mucousy stools. She was in her usual state of fairly good health until 3 days ago when she began to notice LLQ abdominal pain. It would come and go. It became increasingly severe and she described it as a "strong pain." It was associated with a need to use the bathroom, though when she would go she passed only scant bright red blood and some mucus. Pain worsened to the point where she had difficulty sleeping. She ultimately decided to come to the ED for further eval. In the ED, she had stable vital signs. Labs showed mild leukocytosis. Imaging with CT abdomen showed diverticulitis. She was admitted for IV antibiotics. REVIEW OF SYSTEMS A full 10 point review of systems was performed and is otherwise negative except as noted above. Past Medical History: DIABETES TYPE II ? UTERINE PROLAPSE DEPRESSION POSITIVE PPD HEADACHE PERIAORTIC CALCIFICATIONS RENAL CALCULUS R FOOT/ANKLE FX ATYPICAL CHEST PAIN DEPRESSION KNEE PAIN Social History: ___ Family History: Family history was reviewed and is thought impertinent to current presentation. She reports + for DM. Physical Exam: Vitals: ___ Temp: 99.7 PO BP: 134/75 HR: 87 RR: 16 O2 sat: 97% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___ Gen: NAD, lying in bed Eyes: EOMI, sclerae anicteric HENT: NCAT, MMM, OP clear, hearing adequate Cardiovasc: RRR, no obvious MRG. Full pulses, no edema. Resp: normal effort, breathing unlabored, no accessory muscle use, lungs CTA ___ without adventitious sounds. GI: Very tender in LLQ with some involuntary guarding. Mildly distended. No rebound tenderness. Soft, BS+. No HSM. MSK: No significant kyphosis. No palpable synovitis. Skin: No visible rash. No jaundice. Neuro: AAOx3. No facial droop. Psych: Full range of affect. Thought linear. GU: No foley Pertinent Results: ___ 12:00AM BLOOD WBC-5.1 RBC-4.37 Hgb-10.8* Hct-34.7 MCV-79* MCH-24.7* MCHC-31.1* RDW-14.6 RDWSD-42.3 Plt ___ ___ 09:06AM BLOOD Neuts-74.3* Lymphs-16.9* Monos-7.8 Eos-0.4* Baso-0.2 Im ___ AbsNeut-9.24* AbsLymp-2.10 AbsMono-0.97* AbsEos-0.05 AbsBaso-0.03 ___ 12:00AM BLOOD ___ PTT-31.1 ___ ___ 05:12AM BLOOD Glucose-108* UreaN-8 Creat-0.6 Na-143 K-4.6 Cl-105 HCO3-27 AnGap-11 ___ 09:06AM BLOOD ALT-15 AST-14 AlkPhos-75 TotBili-0.7 ___ 09:06AM BLOOD Lipase-31 ___ 05:12AM BLOOD Mg-1.8 ___ 09:19AM BLOOD Lactate-1.3 FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The appendix is normal. There is extensive wall thickening associated with surrounding fat stranding involving a 7 cm segment of sigmoid colon in the lower mid pelvis (2:70). This is associated with small volume free fluid in the pelvis (2:75). There is no intraperitoneal free air. No fluid collections are identified. PELVIS: The urinary bladder is distended, without abnormal wall thickening. REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are within normal limits. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. Calcified lymph nodes are again seen in the mesentery, unchanged from prior. 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 sclerotic focus in the left L5 transverse process is unchanged and likely represents a bone island. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Acute uncomplicated sigmoid diverticulitis. No intraperitoneal free air or fluid collections. 2. If not recently performed, recommend colonoscopy after resolution of acute process exclude underlying mass. RECOMMENDATION(S): Colonoscopy after resolution of acute process, if not recently performed. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetFORMIN XR (Glucophage XR) 500 mg PO BID 2. PARoxetine 10 mg PO DAILY 3. Senna 8.6 mg PO BID:PRN Constipation - First Line 4. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild/Fever over the counter 2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 6 Days through ___ RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*12 Tablet Refills:*0 3. MetroNIDAZOLE 500 mg PO Q8H through ___ RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day Disp #*18 Tablet Refills:*0 4. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain - Severe avoid with alcohol or driving. RX *oxycodone 5 mg 1 tablet(s) by mouth twice a day Disp #*10 Tablet Refills:*0 5. MetFORMIN XR (Glucophage XR) 500 mg PO BID 6. Multivitamins 1 TAB PO DAILY 7. PARoxetine 10 mg PO DAILY 8. Senna 8.6 mg PO BID:PRN Constipation - First Line Discharge Disposition: Home Discharge Diagnosis: Acute sigmoid diverticulitis Epistaxis Type 2 diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT ABDOMEN PELVIS WITH CONTRAST INDICATION: NO_PO contrast; History: ___ with abd pain, LLQNO_PO contrast// r/o diveritucultitis 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 6.4 s, 50.1 cm; CTDIvol = 8.3 mGy (Body) DLP = 413.7 mGy-cm. Total DLP (Body) = 421 mGy-cm. COMPARISON: CT abdomen pelvis 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. 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 appendix is normal. There is extensive wall thickening associated with surrounding fat stranding involving a 7 cm segment of sigmoid colon in the lower mid pelvis (2:70). This is associated with small volume free fluid in the pelvis (2:75). There is no intraperitoneal free air. No fluid collections are identified. PELVIS: The urinary bladder is distended, without abnormal wall thickening. REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are within normal limits. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. Calcified lymph nodes are again seen in the mesentery, unchanged from prior. 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 sclerotic focus in the left L5 transverse process is unchanged and likely represents a bone island. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Acute uncomplicated sigmoid diverticulitis. No intraperitoneal free air or fluid collections. 2. If not recently performed, recommend colonoscopy after resolution of acute process exclude underlying mass. RECOMMENDATION(S): Colonoscopy after resolution of acute process, if not recently performed. Gender: F Race: HISPANIC/LATINO - GUATEMALAN Arrive by WALK IN Chief complaint: Diarrhea, Lower abdominal pain Diagnosed with Dvtrcli of lg int w/o perforation or abscess w/o bleeding temperature: 97.1 heartrate: 96.0 resprate: 18.0 o2sat: 100.0 sbp: 132.0 dbp: 64.0 level of pain: 7 level of acuity: 3.0

This is a ___ woman with DM2, depression, insomnia, epigastric pain/dyspepsia undergoing workup, arthritis, diverticulosis, who presents with 3 days of worsening LLQ abdominal pain and bloody/mucousy stools, found to have acute diverticulitis

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: PODIATRY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: left foot infection Major Surgical or Invasive Procedure: ___: left foot debridement with ___ metatarsal head resection ___: left foot debridement and tendoachilles lengthening History of Present Illness: ___ h/o DM, PVD, CVA ___, multiple foot debridements/amps p/w left foot ulcer. Pt is ___ and her son is with her to translate and obtain the HPI. She noticed pain this morning and a pus-like drainage coming from the wound. ___ normally does dressing changes, unsure of what they use. Previous podiatric care has been received at ___. Pt denies n/v/f/c/sob/cp. No other pedal complaints at this time. Past Medical History: PMH/PSH: DM, PVD, CVA ___, GERD Social History: ___ Family History: non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: VS: 97.8 82 114/49 16 97% RA Gen: NAD, AAOx3, pleasant and cooperative. LLE: DP and ___ pulses palpable. CFT < 3 seconds to distal aspect of foot. Skin temperature is warm to warm proximal to distal. Gross sensation intact. Ulceration measuring 1.0 x 0.9 x 3.0 cm to plantar sub ___ met area. This probes deeply to bone/capsule. Minimal erythema noted. No fluctuance. No frank purulence expressed, more serosanginous and fibrous slough. Malodor present at ulcer site. Plantar aspect of foot tender. RLE: DP and ___ pulses palpable, h/o hallux amp. No open ulcerations or lesions. Gross sensation intact. DISCHARGE PHYSICAL EXAM: VSS, afebrile Gen: NAD Cardio: RRR Pulm: no respiratory distress Abd: soft, nontender Lower extremity: surgical site intact w/sutures ___ place. Skin edges well-coapted, minimal serous drainage. Bivalve cast intact. Pertinent Results: ADMISSION LABS: ___ 09:01PM LACTATE-1.4 ___ 08:45PM GLUCOSE-210* UREA N-23* CREAT-1.1 SODIUM-138 POTASSIUM-4.6 CHLORIDE-103 TOTAL CO2-23 ANION GAP-17 ___ 08:45PM WBC-12.3* RBC-3.19* HGB-8.9* HCT-28.0* MCV-88 MCH-27.8 MCHC-31.7 RDW-14.2 ___ 08:45PM NEUTS-86.8* LYMPHS-8.4* MONOS-3.5 EOS-1.0 BASOS-0.2 ___ 08:45PM PLT COUNT-424 ___ 08:45PM ___ PTT-31.5 ___ DISCHARGE LABS: Foot x-rays ___: IMAGING: HISTORY: History of diabetes and peripheral vascular disease, with foot ulcer draining pus. Evaluate for osteomyelitis. COMPARISON: None. FINDINGS: Three views of the left foot were acquired. There is diffuse demineralization. There is no definite acute fracture or evidence of dislocation. Amputations are seen across the proximal to mid portions of the metatarsals. Marked degenerative changes are seen at the tarsometatarsal joints. Spurring of the dorsal midfoot is noted. There is a moderate-sized inferior calcaneal enthesophyte. There is no cortical erosion to suggest osteomyelitis. No subcutaneous air is seen. A soft tissue defect is noted along the distal medial aspect of the foot. Soft tissue swelling is seen along the distal aspect of the foot. IMPRESSION: No radiographic evidence of osteomyelitis. CXR ___: IMPRESSION: 1. Heart is mildly enlarged, which most likely reflects cardiomegaly, although pericardial effusion should also be considered. Mediastinal contours are within normal limits. There is mild fullness of the perihilar vasculature and slight peribronchial cuffing. These findings suggest mild perihilar and interstitial edema. Streaky opacities at both bases likely reflect bibasilar atelectasis ___ the setting of relatively lower lung volumes. No focal airspace consolidation is seen to suggest pneumonia. No pneumothorax. No acute bony abnormality. EKG ___: Sinus rhythm. Diffuse non-specific ST-T wave flattening. No previous tracing available for comparison. FXR ___: HISTORY: I and D. Postoperative evaluation. FINDINGS: ___ comparison with the study of ___, there has been surgical procedure with postoperative gas ___ soft tissues. Further information can be gathered from the operative report. NIAS ___ Final Report INDICATION: ___ woman status post left foot incision and drainage with non-palpable DP and ___. Please assess for peripheral arterial disease. TECHNIQUE: Evaluation of the bilateral lower extremity arteries was performed with segmental limb pressure measurements, spectral Doppler waveform recordings, and pulse volume assessment. On the right side, triphasic Doppler signal was identified at the level of the common femoral artery. Doppler waveforms along the right superficial femoral artery, the popliteal artery, and the posterior tibial and dorsalis pedis arteries were monophasic. On the left, triphasic Doppler signal was seen along the common femoral, superficial femoral, and popliteal arteries. Doppler waveforms were monophasic at the level of the posterior tibial and the dorsalis pedis arteries. The ankle-brachial indices were 0.86 on the right and 0.77 on the left. Pulse volume recordings were symmetric and abnormally low ___ amplitude at the level of the right ankle and metatarsal area. IMPRESSION: Significant bilateral outflow/infrapopliteal and right SFA disease. The study and the report were reviewed by the staff radiologist. MICRO: **FINAL REPORT ___ GRAM STAIN (Final ___: Reported to and read back by ___. ___ ON ___ AT 0100. 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CHAINS. WOUND CULTURE (Final ___: This culture contains mixed bacterial types (>=3) so an abbreviated workup is performed. Any growth of P.aeruginosa, S.aureus and beta hemolytic streptococci will be reported. IF THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT PRESENT ___ this culture.. BETA STREPTOCOCCUS GROUP B. MODERATE GROWTH. STAPH AUREUS COAG +. SPARSE GROWTH. This isolate is presumed to be resistant to clindamycin based on the detection of inducible 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 _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. ___ 8:55 am SWAB LEFT ___ METATARSAL. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Final ___: This culture contains mixed bacterial types (>=3) so an abbreviated workup is performed. Any growth of P.aeruginosa, S.aureus and beta hemolytic streptococci will be reported. IF THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT PRESENT ___ this culture.. BETA STREPTOCOCCUS GROUP B. SPARSE GROWTH. IDENTIFICATION PERFORMED ON CULTURE # ___ ___. STAPH AUREUS COAG +. SPARSE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. STAPH AUREUS COAG +. SPARSE GROWTH. SECOND MORPHOLOGY. SENSITIVITIES PERFORMED ON CULTURE # ___ ___. 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. A swab is not the optimal specimen for recovery of mycobacteria or filamentous fungi. A negative result should be interpreted with caution. Whenever possible tissue biopsy or aspirated fluid should be submitted. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): A swab is not the optimal specimen for recovery of mycobacteria or filamentous fungi. A negative result should be interpreted with caution. Whenever possible tissue biopsy or aspirated fluid should be submitted. ___ 9:55 am TISSUE Site: BONE LEFT ___ METATARSAL. GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final ___: BETA STREPTOCOCCUS GROUP B. SPARSE GROWTH. IDENTIFICATION PERFORMED ON CULTURE # ___ ___. STAPH AUREUS COAG +. RARE GROWTH. This isolate is presumed to be resistant to clindamycin based on the detection of inducible 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. STAPH AUREUS COAG +. RARE GROWTH. SECOND MORPHOLOGY. SENSITIVITIES PERFORMED ON CULTURE # ___ ___. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. Medications on Admission: metformin er 500mg QD actos 30mg QD lisinopril 20mg QD novolin insulin 10U QD omeprazole 20mg QD amlodipine 10mg QD Discharge Medications: 1. Lisinopril 20 mg PO DAILY 2. Omeprazole 40 mg PO DAILY 3. Pioglitazone 30 mg PO DAILY *AST Approval Required* 4. Amlodipine 10 mg PO DAILY 5. Vancomycin 750 mg IV Q 12H RX *vancomycin 750 mg 750 mg IV every twelve (12) hours Disp #*56 Bag Refills:*0 6. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth q4-6h Disp #*40 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left foot infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report HISTORY: History of diabetes and peripheral vascular disease, with foot ulcer draining pus. Evaluate for osteomyelitis. COMPARISON: None. FINDINGS: Three views of the left foot were acquired. There is diffuse demineralization. There is no definite acute fracture or evidence of dislocation. Amputations are seen across the proximal to mid portions of the metatarsals. Marked degenerative changes are seen at the tarsometatarsal joints. Spurring of the dorsal midfoot is noted. There is a moderate-sized inferior calcaneal enthesophyte. There is no cortical erosion to suggest osteomyelitis. No subcutaneous air is seen. A soft tissue defect is noted along the distal medial aspect of the foot. Soft tissue swelling is seen along the distal aspect of the foot. IMPRESSION: No radiographic evidence of osteomyelitis. Radiology Report PA AND LATERAL CHEST FILM, ___ AT 2:38 A.M. CLINICAL INDICATION: ___ with left foot infection, pre-op evaluation. No comparison studies. Please note that comparison to old films can be helpful to detect subtle interval change. PA and lateral views of the chest ___ at 2:38 are submitted. IMPRESSION: 1. Heart is mildly enlarged, which most likely reflects cardiomegaly, although pericardial effusion should also be considered. Mediastinal contours are within normal limits. There is mild fullness of the perihilar vasculature and slight peribronchial cuffing. These findings suggest mild perihilar and interstitial edema. Streaky opacities at both bases likely reflect bibasilar atelectasis in the setting of relatively lower lung volumes. No focal airspace consolidation is seen to suggest pneumonia. No pneumothorax. No acute bony abnormality. Radiology Report HISTORY: I and D. Postoperative evaluation. FINDINGS: In comparison with the study of ___, there has been surgical procedure with postoperative gas in soft tissues. Further information can be gathered from the operative report. Radiology Report INDICATION: ___ woman status post left foot incision and drainage with non-palpable DP and ___. Please assess for peripheral arterial disease. TECHNIQUE: Evaluation of the bilateral lower extremity arteries was performed with segmental limb pressure measurements, spectral Doppler waveform recordings, and pulse volume assessment. On the right side, triphasic Doppler signal was identified at the level of the common femoral artery. Doppler waveforms along the right superficial femoral artery, the popliteal artery, and the posterior tibial and dorsalis pedis arteries were monophasic. On the left, triphasic Doppler signal was seen along the common femoral, superficial femoral, and popliteal arteries. Doppler waveforms were monophasic at the level of the posterior tibial and the dorsalis pedis arteries. The ankle-brachial indices were 0.86 on the right and 0.77 on the left. Pulse volume recordings were symmetric and abnormally low in amplitude at the level of the right ankle and metatarsal area. IMPRESSION: Significant bilateral outflow/infrapopliteal and right SFA disease. Radiology Report INDICATION: ___ female patient with right PICC line placement. COMPARISON: Prior chest radiograph from ___. TECHNIQUE: Portable chest radiograph. FINDINGS: The right PICC line is curled back and malpositioned. Cardiomediastinal contours are unchanged. The lungs are well expanded and clear. There are no pleural effusions or pneumothorax. IMPRESSION: Malpositioned right PICC line. These findings were discussed with ___ by Dr. ___ telephone on ___ at 10:30 a.m., time of discovery. Radiology Report INDICATION: ___ woman with left foot infection, cultures positive .Needs IV antibiotics. Please place PICC, for repositioning. PHYSICIANS: Dr. ___ (radiology fellow) and Dr. ___ ___ (radiology attending) who was present and supervised the procedure. RADIATION: 6 mGy, 0.8 minutes of fluoroscopy time. PROCEDURE DETAILS: A ___ interpreter was present. The patient was brought to the angiographic suite and placed supine on the table. A preprocedure timeout was performed using three patient identifiers. The skin of the right upper extremity was prepped and draped in usual sterile fashion including the indwelling PICC which had been withdrawn to a midline. Approximately 1 cc of 1% lidocaine was infiltrated into the skin and subcutaneous tissues surrounding the PICC. A nitinol wire was advanced through the PICC which passed centrally without difficulty. The existing PICC was removed and a 4.5 ___ peel-away sheath was advanced over the wire. The new double-lumen Power PICC was cut to 37 cm and flushed. This was then advanced over the wire as peel-away sheath with gradually removed. The wire was then removed. Following completion of this maneuver, the tip was in the distal SVC or cavoatrial junction. The limb was aspirated and flushed without difficulty. The catheter was secured to the skin with a Statlock device and a sterile dressing was applied. There were no immediate post-procedure complications. IMPRESSION: Successful repositioning of a right upper extremity PICC, the tip is now in the distal SVC. The catheter was flushed and ready for use. Gender: F Race: BLACK/CARIBBEAN ISLAND Arrive by WALK IN Chief complaint: LOWER EXTREMITY PAIN Diagnosed with CELLULITIS OF FOOT, ULCER OF HEEL AND MIDFOOT temperature: 97.8 heartrate: 82.0 resprate: 16.0 o2sat: 97.0 sbp: 114.0 dbp: 49.0 level of pain: 6 level of acuity: 3.0

Pt was admitted from the ED on ___ for L foot infection. Pt received IV abx on admission to the floor and was made NPO at midnight for OR. All home medications were resumed. On HD#2, after being consented with translator present, pt went to the OR for debridement of her L foot ulceration and underwent debridement with a ___ met resection. Upon recovering ___ the PACU, pt was transferred back to the floor and resumed a normal diet. While ___ house, pt continued to receive IV antibiotics. She received non-invasive arterial studies on ___ which showed right lower extremity disease at the tibial level. It was decided that she would follow up with Dr. ___ vascular on an outpatient basis. Pt was again made NPO on the evening of ___. She was again consented for surgery on ___ with translator present and ___ the OR an additional debridement of the ulcer with closure was performed. Pt also had a tendoachilles lengthening on the L side. Pt recovered ___ PACU and was transferred back to the floor ___ stable condition. While ___ house, pt's cultures came back positive for MRSA. PICC line was ordered and once a malposition was corrected, it was deemed safe to use. On ___, bivalve cast was ordered for pt to maintain a 90 degree position of the L foot following her TAL. On ___, plantar ulceration was closed at bedside and DSD was reapplied. Pt was discharged to rehab on ___ and will follow up with Dr. ___ also with Dr. ___ ___ ___ clinic.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Dilaudid / Opioids - Morphine Analogues Attending: ___. Chief Complaint: Pancreatic abscess Major Surgical or Invasive Procedure: ___: Successful CT-guided removal of existing 10 ___ pigtail catheter and placement of ___ pigtail catheter into the inferior aspect of the collection. . ___: Successful CT-guided catheter exchange. A 12 ___ multi side-hole biliary catheter was placed within the collection. . ___: Successful CT-guided placement of ___ pigtail catheter into the collection. . ___: Pancreatic debridement. History of Present Illness: The patient is a ___ h/o large infected pancreatic cyst s/p recent ___ drainage c/b sepsis, now p/f ___ ___ in ___ with ___ tube no longer draining, and drainage around tube insertion site. The tube is a ___ multiside hole catheter that was placed into her 23 cm intra-abdominal abscess ___ under CT guidance. It has been secured in place without any noted dislodgment. Drain had been draining about 40cc/day at rehab, but suddenly was no longer draining much at all for past 2 days, now also with increasing leakage around the insertion site of purulent material. The drainage is purulent, tan, foul-smelling and thick. This drainage around the tube insertion site has been persistent despite changes in positioning of the tube. She was told not to flush the tube. She has associated abdominal tenderness and fullness that is mild. She is still able to eat, although her appetite seems reduced, and she's trying to follow low fat diet. She's been moving her bowels daily without difficulty. Denies bloody stools or hematuria. Has been getting OOB to chair, but not ambulating yet at rehab. Is still very fatigued. Taking cipro as prescribed and tolerating well. No diarrhea. Past Medical History: Pancreatic cystic mass s/p EUS-guided aspiration, asthma, COPD, hypothyroidism, hiatal hernia, GERD, migraines Social History: ___ Family History: breast cancer, heart disease, no history of pancreatic cancer Physical Exam: Prior To Discharge: VS: 98.2, 102, 100/63, 16, 96% RA GEN: Pleasant with NAD HEENT: NC/AT, PERRL, EOMI, NJ tube in place and bridled, no scleral icterus CV: Sinus tachy PULM: CTAB ABD: Midline incision with steri strip and c/d/I. LUQ with two red rubber drains to gravity drainage with small amount of purulent drainage, drains inserted in ostomy bag. EXTR: Warm, no c/c/e Pertinent Results: RECENT LABS: ___ 06:07AM BLOOD WBC-14.2* RBC-3.05* Hgb-8.1* Hct-27.0* MCV-89 MCH-26.6 MCHC-30.0* RDW-22.4* RDWSD-69.8* Plt ___ ___ 06:07AM BLOOD Glucose-98 UreaN-15 Creat-0.3* Na-144 K-4.0 Cl-103 HCO3-27 AnGap-14 ___ 06:07AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.0 MICRO: ___ 3:20 pm ABSCESS PANCREATIC ABCESS #1. GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ___ 4:30 pm FLUID,OTHER ABDOMENAL ABSEN. **FINAL REPORT ___ GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. RADIOLOGY: ___ CT ABD: IMPRESSION: 1. Decreased size of a large abdominal abscess measuring 14.7 x 8.8 x 7.0 cm, previously 23.0 x 12.3 x 10.0 cm. A percutaneous drainage catheter is coiled within the abscess. 2. Increased size of a multiloculated cystic lesion arising from the head/neck the pancreas, previously stable. Consider spread of infection into the cystic lesion, attention on follow-up. 3. New, small, bilateral pleural effusions. 4. Again seen large hiatal hernia with again seen flipped upside down stomach. ___ US PANCREAS: IMPRESSION: 12 ___ drainage catheter within the right abdominal collection remains in good position.Given the complexity of this collection and residual thick debris, up sizing the catheter should be considered as well as placing multiple catheters from different sites under CT guidance. ___ CT ABD: IMPRESSION: Marked interval improvement of peripancreatic abscess consistent with known peripancreatic necrosis extending from the pancreas to the right lower quadrant post open debridement. A large drain placed percutaneously ends anterior to the fluid collection in nonorganized pockets of fluid. Stable pancreatic head fluid collection corresponding to walled-off necrosis. No change in bilateral adnexal cystic lesions measuring up to 1.5 cm. Follow-up ultrasound can be obtained in ___ year. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 2. ALPRAZolam 0.5 mg PO BID:PRN anxiety 3. Ciprofloxacin HCl 500 mg PO Q12H 4. Docusate Sodium 100 mg PO BID 5. Levothyroxine Sodium 88 mcg PO DAILY 6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 7. Pantoprazole 40 mg PO Q24H 8. PredniSONE 20 mg PO DAILY 9. Senna 8.6 mg PO BID 10. Vitamin D 1000 UNIT PO DAILY 11. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN 12. Albuterol Inhaler 2 PUFF IH BID 13. Topiramate (Topamax) 100 mg PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 2. Calcium Carbonate 500 mg PO QID:PRN heartburns 3. Cyclobenzaprine 10 mg PO TID:PRN muscle spasms 4. Levofloxacin 500 mg PO Q24H 5. MetroNIDAZOLE 500 mg PO Q8H 6. Mirtazapine 7.5 mg PO QHS 7. Pantoprazole 40 mg PO Q24H 8. TraMADol 50 mg PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp #*20 Tablet Refills:*0 9. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate 10. ProAir HFA (albuterol sulfate) 2 puffs inhalation Q6H:PRN SOB 11. Levothyroxine Sodium 88 mcg PO DAILY 12. PredniSONE 20 mg PO DAILY 13. Topiramate (Topamax) 100 mg PO BID 14. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: 1. Necrotizing pancreas 2. Pancreatic abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (___). Followup Instructions: ___ Radiology Report EXAMINATION: CT-guided catheter exchange INDICATION: ___ with large infected pancreatic cyst s/p ___ drainage c/b sepsis, now p/f rehab with ___ tube no longer draining// please exchange/upsize drain today. please send cultures as well COMPARISON: CT scan of the abdomen pelvis dated ___ PROCEDURE: CT-guided drainage of abdominal collection. OPERATORS: Dr. ___ fellow and Dr. ___ radiologist. Dr. ___ supervised the trainee during the key components of the procedure and reviewed and agrees with the trainee's findings. TECHNIQUE: The risks, benefits, and alternatives of the procedure were explained to the patient. After a detailed discussion, informed written consent was obtained. A pre-procedure timeout using three patient identifiers was performed per ___ protocol. The patient was placed in a supine position on the CT scan table. Limited preprocedure CT scan was performed to localize the collection. 0.038 ___ wire was placed through the existing catheter and position was confirmed using CT fluoroscopy. The existing ___ catheter was then removed over the wire and a ___ dilator was used to dilate the tract. A ___ Exodus catheter was then placed over the wire, however CT fluoroscopic images after placement of the new catheter demonstrated position outside the abdominal collection. The catheter was removed. A satisfactory approach into the collection was not identified through the original catheter insertion site. A decision was then made to insert a new catheter via right lateral approach. Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was inserted into the collection. A sample of fluid was aspirated, confirming needle position within the collection. 0.038 ___ wire was placed through the needle and needle was removed. This was followed by placement of ___ Exodus pigtail catheter into the collection. The metal stiffener and the wire were removed. The pigtail was deployed. The position of the pigtail was confirmed within the collection via CT fluoroscopy. Approximately 110 cc of purulent fluid was aspirated with a sample sent for microbiology evaluation. The catheter was secured by a StatLock. The catheter was attached to suction bulb. Sterile dressing was applied. The procedure was tolerated well, and there were no immediate post-procedural complications. DOSE: Acquisition sequence: 1) Spiral Acquisition 8.5 s, 25.9 cm; CTDIvol = 8.0 mGy (Body) DLP = 197.9 mGy-cm. 2) Stationary Acquisition 14.1 s, 1.4 cm; CTDIvol = 146.8 mGy (Body) DLP = 211.3 mGy-cm. Total DLP (Body) = 419 mGy-cm. SEDATION: Moderate sedation was provided by administering divided doses of 1.5 mg Versed and 75 mcg fentanyl throughout the total intra-service time of 35 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. FINDINGS: 1. Multiloculated gas and fluid containing abdominal collection measuring 6.9 x 8.1 cm in maximal transverse ___, previously 7.0 x 8.8 cm. 2. Small bilateral pleural effusions. 3. Large hiatus hernia containing portions of the pancreas, stomach, and mesenteric fat. IMPRESSION: Successful CT-guided removal of existing 10 ___ pigtail catheter and placement of ___ pigtail catheter into the inferior aspect of the collection. Samples were sent for microbiology evaluation. Radiology Report EXAMINATION: PANCREAS US INDICATION: ___ year old woman with with large infected pancreatic cyst s/p ___ drainage c/b sepsis, p/f rehab with ___ tube no longer draining-> upsized to 12 FR, not draining much, white count increasing// evaluate fluid collection TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: CT abdomen/pelvis ___ and ultrasound guided intervention ___. FINDINGS: The newly placed right mid abdomen catheter is noted to terminate within a heterogeneous complex mid abdominal collection corresponding to the large collection previously seen on CT. This measures approximately 8.5 x 4.4 x 11.5 cm given limitations of ultrasound. This has somewhat decreased in size but remains quite large. IMPRESSION: 12 ___ drainage catheter within the right abdominal collection remains in good position.Given the complexity of this collection and residual thick debris, up sizing the catheter should be considered as well as placing multiple catheters from different sites under CT guidance. RECOMMENDATION(S): These recommendations were made at the time of pancreas Conference as well, ___ by Dr. ___ radiologist. NOTIFICATION: The findings were discussed with Daily, ___, M.D. by ___ ___, M.D. on the telephone on ___ at 10:05 am, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: CT-guided catheter exchange INDICATION: ___ year old woman with large infected pancreatic cyst with ___ Fr drain in place found to have multiloculated collection on ultrasound today// ? drain upsize ? additional drain COMPARISON: CT-guided drain placement dated ___. PROCEDURE: CT-guided drainage of abdominal collection. OPERATORS: Dr. ___ fellow and Dr. ___ radiologist. Dr. ___ supervised the trainee during the key components of the procedure and reviewed and agrees with the trainee's findings. TECHNIQUE: The risks, benefits, and alternatives of the procedure were explained to the patient. After a detailed discussion, informed written consent was obtained. A pre-procedure timeout using three patient identifiers was performed per ___ protocol. The patient was placed in a supine position on the CT scan table. Limited preprocedure CT scan was performed to localize the collection. The skin was cleaned and the site was prepped. The existing drainage catheter was cut and a 0.035 ___ wire was passed through the catheter into the collection. The wire was advanced into the collection and manipulated in order to break up existing septations. There was an immediate increase in drainage from the cut and of the existing catheter. The existing catheter was then removed over the wire, and a 12 ___ multi side-hole biliary drain was advanced over the wire. The plastic stiffener and the wire were removed. The pigtail was deployed. Postprocedure helical CT acquisition was performed which confirmed excellent positioning of the biliary drain, spanning the craniocaudal extent of the collection and with all sideholes distributed throughout the collection. Approximately 50 cc of purulent fluid was aspirated. The catheter was secured by an 0 silk suture and StatLock. The catheter was attached to suction bulb. Sterile dressing was applied. The procedure was tolerated well, and there were no immediate post-procedural complications. DOSE: Acquisition sequence: 1) Spiral Acquisition 8.6 s, 26.5 cm; CTDIvol = 10.6 mGy (Body) DLP = 265.8 mGy-cm. 2) Stationary Acquisition 6.1 s, 1.4 cm; CTDIvol = 64.0 mGy (Body) DLP = 92.1 mGy-cm. 3) Spiral Acquisition 10.8 s, 33.2 cm; CTDIvol = 11.6 mGy (Body) DLP = 368.2 mGy-cm. Total DLP (Body) = 735 mGy-cm. SEDATION: Moderate sedation was provided by administering divided doses of 1 mg Versed and 100 mcg fentanyl throughout the total intra-service time of 25 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. FINDINGS: Gas and fluid containing midabdominal collection measuring 6.0 x 7.4 cm in maximal transverse ___, previously 6.9 x 8.1 cm. IMPRESSION: Successful CT-guided catheter exchange. A 12 ___ multi side-hole biliary catheter was placed within the collection. No immediate postprocedure complication. Radiology Report EXAMINATION: CT-guided drain placement INDICATION: ___ year old woman with large infected pancreatic cyst s/p ___ drainage c/b sepsis, now p/f rehab with ___ tube no longer draining s/p ___ drain exchange x2// additional drain placement COMPARISON: CT-guided catheter exchange dated ___. PROCEDURE: CT-guided drainage of abdominal collection. OPERATORS: Dr. ___ fellow and Dr. ___ radiologist. Dr. ___ supervised the trainee during the key components of the procedure and reviewed and agrees with the trainee's findings. TECHNIQUE: The risks, benefits, and alternatives of the procedure were explained to the patient. After a detailed discussion, informed written consent was obtained. A pre-procedure timeout using three patient identifiers was performed per ___ protocol. The patient was placed in a supine position on the CT scan table. Limited preprocedure CT scan was performed to localize the collection. The 3 way stopcock was removed from the existing biliary catheter, and the catheter was flushed with 20 cc saline. No fluid could be reaspirated. Dilute iodinated contrast was injected into the collection, which demonstrated pooling within locules of the dependent portion of the collection. A 0.035 ___ wire was then introduced in order to break up septations within the collection. Following this drain manipulation, only minimal further fluid could be re-aspirated. At this point, a decision was made to place a second drain more cranially. Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was inserted into the collection. A sample of fluid was aspirated, confirming needle position within the collection. 0.035 ___ wire was placed through the needle and needle was removed. This was followed by placement of ___ Exodus pigtail catheter into the collection. The plastic stiffener and the wire were removed. The position of the catheter was confirmed within the collection via CT fluoroscopy. 30 cc normal saline was flushed into the catheter, with approximately 25 cc dilute purulent fluid re-aspirated. The catheter was secured with a Stat Lock and attached to a suction bulb. The procedure was tolerated well, and there were no immediate post-procedural complications. DOSE: Acquisition sequence: 1) Spiral Acquisition 7.6 s, 23.2 cm; CTDIvol = 11.7 mGy (Body) DLP = 255.3 mGy-cm. 2) Stationary Acquisition 21.7 s, 1.4 cm; CTDIvol = 225.8 mGy (Body) DLP = 325.1 mGy-cm. 3) Spiral Acquisition 7.6 s, 23.2 cm; CTDIvol = 12.1 mGy (Body) DLP = 265.3 mGy-cm. Total DLP (Body) = 856 mGy-cm. SEDATION: Moderate sedation was provided by administering divided doses of 100 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: Mid abdominal collection appears similar in size measuring 6.1 x 7.4 in maximal transverse ___, previously 6.0 x 7.4. There has been some interval decrease in size of the most cranial component of the collection. IMPRESSION: Successful CT-guided placement of ___ pigtail catheter into the collection. No immediate postprocedure complication. Radiology Report INDICATION: ___ year old woman with large infected pancreatic cyst s/p ___ drainage c/b sepsis, now p/f rehab with ___ tube no longer draining s/p ___ drain exchange x2// unsuccessful placement of PICC at bedside, please place in ___, thanks COMPARISON: None 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. MEDICATIONS: None CONTRAST: None FLUOROSCOPY TIME AND DOSE: 54 seconds, 1 mGy PROCEDURE: 1. Single lumen PICC placement through the left brachial vein. PROCEDURE DETAILS: Using sterile technique and local anesthesia, the left 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 PICC line measuring 36.5 cm in length was then placed through the peel-away sheath with its tip positioned in the distal SVC under fluoroscopic guidance. Position of the catheter was confirmed by a fluoroscopic spot film of the chest. The peel-away sheath and guidewire were then removed. The catheter was secured to the skin, flushed, and a sterile dressing applied. The patient tolerated the procedure well. There were no immediate complications. FINDINGS: 1. The accessed vein was patent and compressible. 2. Brachial vein approach single lumen left PICC with tip in the distal SVC. IMPRESSION: Successful placement of a left 36.5 cm brachial approach single lumen PowerPICC with tip in the distal SVC. The line is ready to use. Radiology Report INDICATION: ___ F s/p infected pancreatic cyst debridement// confirm new dobhoff tube position COMPARISON: CT scan from ___ IMPRESSION: There is a Dobhoff tube whose distal portion is looped within a large hiatal hernia. The distal Dobhoff tube projects entirely over the right lung base; however on the prior chest CT, much of the stomach has herniated into the right chest. Heart size is within normal limits. Lungs are grossly clear. There are no pneumothoraces. Pigtail catheter projects over the upper abdomen. Radiology Report INDICATION: ___ year old woman with pancreatic neoplasm/infected cyst, s/p multiple ___ drainage, now s/p debridement, OR drainade.// please evaluate for interval change in peripancreatic cyst, s/p surgical debridement and large drains placement. IV contrast 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 3.7 s, 49.2 cm; CTDIvol = 11.9 mGy (Body) DLP = 587.0 mGy-cm. 2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7 mGy-cm. 3) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7 mGy-cm. Total DLP (Body) = 590 mGy-cm. COMPARISON: Multiple priors dating back to ___ and more recently with procedure CT of ___. FINDINGS: LOWER CHEST: Subsegmental atelectasis of the right lung base secondary to large hiatal hernia. ABDOMEN: The liver, spleen, adrenal glands and kidneys are unremarkable except for a few stable hypodense renal lesions too small to characterize. The gallbladder is within normal limits. No biliary ductal dilatation. PANCREAS: There is a stable 4 cm cystic lesion in the superior aspect of the pancreatic head corresponding to walled-off necrosis. The abscess and peripancreatic necrosis anterior to the pancreatic head extending inferior into the right lower quadrant are markedly improved. For instance, superiorly it measures up to 3.8 cm, previously 8 cm and inferiorly measuring 3.5 cm, previously 7 cm where a drain was placed. Adjacent to the cecum, there are now phlegmonous changes, previously a gas containing fluid collection measuring 6 cm. An anterior percutaneous large-bore rubber drain ends in non organized fluid and soft tissue stranding anterior to the peripancreatic fluid collection. Stable thickening of the left anterior pararenal space sequela of pancreatitis. GASTROINTESTINAL: Large hiatal hernia is again seen. There is no intestinal obstruction or ascites. An enteric tube ends in the third portion of the duodenum. PELVIS: There is a small of free pelvic fluid. Bilateral adnexal cystic lesions measuring up to 1.5 cm are stable. LYMPH NODES: No enlarged abdominal or pelvic lymph nodes are seen. VASCULAR: There is no abdominal aortic aneurysm. The portal vasculature is patent.. BONES: No worrisome osseous lesions are seen. SOFT TISSUES: Postoperative changes are seen in the anterior abdominal wall including pockets of subcutaneous gas. IMPRESSION: Marked interval improvement of peripancreatic abscess consistent with known peripancreatic necrosis extending from the pancreas to the right lower quadrant post open debridement. A large drain placed percutaneously ends anterior to the fluid collection in nonorganized pockets of fluid. Stable pancreatic head fluid collection corresponding to walled-off necrosis. No change in bilateral adnexal cystic lesions measuring up to 1.5 cm. Follow-up ultrasound can be obtained in ___ year. Radiology Report EXAMINATION: CT abdomen/pelvis INDICATION: ___ with abdominal drain for large intraperitoneal 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 not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 16.9 mGy (Body) DLP = 8.4 mGy-cm. 2) Spiral Acquisition 6.2 s, 49.1 cm; CTDIvol = 18.1 mGy (Body) DLP = 888.8 mGy-cm. Total DLP (Body) = 897 mGy-cm. COMPARISON: ___ CT abdomen/pelvis and CT-guided drain placement ___ abdominal MRI ___ CT abdomen/pelvis FINDINGS: LOWER CHEST: New, small, bilateral pleural effusions with adjacent relaxation atelectasis. 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: A multiloculated cystic lesion arising from the head/neck of the pancreas has increased in size since 2 weeks prior, previously stable over multiple months, measuring up to 5.3 x 3.0 cm, most recently 3.6 x 3.0 cm. The pancreatic parenchyma enhances homogeneously. The distal pancreatic tail is included in a portion of the large hiatal hernia sac. 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. Soft tissue or fluid adjacent to the superior pole of the left kidney spanning approximately 2.7 x 1.0 cm is not appreciably changed. Additional soft tissue also adjacent to the anterior superior pole the left kidney is decreased, spanning 1.3 x 1.2 cm, previously 1.6 x 1.2 cm. GASTROINTESTINAL: Large hiatal hernia with flipped upside down stomach again seen. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is not visualized. A large, gas containing, rim enhancing intra-abdominal fluid collection has decreased in size since 2 weeks prior, now measuring up to 14.7 x 8.8 x 7.0 cm, previously 23.0 x 12.3 x 10.0 cm. The abdominal drain is coiled within the mid to superior portion of the fluid collection. PELVIS: The urinary bladder and distal ureters are unremarkable. There is small volume free pelvic fluid. REPRODUCTIVE ORGANS: The uterus and adnexae are unremarkable for patient age. 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 densely sclerotic lesion in the right iliac bone probably reflects a bone island. Another sclerotic lesion left iliac bone probably reflects a bone island. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Decreased size of a large abdominal abscess measuring 14.7 x 8.8 x 7.0 cm, previously 23.0 x 12.3 x 10.0 cm. A percutaneous drainage catheter is coiled within the abscess. 2. Increased size of a multiloculated cystic lesion arising from the head/neck the pancreas, previously stable. Consider spread of infection into the cystic lesion, attention on follow-up. 3. New, small, bilateral pleural effusions. 4. Again seen large hiatal hernia with again seen flipped upside down stomach. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Wound eval Diagnosed with Disease of pancreas, unspecified temperature: 98.3 heartrate: 95.0 resprate: 18.0 o2sat: 95.0 sbp: 110.0 dbp: 59.0 level of pain: 0 level of acuity: 3.0

The patient with known pancreatic abscess s/p ___ drainage was re-admitted from rehabilitation with non working drain. Patient had leukocytosis on 21.1 on admission. CT scan demonstrated decreased abdominal abscess after drainage,, and increased multiloculated cystic lesion concerning for spreading infection (please see Radiology report for details). On ___ patient went in ___, where she underwent exchange and upsize of excising drain from ___ to ___. Patient's was transitioned to Cefepime/Flagyl for Cipro per ID recommendations. Post procedure patient's diet was advanced to regular and patient tolerated diet well. On ___, patient was noticed to have increased WBC and pancreas US was obtained. US demonstrated complex peripancreatic fluid collection with many debris, drain terminated within collection. On the same day, patient underwent drain exchange. Patient's WBC started to downward after procedure. On ___ patient underwent PICC line placement for long term antibiotics. She underwent additional drain placement by ___ via midline approach. Post procedure, new drain was flushed multiple times. Despite flushing, drain output from new drain was zero. For the following 10 days patient was continued on IV antibiotics, she remained afebrile with elevated WBC, drain # 1 continue to have minimal purulent output from drain and around insertion side. Secondary to not demonstrating any improvement, on ___ patient was taken in OR. She underwent open US guided open pancreatic abscess drainage and necrosis debridement. Post operative patient was transferred back to the floor NPO, with IV fluids, on antibiotics, one old ___ drain to bulb suctions, and 2 new red rubber drains to continuous irrigation with suction. The patient was hemodynamically stable. On HD 1, patient was advanced to regular diet, which was poorly tolerated secondary to pain, muscle spasms and lack of appetite. Nutritional consult was requested, and tube feeding was recommended. On POD 5, patient underwent EGD and NJ was placed. Patient was started on tube feeds. On POD 6, patient old ___ drain was dislodged and removed. Patient was transitioned to Levofloxacin from Cefepime per ID recommendations. On POD 8, patient underwent CT scan, which demonstrated marked interval improvement of peripancreatic abscess consistent with known peripancreatic necrosis extending from the pancreas to the right lower quadrant post open debridement. Patient was screened for rehabilitation.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Dilantin / Sulfa (Sulfonamide Antibiotics) / Triptans-5-HT1 Antimigraine Agents / Latex / Ciprofloxacin / aspirin Attending: ___. Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ woman with history of seizures, non-epileptic spells, migraine w/ aura, depression, anxiety, PTSD, and chronic pain presenting with altered mental status following witnessed seizure at home. History is obtained per ED documentation and from partner at bedside. She was in her usual state of health until this morning, when she woke up speaking unintelligibly, which attributed to either seizure activity or exhaustions. She went back to sleep after a short period of time. He became more concerned when he returned home at 1:30pm to find her again not speaking clearly. She then proceeded to have what he describes as her typical ___ mal seizure" with rhythmic shaking of all extremities x ___, with about 4 min of post-ictal sleepiness and lack of verbal output. It is unclear if she returned to baseline after this but around 2:30pm, she became completely unresponsive, with eyes open, so after about 5 min of this he called EMS. She was taken to an ___, where she remained significantly altered and received 2mg Ativan and 1g Keppra. Head CT was done and negative for acute pathology. Neurology was consulted there and recommended transfer for 24h EEG. She has a long history of both seizures and non-epileptic events. Partner reports current event frequency of GTC nearly every day, and "petit mal" seizures at least once daily, going on at least months-years. She is followed by Dr. ___ at ___, who saw her most recently on ___. Seizure history as per her progress note from that day as follows: "Her first seizure was in ___. Her epileptic seizures start with fuzziness, may be associated with a headache, and she has LOC. This can progress to 2 different seizure types, one with low amplitude shaking of the right or bilateral arms and flexion of her right arm and leg, the second with more dramatic bilateral arm shaking. She can have associated tongue biting, bowel/bladder incontinence, and postictal fatigue. She also has nonepileptic seizures described as feeling dissociated with low amplitude shaking of her entire body. She has been diagnosed with both complex partial and generalized tonic-clonic seizures, and nonepileptic seizures.. MRI brain without contrast in ___ at ___ was normal. MRI brain with and without contrast ___ at ___ was normal. Routine EEGs at ___ in ___ and ___ were normal. Routine EEG in ___ showed rare left temporal slowing. A 72 hour ambulatory EEG in ___ showed 28 clinical seizures and 12 electrographic, most with left temporal onset. She had an inpatient EEG LTM admission at ___ in ___ in which she had multiple pushbutton events for head nodding, blinking, shoulder rocking, and tongue fluttering without electrographic correlate. Routine EEG ___ was normal. She has been trialed on Depakote 1250 mg b.i.d., gabapentin 1200 mg q.i.d., Lamictal 300 mg b.i.d., Klonopin, Topamax 150 mg b.i.d. caused kidney stones, and Tegretol caused suicidality. She is currently on Depakote and Lamictal." ROS: unable to obtain Past Medical History: 1. Epilepsy documented epileptic and non epileptic seizures 2. Migraine. 3. Fibromyalgia. 4. Depression. 5. Anxiety. 6. PTSD. 7. Gastroparesis. 8. Hyperlipidemia. 9. Asthma. Social History: ___ Family History: Negative for seizures or epilepsy. Physical Exam: Physical Exam on Admission: =========================== Vitals: T: afebrile P: 56 R: 16 BP: 89/47 SaO2: 98% (RA) General: Minimally responsive HEENT: NC/AT, no scleral icterus noted, MMM Neck: No nuchal rigidity Pulmonary: No increased work of breathing Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT, normoactive bowel sounds Extremities: B/l ___ edema Neurologic: -Mental Status: Obtunded, open eyes to noxious stimuli and following simple 1-step commands - "open your eyes", "stick out your tongue", "show me your thumb". No verbal output. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm. Buries sclerae on lateral gaze bilaterally, with conjugate eye movements. Face symmetric. -Sensory: Grimaces to noxious stimuli in all extremities. -DTRs: Bi ___ Pat Ach L 1+ 1 0 1 R 1+ 1 0 1 Plantar response was flexor bilaterally. -Coordination/gait: unable to assess Physical Exam on Discharge: =========================== General: Lying in bed, NAD HEENT: NC/AT, no scleral icterus noted, MMM Neck: No nuchal rigidity Pulmonary: No increased work of breathing Cardiac: RRR, no M/R/G noted Abdomen: soft, NT, normoactive bowel sounds Extremities: B/l ___ edema Neurologic: -Mental Status: Awake, eyes open and attentive to examiner. Language appears intact w/ latency in speech. No apparent dysarthria. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm. Buries sclerae on lateral gaze bilaterally, with conjugate eye movements. Face symmetric. -Sensory: Intact in all extremities -DTRs: Bi ___ Pat Ach L 1+ 1 0 1 R 1+ 1 0 1 Plantar response was flexor bilaterally. -Coordination/gait: unable to assess Pertinent Results: LABS: ___ 09:10AM BLOOD WBC-10.9* RBC-3.53* Hgb-11.7 Hct-35.0 MCV-99* MCH-33.1* MCHC-33.4 RDW-13.4 RDWSD-49.1* Plt ___ ___ 06:46AM BLOOD Glucose-91 UreaN-9 Creat-0.8 Na-147 K-4.2 Cl-110* HCO3-21* AnGap-16 ___ 06:29PM BLOOD Valproa-104* ___ 06:29PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 06:52PM BLOOD Lactate-1.8 ___ 06:55PM URINE Color-Yellow Appear-Clear Sp ___ ___ 06:55PM URINE Blood-MOD* Nitrite-NEG Protein-30* Glucose-NEG Ketone-TR* Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 06:55PM URINE RBC-9* WBC-4 Bacteri-NONE Yeast-NONE Epi-0 Imaging: CTH OSH: reportedly without acute intracranial abnormalities EEG: No electrographic correlate for clinical episodes seen on video; intermittent brief electrographic patterns concerning for seizure w/ no clinical correlate Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Divalproex (DELayed Release) 750 mg PO QAM 2. Divalproex (DELayed Release) 1250 mg PO QPM 3. DULoxetine 90 mg PO DAILY 4. Propranolol 30 mg PO BID 5. LORazepam 1 mg PO BID:PRN anxiety 6. Fentanyl Patch 75 mcg/h TD Q72H 7. Montelukast 10 mg PO DAILY 8. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath Discharge Medications: 1. LamoTRIgine 150 mg PO BID 2. Prazosin 2 mg PO QHS RX *prazosin 2 mg 1 capsule(s) by mouth At bedtime Disp #*30 Capsule Refills:*0 3. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 4. Divalproex (DELayed Release) 750 mg PO QAM 5. Divalproex (DELayed Release) 1250 mg PO QPM 6. DULoxetine 90 mg PO DAILY 7. Fentanyl Patch 75 mcg/h TD Q72H 8. LORazepam 1 mg PO BID:PRN anxiety 9. Montelukast 10 mg PO DAILY 10. Propranolol 30 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Epileptic and Non-epileptic Seizures Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with seizure, postictal, vomiting// aspiration TECHNIQUE: Single frontal view of the chest COMPARISON: ___ FINDINGS: Enteric tube courses below the diaphragm out of the field of view, but extends into the expected location of the stomach. No focal consolidation is seen. There is no large pleural effusion or pneumothorax. Cardiac silhouette size is mildly enlarged. Mediastinal contours are grossly unremarkable. IMPRESSION: No definite acute cardiopulmonary process. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Seizure, Transfer Diagnosed with Epilepsy, unsp, not intractable, without status epilepticus temperature: 95.5 heartrate: 54.0 resprate: 12.0 o2sat: 99.0 sbp: 100.0 dbp: 60.0 level of pain: unable level of acuity: 2.0

Ms. ___ is a ___ woman with history of seizures, non-epileptic spells, migraine w/ aura, depression, anxiety, PTSD, and chronic pain presenting with altered mental status following witnessed seizure at home. CT head negative for acute process, electrolytes WNL on arrival, tox screen negative, CBC and urine w/o evidence of infection. Valproic acid of 104 on admission. Multiple events captured on cvEEG which have been so far been non-epileptic; however there are brief epileptic events concerning for seizures without clinical correlate. Pt was initially combative upon admission but seems to have settled down. While stable from a neurologic standpoint, psychiatry was consulted to monitor her mental state to determine if safe to leave hospital. She was started on Prazosin 2mg qhs with improvement in behavior. After monitoring over ___ days, it was deemed that pt was stable to go home with psychiatric/neurologic follow up.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: RUQ pain Major Surgical or Invasive Procedure: ___: CT-guided drainage of collection posterior to the right lobe of the liver History of Present Illness: ___ s/p laparoscopic subtotal cholecystectomy for acute on chronic cholecystitis ___ complicated by retained intra-abdominal stones necessitating drainage of abscess and open removal of stones ___ (___) returns with persistent right upper quadrant pain and drainage from his old open cholecystectomy scar. He has not experienced any fevers, chills, nausea, vomiting, constipation or diarrhea. He has experienced roughly a thirty pound weight loss over the last year. Since the ___, he has had a draining sinus from his old incision. He was evaluated by surgery at that time and was noted to have drainage but was otherwise asymptomatic and this was followed. Surgery is now consulted for further workup and management Past Medical History: -DMII (on insulin + metformin) -HTN -HL -chronic back pain / sciatica -bilat eustachean tube dysfxn (followed at ___) -choledocholithiasis + cholecystitis s/p subtotal lap chole ___ Past Surgical History: -3 hernia repairs -knee surgery bilaterally -subtotal lap chole ___ [back wall left behind to avoid bleeding] Social History: ___ Family History: Mother passed at age ___, DMII Physical Exam: Admission Physical Exam ___: Vitals: Temp 97.8 HR 94 BP 145/91 RR 14 97% RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, minimally tender RUQ, no rebound or guarding, normoactive bowel sounds, no palpable masses Incision: lateral pinpoint drainage of purulent fluid Ext: No ___ edema, ___ warm and well perfused Discharge PE: ___: Vitals: 98.2, 70, 134/64, 18, 97% on RA Gen: NAD, comfortable appearing man Lungs: CTAB CV: S1, S2, RRR Abd: soft, nontender, nondistended, ___ guided JP drain in Left flank with scant bilous tinged drainage. Extrm: warm, well perfused, +PP Neuro: A+OX3, MAE to command, PERRL Pertinent Results: ___ 01:30PM PLT COUNT-278 ___ 01:30PM WBC-6.5 RBC-4.05* HGB-11.1* HCT-34.8* MCV-86 MCH-27.4 MCHC-32.0 RDW-15.8* ___ 01:30PM WBC-6.5 RBC-4.05* HGB-11.1* HCT-34.8* MCV-86 MCH-27.4 MCHC-32.0 RDW-15.8* ___ 01:30PM ALBUMIN-3.6 ___ 01:30PM LIPASE-12 ___ 01:30PM ALT(SGPT)-10 AST(SGOT)-13 ALK PHOS-61 TOT BILI-0.2 ___ 01:30PM estGFR-Using this ___ 01:30PM GLUCOSE-198* UREA N-14 CREAT-0.7 SODIUM-139 POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-26 ANION GAP-14 ___ 09:30AM BLOOD WBC-6.2 RBC-4.01* Hgb-11.0* Hct-34.5* MCV-86 MCH-27.5 MCHC-32.0 RDW-15.9* Plt ___ ___ 09:30AM BLOOD Plt ___ ___ 09:30AM BLOOD Glucose-269* UreaN-22* Creat-1.0 Na-137 K-5.1 Cl-100 HCO3-26 AnGap-16 ___ 06:10AM BLOOD ALT-9 AST-14 AlkPhos-61 TotBili-0.4 ___ 09:30AM BLOOD Calcium-9.2 Phos-4.3 Mg-2.0 ___: CT ABD/PELVIS: 1. New subdiaphragmatic fluid collection with rim enhancement along the posterior right hepatic lobe measures up to 4.9 cm, compatible with abscess. 2. New moderate right pleural effusion. 3. Small residual fluid collection along the anterolateral right hepatic lobe appears smaller compared to prior studies; however, superinfection cannot be excluded. 4. Hepatic and renal cysts. 5. Splenomegaly. 6. Enlarged prostate. ___: ___ Drainage: Technically successful CT-guided drainage of collection posterior to the right lobe of the liver with 20 cc of purulent fluid withdrawn, a sample of which was sent for analysis. An additional 90 cc of clear yellow right pleural fluid were withdrawn for better access for drainage of right posterior upper abdominal collection. ___: CXR: There is now complete clearing of pre-existing interstitial parenchymal opacities ___ 3:00 pm FLUID,OTHER LIVER ABSCESS. ___ ADDON PER ___ ___ @0819. GRAM STAIN (Final ___: Reported to and read back by ___ @ 1834 ON ___ - ___. 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): THIN BRANCHING GRAM POSITIVE ROD(S). MODIFIED ACID-FAST STAIN FOR NOCARDIA (Final ___: No thin, branching, partially acid fast rods seen. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Pending): ___ 3:00 pm PLEURAL FLUID ADDON FOR ___ PER ___ ___ @0819. GRAM STAIN (Final ___: Reported to and read back by ___ @ 1834 ON ___ - ___. 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): THIN BRANCHING GRAM POSITIVE ROD(S). MODIFIED ACID-FAST STAIN FOR NOCARDIA (Final ___: No thin, branching, partially acid fast rods seen. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Pending): Medications on Admission: Amitriptyline 25 mg PO HS Hydrochlorothiazide 25 mg PO DAILY Metoprolol Tartrate 75 mg PO BID Lisinopril 20 mg PO DAILY MetFORMIN (Glucophage) 500 mg PO BID Glargine 20 Units SC BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Amitriptyline 25 mg PO HS 3. Docusate Sodium 100 mg PO BID 4. Hydrochlorothiazide 25 mg PO DAILY 5. Metoprolol Tartrate 75 mg PO BID 6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 capsule(s) by mouth every four (4) hours Disp #*25 Capsule Refills:*0 7. Penicillin V Potassium 500 mg PO Q6H RX *penicillin V potassium 500 mg 1 tablet(s) by mouth every six (6) hours Disp #*56 Tablet Refills:*0 8. Sulfameth/Trimethoprim DS 1 TAB PO BID RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by mouth twice a day Disp #*28 Tablet Refills:*0 9. Lisinopril 20 mg PO DAILY 10. MetFORMIN (Glucophage) 500 mg PO BID 11. Glargine 20 Units Breakfast Glargine 20 Units Dinner Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Hepatic Abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: ___ male with right upper quadrant pain for two days, with weight loss. History of cholecystectomy, complicated by recurrent right upper quadrant abscesses. Evaluation for stones, abscesses, or other pathology contributing to right upper quadrant pain. COMPARISON: Comparison is made to outside CT of the chest from ___ and CT of the abdomen and pelvis from ___. TECHNIQUE: Axial MDCT images were obtained through the abdomen and pelvis after the administration of oral and intravenous contrast. Reformatted coronal and sagittal images were also reviewed. DLP: 735.1 mGy-cm. FINDINGS: CT ABDOMEN: A moderate-to-large right pleural effusion is new since the prior CT of the chest (2:1) and is nonhemorrhagic. There is a 1.9 x 4.4 x 4.9 cm subdiaphragmatic fluid collection along the posterior right hepatic lobe (2:13, 601B:49), new since the prior studies, with surrounding fat stranding and relative ___ of the rim, compatible with abscess formation. Additionally, there is a 2.8-cm fluid collection along the lateral right hepatic lobe in the area of prior gallbladder fossa fluid collection, as seen on the prior CT from ___ and previously drained via ultrasound-guided drain placement on ___. This collection is slightly smaller when compared to the prior chest CT from outside hospital on ___. Two 8mm associated hyperdensities compatible with retained gallstones are again noted (2:34, 2:31). An 11-mm hypodensity in the left hepatic lobe (2:8) is unchanged, likely a hepatic cyst. The portal vein is patent, and there is no intra- or extra-hepatic biliary ductal dilatation. The gallbladder is surgically absent. The spleen is enlarged, measuring 14 cm in greatest axial dimension and greatest craniocaudal dimension (601B:41). The bilateral adrenal glands are unremarkable. An exophytic cyst is noted along the lower pole of the right kidney (2:39); otherwise, the kidneys present symmetric nephrograms and excretion of contrast. Fat stranding along Gerota's fascia and extending down the lateral conal fascia on the right is noted. There is no intraperitoneal free air or free fluid. The pancreas is relatively atrophic but unchanged compared to prior studies. Note is made of subcentimeter left renal cysts as well. The stomach, duodenum, and small bowel are normal in course and caliber with no evidence of wall thickening or obstruction. Enteric contrast material is seen to the level of the sigmoid colon. Moderate fecal load is noted. CT PELVIS: The rectum and sigmoid colon are filled with a large amount of fecal material. The bladder and terminal ureters are unremarkable. The prostate gland is enlarged, similar in appearance compared to prior studies. There is no pelvic free fluid. No pelvic side wall or inguinal lymphadenopathy is noted. OSSEOUS STRUCTURES: No lytic or blastic lesion suspicious for malignancy is identified. IMPRESSION: 1. New subdiaphragmatic fluid collection with rim enhancement adjacent to the posterior right hepatic lobe measures up to 4.9 cm, compatible with abscess. 2. New moderate right pleural effusion. 3. Small residual fluid collection along the anterolateral right hepatic lobe appears smaller compared to prior studies; however, superinfection cannot be excluded. Two associated 8 mm hyperdensities persist and are compatible with retained stones. 4. Hepatic and renal cysts. 5. Splenomegaly. 6. Enlarged prostate. Radiology Report HISTORY: ___ man with subdiaphragmatic abscess. Evaluation for retained stones. COMPARISON: Comparison is made to CT of the abdomen and pelvis obtained earlier today, as well as outside CT of the chest from ___ and CT of the abdomen and pelvis from ___. FINDINGS: Limited grayscale and color Doppler ultrasound of the area of concern along the posterior upper right hepatic lobe under the diaphragm demonstrates a moderate right pleural effusion, as well as a hypoechoic fluid collection under the diaphragm, measuring approximately 3.0 x 2.0 x 2.6 cm, compatible with the previously seen findings on recent CT. There is no evidence of calcified gallstones within the area of this new collection. The chronic fluid collection along the anterolateral margin of the right hepatic lobe is similar in appearance to the prior studies, with two adjacent subcentimeter echogenic shadowing stones, as seen previously. IMPRESSION: 1. No evidence of retained gallstones in the area of the new subdiaphragmatic fluid collection along the posterior right hepatic lobe. 2. The previously drained fluid collection along the anterolateral right hepatic lobe is again seen, with two adjacent subcentimeter shadowing gallstones, unchanged. Radiology Report EXAMINATION: CT-guided drainage INDICATION: Right posterior hepatic abscess seen on CT scan. Please aspirate/place drain. Send fluid for gram stain, culture, and bilirubin. COMPARISON: Compared with previous CT abdomen pelvis from ___ and previous abdominal ultrasound from ___. PROCEDURE: CT-guided drainage OPERATORS: Dr. ___, abdominal radiology attending, who was present and supervising throughout the total procedure time and Dr. ___, abdominal radiology fellow. TECHNIQUE: The risks, benefits, and alternatives of the procedure were explained to the patient. After a detailed discussion, informed written consent was obtained from the patient. A pre-procedure timeout using three patient identifiers was performed as per ___ protocol. The patient was placed in a right lateral decubitus position on the CT scan table. Limited preprocedure CTscan of the intended drainage area was performed. Based on the CT findings an appropriate position for the drain placement was chosen. The site was marked. The site was prepped and draped in the usual sterile fashion. 8 cc of 1% lidocaine were administered to the subcutaneous and deep tissues for local anesthetic effect. Under CT guidance, an 18 gauge, 15 cm ___ needle was introduced into the collection posterior to the liver via a posterior approach and during placement a total of 90 cc of clear yellow fluid were withdrawn from the right pleural space in order to obtain better access to the right upper quadrant collection posterior to the liver. Subsequently, a ___ wire was introduced through the ___ needle and exchange was made for a 6 ___ ___ pigtail catheter. A total of 20 cc of green purulent fluid were withdrawn from the catheter, and a sample was sent for culture, gram stain and bilirubin as requested. The pigtail catheter was fixed in place with a 0 silk suture and attached to a JP suction bulb. The procedure was well tolerated and there were no immediate post-procedural complications. DOSE: DLP: 242 mGy-cm. SEDATION: Moderate sedation was provided by administering divided doses of 2 mg Versed and 100 mcg fentanyl throughout the total intra-service time of 22 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. FINDINGS: A pre-procedure CT of the upper abdomen, which is limited due to the lack of contrast, demonstrates a moderate-sized right pleural effusion. Again noted is a well-defined collection posterior to the right lobe of the liver which measures 3.7 x 5.3 cm (3:13). In addition, just deep to the abdominal wall muscles and to the right of the liver there is a small collection measuring 3.2 x 1.1 cm. There are a few prominent porta hepatic lymph nodes, which are likely reactive. There has been prior cholecystectomy. There is mild to moderate atherosclerosis of the visualized abdominal aorta. IMPRESSION: Technically successful CT-guided drainage of collection posterior to the right lobe of the liver with 20 cc of purulent fluid withdrawn, a sample of which was sent for analysis. An additional 90 cc of clear yellow right pleural fluid were withdrawn for better access for drainage of right posterior upper abdominal collection. Findings were discussed with Dr. ___, from the surgery consultation team at 3:20 ___, 15 min after completion of the procedure. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man with liver abscess and pleural effusions s/p ___ drainage of each // please evaluate for pneumothorax COMPARISON: ___. IMPRESSION: There is now complete clearing of pre-existing interstitial parenchymal opacities. Moderate cardiomegaly persists. Status post thoracocentesis of a right pleural effusion. Last filling is a small amount of right effusion, on the lateral than on the frontal image. A part of this effusion could be subpulmonary. There is no evidence of pneumothorax. No left effusion. . Gender: M Race: WHITE - BRAZILIAN Arrive by WALK IN Chief complaint: RUQ abdominal pain Diagnosed with PERITONEAL ABSCESS, DIABETES UNCOMPL ADULT, HYPERTENSION NOS temperature: 98.8 heartrate: 99.0 resprate: 16.0 o2sat: 100.0 sbp: 179.0 dbp: 90.0 level of pain: 5 level of acuity: 3.0

Mr. ___ is a ___ y.o. man with PMH significant for Diabetes, HTN, HLD s/p lap subtotal cholecystectomy in ___ which was complicated by retained stones within the abdomen s/p removal of stones and abscess drainge in ___ who returned with new liver abscess. He presented ___ with increased RUQ abdominal pain and drainage from the incision of his previous cholecystectomy site. CT ABD/PELVIS on admission revealed a new subdiaphragmatic fluid collection with rim enhancement adjacent to the posterior right hepatic lobe measures up to 4.9 cm compatible with abscess and new moderate right pleural effusion. Right upper quadrant ultra sound was negative for retained stone and new subdiaphragmatic fluid collection along the posterior right hepatic lobe consistant with CT scan. On ___, ___ evaluated the patient, placed a drain posterior to the right lobe of the liver, and send culture from the purulent fluid that was aspirated. ___ also aspirated fluid from the new right pleural effusion at this time and sent it for culture. ID was consulted at this time. While inpatient, the patient remained afebrile and hemodynamically stable. His WBC remained in the 6.0-7.0 range. At the time of discharge the patient's drain remained in place with scant, bilous tinged fluid. His gram stain at the time grew out thin branching rods. Given the length of time for this to speciate, the decision was made with ID to send the patient home on empiric coverage for Norcardia and Actinomycosis. He will follow up with ID in 2 weeks. He was tolerating a regular diet without nausea and vomitting. He was ambulating independently. He will follow up with the ___ clinic in 2 weeks and will have ___ services at the time of discharge to assist with drain care.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: adhesive tape Attending: ___. Chief Complaint: fall from horse Major Surgical or Invasive Procedure: none History of Present Illness: ___, otherwise healthy, presenting after a fall from a horse during a riding competition. Per the patient, witnesses and a video taken of the incident, she was riding her horse, when it made a few jerking movements which caused her to likely hit her head and hyperextend her neck on the back of the horse and lose consciousness. After a few seconds, she fell off the horse. According to witnesses, she lost consciousness for about ___ minutes. She denies any memory loss, nausea, vomiting or headaches. Past Medical History: Past Medical History: HTN, lost sense of smell due to head injury many years ago Past Surgical History: cataracts, corneal transplant Social History: ___ Family History: non-contributory Physical Exam: Admission Physical exam: Vitals: 97.9 86 133/77 22 97%RA GEN: A&Ox3, NAD, c-collar in place HEENT: No scleral icterus, mucus membranes moist CV: RRR, no chest wall tenderness PULM: Clear to auscultation b/l ABD: Soft, nondistended, nontender, no rebound or guarding Ext: No ___ edema, ___ warm and well perfused Discharge Physical Exam: VS:98.0, 129/87, 59, 16, 99 Ra Gen: A&O x3. dressed and ambulating in room. NAD. HEENT: hard collar on CV: HRR Pulm: LS ctab Abd: soft NT/ND Ext: WWP no edema, atraumatic Neuro: Intact. No deficits. Pertinent Results: ___ 09:35AM BLOOD WBC-6.0 RBC-4.42 Hgb-14.1 Hct-42.1 MCV-95 MCH-31.9 MCHC-33.5 RDW-13.2 RDWSD-46.6* Plt ___ ___ 02:47PM BLOOD WBC-7.2 RBC-4.45 Hgb-14.2 Hct-42.6 MCV-96 MCH-31.9 MCHC-33.3 RDW-13.7 RDWSD-48.4* Plt ___ ___ 08:45PM BLOOD WBC-10.2* RBC-4.31 Hgb-13.5 Hct-40.9 MCV-95 MCH-31.3 MCHC-33.0 RDW-13.5 RDWSD-47.6* Plt ___ ___ 09:35AM BLOOD Glucose-82 UreaN-15 Creat-0.9 Na-137 K-3.7 Cl-95* HCO3-26 AnGap-16 ___ 02:47PM BLOOD Glucose-115* UreaN-18 Creat-0.9 Na-142 K-3.8 Cl-99 HCO3-28 AnGap-15 ___ 08:45PM BLOOD Glucose-99 UreaN-19 Creat-0.9 Na-141 K-4.0 Cl-100 HCO3-26 AnGap-15 ___ 09:35AM BLOOD Calcium-9.2 Phos-2.3* Mg-1.9 ___ 02:47PM BLOOD Calcium-9.6 Phos-2.9 Mg-2.0 Radiology: MR ___ ___: 1. Focal narrowing and irregularity of the distal V2 segment of the right vertebral artery and as it passes through the right C2 transverse foramen at the site of the known fracture. Findings are suspicious for dissection. 2. There is no infarct or parenchymal hemorrhage. There is a small amount of dependent hemorrhage in the occipital horns of both lateral ventricles. 3. 4.5 cm heterogenous right thyroid mass. Ultrasound is advised for further evaluation. CT c-spine ___: 1. Comminuted mildly impacted fracture of the right C2 articular pillar and transverse process including significant impingement on the right vertebral artery foramen. 2. Moderate degenerative changes probably explaining small multilevel spondylolisthesis. 3. Large nodule in the right thyroid. ___ evaluation with ultrasound is recommended when clinically appropriate. CT Head ___: No evidence of a cute intracranial process or injury. Pelvis X-ray ___: No evidence of fracture or dislocation. Medications on Admission: aspirin 81mg daily Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Aspirin 81 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: [] Right C2 articular pillar and transverse process fracture [] Right vertebral foraminal stenosis and possible focal dissection of the right distal V2 segment Incidental Finding: A large nodule in the right thyroid lobe measures up to 2.9 cm and contains coarse calcifications. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: MRI AND MRA BRAIN AND MRA NECK PT11 MR ___ INDICATION: History: ___ with question of possible vertebral artery dissection. Fell off of a horse w spinal verteblra fracture// eval vertebral artery dissection, eval stroke TECHNIQUE: Three dimensional time of flight MR arteriography was performed through the brain with maximum intensity projection reconstructions. Postcontrast angiography of the neck was performed. 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: CTA head and neck ___, CT head ___. FINDINGS: MRI Brain: There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. There are nonspecific bilateral supratentorial T2/FLAIR white matter hyperintensities which may represent the sequelae of microangiopathy. There is a small amount of hypointensity on the gradient echo sequence in the occipital horns of both lateral ventricles, which may represent a small amount of layered hemorrhage. The ventricles otherwise normal. The sulci are of normal caliber and configuration. MRA brain: The intracranial vertebral and internal carotid arteries and their major branches appear normal without evidence of stenosis, occlusion, or aneurysm formation. There is a fetal left posterior cerebral artery. MRA neck: There is narrowing and irregularity of the distal V2 segment of the right vertebral artery and as it passes through the right transverse foramen of C2, at the site of the known fracture. There is reconstitution in the V3 segment. This is suspicious for dissection. 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. Note is made of a 4.5 cm heterogenous right thyroid mass. Ultrasound is advised for further evaluation. IMPRESSION: 1. Focal narrowing and irregularity of the distal V2 segment of the right vertebral artery and as it passes through the right C2 transverse foramen at the site of the known fracture. Findings are suspicious for dissection. 2. There is no infarct or parenchymal hemorrhage. There is a small amount of dependent hemorrhage in the occipital horns of both lateral ventricles. 3. 4.5 cm heterogenous right thyroid mass. Ultrasound is advised for further evaluation. RECOMMENDATION(S): Ultrasound is advised for further evaluation of the 4.5 cm right thyroid mass. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Head injury, Loss of consciousness, s/p Fall Diagnosed with Oth disp fx of second cervical vertebra, init for clos fx, Animl-ridr injured by fall fr horse in nonclsn acc, init temperature: 97.9 heartrate: 86.0 resprate: 22.0 o2sat: 97.0 sbp: 133.0 dbp: 77.0 level of pain: 0 level of acuity: 2.0

___ admitted to the Trauma service status post fall from horse with +LOC, found to have C2 fracture and CTA head and neck concerning for vertebral artery dissection. The patient was GCS15 and neurovascularly intact and hemodynamically stable. Orthopedic Spine was consulted and they recommended nonoperative management with a hard cervical collar at all times. Neurology was consulted for the vertebral artery dissection, and they recommended daily aspirin. The patient was ambulating independently in the room and in no pain. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. . At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient and her husband received discharge teaching and ___ instructions with understanding verbalized and agreement with the discharge plan. They elected to find Orthopedic Spine and Neurology providers to ___ with more locally where they lived in ___, as they had only been visiting ___ for a horse competition.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Chest pain Major Surgical or Invasive Procedure: ___ - Cardiac Catheterization with IABP placement ___ -Emergency coronary artery bypass graft x3, left internal mammary artery to left anterior descending artery and saphenous vein grafts to obtuse marginal and saphenous vein graft to posterior left ventricular branch History of Present Illness: ___ with h/o HTN, HLD, DM trasnferred from ___ with chest pain and EKG changes concerning for inferior STEMI. Pt developed L-sided chest pressure around 7:30pm this evening. Took and aspirin 325 and went to ___. Describes chest pain as pressure, ___ without radiation. No associated SOB or diaphoresis. Transient nausea prior to arrival at OSH ED. Pt was given nitro at ___ and CP subsided. Pt reports recurrence of CP in our ED, which again subsided with SL nitro. Pt reports since early ___ he has been experiencing persistent DOE and occasional exertional chest discomfort. No prior cardiac hx. Does not believe he has had prior stress testing. No prior caths. At ___, EKG at 22:09 with sub-mm ST elevation in II/III/AvF. He had a negative troponin and negative ddimer. He received nitro once at presentation with resolution of his pain. He then received plavix 600 and started on heparin gtt. In the ED, initial vitals were 98.2 85 ___ 99% ra. EKG with sub-mm STE in III, II and aVF. Labs and imaging significant for Hct of 35, plt 171, normal coags, BUN/Cr ___, trop 0.14. Patient continued on heparin gtt, metoprolol 25mg PO, SL nitro x1. Sent to cath lab. Vitals on transfer were 84 135/89 19 98%. In the cath lab, pt noted to have 3-vessel disease with 100% proximal RCA occlusion with L to R collaterals, 95% LAD origin occlusion, 80% LCX origin occlusion. Cards surg consulted. Plan for CABG. IABP placed. On arrival to the CCU, patient without complaints. Denies CP, SOB. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Hyperlipidemia, +Hypertension, + Myocardial infarction 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: - s/p cholecystectomy years ago Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Admission PE: VS: 97.9, HR 65, BP 104/59, 14, 99% 4L NC GENERAL: WDWN, lying flat in bed, in NAD. Oriented x3. HEENT: NCAT. Sclera anicteric NECK: Supple, unable to assess JVP because lying flat CARDIAC: unable to appreciate heart sounds b/c of IABP sounds LUNGS: CTAB as best can auscultate with IABP sounds. Resp were unlabored, no accessory muscle use. ABDOMEN: Soft, NTND. Normoactive BS R Groin: IABP in place, small amt of bleeding from site, no hematoma or ecchymosis visible, nontender to palpation EXTREMITIES: No ___ edema, warm and well perfused, 2+ DP pulses. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. . Pertinent Results: Admission Labs: ___ 04:26AM GLUCOSE-134* UREA N-20 CREAT-0.8 SODIUM-138 POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-19* ANION GAP-18 ___ 04:26AM ALT(SGPT)-33 AST(SGOT)-50* CK(CPK)-410* ALK PHOS-43 TOT BILI-0.3 ___ 04:26AM CK-MB-29* MB INDX-7.1* cTropnT-0.50* ___ 04:26AM CALCIUM-9.0 PHOSPHATE-4.5 MAGNESIUM-1.8 ___ 04:26AM WBC-6.7 RBC-4.04* HGB-12.6* HCT-37.2* MCV-92 MCH-31.2 MCHC-33.9 RDW-12.6 ___ 04:26AM PLT COUNT-169 ___ 04:26AM ___ PTT-49.4* ___ ___ 03:32AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 03:32AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG ECHO ___ The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction with inferior and distal/apical akinesis (muiltivessel CAD). The remaining segments contract normally (LVEF = 35%). Right ventricular chamber size is normal. with mild global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Moderate regional left ventricular systolic dysfunction, c/w multivessel CAD. Preserved right ventricular systolic function. No clinically-significant valvular disease seen. . Cardiac Catheterization ___ LAD: 95% at origin LCX: 80% at origin, 90% OM1, 50% OM2 RCA: 100% proximal ___ 06:10AM BLOOD WBC-5.0 RBC-2.84* Hgb-8.9* Hct-26.2* MCV-92 MCH-31.3 MCHC-33.9 RDW-12.8 Plt ___ ___ 06:50PM BLOOD Hct-25.4* Plt ___ ___ 06:00AM BLOOD WBC-5.6 RBC-2.79* Hgb-9.0* Hct-25.6* MCV-92 MCH-32.4* MCHC-35.2* RDW-13.0 Plt Ct-90* ___ 02:58AM BLOOD WBC-5.8 RBC-2.88* Hgb-9.0* Hct-26.5* MCV-92 MCH-31.1 MCHC-33.9 RDW-13.0 Plt Ct-64* ___ 05:13PM BLOOD Hct-26.8* ___ 06:10AM BLOOD Glucose-112* UreaN-13 Creat-0.9 Na-139 K-4.0 Cl-101 HCO3-30 AnGap-12 ___ 06:00AM BLOOD Glucose-143* UreaN-13 Creat-0.9 Na-141 K-3.8 Cl-103 HCO3-30 AnGap-12 ___ 02:58AM BLOOD Glucose-145* UreaN-10 Creat-1.0 Na-140 K-4.9 Cl-106 HCO3-28 AnGap-11 ___ 01:55AM BLOOD Glucose-129* UreaN-10 Creat-0.8 Na-140 K-5.2* Cl-109* HCO3-24 AnGap-12 Medications on Admission: Lipitor 20 mg PO daily Lisinopril 20 mg PO daily Metformin 500 mg PO daily Discharge Medications: 1. Atorvastatin 80 mg PO DAILY RX *atorvastatin 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. MetFORMIN (Glucophage) 500 mg PO DAILY 3. Aspirin EC 81 mg PO DAILY RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth daily Disp #*100 Tablet Refills:*0 4. Furosemide 20 mg PO DAILY RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*5 Tablet Refills:*0 5. Metoprolol Tartrate 25 mg PO TID RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 6. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth Q 4 hrs Disp #*30 Tablet Refills:*0 7. Potassium Chloride 20 mEq PO DAILY RX *potassium chloride 20 mEq 1 tablet by mouth daily Disp #*5 Tablet Refills:*0 8. Ranitidine 150 mg PO BID RX *ranitidine HCl [Acid Control] 150 mg 1 by mouth twice a day Disp #*60 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: -Coronary artery disease -Myocardial infarction -Hyperlipidemia -DMII -HTN Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Percocet Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Trace Edema Followup Instructions: ___ Radiology Report HISTORY: IABP placement. FINDINGS: No previous images. Low lung volumes probably account for much of the prominence of the transverse diameter of the heart. There is no vascular congestion, pleural effusion, or acute focal pneumonia. The tip of the IABP lies approximately 2 cm above the superior aspect of the left mainstem bronchus. It is positioned just below the transverse arch of the aorta. Radiology Report HISTORY: CABG. FINDINGS: In comparison with the earlier study of this date, there has been placement of a Swan-Ganz catheter with its tip in the right pulmonary artery. Endotracheal tube is in place with its tip approximately 4 cm above the carina. Nasogastric tube extends to the stomach with the side hole at the esophagogastric junction. Left chest tube is in place, and there is no evidence of pneumothorax. Retrocardiac opacification is consistent with volume loss in the lower lobe and pleural effusion. Radiology Report AP CHEST, 3:32 P.M., ___ HISTORY: CABG. Look for pneumothorax after chest tube removal. IMPRESSION: AP chest compared to ___: Endotracheal tube, Swan-Ganz catheter, intra-aortic pump balloon, left pleural and midline drains have been removed. Small left pleural effusion is comparable to ___, small right pleural effusion is greater, and cardiac silhouette has increased in caliber minimally. Lower lungs are partially atelectatic, stable on the left, worse on the right than before, but mild. The upper lungs are clear. There is no pneumothorax. Right jugular introducer ends at the thoracic inlet. Radiology Report HISTORY: Status post CABG. Evaluate for effusion. TECHNIQUE: AP and lateral chest radiograph, 3 views. COMPARISON: ___ through ___ FINDINGS: Cardiac silhouette is mildly enlarged and unchanged from ___. Postoperative appearance of the mediastinal silhouette and hilar contour is stable. Small left greater than right pleural effusions with associated bibasilar atelectasis is unchanged. There is no pneumothorax. IMPRESSION: Persistent left greater than right small pleural effusions with bibasilar atelectasis. Gender: M Race: WHITE Arrive by UNKNOWN Chief complaint: CP Diagnosed with CHEST PAIN NOS, SHORTNESS OF BREATH, ABNORM ELECTROCARDIOGRAM, HYPERTENSION NOS temperature: 98.2 heartrate: 85.0 resprate: 16.0 o2sat: 99.0 sbp: 110.0 dbp: 80.0 level of pain: 0 level of acuity: 2.0

Mr. ___ was admitted to the ___ on ___ via transfer from ___ with chest pain and EKG changes concerning for inferior ST-Elevation Myocardial infarction. He underwent a cardiac catheterization and was found to have severe 3-vessel disease and an intra-aortic balloon pump was placed as a bridge to surgery. The cardiac surgery service was consulted and Mr. ___ was worked-up in the usual preoperative manner. On ___ he was taken to the operating room where he underwent emergency coronary artery bypass graft x3, left internal mammary artery to left anterior descending artery and saphenous vein grafts to obtuse marginal and saphenous vein graft to posterior left ventricular branch. Postoperatively he was taken to the intensive care unit for monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic support. Intra-aortic balloon pump was removed. He was kept in the ICU on POD1 due to Neosynephrine requirements. Beta blocker was eventually initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery on POD2. Beta blockers were increased due to tachycardia. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home with visitng nurse services in good condition with appropriate follow up instructions.

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: None History of Present Illness: Ms. ___ is a ___ year old lady with a history of IgM lambda restricted neoplasm with plasmacytic differentiation refractory to multiple treatments, who was transferred from ___ ___ for altered mental status, found to have GNR bacteremia of unclear source. Patient reportedly found to be sleeping next to dumpster at her house by neighbor, unable to recognize surroundings and did not know her son's phone number, but was able to speak in full sentences. At baseline lives alone, walks without assistance, able to cook, do chores, and pay her own bills. Neighbor called EMS, who took her to ___. She returned to baseline in CHA ED after ~1 hour of confusion. Primary oncologist Dr. ___ was contacted, and he requested that patient be transferred to ___ for plasmapheresis. Last plasmapheresis was on ___. CTH performed in CHA ED reportedly was unremarkable, but BCx with ___ bottles of GNR. She was unable to go to ___ due to bed unavailability and hence was routed to ___. In ED initial VS: 98.6 104/58 16 98% RA Exam: CN III-XII intact, strength ___ throughout, sensation to light touch intact, normal cerebellar testing and gait, CTAB, RRR. She had fever to Tmax of 103 degrees but remained hemodynamically stable. In the setting of fevers she had waxing and waning episodes of confusion (~1:30 AM forgot where she was and urinated on self, another episode at 4:00 AM). Labs significant for: WBC 3.7 Hgb 6.8 Plt 49 Na 141 K 4.1 Cl 100 CO2 26 BUN 28 Cr 1.5 AST 8 ALT 11 AP 49 LDH 158 Tbili 0.3 Alb 3.2 TP 7.6 Hapto 109 Free Kappa/Free lambda/IgM pending Influenza A/B PCR negative Lactate 1.8 Flu PCR negative VBG 7.51/35/29 (pH/pCO2/HCO3) No LP was performed given significant thrombocytopenia Patient was given: - NS 2.5L - Vancomycin 1000 mg IV once - Ceftriaxone 1 g IV x 2 - Ampicillin 2 g IV q4H Imaging notable for: - CTH without contrast: 1. No evidence of mass, hemorrhage or infarction. 2. Numerous lytic lesions throughout the calvarium and in the right mandibular condyle are suspicious for myeloma lesions. 3. Complete opacification of the right mastoid air cells. This finding is nonspecific, but can be seen in mastoiditis. 4. Additional paranasal sinus inflammatory changes. - MR head and MRA neck with and without contrast: 1. Multiple enhancing lesions at the right skullbase involving the petrous apex, right Meckel's cave, right occipital condyle, right mandibular condyle/ramus with adjacent soft tissue involvement of the medial pterygoid and masseter muscles. Of note, there is expansion and evidence of cortical destruction of the right mandibular condyle. Findings are suspicious for metastatic disease. 2. Evidence of associated compression of the right sigmoid sinus without occlusion. 3. Numerous enhancing cervical spine and calvarial lesions compatible with metastatic disease, likely representing multiple myeloma. 4. Complete opacification the right mastoid air cells can be seen in setting of mastoiditis. 5. Normal MRA head and neck. 6. Evidence of mild white matter chronic small vessel disease. CXR ___ Mild interstitial edema. No definite focal consolidation. Consults: - Neurology: Most concerning for toxic metabolic encephalopathy in setting of underlying malignancy and infection. MRI/MRA can be performed but unlikely to show stroke. - Heme/onc: ___ be related to hyperviscosity syndrome versus toxic metabolic encephalopathy, would pull pheresis catheter and follow up labs. No strong feeling about LP. VS prior to transfer: 103.2 121 110/41 97% RA On arrival to the MICU, patient was sleepy but arousable to voice. She was able to answer yes/no questions but would doze off mid-conversation. Knew that she was in a hospital. Of note, 2 weeks ago she developed symptoms of a cough productive of white sputum, and also had recent admission to ___ ___ for TLS in setting of venetoclax initiation. Other past infections include pneumonia in ___ treated with levofloxacin, and in ___ had vaginal/labial soft tissue with doxycycline. Per heme/onc note, most recent labs from ___ ___ demonstrate: WBC 2.63, ANC 1.51, Hb 8.3, Hct 24.5, plt 91, BUN/Cr ___ (0.9 on ___. Ca 9.5, P 4.0, Uric acid 3.6, Total protein 9.5, Albumin 3.5, Globulin 6.0, LDH 169, IgG<40, IgA<5, IgM 5950. Also of note, reportedly she is usually not symptomatic from hyperviscosity until IgM > 8000 mg/dL, and typical symptoms are weakness, fatigue, bilateral foot pain/neuralgia. Past Medical History: ONCOLOGIC HISTORY: - ___: Presented with anemia, found to high protein level IGM > 3000 mg/dl., wbc 6.7, Hb 10.5. SPEP showed 3.5 g/dl monoclonal spike, immunofixation c/w IgM lambda monoclonal band. - ___: Bone marrow aspirate and biopsy showed moderately hypercellular marrow with > 80% involvement by diffuse monotonous population of plasma cells with irregular nuclei, dispersed chromatin and prominent nucleoli. Immunoperoxidase studies showed monotypic cytoplasmic reactivity with CD 138 positive plasma cells for lambda light chain. Flow cytometric analysis showed a monotypic B cell population positive for CD19, CD20, FMC7, CD23, and lambda positive. Orginal gain on plasma cells showed that they are psotivie for CD138, CD38, negative fro CD19, CD20, CD56. MYD88 mutation was sent to ___ and was reportedly negative, although her patologists determined that this is a hematopoietic neoplasm with predominantly plasmacytic differentiation. Although there are clonal B cells and clonal plasma cells which questions possibility of lymphoplasmacytic lymphoma, pathologists favor MM. - ___: Started revlimid/bortezomib/dexamethasone. - ___: VWD screening demonstrated low levels - ___: C1 CyBorD therapy started - ___: PET: 5.0 x 6.9z 8.7 cm circumscribed ovoid gluteal mass (later upon biopsy identified as benign nerve sheath tumor) - ___: Plasmapheresis - ___: CyBorD - ___: Bendamustine/Rituxan - ___: Daratumumab - ___: Carfilzomib, dexamethasone, lenalidomide (CaRD) - ___: elotuzumab, lenalidomide, dexamethasone - ___: Ixazomib/melphalan/prednisone (C2 delayed ___ PNA) - S/p C2 Everolimus - Retinal hemorrhages identified - Discussed auto-transplant with Dr. ___ and son/patient agreed to defer - ___: C1 ixazomib 4 mg/venetoclax 200 mg/dexamethasone 20 mg - ___: Evidence of TLS on labs, admitted for TLS s/p 1 dose rasburicase, received allopurinol. Ventoxlax dose reduced to 200 mg on ___ - ___: Disease progression requiring multiple plasmapheresis - ___: Venetoclax dose increased to 400 ___ MEDICAL & SURGICAL HISTORY: Multiple myeloma (followed by DFCI/DWH, receives weekly pheresis on ___ Anemia Hypertension Diabetes mellitus Hyperlipidemia Tumor Lysis Syndrome Ocular hemorrhages Peripheral neuropathy Acute Kidney Injury Fever Pancytopenia VWD Senile osteoporosis Astigmatism Low Back Pain Colonic Polyps Social History: ___ Family History: Mother- ___ Father- DM Sister- ___ cancer Physical Exam: PHYSICAL EXAM ON ADMISSION: =========================== VITALS: Reviewed in ___ GENERAL: Alert, oriented, sleepy and drifts off mid-conversation HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Crackles in bilateral bases R>L CV: R pheresis port site c/d/I, Regular rate and rhythm, normal S1 S2, ___ SEM at LSB ABD: soft, mildly TTP in RUQ, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: No rashes appreciated NEURO: CN II-XII intact, AO x 2 (self, hospital, month), moves all four extremities symmetrically and with purpose, strength ___ throughout, cerebellar testing not assessed PHYSICAL EXAM ON DISCHARGE: =========================== Vitals: 98.5PO 132 / 70 62 16 100% RA General: Well-appearing, well nourished, in no acute distress. Heent: PERRLA. EOMI Anicteric sclerae. Oropharynx without erythema or exudate. Neck: Supple without thyromegaly or adenopathy. Heart: Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. Lungs: Clear to auscultation bilaterally without rhonchi, rales, or wheezes. Normal respiratory effort. Abdomen: Soft, nontender, nondistended, normoactive bowel sounds throughout. No hepatosplenomegaly. Skin: Skin type V. No significant lesions or eruptions. Extremities: Warm, well perfused, trace peripheral edema. Neuro: Alert and oriented x3. No gross focal deficits. Access: port clean, dry Pertinent Results: LAB RESULTS ON ADMISSION: ========================= ___ 09:13PM BLOOD WBC-5.8 RBC-2.16* Hgb-6.5* Hct-19.7* MCV-91 MCH-30.1 MCHC-33.0 RDW-17.0* RDWSD-55.4* Plt Ct-62* ___ 09:13PM BLOOD Neuts-79* Bands-5 Lymphs-8* Monos-7 Eos-1 Baso-0 ___ Myelos-0 AbsNeut-4.87 AbsLymp-0.46* AbsMono-0.41 AbsEos-0.06 AbsBaso-0.00* ___ 09:13PM BLOOD Plt Smr-VERY LOW* Plt Ct-62* ___ 01:10PM BLOOD SerVisc-2.1* ___ 03:33AM BLOOD VWF AG-320* VWF ___ ___ 09:13PM BLOOD Glucose-155* UreaN-28* Creat-1.5* Na-141 K-4.1 Cl-100 HCO3-26 AnGap-15 ___ 09:13PM BLOOD ALT-11 AST-8 LD(LDH)-158 AlkPhos-49 TotBili-0.3 ___ 09:13PM BLOOD TotProt-7.6 Albumin-3.2* Globuln-4.4* Calcium-8.7 Phos-4.5 Mg-2.0 ___ 09:13PM BLOOD PEP-AWAITING F FreeKap-0.8* FreeLam-1816* Fr K/L-0.00* IgG-LESS THAN IgA-LESS THAN IgM-5195* IFE-PND ___ 05:55AM BLOOD Tobra-1.6* ___ 06:43AM BLOOD ___ pO2-34* pCO2-35 pH-7.51* calTCO2-29 Base XS-4 Intubat-NOT INTUBA ___ 06:43AM BLOOD O2 Sat-66 DISCHARGE LABS: =============== ___ 05:18AM BLOOD WBC-3.7* RBC-1.93* Hgb-5.8* Hct-18.4* MCV-95 MCH-30.1 MCHC-31.5* RDW-17.5* RDWSD-60.9* Plt Ct-55* ___ 05:18AM BLOOD ___ PTT-30.4 ___ ___ 01:10PM BLOOD SerVisc-2.1* ___ 03:33AM BLOOD SerVisc-2.0* ___ 11:34AM BLOOD SerVisc-2.4* ___ 07:54AM BLOOD SerVisc-2.8* ___ 09:30AM BLOOD SerVisc-3.1* ___ 06:25AM BLOOD SerVisc-2.9* ___ 03:33AM BLOOD FacVIII-138 ___ 03:33AM BLOOD VWF AG-320* VWF ___ ___ 05:18AM BLOOD Glucose-104* UreaN-13 Creat-0.8 Na-144 K-3.9 Cl-109* HCO3-20* AnGap-15 ___ 05:18AM BLOOD ALT-22 AST-9 LD(___)-218 AlkPhos-57 TotBili-0.2 ___ 05:18AM BLOOD TotProt-8.2 Albumin-2.8* Globuln-5.4* Calcium-8.6 Phos-2.8 Mg-2.0 ___ 09:13PM BLOOD PEP-ABNORMAL B FreeKap-0.8* FreeLam-1816* Fr K/L-0.00* IgG-LESS THAN IgA-LESS THAN IgM-5195* IFE-MONOCLONAL ___ 03:33AM BLOOD IgM-___* ___ 05:55AM BLOOD IgG-<40* IgA-<5* IgM-4998* ___ 05:35AM BLOOD IgM-5342* ___ 07:54AM BLOOD IgM-5802* ___ 09:30AM BLOOD IgM-6258* ___ 06:25AM BLOOD IgM-___* ___ 05:18AM BLOOD IgM-6000* MICROBIOLOGY: ============= Blood Culture, Routine COLLECTED ___ ESCHERICHIA COLI. FINAL SENSITIVITIES. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ___ 11:00 am BLOOD CULTURE: NO GROWTH ___ 2:38 pm CATHETER TIP-IV WOUND CULTURE (Final ___: No significant growth. ___ 5:35 am BLOOD CULTURE, NO GROWTH TO DATE ___ 7:00 pm BLOOD CULTURE Blood Culture, NO GROWTH TO DATE IMAGING: ========= CT HEAD ___: 1. No evidence of mass, hemorrhage or infarction. 2. Numerous lytic lesions throughout the calvarium and in the right mandibular condyle are suspicious for myeloma lesions. 3. Complete opacification of the right mastoid air cells. This finding is nonspecific, but can be seen in mastoiditis. 4. Additional paranasal sinus inflammatory changes. MRI BRAIN ___: 1. Multiple enhancing lesions at the right skullbase involving the petrous apex, right Meckel's cave, right occipital condyle, right mandibular condyle/ramus with adjacent soft tissue involvement of the medial pterygoid and masseter muscles. Of note, there is expansion and evidence of cortical destruction of the right mandibular condyle. Findings are suspicious for metastatic disease. 2. Evidence of associated compression of the right sigmoid sinus without occlusion. 3. Numerous enhancing cervical spine and calvarial lesions compatible with metastatic disease, likely representing multiple myeloma. 4. Complete opacification the right mastoid air cells can be seen in setting of mastoiditis. 5. Normal MRA head and neck. 6. Evidence of mild white matter chronic small vessel disease. CTA ABDOMEN PELVIS ___: 1. Numerous small lucent lesions are noted throughout the imaged osseous structures, compatible with the patient's history of multiple myeloma. 2. A large lucent lesion with associated marrow replacement, cortical thinning and posterior cortical discontinuity is seen in the proximal left femur. This places the patient at significant risk for pathologic fracture, and consideration of nonweightbearing status is recommended. 3. Heterogeneously enhancing soft tissue mass adjacent to the proximal left femur is not imaged in its entirety on this study. Recommend further evaluation with comparison to prior studies and contrast enhanced MRI of the left femur. 4. Small bilateral pleural effusions. 5. No acute process in the abdomen or pelvis. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. ixazomib 4 mg oral 1X/WEEK 2. Acyclovir 400 mg PO DAILY 3. Allopurinol ___ mg PO DAILY 4. venetoclax 400 mg oral DAILY 5. Dexamethasone 4 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 8. MetFORMIN (Glucophage) 500 mg PO BID 9. Atenolol 50 mg PO DAILY 10. Hydrochlorothiazide 25 mg PO DAILY 11. Famotidine 20 mg PO BID Discharge Medications: 1. CefTAZidime-Heparin Lock 1.25 mg LOCK PRN port 2. CefTRIAXone 2 gm IV Q 24H 3. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using HUM Insulin 4. Acyclovir 400 mg PO Q12H 5. Allopurinol ___ mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Dexamethasone 4 mg PO DAILY 8. Famotidine 20 mg PO BID 9. ixazomib 4 mg oral 1X/WEEK 10. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 11. venetoclax 400 mg oral DAILY 12. HELD- Atenolol 50 mg PO DAILY This medication was held. Do not restart Atenolol until you no longer have an infection. 13. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication was held. Do not restart Hydrochlorothiazide until you no longer have an infection. 14. HELD- MetFORMIN (Glucophage) 500 mg PO BID This medication was held. Do not restart MetFORMIN (Glucophage) until you go home. Discharge Disposition: Extended Care Discharge Diagnosis: Primary diagnosis: High grade E. coli bacteria bloodstream infection Secondary diagnosis: Hyperviscocity Syndrome, IgM Multiple Myeloma Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: MRI ___ AND MRA NECK PT13 INDICATION: ___ year old woman with altered mental status// Stroke or lesion 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 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 ___. FINDINGS: MRI BRAIN: There are multiple enhancing lesions at the right skullbase notably involving the right petrous apex and right occipital condyle with evidence of some adjacent soft tissue invasion. There is also involvement of the right Meckel's cave (series 105, image 42). There is an enhancing lesion expanding and causing partial destruction of the right mandibular condyle. Enhancing abnormality extends to the right mandibular ramus. Surrounding soft tissue involvement includes the right medial pterygoid and right masseter muscles. There are numerous enhancing cervical spine and calvarial lesions measuring up to 1.9 cm at the left vertex. Mild scattered subcortical, deep and periventricular white matter and pontine T2/FLAIR hyperintensities are nonspecific but compatible with chronic small vessel ischemic disease given the patient's age. There is a small old right caudate head lacunar infarct. There is no evidence of acute hemorrhage, edema, midline shift or acute infarction. The ventricles and sulci are normal in caliber and configuration. The major intracranial vascular flow voids are maintained. There is near complete opacification of the right mastoid air cells. Mild mucosal thickening of the ethmoid air cells and a few small retention cysts within the bilateral sphenoid sinuses. The orbits are unremarkable. 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. Multiple enhancing lesions at the right skullbase involving the petrous apex, right Meckel's cave, right occipital condyle, right mandibular condyle/ramus with adjacent soft tissue involvement of the medial pterygoid and masseter muscles. Of note, there is expansion and evidence of cortical destruction of the right mandibular condyle. Findings are suspicious for metastatic disease. 2. Evidence of associated compression of the right sigmoid sinus without occlusion. 3. Numerous enhancing cervical spine and calvarial lesions compatible with metastatic disease, likely representing multiple myeloma. 4. Complete opacification the right mastoid air cells can be seen in setting of mastoiditis. 5. Normal MRA head and neck. 6. Evidence of mild white matter chronic small vessel disease. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: History: ___ with altered mental status// Bleed or mass 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, 16.8 cm; CTDIvol = 47.7 mGy (Head) DLP = 802.7 mGy-cm. 2) Sequenced Acquisition 2.0 s, 4.2 cm; CTDIvol = 47.7 mGy (Head) DLP = 200.7 mGy-cm. Total DLP (Head) = 1,003 mGy-cm. COMPARISON: None. FINDINGS: There is no evidence of infarction,hemorrhage,edema, or mass. The ventricles and sulci are normal in size and configuration. Periventricular and subcortical white matter hypodensities are nonspecific but likely reflect sequelae of chronic small vessel ischemic disease. Atherosclerotic vascular calcifications of the bilateral cavernous internal carotid arteries are noted. There are numerous round lytic lesions throughout the calvarium and in the right mandibular condyle are suspicious for myeloma lesions, given the patient's history of multiple myeloma. There is complete opacification of the right mastoid air cells, which is nonspecific but can be seen in acute mastoiditis. Additionally, moderate mucosal thickening is present in the anterior ethmoid air cells and sphenoid sinuses. The left mastoid air cells, maxillary and frontal sinuses are clear. IMPRESSION: 1. No evidence of mass, hemorrhage or infarction. 2. Numerous lytic lesions throughout the calvarium and in the right mandibular condyle are suspicious for myeloma lesions. 3. Complete opacification of the right mastoid air cells. This finding is nonspecific, but can be seen in mastoiditis. 4. Additional paranasal sinus inflammatory changes. Radiology Report INDICATION: ___ year old woman with GNR bacteremia, concern for infected line// please remove pheresis line COMPARISON: none TECHNIQUE: OPERATORS: Dr. ___ ___ (interventional radiology attending) performed the procedure. ANESTHESIA: 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: 1% lidocaine CONTRAST: None FLUOROSCOPY TIME AND DOSE: None PROCEDURE: 1. Left chest tunneled pheresis catheter removal. PROCEDURE DETAILS: The procedure was performed at bedside. The Left chest tunneled line site was cleaned and draped in standard sterile fashion. 1% lidocaine was administered around the tube track. The cuff was loosened with a bent forceps. The catheter was removed with gentle traction while manual pressure was held at the venotomy site. Hemostasis was achieved after3 min of manual pressure. A clean sterile dressing was applied. The tip was sent for culture. The patient tolerated the procedure well. There were no immediate postprocedural complications. FINDINGS: Expected appearance after tunneled line removal. IMPRESSION: Successful removal of a left chest tunneled line. Radiology Report INDICATION: ___ year old woman with GNR bacteremia, concern for abdominal source// eval for abscess, fistula, or other source of bacteremia 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, 46.2 cm; CTDIvol = 15.8 mGy (Body) DLP = 731.3 mGy-cm. 2) Stationary Acquisition 7.3 s, 0.5 cm; CTDIvol = 40.0 mGy (Body) DLP = 20.0 mGy-cm. Total DLP (Body) = 751 mGy-cm. COMPARISON: None. FINDINGS: LOWER CHEST: Small right and trace left nonhemorrhagic pleural effusions with adjacent compressive atelectasis. 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 is mildly enlarged, measuring 13.5 cm, with normal attenuation throughout. No evidence of focal lesions. Incidental note is made of a small accessory spleen. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: Cortical scarring with calcification is seen along the upper pole of the left kidney. Multiple bilateral subcentimeter cortical hypodensities are noted, too small to fully characterize, likely representing cysts. There is no suspicious renal lesion, or evidence of hydronephrosis. No perinephric abnormality detected. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. Diverticulosis of the colon is noted, without evidence of wall thickening and fat stranding. The appendix is normal. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are within normal limits. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. SOFT TISSUES AND BONES: Numerous small lucent lesions are noted throughout the imaged osseous structures, particularly within the bilateral iliac bones and proximal femurs, compatible with the patient's history of multiple myeloma. There is a large lucent lesion with associated marrow replacement, cortical thinning and posterior cortical discontinuity in the proximal left femur (2:75), which is partially imaged. A heterogeneously enhancing soft tissue mass is seen adjacent to the proximal left femur (2:81), however this finding is not imaged in its entirety on this study. Age indeterminate mild compression deformities are seen involving L1 and L4. Note is made of diffuse anasarca. There is a tiny fat containing umbilical hernia. IMPRESSION: 1. Numerous small lucent lesions are noted throughout the imaged osseous structures, compatible with the patient's history of multiple myeloma. 2. A large lucent lesion with associated marrow replacement, cortical thinning and posterior cortical discontinuity is seen in the proximal left femur. This places the patient at significant risk for pathologic fracture, and consideration of nonweightbearing status is recommended. 3. Heterogeneously enhancing soft tissue mass adjacent to the proximal left femur is not imaged in its entirety on this study. Recommend further evaluation with comparison to prior studies and contrast enhanced MRI of the left femur. 4. Small bilateral pleural effusions. 5. No acute process in the abdomen or pelvis. RECOMMENDATION(S): 1. A large lucent lesion with associated marrow replacement, cortical thinning and posterior cortical discontinuity is seen in the proximal left femur. This places the patient at significant risk for pathologic fracture, and consideration of nonweightbearing status is recommended. 2. Heterogeneously enhancing soft tissue mass adjacent to the proximal left femur is not imaged in its entirety on this study. Recommend further evaluation with comparison to prior studies and contrast enhanced MRI of the left femur. NOTIFICATION: The findings and recommendations were discussed with ___ ___, M.D. by ___, M.D. on the telephone on ___ at 8:03 pm, 10 minutes after discovery of the findings. Radiology Report EXAMINATION: BILAT UP EXT VEINS US INDICATION: ___ year old woman with chronic port, GNR bacteremia, AMS.// please ultrasound bilateral subclavian veins to rule out thrombus TECHNIQUE: Grey scale and Doppler evaluation was performed on the bilateral internal jugular and subclavian veins. COMPARISON: None available. FINDINGS: There is normal flow with respiratory variation in the bilateral subclavian veins. The left internal jugular vein has nonocclusive thrombus. The left subclavian vein is patent. The right internal jugular and subclavian veins are patent. IMPRESSION: Targeted ultrasound of the bilateral internal jugular and subclavian veins demonstrates nonocclusive thrombus in the left internal jugular vein. Patent right internal jugular and bilateral subclavian veins. NOTIFICATION: The findings were discussed with MICU resident, ___ by ___, M.D. on the telephone on ___ at 7:10 pm, 10 minutes after discovery of the findings. Radiology Report EXAMINATION: Chest AP INDICATION: ___ year old woman with multiple myeloma and hyperviscosity syndrome p/w E. Coli bacteremia now with productive cough.// rule out pneumonia TECHNIQUE: Chest AP view COMPARISON: ___ IMPRESSION: Right-sided Port-A-Cath tip projects to the SVC. There is a small right pleural effusion which is new since the prior study. There are old healed left-sided rib fractures. There is mild pulmonary vascular congestion. Cardiomediastinal silhouette is stable. No pneumothorax is seen. Radiology Report INDICATION: ___ year old woman with IgM Multiple myeloma and hyperviscocity syndrome who presented with E. coli bacteremia and L IJ thrombus with previous line removed given concern for infectious thrombus, now requiring line replacement for pheresis.// Please place tunneled pheresis line needed for weekly pheresis for hyperviscocity syndrome. Had L IJ tunneled pheresis line removed ___ for positive blood cultured. Now negative blood cultures since ___. ID approves. Just spoke with ___. Platelets 41. Difficult to give platelets given COMPARISON: None TECHNIQUE: OPERATORS: Dr. ___, performed the procedure. ANESTHESIA: Sedation was provided by administrating divided doses of 2 mg of fentanyl while 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% lidocaine fentanyl CONTRAST: 0 ml of 0 contrast. FLUOROSCOPY TIME AND DOSE: 2.9 min, 11 mGy PROCEDURE: 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 left upper chest was prepped and draped in the usual sterile fashion. Under continuous ultrasound guidance, the inferior aspect of the left internal jugular vein was compressible and accessed using a micropuncture needle. Permanent ultrasound images were obtained before and after intravenous access, which confirmed vein patency. Subsequently a Nitinol wire was passed into the right atrium using fluoroscopic guidance. The needle was exchanged for a micropuncture sheath. The Nitinol wire was removed and ___ 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 tunnel over the upper anterior chest wall. After instilling superficial and deeper local anesthesia using lidocaine , a small skin incision was made at the tunnel entry site. A 27cm tip-to-cuff length catheter was selected. The catheter was tunneled from the entry site towards the venotomy site from where it was brought out using a tunneling device. 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 catheter was threaded into the right side of the heart with the tip in the right atrium. The sheath was then peeled away. The catheter was sutured in place with 0 silk sutures. Steri-strips were also used to close the venotomy incision site. Final spot fluoroscopic image demonstrating good alignment of the catheter and no kinking. The tip is in the right atrium. The catheter was flushed and both lumens were capped. Sterile dressings were applied. The patient tolerated the procedure well. FINDINGS: Superiorly, occluded left internal jugular vein. More centrally, patent small area of internal jugular vein, accessed under ultrasound guidance. Final fluoroscopic image showing pheresis catheter with tip terminating in the right atrium. IMPRESSION: Successful placement of a 27cm tip-to-cuff length tunneled pheresis/dialysis line. The tip of the catheter terminates in the right atrium. The catheter is ready for use. Gender: F Race: BLACK/CARIBBEAN ISLAND Arrive by AMBULANCE Chief complaint: Altered mental status, Transfer Diagnosed with Altered mental status, unspecified temperature: 98.6 heartrate: 98.0 resprate: 16.0 o2sat: 98.0 sbp: 104.0 dbp: 58.0 level of pain: 0 level of acuity: 2.0

Ms. ___ is a ___ year old woman with a history of IgM lambda restricted neoplasm with plasmacytic differentiation refractory to multiple treatments, who was transferred from ___ ___ for altered mental status, found to have high grade E. coli bacteremia of unclear source s/p L pheresis catheter removal, and incidental finding of L IJ thrombus. ED course ___ ================ In the ED, neurology was consulted for evaluation of altered mental status. She received CTH without contrast which did not demonstrate mass, hemorrhage or infarction, but with opacification of R mastoid air cells. MR head and MRA neck without contrast was also pursued with findings of mild white matter chronic small vessel disease, enhancing cervical spine and calvarial lesions compatible with metastatic disease, as well as enhancing lesions at the right skullbase. She developed fever to Tmax of 103. Given altered mental status and low platelets count of 39-49, it was felt that LP was contraindicated, and she was covered empirically with vancomycin 1000 mg + ceftriaxone 1 g IV x 2, and ampicillin 2 g due to concern for meningitis. Heme/onc was consulted due to concern for hyperviscoscity contributing to altered mental status but as IgM level was ~5000, below the threshold for which she typically experiences symptoms, pheresis was not pursued. During ED course, blood cultures from CHA returned as positive for ___ bottles of GNR, with time to positivity of ~8 hours. Due to concern that his pheresis cathether could be source of her bacteremia, it was removed in the ED and catheter tip was sent for culture. She received 2.5L NS. MICU course ___ ======================= On admission to the MICU, patient initially had persistently altered mental status, dozing off mid-sentence, but no focal neurologic findings. Due to concern for sepsis from high grade GNR bacteremia, antibiotics were initially broadened to vancomycin + cefepime + ampicillin, and she received 1 dose of tobramycin for double coverage. MAPs were initially in ___, and she received further fluid resuscitation with subsequent improvement to MAPs of ___. Despite CT/MRI findings, mastoditis was thought to be unlikely given absence of symptoms, and urine cultures returned as negative. To further investigate source of bacteremia, she received CT A/P to evaluate for abdominal source (unrevealing for source) as well as bilateral UE ultrasounds to look for thombus as nidus of infection (nonocclusive thrombus in the left internal jugular vein). No anticoagulation for LIJ thrombus was pursued given persistent thrombocytopenia. On the morning of ___, mental status improved to baseline, hence antibiotics were de-escalated to cefepime. Infectious diseases was consulted because of concern for seeding of port, and recommended removal of R portacath. Course was complicated by anemia with Hgb ~6 which was significantly off of her recent baseline of 8, so was transfused 1 U only as per heme/onc in order to prevent significant elevation in viscosity. No evidence of significant hyperviscocity hence pheresis continued to be deferred. She was transferred to the floor in stable condition. Oncology medicine course ___ ==================================== She was transferred to the oncology floor in stable condition. #E.coli bacteremia Patient presented with fever and AMS found to have GNR bacteremia at outside hospital initially treated with broad spectrum as meningitis could not be ruled out as LP contraindicated with low platelets. E. coli grew from admission Bcx of unclear source as UA negative and CT A/P without explanation. Patient had L IJ thrombus, pheresis line was removed on ___ given concern for source of infection. Port was left in place and patient has been receiving antibiotic locks in port. Can consider removal of port given concern for seeding. Treated initially with cefepime (___) transitioned to ceftriaxone (___). Patient will require prolonged course of abx therapy given presence of intravascular thrombus, likely 4 weeks. Also receiving Ceftazadime port antibiotic locks. #Multiple myeloma Patient with IgM level 6033 on ___ and viscocity 2.9. Per patient she usually becomes symptomatic with IgM at 8000. Pheresis catheter was removed on ___ for source control of GNR bacteremia. Cultures were clear as of ___, pheresis catheter was replaced on ___ following discussion with Dr. ___. She did not receive pheresis during this admission. She was continued on home Ixazomib, Venetoclax, Dexamethasone. #Anemia Pt was found to have anemia with Hgb ~6 which was significantly off of her recent baseline of 8. Patient received 1unit pRBCs on ___. Held additional transfusions in setting of hypedrviscocity. H/H at time of transfer 5.___.9, patient asymptomatic. Patient will need additional blood transfusions following pheresis. #Thrombocytopenia Likely ___ her disease and chemotherapy agents, as did not have indices suggestive of hemolysis. She received one unit of platelets on ___ prior to placement of pheresis catheter. DVT ppx held given platelets <50. #Left IJ thrombus Identified during duplex of upper extremity while looking for source of bacteremia. Of note, patient had tunneled pheresis catheter on that side so may have had slower drainage in IJ as a result. Patient was not anticoagulated after identification. She remained thrombocytopenic, anticoagulation contraindicated at current plt level. #Risk of fracture ___ femur erosion by soft tissue mass CT of A/P ordered for ID workup identified a large lucent lesion with associated marrow replacement, cortical thinning and posterior cortical discontinuity seen in the proximal left femur which places the patient at significant risk for pathologic fracture. A heterogeneously enhancing soft tissue mass adjacent to the proximal left femur was seen as well and was thought to be related to her malignancy. Outside records from ___ show left femur lesions, unclear if soft tissue mass is new. Consider orthopedics consultation. Additional information for transfer to ___ (also verbally communicated to Dr. ___: Resistant ___ has been detected recently on this ___ medical floor. The patient on has been cared for on Contact Precautions at ___ out of an abundance of caution. ___ has not been isolated in any of this patient’s clinical specimens and she has no current signs of infection. If she develops clinical signs of infection and a yeast infection is on the differential, would consider including coverage for ___ auris, a multidrug-resistant strain, with an echinocandin. #HCP/Contact: son ___ ___ #Code: Full confirmed

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: weakness, hypotension Major Surgical or Invasive Procedure: Left knee aspiration (___) Left knee intraarticular steroid injection (___) History of Present Illness: : Mr. ___ is a ___ yrs. male with PMH notable for CKD s/p renal transplant (___), PVD s/p endarterectomy of external iliac artery, prostate cancer s/p radiation c/b radiation proctitis, DM, HLD who who presents with weakness, lightheaded and pre-syncope. Pt. was in his usual state of health until ___ days prior to presentation when pt. noted the onset of weakness and generalized malaise s/p cystoscopy done at ___. He denies fevers/chills but does endorse decreased PO intake as well as loose stools and mild generalized abdominal pain. He denies nausea or vomiting, chest pressure, palpitations or abdominal pain. His loose stools are described as watery occurring initially ___ and now is less often. Pt. denies dysuria or urgency but does note increased frequency. Pt thought he was previously having UTI symptoms and dropped off UA at his outpatient provider's office. He then presented to his PCPs office on ___ and was found to have BP 90/40 and was orthostatic. The only new medication is a new insulin regimen over the last 2 weeks. He has switched to Lantus and novolog sliding scale from a 70/30 mixture. Pt. denies sick contacts. His last hospitalization per the pt. was several years ago. In the ED, initial vitals were: 97.3 68 118/60 24 97% RA. ___ 445 - Labs notable for the following: Lactate: 2.4 127 92 85 435 AGap=20 ------------- 4.2 19 3.1 9.9 16.3>-----< 422 31.9 - Baseline Cr is 1.5-1.8. - UA notable for large leukocytes, neg nitrites and WBC of 84. - Patient received 1 gm CTX and 1 L NS - On the floor, patient feels comfortable in NAD. Past Medical History: - ESRD ___ T2DM status postpost cadaveric renal transplant in ___ (initial transplant attempt failed ___ extensive iliac artery inflow stenosis to the graft. Second transplant following a left external iliac artery endarterectomy was performed by Dr. ___ at ___. The current kidney is on the left and is functioning well with creatinine ranging from 1.3–1.7). - Peripheral vascular disease status post endarterectomy of the left (possibly R, unclear by documentation) external iliac artery - Chronic ___ claudication - Poorly controlled type 2 DM (Type 2, insulin dependent) - HLD - HTN (dx. ___ - Gout - Benign testicular neoplasm - Hyperparathyroidism (s/p 2 surgeries, ___ surgery unable to find gland, MRI post surgery also did not find any remaining glands) - Prostate cancer s/p radiation complicated by radiation proctitis with evidence of biochemical recurrency (followed by oncology (___) and holding androgen deprivation at this time (as of ___ due to slow doubling time - History of a positive PPD - OSA - now longer on CPAP Social History: ___ Family History: Mother with hx. of DM, deceased ___ complications. Pt. with 2 maternal uncles with hx. of DM, both deceased ___ complications. Brother with hx. of throat cancer. Another brother with CAD s/p CABG. Physical Exam: ON ADMISSION Vital Signs: 97.6, 130/52, 62, 18, 99% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: large midline scar and smaller vertical scarring on left and right side. Palpable left sided donor kidney in LLQ, non tender to palpation. Abdomen in general non-tender, non-distended, bowel sounds present, no rebound or guarding, no CVA tenderness, and no suprapubic tenderness GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or trace pitting edema bilaterally up to the shins Neuro: CNII-XII intact, ___ strength upper/lower extremities grossly normal sensation, gait deferred. ON DISCHARGE Vital Signs: 98.4, 155/53, 79, 18, 98% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD. Blisters around nose. Crusted. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: large midline vertical scar and smaller vertical scarring on left (current functional transplant from ___ right side (failed transplant). Palpable left sided donor kidney in LLQ, non tender to palpation. Abdomen in general non-tender, with mild distention, bowel sounds present, no rebound or guarding, no CVA tenderness, and no suprapubic tenderness GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis and trace pitting edema bilaterally up to the shins. Pain persists on left knee flexion. Left knee tender to palpation but improved over suprapatellar region. Notable swelling L>R knee, with mild erythema and warmth stable from yesterday afternoon. Left midfoot with improved tenderness to palpation and on dorsiflexion. No swelling/erythema appreciated Neuro: CNII-XII intact, strength testing in LLE limited secondary to pain. Pertinent Results: LABS ON ADMISSION ___ 01:00PM BLOOD WBC-16.3* RBC-4.28* Hgb-9.9* Hct-31.9* MCV-75* MCH-23.1* MCHC-31.0* RDW-14.6 RDWSD-38.3 Plt ___ ___ 01:00PM BLOOD Neuts-86.8* Lymphs-6.2* Monos-5.5 Eos-0.2* Baso-0.3 Im ___ AbsNeut-14.11* AbsLymp-1.01* AbsMono-0.90* AbsEos-0.03* AbsBaso-0.05 ___ 01:00PM BLOOD Plt ___ ___ 01:00PM BLOOD Glucose-435* UreaN-85* Creat-3.1* Na-127* K-4.2 Cl-92* HCO3-19* AnGap-20 ___ 08:27AM BLOOD ALT-14 AST-20 AlkPhos-77 TotBili-0.5 ___ 08:27AM BLOOD Calcium-10.0 Phos-3.3 Mg-1.7 ___ 08:27AM BLOOD tacroFK-9.5 ___ 02:13PM BLOOD Lactate-2.4* LABS ON DISCHARGE ___ 07:40AM BLOOD WBC-12.1* RBC-3.83* Hgb-8.5* Hct-28.2* MCV-74* MCH-22.2* MCHC-30.1* RDW-14.5 RDWSD-38.1 Plt ___ ___ 07:40AM BLOOD ___ PTT-29.3 ___ ___ 07:40AM BLOOD Glucose-209* UreaN-37* Creat-1.8* Na-132* K-5.3* Cl-95* HCO3-22 AnGap-20 ___ 07:40AM BLOOD ALT-21 AST-29 AlkPhos-93 TotBili-0.4 ___ 07:40AM BLOOD Calcium-11.2* Phos-4.0 Mg-2.1 ___ 07:40AM BLOOD tacroFK-4.9* PERTINENT LABS JOINT FLUID ANALYSIS WBC 43,500. 96% PMNs. Monosodium urate crystals IMAGING ___ Renal US IMPRESSION: Normal appearance of the transplant kidney. Nondependent echogenic focus along the bladder wall may represent an adherent bladder stone. ___ CXR IMPRESSION: Bibasilar opacities more compatible with atelectasis than pneumonia. ___ ECG Sinus rhythm. Left anterior fascicular block. Right bundle-branch block. Consider right ventricular hypertrophy. No previous tracing available for comparison. Clinical correlation is suggested. ___ Bilateral Knee XR FINDINGS: = Left knee: No acute fractures or dislocations are seen.Joint spaces are preserved without significant degenerative changes. There is a moderate-sized joint effusion.There is normal osseous mineralization.There are extensive vascular calcifications. Right knee: No acute fractures or dislocations are seen.Joint spaces are preserved without significant degenerative changes. There is no significant knee joint effusion.There is normal osseous mineralization.Vascular calcifications are seen. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ with DOE COMPARISON: None FINDINGS: PA and lateral views of the chest provided. Bibasilar opacities are most compatible with atelectasis though difficult to exclude an early pneumonia. No large effusion or pneumothorax. No congestion or edema. Cardiomediastinal silhouette appears normal. Bony structures are intact. No free air below the right hemidiaphragm. IMPRESSION: Bibasilar opacities more compatible with atelectasis than pneumonia. Radiology Report EXAMINATION: RENAL TRANSPLANT U.S. INDICATION: Evaluate a left lower quadrant renal transplant a patient with a KI and UTI. TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images of the renal transplant were obtained. COMPARISON: None. FINDINGS: The left lower quadrant transplant renal morphology is normal. Specifically, the cortex is of normal thickness and echogenicity, pyramids are normal, there is no urothelial thickening, and renal sinus fat is normal. There is no hydronephrosis and no perinephric fluid collection. The resistive index of intrarenal arteries ranges from 0.75 to 0.79, within the normal range. The main renal artery shows a normal waveform, with prompt systolic upstroke and continuous antegrade diastolic flow, with peak systolic velocity of 48.6. Vascularity is symmetric throughout transplant. The transplant renal vein is patent and shows normal waveform. A nondependent echogenic focus along the bladder wall may represent an adherent bladder stone. IMPRESSION: Normal appearance of the transplant kidney. Nondependent echogenic focus along the bladder wall may represent an adherent bladder stone. Radiology Report EXAMINATION: KNEE (AP, LAT AND OBLIQUE) BILAT INDICATION: ___ year old man with ESRD s/p renal transplant ___, presenting with UTI and increased Cr. Course complicated by left knee pain: tap revealed 43,500 WBC >90% PMNs and monosodium urate crystals. // Pt with possible left knee septic arthritis and gout. COMPARISON: None FINDINGS: Left knee: No acute fractures or dislocations are seen.Joint spaces are preserved without significant degenerative changes. There is a moderate-sized joint effusion.There is normal osseous mineralization.There are extensive vascular calcifications. Right knee: No acute fractures or dislocations are seen.Joint spaces are preserved without significant degenerative changes. There is no significant knee joint effusion.There is normal osseous mineralization.Vascular calcifications are seen. IMPRESSION: As above. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Dyspnea, Weakness, Hyperglycemia Diagnosed with Urinary tract infection, site not specified temperature: 97.3 heartrate: 68.0 resprate: 24.0 o2sat: 97.0 sbp: 118.0 dbp: 60.0 level of pain: unable level of acuity: 2.0

___ is a ___ yrs male with CKD s/p transplant in ___ who over the past 10 days, after cystoscopy, felt very weak, lightheaded and nearly syncopized at an outpatient appointment presenting with UTI. # Complicated urinary tract infection: Most likely weakness, hypotension and fatigue are secondary to urinary tract infection s/p recent cystoscopy. He presented to the ED with dirty UA and Cr bump to 3.1 from baseline of 1.4-1.8. UCx from outside PCP's office showed >100,000 CFU of GNRs that are non-lactose fermenters. He was started on IVF and CTX and then changed to PO ciprofloxacin (Day #1 ___ after cultures started speciating. Species and sensitivities were pending at discharge in Atrius. Other infectious etiologies were ruled out: CXR clear, blood cx ngtd, stool cultures, CMV viral load and EBV PCR all were negative. #Pre-renal azotemia: Most likely was secondary to hypovolemia in setting of urinary tract infection. Patient was found to be orthostatic at his PCP's office and his urine cultures showed as above. He was given IVF and CTX and then was switched to ___ ___ for UTI. Cr decreased to his baseline (1.8) and was stable for 2 days before discharge. #Crystal proven gout (left knee): patient has history of gout and is not on any preventative medications currently. In addition, patient is immunosuppressed. Pt. had monoarticular swelling of left knee with warmth posed concern for septic arthritis. Rheumatology consulted and tapped effusion on ___ which showed 43,500 WBCs, 96% PMNs and monosodium urate crystals. IV Vancomycin 1gm q12 hr initiated while gram stain was pending, but discontinued as WBCs most likely ___ to gout flare and gram stain negative. Patient received colchicine 0.6 on ___ and an intraarticular steroid injection done by Rheumatology on ___. Pain control with Tylenol and breakthrough with oxycodone. #Hyponatremia: most likely was due to hypovolemic hyponatremia w/UTI + pseuodhyponatremia in setting of hyperglycemia. Resolved with boluses of NS and better glucose control. #ESRD s/p left renal transplant ___. Baseline Cr 1.4-1.8. Patient maintains right lower arm fistula. Cr elevated on admission to 3.1. Cr improved to baseline after treatment of UTI and IVF. Tacrolimus 4mg BID, cellcept 500 mg BID continued #Hyperparathyroidism: Cinacalcet increased slightly on this admission. #Uncontrolled Diabetes Mellitus Type II. Patient had glucose into the 400s on admission. Continued Lantus at an increased dose from 40 to 53 units daily and d/c'd Humalog 12 with meals and instead put him on ISS while in house with good control. Continued gabapentin 300mg capsule daily. #BPH: Continued home tamsulosin. #Coronary artery disease. Continued pravastatin 80 mg daily, metoprolol tartrate 25 QID, increased amlodipine 5 mg to 10mg daily, continued aspirin 81 daily and withheld chlorthalidone 25 mg daily (in setting ___ and infection). #Hypertension BPs recovered following abx and IVF. Increased amlodipine 5 mg to 10mg daily. Continued metoprolol at fractionated dosing as met tartrate 25 QID. Withheld chlorthalidone in setting of ___. #seasonal allergies Continued fluticasone nasal spray #GERD: continued home ranitidine TRANSITIONAL ISSUES =================== [] Antibiotics: Cipro for 10 day course (Day #1 ___ thru ___. []Labs: Outpatient chemistry 10 within 3 days of discharge to ensure stability of Cr and good control of Ca with new dose of Cinacalcet. He should continue with twice weekly chem 10 and tacrolimus levels at rehab ___ and ___. Please fax labs to: Nephrology - Transplant Team at ___: ___. and Dr. ___: ___ [] Tacro Goal: ___. Must be a true tacro trough (drawn within 1 hour prior to AM dose). []Rehab Consult: Please have nephrology consulted at rehab and evaluate patient given complex case. []Urine Culture: ___ has a Urine culture from ___ pending. Will need to ensure species is sensitive to cipro once culture finalizes. []HTN: Given ___ and hyponatremia, in place of chlorthalidone, we increased his amlodipine to 10 mg daily on discharge for better BP control. If needs improved BP control, consider restarting chlorthalidone with stable Cr and BP >140. []Insulin: Lantus regimen was altered during stay for high glucose. He is currently at 53 units Lantus AM with NO standing Humalog and ISS. Please continue to monitor blood sugars 4x daily and adjust as necessary. []Hypercalcemia: Patient will be discharged on cinacalcet at 90 mg daily from 60 mg daily []Gout Flare: Patient in middle of gout flare. He received 1 dose of colchicine without good effect, and because of medication interactions, decided to give intraarticular injection of left knee. []Outpatient F/Up: needs outpatient follow up with urologist, nephrologist, and primary care provider. []Bladder Stone: Patient had cystoscopy on ___ showing non-obstructive bladder stone. Consider outpatient removal, and analysis for urate crystals. If + for urate crystals, may need to be placed on urate lowering medications. Please fax results to Attn Dr. ___: ___ # CODE: Full Code, confirmed # CONTACT: ___ (wife, HCP) ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with Afib on warfarin, SSS s/p permanent pacemaker, and CAD with h/o MI who presented to the ED with precordial chest pain. The pain developed at 3AM after he got up to go to the bathroom. It lasted for ~5 hours until he was in the ED and had been on a nitro gtt for about 1 hour. It did not resolve with SL nitro. The pain was "somewhere in between" pressure and sharp pain. It did not radiate, it was non-pleuritic. It was not associated with SOB, diaphoresis, n/v, or lightheadedness. He says he has never had similar pain. His prior MI was asymptomatic. He was admitted ___ with chest pain that was thought to be due to esophageal dysmotility but he reports that this has resolved. In the ED, initial vitals were 97.6 59 163/60 16 97% RA EKG: HR 69, V paced Labs/studies notable for: trop 0.05, INR 1.9 Patient was given: nitroglycerin 0.4 mg SL, IV nitroglycerin Vitals on transfer: 98.1 55 111/59 16 95% RA On the floor, he reports that he feel wells. He has no chest pain. He has no SOB, lightheadedness or palpitations. He does have ___ edema which is a chronic problem for him for which he takes Lasix. No orthopnea or PND. On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: - Atrial fibrillation: on warfarin - Sick sinus syndrome: s/p PPM ___ Sensia) * Last interrogated ___ showing frequent PVCs but otherwise functioning well - Coronary artery disease * Status post inferior wall MI, EF of 45%, total occlusion of the RCA on catheterization. No intervention. - Systolic heart failure with EF 45% - Mitral regurgitation - Aortic regurgitation - Pulmonary hypertension - Macular degeneration (near blind) - Benign prostatic hyperplasia - Rectus diastasis - Prior h/o mechanical fall in ___ on his R shoulder. No fractures. Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. No diseases run in family. Physical Exam: ADMISSION: Vitals: 97.8 65 127/75 26 95 RA General: well-appearing elderly man in NAD HEENT: sclerae anicteric, conjunctivae noninjected, OP clear Neck: supple, no LAD, JVP not elevated CV: irregularly irregular, no murmurs appreciate Lungs: lungs clear to auscultation bilaterally, no w/r/r Abdomen: Soft, NTND GU: No Foley Extr: 2+ pitting edema to mid shin, WWP Neuro: AOx3, MAE, grossly nonfocal DISCHARGE: Vitals: Tm 99.3 Tc 98.2 ___ 55-67 ___ 96 RA General: well-appearing elderly man in NAD HEENT: sclerae anicteric, conjunctivae noninjected, OP clear Neck: supple, no LAD, JVP not elevated CV: irregularly irregular, no murmurs appreciate Lungs: lungs clear to auscultation bilaterally, no w/r/r Abdomen: Soft, NTND GU: No Foley Extr: 2+ pitting edema to mid shin, WWP Neuro: AOx3, MAE, grossly nonfocal Pertinent Results: ADMISSION: ___ 05:10AM BLOOD WBC-7.7 RBC-3.88* Hgb-11.4* Hct-35.1*# MCV-91 MCH-29.4 MCHC-32.5 RDW-14.9 RDWSD-49.6* Plt ___ ___ 05:10AM BLOOD Neuts-56.1 ___ Monos-14.9* Eos-1.3 Baso-0.3 Im ___ AbsNeut-4.34 AbsLymp-2.05 AbsMono-1.15* AbsEos-0.10 AbsBaso-0.02 ___ 05:10AM BLOOD ___ PTT-35.2 ___ ___ 05:10AM BLOOD Glucose-104* UreaN-27* Creat-1.5* Na-134 K-3.9 Cl-100 HCO3-21* AnGap-17 ___ 05:10AM BLOOD CK-MB-8 ___ 05:10AM BLOOD cTropnT-0.04* ___ 01:29PM BLOOD CK-MB-5 cTropnT-0.03* proBNP-2579* DISCHARGE: ___ 06:00AM BLOOD WBC-5.9 RBC-3.60* Hgb-10.9* Hct-32.7* MCV-91 MCH-30.3 MCHC-33.3 RDW-15.0 RDWSD-50.0* Plt Ct-91* ___ 06:00AM BLOOD ___ PTT-34.7 ___ ___ 06:00AM BLOOD Glucose-92 UreaN-28* Creat-1.6* Na-133 K-3.9 Cl-100 HCO3-21* AnGap-16 ___ 06:00AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.0 IMAGING: ___ CHEST X RAY: 1. Mild vascular congestion. 2. Stable moderate right and small left pleural effusion. 3. Right lower lobe opacity likely represents combination of pleural effusion and atelectasis however superimposed infection cannot be excluded. 4. Left lower lobe atelectasis. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 25 mg PO DAILY 2. Multivitamins 1 TAB PO DAILY 3. Psyllium Powder 1 PKT PO BID 4. TraZODone 50 mg PO QHS 5. Warfarin 2 mg PO 5X/WEEK (___) 6. Lo-Peramide (loperamide) 2 mg oral DAILY 7. lecithin 1,200 mg oral DAILY 8. zinc 15 mg oral DAILY 9. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral DAILY 10. Ascorbic Acid ___ mg PO DAILY 11. Famotidine 40 mg PO DAILY 12. Furosemide 20 mg PO DAILY 13. Cholestyramine 8 gm PO BID 14. Warfarin 1.5 mg PO 2X/WEEK (___) Discharge Medications: 1. Ascorbic Acid ___ mg PO DAILY 2. Cholestyramine 8 gm PO BID 3. Furosemide 20 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Psyllium Powder 1 PKT PO BID 6. TraZODone 50 mg PO QHS 7. Warfarin 2 mg PO 5X/WEEK (___) 8. Warfarin 1.5 mg PO 2X/WEEK (___) 9. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral DAILY 10. lecithin 1,200 mg oral DAILY 11. Lo-Peramide (loperamide) 2 mg oral DAILY 12. zinc 15 mg oral DAILY 13. Famotidine 20 mg PO Q24H RX *famotidine 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 14. Metoprolol Succinate XL 25 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: Coronary artery disease Sick sinus syndrome Secondary diagnoses: Atrial fibrillation Systolic heart failure 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 radiograph. INDICATION: ___ with chest pain. Assess for acute process. TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph ___, ___. FINDINGS: A pacemaker projects over the left chest wall with lead tips in the right atrium and right ventricle, unchanged since prior examination. The lungs are mildly hypoinflated with persistent moderate right and small left pleural effusions bibasilar opacities. Mild vascular congestion noted. No pneumothorax. Heart is partially obscured due to overlying parenchymal disease. Aortic arch calcifications noted. Mediastinal contour and hila are unremarkable. IMPRESSION: 1. Mild vascular congestion. 2. Stable moderate right and small left pleural effusion. 3. Right lower lobe opacity likely represents combination of pleural effusion and atelectasis however superimposed infection cannot be excluded. 4. Left lower lobe atelectasis. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Chest pain Diagnosed with Other chest pain temperature: 97.6 heartrate: 59.0 resprate: 16.0 o2sat: 97.0 sbp: 163.0 dbp: 60.0 level of pain: 5 level of acuity: 2.0

___ is a ___ year old man with a history of SSS/atrial fibrillation s/p PPM on warfarin and history of CAD and inferior wall MI who presented with chest pressure and an equivocal troponin in ED. # Troponinemia/chest pain: Mr. ___ troponin was elevated to 0.04 in the ED and trended to 0.03 following admission. He described a 5 hour episode of chest pressure/pain, which was then concerning for demand ischemia in the setting of poorly regulated HR. An ECG showed V pacing and he has no events recorded on telemtry. He was not willing to remain in the hospital for pacemaker interrogation, however. He will follow up in 2 weeks for pacemaker interrogation. He was walked with nursing and had an appropirate increase in his HR (from 80 to 89) without any symptoms of angina. # Atrial fibrillation: Patient continued on warfarin. # GERD: patient continued on omeprazole. # Insomnia: Patient continued on trazodone. # Diarrhea: This is a chronic problem for Mr. ___ for which he follows with GI. He was continued on his home loperamide, cholestyramine, and psyllium.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Ampicillin / Shellfish Attending: ___. Chief Complaint: Altered Mental Status, Urosepsis Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ yo woman with h/o schizoaffective d/o and recurrent UTI who presented to the ED with generalized fatigue. She had increased generalized fatigue over the past 2 days. She was accompanied by her caregiver who states the has become more lethargic. Additionally has been noted to have more frequent urination. Otherwise without acute complaints. Her last admission was in ___ for urosepsis and AMS. During that admission, blood and urine cultures revealed Pan-sensitive E. coli bacteremia. CT abd/pelvis revealed an area of cortical hypoenhancement within the left renal mid-pole cortex with mild neighboring fat stranding. She was treated with antibiotics and her AMS resolved. The renal lesion resolved on follow up imaging ___. Her last documented UTI was ___ with pansensitive E. coli treated by her PCP with nitrofurantoin ___ 7 days. In the ED, initial vitals were: 98.0 83 114/74 18 93% with a Tmax of 102.6. She became hypotensive to 89/52. Labs were significan for WBC 7.1, Glucose 623, UA with 65 WBC, 2RBC, few bacteria, glucose 1000, 10 ketones, Tr prot, neg nitrites. Lactate 1.4, ammonia 12. She received 4L IVF after which SBP elevated to 100s. A RIJ was placed. Tx with 10 units regular insulin and ceftriaxone. Blood and urine cx sent. Patient subsequently became somnolent and was started on pressors. On arrival to the MICU, patient was somnolent but arousable with sternal rub. Repeat blood glc was in 200s and an ABG was drawn. Pressors were d/c'd with SBP in 150s. Past Medical History: - AMENORRHEA - CERVICAL RADICULOPATHY - DIABETES TYPE II - ERYTHEMA MULTIFORME - bactrim. - GASTROESOPHAGEAL REFLUX - HYPERCHOLESTEROLEMIA - OBESITY - SCHIZOPHRENIA - SCIATICA - TOBACCO ABUSE - STRESS URINARY INCONTINENCE - CAD Social History: ___ Family History: Unknown Physical Exam: Initial Physical Exam Vitals: T:98.7 BP:153/92 P:92 R:23 O2:92% 3L General- lethargic, arousable to sternal rub HEENT- Sclera anicteric, dentition poor, food material in mouth Lungs- Loud transmitted upper airway sounds throughout CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, non-distended, bowel sounds present, no rebound tenderness or guarding GU- foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- PERRRL. non-cooperative with exam Pertinent Results: INITIAL LABS ___ 08:15PM BLOOD WBC-7.1 RBC-4.12* Hgb-11.7* Hct-39.5 MCV-96 MCH-28.5 MCHC-29.7* RDW-12.9 Plt ___ ___ 08:15PM BLOOD Neuts-50.4 ___ Monos-7.4 Eos-0.8 Baso-0.5 ___ 08:15PM BLOOD Glucose-623* UreaN-18 Creat-1.1 Na-134 K-5.0 Cl-95* HCO3-28 AnGap-16 ___ 08:15PM BLOOD ALT-13 AST-17 LD(LDH)-236 AlkPhos-64 TotBili-0.3 ___ 08:15PM BLOOD Albumin-3.5 ___ 02:32AM BLOOD Calcium-7.9* Phos-2.8 Mg-1.7 ___ 02:32AM BLOOD %HbA1c-13.9* eAG-352* ___ 08:15PM BLOOD Ammonia-12 ___ 08:15PM BLOOD Valproa-95 ___ 02:32AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 02:00AM BLOOD Type-ART pO2-78* pCO2-52* pH-7.31* calTCO2-27 Base XS-0 ___ 08:30PM BLOOD Lactate-1.4 ___ 08:40PM URINE Color-Straw Appear-Hazy Sp ___ ___ 08:40PM URINE Blood-TR Nitrite-NEG Protein-TR Glucose-1000 Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG ___ 08:40PM URINE RBC-2 WBC-65* Bacteri-FEW Yeast-NONE Epi-1 ___ 08:40PM URINE WBC Clm-FEW ___ 08:40PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG ___ 8:40 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 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-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S IMAGING ___ CXR Low lung volumes are seen with secondary crowding of the bronchovascular markings. No definite consolidation identified. Cardiomediastinal silhouette is unchanged given differences in positioning and technique. No acute osseous abnormality detected. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Rosuvastatin Calcium 10 mg PO QHS 2. RISperidone 3 mg PO BID 3. Vitamin D 50,000 UNIT PO 1X/MONTH 4. Aspirin 81 mg PO DAILY 5. Benztropine Mesylate 1 mg PO BID 6. Citalopram 40 mg PO DAILY 7. Divalproex (DELayed Release) 250 mg PO QAM 8. Divalproex (DELayed Release) 500 mg PO QHS 9. Nicotine Patch 7 mg TD DAILY 10. Propranolol LA 60 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Benztropine Mesylate 1 mg PO BID 3. Citalopram 40 mg PO DAILY 4. Divalproex (DELayed Release) 250 mg PO QAM 5. Divalproex (DELayed Release) 500 mg PO QHS 6. Nicotine Patch 7 mg TD DAILY 7. RISperidone 3 mg PO BID 8. Rosuvastatin Calcium 10 mg PO QHS 9. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*12 Tablet Refills:*0 10. Glargine 8 Units Bedtime Insulin SC Sliding Scale using REG Insulin RX *blood sugar diagnostic [FreeStyle Lite Strips] Disp #*4 Box Refills:*0 RX *insulin glargine [Lantus] 100 unit/mL ___t bedtime Disp #*30 Each Refills:*0 RX *lancets 30 gauge Disp #*120 Each Refills:*0 RX *insulin regular human [Humulin R] 100 unit/mL Sliding Scale Up to 10 Units QID per sliding scale Disp #*120 Each Refills:*0 RX *insulin syringe-needle U-100 [Ultra Comfort Insulin Syringe] 30 gauge Disp #*100 Syringe Refills:*1 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 12. Vitamin D 50,000 UNIT PO 1X/MONTH 13. Propranolol LA 60 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: - Urinary tract infection - Hyperglycemia, poorly controlled DM2 Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report PORTABLE CHEST: ___ HISTORY: ___ female with generalized weakness and altered mental status. Question pneumonia. COMPARISON: ___. FINDINGS: Single portable view of the chest. Low lung volumes are seen with secondary crowding of the bronchovascular markings. No definite consolidation identified. Cardiomediastinal silhouette is unchanged given differences in positioning and technique. No acute osseous abnormality detected. Radiology Report PATIENT HISTORY: ___ years old woman with new right IJ central line, evaluate line placement. COMPARISON: Exam is compared to chest x-ray of ___ at 8:41 p.m. FINDINGS: New right jugular catheter has been positioned with tip ending in distal right atrium. Catheter should be pulled back of 3 cm. Lung volume is still low with opacification of the left lung base, probably for atelectasis. There are sign of mild central vein distention. There is no pneumothorax. IMPRESSION: New right jugular catheter has been placed with tip ending in distal right atrium, it should be withdrawn 3 cm. Left lung base atelectasis and mild vascular congestion are stable. Findings were paged to Dr ___ ___ at 5.00 by Dr ___ Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: ALTERED MENTAL STATUS Diagnosed with ALTERED MENTAL STATUS temperature: 98.0 heartrate: 83.0 resprate: 18.0 o2sat: 93.0 sbp: 114.0 dbp: 74.0 level of pain: 13 level of acuity: 1.0

Ms. ___ is a ___ y/o woman with schizoaffective disorder, h/o pyelonephritis and urosepsis who presented to the ED with AMS and urinary symptoms. She had a UA consistent with UTI and briefly required pressor support. ICU COURSE # UROSEPSIS/SHOCK: Ms. ___ presented with urinary frequency and altered mental status. A urinalysis was consistent with a UTI, and she was started on ceftriaxone. A urine culture subsequetnly grew E. Coli that was pansensitive, and ciprofloxacin was used with plans for a total of 10 days of abx treatment. Day 1 of abx was in the ED on the evening of ___. The patient remained clinically stable for the rest of her ICU admission and did not require further pressor support. Ms. ___ has recurrent UTI and has a cystocele which may contribute to potentially some urinary retention. # ALTERED MENTAL STATUS: Ms. ___ initially presented with lethargy in the setting of severe sepsis. She has a h/o AMS in setting of sepsis with negative neuro workup and resolution of symptoms after tx of infx. On day of transfer out of the ICU, her AMS had improved significantly. She was awake, verbal, answering questions and following commands. She continued to do well on the floor and was interactive and close to her baseline on dates of discharge. # HYPERGLYCEMIA/DIABETES: Ms. ___ presented with hyperglycemia in the setting of severe infx. She has a h/o DM II, treated by PCP with diet/exercise. Her last HbA1C was 6.8 (___). Blood glucose on admission was 623 with glucose and ketones in urine. A repeat HbA1C this admission was 13.9%. She was managed medicaly with an initial 10 units of regular insulin and then an insulin sliding scale. ___ was consulted and the decision was to place her on metformin 500 mg BID and insulin lantus at 8u QHS. SHe was also placed on insulin sliding scale. A ___ educator came in to educate the foster parents (who incidentally have experience with insulin since the father was reportedly a diabetic). She will follow up closely with ___ within this week. # SCHIZOAFFECTIVE DISORDER: Ms. ___ has a known diagnosis of schizoaffective disorder for which she takes multipled medications. Her home valproic acid and risperadone were continued IV while she was altered. She was eventually transitioned to all of her psychiatric medications PO including citalopram and benztropine once her AMS improved.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: codeine / scallops / lisinopril Attending: ___ Chief Complaint: abdominal distension Major Surgical or Invasive Procedure: Paracentesis ___ (1.7L removed) History of Present Illness: Patient is a ___ y/o female w/ a PMHx of EtOH cirrhosis c/b EVs and ascites, SCC of lung, brain aneurysm, breast cancer s/p masectomy, and COPD who p/w worsening abd distention x3 wks and watery, yellow diarrhea since ___. She reports she has had chronic watery yellow diarrhea for at least 5 months which doesn't seem to be affected by diet. She trialed immodium (though only daily dosing) without improvement. In the last ___ weeks her abdomen has been feeling larger and more distended and this has been accompanied by increasing DOE from the pressure in her abdomen. She reports she can walk around ok but she notes she is more short of breath when climbing stairs. She also noticed that her legs became more swollen around the same time as her abdomen. Otherwise she has not had fevers or chills or any other infectious symptoms. She does note that she has had a decrease in her appetite for many months but she has been making a big effort to eat so that she has not lost weight. Denies bloody or black stools, dizziness, was encouraged to come in by primary GI doctor for help with alcohol cessation and evaluation by the liver team as well as work up for chronic diarrhea. Past Medical History: - upper GIB d/t esophageal varices seen on EGD, requiring transfusion ___ pRBCs - SCC of lung s/p LLL resection ___ - brain aneurysm clipping ___ - breast CA s/p mastectomy - appendectomy - COPD with chronic cough productive of clear mucus - IBS, chronic diarrhea - MGUS Social History: ___ Family History: Father ___ Cancer Maternal Grandmother ___ - Unknown Type Maternal Uncle ___ Mother ___ Sister Cancer; ___ Dermatitis; Hypertension Physical Exam: ADMISSION EXAM =========================== VS: T98.2 PO BP120/71 HR104 RR16 SaO294%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: scattered wheezes, No rales or rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: Tight/distended, mild tenderness to palpation of Right LQ, no rebound/guarding EXTREMITIES: 2+ edema to bilateral knees, no cyanosis or clubbing NEURO: A&Ox3, moving all 4 extremities with purpose, CN ___ intact SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE EXAM =========================== Vital signs stable GENERAL: Older appearing woman in no acute distress. Comfortable. AAOx3. HEENT: NCAT, EOMI, anicteric, MMM CARDIAC: Regular rate & rhythm. Normal S1/S2. No murmurs, rubs, or gallops. PULMONARY: Clear to auscultation bilaterally. Breathing comfortably on room air. ABDOMEN: +caput medusae. Firm, dull to percussion with tense ascites, mildly TTP in LLQ EXTREMITIES: Warm, well perfused, 3+ pitting edema to thighs. SKIN: No significant rashes. NEURO: AAOx3. Moving all four extremities with purpose. No tremor. Pertinent Results: ADMISSION LABS =========================== ___ 10:14PM BLOOD WBC-6.4 RBC-2.86* Hgb-9.7* Hct-28.6* MCV-100* MCH-33.9* MCHC-33.9 RDW-15.9* RDWSD-57.5* Plt Ct-UNABLE TO ___ 10:14PM BLOOD Neuts-59.4 ___ Monos-12.1 Eos-0.5* Baso-0.5 Im ___ AbsNeut-3.82 AbsLymp-1.72 AbsMono-0.78 AbsEos-0.03* AbsBaso-0.03 ___ 10:14PM BLOOD ___ PTT-28.5 ___ ___ 10:14PM BLOOD Glucose-83 UreaN-9 Creat-0.6 Na-134* K-3.6 Cl-94* HCO3-24 AnGap-16 ___ 10:14PM BLOOD ALT-47* AST-149* AlkPhos-240* TotBili-0.7 ___ 10:14PM BLOOD Albumin-2.4* ___ 10:17PM BLOOD Lactate-2.1* PERTINENT LABS =========================== ___ 07:01AM BLOOD WBC-5.0 RBC-2.61* Hgb-9.0* Hct-26.0* MCV-100* MCH-34.5* MCHC-34.6 RDW-15.5 RDWSD-56.2* Plt Ct-79* ___ 07:01AM BLOOD Glucose-81 UreaN-11 Creat-0.7 Na-134* K-4.1 Cl-97 HCO3-25 AnGap-12 ___ 07:01AM BLOOD ALT-33 AST-87* LD(LDH)-364* AlkPhos-182* TotBili-0.9 ___ 07:10AM BLOOD GGT-407* ___ 07:10AM BLOOD calTIBC-114* VitB12-844 Hapto-123 Ferritn-1660* TRF-88* ___ 07:10AM BLOOD TSH-2.4 ___ 05:40AM BLOOD 25VitD-23* ___ 07:10AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG ___ 07:10AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE ___ 07:10AM BLOOD IgA-333 ___ 07:10AM BLOOD tTG-IgA-6 DISCHARGE LABS =========================== ___ 07:01AM BLOOD WBC-5.0 RBC-2.61* Hgb-9.0* Hct-26.0* MCV-100* MCH-34.5* MCHC-34.6 RDW-15.5 RDWSD-56.2* Plt Ct-79* ___ 07:01AM BLOOD ___ PTT-30.2 ___ ___ 07:01AM BLOOD Glucose-81 UreaN-11 Creat-0.7 Na-134* K-4.1 Cl-97 HCO3-25 AnGap-12 ___ 07:01AM BLOOD ALT-33 AST-87* LD(LDH)-364* AlkPhos-182* TotBili-0.9 ___ 07:01AM BLOOD Albumin-2.6* Calcium-8.2* Phos-2.6* Mg-1.6 PERTINENT STUDIES =========================== RUQUS (___) 1. Cirrhosis with moderate volume ascites. Portal vein is patent with hepatopetal flow. 2. Cholelithiasis without evidence of acute cholecystitis. Mild gallbladder wall thickening likely due to liver disease. CXR (___) Lungs are low volume with bibasilar atelectasis. Heart size is top-normal. There is no pleural effusion. No pneumothorax is seen TTE (___) IMPRESSION: Normal biventricular cavity sizes, regional/global systolic function. No valvular pathology or pathologic flow identified. High normal estimated pulmonary artery systolic pressure. PERTINENT MICRO =========================== __________________________________________________________ ___ 8:39 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool 2 OF 3. OVA + PARASITES (Pending): __________________________________________________________ ___ 11:53 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. __________________________________________________________ ___ 10:57 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. __________________________________________________________ ___ 10:57 am STOOL CONSISTENCY: NOT APPLICABLE 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). __________________________________________________________ ___ 3:14 pm PLEURAL FLUID PLEURAL FLUID. GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. __________________________________________________________ ___ 1:00 pm BLOOD CULTURE Blood Culture, Routine (Pending): __________________________________________________________ ___ 10:26 am BLOOD CULTURE #1. Blood Culture, Routine (Pending): Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 325 mg PO DAILY 2. Losartan Potassium 25 mg PO DAILY 3. Omeprazole 20 mg PO DAILY 4. Rosuvastatin Calcium 10 mg PO QPM 5. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 6. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H 7. Ranitidine 300 mg PO QHS Discharge Medications: 1. Creon 12 1 CAP PO TID W/MEALS RX *lipase-protease-amylase [Pancreaze] 2,600 unit-6,200 unit-10,850 unit 1 capsule(s) by mouth TID with meals Disp #*90 Capsule Refills:*0 2. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. Furosemide 20 mg PO DAILY RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 4. Multivitamins 1 TAB PO DAILY RX *multivitamin 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 5. Spironolactone 50 mg PO DAILY RX *spironolactone 50 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 6. Thiamine 100 mg PO DAILY RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 7. Vitamin D 400 UNIT PO DAILY RX *ergocalciferol (vitamin D2) 400 unit 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 8. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 9. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H 10. Omeprazole 20 mg PO DAILY 11. Ranitidine 300 mg PO QHS 12. Rosuvastatin Calcium 10 mg PO QPM 13. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ================= Cirrhosis Tachycardia Hyponatremia Diarrhea Anemia Thrombocytopenia ETOH Use Disorder SECONDARY ISSUES ================ Smoking Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ w/ decompensated cirrhosis, tachycardia, and known COPD// cause for tachycardia/ mild hypoxia? TECHNIQUE: Chest AP view COMPARISON: None IMPRESSION: Lungs are low volume with bibasilar atelectasis. Heart size is top-normal. There is no pleural effusion. No pneumothorax is seen Radiology Report EXAMINATION: Ultrasound-guided therapeutic and diagnostic paracentesis INDICATION: ___ with history of alcohol abuse with new moderate ascites// diagnostic paracentesis TECHNIQUE: Ultrasound guided diagnostic and therapeutic paracentesis COMPARISON: None FINDINGS: Limited grayscale ultrasound imaging of the abdomen demonstrated a small amount of ascites. A suitable target in the deepest pocket in the right lower quadrant was selected for paracentesis. PROCEDURE: The procedure, risks, benefits and alternatives were discussed with the patient and written informed consent was obtained. A preprocedure time-out was performed discussing the planned procedure, confirming the patient's identity with 3 identifiers, and reviewing a checklist per ___ protocol. Under ultrasound guidance, an entrance site was selected and the skin was prepped and draped in the usual sterile fashion. 1% lidocaine was instilled for local anesthesia. A 5 ___ catheter was advanced into the largest fluid pocket in the right lower quadrant and 1.7 L of clear, amber colored fluid were removed. Fluid samples were submitted to the laboratory for cell count, differential, culture, and cytology. The patient tolerated the procedure well without immediate complication. Estimated blood loss was minimal. Dr. ___ personally 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. 1.7 L of fluid were removed. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Dyspnea, Epigastric pain Diagnosed with Epigastric pain temperature: 98.4 heartrate: 103.0 resprate: 16.0 o2sat: 95.0 sbp: 104.0 dbp: 70.0 level of pain: 3 level of acuity: 2.0

___ history of EtOH use disorder with outpatient workup for presumed cirrhosis, esophageal varices (with history of bleed), breast and lung cancer, and COPD who p/w new ascites and diarrhea. # Cirrhosis: History of ETOH use disorder with new diagnosis of cirrhosis. Carrier of H63D mutation (hemochromatosis), but likely cirrhosis is due to ETOH use. Cause of subacute decompensation is unclear, though possibly due to progressive ETOH use. Hepatitis serologies negative, AMA, anti-smooth AB negative. No portal vein thrombosis on RUQUS. Diagnostic paracentesis with high SAAG is consistent with. No SBP on ascetic fluid. Previous EGD at ___ with known varices and patient has a history of variceal bleed. Paracentesis on ___ w/ 1.7L removed. No history of hepatic encephalopathy. MELD score 7 at time of discharge. Patient was started on Lasix 20 mg QD, spironolactone 50 mg QD. She will need an EGD as an outpatient in addition to hepatitis serologies. # Tachycardia: HR 90-110 over the first 24H of admission. Suspect most likely intravascular volume depletion related to cirrhosis as resolved with albumin/IVF. Less likely cardiogenic, or PE. TSH normal. HR improved with IVF. TTE ___ without evidence of CM or valvular disease. # Hyponatremia: Likely due to combination of poor PO solute intake iso heavy alcohol use and RAAS/ADH activation iso cirrhosis. Patient should continue 2g sodium restricted diet and 2L fluid restriction after discharge. She should continue Lasix 20 mg QD. BMP recheck at ___ ___. # Diarrhea: Chronic diarrhea x5 months. Differential includes pancreatic exocrine dysfunction vs. malabsorption. Less likely infectious. C.diff negative. TTG negative. Patient was started on creon TID with meals. Fecal elastase, O&P and stool culture pending. # Macrocytic Anemia: Macrocytic anemia likely due to marrow suppression in the setting of heavy alcohol use. Iron within normal limits, low TIBC consistent with ACD. Has a history of variceal bleed, but stool guaiac negative, no evidence of acute bleed. Hb on discharge 9.0. # Thrombocytopenia: Acute on chronic thrombocytopenia. No splenomegaly on RUQ. # EtOH Use Disorder: History of significant ETOH intake (4 glasses-1 bottle wine/day). Drinking for ___ years, longest sober x1 week with "tremors" but no seizures. Last drink ___ prior to arrival. Patient did not score on CIWA during admission. Social work was consulted. Patient was started on thiamine, folic acid and multivitamin. # HTN: Held home losartan 25 mg QD given recent normotension. # History of CVA: S/p coiled aneurysm. Patient reports she was taking 325 mg of aspirin daily, but recent PCP note says patient should be on 81 mg QD. Patient continued on rosuvastatin 10 mg PO QPM. # Cholelithiasis: Incidentally noted. Will need outpatient monitoring. # Severe Protein Calorie Malnutrition: Patient with severe hypoalbuminemia likely iso cirrhosis and poor PO intake. Urine pr/cr ratio 0.2. Nutrition was consulted, advised ensure enlive TID. Patient was started on supplements as above in addition to vitamin D. Vitamin A, E and zinc pending at time of admission.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Cetacaine Attending: ___. Chief Complaint: Anaphylaxis Major Surgical or Invasive Procedure: Laryngoscopy by ENT x2 ___ and ___ History of Present Illness: She has history of laryngeopharyngeal reflux since ___ with hoarseness. Seen at ___ ENT today for ___ removal of lesion of L vocal cord with reconstruction and local tissue flap in ___, on path no malignant cells seen. On day of admission patient had received a laryngoscopy and post-operatively received 1% lidocaine, Afrin and cetecaine (never had this medication) after the procedure. Patient then went to the parking lot, and then felt an acute onset of dyspnea, throat swelling, and urticarial with pruritus. Patient then went back to urgent care and received Benadryl 50 mg, Benadryl 25 mg (10:07), and then received 2 doses of epi-pen (9:15 and 9:58), and solumedrol IV (10:06 AM). Patient then referred to the ___ ED given persistent symptoms. In the ED, initial vitals: T 97, BP 131/100, RR 15, 100% RA On exam: BUE urticarial, no wheeze, hydrops uvula Labs were significant for: wbc 7.7, hgb 14, Cr 1.2 (baseline 0.8-1), AG 23, ast 43, tn < 0.01 Imaging was significant for: No acute cardiopulmonary process on CXR. EKG w/ HR 96, NSR, LAD, LAFB, borderline RBBB, no STE/STD/TWI Consults: ENT Patient received: Patient was given DuoNeb and albuterol nebs, started on epinephrine gtt, glycopyrrolate, famotidine, racemic epinephrine, IV Tylenol, dexamethasone 10mg x2 and epinephrine pen x 2. Her stridor and rash initially improved, but then she had new voice changes concerning for worsening airway edema. She was seen emergently by ENT who did laryngoscopy revealing anterior swelling (tongue and uvula) with normal glottis. Intubation was deemed unnecessary at the time. She was transferred to the ICU for airway monitoring. Past Medical History: Laryngeopharyngeal reflux since ___ with hoarseness HTN DM last A1C 9.6 ___ obesity HL Mild asthma Social History: ___ Family ___: Not assessed Physical Exam: ADMISSION PHYSICAL EXAM ====================== Vitals: T: Afebrile BP: 160/70 P: 122 R: 17 O2: 94% GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, ___ swelling and hoarseness, nasal trumpet in place NECK: supple, JVP not elevated, no LAD LUNGS: Mild wheeze bilaterally 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 GU: No foley in place EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: No lesions. No urticarial. NEURO: A&O x3. CN II-XII intact. Sensation, strength intact. DISCHARGE PHYSICAL EXAM ====================== VS: 97.3 146 / 85 82 18 95 RA GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, Mild asymmetric lip swelling. No tongue or uvula swelling visualized. NECK: supple, JVP not elevated, no LAD LUNGS: CTAB CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: No foley in place EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: No lesions. No urticarial. NEURO: A&O x3. CN II-XII intact. Sensation, strength intact. Pertinent Results: ADMISSION LAB RESULTS ==================== ___ 10:20AM BLOOD WBC-7.7 RBC-4.89 Hgb-14.1 Hct-42.6 MCV-87 MCH-28.8 MCHC-33.1 RDW-13.4 RDWSD-41.4 Plt ___ ___ 10:20AM BLOOD Neuts-31.9* Lymphs-60.2* Monos-6.6 Eos-0.9* Baso-0.1 Im ___ AbsNeut-2.44 AbsLymp-4.62* AbsMono-0.51 AbsEos-0.07 AbsBaso-0.01 ___ 10:20AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-1+ Ovalocy-OCCASIONAL ___ 04:20AM BLOOD ___ PTT-26.7 ___ ___ 10:20AM BLOOD Glucose-205* UreaN-28* Creat-1.2* Na-134 K-5.7* Cl-91* HCO3-20* AnGap-29* ___ 04:20AM BLOOD Glucose-200* UreaN-36* Creat-1.2* Na-138 K-4.3 Cl-97 HCO3-24 AnGap-21* ___ 10:20AM BLOOD ALT-23 AST-43* AlkPhos-47 TotBili-0.4 ___ 10:20AM BLOOD Lipase-41 ___ 10:20AM BLOOD cTropnT-<0.01 ___ 04:20AM BLOOD Albumin-4.5 Calcium-9.2 Phos-2.8 Mg-1.5* ___ 04:26AM BLOOD ___ pO2-94 pCO2-40 pH-7.44 calTCO2-28 Base XS-2 ___ 04:26AM BLOOD Lactate-3.8* DISCHARGE LAB RESULTS ==================== ___ 10:20AM PLT SMR-NORMAL PLT COUNT-279 ___ 06:00AM BLOOD WBC-9.2 RBC-4.09 Hgb-11.5 Hct-35.7 MCV-87 MCH-28.1 MCHC-32.2 RDW-13.6 RDWSD-43.0 Plt ___ ___ 06:00AM BLOOD Plt ___ ___ 06:00AM BLOOD Glucose-262* UreaN-33* Creat-0.9 Na-137 K-4.4 Cl-95* HCO3-26 AnGap-20 ___ 06:00AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.3 IMAGING/STUDIES: ============== CXR ___: No acute cardiopulmonary process. Fiberoptic exam (___): In the context of the patient's clinical presentation and the need to visualize the regions in close proximity, the decision was made to proceed with an endoscopic exam. Accordingly, after verbal consent, the fiberoptic scope was passed to visualize the regions of concern. The findings were: Nasal cavity: Turbinate mucosa pink, moist, no pus or polyps, significant clear mucous in nasopharynx and nasal cavity, Nasopharynx: Watery edema of soft palate Oropharynx: Symmetric soft palatal elevation, no mucosal lesions, masses, or erythema, tongue base without lesions Hypopharynx: No masses or lesions in vallecula, mild edema of piriform sinuses, no post-cricoid edema; no erythema; mild pooling of secretions Larynx: Epiglottis crisp, mild edema just at the tip of the epiglottis; True vocal cords symmetric with normal movement bilaterally; Arytenoids without erythema, normal movement of vocal processes, crisp arytenoids. MICROBIOLOGY: ============= none Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze 2. Pravastatin 80 mg PO QPM 3. Omeprazole 20 mg PO DAILY 4. MetFORMIN (Glucophage) 1000 mg PO BID 5. Chlorthalidone 25 mg PO DAILY 6. irbesartan 300 mg oral DAILY Discharge Medications: 1. Cetirizine 10 mg PO DAILY RX *cetirizine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection BID:PRN RX *epinephrine [EpiPen 2-Pak] 0.3 mg/0.3 mL 1 injection INJ PRN Disp #*2 Each Refills:*0 3. OneTouch Ultra Test (blood sugar diagnostic) miscellaneous BID:PRN RX *blood sugar diagnostic [OneTouch Ultra Test] PRN Disp #*50 Strip Refills:*0 4. OneTouch Ultra2 (blood-glucose meter) miscellaneous DAILY RX *blood-glucose meter daily Disp #*1 Kit Refills:*0 5. OneTouch UltraSoft Lancets (lancets) miscellaneous BID:PRN RX *lancets [OneTouch UltraSoft Lancets] PRN Disp #*100 Each Refills:*0 6. PredniSONE 30 mg PO DAILY Duration: 2 Doses This is dose # 1 of 3 tapered doses RX *prednisone 10 mg ___ tablet(s) by mouth daily Disp #*11 Tablet Refills:*0 7. PredniSONE 20 mg PO DAILY Duration: 2 Doses This is dose # 2 of 3 tapered doses 8. PredniSONE 10 mg PO DAILY Duration: 1 Dose This is dose # 3 of 3 tapered doses 9. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze 10. Chlorthalidone 25 mg PO DAILY 11. irbesartan 300 mg oral DAILY 12. MetFORMIN (Glucophage) 1000 mg PO BID 13. Omeprazole 20 mg PO DAILY 14. Pravastatin 80 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Anaphylaxis SECONDARY DIAGNOSIS: Hypertension Laryngeopharyngeal reflux 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: ___ angeioedema eval for lower respiratory infection// ___ angeioedema eval for lower respiratory infection TECHNIQUE: Single frontal view of the chest COMPARISON: None FINDINGS: No focal consolidation is seen. There is no large pleural effusion or pneumothorax. The cardiac and mediastinal silhouettes are unremarkable. No pulmonary edema is seen. IMPRESSION: No acute cardiopulmonary process. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Allergic reaction Diagnosed with Shock due to anesthesia, initial encounter, Adverse effect of local anesthetics, initial encounter, Oth places as the place of occurrence of the external cause temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: unable level of acuity: 1.0

___ w/ PMH of asthma, HTN, DM, HLD admitted for anaphylaxis. She presented with shortness of breath, throat swelling, urticaria thought to be reaction to topical cetecaine applied to the airway during an outpatient ENT procedure. She was treated with diphenhydramine, epipen, IV solumedrol then placed on a epinephrine gtt in the ED. Repeat ENT scope in the ED showed swelling of the uvula and soft palate, but clear airway. Patient was admitted to ICU for airway monitoring but never required intubation. She was treated with cetirizine and IV dexamethasone in the ICU. Repeat laryngoscope on ___ showed resolved edema. She was subsequently transferred to the floor on ___, then discharged on ___ with plan for outpatient follow up with her PCP and ___. She was discharged on a steroid taper, cetirizine, and with an Epi-Pen. She was also instructed to check her fingerstick qAM while on steroids and report values >350 to her PCP.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ ___ Complaint: LLQ pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year old male with a PMH of recurrent diverticulitis who presents to the ED with worsening LLQ abdominal pain in setting of recent admission for complicated diverticulitis ___ he presented to ___ ED with LLQ, CT scan showed diverticulitis with an associated abscess. He was started on ciprofloxacin/metronidazole and a drain was placed by interventional radiology. His abdominal pain resolved and he was discharged home with the drain still in place and oral antibiotics with instructions to follow up in acute care surgery clinic where his drain was pulled ___. In the interim, he has not had any further episodes of abdominal pain until ___ when he developed worsening LLQ pain and obstipation. He has since been able to pass gas but continues to have pain in RLQ. He is able to eat and maintain hydration. He denies nausea or vomiting. Past Medical History: PMH: HTN, diverticulitis PSH: ear surgery Social History: ___ Family History: Non-contributory Physical Exam: GENERAL: In no acute distress VITALS: Temp 98.4 HR: 71/min BP: 144/89 RR: 14/min Sat: 98% HEART: Regular rate and rhythm LUNGS: Clear, no increased work of breathing EXTREMITIES: Reveal no edema, WWP ABDOMEN: very tender in LLQ to palpation, distended Discharge Physical Exam: VS: T: 97.8 PO BP: 141/99 L Sitting HR: 73 RR: 18 O2: 98% Ra GEN: A+Ox3, NAD HEENT: atraumatic CV: RRR PULM: CTA b/l ABD: midline incision with receding erythema. Gently packed with gauze and covered with dsd cdi. EXT: wwp, no edema b/l Pertinent Results: IMAGING: ___: CXR: No acute cardiopulmonary abnormality. ___: CT Abdomen/Pelvis: 1. Re-accumulation of a sigmoid diverticular collection following removal of pigtail drainage catheter. This collection measures 1.5 x 2.7 x 3.6 cm. 2. Improving sigmoid diverticulitis, as the degree of wall thickening and stranding has decreased compared to ___. 3. Drainage tract in the left rectus muscle is noted, with phlegmonous change and a small 1 cm collection. LABS: ___ 10:55PM WBC-9.7 RBC-3.90* HGB-12.2* HCT-34.3* MCV-88 MCH-31.3 MCHC-35.6 RDW-13.6 RDWSD-43.8 ___ 10:55PM PLT COUNT-183 ___ 10:55PM ___ ___ 02:48PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 02:48PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 02:48PM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE EPI-0 ___ 02:02PM LACTATE-1.5 ___ 01:57PM GLUCOSE-112* UREA N-11 CREAT-1.1 SODIUM-132* POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-24 ANION GAP-8* ___ 01:57PM ALT(SGPT)-13 AST(SGOT)-17 ALK PHOS-85 TOT BILI-0.7 ___ 01:57PM LIPASE-12 ___ 01:57PM ALBUMIN-4.2 ___ 01:57PM WBC-7.9 RBC-4.75 HGB-14.6 HCT-42.2 MCV-89 MCH-30.7 MCHC-34.6 RDW-13.6 RDWSD-44.5 ___ 01:57PM NEUTS-70.7 LYMPHS-18.9* MONOS-9.2 EOS-0.3* BASOS-0.5 IM ___ AbsNeut-5.56 AbsLymp-1.48 AbsMono-0.72 AbsEos-0.02* AbsBaso-0.04 ___ 01:57PM PLT COUNT-226 Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen 1000 mg PO Q8H Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 10 Days Take with food. RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*20 Tablet Refills:*0 2. Bisacodyl ___AILY:PRN Constipation - Second Line may hold for diarrhea or loose stool. 3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate this medication may cause drowsiness. RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*5 Tablet Refills:*0 4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line may hold for diarrhea or loose stool. 5. Senna 8.6 mg PO BID may hold for diarrhea or loose stool. 6. Acetaminophen 1000 mg PO Q8H Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Pericolonic abscess Diverticulitis 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 left lower quadrant pain, recent hospitalization for abscess drainage, wheezing over the last 2 days and bilateral lower lobe crackles// Bilateral lower lobe crackles, concern for atelectasis versus pneumonia TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph ___ and CT chest ___ FINDINGS: Heart size is normal. The mediastinal and hilar contours are normal. The pulmonary vasculature is normal. Lungs are clear. No pleural effusion or pneumothorax is seen. There are no acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary abnormality. Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: NO_PO contrast; History: ___ with left lower quadrant pain after recent complicated diverticulitis and abscess drainageNO_PO contrast// Concern for complicated diverticulitis, abscess reaccumulation, SBO TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 19.3 mGy (Body) DLP = 9.6 mGy-cm. 2) Spiral Acquisition 5.5 s, 43.6 cm; CTDIvol = 11.2 mGy (Body) DLP = 485.7 mGy-cm. 3) Spiral Acquisition 1.6 s, 12.3 cm; CTDIvol = 10.8 mGy (Body) DLP = 132.2 mGy-cm. Total DLP (Body) = 627 mGy-cm. COMPARISON: Reference CT abdomen and pelvis dated ___. 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. A fluid attenuation hypodensity in segment 4A unchanged from priors most consistent with a cyst (04:12). There are no new or suspicious hepatic lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: There is a small hiatal hernia. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. An anterior approach pigtail catheter has been removed. Colonic diverticulosis is re-demonstrated, with the collection in the proximal sigmoid colon measuring 1.5 x 2.7 x 3.6 cm, previously 2.9 x 5.7 x 5.4 cm on ___, and was subsequently collapsed when the pigtail catheter was placed (02:56). Additionally, wall thickening and stranding adjacent to the sigmoid colon has decreased suggesting resolving diverticulitis. Normal appendix. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The prostate gland is mildly enlarged. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Severe atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: Tract from the previously placed pigtail catheter is noted in the inferior left rectus musculature (02:53), with phlegmonous change and a small 1 cm collection in the rectus itself. IMPRESSION: 1. Re-accumulation of a sigmoid diverticular collection following removal of pigtail drainage catheter. This collection measures 1.5 x 2.7 x 3.6 cm. 2. Improving sigmoid diverticulitis, as the degree of wall thickening and stranding has decreased compared to ___. 3. Drainage tract in the left rectus muscle is noted, with phlegmonous change and a small 1 cm collection. Gender: M Race: OTHER Arrive by WALK IN Chief complaint: LLQ abdominal pain Diagnosed with Dvtrcli of intest, part unsp, w perf and abscess w/o bleed, Left lower quadrant pain temperature: 97.6 heartrate: 92.0 resprate: 18.0 o2sat: 96.0 sbp: 154.0 dbp: 97.0 level of pain: 4 level of acuity: 3.0

Mr. ___ is a ___ y/o M with a PMH of recurrent diverticulitis w/ associated abscess for which he underwent ___ drainage and treatment with antibiotics. His drain was removed in ___ clinic on ___ and he presented to the ED this admission w/ worsening LLQ pain. He had a CT A/P which showed a 3 cm pericolic abscess and diffuse sigmoid stranding with stranding around the left rectus and 1 cm abscess. The patient was treated with zosyn and the old drain site opened up on its own and was further surgically extended. The abscess drained through this opening, therefore ___ intervention was not necessary. The patient tolerated a regular diet. He remained stable from a cardiopulmonary standpoint; vital signs were routinely monitored. Pain was managed with oxycodone and acetaminophen. The patient was discharged on a 10 day total course of Augmentin. The patient received subcutaneous heparin and ___ dyne boots were used during this stay and was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, ambulating, voiding without assistance, and pain was well controlled. The erythema surrounding the wound was receding, and this area was marked with a surgical pen. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. He was discharged home with ___ services.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Penicillins / Ceclor / Demerol / Codeine / latex / shellfish derived / Iodinated Contrast- Oral and IV Dye Attending: ___. Major Surgical or Invasive Procedure: - PTBD placement x2 (___) - Cholangiogram with upsizing of drains and aspiration of ___ fluid (___) - PTBD drain exchange, placement of perihepatic abscess drain (___) - Abscess drain exchange and upsize, PTBD drain exchange and upsize (___) attach Pertinent Results: ADMISSION LABS: ___ 01:38PM BLOOD WBC-5.3 RBC-4.48 Hgb-13.3 Hct-40.8 MCV-91 MCH-29.7 MCHC-32.6 RDW-15.0 RDWSD-50.1* Plt ___ ___ 01:38PM BLOOD Neuts-76.2* Lymphs-15.2* Monos-6.2 Eos-1.1 Baso-0.9 Im ___ AbsNeut-4.05 AbsLymp-0.81* AbsMono-0.33 AbsEos-0.06 AbsBaso-0.05 ___ 01:38PM BLOOD Glucose-119* UreaN-18 Creat-0.6 Na-134* K-4.2 Cl-98 HCO3-25 AnGap-11 ___ 01:38PM BLOOD ALT-24 AST-26 AlkPhos-228* TotBili-0.4 ___ 07:05AM BLOOD Albumin-3.7 Phos-2.5* Mg-2.2 ___ 01:38PM BLOOD Albumin-4.3 ___ 01:38PM BLOOD Lipase-23 ___ 01:38PM BLOOD ALT-24 AST-26 AlkPhos-228* TotBili-0.4 INTERVAL LABS: ___ 05:51PM BLOOD ___ pO2-97 pCO2-35 pH-7.39 calTCO2-22 Base XS--2 Comment-GREEN TOP ___ 07:45AM BLOOD Free T4-1.5 ___ 07:45AM BLOOD TSH-3.5 ___ 07:50AM BLOOD cTropnT-<0.01 ___ 03:35PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 12:54AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 07:30AM BLOOD CK-MB-2 cTropnT-<0.01 MICRO: UCx (___): GRAM NEGATIVE ROD(S). >100,000 CFU/mL. UCx (___): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Abscess culture (___): KLEBSIELLA PNEUMONIAE. MODERATE GROWTH. MIXED BACTERIAL FLORA. 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--------- 2 I GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S IMAGING/STUDIES: ___ Biliary drain check FINDINGS: 1. Possibly occluded pre-existing perihepatic drain with contrast opacification of the perihepatic collection. 2. Antegrade cholangiogram through the right posterior drain demonstrates adequate drainage of the right posterior biliary system. 3. Antegrade cholangiogram fluid right anterior drain demonstrates adequate drainage of the right anterior biliary system. 4. Cone beam CT demonstrating mildly dilated right anterior and posterior biliary systems. Limited assessment for evidence of choledocholithiasis. 5. Pull-back cholangiogram to the right posterior biliary access demonstrating leakage of contrast into the perihepatic space. IMPRESSION: Successful exchange of existing percutaneous transhepatic biliary drainage catheters with new 14 ___ right posterior transhepatic biliary drainage catheter, 12 ___ right anterior transhepatic biliary drainage catheters. ___ ___ guided PTC PROCEDURE: 1. Cholangiogram through existing right anterior and posterior percutaneous transhepatic biliary drainage access. 2. Exchange of the existing right posterior percutaneous transhepatic biliary drainage catheter with a new modified 12 ___ modified APD L internal external PTBD catheter. 3. Exchange of the existing right anterior percutaneous transhepatic biliary drainage catheter with a new modified 12 ___ modified APD L internal external PTBD catheter. 4. Ultrasound-guided abscess drainage. FINDINGS: 1. Right posterior pull-back cholangiogram demonstrates leakage of contrast into the perihepatic space. Antegrade passage of contrast noted into the bowel. 2. Right anterior drainage catheter noted to be retracted on scout image. Right anterior pull-back cholangiogram demonstrates no evidence of pericatheter leakage. Antegrade passage of contrast noted into the bowel. IMPRESSION: Successful fluoroscopic guided perihepatic collection abscess drain placement. Successful right anterior and right posterior biliary catheter exchange for new modified 12 ___ APD L ___ ___ guided biliary catheter check PROCEDURE: 1. Ultrasound-guided percutaneous aspiration of the perihepatic fluid collection. 2. Antegrade and pull-back cholangiogram through the right anterior biliary drain. 3. Antegrade and pull-back cholangiogram through the right posterior PTBD. 4. Exchange of the existing percutaneous trans-hepatic biliary drainage catheters with a new modified 12 ___ APDL internal external biliary drainage catheters. FINDINGS: 1. Approximately 80 cc of purulent fluid aspirated from the perihepatic fluid collection. A sample of fluid was sent for pathological analysis. 2. Initial injection through the right anterior PTBD demonstrated the catheter to be in good position. 3. Initial contrast injection through the existing right posterior PTBD demonstrates the catheter to be slightly pulled back and pericatheter leakage along the catheter into the peritoneum. 4. Pull-back and antegrade cholangiogram through the posterior right PTBD demonstrates good passage of contrast into the small bowel without significant stricture. 5. Pull-back and antegrade cholangiogram through the anterior right PTBD showed good antegrade flow of contrast from the anterior ducts into the small bowel without significant stricture. 6. Successful exchange and repositioning of indwelling 10 ___ percutaneous transhepatic biliary drainage catheters with new modified 12 ___ right anterior and posterior APDL catheters (additional side holes placed) acting as internal external biliary drainage catheters. IMPRESSION: Successful ultrasound-guided drainage of approximately 80 cc of purulent perihepatic fluid. Samples of fluid were sent for analysis. Successful exchange of existing right anterior and posterior percutaneous transhepatic biliary drainage catheters with new modified internal external 12 ___ APDL catheters. CT abd/pelvis W/WO contrast (___): IMPRESSION: 1. Interval development of a small amount of perihepatic ascites with associated scalloping of the liver and peritoneal thickening and enhancement, consistent with peritonitis. 2. Patchy areas of arterial hyperenhancement of the hepatic parenchyma at the sites of scalloping, which normalize on subsequent postcontrast phases, are likely perfusional due to mass effect. No new biliary dilatation or peribiliary pattern of enhancement to suggest active cholangitis. 3. Appropriate positioning of right anterior and right posterior internal-external percutaneous biliary drainage catheters. 4. Calcifications in the jejunum measuring up to 5 mm, likely reflecting forward movement of known intraductal stones. CXR portable (___): IMPRESSION: Very minor suspected new right basilar volume loss, otherwise unchanged. AXR (___): IMPRESSION: Minimal distension and dilatation of the transverse colon, not necessarily significant. No free air. CT head without contrast (___): IMPRESSION: 1. No evidence of acute intracranial abnormality. TTE (___): IMPRESSION: Mild symmetric left ventricular hypertrophy with normal cavity size and hyperdynamic global systolic function with mild mid-cavitary gradient. No valvular pathology identified. The patient has evidence of high output syndrome (e.g. anemia, fever, thyrotoxicosis, thiamine deficiency, peripheral shunt, etc.). CXR (___): IMPRESSION: Heart size and mediastinum are stable. Lungs are clear. There is no appreciable pleural effusion. There is no pneumothorax. CT abd/pelvis with contrast (___): IMPRESSION: 1. No finding to explain left sided abdominal pain. 2. Mild to moderate intrahepatic biliary duct dilation and subtle focal parenchymal hyperenhancement, similar to but better evaluated on the recent MRCP, likely chronic cholangitis. 3. Stable post Whipple and hepaticojejunostomy appearance. CXR PA/Lat (___): IMPRESSION: No acute cardiopulmonary process. DISCHARGE LABS: ___ 09:00AM BLOOD WBC-6.4 RBC-3.67* Hgb-10.9* Hct-34.4 MCV-94 MCH-29.7 MCHC-31.7* RDW-15.9* RDWSD-53.3* Plt ___ ___ 09:00AM BLOOD Glucose-145* UreaN-17 Creat-0.4 Na-130* K-4.2 Cl-97 HCO3-25 AnGap-8* ___ 09:00AM BLOOD ALT-11 AST-16 LD(LDH)-99 AlkPhos-193* TotBili-0.3 ___ 09:00AM BLOOD Albumin-2.8* Calcium-9.0 Phos-2.6* Mg-2.1 ___ 08:18AM BLOOD VitB12-1697* Folate-8 ___ 08:57AM BLOOD %HbA1c-6.2* eAG-131* ___ 07:45AM BLOOD TSH-3.5 CT abd/pelvis without contrast: 1. Near complete resolution of fluid collection at the liver dome, with no significant fluid at the pigtail and a small focal 4.4 x 2.7 cm loculation anterior and medial to the pigtail. No new fluid collections identified. 2. Unchanged positioning of the right anterior and right posterior internal external percutaneous biliary drainage catheters. No new biliary dilatation, within limits of noncontrast imaging. 3. Stable postsurgical changes from prior Whipple procedure. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. aMILoride 5 mg PO DAILY 2. amLODIPine 5 mg PO DAILY 3. Hydrochlorothiazide 50 mg PO DAILY 4. Pancreaze (lipase-protease-amylase) 10,500-35,500- 61,500 unit oral DAILY 5. Nortriptyline 25 mg PO QHS 6. Omeprazole 40 mg PO DAILY 7. Topiramate (Topamax) 50 mg PO DAILY 8. Ursodiol 300 mg PO BID 9. Glargine Unknown Dose Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. amLODIPine 5 mg PO DAILY 3. Cefpodoxime Proxetil 400 mg PO Q12H RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp #*56 Tablet Refills:*0 4. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth BIDPRN Disp #*60 Capsule Refills:*0 5. Metoprolol Tartrate 12.5 mg PO BID RX *metoprolol tartrate 25 mg 12.5 mg by mouth twice a day Disp #*60 Tablet Refills:*0 6. MetroNIDAZOLE 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth three times per day Disp #*42 Tablet Refills:*0 7. Multivitamins W/minerals 1 TAB PO DAILY 8. Nortriptyline 25 mg PO QHS 9. Omeprazole 40 mg PO DAILY 10. Pancrelipase 5000 1 CAP PO TID W/MEALS 11. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 [ClearLax] 17 gram 1 dose by mouth dailyprn Disp #*20 Packet Refills:*0 12. Topiramate (Topamax) 100 mg PO BID 13. TraMADol 25 mg PO Q6H:PRN Pain - Moderate RX *tramadol [Ultram] 50 mg 25 tablet(s) by mouth every 6 hours as needed Disp #*20 Tablet Refills:*0 14. Ursodiol 300 mg PO BID 15.Equipment Rolling Walker Dx: Unsteady gait (R26.81), Px: good, ___: 13 months Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Biliary obstruction Chronic cholangitis Sepsis ___ peritonitis after biliary drain placement Delirium Chest pain Hyponatremia 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: NO_PO contrast; History: ___ with L flank and L sided abd pain/tenderness CAN TOLERATE NON-IONIC CONTRAST ONLYNO_PO contrast// Assess for diverticulitis, hx of pancreatic CA s/p whipple. CAN TOLERATE NON-IONIC CONTRAST ONLY TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 16.9 mGy (Body) DLP = 8.4 mGy-cm. 2) Spiral Acquisition 5.9 s, 46.1 cm; CTDIvol = 8.9 mGy (Body) DLP = 408.0 mGy-cm. Total DLP (Body) = 416 mGy-cm. COMPARISON: MRCP from ___. CT of the abdomen pelvis 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. The left hepatic lobe is atrophic. There is no evidence of focal lesions. Mild intrahepatic biliary duct dilation and patchy parenchymal hyperenhancement, similar to recent MRI. There is no evidence of extrahepatic biliary dilatation. The gallbladder is surgically absent. PANCREAS: Patient is status post Whipple. The remaining 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 solid renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The patient is status post hepaticojejunostomy. 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 is not visualized. No adnexal abnormality is seen. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Unchanged 6 mm of anterolisthesis L4 over L5. Post kyphoplasty changes of T12 are noted. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. No finding to explain left sided abdominal pain. 2. Mild to moderate intrahepatic biliary duct dilation and subtle focal parenchymal hyperenhancement, similar to but better evaluated on the recent MRCP, likely chronic cholangitis. 3. Stable post Whipple and hepaticojejunostomy appearance. Radiology Report INDICATION: ___ year old female with chief complaint of worsening abdominal pain, diarrhea, chills. H/o whipple in ___, has intermittent posterior RUQ abdominal pain likely associated with recurrent biliary stones, scheduled for PTBD on ___// PTBD COMPARISON: CT ___ and MRI ___. TECHNIQUE: OPERATORS: Dr. ___ interventional radiologist, performed the procedure. ANESTHESIA: General anesthesia. MEDICATIONS: See anesthesiology notes. CONTRAST: 50 ml of Optiray contrast FLUOROSCOPY TIME AND DOSE: 25.2, 3 minutes 40 mGy PROCEDURE: 1. Transabdominal ultrasound. 2. Ultrasound guided right percutaneous posterior transhepatic bile duct access. 3. Percutaneous transhepatic cholangiogram right posterior duct system 4. Ultrasound-guided right percutaneous anterior transhepatic bile duct access 5. Percutaneous transhepatic cholangiogram right anterior duct system 6. Right anterior duct stricture cholangioplasty 7. Right posterior duct stricture cholangioplasty 8. ___ right anterior biliary drain. 9. ___ right posterior biliary drain. PROCEDURE DETAILS: Following the discussion of the risks, benefits, and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The right abdomen was prepped and draped in the usual sterile fashion. Under ultrasound guidance, a 21G Cook needle was advanced into right posteriorbiliary system. Images of the access were stored on PACS. A percutaneous transhepatic cholangiogram of the right posterior system was performed, demonstrating delayed drainage of contrast. Therefore, decision was made to proceed with drain placement within this duct system, and a peripheral duct was selected for access. A second needle was used to target the peripheral duct, and once this was punctured, a Headliner wire was advanced under fluoroscopic guidance into the posterior duct. A skin ___ was made over the needle and the needle was removed over the wire. The inner portion of an Accustick set was then advanced over the wire, and the headliner wire was exchanged for a Nitinol wire. The entire Accustick set was then advanced into the posterior duct system over the Nitinol wire. A Roadrunner wire was used to cross through the posterior duct stricture into the common hepatic duct and hepaticojejunostomy. Over this, a 6 ___ sheath was placed, with the tip positioned within the hepaticojejunostomy. At this point, contrast opacification of the right anterior system was noted without drainage or emptying into the posterior duct access. Therefore, a decision was made to access this system to be interrogated separately. Under ultrasound guidance, a 21 gauge cook needle was advanced into the right anterior biliary system. Images of the access were stored on PACs. The percutaneous transhepatic cholangiogram of the right anterior system was performed, demonstrating delayed drainage of contrast. Therefore, a decision was made to proceed with drain placement within this duct system, and a peripheral duct was selected for access. A second needle was used to target to the peripheral duct, and once this was punctured, a headliner wire was advanced under fluoroscopic guidance into the anterior duct. A skin ___ was made over the needle, and the needle was removed over the wire. The inner portion of an Accustick set was then advanced over the wire, the headliner wire was exchanged for a Nitinol wire. Entire Accustick set was then advanced into the anterior duct system over the Nitinol wire. A Roadrunner wire was used to cross through the anterior duct stricture, into the common hepatic duct and hepaticojejunostomy. Over this, a 6 ___ sheath was placed. Next, an over-the-wire pull-back cholangiogram was performed through each sheath, demonstrating focal strictures of the right anterior and posterior ducts systems. A decision was made to perform cholangioplasty, and a 6 mm x 4 cm Conquest balloon was advanced over the wire and used to dilate the right posterior duct stricture. This was then removed and advanced over the wire and used to dilate the anterior duct stricture. Balloon sweep of each duct was performed prior to removal. Following this, a drain was placed within each system. Next, an modified 10 ___ APDL, with additional sideholes was placed within the right anterior system, with the pigtail positioned within the Roux limb. Similarly, a modified 10 ___ APD L was placed within the right posterior system. In both instances, sideholes were present above and below the site of stricture. Contrast injection confirmed appropriate position. The catheters were flushed with saline, secured with stay sutures to the skin and sterile dressings were applied. The catheter was attached to a bag. The patient tolerated the procedure well. There were no immediate complications. FINDINGS: 1. Initial percutaneous transhepatic cholangiogram of the right posterior duct system demonstrates focal stricture. Opacification of the right anterior system was noted, without continuity and joint drainage. 2. Initial percutaneous transhepatic cholangiogram of the right anterior duct system demonstrates separate focal stricture. 3. Successful cholangio plasty of the right anterior and posterior duct strictures with a 6 mm x 4 cm balloon. 4. Successful placement of right anterior and posterior drainage catheters across the separate sites of stricture. Balloon sweep of both ducts systems also performed. Filling defects were not well visualized due to debris from placement at the time of the procedure. IMPRESSION: Successful placement of right anterior and right posterior ___ internal-external biliary drains across the site of stricture, with cholangioplasty. The patient should return in 6 weeks for repeat cholangiography, additional cholangioplasty, and evaluation for intraductal stones. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with chest pain// ?etiology of chest pain ?etiology of chest pain IMPRESSION: Heart size and mediastinum are stable. Lungs are clear. There is no appreciable pleural effusion. There is no pneumothorax. Radiology Report EXAMINATION: Chest radiograph, portable AP semi-upright. INDICATION: Change in mental status. COMPARISON: ___. FINDINGS: Cardiac, mediastinal and hilar contours appear stable. Mild new suspected atelectasis at the right lung base no definite pleural effusion. No visible pneumothorax. Para pigtail drains again projects over the right upper quadrant. Unchanged thoracolumbar vertebroplasty site. IMPRESSION: Very minor suspected new right basilar volume loss, otherwise unchanged. Radiology Report EXAMINATION: Abdominal radiographs, two views. INDICATION: Status post biliary drain placements with change in mental status and abdominal pain. COMPARISON: Prior CT from ___. FINDINGS: 2 biliary drains project over the right upper quadrant. Stomach is not substantially distended. There is no dilatation of small bowel. Transverse colon is minimally dilated. Maximum caliber the colon is 7 cm. No evidence of free air. Thoracolumbar vertebroplasty site at T12. Bones appear demineralized. IMPRESSION: Minimal distension and dilatation of the transverse colon, not necessarily significant. No free air. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman with change in mental status// ? evidence of bleeding or other etiology for altered mentation TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 50.0 mGy (Head) DLP = 940.0 mGy-cm. Total DLP (Head) = 940 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 white matter hypodensities consistent with small vessel ischemic changes. There is no evidence of fracture. Partial opacification of the right mastoid air cells. Otherwise, the remaining visualized portions of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. Patient is status post bilateral lens replacements. IMPRESSION: 1. No evidence of acute intracranial abnormality. Radiology Report EXAMINATION: CT ABD AND PELVIS W AND W/O CONTRAST, ADDL SECTIONS INDICATION: ___ year old woman s/p ___ with recurrent cholangitis s/p PTBD placements x2 on ___, now with sepsis of unknown etiology.// ? evidence of abscess/infection and are drains in correct position TECHNIQUE: Multiphasic Liver: Multidetector CT of the abdomen was done 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 was scanned in the early arterial phase, followed by a scan of the abdomen and pelvis in the portal venous phase, followed by a scan of the abdomen in equilibrium phase (3-min delay). Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.1 s, 26.4 cm; CTDIvol = 5.7 mGy (Body) DLP = 145.9 mGy-cm. 2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9 mGy-cm. 3) Stationary Acquisition 3.0 s, 0.2 cm; CTDIvol = 50.3 mGy (Body) DLP = 10.1 mGy-cm. 4) Spiral Acquisition 3.2 s, 20.8 cm; CTDIvol = 10.6 mGy (Body) DLP = 213.2 mGy-cm. 5) Spiral Acquisition 7.2 s, 46.9 cm; CTDIvol = 9.3 mGy (Body) DLP = 429.1 mGy-cm. 6) Spiral Acquisition 3.2 s, 20.8 cm; CTDIvol = 9.9 mGy (Body) DLP = 199.8 mGy-cm. Total DLP (Body) = 1,000 mGy-cm. COMPARISON: CT abdomen and pelvis from ___ FINDINGS: LOWER CHEST: Interval development of a small right pleural effusion with associated relaxation atelectasis. No left pleural effusion. ABDOMEN: HEPATOBILIARY: The patient is status post hepaticojejunostomy. There is interval development of a small amount of perihepatic ascites with associated scalloping of the liver and peritoneal thickening and enhancement, consistent with peritonitis. Patchy areas of arterial hyperenhancement of the hepatic parenchyma at the sites of scalloping, which normalize on subsequent postcontrast phases, are likely perfusional due to mass effect. There is no evidence of focal lesions. Patient is status post placement of percutaneous biliary drainage catheters in the right anterior and right posterior hepatic bile ducts. The biliary drainage catheters appear appropriately positioned with pigtails in the jejunum. Atrophy and fibrosis of the left hepatic lobe with dilatation of intrahepatic bile ducts is similar to prior studies. There is no new biliary dilatation or peribiliary pattern of enhancement to suggest active cholangitis. There are calcifications in the jejunum measuring up to 5 mm, likely reflecting forward movement of known intraductal stones. A stable area of hypoenhancement the inferior border of segment V likely reflects retractor injury. The gallbladder is surgically absent. PANCREAS: Status post pancreaticoduodenectomy. The remaining portion of the pancreatic body and tail is atrophic, without ductal dilatation. 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 solid renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Stable postsurgical changes related to prior pancreaticoduodenectomy. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. There is mild fecalization of contents in the distal ileum reflecting slow transit. The colon and rectum are unremarkable. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus is not visualized. No adnexal abnormality is seen. LYMPH NODES: Several prominent mesenteric lymph nodes measuring up to 8 mm are unchanged. There is no retroperitoneal lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic disease is noted. Again seen is narrowing of the main portal vein just before the bifurcation of the right and left portal veins, unchanged and likely postsurgical in nature. Portal vasculature is patent. BONES: There is no evidence of worrisome osseous lesions or acute fracture. A compression fracture of the T12 vertebral body with kyphoplasty material is unchanged. There are severe multilevel degenerative changes of the lumbar spine. Grade 1 anterolisthesis of L4 on L5 is unchanged. SOFT TISSUES: There are postsurgical changes along the ventral lower abdominal wall. IMPRESSION: 1. Interval development of a small amount of perihepatic ascites with associated scalloping of the liver and peritoneal thickening and enhancement, consistent with peritonitis. 2. Patchy areas of arterial hyperenhancement of the hepatic parenchyma at the sites of scalloping, which normalize on subsequent postcontrast phases, are likely perfusional due to mass effect. No new biliary dilatation or peribiliary pattern of enhancement to suggest active cholangitis. 3. Appropriate positioning of right anterior and right posterior internal-external percutaneous biliary drainage catheters. 4. Calcifications in the jejunum measuring up to 5 mm, likely reflecting forward movement of known intraductal stones. Radiology Report INDICATION: ___ with hx Whipple, recurrent choledocholithiasis and cholangitis s/p multiple ERCPs, s/p R ant and R post int-ext biliary drains, now with perihepatic fluid, peritoneal thickening, leakage around PTBD 1.// PTBD check and change, aspirate fluid COMPARISON: CT of the abdomen pelvis dated ___ TECHNIQUE: OPERATORS: Dr. ___, attending Interventional Radiologist and Dr. ___ fellow performed the procedure. Dr. ___ personally supervised the trainee during any key components of the procedure where applicable and reviewed and agrees with the findings as reported below. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 100mcg of fentanyl and 1 mg of midazolam throughout the total intra-service time of 95 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: See above CONTRAST: 35 ml of Optiray contrast FLUOROSCOPY TIME AND DOSE: 12.9 minutes, 61 mGy PROCEDURE: 1. Ultrasound-guided percutaneous aspiration of the perihepatic fluid collection. 2. Antegrade and pull-back cholangiogram through the right anterior biliary drain. 3. Antegrade and pull-back cholangiogram through the right posterior PTBD. 4. Exchange of the existing percutaneous trans-hepatic biliary drainage catheters with a new modified 12 ___ APDL internal external biliary drainage catheters. 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/mid abdomen was prepped and draped in the usual sterile fashion. Under ultrasound guidance, the right perihepatic fluid collection was identified. 1% lidocaine was instilled in the skin and subcutaneous tissues. A 21 gauge 15 cm needle was used to access the fluid collection. 80 cc of fluid was aspirated. The needle was removed. Initial scout images showed biliary drains in the appropriate position. The right tubes were injected with dilute contrast. The images were stored on PACS. Following the subcutaneous injection of 1% lidocaine and instillation of lidocaine jelly into the skin site, the right posterior catheter was cut and a ___ wire was advanced through the catheter into the jejunum. The catheter was removed and a 7 ___ bright tip sheath was advanced. Antegrade and pull back cholangiogram were then performed through the sheath with findings as outlined below. The catheter was removed over the wire and a 12 ___ percutaneous trans hepatic biliary modified APDL drainage catheter was advanced into the jejunum. Side holes were positioned above and below the level of obstruction to facilitate internal drainage. The wire and inner stiffener were removed, the catheter was flushed, the loop was formed, the catheter was attached to a bag and sterile dressings were applied. On the left, similarly the catheter was cut and ___ wire was advanced through the catheter into the jejunum. The catheter was removed and a 6 ___ bright tip sheath was advanced. Antegrade and pull back cholangiogram were then performed with findings as outlined below. The catheter was removed over the wire and a 12 ___ percutaneous transhepatic modified APDL biliary drainage catheter was advanced into the duodenum. Side holes were positioned above and below the level of obstruction to facilitate internal drainage. The wire and inner stiffener were removed, the catheter was flushed, the loop was formed, the catheter was attached to a bag and sterile dressings were applied. The patient tolerated the procedure well and there were no immediate post-procedure complications. FINDINGS: 1. Approximately 80 cc of purulent fluid aspirated from the perihepatic fluid collection. A sample of fluid was sent for pathological analysis. 2. Initial injection through the right anterior PTBD demonstrated the catheter to be in good position. 3. Initial contrast injection through the existing right posterior PTBD demonstrates the catheter to be slightly pulled back and pericatheter leakage along the catheter into the peritoneum. 4. Pull-back and antegrade cholangiogram through the posterior right PTBD demonstrates good passage of contrast into the small bowel without significant stricture. 5. Pull-back and antegrade cholangiogram through the anterior right PTBD showed good antegrade flow of contrast from the anterior ducts into the small bowel without significant stricture. 6. Successful exchange and repositioning of indwelling 10 ___ percutaneous transhepatic biliary drainage catheters with new modified 12 ___ right anterior and posterior APDL catheters (additional side holes placed) acting as internal external biliary drainage catheters. IMPRESSION: Successful ultrasound-guided drainage of approximately 80 cc of purulent perihepatic fluid. Samples of fluid were sent for analysis. Successful exchange of existing right anterior and posterior percutaneous transhepatic biliary drainage catheters with new modified internal external 12 ___ APDL catheters. Radiology Report INDICATION: ___ year old woman with recurrent cholangitis s/p PTBD placements, now with leakage at posterior drain site. plan for cholangiogram with abscess drainage// Cholangiogram, abscess drainage COMPARISON: Biliary catheter exchange ___ TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ performed the procedure. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 75mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service time of 45 minutes during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: Ceftriaxone 1 g IV CONTRAST: 45 ml of gadolinium contrast FLUOROSCOPY TIME AND DOSE: 6.1, 26 mGy PROCEDURE: 1. Cholangiogram through existing right anterior and posterior percutaneous transhepatic biliary drainage access. 2. Exchange of the existing right posterior percutaneous transhepatic biliary drainage catheter with a new modified 12 ___ modified APD L internal external PTBD catheter. 3. Exchange of the existing right anterior percutaneous transhepatic biliary drainage catheter with a new modified 12 ___ modified APD L internal external PTBD catheter. 4. Ultrasound-guided abscess drainage. 5. 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. Scout image was obtained. Following the installation of 1% lidocaine in the subcutaneous tissues, contrast injection was performed through the right posterior biliary catheter. The catheter was cut and ___ wire was advanced into the jejunum and the catheter was removed over wire. An 7 ___ vascular sheath was placed over the wire. Pull-back cholangiogram was performed. The sheath was then removed and a new 12 ___ modified (and extra sideholes) APDL catheter was advanced over the wire. The wire was removed and the locking loop was formed within the jejunum. The catheter was attached to a bag drainage. Sterile dressing and sutures were applied. Following the installation of 1% lidocaine in the subcutaneous tissues, contrast injection was performed through the right anterior biliary catheter. The catheter was cut and ___ wire was advanced into the jejunum and the catheter was removed over wire. An 7 ___ vascular sheath was placed over the wire. Pull-back cholangiogram was performed. The sheath was then removed and a new 12 ___ modified (and extra sideholes) APDL catheter was advanced over the wire. The wire was removed and the locking loop was formed within the jejunum. The catheter was attached to a bag drainage. Sterile dressings and sutures were applied. Next attention was turned to the perihepatic collection. Under fluoroscopic guidance a 21 gauge needle was advanced into the perihepatic collection an 018 wire was advanced. Using a micropuncture sheath exchange was made for short Amplatz wire. Modified 8 ___ APD L (extra sideholes) was then advanced over the wire into the perihepatic collection. The wire was removed and the locking loop was formed within the perihepatic space. The catheter was attached to a bag drainage. Sterile dressings and sutures were applied. Apes The patient tolerated procedure well without complication. FINDINGS: 1. Right posterior pull-back cholangiogram demonstrates leakage of contrast into the perihepatic space. Antegrade passage of contrast noted into the bowel. 2. Right anterior drainage catheter noted to be retracted on scout image. Right anterior pull-back cholangiogram demonstrates no evidence of pericatheter leakage. Antegrade passage of contrast noted into the bowel. IMPRESSION: Successful fluoroscopic guided perihepatic collection abscess drain placement. Successful right anterior and right posterior biliary catheter exchange for new modified 12 ___ APD L Radiology Report EXAMINATION: US ABD LIMIT, SINGLE ORGAN INDICATION: ___ yo F PMHx HTN, T2DM, pancreatic head carcinoma s/p Whipple resection (___), recurrent choledocolithiasis and cholangitis s/p multiple ERCPs, who presented with LUQ abdominal pain, found to have moderate intrahepatic biliary duct dilation and chronic cholangitis on CT, likely from central strictures, now s/p ___ placement of two percutaneous transhepatic biliary drains on ___ with course complicated by sepsis ___ peritonitis andperi-hepatic abscess now s/p aspiration of perihepatic fluidcollection by ___ (___), placement of abscess drain (___) and upsizing of drains (___). Please assess for TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: CT abdomen and pelvis ___. FINDINGS: LIVER: The imaged hepatic parenchyma appears within normal limits. Again seen is small volume perihepatic ascites, which appears to indent the liver contour. The overall volume appears similar to the prior study, subject to differences in modality, with a sliver measuring approximately 5.7 x 1.0 cm. There is associated mild peritoneal thickening, irregularity, and echogenicity, which could reflect peritonitis. A percutaneous biliary drainage catheter is partially imaged. IMPRESSION: Small volume perihepatic ascites, not substantially changed, subject to differences in modality, with findings likely reflecting peritonitis. Radiology Report INDICATION: ___ year old woman with panc head mass s/p Whipple. PTBDs in place. perihepatic abscess drain leakage// ___ year old woman with panc head mass s/p Whipple. PTBDs in place. perihepatic abscess drain leakage COMPARISON: Cholangiogram and drain check dated ___ TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and Dr. ___ 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 150mcg of fentanyl and 3 mg of midazolam throughout the total intra-service time of 45 minutes during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: See above CONTRAST: 50 ml of Optiray contrast FLUOROSCOPY TIME AND DOSE: 9.0 minutes, 58 mGy PROCEDURE: 1. Cholangiogram through existing right anterior and posterior percutaneous transhepatic biliary drainage access. 2. Cone beam CT cholangiogram. 3. Antegrade and Pull-back cholangiograms was performed through the right posterior and anterior biliary drains. 4. Exchange of the existing right anterior percutaneous transhepatic biliary drainage catheter with a new modified 12 ___ APDL catheter. 5. Upsize of the previous right posterior percutaneous transhepatic biliary drainage catheter with a new 14 ___ APDL catheter. 6. Upsize and replacement of the previous 8 ___ APD L catheter to a new 10 ___ biliary catheter in the perihepatic collection. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The right/mid abdomen was prepped and draped in the usual sterile fashion. Initial scout images showed biliary drain in the appropriate position. The perihepatic drainage tube was injected with dilute contrast. The images were stored on PACS. Following the subcutaneous injection of 1% lidocaine into the skin site, the perihepatic catheter was injected with dilute contrast. Next, dilute contrast was administered in the right anterior and right posterior biliary drains. A cone beam CT was performed. Rotational cone-beam CT angiography was performed to help delineate the anatomy. Multiplanar CT images were reconstructed and 3D volume-rendered images of the arterial anatomy required post-processing on an independent workstation under direct physician ___. These images were used in the interpretation, decision making for intervention and reporting of this procedure. Next, both right biliary drains were cut and 035 inch ___ wires were advanced into the small bowel through the catheters. The catheters were then removed over the wire. Over the wire, 8 ___ sheaths were advanced into the small bowel. Antegrade and Pull-back cholangiograms were performed, with findings as below. Next, the perihepatic catheter was cut and a 135 inch ___ wire was advanced into the perihepatic space. The catheter was removed. A new 10 ___ modified biliary drain was advanced into the perihepatic space. Approximately 10 cc of bilious fluid mixed with debris was aspirated. The catheter was connected to a JP drain. The right anterior and posterior biliary access drains were placed. The sheath was removed over the wire, and a 14 ___ modified APDL drain was advanced into the small bowel the of the right posterior biliary access. The sheath was removed over the wire and a 12 ___ modified APDL drain was advanced into the small bowel through the right anterior biliary access. The wires and inner stiffeners were removed, the catheters were flushed, the loops formed, and the catheters were attached to drainage bag and sterile dressings were applied. The patient tolerated the procedure well and there were no immediate post-procedure complications. FINDINGS: 1. Possibly occluded pre-existing perihepatic drain with contrast opacification of the perihepatic collection. 2. Antegrade cholangiogram through the right posterior drain demonstrates adequate drainage of the right posterior biliary system. 3. Antegrade cholangiogram fluid right anterior drain demonstrates adequate drainage of the right anterior biliary system. 4. Cone beam CT demonstrating mildly dilated right anterior and posterior biliary systems. Limited assessment for evidence of choledocholithiasis. 5. Pull-back cholangiogram to the right posterior biliary access demonstrating leakage of contrast into the perihepatic space. IMPRESSION: Successful exchange of existing percutaneous transhepatic biliary drainage catheters with new 14 ___ right posterior transhepatic biliary drainage catheter, 12 ___ right anterior transhepatic biliary drainage catheters. Successful upsize of the perihepatic drain to a 10 ___ biliary drainage catheter. Radiology Report EXAMINATION: CT ABD AND PELVIS W/O CONTRAST INDICATION: See above// Known biliary drains and known ___ abscess with drain. Mildly increasing pain after capping biliary drains. TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired without intravenous contrast. Non-contrast scan has several limitations in detecting vascular and parenchymal organ abnormalities, including tumor detection. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 7.1 s, 46.4 cm; CTDIvol = 9.7 mGy (Body) DLP = 444.5 mGy-cm. Total DLP (Body) = 445 mGy-cm. COMPARISON: Prior CT abdomen/pelvis dated ___. FINDINGS: LOWER CHEST: Small right pleural effusion and associated atelectasis. Otherwise, visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: Patient is status post hepaticojejunostomy. There is redemonstration of percutaneous biliary drainage catheters in the right anterior and right posterior hepatic bile ducts. The drainage catheters appear unchanged in positioning, terminating in the jejunum. The liver demonstrates homogeneous attenuation throughout. Similar-appearing left hepatic lobe atrophy is again seen. There is no evidence of focal lesions within the limitations of an unenhanced scan. No new intrahepatic or extrahepatic biliary dilatation noted. The gallbladder is surgically absent. Perihepatic drainage catheter has pigtail curled in the subphrenic/suprahepatic space without residual fluid at the pigtail. There is a 4.4 x 2.7 cm loculated fluid collection along the dome of the liver, several centimeters medial and anterior to the location of the pigtail. PANCREAS: Patient is status post pancreaticduodenectomy. The remaining portion of the pancreas is atrophic., no 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 suspicious 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. PELVIS: The urinary bladder and distal ureters are unremarkable. Bladder is decompressed. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus is not visualized. No adnexal abnormality is seen. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Left convex lumbar scoliosis with T12 compression deformity and kyphoplasty changes. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Near complete resolution of fluid collection at the liver dome, with no significant fluid at the pigtail and a small focal 4.4 x 2.7 cm loculation anterior and medial to the pigtail. No new fluid collections identified. 2. Unchanged positioning of the right anterior and right posterior internal external percutaneous biliary drainage catheters. No new biliary dilatation, within limits of noncontrast imaging. 3. Stable postsurgical changes from prior Whipple procedure. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Abd pain Diagnosed with Unspecified abdominal pain temperature: 98.7 heartrate: 95.0 resprate: 18.0 o2sat: 100.0 sbp: 92.0 dbp: 77.0 level of pain: 6 level of acuity: 3.0

The pt was admitted for abdominal pain on ___. CT showed moderate intra-hepatic biliary duct dilation and chronic cholangitis. ___ placed two transhepatic biliary duct drains on ___ with initial improvement in her pain. The pt developed chest pain on ___. EKG did not show ischemic changes. Trop was negative. She was seen by cardiology and started on MTP, captopril, and atorvastatin. The pt reported that the pain was better with burping. A GI etiology was suspected. MTP was continued. Shortly thereafter, she developed a ___ abscess (see below) which explained her "chest pain" ___ GI pathology. After treatment of the abscess, the pt had no further chest pain, confirming the non-cardiac etiology. Shortly after ___, the pt developed delirium. CT head was negative for acute changes. She had increasing WBC and fever consistent with an infectious etiology for her delirium. CT abd/pelvis ___ showed perihepatic ascites with associated peritoneal thickening and enhancement consistent with peritonitis. She was treated with CTX/flagyl. She underwent aspiration of the perihepatic collection by ___ and upsizing of her drains on ___. The drains were upsized again ___ and an abscess drain was placed ___ as well. Therefore the pt had two transhepatic biliary duct drains as well as one ___ abscess drain. ID was consulted ___ who agreed with CTX/flagyl. The abscess grew klebseilla and mixed bacterial flora. On ___, the pt's WBC normalized. Her two transhepatic biliary drains were capped. She had mildly increased RUQ abdominal pain on ___ and CT was repeated but it showed improved findings. The abscess was much smaller. There was a residual area of abscess on the hepatic dome. The imaging was reviewed by ___ who found this abscess to be communicating with the drain. Their assessment appears to be correct because the drain continued to have output, consistent with ongoing drainage of the residual fluid. The pain began to gradually improve without further worsening. Pt remained afebrile and WBC remained normal. AP was variable but TBili was normal. She was monitored several days with the biliary drains capped and continued to improve. The pt was therefore discharged with the following plan: - Biliary drains capped. Follow up with ___ to manage biliary drains was arranged prior to discharge. ___ care for biliary drain management was arranged prior to discharge. - Abscess drain remained draining to bulb. Pt and her nursing student granddaughter (who lives with her) were trained in how to empty the drain and measure output. They were instructed to call ___ when the output was <10 cc for three days, so that they could follow up with ___ at that time to re-assess abx and drain removal, and for possible re-imaging. This was per ___ recommendations. - Abx were continued. Pt was given a two week course of prescriptions for cefpodoxime and flagyl. F/up with ID was arranged prior to discharge in 1.5 weeks' time to determine whether ongoing abx were required and to possibly re-image. At the time of discharge, the pt was feeling well. Her pain was mild and controlled with Tylenol and occasional Ultram. She had no chest pain or SOB. She had no confusion. She was ambulating independently with supervision. She was regaining strength. Pt was tolerating PO intake well. She was discharged home with very close home support including nearly ___ care by her family and nurses hired by her family.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: ?post-ictal ?seizures ?change in neuro baseline ?imaging needed Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ female with a PMHx of TLE (followed by ___ neurologist, reportedly R>L per prior EEGs), ___, and narcolpesy who presents as a transfer from ___ after generalized weakness (but ?L>R), fatigue, diplopia, vertigo, gait instability, and "slowed" behavior. Woke up feeling normal. At 9am, she started having diplopia, fatigue, and felt unable to walk. Horizontal diplopia Didn't try to close either eye, not sure if up close or far away. Not sure if worse with lateral or primary gaze (?worse to left). Has never had diplopia before. Diplopia persisted until about 1pm, after which she had blurry vision bilaterally. She also had counterclockwise room-spinning vertigo and felt like she was on a boat. She "felt drunk." The vertigo would last minutes at a time; it was not positional or precipitated by head movements. The above symptoms also persisted until about 1pm (while at ___. After the onset of diplopia, she sat for an hour. When she tried to get up, she would fall backwards because she felt off balance. Husband helped her to the car, and she may have been listing to right (she's not sure). Felt like she "had to remember to breath." Husband took her to ___. Felt like she "couldn't move" (although could move fingers and toes) including head and limbs because "it was too hard." Per ___ notes, she had apparent full strength with coaching. Initially described whole body weakness but later said left side may have been worse compared with right. Was told she looked pale. After an hour, weakness improved (still not at baseline). "Everything was tingling." "Couldn't keep up with what others were saying." During this time, she denied HA but had posterior bilateral neck pain more severe than prior pain and bilateral which is unusual (prior neck pain had been unilateral). The pain felt achy. No recent heavy lifting. She went to her outpatient marriage counselor today, where she reported generalized weakness, diplopia, and neck pain as above. She has a witnessed fall without head strike wherein she went down to her knees and then to her buttocks. Psychiatrist sent her to ___. She had a tele-stroke with head CT done (reportedly negative), and no intervention was done. Noted at ___ to be slightly drowsy. Patient notes that, while there, she felt like she "[couldn't] keep up with visual stimuli," which has improved but persisted. Her neurologist at ___ (Dr. ___ requested a neurology evaluation. She was then transferred to ___ for neurology evaluation and possible MRI. At the time of interview, her weakness and diplopia have improved. She continues to feel "woozy" and "slow". Denies F/C or recent illnesses. No recent sleep deprivation. No missed or extra doses of Lamictal. Has 1 beer the night prior to presentation but none subsequently. No recent illicits or new substances. TLE history: Diagnosed ___ years ago. Followed by neurologist Dr. ___ ___ at ___. Treated with lamictal 300mg BID (last uptitration 6 months ago). Has not trialed any other AEDs. Semiology: 1) Olfactory events (smells electrical fire) x 30 seconds sometimes in clusters for up to 10 min, no shaking or LOC. Occur once every two weeks -->No recent change in frequency 2) Limb jerking: will have a single "jerk" of ___ limbs and no subsequent movements. Arm, leg, or both. Sometimes right side and sometimes left side. Can also have jerking of her abdomen or a quick abnormal movement of her lips. Sometimes head or torso will turn to right. Jerks can occur up to 10 times a day. Denies aura, LOC, tongue biting, urinary incontinence, stool incontinence, drooling, eye deviation, or post-ictal confusion. -->Had more jerks the last couple nights per husband. Felt like she was about to jerk at ___ (felt restless). 3) Six months ago, she had one episode of whole body shaking lasting 10 seconds while sleeping witnessed by husband On neuro ROS, the pt denies headache, loss of vision, dysarthria, dysphagia, lightheadedness, tinnitus, and hearing difficulty. Denies difficulties producing or comprehending speech. Denies numbness. No bowel or bladder incontinence or retention. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation, or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: Temporal lobe epilepsy ___ Narcolepy IBS Social History: ___ Family History: Her niece has a variant of uncertain significance in the BRCA2 gene (patient tested and does not have this). heart disease--dad. ___. Son with ___. Son has awake when dream still happening. Physical Exam: =============================================== ADMISSION PHYSICAL EXAMINATION =============================================== Physical Exam: Vitals: T: 98.4 P: 82 R: 16 BP: 121/76 SaO2: 97RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, No nuchal rigidity, +paraspinal TTP in neck, no bony TTP, no meningismus Pulmonary: breathing comfortably on RA Cardiac: WWP Abd: soft, NT/ND Extremities: No C/C/E bilaterally 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 with very mild speech latency (takes a while to answer or finish answer). 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. There was no evidence of apraxia or neglect. -Cranial Nerves: ___, III, IV, VI: PERRL 3 to 2mm and brisk. WIth left gaze, could not abduct fully (crosses well past midline). Saw 1 finger "with halo," which improved when either eye was covered. With right gaze, could not adduct fully (crosses well past midline) with 2 beats of nystagmus. Saw 2 fingers when 1 shown with right gaze, and this improved when either eye was covered. VFF to confrontation. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk and tone. No pronation, no drift. No orbiting with arm roll. No adventitious movements, such as tremor, noted. No asterixis noted. [___] [C5] [C5] [C7] [C6] [C7] [T1][L2] [L3] [L5] [L4] [S1][L5] L 5 5 5 5 5 5 4+* 5 5 4+* 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 *Limited by effort -Sensory: No deficits to light touch. Decreased sensation to temp on left (90% compared to right). Normal proprioception. No extinction. -DTRs: ___ brisk. +Suprapatellar. No crossed adductors or pectoralis jerks. No jaw jerk. Toes down. -Coordination: On FNF on left, she touched each target ___ times but did not veer to one side. HKS normal. No dysdiadochokinesia. -Gait: Fell backward onto bed after standing up. Sway with eyes open, could not attempt Romberg. Small, hesitant steps with gait testing but did not list to one side. Unable to tandem (swaying to both sides). ============================================ Discharge examination: ============================================ Unchanged from admission except as documented below: CN: EOMI, no nystagmus. PERRL 4->2. Facial sensation intact to LT throughout. Facial activation symmetric. Weber test is symmetric. Palate elevates symmetrically. Tongue protrudes to midline and moves briskly to each side. Coordination: FTN without dysmetria. RAM are smooth and fast. Vestibular: Past pointing with eyes closed intermittently errs to the left, no errors noted to the right. ___ testing with some forward motion but no lateral nor rotatory motion after one minute. Gait: Astasia without abasia with Romberg testing. Gait mildly wide-based. Able to heel, toe and tandem walk. Pertinent Results: ___ 06:50PM BLOOD WBC-9.5# RBC-4.57 Hgb-14.3 Hct-43.9 MCV-96 MCH-31.3 MCHC-32.6 RDW-13.1 RDWSD-46.7* Plt ___ ___ 05:50AM BLOOD WBC-6.7 RBC-4.46 Hgb-14.2 Hct-43.3 MCV-97 MCH-31.8 MCHC-32.8 RDW-13.1 RDWSD-46.7* Plt ___ ___ 06:50PM BLOOD Glucose-89 UreaN-7 Creat-0.9 Na-139 K-4.0 Cl-103 HCO3-23 AnGap-17 ___ 05:50AM BLOOD Glucose-83 UreaN-9 Creat-0.9 Na-140 K-4.1 Cl-103 HCO3-24 AnGap-17 ___ 06:50PM BLOOD ALT-17 AST-17 AlkPhos-61 TotBili-0.5 ___ 06:50PM BLOOD Lipase-24 ___ 06:50PM BLOOD cTropnT-<0.01 ___ 03:30PM BLOOD %HbA1c-4.8 eAG-91 ___ 05:05AM BLOOD Triglyc-98 HDL-89 CHOL/HD-2.4 LDLcalc-106 ___ 03:30PM BLOOD TSH-2.4 ___ 05:50AM BLOOD ___ ___ 06:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG ___ 03:30PM BLOOD CARDIOLIPIN ANTIBODIES (IGG, IGM)-PND ___ 03:30PM BLOOD BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA, IGM, IGG)-PND ___ 09:14PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG ___ 09:14PM URINE UCG-NEGATIVE ___ 09:14PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG Imaging: Non-Contrast CT of Head (___): no acute intracranial abnormalities on my review CXR: No acute cardiopulmonary process. Likely external structure mimicking pleural reflection line at the left lung apex for which repeat exam in expiration is suggested to exclude pneumothorax. CTA: 1. No acute intracranial abnormality. 2. Patent intracranial vascular without significant stenosis, occlusion, or aneurysm. 3. Patent cervical vasculature without significant stenosis, occlusion, or dissection. TTE ___: Two bubbles seen in the left heart at rest not replicated with maneuvers. This is suggestive of a small intrapulmonary shunt but PFO cannot be excluded and if there is high suspicion for an embolic CVA, TEE with aggitated saline can help to clarify. TEE ___: No atrial septal defect or patent foramen ovale by color doppler or saline contrast. DVT u/s BLE: No evidence of deep venous thrombosis in the right or left lower extremity veins. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Citalopram 40 mg PO DAILY 2. LamoTRIgine 300 mg PO BID Discharge Medications: 1. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 2. Atorvastatin 40 mg PO QPM RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 3. Citalopram 40 mg PO DAILY 4. LamoTRIgine 300 mg PO BID Discharge Disposition: Home Discharge Diagnosis: TIA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CTA HEAD AND CTA NECK Q16 CT INDICATION: Double vision and weakness. 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 Omnipaque350 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 5.1 s, 39.8 cm; CTDIvol = 31.9 mGy (Head) DLP = 1,271.7 mGy-cm. Total DLP (Head) = 2,191 mGy-cm. COMPARISON: Outside hospital noncontrast head CT ___. 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 trace mucosal wall thickening in the inferior aspects of the bilateral maxillary sinuses. The remainder of the visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. CTA HEAD: There is variant bilateral hypoplastic vertebral arteries and basilar artery with variant fetal type origin of the bilateral posterior cerebral arteries. Though A1 segment on the right is present, a terminates early, and there is variant origin of the bilateral a 2 segments from the left A1 segment of the anterior cerebral artery. The vessels of the circle of ___ and their principal intracranial branches appear normal without stenosis, occlusion, or aneurysm formation. The dural venous sinuses are patent. CTA NECK: The carotid and vertebral arteries and their major branches appear normal with no evidence of stenosis or occlusion or dissection. There is no evidence of internal carotid stenosis by NASCET criteria. OTHER: The visualized portion of the lungs are clear. The visualized portion of the thyroid gland is within normal limits. There is no lymphadenopathy by CT size criteria. IMPRESSION: 1. No acute intracranial abnormality. 2. Patent intracranial vascular without significant stenosis, occlusion, or aneurysm. 3. Patent cervical vasculature without significant stenosis, occlusion, or dissection. Radiology Report EXAMINATION: MRI AND MRA BRAIN AND MRA NECK PT11 MR HEAD NECK. INDICATION: Acute onset diplopia, neck pain and disequilibrium. 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 14 mL of Multihance intravenous contrast. Axial T1 fat sat images were acquired per dissection protocol. Brain imaging was performed with sagittal T1 and axial FLAIR, T1 T2, gradient echo and diffusion technique. Sagittal MP rage images were acquired with axial and coronal reformats. 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: CTA head and neck ___. FINDINGS: MRI BRAIN: There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. The ventricles and sulci are normal in caliber and configuration. There is no abnormal enhancement after contrast administration. There is no abnormal focus of slowed diffusion. The dural venous sinuses are patent on MP rage images. The principal intracranial vascular flow voids are preserved. There is trace mucosal wall thickening in the inferior aspects of the maxillary sinuses. The remainder the visualized paranasal sinuses are grossly clear. The orbits are grossly unremarkable. MRA BRAIN: The bilateral vertebral arteries and basilar artery are somewhat hypoplastic, with variant fetal type origin of the bilateral posterior cerebral arteries. The intracranial vertebral and internal carotid arteries and their major branches appear patent without evidence of stenosis, occlusion, or aneurysm formation. MRA NECK: The common, internal and external carotid arteries appear patent. There is no evidence of internal carotid artery stenosis by NASCET criteria. The origins of the great vessels, subclavian and vertebral arteries appear patent bilaterally. There is no evidence of dissection. IMPRESSION: 1. No acute intracranial abnormality including infarct, hemorrhage, or enhancing mass. 2. Patent intracranial vasculature without significant stenosis, occlusion, or aneurysm. 3. Patent cervical vasculature without significant stenosis, occlusion, or dissection. Radiology Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ year old woman with TIA and intrapulmonary shunt vs PFO on echo // r/o DVT TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, flow, and augmentation of the bilateral common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: No evidence of deep venous thrombosis in the right or left lower extremity veins. Gender: F Race: WHITE - OTHER EUROPEAN Arrive by AMBULANCE Chief complaint: Transfer, Weakness Diagnosed with Weakness temperature: 98.4 heartrate: 82.0 resprate: 16.0 o2sat: 97.0 sbp: 121.0 dbp: 76.0 level of pain: 5 level of acuity: 2.0

Ms. ___ was admitted with acute onset of diplopia, gait instability and neck ache. Exam showed a left internuclear ophthalmoplegia and left cranial nerve six palsy as well as gait instability with some elements of functional overlay. The eye movement abnormalities resolved by the morning of ___, and the gait difficulty resolved hours thereafter. It is unclear whether this episode is related to TIA vs basilar migraine, a less likely, though possible, alternative explanation is MRI-negative stroke, as the expected stroke size in the brainstem would be expected to be quite small, and likely in the L pons. We completed workup for TIA, which showed hyperlipidemia, and atorvastatin 40 mg qhs was started. Echo showed possible PFO, but TEE proved absence of PFO. Hypercoagulability studies pending and 30 day heart rhythm monitor was hooked up on discharge. She was started on ASA 81 and atorvastatin 40 mg daily. She will follow up with her outpatient Neurologist. ==================================== Transitional Issues: [ ] LDL goal <70

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: S/p fall Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a ___ year old male w/ hx of anemia, DVT/PE(Coumadin), glaucoma, CKD, NSTEMI, thrombocytopenia, and prior falls who presents to ___ following an unwitnessed ground level fall,+posterior headstrike, -LOC. Shortly after his fall he began having RLE pain and was able to contact life alert. On presentation to ___ pt. is in no acute distress and complaining of RLE(thigh) pain. Pt.'s INR was found to be 9.9 for which he received Kcentra and Vitamin K and a Hgb of 7.8. ACS consulted for hematoma 8.9 cm hematoma found on RLE CT. Past Medical History: Anemia, B12 deficiency BPH Bladder cancer hx Carpal tunnel syndrome Cataract Chronic low back pain DVT/PE on Coumadin Glaucoma HLD OA CKD Vocal cord polyps Eczematous dermatitis NSTEMI ___ Depression Thrombocytopenia Social History: ___ Family History: Reviewed and found to be not relevant to this illness/reason for hospitalization. Physical Exam: Admission Physical Exam: ___ 0245 Temp: 97.9 PO BP: 157/86 HR: 64 RR: 18 O2 sat: 98% O2 delivery: NC 2L GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist, dry blood posterior scalp CV: RRR, normal S1 and S2 PULM: Mild shortness of breath ABD: Soft, nondistended, nontender, no rebound or guarding normoactive bowel sounds, no palpable masses Pelvis: Stable MSK: Right ___ pain w movement, however able to flex and extend ___ and ___. Sensation intact =================== DISCHARGE Physical Exam: ___ BP: 123/77 HR: 71 RR: 16 O2 sat: 97% O2 delivery: RA GEN: Elderly, NAD HEENT: Large ecchymosis on right neck LUNGS: CTAB HEART: RRR, nl S1, S2. No m/r/g. EXTREMITIES: Mild pain to palpation in right quad, but no gross changes to leg NEURO: AOx3. Horse voice. Pertinent Results: LABS: ___ 07:55PM BLOOD WBC-7.1 RBC-2.43* Hgb-7.8* Hct-24.5* MCV-101* MCH-32.1* MCHC-31.8* RDW-16.4* RDWSD-60.4* Plt ___ ___ 07:55PM BLOOD ___ PTT-47.4* ___ ___ 07:55PM BLOOD Glucose-109* UreaN-27* Creat-1.9* Na-141 K-4.3 Cl-110* HCO3-21* AnGap-10 ___ 11:47PM BLOOD CK-MB-3 cTropnT-0.04* ___ ___ 08:03PM BLOOD Calcium-8.5 Phos-2.4* Mg-1.8 ___ 06:05AM BLOOD TSH-2.2 ___ 05:45AM BLOOD WBC-7.4 RBC-2.48* Hgb-7.9* Hct-25.0* MCV-101* MCH-31.9 MCHC-31.6* RDW-16.4* RDWSD-60.0* Plt ___ ___ 05:45AM BLOOD ___ ___ 05:45AM BLOOD Glucose-99 UreaN-30* Creat-2.0* Na-142 K-4.4 Cl-109* HCO3-21* AnGap-12 IMAGING: ___ CXR IMPRESSION: Mild pulmonary edema and probable small right pleural effusion. Bibasilar patchy opacities, likely atelectasis. CT Head IMPRESSION: 1. Large right occipital subgaleal hematoma. No acute fracture. 2. No acute intracranial abnormality. CT C-spine: IMPRESSION: 1. No acute fracture or malalignment. 2. Moderate to severe cervical spondylosis. 3. Findings suggest mild volume overload in the lung apices. CT RLE 1. Right proximal thigh intramuscular hematoma measuring up to 8.9 cm with two foci of contrast extravasation compatible with active bleeding. 2. No fracture or dislocation. 3. Prostatomegaly. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q8H 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Docusate Sodium 100 mg PO BID 5. Finasteride 5 mg PO DAILY 6. FLUoxetine 40 mg PO DAILY 7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 8. Multivitamins 1 TAB PO DAILY 9. QUEtiapine Fumarate 25 mg PO QHS 10. Terazosin 4 mg PO QHS 11. Timolol Maleate 0.5% 1 DROP BOTH EYES BID 12. Vitamin E 400 UNIT PO DAILY 13. ammonium lactate ___ % topical BID:PRN 14. Cyanocobalamin 1000 mcg IM/SC MONTHLY 15. melatonin 6 mg oral QHS 16. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 17. Warfarin 5 mg PO DAILY16 Discharge Medications: 1. Tamsulosin 0.4 mg PO QHS 2. Warfarin 2.5 mg PO DAILY16 3. Acetaminophen 1000 mg PO Q8H 4. ammonium lactate ___ % topical BID:PRN 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 40 mg PO QPM 7. Cyanocobalamin 1000 mcg IM/SC MONTHLY 8. Docusate Sodium 100 mg PO BID 9. Finasteride 5 mg PO DAILY 10. FLUoxetine 40 mg PO DAILY 11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 12. melatonin 6 mg oral QHS 13. Multivitamins 1 TAB PO DAILY 14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 15. QUEtiapine Fumarate 25 mg PO QHS 16. Timolol Maleate 0.5% 1 DROP BOTH EYES BID 17. Vitamin E 400 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Mechanical Fall Right Thigh Hematoma Acute on chronic anemia Secondary: Hx of DVT/PE Chronic Systolic Heart Failure CAD CKD BPH Pernicious Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with dyspnea// evaluate for pulmonary edema COMPARISON: Chest radiographs ___ FINDINGS: Portable AP view of the chest provided. No focal consolidation. Interval improvement in now minimal pulmonary edema. Small bilateral pleural effusions. No pneumothorax. Moderate cardiomegaly is unchanged. IMPRESSION: Interval improvement of pulmonary edema, now nearly resolved. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: s/p Fall Diagnosed with Other specified injuries of head, initial encounter, Contusion of right thigh, initial encounter, Fall on same level, unspecified, initial encounter, Personal history of other venous thrombosis and embolism, Long term (current) use of anticoagulants temperature: 99.1 heartrate: 66.0 resprate: 16.0 o2sat: 94.0 sbp: 133.0 dbp: 74.0 level of pain: 0 level of acuity: 2.0

Summary: Mr ___ is a ___ y/o M with PMHx significant for DVT/PE (on Coumadin), CKD, pernicious anemia, and prior falls who presents after an unwitnessed ground level fall with headstrike. A thorough radiologic workup did not reveal and intracranial or bony abnormalities, but did reveal a intramuscular right thigh hematoma. He was initially admitted to trauma surgery with a supratherapeutic INR (iso chronic warfarin use), which was reversed with PCC and vitamin K, and treated supportively and received 1 u PRBC, with stable blood counts. He was later transferred to medicine. On medicine he was worked up for mechanical fall vs syncope, ultimately deeming mechanical fall most likely (see workup below). ___ worked with patient and recommended rehab.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: n/v/d Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ yo woman with h/o SB-IPMNs, biopsy-proven metastatic adenocarcinoma, thought to be likely pancreatic (local extension to kidney, liver), w/ disease progression on gemcitabine/abraxane transitioned to ___ (___) admitted from home w/ n/v/d. In the ED initial vitals were: 99.5 101 138/80 18 99% RA Labs: Lactate 4.9 -> 1.5, WBC initially 39.6 down to 16.2, hemoglobin 9 down to 7.0, platelet count 129 down to 54, C. difficile negative, potassium 3.0 In the ED she received: 2 doses of Zosyn, about 4 L of IV fluids, 20 mEq IV potassium, loperamide, omeprazole, fluoxetine, ondansetron Vitals on transfer: 98.7 94 162/65 16 98% RA Imaging: CT A&P ___ showed no acute process, 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. Per discussion of the ED, patient was noted to be well-appearing this morning but was very concerned about her prior nausea and diarrhea and scared to eat. On reassessment patient endorsed that she felt too weak to go home and asked to be monitored overnight. 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: - ___: gallstone pancreatitis after a cholecystectomy. Found to have multiple small, sub-cm SB-IPMNs (largest 5mm in the tail) as well as an enhancing L renal lesion (10mm). - ___: EUS with multiple small cystic lesions, largest 10mm in the neck. Biopsy not performed due to size. - ___: MRCP showed unchanged appearance in known SB-IPMNs - ___: p/w intermittent "gnawing" pain on her L side, occasional anorexia, and 5 pound weight loss in 6 months. - ___: MRCP showed abnormality along the pancreatic head, 3.6cm segment 4b liver lesion, 4.6 x 6 x 5cm mass in the L kidney extending superiorly to the adrenal gland and anteriorly into the pancreatic body/tail with RP ___. - ___: EUS showed 2.7cm pancreatic head mass, 2.5 x 1.7cm L lobe liver lesion. Biopsy of pancreatic mass and liver c/w moderately-to-poorly differentiated adenocarcinoma. Kidney mass could not be biopsied. - ___: C1D1 gemcitabine/nab-paclitaxel. D8 dose reduced nab 20% and gem 25% for low counts, D15 held for ANC 440. - ___: C2D1 gem/nab. Gem ___ 25%, nab ___ 20%. D15 delayed a week for neutropenia. - ___: C3D1 gem/nab. Dropped Day 8. D15 ANC borderline (1440) - ___ C4D1 gem/nab. Continue Q14D dosing, start Neulasta. - ___: C5D1 gem/nab, Q14D, Neulasta support. ___ nab 20% for neuropathy - ___: C6D1 gem/nab, Q14D, Neulasta. ___ nab 25%. - ___: progression on imaging - ___: C1D1 ___ PAST MEDICAL HISTORY: Obesity HTN anxiety depression (followed by Dr. ___ psychiatry) temporal arteritis osteopenia s/p TAH/BSO (fibroids) s/p R knee surgery (meniscus) s/p lap CCY (___) *** Jehovah's witness: does not want blood transfusion or blood products, no other limitations. Social History: ___ Family History: Mo - breast cancer, HTN No FHx GI cancers Physical Exam: VITAL SIGNS: ___ 0854 BP: 101/66 rechecked by RN L Sitting ___ 0718 Temp: 98.6 PO BP: 95/57 HR: 70 RR: 16 O2 sat: 95% O2 delivery: ra General: NAD HEENT: MMM PULM: no resp distress ABD: BS+ SNT/ND but has TTP to deep palpation of the epigastrium LIMBS: No ___, WWP SKIN: No rashes on extremities NEURO: Speech fluent, strength grossly intact PSYCH: thought process logical, linear, future oriented ACCESS: Port site intact w/o erythema Pertinent Results: ___ 04:42AM BLOOD WBC-9.9 RBC-2.98* Hgb-8.3* Hct-27.0* MCV-91 MCH-27.9 MCHC-30.7* RDW-18.5* RDWSD-59.2* Plt ___ ___ 04:42AM BLOOD Glucose-99 UreaN-7 Creat-1.0 Na-135 K-3.8 Cl-103 HCO3-18* AnGap-14 ___ 06:47AM BLOOD ALT-34 AST-19 AlkPhos-103 TotBili-0.4 ___ 09:13PM BLOOD ALT-20 AST-17 AlkPhos-158* TotBili-0.4 ___ 04:42AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.6 ___ 09:13PM BLOOD Albumin-3.7 Calcium-8.8 Phos-3.1 Mg-2.0 ___ 04:42AM BLOOD Cortsol-15.2 ___ 01:49AM BLOOD Lactate-1.5 ___ 11:02PM BLOOD Lactate-4.9* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 50 mg PO DAILY 2. FLUoxetine 40 mg PO DAILY 3. Valsartan 320 mg PO DAILY 4. Acetaminophen 650 mg PO Q8H:PRN back pain 5. Docusate Sodium 100 mg PO BID 6. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral DAILY 7. Fish Oil (Omega 3) 1000 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. triamterene-hydrochlorothiazid ___ mg ORAL DAILY 10. Vitamin B Complex 1 CAP PO DAILY 11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain 12. Omeprazole 20 mg PO DAILY Discharge Medications: 1. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN heartburn RX *alum-mag hydroxide-simeth [Maalox Maximum Strength] 400 mg-400 mg-40 mg/5 mL ___ ml by mouth qid prn heartburn Refills:*0 2. Diphenoxylate-Atropine 2 TAB PO QID diarrhea RX *diphenoxylate-atropine [Lomotil] 2.5 mg-0.025 mg 2 tablet(s) by mouth four times a day Disp #*80 Tablet Refills:*0 3. LOPERamide 4 mg PO Q4H RX *loperamide 2 mg 4 mg by mouth q4hrs Disp #*168 Tablet Refills:*0 4. Omeprazole 40 mg PO DAILY RX *omeprazole 40 mg 1 capsule(s) by mouth once a day Disp #*30 Capsule Refills:*0 5. Acetaminophen 650 mg PO Q8H:PRN back pain 6. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral DAILY 7. FLUoxetine 40 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain 10. Vitamin B Complex 1 CAP PO DAILY 11. HELD- Docusate Sodium 100 mg PO BID This medication was held. Do not restart Docusate Sodium until your diarrhea resolves 12. HELD- Fish Oil (Omega 3) 1000 mg PO DAILY This medication was held. Do not restart Fish Oil (Omega 3) until your oncologist instructs you to resume. This can increase your risk of bleeding 13. HELD- triamterene-hydrochlorothiazid ___ mg ORAL DAILY This medication was held. Do not restart triamterene-hydrochlorothiazid until your oncologist instructs you to resume 14. HELD- Valsartan 320 mg PO DAILY This medication was held. Do not restart Valsartan until your oncologist instructs you to take Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Diarrhea Metastatic adenocarcinoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: +PO contrast; History: ___ with pancreatic cancer on chemo and cholecystectomy who presents with NVD+PO contrast// ?SBO or infectious/inflamm process (colitis?) TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 24.1 mGy (Body) DLP = 12.0 mGy-cm. 2) Spiral Acquisition 5.6 s, 44.1 cm; CTDIvol = 23.6 mGy (Body) DLP = 1,038.5 mGy-cm. Total DLP (Body) = 1,050 mGy-cm. COMPARISON: None. FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. A 1.7 cm hypodense lesion in hepatic segment 4 is unchanged from the prior CT. The gallbladder is surgically absent. Biliary dilation is within expected post cholecystectomy limits. PANCREAS: The known pancreatic head ill defined hypodensity is not well visualized. A 1.1 cm hypodensity in the anterior aspect of the pancreatic neck is unchanged. Coarse pancreatic tail calcifications are unchanged. A heterogeneous masses involving the pancreatic tail, left adrenal gland, and left Kidney is re-demonstrated, measuring approximately 5.2 x 4.9 by 3.3 cm, not significantly changed from the prior study. 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: Right lower pole simple cysts are re-demonstrated. Lesion invading the upper pole of the left Kidney is described above. There is no hydronephrosis bilaterally. 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: Status post hysterectomy. LYMPH NODES: A 2.4 x 2.2 cm left para-aortic necrotic lymph node previously measured 3.4 x 3.3 cm. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. Splenic vein is not visualized. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. Right breast calcification is noted. Please note that CT is not optimized for breast evaluation. IMPRESSION: 1. No acute intra-abdominal process. 2. Known pancreatic cancer tumor burden described above. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: n/v/d Diagnosed with Diarrhea, unspecified, Vomiting, unspecified, Leukemoid reaction temperature: 99.5 heartrate: 101.0 resprate: 18.0 o2sat: 99.0 sbp: 138.0 dbp: 80.0 level of pain: 0 level of acuity: 2.0

___ w/ SB-IPMNs, biopsy-proven metastatic adenocarcinoma, presumed pancreatic (local renal/hepatic extension), now on ___ (___) admitted from home w/ diarrhea, presumed to be chemo related, now resolving. # Nausea, vomiting, diarrhea # Fecal incontinence (w/ urinary continence) Pt has been having diarrhea for 3 days PTA. Afebrile. Appeared clinically well and non-toxic. Etiology likely secondary to recent Irinotecan and ___. Stool cultures NGTD and c.diff neg. She improved w/ standing loperamide and lomitil. Her K and Mg were repleted. # Normocytic anemia Stable, dipped with IVF administration ** Pt is Jehovah's witness, confirmed ___ NO BLOOD PRODUCTS ** # Metastatic adenocarcinoma CT on admission revealed no changes from prior CT scan. C2D15 will be due ___ but pt would prefer to postpone this. Dr ___ was updated and will see pt in clinic for f/u on her GI symptoms and likely postpone chemo to the following week. # HTN Her SPB was in the low 100s (normal cortisol) despite holding valsartan and tiamterene-hctz and giving atenolol. Instructed her not to resume any of her antihypertensives. FEN: Regular diet ACCESS: PORT CODE STATUS: FC (presumed) DISPO: Home w/ ___ services BILLING: >30 min spent coordinating care for discharge

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: Codeine / fentanyl Attending: ___ Chief Complaint: Code Stroke Major Surgical or Invasive Procedure: n/a History of Present Illness: Mr. ___ is a ___ Right handed man with a past medical history of prior testicular cancer, hyperlipidemia and an extensive smoking history who presents to the ED with a ___ hour history of left hand weakness and sensory change. Neurology Consulted for ? Code Stroke vs possible compressive neuropathy. According to the patient, he woke up this morning feeling well. Around ___ (patient not sure), he was relaxing on the couch, drinking a couple of beers when he reached for his drink with his left hand. He realized he was having trouble holding it and actually knocked his drink over. Subsequently, he had to use both hands to hold it. Shortly following his attempt to drink and attempted to light his cigarette and realized he could not use his lighter with his left hand. Proceeding his weakness, he reports his position as leaning his left arm and side against the side of his couch, but does not recall having his left arm and armpit relaxing over the side. He reports that while he was watching movies for several hours, he feels that he did shift position and intermittently get up from his position. Concerned, he called his friend and subsequently his PCP before presenting to the ED at their recommendation. He was subsequently called as a code stroke. On review of systems, the patient endorses: being hungry. On neuro ROS, the pt denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies OTHER focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. Past Medical History: - Depression/Anxiety - Arthritis - Hyperlipidemia - Anal warts - H/O HepB infection - Stable lung nodule - Embronal carcinoma metastatic to paraaortic lymph nodes diagnosed in ___ s/p orchiectomy and who completed 4 cycles of carboplatinum etoposide in ___ without XRT or retroperitoneal LN dissection. He had interval resolution of LAD on CT, his last CT was without contrast in ___, and his HCG and AFP have never been abnormal, last checked ___. Social History: ___ Family History: - Unknown to the patient. Physical Exam: T 97.8 HR 80 BP 132/69 RR20 99% - General/Constitutional: Lying in bed comfortably, well-appearing - Eyes: Round, regular pupils. No conjunctival icterus, no injection. - Neck: No meningismus.Supple. - Skin: No obvious rashes or lesions - Cardiovascular: RRR. S1 S2. No m/r/g - Respiratory: CTA b/l. No w/r/r - Gastrointestinal: Soft. Nontender. Nondistended. - Psychiatric: Appropriate in given situation. ___ Stroke Scale - Total [2] 1a. Level of Consciousness - 1b. LOC Questions - 1c. LOC Commands - 2. Best Gaze - 3. Visual Fields - 4. Facial Palsy - 1 (left lip droop, chronic) 5a. Motor arm, left - 0 (fingers curl on pronator drift, but no drop) 5b. Motor arm, right - 6a. Motor leg, left - 6b. Motor leg, right - 7. Limb Ataxia - 8. Sensory - 1 (LUE sensory change) 9. Language - 10. Dysarthria - 11. Extinction and Neglect - Neurologic Examination: - Mental Status - Awake, alert, oriented x 3. Attention to examiner easily attained and maintained. Concentration maintained when recalling months backwards. Recalls a coherent history. Structure of speech demonstrates fluency with full sentences, intact repetition, and intact verbal comprehension. Content of speech demonstrates intact naming (high and low frequency) and no paraphasias. Normal prosody. No dysarthria. Verbal registration and recall ___. No apraxia in either hand. No evidence of hemineglect. No left-right agnosia. - Cranial Nerves - [II] PERRL 3->2 brisk. VF full to number counting (each eye tested individually). [III, IV, VI] EOMI, no nystagmus. [V] V1-V3 without deficits to light touch bilaterally. [VII] Left lip facial droop/asymmetry with activation (chronic). [VIII] Hearing intact to room voice. [IX, X] Palate elevation symmetric. [XI] Trapezius strength ___ bilaterally. [XII] Tongue midline. - Motor - Normal bulk and tone. Left fingers curl on pronator assessment, but no clear pronation. No tremor or asterixis. =[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas] [___] L 5 5 5 2 4 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 Flexion at DIP ___. - Sensory - Patient endorses 50-60% of sensation to light touch and pinprick in his LUE at his hand in distributions of medial, radial and ulnar nerves. There is no clear nerve distribution (spinal or peripheral). Proprioception and Graphesthesia are preserved in the left hand. In his forearm, there appears to be patchy decrease in sensation circumferentially ending approximately ___ of the way up his arm. Otherwise Proprioception mildly decreased in b/l ___ at great toes, but otherwise intact. Light touch and pinprick otherwise observed elsewhere in his body. - Reflexes =[Bic] [Tri] [___] [Quad] [Gastroc] L 1 1 1 2 2 R 1 1 1 2 2 Plantar response upgoing bilaterally. - Coordination - No dysmetria with finger to nose or heel-shin testing with either hand. He is able to coordinate his left hand and fingure accurately. Pertinent Results: ___ 05:10AM BLOOD WBC-9.2 RBC-4.67 Hgb-14.5 Hct-42.8 MCV-92 MCH-31.0 MCHC-33.8 RDW-14.2 Plt ___ ___ 03:30PM BLOOD WBC-16.0*# RBC-5.05 Hgb-15.4 Hct-45.9 MCV-91 MCH-30.6 MCHC-33.6 RDW-14.1 Plt ___ ___ 05:10AM BLOOD Plt ___ ___ 05:10AM BLOOD ___ PTT-31.6 ___ ___ 03:30PM BLOOD Plt ___ ___ 03:30PM BLOOD ___ PTT-33.4 ___ ___ 05:10AM BLOOD Glucose-100 UreaN-15 Creat-0.8 Na-141 K-4.3 Cl-102 HCO3-28 AnGap-15 ___ 03:37PM BLOOD Creat-0.9 ___ 03:30PM BLOOD UreaN-8 ___ 05:10AM BLOOD ALT-17 AST-25 AlkPhos-66 TotBili-0.5 ___ 03:30PM BLOOD ALT-19 AST-32 AlkPhos-66 TotBili-0.6 ___ 05:10AM BLOOD Albumin-4.2 Cholest-221* ___ 05:10AM BLOOD %HbA1c-5.2 eAG-103 ___ 05:10AM BLOOD Triglyc-57 HDL-93 CHOL/HD-2.4 LDLcalc-117 ___ 05:10AM BLOOD TSH-2.2 ___ 03:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 03:34PM BLOOD Glucose-76 Na-142 K-3.9 Cl-94* calHCO3-31* MRI Head ___: IMPRESSION: 1. No intracranial hemorrhage or acute infarct. 2. No evidence of aneurysm, dissection or significant steno-occlusive disease on MRA of the brain and neck. CXR ___ IMPRESSION: No acute cardiopulmonary abnormality. ___ ___: IMPRESSION: No acute intracranial abnormality. Please note, however, that MR is more sensitive in the detection of acute stroke. Medications on Admission: - acyclovir 200 mg capsule 1 Capsule(s) by mouth daily - bupropion HCl SR 150 mg tablet,sustained-release daily - clonazepam 0.5 mg tablet ___ Tablet(s) by mouth once a day - Cymbalta 60 mg capsule,delayed release One Capsule(s) daily - fluticasone 50 mcg/actuation nasal spray ___ sprays(s) each nostril daily - trazodone 150 mg tablet ___ Tablet(s) by mouth QHS PRN insomnia - cetirizine 10 mg tablet- by mouth once a day (OTC) Discharge Medications: 1. Acyclovir 200 mg PO DAILY 2. BuPROPion (Sustained Release) 150 mg PO QAM 3. Cetirizine 10 mg PO DAILY 4. ClonazePAM 0.75-1 mg PO DAILY 5. Duloxetine 60 mg PO DAILY 6. Fluticasone Propionate NASAL 2 SPRY NU DAILY 7. TraZODone 150 mg PO QHS:PRN insomnia 8. Outpatient Occupational Therapy Discharge Disposition: Home Discharge Diagnosis: - Radial neuropathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Left upper extremity weakness. Evaluate for stroke. TECHNIQUE: Helical axial MDCT images were obtained through the brain without the administration of IV contrast. Reformatted images in coronal and sagittal axes were generated. DOSE: DLP: 891.9 mGy-cm; CTDIvol: 55.8 mGy. COMPARISON: Noncontrast CT head from ___. FINDINGS: There is no acute large territorial infarct, hemorrhage, edema, or mass effect. The ventricles and sulci are normal in size and configuration. The basal cisterns are patent and there is preservation of gray-white matter differentiation. There is no acute fracture. Moderate mucosal thickening is seen within the ethmoid air cells, mild mucosal thickening is demonstrated in the left frontal sinus, both maxillary sinuses and sphenoid sinuses, findings which suggest ongoing inflammation. The remaining visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. IMPRESSION: No acute intracranial abnormality. Please note, however, that MR is more sensitive in the detection of acute stroke. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with left arm weakness TECHNIQUE: Chest PA and lateral COMPARISON: ___ chest radiograph, ___ chest CT FINDINGS: Cardiac silhouette size is normal. The mediastinal and hilar contours are unremarkable. Pulmonary vasculature is normal. Minimal streaky opacities in the lung bases likely reflect atelectasis. No focal consolidation, pleural effusion or pneumothorax is present. Upper lobe predominant emphysema is re- demonstrated. Mild degenerative changes are noted in the thoracic spine. IMPRESSION: No acute cardiopulmonary abnormality. Radiology Report EXAMINATION: MRI AND MRA BRAIN AND MRA NECK INDICATION: ___ man with history of hyperlipidemia and smoking, presents with left hand weakness and sensory change. Please evaluate for infarct, ischemia. 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 15cc 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. COMPARISON: CTA head without contrast ___, MRI head with without contrast of ___. FINDINGS: MRI Brain: There is no intra or extra-axial mass, acute hemorrhage or infarct. Sulci, ventricles and cisterns are within expected limits for the patient's age. The major intracranial flow voids are preserved. Mild mucosal thickening of the paranasal sinuses is noted. The orbits are unremarkable. The left mastoid air cell demonstrates fluid signal at the tip. MRA brain: The left A1 segment is not seen, presumably congenitally absent. The left posterior communicating artery is not noted. Otherwise, the intracranial ICA, remainder of the ACAS, MCAs and their major branches are unremarkable. The right vertebral artery is dominant. Otherwise, the posterior circulation is unremarkable. There is no aneurysm within the confines of MRI technique. MRA neck: There is a normal 3 vessel arch. 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. No intracranial hemorrhage or acute infarct. 2. No evidence of aneurysm, dissection or significant steno-occlusive disease on MRA of the brain and neck. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: L Arm numbness Diagnosed with MUSCSKEL SYMPT LIMB NEC, ASYMPTOMATIC HIV INFECTION temperature: 97.8 heartrate: 80.0 resprate: 20.0 o2sat: 99.0 sbp: 132.0 dbp: 69.0 level of pain: 0 level of acuity: 1.0

# Left Radial Neuropathy - Patient was called as a code stroke in the ED. ___ was non-acute. His exam was primarily concerning for a radial neuropathy, but sensory distribution was unusual and small subcotrical stroke was a possibility. He was admitted and underwent risk factor stratification. MRI was negative for Stroke and he was discharged with a left wrist splint and OT referral. No medication changes were made.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: codeine / sulfa Attending: ___. Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ woman recently admitted to our hospital with a new left MCA stroke, currently on apixaban, with past medical history of dysphasia, chronic atrial fibrillation, systolic heart failure with unknown ejection fraction, type 2 diabetes, anemia who presents from her nursing home with fever greater than 100 x4 days, as well as white blood cell count of 20. In review of the medical record, the patient was just discharged from our hospital after presenting with a aphasia and right-sided weakness. She was found to have an acute ischemic stroke with a left MCA syndrome. She was out of the window for TPA and given the location of her thrombus, she was deemed not to be a thrombectomy candidate. She was continued on ASA. Initially AC was deferred but was later started one week after stroke. She was also found to have a-fib with RVR and was eventually transitioned to apixaban. She had post-CVA dysphagia, and a PEG tube was placed on ___. She had heart failure workup given new onset a-fib and was found to be fluid overloaded and her echo showed ejection fraction 45%. She was aggressively diuresed with IV Lasix. She also had a UTI which was treated with ceftriaxone and proctitis seen on CT A/P and completed a 5 day course of CTX/flagyl. Other complications are reviewed in discharge summary of ___. Discharged confused and bedbound. Since discharge, patient has been living at ___ ___ in ___ for ___ rehab. At discharge, patient was following some commands and was interactive with her family. Patient was initially doing well but started to become more unresponsive and lethargic starting on ___. She had labs done there and showed a leukocytosis to 20. She was also having low-grade fevers to a max of 100.0. The plan was to take patient to ___ for a CT scan, but given the concerns of the family, patient was transferred to ___ for further evaluation. In the ED: Patient was unable to provide additional history or respond to questions. Exam: VS: [] WNL [x] abnormal - tachy 110s, BP ___ Constitutional: Comfortable. NAD. chronically ill. Head/eyes: NCAT, PERRLA. ENT/neck: Dry MM. Chest/Resp: Diminished sounds at bases. otherwise CTAB. Cardiovascular: RRR, Normal S1/S2. Abdomen: Gtube in place L abdomen. Soft, nondistended. ? ttp as pt moans when pressed. Musc/Extr/Back: ___. No edema. Skin: No rash. Warm and dry. Neuro: Moans with unintelligible sounds. GCS 8 (E2/V1/M5). No facial droop. Withdraws to pain on L > R. Labs were notable for: CBC- WBC 16.5 -> 15.9, Hgb 9.5 -> 8.4 Chem- Na 138, K 3.1, BUN 40, Cr 0.7 LFTs- ALT Imaging was notable for: CT HEAD: 1. No evidence of intracranial hemorrhage. 2. Gyriform hyperenhancement of the cortical gray and adjacent white matter within the evolving left MCA infarct most likely reflects laminar necrosis. MRI could further evaluate. CXR: 1. No focal consolidation to suggest pneumonia. 2. Increased prominence of interstitial markings may suggest mild pulmonary edema. No pleural effusion. CT ABD & PELVIS WITH CONTRAST: 1. No evidence of acute intra-abdominal process. Appropriately positioned gastrostomy tube. 2. Stable diffuse main pancreatic ductal dilation. No visualized lesions although a stricture or subtle mass is possible. 3. Mild proctitis, improved from ___. Unchanged vertebral body compression deformities. 5. Stable indeterminate hepatic hypodensities. 6. 5 mm right basilar subpleural pulmonary nodule. Patient received IV cefepime/vancomycin/flagyl, 2L NS bolus and maintentance IVF, metoprolol tartate 25mg, potassium chloride 80 mEq, digoxin 0.125mg, apixaban 2.5mg Upon arrival to the floor, the patient is awake but is speaking incoherently. She is unable to provide more history. When asked if she is having pain, she nods her head but unable to specify where she is having pain. ROS: (+) per HPI 10 point ROS reviewed and negative other than those stated in HPI. Past Medical History: MEDICAL & SURGICAL HISTORY: 1. Afib on apixaban 2. CHF 3. HTN 3. HLD 4. Diabetes mellitus 5. Hearing loss 6. Left MCA stroke Social History: ___ Family History: FAMILY HISTORY: Non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM: General: Elderly woman appears in no acute distress HEENT: Lips peeling and oral mucosa appears dry Neck: JVP elevated. No Nuchal rigidity Lungs: Clear lung fields bilaterally CV: Tachycardic, Normal S1, S2, soft systolic murmur at RUSB GI: Normal bowel sounds. Non-tender to palpation. PEG tube in place, no surrounding erythema, induration or discharge Ext: edematous RUE. No ___ edema. Extremities warm and well perfused Neuro: Arouses to voice. Speaking incoherently. EOMI grossly intact. Pupils reactive 2mm -> 1mm bilaterally. Able to squeeze finger on left side. Unable to actively move R arm. RLE spontaneously. DISCHARGE PHYSICAL EXAM: VITALS: 24 HR Data (last updated ___ @ 1125) Temp: 98.4 (Tm 98.6), BP: 145/83 (118-145/71-83), HR: 100 (68-100), RR: 18 (___), O2 sat: 96% (94-99), O2 delivery: RA General: Elderly woman appears in no acute distress, somnolent HEENT: Lips peeling and oral mucosa appears dry Neck: JVP elevated. No Nuchal rigidity Lungs: Clear lung fields bilaterally CV: Tachycardic, Normal S1, S2, soft systolic murmur at RUSB GI: Normal bowel sounds. Non-tender to palpation. PEG tube in place, no surrounding erythema, induration or discharge Ext: edematous RUE. No ___ edema. Extremities warm and well perfused Neuro: Arouses to voice. Speaking incoherently. EOMI grossly intact. Pupils reactive 2mm -> 1mm bilaterally. Able to squeeze finger on left side. Unable to actively move R arm. RLE spontaneously. Pertinent Results: ADMISSION LABS: ==================== ___ 11:58PM BLOOD WBC-16.5* RBC-3.04* Hgb-9.5* Hct-29.2* MCV-96 MCH-31.3 MCHC-32.5 RDW-14.0 RDWSD-49.6* Plt ___ ___ 11:58PM BLOOD Neuts-82.3* Lymphs-8.9* Monos-7.7 Eos-0.1* Baso-0.2 Im ___ AbsNeut-13.56* AbsLymp-1.46 AbsMono-1.27* AbsEos-0.02* AbsBaso-0.03 ___ 11:58PM BLOOD ___ PTT-28.4 ___ ___ 11:58PM BLOOD Glucose-269* UreaN-53* Creat-0.8 Na-134* K-3.3* Cl-90* HCO3-31 AnGap-13 ___ 11:58PM BLOOD ALT-133* AST-100* AlkPhos-223* TotBili-0.4 ___ 11:58PM BLOOD Albumin-3.0* Calcium-8.7 Phos-3.4 Mg-2.1 PERTINENT LABS: ==================== ___ 10:30AM BLOOD calTIBC-140* Ferritn-162* TRF-108* ___ 12:01AM BLOOD Lactate-1.7 Creat-0.8 ___ 10:30AM BLOOD Ret Aut-2.7* Abs Ret-0.07 ___ 11:58PM BLOOD cTropnT-<0.01 ___ 04:45AM BLOOD CK-MB-<1 ___ 04:45AM BLOOD cTropnT-0.01 DISCHARGE LABS: ==================== ___ 07:15AM BLOOD WBC-18.5* RBC-3.15* Hgb-9.7* Hct-30.8* MCV-98 MCH-30.8 MCHC-31.5* RDW-14.3 RDWSD-50.5* Plt ___ ___ 07:15AM BLOOD Neuts-81.7* Lymphs-9.3* Monos-6.4 Eos-0.8* Baso-0.3 Im ___ AbsNeut-15.08* AbsLymp-1.72 AbsMono-1.19* AbsEos-0.15 AbsBaso-0.05 ___ 07:15AM BLOOD Glucose-262* UreaN-37* Creat-0.7 Na-133* K-5.2 Cl-94* HCO3-29 AnGap-10 ___ 07:04AM BLOOD ALT-48* AST-20 AlkPhos-125* TotBili-0.2 ___ 07:15AM BLOOD Calcium-8.5 Phos-3.8 Mg-1.8 IMAGING/RESULTS: ================== NON-CONTRAST HEAD CT ___: 1. Evaluation is moderate limited by motion.. 2. No definite hemorrhage. 3. Findings consistent with subacute left MCA infarct. CT ABD/PELVIS W/O CONTRAST ___: 1. No evidence of acute intra-abdominal process. Appropriately positioned gastrostomy tube. 2. Stable diffuse main pancreatic ductal dilation. No visualized lesions although a stricture or subtle mass is possible. 3. Mild proctitis, improved from ___. Unchanged vertebral body compression deformities. 5. Stable indeterminate hepatic hypodensities. 6. 5 mm right basilar subpleural pulmonary nodule. CXR ___: 1. No focal consolidation to suggest pneumonia. 2. Increased prominence of interstitial markings may suggest mild pulmonary edema. No pleural effusion. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Furosemide 20 mg PO DAILY 2. Metoprolol Tartrate 50 mg PO Q6H 3. Apixaban 2.5 mg PO BID 4. Atorvastatin 40 mg PO QPM 5. Digoxin 0.125 mg PO DAILY 6. Diltiazem 30 mg PO Q6H 7. Famotidine 20 mg PO DAILY 8. Lidocaine 5% Patch 1 PTCH TD QAM 9. PARoxetine 20 mg PO DAILY Discharge Medications: 1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Glargine 38 Units Bedtime Insulin SC Sliding Scale using REG Insulin 3. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 4. Senna 8.6 mg PO BID:PRN Constipation - First Line 5. Apixaban 2.5 mg PO BID 6. Atorvastatin 40 mg PO QPM 7. Digoxin 0.125 mg PO DAILY 8. Diltiazem 30 mg PO Q6H 9. Famotidine 20 mg PO DAILY 10. Furosemide 20 mg PO DAILY 11. Lidocaine 5% Patch 1 PTCH TD QAM 12. Metoprolol Tartrate 50 mg PO Q6H 13. PARoxetine 20 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Altered mental status Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: History: ___ with fever, +wbc, AMS// acute process? 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, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 802.7 mGy-cm. 2) Sequenced Acquisition 8.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 1,605 mGy-cm. COMPARISON: Head CT from ___. FINDINGS: Evaluation is moderate to severely limited by motion. Focal linear streak like hyperdensity along the left frontal inner calvarium is felt to likely be artifactual. Increasingly hypodense left MCA territory evolving infarct is without hemorrhagic conversion or worsening mass effect. No midline shift. No definite new infarct. Redemonstrated chronic right insular lacunar infarct, involutional changes, and periventricular white matter hypodensities suggestive microangiopathy. No definite fracture although motion markedly limits assessment of sinuses and skull base. Unchanged partial opacification of the bilateral mastoid air cells. The visualized sinuses are without significant sinus disease. IMPRESSION: 1. Evaluation is moderate limited by motion.. 2. No definite hemorrhage. 3. Findings consistent with subacute left MCA infarct. Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: NO_PO contrast; History: ___ with fever, +WBC, AMS- withdraws and moans when abdomen palpatedNO_PO contrast// acute process? is G tube appropriately located? TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 14.4 mGy (Body) DLP = 7.2 mGy-cm. 2) Spiral Acquisition 6.3 s, 49.6 cm; CTDIvol = 12.5 mGy (Body) DLP = 617.3 mGy-cm. Total DLP (Body) = 625 mGy-cm. COMPARISON: CT of the abdomen and pelvis from ___. FINDINGS: LOWER CHEST: Mild dependent atelectasis. 5 mm right basilar subpleural pulmonary nodule (2:1). No pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. Stable subcentimeter hypodensities in hepatic segment IV, too small to characterized. There is no evidence of new focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is not visualized. PANCREAS: The pancreas is markedly atrophic. Diffuse main pancreatic ductal dilation to 10 mm appears stable. No visualized focal lesions. No peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of hydronephrosis. Both kidneys contain cysts. There is no perinephric abnormality. GASTROINTESTINAL: A gastrostomy tube is appropriately positioned in the stomach. The stomach is otherwise unremarkable. 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 normal. Stool distends the rectum to 4.8 cm without evidence of surrounding stercoral colitis. Mild mucosal hyperenhancement of the lower rectum may suggest mild residual proctitis, improved from ___. PELVIS: The urinary bladder contains a Foley catheter. The distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are within normal limits. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic disease is noted. Venous structures are not well evaluated due to phase of contrast. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Moderate compression deformity of L1 vertebral body with evidence of prior kyphoplasty and mild compression deformity of the L2 vertebral body appear unchanged. Post left total hip arthroplasty associated streak artifact limiting assessment of adjacent structures. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. No evidence of acute intra-abdominal process. Appropriately positioned gastrostomy tube. 2. Stable diffuse main pancreatic ductal dilation. No visualized lesions although a stricture or subtle mass is possible. 3. Mild proctitis, improved from ___. Unchanged vertebral body compression deformities. 5. Stable indeterminate hepatic hypodensities. 6. 5 mm right basilar subpleural pulmonary nodule. RECOMMENDATION(S): For incidentally detected nodules smaller than 6mm in the setting of an incomplete chest CT, no CT follow-up is recommended. See the ___ ___ Guidelines for the Management of Pulmonary Nodules Incidentally Detected on CT" for comments and reference: ___ Radiology Report EXAMINATION: CHEST (SINGLE VIEW) INDICATION: History: ___ with fever, +wbc, AMS// pna? TECHNIQUE: Chest AP COMPARISON: Multiple prior chest radiographs, most recently ___ volumes are slightly lower and interstitial markings are more prominent on prior chest radiographs. No focal consolidation suggest pneumonia. Cardiomediastinal silhouette and hila are normal. No pneumothorax or pleural effusion. FINDINGS: 1. No focal consolidation to suggest pneumonia. 2. Increased prominence of interstitial markings may suggest mild pulmonary edema. No pleural effusion. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: History: ___ with confusion, ___ CT degraded by motion artifact// evaluate for SDH or other acute process TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained without intravenous contrast. Coronal and sagittal reformations and bone algorithms reconstructions were also performed. Please note intravenous contrast was administered for abdominal CT approximately 3 hours prior. DOSE: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 17.1 cm; CTDIvol = 46.8 mGy (Head) DLP = 802.7 mGy-cm. 2) Sequenced Acquisition 8.0 s, 17.1 cm; CTDIvol = 46.8 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 1,605 mGy-cm. COMPARISON: Head CT from 3 hours prior, ___ FINDINGS: There is contrast within intravascular system from CT scan abdomen pelvis performed contrast ___ at 00:47. Presence of contrast limits evaluation for hemorrhage. Previously described area of high density in left frontal extra-axial space was indeed artifactual. No evidence of intracranial hemorrhage. Gyriform hyperenhancement of the cortical gray and adjacent white matter consistent with subacute left MCA infarct, most notably in the left frontotemporal lobe and corona radiata, caudate body. Follow-up recommended to document continued evolution in expected atrophy, and exclude underlying infiltrative process. The ventricles and sulci are unchanged. No evidence increased mass-effect. No evidence of acute fracture. The paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: 1. Left MCA zone enhancement, consistent with subacute infarct. Continued follow-up recommended to document expected evolution, exclude infiltrative process. 2. Brain parenchymal atrophy.. RECOMMENDATION(S): Follow-up head CT in ___ weeks. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Elevated wbc, Fever Diagnosed with Fever, unspecified temperature: 98.8 heartrate: 111.0 resprate: 18.0 o2sat: 98.0 sbp: 106.0 dbp: 77.0 level of pain: 0 level of acuity: 3.0

Patient summary: Ms. ___ is a ___ woman recently admitted to our hospital with a new left MCA stroke, currently on apixaban, with past medical history of dysphasia, chronic atrial fibrillation, systolic heart failure (EF 46%), type 2 diabetes, anemia who presents from her nursing home with AMS and fever greater than 100 x4 days, as well as white blood cell count of 20.

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, abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: Chief Complaint: Abdominal pain History of Present Illness: ___ year old woman w/ h/o sphincter of Oddi dysfunction s/p total of 4 ERCPs w/ sphincterotomy in ___ at ___ and extension on ___ ___ presents w/ abdominal pain. Following her admission for ERCP in ___, she had no abdominal pain for 3 weeks and then the abdomial pain came back and she was seen in the ED three times w/ normal LFTs and unchanged RUQ ultrasounds. She was discharged to follow up with GI as an outpatient, but today presents as she has been unable to tolerate the pain at home. Last night she was carrying her son and she heard a pop in her shoulder and this pain exacerbated her abominal pain. Pt has had n/v, (vomitted ___ x/d) no diarrhea, non-bilious non-bloody. Patient says she has pain when she eats but also has pain when she doesnt eat. Pt states pain is to her RUQ c/w prior episodes of pain. She believes that avoiding breads and gluten help with her pain. Pain located epigastric and LLQ. In the ED, initial vital signs were 98.1 90 116/88 18 100%. Patient was given zofran 4 mg IV, dilaudid IV 1mg x3, ativan 1mg IV and 1L NS. Labs including LFTs were unremarkable. CXR was done which was negative for acute process. As the patient had had two RUQ ultrasounds in the past week no further abdominal imaging was pursued. Blood and urine cultures were sent. Patient was admitted for pain control and evaluation by GI. VS on transfer were: 98.0, HR 67, BP 99/46, O2 sat 100%, RR 18. On the floor, T 98.3 98/57 87 18 98%RA Past Medical History: - Depression - Sphincter of Oddi dysfunction - ?possible chronic pancreatitis-given the EUS performed by Dr ___ on ___ showing lobularity and changes c/w chronic pancretaitis - History of acute cholecystitis s/p CCY as below SURGICAL HISTORY: - Cholecystectomy ___ at ___ Social History: ___ Family History: - Mother: ___ cancer and s/p CCY for "gallbladder attacks" - Father: Healthy - No history of pancreatitis, heart disease, or non-breast malignancy Physical Exam: Vitals- T 98.3 98/57 87 18 98%RA General- Alert, oriented, no acute distress HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- Clear to auscultation bilaterally, no wheezes, rales, ronchi CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, epigastric tender, LLQ tender. non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- no foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal Vitals- T 98.3 98/57 87 18 98%RA General- Alert, oriented, no acute distress HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- Clear to auscultation bilaterally, no wheezes, rales, ronchi CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, epigastric tender, LLQ tender. non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- no foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal Pertinent Results: ___ 06:40AM BLOOD Albumin-4.5 Calcium-9.1 Phos-3.7 Mg-2.1 ___ 06:40AM BLOOD ALT-10 AST-17 AlkPhos-34* TotBili-0.3 ___ 06:40AM BLOOD Glucose-96 UreaN-11 Creat-0.7 Na-139 K-4.6 Cl-105 HCO3-25 AnGap-14 ___ 07:20AM BLOOD Glucose-92 UreaN-7 Creat-0.6 Na-139 K-4.1 Cl-106 HCO3-25 AnGap-12 ___ 06:40AM BLOOD ___ PTT-30.3 ___ ___ 06:40AM BLOOD WBC-5.2 RBC-4.32 Hgb-13.3 Hct-39.0 MCV-90 MCH-30.8 MCHC-34.1 RDW-12.7 Plt ___ ___ 07:20AM BLOOD WBC-5.0 RBC-4.04* Hgb-12.5 Hct-36.3 MCV-90 MCH-30.8 MCHC-34.3 RDW-12.3 Plt ___ ruq u/s FINDINGS: The lungs are clear with no evidence of a consolidation, effusion, or pneumothorax. Cardiomediastinal silhouette is normal. No acute fractures are identified. No free air is noted under the hemidiaphragms. IMPRESSION: No acute cardiopulmonary process. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Escitalopram Oxalate 20 mg PO DAILY 2. Lorazepam 0.5 mg PO BID PRN anxiety 3. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain 4. Polyethylene Glycol 17 g PO DAILY:PRN constipation when taking dilaudid 5. Senna 1 TAB PO DAILY:PRN constipation Discharge Medications: 1. Escitalopram Oxalate 20 mg PO DAILY 2. Lorazepam 0.5 mg PO BID PRN anxiety 3. Polyethylene Glycol 17 g PO DAILY:PRN constipation when taking dilaudid 4. Senna 1 TAB PO DAILY:PRN constipation 5. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain 6. Hyoscyamine 0.125 mg PO Q12H PRN pain, spasm RX *hyoscyamine sulfate [Hyomax] 0.125 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*60 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: primary: abdominal pain secondary Depression Sphincter of Oddi dysfunction s/p 4 ERCPs Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Nausea and abdominal pain. COMPARISON: Chest radiograph from ___. FINDINGS: The lungs are clear with no evidence of a consolidation, effusion, or pneumothorax. Cardiomediastinal silhouette is normal. No acute fractures are identified. No free air is noted under the hemidiaphragms. IMPRESSION: No acute cardiopulmonary process. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: ABDOMINAL PAIN Diagnosed with ABDOMINAL PAIN RUQ temperature: 98.1 heartrate: 90.0 resprate: 18.0 o2sat: 100.0 sbp: 116.0 dbp: 88.0 level of pain: 9 level of acuity: 3.0

___ year old woman w/ h/o sphincter of Oddi dysfunction s/p total of 4 ERCPs w/ sphincterotomy presents w/ abdominal pain. #Abdominal Pain: Pt has chronic abdominal pain and has previous dx of sphincter of odi dysfunction requring ERCP sphincterotomies. She has felt relief of pain after her last ERCP but three weeks she had pain again. Her LFTs, lipase were wnl and RUQ u/s showed common bile duct dilation which she has had on prior imaging. Her lipase and LFTs are all wnl which is reassuring. ERCP was consulted and they felt this was abdominal spasm and not related to her pancreas because of normal labs. She was kept NPO and given IVF for 24 hrs and we managed her pain with dilaudid 2mg q4H prn and tylenol prn. She was also given miralax for bowel regimen while on narcotics. She was then switched to a normal diet and patient was able to take in PO well. She will follow up with her pancreas doctors. It weas recommedned pt try Hyoscyamine 0.125 mg PO Q12H PRN for abdominal spasm. #Depression/anxiety: -continued escitalopram -continued lorazepam .5 mg BIDprn #Tobacco: - gave nicotine patch

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: incidentally found head bleed Major Surgical or Invasive Procedure: IVC filter placement History of Present Illness: HPI: Mr. ___ is a ___ with h/o diabetes, hypertension (high blood pressure), renal disease, gout, acoustic neuroma s/p cyberknife and parkinsons's who was sent in for subacute subdural hematoma. Patient was getting an head MRI at ___ in ___. The MRI showed subacute blood in a chronic subdural fluid collection. Patient reports he has no numbness, weakness, headache. Denies any recent falls or trauma. Denies any double vision. Denies fever, chills, chest pain, cough. Reports he went in for his yearly MRI for his prior acoustic neuroma. Reports he was very surprised at this phone call. His son corroborates that he has been at his baseline to improved with increased mobility. Reports he does have some left leg weakness at baseline though no acute changes. Reports he has been on Coumadin for about a year due to a DVT in his left leg but has not had a recent ultrasound to see if the DVT is still there. He and his son deny any history of trauma, falls, trips, head strike or other accidents. He does not report any headaches or visual changes. In ER: (Triage Vitals:0| 98.4|53 |162/67 |18 |100% RA ) INR = ___ Meds Given: None Fluids given: None Radiology Studies: B/L E US: IMPRESSION: 1. Occlusive thrombus of the left superficial femoral and a left peroneal vein. 2. No right lower extremity deep venous thrombosis . consults called: Neurosurgery: Patient evaluated and imaging reviewed. Routine outpatient MRI from today shows small R subacute on chronic SDH with no mass effect or MLS. Patient is completely asymptomatic with no neurologic deficits. Recommend reversal of INR with 1 ___ in the ER. After FFP administered patient may discharge home. Hold Coumadin until follow up. Patient should follow up in 4 week with Dr. ___ with repeat ___ at that time. Please call ___ to schedule this appointment. Plan determined by attending Dr. ___ ___ Medical History: PMH: His neurological history started with dizziness and imbalance in ___, which was followed locally. Incidental right vestibular schwannoma was picked up on a head MRI. This was then followed by Dr. ___ with serial MRIs. In ___, MRI showed increase in size of schwannoma and he was referred to radiation oncology. He completed Cyberknife SRS on ___ to 2500cGy. . Past Medical History: Prostate cancer treated with radiation. Skin cancer resected from right ear ___ and left ear ___. Melanoma resected from his back over ___ years ago. Hypertension, Vitamin B12 deficiency dx ___. Left lower DVT & PE in ___ on Eliquis- then switched to Coumadin Hypothyroidism. Social History: ___ Family History: Mother deceased after complications of cardiac surgery at ___ which was a stroke. Father deceased at ___, Physical Exam: VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: LLE edema and weakness 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 Right neck IVC filter placed, covered with gauze, CDI Pertinent Results: ___ 07:40AM BLOOD WBC-8.0 RBC-4.90 Hgb-15.1 Hct-42.3 MCV-86 MCH-30.8 MCHC-35.7 RDW-12.6 RDWSD-39.6 Plt ___ ___ 07:40AM BLOOD Plt ___ ___ 07:40AM BLOOD ___ PTT-35.4 ___ ___ 07:44AM BLOOD Glucose-97 UreaN-24* Creat-1.4* Na-144 K-3.8 Cl-102 HCO3-29 AnGap-13 ___ 07:40AM BLOOD Glucose-93 UreaN-19 Creat-1.3* Na-144 K-3.8 Cl-103 HCO3-27 AnGap-14 ___ 07:40AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.0 Final Report INDICATION: ___ year old man with ___ DVT and acute on chronic bleeding to ___// please place a removable IVC filter into patient as he has DVT and SHD with acute on chronic bleeding COMPARISON: ___ CT abdomen pelvis from outside institution. 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: Sedation was provided by administrating divided doses of 75 mcg of fentanyl while the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. . MEDICATIONS: None. CONTRAST: 20 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 3.2 min, 18 mGy PROCEDURE: 1. Left iliac vein and IVC venogram. 2. Infrarenal retrievable IVC filter deployment. 3. Post-filter placement venogram. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the healthcare proxy. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The right neck was prepped and draped in the usual sterile fashion. Under ultrasound and fluoroscopic guidance, the patent and compressible right internal jugular vein was punctured using a 21G micropuncture needle. Ultrasound images of the access was stored on PACS. A ___ wire was advanced through the micropuncture sheath into the inferior vena cava. Using a 5 ___ x 65 cm Kumpe catheter, the ___ wire was advanced into the left iliac vein. The micropuncture sheath was exchanged for the sheath including the inner dilator of an internal jugular vein approach Denali IVC filter. The sheath/dilator was advanced into the left iliac vein. The wire was removed. The inner dilator was flushed. Gentle contrast injection confirmed positioning within the left iliac vein. A left common iliac and inferior vena cava venogram was performed. Based on the results of the venogram, detailed below, a decision was made to place a retrievable infrarenal filter. The inner dilator of the sheath was removed. The sheath was flushed with saline. A vena cava filter was advanced through the sheath until the cranial tip was at the level of the inferior margin of the lower renal vein. The sheath was then withdrawn until the filter was deployed. The wire and loading device were then removed through the sheath and a repeat contrast injection was performed, confirming appropriate filter positioning. The final image was stored on PACS. The sheath was removed and pressure was held for 10 minutes, at which point hemostasis was achieved. A sterile dressing was applied. The patient tolerated the procedure well and there were no immediate post procedure complications. FINDINGS: 1. Patent normal sized, non-duplicated IVC with single bilateral renal veins and no evidence of a clot. 2. Successful deployment of an infra-renal retrievable IVC filter. IMPRESSION: Successful deployment of infrarenal, retrievable IVC filter. RECOMMENDATION(S): If the filter is no longer medically indicated, it may be removed by our service at any time. Our service can be contacted for a clinic appointment at ___. Alternatively, the filter is approved for permanent usage if the patient requires it to remain permanently in place. 1. Occlusive thrombus of the left superficial femoral and a left peroneal vein. 2. No right lower extremity deep venous thrombosis. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Lisinopril 10 mg PO DAILY 2. Metoprolol Succinate XL 50 mg PO DAILY 3. Warfarin 2.5 mg PO DAILY16 4. amLODIPine 5 mg PO DAILY 5. Carbidopa-Levodopa (___) ODT 1 TAB PO TID 6. Furosemide 40 mg PO DAILY 7. Donepezil 10 mg PO QHS 8. Potassium Chloride 10 mEq PO DAILY 9. Levothyroxine Sodium 100 mcg PO DAILY 10. Cyanocobalamin 1000 mcg PO DAILY 11. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Carbidopa-Levodopa (___) ODT 1 TAB PO TID 2. Cyanocobalamin 1000 mcg PO DAILY 3. Donepezil 10 mg PO QHS 4. Furosemide 40 mg PO DAILY 5. Levothyroxine Sodium 100 mcg PO DAILY 6. Lisinopril 10 mg PO DAILY 7. Metoprolol Succinate XL 50 mg PO DAILY 8. Potassium Chloride 10 mEq PO DAILY Hold for K > 5.5 9. Vitamin D 1000 UNIT PO DAILY 10. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do not restart amLODIPine until PCP follow up ___ Disposition: Home With Service Facility: ___ Discharge Diagnosis: Subacute on chronic subdural hematoma Occlusive thrombus of the left superficial femoral and a left peroneal vein Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: History: ___ with prior dvT on coumadin// dvt? TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: None. FINDINGS: Left lower extremity: There is normal compressibility, flow, and augmentation of the left common femoral and popliteal veins. Normal color flow is demonstrated in the posterior tibial. There is noncompressibility and no color flow seen in the left superficial vein and in a single left peroneal vein. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. Right lower extremity: There is normal compressibility, flow, and augmentation of the right common femoral, femoral, and popliteal veins. Normal color flow is demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: 1. Occlusive thrombus of the left superficial femoral and a left peroneal vein. 2. No right lower extremity deep venous thrombosis. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 10:15 pm, 60 minutes after discovery of the findings. Radiology Report INDICATION: ___ year old man with ___ DVT and acute on chronic bleeding to ___// please place a removable IVC filter into patient as he has DVT and SHD with acute on chronic bleeding COMPARISON: ___ CT abdomen pelvis from outside institution. 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: Sedation was provided by administrating divided doses of 75 mcg of fentanyl while the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. . MEDICATIONS: None. CONTRAST: 20 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 3.2 min, 18 mGy PROCEDURE: 1. Left iliac vein and IVC venogram. 2. Infrarenal retrievable IVC filter deployment. 3. Post-filter placement venogram. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the healthcare proxy. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The right neck was prepped and draped in the usual sterile fashion. Under ultrasound and fluoroscopic guidance, the patent and compressible right internal jugular vein was punctured using a 21G micropuncture needle. Ultrasound images of the access was stored on PACS. A ___ wire was advanced through the micropuncture sheath into the inferior vena cava. Using a 5 ___ x 65 cm Kumpe catheter, the ___ wire was advanced into the left iliac vein. The micropuncture sheath was exchanged for the sheath including the inner dilator of an internal jugular vein approach Denali IVC filter. The sheath/dilator was advanced into the left iliac vein. The wire was removed. The inner dilator was flushed. Gentle contrast injection confirmed positioning within the left iliac vein. A left common iliac and inferior vena cava venogram was performed. Based on the results of the venogram, detailed below, a decision was made to place a retrievable infrarenal filter. The inner dilator of the sheath was removed. The sheath was flushed with saline. A vena cava filter was advanced through the sheath until the cranial tip was at the level of the inferior margin of the lower renal vein. The sheath was then withdrawn until the filter was deployed. The wire and loading device were then removed through the sheath and a repeat contrast injection was performed, confirming appropriate filter positioning. The final image was stored on PACS. The sheath was removed and pressure was held for 10 minutes, at which point hemostasis was achieved. A sterile dressing was applied. The patient tolerated the procedure well and there were no immediate post procedure complications. FINDINGS: 1. Patent normal sized, non-duplicated IVC with single bilateral renal veins and no evidence of a clot. 2. Successful deployment of an infra-renal retrievable IVC filter. IMPRESSION: Successful deployment of infrarenal, retrievable IVC filter. RECOMMENDATION(S): If the filter is no longer medically indicated, it may be removed by our service at any time. Our service can be contacted for a clinic appointment at ___. Alternatively, the filter is approved for permanent usage if the patient requires it to remain permanently in place. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abnormal MRI Diagnosed with Nontraumatic chronic subdural hemorrhage temperature: 98.4 heartrate: 53.0 resprate: 18.0 o2sat: 100.0 sbp: 162.0 dbp: 67.0 level of pain: 0 level of acuity: 2.0

___ year old male with h/o an acoustic neuroma s/p cyberknife, LLE DVT, PE, ___ Disease on sinemet who presents after an incidental finding of subacute on chronic SDH on routine MRI. #subacute on chronic SDH on routine MRI. -patient s/p IVC filter, he is comfortable - no midline shift or mass effect on imaging per neurosurgery's read, pending radiology read of MRI - Follow up in 4 weeks with Dr. ___ with repeat ___ at that time. Call ___ to schedule this appointment. DVT/PE hx; last PE approx. ___ ago - pt was on Coumadin, US demonstrates residual thrombous of LLE - heme and neuro-onc were consulted, recommended IVC filter - Stopped Coumadin - Held amlodipine given LLE swelling

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fall Major Surgical or Invasive Procedure: R hip hemiarthroplasty ___ History of Present Illness: ___ year-old male with a history significant for dementia who presents after a fall down a flight of approximately 12 stairs. Per the patient's family, the fall was unwitnessed. The patient presently reports pain in his right knee, left hand, and left hip. He is able to answer basic yes/no ROS questions but incapable of answering more substantive questions. Past Medical History: PMH: Afib, colorectal Ca, alzheimers, CHF, HTN PSH: Colorectal Ca s/p resection with colostomy Social History: ___ Family History: NC Physical Exam: On discharge, Mr. ___ was a pleasantly demented man. He was AVSS. He was alert but not oriented. He had significant secretions and his lungs had crackles throughout. His heart was irregular. His abdomen was soft and nontender. Pertinent Results: ___ 04:00AM BLOOD WBC-15.5* RBC-4.45* Hgb-12.7* Hct-38.5* MCV-87 MCH-28.5 MCHC-32.9 RDW-14.6 Plt ___ ___ 05:49AM BLOOD WBC-17.9* RBC-3.23*# Hgb-9.4*# Hct-28.7*# MCV-89 MCH-29.1 MCHC-32.7 RDW-14.8 Plt ___ ___ 02:03AM BLOOD WBC-11.9* RBC-2.75* Hgb-7.9* Hct-24.8* MCV-90 MCH-28.7 MCHC-31.8 RDW-15.3 Plt ___ ___ 12:19AM BLOOD WBC-15.7* RBC-3.10* Hgb-9.0* Hct-28.6* MCV-92 MCH-29.1 MCHC-31.5 RDW-16.1* Plt ___ ___ 12:19AM BLOOD Glucose-117* UreaN-33* Creat-0.9 Na-152* K-4.8 Cl-117* HCO3-28 AnGap-12 ___ 04:00AM BLOOD Glucose-173* UreaN-17 Creat-1.5* Na-137 K-4.5 Cl-101 HCO3-24 AnGap-17 Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Fluticasone Propionate 110mcg 2 PUFF IH BID 2. Digoxin 0.25 mg PO DAILY 3. Diltiazem 60 mg PO QID Discharge Disposition: Extended Care Discharge Diagnosis: Fall Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Followup Instructions: ___ Radiology Report INDICATION: Right knee and hip pain. COMPARISON: Pelvic radiograph ___ from ___ CT ___. FINDINGS: Frontal and cross-table lateral images of the right femur were obtained for a total of four images. There is a comminuted transcervical fracture through the right femoral neck with mild superior displacement of the distal fracture fragment. IMPRESSION: Comminuted right transcervical femoral neck fracture as seen on CT. Radiology Report MR THORACIC SPINE WITHOUT CONTRAST ___ HISTORY: Trauma with thoracic spine fractures. Sagittal imaging was performed with long TR, long TE fast spin echo, STIR, and short TR, short TE spin echo technique. Limited axial imaging was performed. Comparison to a torso CT of ___. FINDINGS: There are compression fractures of the T3, T4, and T5 vertebral bodies. There is a possible fracture of the superior endplate of T6. There is a small amount of retropulsed bone at the T5 level that appears to contact but not compress the thoracic spinal cord. Images of the remainder of the spine demonstrate normal alignment with no other findings suggesting acute fracture. The STIR images demonstrate faint hyperintensity involving the interspinous and interlaminar regions, perhaps indicating some level of injury to these ligaments. However, note that the torso CT demonstrates a horizontally oriented fracture through the T4 spinous process that is clearly chronic. Thus, the acuity of these minor signal intensity changes in the posterior ligamentous complex is uncertain. A preliminary report was issued that read "T5 vertebral body compression fracture with probable extension into the left pedicle. Mild retropulsion of the posterior fracture fragments into the spinal canal with mild associated canal narrowing. No abnormal cord signal. Increased linear T2 signal within the T4 vertebral body, consistent with a fracture. No posterior retropulsion. Linear T2 signal within the T4 spinous process is consistent with a fracture. Minimal surrounding soft tissue increased T2 signal could represent damage to the interspinous ligaments. Increased T2 signal along the superior endplate of the T3 vertebral body, possibly a fracture versus stress rejection. Heterogeneous signal intensity within the anterior longitudinal ligament at the level of the T5 vertebral body superior endplate indicative of ligamentous injury. Given probable three-column injury, findings are concerning for an unstable spine. Findings discussed with Dr. ___ by Dr. ___ at 12:20 a.m. via telephone on ___ CONCLUSION: Fractures of the T3, 4, and 5 vertebral bodies with possible slight superior endplate fracture of T6. Retropulsed fragment at T5 slightly indents the thecal sac but does not appear to compress the spinal cord. Ambiguous mild hyperintensity in the region of the posterior ligamentous complex. Disruption of the anterior and posterior margins of the vertebral bodies confirms at least two-column injury however. Radiology Report STUDY: AP chest, ___. CLINICAL HISTORY: Patient with right hip hemiarthroplasty. FINDINGS: Comparison is made to prior study from ___. Two views of the right hip from the operating room demonstrate interval placement of a hemiarthroplasty with a non-cemented component. No periprosthetic fractures are seen. There is soft tissue swelling and gas consistent with the recent surgery. Radiology Report CHEST RADIOGRAPH INDICATION: Status post trauma, evaluation for pulmonary edema or consolidations. COMPARISON: Outside hospital film from ___. FINDINGS: As compared to the previous radiograph, the patient shows the hyperextended stomach. The hyperextended stomach displaces the left hemidiaphragm upwards. In addition, there is newly appeared left retrocardiac and left lower lobe atelectasis, combined to blunting of the left costophrenic sinus, potentially suggestive of mild left pleural effusion. The right lung bases also shows minimal basal atelectasis. Otherwise, the lung parenchyma is unremarkable. No evidence of pneumonia or pulmonary edema. Left distal clavicular fracture with mild displacement is noted. Radiology Report AP CHEST, 4:11 A.M. ON ___ HISTORY: ___ man after increasing hypoxia. Suspect pulmonary edema. IMPRESSION: AP chest compared to ___ at 6:35 p.m.: Left upper lobe is newly collapsed, in addition to pre-existing left lower lobe atelectasis, shifting mediastinum markedly to the left. Some left pleural effusion may be present as well, but the major change is atelectasis. Right lung is grossly clear. New endotracheal tube is within 15 mm of the carina and should be withdrawn 2.5 cm for appropriate positioning. Once again stomach is moderately distended with air. Radiology Report AP CHEST, 5:13 A.M., ___ HISTORY: ___ man with acute respiratory failure. Evaluate for collapse. IMPRESSION: PA and lateral chest compared to ___. Aeration has improved in the left apex, but the lingula and lower lobe are still collapsed. Newly aerated upper lobe shows there is at least a modicum of left pleural effusion, probably secondary to the severe atelectasis. Right lung is clear. Tiny right pleural effusion is of no clinical significance. Stomach is still moderately distended with air and fluid. ET tube has been repositioned, now in standard position. Radiology Report HISTORY: Fall down stairs, proctosigmoidectomy with prominent bowel loops. Evaluate for obstruction or free air. COMPARISON: CT abdomen/pelvis from ___, chest radiograph from ___. FINDINGS: Abdomen, AP, 3 individual views: Nasogastric tube has been progressively advanced over the three images to just beyond the gastroesophageal junction, with side port in the distal esophagus. Markedly distended and air-filled stomach. Small bowel loops measure up to 2.7 cm and are largely filled with air. The colon is also patent. Moderate fecal loading. No upright or left lower lateral decubitus radiographs obtained to assess for free air. In the visualized portion of the chest, endotracheal tube terminates 3.7 cm above the carina. Decreased small left and trace right pleural effusions. There is persistent retrocardiac opacity. Discoid atelectasis in the left upper lobe. Patchy nodular opacities in both lower lobes, suggesting aspiration. Mild degenerative changes throughout the thoracolumbar spine. Right bipolar hip hemiarthroplasty, with noncemented component. IMPRESSION: 1. Prominent gastric bubble, NG tube advanced over the three images. 2. No radiographic evidence of obstruction. Images not tailored for detection of free air. Radiology Report AP CHEST, 5:39 A.M. ___ HISTORY: A ___ man after fall with a large dilated colon. IMPRESSION: AP chest compared to ___: Leftward mediastinal shift indicates that at least some of the persistent opacification in the left lower lobe is due to atelectasis, though pneumonia is not excluded. Small-to-moderate bilateral pleural effusions are stable. Heart size normal. ET tube in standard placement. Nasogastric tube ends in the upper stomach, would need to be advanced 5 cm to move all the side ports beyond the GE junction. Right jugular line ends in the mid-to-low SVC. No pneumothorax. Radiology Report INDICATION: Status post bronchoscopy for mucous plug. Presenting with elevated temperature. Evaluate for pneumonia. COMPARISON: Chest radiograph from ___ at 5:13 a.m. FINDINGS: The endotracheal tube is appropriately positioned, ending 3.5 cm above the level of the carina. A new enteric catheter courses below the level of the diaphragm and out of the field of view inferiorly. There has been marked improvement in aeration of the left mid-to-lower lung, status post bronchoscopy with presumed removal of a mucous plug. Moderate left lower lung/retrocardiac atelectasis persists. Concomitant infection or re-expansion edema in this region is not excluded. A small left pleural effusion may be present. There may also be a tiny right pleural effusion, not significantly changed. There is no pneumothorax. The heart size is normal. The mediastinal contours are normal. IMPRESSION: 1. Marked interval improvement in aeration of the left mid-to-lower lung with moderate residual volume loss at the left lung base. Given the persistent left lower lung opacities, infection or re-expansion edema in this region is not excluded. 2. Possible small left and tiny right pleural effusions. Radiology Report INDICATION: New central line placement. Assess for pneumothorax and evaluate position. COMPARISON: Chest radiograph from ___ at 2:39 p.m. FINDINGS: A single frontal radiograph of the chest was acquired. The endotracheal tube is appropriately positioned, ending 3.6 cm above the level of the carina. An enteric catheter passes below the level of the diaphragm and out of the field of view inferiorly, not significantly changed. There has been interval insertion of a right internal jugular central venous catheter with its tip at the level of the mid SVC. There is no pneumothorax. Heterogeneous opacities in the left mid-to-lower lung are at least partially attributable to atelectasis, although infection or reexpansion edema related to recent mucus plug removal at bronchoscopy are not excluded. There is minimal right lower lung atelectasis. Small pleural effusions, left greater than right, are not excluded but would not be significantly changed. The heart size is unchanged. The mediastinal contours are normal. IMPRESSION: 1. Appropriately positioned new right internal jugular central venous catheter, ending in the mid SVC. No pneumothorax. 2. Unchanged left mid-to-lower lung heterogeneous opacities, likely atelectasis, although infection or reexpansion edema is not excluded. 3. Possible small bilateral pleural effusions, left greater than right, not significantly changed. Radiology Report REASON FOR EXAMINATION: Traumatic fall, evaluation of the patient after intubation. The ET tube tip is approximately 5 cm above the carina. The NG tube tip is in the stomach. The right internal jugular line tip is at the level of mid SVC. Heart size and mediastinum are unchanged in appearance. There is no change in left lower lobe consolidation and bilateral pleural effusions. No pneumothorax is seen. Radiology Report TYPE OF EXAMINATION: Chest AP portable single view. INDICATION: ___ male patient with hypoxia. Possible mucus plugging obstructing airways, evaluate. AP single view of the chest has been obtained with patient in semi-upright position. Comparison is made with the next preceding similar study obtained seven hours earlier during the same day. Patient remains intubated, the ETT in unchanged position. An NG tube can now be identified, seen to reach just below the diaphragm. A right internal jugular approach central venous line terminating in mid portion of SVC unchanged. No pneumothorax has developed. The previously described basal densities suggestive of some pleural effusions appear unchanged. No evidence of new infiltrates or major atelectasis. Thus no radiographic suspicion for mucus plugging of the central airways. Radiology Report SINGLE FRONTAL VIEW OF THE CHEST REASON FOR EXAM: Intubated patient. Comparison is made with prior study, ___. Large left and moderate right pleural effusions are likely unchanged allowing the difference in positioning of the patient. Cardiac size is partially obscured by the pleural abnormality. Lines and tubes are in standard position. Bibasilar opacities, larger on the left side, are combination of pleural effusions and atelectases. Radiology Report CHEST RADIOGRAPH INDICATION: Extubation, evaluation for interval change. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, the patient has been extubated. Right internal jugular vein catheter and the nasogastric tube are unchanged. Lung volumes have slightly decreased. The extent of the pre-existing left pleural effusion as well as the accompanying atelectasis and the subtle opacities at the right lung bases are minimally more pronounced than on the previous image. No other changes. No pneumothorax. Radiology Report AP CHEST, 5:05 A.M., ___ HISTORY: ___ man after a fall. Evaluate left lower lobe pneumonia. IMPRESSION: AP chest compared to ___: Moderate-to-large left pleural effusion unchanged since ___. Small right pleural effusion unchanged. Right lower lobe consolidation present since ___ has not cleared, and there is severe consolidation at the base of the left lung, both of which could be entirely atelectasis. Upper enteric drainage tube ends in the upper portion of the stomach, substantially distended with air and fluid. Dr. ___ was paged at 2:15 p.m., two minutes after the findings were recognized. Radiology Report INDICATION: Left hand pain after fall, especially the fifth digit. COMPARISON: No relevant comparisons available. FINDINGS: Frontal, oblique and lateral views of the left hand were obtained. The left fifth digit middle and distal phalanges are dislocated radially and anteriorly at the fifth PIP joint. There is a tiny cortical capsular injury with some cortical fragments. Mild degenerative change is seen in the PIP and DIP joints as well as the first CMC joint. No radiopaque foreign body. IMPRESSION: Dislocation at the left fifth digit PIP joint with cortical capsular injury. Radiology Report INDICATION: Fall down stairs with femur fracture. Pain along the chest wall and abdomen. The patient has ostomy for prior colon cancer. COMPARISON: CT C-spine, pelvic radiograph, CXR ___, all performed at ___. TECHNIQUE: MDCT-acquired axial images from the thoracic outlet to the pubic symphysis were displayed at 5-mm slice thickness without intravenous contrast. IV contrast was not administered due to patient's renal function. Coronal and sagittal reformations of the torso and bone reconstructions of the upper thoracic spine were provided for review. FINDINGS: The thoracic aorta and pulmonary artery are normal in caliber. There is no mediastinal hematoma. No pathologically enlarged axillary or mediastinal lymph nodes are identified. Evaluation for hilar lymphadenopathy is limited without IV contrast. Mild coronary artery calcifications are of unknown hemodynamic significance. There is no pericardial effusion. A tiny left nonhemorrhagic pleural effusion is seen. Lung window images demonstrate a 4-mm focus of pleural thickening along the right major fissure. There is mild dependent bibasilar atelectasis. No worrisome nodule, mass or consolidation. No evidence of pulmonary contusion or pneumothorax. CT ABDOMEN: Evaluation of the intra-abdominal organs is limited without intravenous contrast. The unenhanced liver, gallbladder, spleen, pancreas and bilateral adrenal glands are normal. There is no renal stone, hydronephrosis or contour-altering renal mass. The patient is status post proctosigmoidectomy with an end colostomy. There is no bowel obstruction. No mesenteric hematoma. The abdominal aorta is of normal caliber throughout. Atherosclerotic calcifications are seen at the origin of the celiac trunk, SMA and renal arteries, but vessel patency cannot be evaluated on this study. No pathologically enlarged mesenteric or retroperitoneal lymph nodes are identified. CT PELVIS: The patient is status post proctosigmoidectomy. Soft tissue density anterior to the sacrum is due to radiation change. A Foley catheter decompresses the bladder. The prostate is normal. There is no free fluid and no pelvic or inguinal lymphadenopathy. BONE WINDOWS: No bone finding suspicious for infection or malignancy is seen. There is a comminuted right femoral neck fracture. In the thoracic spine, there is a comminuted fracture of the anterior and posterior endplates of the T5 vertebral body with 5-mm retropulsion of posterior fragments. Additionally, there is a fracture of the inferior endplate of T4 as well as the T4 spinous process. Slightly increased density in T3 may be due to fracture/bone marrow edema. Loss of vertebral body height of the T1 vertebral body is of unknown acuity. Mild degenerative change is seen in the lower lumbar spine. No rib fracture is identified. IMPRESSION: 1. Vertebral body fractures of the T4 and T5 vertebral bodies with 5-mm retropulsion of the T5 vertebral body posterior elements in the spinal canal. MRI is recommended to evaluate the cord. Possible T3 vertebral body fracture. Loss of T1 vertebral body height of unknown chronicity. 2. Comminuted right femoral neck fracture. 3. No evidence of acute injury in the chest, abdomen or pelvis. 4. Status post end colostomy with proctosigmoidectomy. Radiation change in the presacral space. Preliminary findings were discussed with Dr. ___ (Trauma Surgery) in person at 4:30, ___. Radiology Report HISTORY: Right knee pain after fall. Evaluate for fracture. COMPARISON: Knee radiograph ___ at 12:50 a.m. from ___. FINDINGS: Frontal, oblique and cross-table lateral views of the right knee were obtained. There is no fracture or dislocation. Degenerative change is seen with tricompartmental osteophytosis and sharp tibial spines as well as medial joint space narrowing. There is no lipohemarthrosis. Small knee joint effusion. IMPRESSION: No fracture or dislocation. Radiology Report INDICATION: Status post reduction of fifth digit. ___ at 3:30 a.m. FINDINGS: Three views of the left fifth digit were obtained. There has been interval reduction of the fifth digit middle and distal phalanges with respect to the proximal phalanx, now in anatomic alignment. Again seen are cortical fragments suggesting capsular injury and adjacent soft tissue swelling. IMPRESSION: Anatomic alignment of fifth digit after reduction with adjacent cortical fragments. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: HIP/THRORASIC FX Diagnosed with FX NECK OF FEMUR NOS-CL, DISL INTERPHALN HAND-CL, FALL ON STAIR/STEP NEC, ABNORMAL COAGULATION PROFILE, FX DORSAL VERTEBRA-CLOSE temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: 13 level of acuity: 2.0

Mr. ___ was transferred to the ICU on POD 2 after he was noted to have dyspnea with O2 saturation of 70% while on the floor. An ABG was obtained revealin a Po2 of 47. The patient was intubated for hypoxic respiratory failure. A CXR was obtained revealing left upper lobe collapse in addition to pre-exisiting left lower lobe atelectasis seen on prior xray. A bronchoscopy was performed revaling extensive mucous plugging in the left mainstem and lower lobes. Post-procedure he was noted to become hypotensive to the 60's. He was given IV fluid boluses and was started on a Levophed drip with adequate response. Later on he spiked a fever to 102 with pan-cultures sent and he was started on Vancomycin and Cefepime. An ECHO was obtained revealing mild RV dilation with depressed EF of 45-50%. Subsequent chest xrays show improved lung expansion but with persistent left lower lobe opacity concerning for infiltrate. On POD 3 a BAL was sent with gram stain showing GNR and eventually grew pan sensitive E. Coli, so his antibiotic coverage was changed to ceftriaxone. He was able to wean off pressors and tube feeds were initiated. He was able to wean down his ventilatory requirements and was tolerating pressure support. He was extubated on POD5, however he required continue nasotracheal suctioning for pulmonary toilet. On POD7 a family meeting was held and the patient the decision was made to transfer the patient to hospice.

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Diarrhea, nausea Major Surgical or Invasive Procedure: None History of Present Illness: ___ s/p lap ___ fundoplication in ___ (Dr ___, presenting with a 1 day history of dry heaving/nausea and loose stools after returning from a trip to ___. Patient and husband had a trip to ___, and husband had similar symptoms a few days ago. Patient was in her normal state of health until returning from ___ this morning, when she had acute onset of dry heaving and diarrhea. Diffuse crampy abdominal pain and distension. She has been passing flatus all along. Past Medical History: Past Medical History: - cervical radiculopathy - GERD -> hoarseness; low ___ pressures on manometry - chronic pain syndromes - pancreatic cyst Past Surgical History: - Lap Ni___ fundoplication ___ (___) - C5-C6 anterior cervical fusion ___ (___) - TAH ___ due to uterine bleeding Social History: ___ Family History: HTN in both parents, negative for joint disease Physical Exam: VS: 98.6, 64, 131/81, 18, 100% RA Gen: NAD, AAOx3 CV: RRR +S1/S2, no m/r/g Pulm: CTAB no w/r/r Abd: soft, nontender, nondistended, +BS, no r/r/g, no palpable masses Ext: No ___ edema/cyanosis/clubbing Pertinent Results: KUB ___ IMPRESSION: No evidence of intestinal obstruction or perforation; gas-distended stomach may benefit from decompression. KUB ___ IMPRESSION: Nonspecific gas pattern with some loops of gas-distended proximal small bowel likely represents passage of gas from the stomach into the small bowel. Stomach is now largely decompressed. Medications on Admission: morphine ER 15 tid prn, methadone prn, Align 4 mg', Calcium Carbonate-Vitamin D3 600 mg-400', Cymbalta 60 mg bid, Lyrica 150 tid, capsaicin 0.075 % Topical Cream, hydrochlorothiazide 25 mg', multivitamin, omeprazole 20 mg', oxycodone prn, zolpidem ER 6.25 mg prn Discharge Medications: 1. Morphine SR (MS ___ 15 mg PO TID:PRN pain RX *morphine [MS ___ 15 mg 1 tablet(s) by mouth three times a day Disp #*21 Tablet Refills:*0 2. Methadone 5 mg PO PRN prn 3. Align *NF* (bifidobacterium infantis) Dosage uncertain Oral daily 4. Calcarb 600 With Vitamin D *NF* (calcium carbonate-vitamin D3) 600 mg(1,500mg) -200 unit Oral daily 5. Pregabalin 150 mg PO TID 6. Capsaicin 0.025% 1 Appl TP TID 7. Hydrochlorothiazide 25 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Omeprazole 20 mg PO DAILY 10. Zolpidem Tartrate 6.25 mg PO HS:PRN sleep 11. Duloxetine 60 mg PO BID 12. Ondansetron 4 mg PO Q8H:PRN nausea RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*10 Tablet Refills:*1 13. DiphenhydrAMINE 25 mg PO Q6H:PRN nausea RX *diphenhydramine HCl 25 mg 1 tablet by mouth every six (6) hours Disp #*20 Tablet Refills:*1 Discharge Disposition: Home Discharge Diagnosis: Nausea and diarrhea - probable gastroenteritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: ___ female with a history of a Nissen fundoplication ___, now with dry heaves and diarrhea. STUDY: Upright and supine abdominal radiographs. COMPARISON: Abdominal radiograph from ___ and CT of the abdomen and pelvis with contrast from ___ as well as MR of the abdomen from ___. FINDINGS: There is no free air. There are no dilated loops of small or large bowel, although the stomach is noted to be markedly distended with gas. Stool ball is noted within the rectum. The visualized lung bases and osseous structures appear within normal limits. IMPRESSION: No evidence of intestinal obstruction or perforation; gas-distended stomach may benefit from decompression. Radiology Report INDICATION: ___ woman with nausea, vomiting, diarrhea, ? change in gastric distention. COMPARISON: ___ at 1:35 a.m. (earlier on the same day). FINDINGS: AP upright and supine views of the abdomen show partial decompression of the stomach and mild increased gaseous distention of the proximal loops of small bowel as compared to the prior study. The nonspecific bowel gas pattern likely represents movement of gas from the stomach into the small bowel. No signs of obstruction. No pneumatosis and no free air. No significant soft tissue calcifications. Osseous structures are unchanged. IMPRESSION: Nonspecific gas pattern with some loops of gas-distended proximal small bowel likely represents passage of gas from the stomach into the small bowel. Stomach is now largely decompressed. Gender: F Race: HISPANIC OR LATINO Arrive by WALK IN Chief complaint: DRY HEAVES Diagnosed with PARALYTIC ILEUS, ABDOMINAL PAIN EPIGASTRIC temperature: 96.0 heartrate: 80.0 resprate: 16.0 o2sat: 100.0 sbp: 155.0 dbp: 87.0 level of pain: 8 level of acuity: 3.0

Ms. ___ presented to the ED on ___ with diarrhea and nausea. An NGT was placed with immediate relief of symptoms. She was admitted for rehydration. She was kept NPO, and KUB showed no signs of obstruction or perforation, but just generalized bowel distention. KUB obtained later the same day showed improvement in distention. Her nausea improved on ___, with no diarrhea. She was started on sips. On ___, she was advanced to a regular diet, which she tolerated. She had one episode of diarrhea and 3 additional small stools. She felt much improved and was able to tolerate adequate PO. She was discharged in good condition with nausea medication PRN.

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Spironolactone / Oxycodone Attending: ___ Chief Complaint: AMS Major Surgical or Invasive Procedure: Intubation History of Present Illness: ___ female with history of cryptogenic cirrhosis complicated by hepatic encephalopathy and variceal bleeding s/p banding and TIPS presents as a transfer from ___ for altered mental status. Patient was admitted here last ___, underwent EGD with esophageal banding for variceal bleeding(2 cords grade II) and was discharged to rehabilitation. Per daughter, pt has been progressively more confused for the last week and she was found this morning to have worsening altered mental status and was initially evaluated at ___ with a head CT, which was unremarkable. In the ED, initial vitals: 97.4 72 113/65 18 100% 2L NC. No tappable pocket for ascities on ED bedside U/S. Urine/serum tox negative. Labs notable for positive UA(mod leuk, few bacteria, 27WBC). CT head: no acute intractranial process(at ___. CXR: no acute cardiopulmonary abnormality. Was started on protonix, octreotide given guaiac positive stools. Also given 2gm IV CTX, 1L NS, 1L lactulose PR. On transfer, vitals were: 97.4 91 146/69 18 100% RA On arrival to the MICU, patient was obtunded. Unable to obtain ROS. Past Medical History: # Crytogenic cirrhosis c/b portal hypertension and ascites. No history of SBP in the past. # ? Sarcoidosis based on non-caseating granuloma biopsied on colon but without other organ manifestations # Hypertension # Eczema # Type 2 Diabetes, diet controlled # SBO during hospitalization, ___ # Cryptococcal osteomyelitis of L ___ anterolateral rib previously on fluconazole but stopped by ID on ___ # h/o severe VZV (R leg & lower back), ___ Social History: ___ Family History: -Paternal aunts with cancers of some sort, unclear what kind. -Mom, Dad and Sister all with ___, mother with HTN Physical Exam: PHYSICAL EXAM on admission to ICU ==================================== Vitals- T: 97.6 BP:144/62 P:88 R:20 18 O2:100% GENERAL: obtunded, not arousable HEENT: Sclera anicteric, oral mucosa dry, 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 NEURO: obtunded, +astrexis, + ___ clonus PHYSICAL EXAM ON DISCHARGE: ============================ VITALS: Temp. 98.6, BP 143/58, HR 80, RR 18, 95% RA, 2BM's General: Thin frail appearance. Oriented to place, self, date and upcoming birthday. Able to follow complex commands HEENT: Sclera anicteric, MMM, PERRL CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur heard best at LLSB Abdomen: Distended, NT in all 4 quadrants with increased distention. Mild amount of ascites. Non-tender to palpation. Lungs: Clear to auscultation bilaterally. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. No asterixis Neuro: CN II-XII intact, ___ strength in upper and lower extremities. No asterexis Pertinent Results: LABS ON ADMISSION: =================== ___ 04:01PM BLOOD Neuts-77.8* Lymphs-12.5* Monos-7.1 Eos-1.9 Baso-0.7 ___ 04:01PM BLOOD ___ PTT-42.8* ___ ___ 04:01PM BLOOD Glucose-112* UreaN-18 Creat-1.1 Na-137 K-4.5 Cl-107 HCO3-21* AnGap-14 ___ 11:16AM BLOOD Glucose-139* UreaN-22* Creat-1.3* Na-141 K-4.2 Cl* ___ 04:01PM BLOOD Lipase-141* ___ 03:29AM BLOOD cTropnT-0.05* ___ 05:37AM BLOOD freeCa-1.24 ___ 07:30PM BLOOD Lactate-2.3* LABS ON DISCHARGE: ===================== ___ 06:32AM BLOOD WBC-5.6 RBC-2.96* Hgb-9.0* Hct-28.2* MCV-96 MCH-30.4 MCHC-31.9 RDW-19.2* Plt Ct-67* ___ 06:32AM BLOOD Glucose-201* UreaN-21* Creat-1.1 Na-138 K-4.1 Cl-105 HCO3-26 AnGap-11 ___ 06:32AM BLOOD ALT-17 AST-34 AlkPhos-161* TotBili-2.2* ___ 06:32AM BLOOD Calcium-9.5 Phos-3.1 Mg-2.0 MICRO: ========= Blood and urine culture ___ negative STUDIES: ======== RUQ US with doppler: IMPRESSION: 1. Technically limited study given the patient's encephalopathy. TIPS shows wall to wall flow with slightly decreased velocities from ___. 2. Gallbladder distention with cholelithiasis. If there is concern for cholecystitis, hepatobiliary scan would be recommended. 3. Cirrhosis with moderate ascites. CXR ___: IMPRESSION: Interstitial prominence, concerning for interstitial edema. No focal consolidation or pneumothorax. CT head with contrast ___: IMPRESSION: 1. No acute intracranial abnormality. 2. No evidence of acute intracranial hemorrhage. CT abd/pelvis w/o contrast: IMPRESSION: 1.Cirrhotic liver with small amount of perihepatic ascites. TIPS patency cannot be evaluated due to lack of intravenous contrast. 2. Distended gallbladder with dependent sludge versus small dependent gallstones. If there is concern for cholecystitis, nuclear medicine HIDA scan may be considered. 3. Mildly dilated cecum without evidence of cecal wall thickening or adjacent inflammatory change. 4. Small bilateral nonhemorrhagic pleural effusions with underlying bibasilar atelectasis. 5. 9 mm nodular opacity in the lateral aspect of the right lower lobe not present on CT ___ and likely of infectious or inflammatory etiology. ___ HIDA scan: IMPRESSION: No evidence of acute cholecystitis. Gallbladder US ___: IMPRESSION: Trace perihepatic ascites. Paracentesis canceled because of insufficient fluid. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q8H:PRN pain 2. Amiloride HCl 10 mg PO DAILY 3. Furosemide 60 mg PO DAILY 4. Lactulose 30 mL PO TID 5. Omeprazole 20 mg PO BID 6. Rifaximin 550 mg PO BID 7. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN throat pain 8. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 9. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 10. Glucose Gel 15 g PO PRN hypoglycemia protocol 11. Hemorrhoidal Suppository ___ID PRN pain 12. Multivitamins W/minerals 1 TAB PO DAILY 13. Simethicone 40-80 mg PO QID:PRN gas 14. Sucralfate 1 gm PO QID 15. Fluticasone Propionate NASAL 2 SPRY NU BID 16. Polyethylene Glycol 17 g PO DAILY:PRN constipation 17. Vitamin D 5000 UNIT PO DAILY Discharge Medications: 1. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 2. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 3. Glucose Gel 15 g PO PRN hypoglycemia protocol 4. Lactulose 30 mL PO TID Goal bowel movement of ___ per day. Give 30 ml Q2 hours if < 3 BM's or confusion. 5. Multivitamins W/minerals 1 TAB PO DAILY 6. Omeprazole 20 mg PO BID 7. Rifaximin 550 mg PO BID 8. Simethicone 40-80 mg PO QID:PRN gas 9. Sucralfate 1 gm PO QID 10. Vitamin D 5000 UNIT PO DAILY 11. Acetaminophen 650 mg PO Q8H:PRN pain 12. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN throat pain 13. Fluticasone Propionate NASAL 2 SPRY NU BID 14. Hemorrhoidal Suppository ___ID PRN pain 15. Polyethylene Glycol 17 g PO DAILY:PRN constipation 16. Furosemide 20 mg PO DAILY 17. Ciprofloxacin HCl 250 mg PO Q24H 18. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Primary: Hepatic Encephalopathy Spontaneous Bacterial Peritonitis Secondary: Cryptogenic cirrhosis Grade II esophageal varices s/p banding Anemia Thrombocytopenia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). 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: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: History: ___ with altered mental status, history of cirrhosis 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. There is a moderate amount of ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 4 mm. GALLBLADDER: The gallbladder is distended with stones. There is no 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 12.5 cm. DOPPLER: Evaluation is limited by the patient's inability to cooperate. A TIPS is in place with wall-to-wall flow. Velocities in the proximal, mid and distal TIPS are 197, 170 and 140 centimeters/seconds, respectively. These previously measured 215, 191 and 245 cm/sec. Flow within the left and right portal veins are appropriately reversed towards the TIPS. The main hepatic artery is patent. The hepatic veins are difficult to assess. IMPRESSION: 1. Technically limited study given the patient's encephalopathy. TIPS shows wall to wall flow with slightly decreased velocities from ___. 2. Gallbladder distention with cholelithiasis. If there is concern for cholecystitis, hepatobiliary scan would be recommended. 3. Cirrhosis with moderate ascites. Radiology Report EXAMINATION: Portable supine chest INDICATION: ___ year old woman with hepatic encephalopathy s/p NG placement // correct NG placement TECHNIQUE: Portable supine chest COMPARISON: ___ 12:15 FINDINGS: Enteric tube extends to the stomach. Multiple embolization coils overlying the right upper quadrant. Marked cardiomegaly is again demonstrated. Tortuous thoracic aorta. Interstitial prominence of the lungs, suggestive of interstitial edema no focal consolidation or pneumothorax. IMPRESSION: Interstitial prominence, concerning for interstitial edema. No focal consolidation or pneumothorax. Radiology Report EXAMINATION: ABDOMEN (SUPINE AND ERECT) INDICATION: ___ year old woman with acute onset abd pain, free air. TECHNIQUE: Supine and left lateral decubitus abdominal films. COMPARISON: Abdominal radiograph dated ___. FINDINGS: Enteric tube with the side port within the stomach. A TIPS is seen in the appropriate position. Vascular embolization coils are seen the right upper quadrant. There are clips in the lower pelvis. There are scattered regions of air within the small and large bowel, nonspecific. No free air on the left lateral decubitus film. IMPRESSION: No free air. Radiology Report EXAMINATION: CT abdomen and pelvis without intravenous contrast. INDICATION: ___ female with history of cryptogenic cirrhosis complicated by hepatic encephalopathy and variceal bleeding s/p banding and TIPS presents as a transfer from ___ for altered mental status rising lactate,and concern for DIC // r/o acute process, ishemic bowel, SBO W/ PO contrast TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis without intravenous contrast administration. Coronal and sagittal reformations were performed and reviewed on PACS. Oral contrast was administered. DOSE: DLP: 448 mGy-cm (abdomen and pelvis). IV Contrast: Intravenous contrast was not administered for this examination. COMPARISON: CT abdomen and pelvis ___. FINDINGS: LOWER CHEST: Small bilateral nonhemorrhagic pleural effusions and adjacent bibasilar atelectasis are unchanged. Small patchy opacity in lateral aspect of the right lower lobe may represent focus of atelectasis. ABDOMEN: Evaluation of abdominal and pelvic structures is limited due to lack of intravenous contrast. HEPATOBILIARY: Liver demonstrates mildly heterogeneous attenuation and nodular contour consistent with cirrhosis. A TIPS is present in the right portal and right hepatic veins. TIPS patency cannot be evaluated due to lack of intravenous contrast. There is a small amount of perihepatic ascites. The gallbladder is distended with dependent sludge. Lack of intravenous contrast prevents evaluation for gallbladder wall enhancement.. 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 renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: Small bowel loops demonstrate normal caliber and wall thickness. The cecum is mildly dilated measuring up to 9.8 cm, however there is no evidence of cecal wall thickening or adjacent inflammatory change. The appendix is not visualized in this examination. RETROPERITONEUM: There is no evidence of retroperitoneal and mesenteric lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. There is mild to moderate calcium burden in the abdominal aorta and great abdominal arteries. PELVIS: The urinary bladder is decompressed by indwelling catheter. There is no evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: Reproductive organs are within normal limits. BONES AND SOFT TISSUES: There is no evidence of worrisome lesions. There are degenerative changes of the lower lumbar spine including disc space narrowing at L5-S1 and associated degenerative endplate changes. Abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Cirrhotic liver with small amount of perihepatic ascites. TIPS patency cannot be evaluated due to lack of intravenous contrast. 2. Distended gallbladder with dependent sludge versus small dependent gallstones. If there is concern for cholecystitis, nuclear medicine HIDA scan may be considered. 3. Mildly dilated cecum without evidence of cecal wall thickening or adjacent inflammatory change. 4. Small bilateral nonhemorrhagic pleural effusions with underlying bibasilar atelectasis. 5. 9 mm nodular opacity in the lateral aspect of the right lower lobe not present on CT ___ and likely of infectious or inflammatory etiology. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with new intubation. // ET placement COMPARISON: ___. IMPRESSION: The patient has been intubated. The tip of the endotracheal tube projects 3.8 cm above the carinal. The position of the nasogastric tube is unchanged. Unchanged moderate cardiomegaly. Slightly improving pulmonary edema and parenchymal opacities, notably in the perihilar sounds on the right and in the left upper lobe, potentially suggesting infection. No pleural effusions. No pneumothorax. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ female with cryptogenic cirrhosis complicated by portal hypertension, variceal bleed status post TIPS, now with altered mental status and concern for and concern for Disseminated intravascular coagulopathy evaluate for acute intracranial hemorrhage. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: DLP: 935 mGy-cm CTDI: 54.2 mGy COMPARISON: ___ noncontrast head CT FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles and sulci are prominent consistent with atrophy. No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: 1. No acute intracranial abnormality. 2. No evidence of acute intracranial hemorrhage. Radiology Report INDICATION: L dl power picc 40cm iv ping ___ ___ year old woman with picc // L dl power picc 40cm iv ping ___ Contact name: ping, ___: ___ EXAMINATION: CHEST PORT. LINE PLACEMENT TECHNIQUE: Portable Chest radiograph, frontal view COMPARISON: Chest radiograph ___ FINDINGS: Left PICC terminates at low SVC. ET tube terminates 3.4 cm above the carina. NG tube courses below the diaphragm and out of view. The stent and several coils in right upper quadrant of the abdomen are in unchanged position. Mild pulmonary edema is similar to prior. Cardiac silhouette is borderline enlarged. IMPRESSION: Left PICC terminates in low SVC. Otherwise no notable change from 1 day prior. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman s/p intubation // ET tube placement TECHNIQUE: Portable AP radiograph of the chest. COMPARISON: ___. FINDINGS: The endotracheal tube has been withdrawn, and now terminates at the level of the clavicles. The left-sided PICC line terminates in the low SVC. A nasogastric tube coils in the stomach. Bilateral interstitial and airspace opacities most likely due to pulmonary edema are not appreciably changed. Moderate cardiomegaly despite the projection is also unchanged. A right upper quadrant stent and coils are again noted. IMPRESSION: Repositioned ETT now terminates at the level of the clavicles. No other significant interval change. Radiology Report INDICATION: ___ year old woman with new dobhoff placement (needs 2 step placement // DObhoff placement COMPARISON: Compared to prior radiographs from ___. IMPRESSION: The nasogastric tube is no longer seen. There is an endotracheal tube and left-sided central venous line which are unchanged position. There is cardiomegaly and a left retrocardiac opacity. There is moderate pulmonary edema, stable. Radiology Report INDICATION: ___ year old woman with dobhoff placement // dobhoff placement COMPARISON: Radiographs from ___. IMPRESSION: There is a Dobbhoff tube whose distal tip is in the stomach. The endotracheal tube and left-sided central venous line are unchanged position. There is cardiomegaly and a left retrocardiac opacity. There is persistent pulmonary edema, stable. Radiology Report EXAMINATION: LIMITED ABDOMINAL ULTRASOUND. INDICATION: ___ year old woman with cryptogenic cirrhosis s/p TIPS who has been hospitalized for hepatic encephalopathy s/p treatment for spontaneous bacterial peritonitis with slight worsening abdominal distention and tenderness. TECHNIQUE: Grayscale ultrasound images of all 4 quadrants. COMPARISON: CT abdomen and pelvis ___. FINDINGS: Grayscale ultrasound in all 4 quadrants demonstrates trace perihepatic ascites. There was no adequate pocket of fluid for diagnostic paracentesis. IMPRESSION: Trace perihepatic ascites. Paracentesis canceled because of insufficient fluid. NOTIFICATION: Findings discussed with Dr. ___ by Dr. ___ on ___ at 14:00, 5 min after they were made. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Altered mental status Diagnosed with HEPATIC ENCEPHALOPATHY, CIRRHOSIS OF LIVER NOS temperature: 97.4 heartrate: 72.0 resprate: 18.0 o2sat: 100.0 sbp: 113.0 dbp: 65.0 level of pain: 13 level of acuity: 2.0

___ with PMH significant for cryptongenic cirrhosis c/b hepatic encephalopathy and recent admission for variceal bleeding (___) s/p banding and TIPS on ___ admitted to MICU on ___ for AMS now transferred to medicine. She intiially presented to ___ in the setting of 1 week of progressive confusion. CT head there unremarkable and transferred to ___ ED and then ___ ICU.

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 and vomiting Major Surgical or Invasive Procedure: ERCP with duodenal stent clean out on ___ History of Present Illness: Ms. ___ is a ___ year old female with pancreatic cancer s/p recent admission for biliary and duodenal stenting who presents from home with nausea and vomiting. The patient ws recently admitted at ___ from ___ with nausea and vomiting. Imaging at that time demonstrated disease progression and occlusion of her prior duodenal stent and she underwent duodenal stenting on ___. Her post procedural course was complicated by significant nausea and vomiting for which she was started on a dexamethasone taper in addition to antibiotics for cholangitis (Augmentin x7 days). Patient states that she has been vomiting for several days prior to this admission. Reports not passing gas or having a bowel movement in the past 2 days. Presented to OSH, where patient was hypotensive to 88/40 and tachycardic 130s and received IV fluids and Zofran. CT at outside hospital showed no signs of mesenteric ischemia or SBO. Patient had improvement in her lactate from 8.5->4.6 after fluids. In the ED, the initial vital signs were: T 99 HR 98 BP 97/61 Spo2 98% Laboratory data was notable for: Normal Chem 10 ALT 63 AST 53 AP 99 TBil 1.0 Alb 3.2 Hgb 9.7 Lactate 1.4 The patient received: ___ 02:44 IVF LR ___ 03:08 IV LORazepam 1 mg ___ 04:12 IV Pantoprazole 40 mg ___ 04:12 IV Piperacillin-Tazobactam (4.5 g ordered) On the floor, patient states that she is still mildly nauseated. She has never had abdominal pain. She has not vomited since she left the OSH ED. She says there was a slight blood tinge to some of the vomit, and some of it may have looked feculent. Past Medical History: ___ started experiencing nausea, vomiting, fatigue, choluria and pruritus. She was seen by her PCP and was found to have elevated LFTs and CT scan showed diffuse enlargement of the pancreatic head with soft tissue extending along the proximal SMA and SMV concerning for primary neoplasm. She was referred to Dr. ___ at ___ and underwent ERCP/EUS on ___ which showed a dilated CBD with hypoechoic mucosal abnormality around the distal CBD, but no discrete mass was seen. FNA non-diagnostic and ampullary biopsies showed only duodenitis. The pancreatic duct and parenchyma appeared normal. A dilated CBD was noted on cholangiogram and she had 2 plastic stents placed. CA ___ and IgG4 both mildly elevated to 126 and 96, respectively. Ms. ___ had a repeat CT scan done one month later which continued to show findings suspicious for malignancy. Repeat ERCP/EUS in ___ showed a 2.1 x 2.2cm mass in the HOP with poorly defined borders and the remainder of the pancreas was unremarkable. FNA was again negative. ERCP with Spy showed some edematous changes in the intra and extrahepatic biliary system, but Spybite biopsies again non-diagnostic. Patient continued to be symptomatic and subsequently developed weight loss of approximate 50 lbs. In late ___ she had triple phase CT done which showed similar findings as prior imaging and more suspicious for AIP and started empirically on Prednisone 40mg in early ___. She was referred to Dr. ___ arranged for ___ given high concerns for malignancy as well as to assess for any treatment response since initiation of steroids. MRCP on ___ confirmed a 1.9cm mass in the uncinate with diffuse and infiltrating soft tissue encasing the SMA and SMV as well as focal segmental narrowing of the SMV without thrombosis. Referred for EUS which confirmed an approx. 2cm pancreatic head/uncinate mass with two 1.5cm LNs in the porta hepatis and peripancreatic region. FNB of mass was consisted for ductal adenocarcinoma and LN FNBs negative. Patient was referred to our MDC by Dr. ___ Dr. ___. Ms. ___ was evaluated in our Pancreatic Cancer MDC on ___ and our assessment was that she had locally advanced disease likely representing unresectable cancer. The consensus recommendation was to initiate treatment with systemic chemotherapy. - ___: C1D1 FOLFIRINOX - ___: C1D15 - ___: C2D1 FOLFIRINOX - ___: C2D15 - ___: C3D1 FOLFIRINOX - ___: C4D1 FOLFIRINOX - ___: C5D1 FOLFIRINOX - ___: C6D1 FOLFIRI (oxali held due to neuropathy) - ___: Admission for biliary obstruction, ERCP found new CHD stricture, metal stent placed. - ___: C6D15 FOLFIRI PAST MEDICAL HISTORY: - Pancreatic Cancer, as above - Hypertension - s/p C-section - Chemotherapy-Induced Peripheral Neuropathy - LLE DVT in ___ Social History: ___ Family History: Mother with ovarian CA (diagnosed ___). Father with bladder CA. PGF with pancreatic CA (diagnosed in his ___. PGM with colon CA (diagnosed in ___. Physical Exam: ADMISSION PHYSICAL EXAM 24 HR Data (last updated ___ @ 647) Temp: 98.3 (Tm 98.3), BP: 104/72, HR: 99, RR: 18, O2 sat: 96%, O2 delivery: Ra GENERAL: NAD HEENT: Sclerae anicteric, MMM NECK: Supple, no LAD CV: NR, RR. Normal S1/S2, no murmurs, gallops, or rubs PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABD: Abdomen soft, nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly, negative ___ sign EXT: WWP, no cyanosis, clubbing, or edema, 2+ radial pulses bilaterally SKIN: Warm and well perfused, no excoriations or lesions, no rashes NEURO: Alert, moving all 4 extremities with purpose, face symmetric DISCHARGE PHYSICAL EXAM VS: ___ 1334 Temp: 98.4 PO BP: 131/93 HR: 87 RR: 18 O2 sat: 97% O2 delivery: RA GENERAL: Well appearing, in NAD HEENT: Sclerae anicteric, MMM NECK: Supple, no LAD CV: NR, RR. Normal S1/S2, no murmurs, gallops, or rubs PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABD: Abdomen soft, nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly, negative ___ sign EXT: WWP, no cyanosis, clubbing, or edema, 2+ radial pulses bilaterally SKIN: Skin type III. Warm and well perfused, no excoriations or lesions, no rashes NEURO: Alert, moving all 4 extremities with purpose, face symmetric Pertinent Results: ADMISSION LABS ___ 03:00AM BLOOD WBC-9.7 RBC-3.32* Hgb-9.7* Hct-28.9* MCV-87 MCH-29.2 MCHC-33.6 RDW-13.5 RDWSD-41.3 Plt ___ ___ 03:00AM BLOOD Neuts-77.6* Lymphs-13.1* Monos-7.9 Eos-0.5* Baso-0.4 Im ___ AbsNeut-7.53* AbsLymp-1.27 AbsMono-0.77 AbsEos-0.05 AbsBaso-0.04 ___ 05:52AM BLOOD ___ PTT-133.8* ___ ___ 01:00PM BLOOD ___ PTT-31.1 ___ ___ 03:00AM BLOOD Glucose-117* UreaN-21* Creat-0.8 Na-140 K-4.1 Cl-101 HCO3-24 AnGap-15 ___ 03:00AM BLOOD ALT-63* AST-53* AlkPhos-99 TotBili-1.0 ___ 03:00AM BLOOD Lipase-41 ___ 03:00AM BLOOD cTropnT-<0.01 ___ 03:00AM BLOOD Albumin-3.2* Calcium-8.4 Phos-3.7 Mg-1.8 ___ 03:07AM BLOOD Lactate-1.4 DISCHARGE LABS ___ 05:26AM BLOOD WBC-4.0 RBC-2.82* Hgb-8.4* Hct-25.2* MCV-89 MCH-29.8 MCHC-33.3 RDW-15.2 RDWSD-44.3 Plt ___ ___ 05:26AM BLOOD Neuts-53.7 ___ Monos-9.7 Eos-2.0 Baso-0.7 Im ___ AbsNeut-2.17 AbsLymp-1.34 AbsMono-0.39 AbsEos-0.08 AbsBaso-0.03 ___ 05:26AM BLOOD ___ PTT-33.6 ___ ___ 05:26AM BLOOD Glucose-99 UreaN-2* Creat-0.6 Na-140 K-3.6 Cl-103 HCO3-23 AnGap-14 ___ 05:26AM BLOOD Albumin-3.2* Calcium-8.0* Phos-4.0 Mg-2.0 ___ 05:26AM BLOOD ALT-20 AST-16 LD(LDH)-168 AlkPhos-72 TotBili-0.3 REPORTS EGD ___ Normal stomach and esophagus. Food partially obstructing the duodenal stent successfully removed with balloon sweep. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 5 mg PO BID 2. Mirtazapine 15 mg PO QHS 3. Docusate Sodium 100 mg PO BID 4. LORazepam 1 mg PO QHS:PRN insomnia 5. Nystatin Oral Suspension 5 mL PO QID 6. Polyethylene Glycol 17 g PO DAILY Discharge Medications: 1. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line RX *bisacodyl 5 mg 2 tablet(s) by mouth once a day Disp #*60 Tablet Refills:*0 2. Ciprofloxacin HCl 500 mg PO BID RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 3. Metoclopramide 10 mg PO QIDACHS RX *metoclopramide HCl 10 mg 1 tablet(s) by mouth four times a day Disp #*120 Tablet Refills:*0 4. Senna 17.2 mg PO BID RX *sennosides 8.6 mg 2 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 5. Apixaban 5 mg PO BID 6. Docusate Sodium 100 mg PO BID 7. LORazepam 1 mg PO QHS:PRN insomnia 8. Mirtazapine 15 mg PO QHS 9. Nystatin Oral Suspension 5 mL PO QID 10. Polyethylene Glycol 17 g PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY ======= - Klebsiella bacteremia - Sepsis - Duodenal stent obstruction - Transaminitis - Pancreatic adenocarcinoma SECONDARY ========= - Acute anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with new NG// NG placement TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: There are low bilateral lung volumes. The tip of an enteric tube projects over the stomach. A right chest wall Port-A-Cath tip extends to the right atrium. Biliary and duodenal stents project over the upper abdomen. There is no focal consolidation, pleural effusion or pneumothorax. The size of the cardiac silhouette is within normal limits. IMPRESSION: The tip of the nasogastric tube projects over the stomach. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: N/V Diagnosed with Hypovolemia temperature: 99.0 heartrate: 98.0 resprate: nan o2sat: 98.0 sbp: 97.0 dbp: 61.0 level of pain: 0 level of acuity: 3.0

PATIENT SUMMARY ================== Ms. ___ is ___ year old woman with locally advanced, unresectable pancreatic cancer with disease progression s/p 6 cycles of FOLFIRINOX complicated by biliary obstruction s/p biliary stent placement, cholangitis and duodenal obstruction s/p stenting x2 presents with nausea and vomiting, found to have Klebsiella bacteremia and duodenal stent obstruction s/p ERCP and stent cleanout. ACUTE ISSUES ================== #KLEBSIELLA BACTEREMIA #SEPSIS #NAUSEA/VOMITING #TRANSAMINITIS #DUODENAL STENT OBSTRUCTION Patient had a recent admission for duodenal obstruction thought to be due to tumor progression, s/p bare metal stent placement within her prior stent. She re-presented with nausea and vomiting reminiscent of prior obstructions. She was initially hemodynamically unstable at OSH. Reassuringly, her CT abd/pelvis at OSH demonstrated no obstruction and her emesis has been non-bloody, but occasionally blood streaked. OSH blood cultures grew Klebsiella sensitive to amikacin, amp/sul, cefepime, ceftaz, ceftriaxone, cipro, etrapenem, gentamicin, meropenem, pip-tazo, resistant to ampicillin. Possible sources include biliary (although no bili or alk phos elevation) or GI translocation given duodenal stent with recent instrumentation. ___ and ___ blood cultures negative. Started on pip-tazo at the OSH, broadened to vanco/cefepime/metronidazole (___) after transfer to ___. Discontinued vancomycin ___ and transitioned to CTX monotherapy on ___, then PO ciprofloxacin on ___. Endoscopy ___ showed food obstructing duodenal stent, which was successfully removed. ERCP recommended a pureed/soft food diet to reduce risk of stent re-obstruction. Started metoclopramide, dexamethasone 4mg BID, and dronabinol for nausea with good effect. Discharged with plan to continue ciprofloxacin to complete 14 day course of antibiotics (___). #ACUTE ANEMIA #CONCERN FOR UGIB #Hx OF DVT Significant hemoglobin drop since last admission, concerning for upper GI bleed. Initially downtrending, but stabilized. Previously on apixaban for DVT in ___, which was held in the setting of procedures. Started enoxaparin ___ and transitioned back to apixaban at discharge. CHRONIC ISSUES ================ #PANCREATIC CANCER Recent imaging with disease progression. She was seen by her outpatient oncologist Dr. ___ with plans to return to clinic on ___ for chemotherapy. #MALNUTRITION: Continued home mirtazapine. TRANSITIONAL ISSUES ===================== [] Repeat CBC after completion of ciprofloxacin (___nding ___. [] Chemotherapy - discharged with appointment to resume chemotherapy with FOLFIRI in clinic on ___. [] Patient discharged on pureed/soft food diet to minimize risk of duodenal stent obstruction per ERCP, f/u nutrition. #HCP/CONTACT: Name of health care proxy: ___ ___: husband Phone number: ___ Cell phone: ___ #CODE STATUS: Full - presumed

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: bacitracin / latex / terbinafine Attending: ___ Chief Complaint: Dyspnea/Cough Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is an ___ yo M with asthma, multiple pulmonary nodules, neurogenic bladder, who was discharged ___ after 6 day hospitalization for asthma exacerbation and bronchitis, who presents today with cough and shortness of breath. Mr. ___ was hospitalized ___ for productive cough, dyspnea, and fever, and was treated for bronchitis and asthma with azithromycin and prednisone. His course was notable for diffuse wheezing with O2 sat to 80%, normal WBC, negative legionella, untreated asymptomatic bacteriuria, and CXR with no infiltrate, CT chest demonstrating bronchitis and mucous plugging and possible COPD. He was discharged on ___ with prednisone taper (on 40) and new advair, with good oxygen saturations on room air at rest and with ambulation. Last night, Mr. ___ had 2 episodes of chest congestion and mild SOB, which were relieved by albuterol. Then, he woke up this morning, and noted more SOB, which partially responded to albuterol inhaler. Then, he began to feel dizzy and confused, so he called EMS and was taken to OSH. At OSH, he had O2 sats to the ___. He had labs notable for a leukocytosis to 11.5 and CXR demonstrating new retrocardiac opacity. He received albuterol nebulizers and vanc/cefepime for presumed pneumonia. Patient was then transferred to ___. Mr. ___ endorses cough productive of yellow sputum w no hemoptysis. He denies any fevers, chills, night sweats, rhinorrhea, sore throat, chest pain, n/v, dysuria/hematuria, joint pains, muscle aches. With respect to his asthma, Mr. ___ has about ___ exacerbations yearly, usually iso URI. He has been hospitalized once for asthma. - In the ED, initial vitals were: T 97.4 HR 124--> 74 BP 142/81--> 134/73 RR ___ O2 sat 93-94% on RA-2L - Exam was notable for: Mild wheezing - Labs were notable for: - CBC with WBC 11.9 w 85% PMNs, H/H 11.7/36.4; BMP wnl; UA w 11 WBCs and no bacteria - UCx pending - Negative Flu A and B PCR - Studies were notable for: - CT chest showing increased posterior basal opacities likely representing a combination of atelectasis and developing pneumonia. - The patient was given: - LR infusion - Cefepime 2g IV - Duoneb (last at 1:45pm) - Prednisone 30 mg PO On arrival to the floor, Mr. ___ is stable and breathing well on 2L. He reports feeling comfortable. REVIEW OF SYSTEMS: ================== Per HPI, otherwise, negative for abdominal pain, diarrhea, melena, hematochezia. Past Medical History: Asthma Neurogenic bladder Sciatica Thyroid nodule Pulmonary nodules BCC History of TIA at age ___ Bilateral hip replacement Social History: ___ Family History: Son - asthma Physical ___: ADMISSION PHYSICAL EXAM: ======================== VITALS: ___ 1516 Temp: 97.7 PO BP: 128/77 HR: 82 RR: 18 O2 sat: 91% O2 delivery: Ra GENERAL: Laying in hospital bed, alert and interactive. Comfortable. HEENT: PERRL. MMM. OP w/o erythema, exudate, or lesions. NECK: No cervical lymphadenopathy. CARDIAC: Regular rhythm, normal rate. ___ systolic murmur best appreciated at cardiac apex. No rubs/gallops. LUNGS: Breathing comfortably on 2L. Lungs with minimal expiratory wheeze and crackles in left lower lung field, right lower lung field, and right middle lobe lung field. BACK: No CVA tenderness. ABDOMEN: Soft, non-tender, non-distended. EXTREMITIES: Warm and well-perfused, no cyanosis. No edema. 2+ DPs bilaterally. NEUROLOGIC: Awake and alert. CN2-12 grossly intact. Moving all 4 limbs spontaneously. DISCHARGE PHYSICAL EXAM: =========================== 24 HR Data (last updated ___ @ 2328) Temp: 98.4 (Tm 98.7), BP: 116/82 (100-197/51-82), HR: 76 (76-96), RR: 18 (___), O2 sat: 92% (91-95), O2 delivery: Ra GENERAL: Sitting up in chair in NAD. Comfortable. CARDIAC: Regular rhythm, normal rate. ___ systolic murmur best appreciated at cardiac apex. No rubs/gallops. LUNGS: Breathing comfortably on RA. CTA b/l. Decreased bibasilar breath sounds ABDOMEN: Soft, non-tender, non-distended. EXTREMITIES: Warm and well-perfused, no cyanosis. No edema. 2+ DPs bilaterally. NEUROLOGIC: No focal deficits. Pt is alert and conversational sitting upright in bedside chair moving all four extremities with purpose. Pertinent Results: ADMISSION LABS: ================== ___ 07:04AM BLOOD WBC-13.3* RBC-4.08* Hgb-12.1* Hct-37.3* MCV-91 MCH-29.7 MCHC-32.4 RDW-12.6 RDWSD-42.2 Plt ___ ___ 01:30PM BLOOD Neuts-85* Bands-1 Lymphs-5* Monos-2* Eos-0* ___ Metas-5* Myelos-2* AbsNeut-10.23* AbsLymp-0.60* AbsMono-0.24 AbsEos-0.00* AbsBaso-0.00* ___ 07:04AM BLOOD Plt ___ ___ 07:04AM BLOOD Plt ___ ___ 07:04AM BLOOD Glucose-88 UreaN-12 Creat-0.8 Na-141 K-4.1 Cl-101 HCO3-26 AnGap-14 ___ 07:04AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.1 KEY INTERVAL LABS: ================== ___ 05:30AM BLOOD CK-MB-5 cTropnT-<0.01 MICROBIOLOGY: =============== ___ Urine Culture: URINE CULTURE (Final ___: NO GROWTH. ___ MRSA Nasal: No MRSA isolated. ___ Urine Legionella: Negative ___: S. PNEUMONIAE ANTIGENS, Not Detected URINE ___ Expectorated Sputum: GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. 2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS. RESPIRATORY CULTURE (Preliminary): SPARSE GROWTH Commensal Respiratory Flora. GRAM NEGATIVE ROD(S). SPARSE GROWTH. GRAM NEGATIVE ROD #2. SPARSE GROWTH. KEY IMAGING: ============ ___ CT Chest w/o Contrast: Diffuse bronchial wall thickening with increased posterior basal opacities likely representing a combination of atelectasis and developing pneumonia. Mild mucous plugging in the lower lobes. Small volume aerosolized material in the lower trachea and bilateral mainstem bronchi. A hypodensity within segment 2 of the liver is again noted likely a cyst, measuring 19 x 22 mm. ___ CTA Chest: 1. No pulmonary embolism or signs of right heart strain. 2. Diffuse bronchial wall thickening and increased mucous plugging in the lower lobes with associated posterior basal opacities likely combination of atelectasis and aspiration pneumonitis. DISCHARGE LABS: ================ ___ 07:15AM BLOOD WBC-12.3* RBC-3.89* Hgb-11.8* Hct-35.7* MCV-92 MCH-30.3 MCHC-33.1 RDW-12.9 RDWSD-42.3 Plt ___ ___ 07:15AM BLOOD Plt ___ ___ 07:15AM BLOOD Glucose-100 UreaN-16 Creat-0.9 Na-143 K-3.9 Cl-106 HCO3-22 AnGap-15 ___ 07:15AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.2 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath 3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 4. GuaiFENesin ER 1200 mg PO Q12H 5. Sodium Chloride 3% Inhalation Soln 15 mL NEB ONCE MR1 6. Polyethylene Glycol 17 g PO DAILY 7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing 8. PredniSONE 40 mg PO DAILY Tapered dose - DOWN 9. PredniSONE 30 mg PO DAILY Tapered dose - DOWN 10. PredniSONE 20 mg PO DAILY Tapered dose - DOWN 11. PredniSONE 10 mg PO DAILY Tapered dose - DOWN 12. Omeprazole 40 mg PO DAILY 13. Terazosin 5 mg PO BID Discharge Medications: 1. LevoFLOXacin 750 mg PO DAILY Duration: 3 Days Last day ___ RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*3 Tablet Refills:*0 2. PredniSONE 30 mg PO DAILY Take one dose ___, then continue with 20mg taper on ___ Tapered dose - DOWN 3. Sodium Chloride 3% Inhalation Soln 15 mL NEB BID:PRN wheezing 4. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath 5. Aspirin 81 mg PO DAILY 6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 7. GuaiFENesin ER 1200 mg PO Q12H 8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing 9. Omeprazole 40 mg PO DAILY 10. Polyethylene Glycol 17 g PO DAILY 11. PredniSONE 10 mg PO DAILY Duration: 3 Days First day ___ Tapered dose - DOWN 12. PredniSONE 20 mg PO DAILY Duration: 3 Days First day ___ Tapered dose - DOWN 13. Terazosin 5 mg PO BID 14.Nebulizer Machine Asthma ICD-___: ___ Discharge Disposition: Home Discharge Diagnosis: Hospital Acquired Pneumonia Asthma Presyncope Asymptomatic Bacteriuria Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: Noncontrast chest CT INDICATION: ___ with cough, ?retrocardiac opacity// ?PNA TECHNIQUE: Multidetector scanning of the chest was performed and reconstructed as contiguous 5- and 1.25-mm thick axial, 2.5-mm thick coronal and sagittal, and 8 x 8 mm MIPs axial images. No IV Contrast administered. DOSE Total DLP (Body) = 538 mGy-cm. COMPARISON: Prior from ___ FINDINGS: The imaged base of neck including the partially visualized thyroid is unremarkable. Thoracic aorta is mildly calcified though normal in course and caliber. There is aortic valvular calcification and mild coronary artery calcification. The heart is within normal limits of size. No pericardial effusion is seen. There is a small hiatal hernia. The main pulmonary artery is normal in caliber. There is no mediastinal, axillary adenopathy. Secretions are noted along the dependent wall of the lower trachea extending partially into the left and right mainstem bronchi. Bronchial wall thickening is noted diffusely concerning for airways inflammation. In addition, there is posterior basal opacity which is increased slightly from prior likely representing a combination of atelectasis and developing pneumonia. There is mild mucous plugging in the lower lobes. No worrisome nodule or mass is seen. Biapical pleuroparenchymal scarring is again noted. Motion artifact somewhat limits evaluation of the lungs. In the imaged upper abdomen, no worrisome findings. A hypodensity within segment 2 of the liver is again noted likely a cyst, measuring 19 x 22 mm. Also noted is colonic diverticulosis. Bones: No worrisome lytic or blastic osseous lesion. IMPRESSION: Diffuse bronchial wall thickening with increased posterior basal opacities likely representing a combination of atelectasis and developing pneumonia. Mild mucous plugging in the lower lobes. Small volume aerosolized material in the lower trachea and bilateral mainstem bronchi. Radiology Report EXAMINATION: CTA CHEST INDICATION: ___ year old man with asthma, chronic bronchitis, presenting after presyncopal episode in setting of tachycardia, hypoxemia// evaluate for PE 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 2.4 s, 31.9 cm; CTDIvol = 11.2 mGy (Body) DLP = 357.0 mGy-cm. 2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7 mGy-cm. 3) Stationary Acquisition 2.4 s, 0.5 cm; CTDIvol = 13.3 mGy (Body) DLP = 6.6 mGy-cm. Total DLP (Body) = 365 mGy-cm. COMPARISON: Prior Chest CTs most recently dated ___ FINDINGS: NECK, THORACIC INLET, AXILLAE: The visualized thyroid is unremarkable. 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 mild coronary arterial calcification. There is no pericardial effusion. VESSELS: Vascular configuration is conventional. Aortic caliber is normal. There are no filling defects within the pulmonary arteries. The main pulmonary arteries not enlarged. PULMONARY PARENCHYMA and AIRWAYS: There is bronchial wall thickening, unchanged since the scan performed 2 days ago. Posterior basal opacities are not significantly changed. Mucous plugging is again seen in the lower lobes and is increased. Dependent secretions are seen in the trachea and mainstem bronchi. There is no worrisome nodule or mass. Biapical pleuroparenchymal scarring is again noted. PLEURA: There is no pleural effusion or pneumothorax. CHEST WALL AND BONES: There is no worrisome lytic or sclerotic lesion. Multilevel degenerative changes are present. UPPER ABDOMEN: This study is not tailored for evaluation of the abdomen. Allowing for this, the partially visualized upper abdomen is notable for hepatic hypodensities, likely cysts. A small hiatal hernia is present.. IMPRESSION: 1. No pulmonary embolism or signs of right heart strain. 2. Diffuse bronchial wall thickening and increased mucous plugging in the lower lobes with associated posterior basal opacities likely combination of atelectasis and aspiration pneumonitis. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Dyspnea, Transfer Diagnosed with Pneumonia, unspecified organism temperature: 97.4 heartrate: 124.0 resprate: 18.0 o2sat: 94.0 sbp: 142.0 dbp: 81.0 level of pain: 0 level of acuity: 3.0

TRANSITIONAL ISSUES: ===================== [ ] Repeat Chest CT in 3 months to evaluate small pulmonary nodules, monitor for progression of ___ opacities [ ] Consider follow-up of incidentally found hypodensity within segment 2 of the liver is again noted likely a cyst, measuring 19 x 22 mm, from CT Chest w/o Contrast [ ] To complete Levofloxacin ___ (total 8 day course HAP treatment) [ ] Prednisone taper: 30mg ___ 20mg ___ 10mg ___ [ ] Repeat CBC in one week to monitor for leukocytosis [ ] f/u final sputum culture speciation [ ] Patient given prescription for nebulizer machine. Recently started on duonebs and saline nebs, as well as Advair. Can consider alternating regimen pending improvement/control of symptoms [ ] Would perform pulmonary function testing in this elderly patient with presumed asthma diagnosis, hypoxemia despite appearing relatively well, with imaging suggestive of chronic bronchitis [ ] Consider Pulmonology referral [ ] Ensure patient using Acapella device Mr. ___ is an ___ yo M with asthma, neurogenic bladder (Self caths at baseline), who was discharged ___ after 6 day hospitalization for asthma exacerbation and bronchitis, who presented with cough and shortness of breath, with CXR and CT showing lower lobe infiltrates, most consistent with pneumonia iso recent asthma exacerbation.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Simvastatin Attending: ___. Chief Complaint: Massive pulmonary embolism Major Surgical or Invasive Procedure: None History of Present Illness: ___ male w/ h/o NIDDM2, HTN, CKD admitted for massive pulmonary embolism. Patient notes new dyspnea on exertion, beginning one week ago. He explains dyspnea has progressively worsened, requiring less exertion to stimulate discomfort. Reportedly, HR 100 at rest -> 140 when ambulating short distance. He endorses associated lightheadedness and mild chest tightness, but otherwise denies frank chest pain, palpitations or lower extremity pain. Patient, moreover, denies prior history VTE, recent hospitalization or immobility, surgery within three months, active malignancy, steroid or testosterone use. Bedside V-scan without focal WMA, but notable for septal flattening and (?) ___ sign. Bedside LENIS revealed left femoral-popliteal DVT. CT-PE was obtained, which demonstrated massive pulmonary embolism involving the distal right and left main pulmonary arteries with extension into multiple distal branches bilaterally with a thin connecting thrombus crossing the midline. There was also prominence of the right ventricle with flattening of the interventricular septum. MASCOT recommended heparin bolus and gtt were accordingly initiated. Vitals on transfer: T 98.2, HR 77, BP 129/73, RR 20, O2 95% RA On arrival to the CCU: patient comfortably ambulated to bed. Corroborated aforementioned history. Denies shortness of breath at rest. Minor left calf tenderness. Uncertain if any change in symptomatology since arrival to emergency department. Last prolonged travel to ___ (estimated 2-hour flight) in ___. Previously, flew to ___ in ___. No fatigue, weight changes, anorexia in prior months. Past Medical History: PAST MEDICAL HISTORY: -NIDDM2 -Hypertension -Hyperlipidemia -Nephrolithiasis -CKD ___ hypertensive/diabetic nephropathy and NSAID use -Gout Social History: ___ Family History: FAMILY HISTORY: no history of bleeding/thrombotic disorders. -Maternal h/o CHF, atrial fibrillation -Paternal h/o IPF -Sororal h/o breast cancer -Otherwise, no familial bleeding/thrombotic disorders Physical Exam: Admission Physical Exam: ======================== PHYSICAL EXAMINATION: VS T 98.2, HR 76, BP 131/89, RR 14, O2 95% GEN: NAD, sitting in bed HEENT: PEERL, EOMI, anicteric sclerae, no conjunctival pallor, MMM NECK: supple, no JVD, no LAD CV: RRR, S1/S2, no m/r/g PULM: unlabored, CTAB GI: soft, non-distended, non-tender, normoactive BS, no organomegaly GU: no Foley EXT: warm, pulses palpable and symmetric, non-edematous, minor tenderness in left calf Discharge Exam: --------------- PHYSICAL EXAMINATION: VS Reviewed in OMR GEN: Patient appears to be a well nourished male laying in bed in no pain or distress HEENT: EOM grossly intact, anicteric sclerae, no conjunctival pallor, MMM NECK: supple, no JVD appreciated on exam CV: RRR, S1/S2, no m/r/g PULM: unlabored, CTAB GI: soft, non-distended, non-tender, normoactive BS, no organomegaly GU: no Foley EXT: warm, pulses palpable and symmetric, non-edematous, no tenderness in the calf bilaterally Pertinent Results: Admission Labs: =============== ___ 10:30PM URINE HOURS-RANDOM ___ 10:30PM URINE UHOLD-HOLD ___ 10:30PM URINE UHOLD-HOLD ___ 10:30PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-30* GLUCOSE-TR* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 10:30PM URINE RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE EPI-0 ___ 10:30PM URINE HYALINE-1* ___ 10:30PM URINE MUCOUS-RARE* ___ 07:54PM GLUCOSE-198* UREA N-30* CREAT-1.8* SODIUM-139 POTASSIUM-4.8 CHLORIDE-100 TOTAL CO2-20* ANION GAP-19* ___ 07:54PM estGFR-Using this ___ 07:54PM cTropnT-0.02* ___ 07:54PM CK-MB-4 proBNP-5224* ___ 07:54PM WBC-8.7 RBC-4.70 HGB-13.9 HCT-43.3 MCV-92 MCH-29.6 MCHC-32.1 RDW-13.0 RDWSD-43.4 ___ 07:54PM NEUTS-67.5 ___ MONOS-8.8 EOS-0.8* BASOS-0.3 IM ___ AbsNeut-5.88# AbsLymp-1.92 AbsMono-0.77 AbsEos-0.07 AbsBaso-0.03 ___ 07:54PM NEUTS-67.5 ___ MONOS-8.8 EOS-0.8* BASOS-0.3 IM ___ AbsNeut-5.88# AbsLymp-1.92 AbsMono-0.77 AbsEos-0.07 AbsBaso-0.03 Imaging: ========== ECHO ___ The left atrial volume index is normal. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF = 45 %) secondary to direct ventricular interaction. The right ventricular free wall thickness is normal. The right ventricular cavity is mildly dilated with severe global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. CTA CHEST: IMPRESSION: 1. Massive pulmonary embolism involving the distal right and left main pulmonary arteries, with extension into multiple distal branches bilaterally, and a thin thrombus crossing the midline. 2. Prominence of the right ventricle, with some flattening of the interventricular septum is concerning for right heart strain. Recommend clinical correlation, and further evaluation with EKG and echocardiography as indicated. 3. Small hypodense nodules in the lower pole of the right thyroid, measuring up to 6 mm, may be further evaluated with nonemergent thyroid ultrasound. Bilateral Lower Ext: Vein US: IMPRESSION: 1. DVT involving the left superficial femoral, left popliteal, and left posterior tibial veins. 2. No DVT in the right lower extremity veins. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 2:23 pm, 2 minutes after discovery of the findings. Discharge Labs: =============== ___ 06:45AM BLOOD WBC-6.2 RBC-3.91* Hgb-12.0* Hct-35.5* MCV-91 MCH-30.7 MCHC-33.8 RDW-12.8 RDWSD-41.5 Plt ___ ___ 06:45AM BLOOD Plt ___ ___ 06:45AM BLOOD Glucose-155* UreaN-26* Creat-1.5* Na-140 K-4.5 Cl-103 HCO3-20* AnGap-17* ___ 06:45AM BLOOD Calcium-8.7 Phos-4.4 Mg-1.9 Micro Data: ============ ___ 10:30 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: < 10,000 CFU/mL. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. GlipiZIDE XL 5 mg PO DAILY 2. Lisinopril 5 mg PO DAILY 3. MetFORMIN (Glucophage) 1000 mg PO BID 4. Rosuvastatin Calcium 20 mg PO QPM 5. Aspirin 81 mg PO DAILY Discharge Medications: 1. Rivaroxaban 15 mg PO BID RX *rivaroxaban [___] 15 mg (42)- 20 mg (9) 15 mg by mouth twice daily for 21 days then 20mg daily after that Disp #*1 Dose Pack Refills:*0 2. Aspirin 81 mg PO DAILY 3. GlipiZIDE XL 5 mg PO DAILY 4. MetFORMIN (Glucophage) 1000 mg PO BID 5. Rosuvastatin Calcium 20 mg PO QPM 6. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do not restart Lisinopril until you are instructed by your primary care physician to restart it. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: #Sub-massive bilateral acute pulmonary embolism #Acute Renal Failure Secondary Diagnosis: # Left Leg Deep Venous Thrombosis # Non Insulin Dependent Diabetes # Thyroid Nodule # Hypertension 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 dyspnea// ?pneumonia, fluid TECHNIQUE: Chest PA and lateral COMPARISON: None. FINDINGS: Heart size is normal. Mediastinal and hilar contours are within normal limits. The pulmonary vasculature is normal. Lungs are clear. No pleural effusion or pneumothorax is present. No acute osseous abnormalities are visualized. IMPRESSION: No acute cardiopulmonary abnormality. Radiology Report EXAMINATION: CTA CHEST WITH CONTRAST INDICATION: History: ___ with type II DM with dyspnea on exertion// ?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, 0.5 cm; CTDIvol = 2.4 mGy (Body) DLP = 1.2 mGy-cm. 2) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 14.4 mGy (Body) DLP = 7.2 mGy-cm. 3) Spiral Acquisition 4.8 s, 37.8 cm; CTDIvol = 19.7 mGy (Body) DLP = 743.4 mGy-cm. Total DLP (Body) = 752 mGy-cm. COMPARISON: None FINDINGS: HEART AND VASCULATURE: There is massive pulmonary embolism involving the distal right and left main pulmonary arteries, with extension into multiple distal branches bilaterally. A connecting thrombus is noted crossing the midline, connecting the two main areas of thrombus in the left and right main pulmonary arteries. There is prominence of the right ventricle, with some flattening of the interventricular septum. The thoracic aorta is normal in caliber without evidence of dissection or intramural hematoma. The heart and pericardium are within normal limits. No pericardial effusion is seen. AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar lymphadenopathy is present. No mediastinal mass. PLEURAL SPACES: No pleural effusion or pneumothorax. LUNGS/AIRWAYS: Dependent atelectasis is noted. No focal consolidations or suspicious pulmonary masses are seen. The airways are patent to the level of the segmental bronchi bilaterally. BASE OF NECK: Small hypodense nodules measuring up to 6 mm are seen in the lower pole of the right thyroid lobe. ABDOMEN: Included portion of the upper abdomen is notable for a small hiatal hernia. BONES: No suspicious osseous abnormality is seen.? There is no acute fracture. IMPRESSION: 1. Massive pulmonary embolism involving the distal right and left main pulmonary arteries, with extension into multiple distal branches bilaterally, and a thin thrombus crossing the midline. 2. Prominence of the right ventricle, with some flattening of the interventricular septum is concerning for right heart strain. Recommend clinical correlation, and further evaluation with EKG and echocardiography as indicated. 3. Small hypodense nodules in the lower pole of the right thyroid, measuring up to 6 mm, may be further evaluated with nonemergent thyroid ultrasound. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 3:30 am, 2 minutes after discovery of the findings. Radiology Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ male admitted for massive pulmonary embolism.// Evaluate for lower extremity 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 right common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the right posterior tibial and peroneal veins. Deep venous thrombus is seen in the left superficial femoral vein, extending to the popliteal vein and into one of the left posterior tibial veins in the calf. Normal compressibility and flow are demonstrated in the left common femoral vein and proximal left superficial femoral vein. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: 1. DVT involving the left superficial femoral, left popliteal, and left posterior tibial veins. 2. No DVT in the right lower extremity veins. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 2:23 pm, 2 minutes after discovery of the findings. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Dyspnea Diagnosed with Chest pain, unspecified, Other pulmonary embolism without acute cor pulmonale temperature: 97.0 heartrate: 100.0 resprate: 20.0 o2sat: 95.0 sbp: 133.0 dbp: 80.0 level of pain: 2 level of acuity: 3.0

Information for Outpatient Providers: ___ ======== Mr. ___ is a ___ male w/ h/o NIDDM2, HTN, CKD p/w progressive dyspnea on exertion with tachycardia found to have massive pulmonary embolism with RV strain; hemodynamically stable without respiratory distress. The patient was anti-coagulated with heparin and observed in the CCU. He also had bilateral lower extremity ultrasounds performed which showed a right sided DVT extending up into the popliteal vein. His oxygen requirement was weaned to room air by discharge and he was discharged on rivaroxaban. A hypercoagulable work up is planned as an outpatient as this was an unprovoked PE and DVT. #) CORONARIES: unknown #) PUMP: no focal WMA; septal flattening #) RHYTHM: NSR #)Acute Bilateral Pulmonary Embolism: Patient presented to the hospital with worsening shortness of breath and was found to have massive/submassive bilateral distal PA w/ thin midline thrombus + left fem-pop DVT by bedside U/S. Some right-side strain, as evidenced by septal flattening and elevated NTproBNP, albeit unremarkable exam. IVC VTE seemingly unprovoked. Age-appropriate cancer screening unremarkable. We deferred the thrombophilia work-up to the outpatient setting. He also had an EHCO which showed abnormal septal motion/position consistent with right ventricular pressure/volume overload. #Left Lower Extremity DVT: The patient had bilateral lower extremity ultrasounds done which demonstrated a DVT in the left superficial femoral, left popliteal, and left posterior tibial veins. He was treated as his PE above with heparin and then discharged on rivaroxaban. #) ___ on CKD: Cr 1.8 (baseline Cr 1.4) ___ diabetic/hypertensive nephropathy and NSAID use. Pre- and post-contrast hydration accordingly administered for CTA chest. Suspect pre-renal in the context of suboptimal hydration. We monitor for CIN with daily labs. On the day of discharge his Cr. was 1.5. #) NIDDM2: HgbA1C 7.4% (___). Glipizide XL 5 mg, metformin 1000 mg BID. He was on a sliding scale for insulin. #) HTN: normotensive, but hold home lisinopril 5 mg, given ___. #) Thyroid nodules: incidental, measuring up to 6 mm, as above.

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: Newly diagnosed interstitial ectopic pregnancy Major Surgical or Invasive Procedure: Inter-gestational sac methotrexate administration History of Present Illness: Ms. ___ is a ___ G2P1001 at 6w3d by ___ trimester US who presents for evaluation of newly diagnosed interstitial ectopic pregnancy. Pt states that she has been taking OCPs with regular periods approximately every ___ days with ___leeding. Her LMP was around ___. She reports that she started feeling nauseous with breast tenderness around that time and finally took a pregnancy test 1 week ago which returned positive. She presented to ___ for her initial OB visit on ___ and was diagnosed with a L interstitial ectopic pregnancy by US. MFM at ___ was consulted regarding management and she was recommended for evaluation in the ED with likely plan for admission to the GYN service for further management. On exam here, pt denies any abdominal pain or vaginal bleeding. She denies any chest pain, shortness of breath, dizziness or lightheadedness. Past Medical History: OBHx: - SVD x 1 3799g (___), c/b retained POCs requiring D&C and transfusion GYNHx: - Was on OCPs (Reclipsen) when she conceived - reports remote h/o abnormal pap, with normal follow up; last pap ___ wnl - denies h/o STIs, including GC/CT/HSV MedHx: - ?cHTN (multiple elevated BPs in office >140/90) - ?migraine headaches w/ aura, last episode approximately ___ year ago - ADD, discontinued Adderall - Raynaud's disease - h/o H. pylori, s/p EGD x 2, no h/o PUD SurgHx: - D&C Pertinent Results: ___ PUS ___ IMPRESSION: 1. Left-sided interstitial ectopic pregnancy with a single live embryo identified with a crown-rump length of 8.5 mm representing a gestational age of 6 weeks and 6 days. 2. No evidence of an intrauterine gestational sac. The uterus is otherwise normal. 3. The ovaries are normal. No free fluid. ___ 01:15PM BLOOD WBC-5.1 RBC-3.99 Hgb-12.0 Hct-37.6 MCV-94 MCH-30.1 MCHC-31.9* RDW-13.1 RDWSD-45.3 Plt ___ ___ 01:15PM BLOOD ALT-64* AST-25 TotBili-0.6 DirBili-<0.2 IndBili-0.6 ___ 08:45AM BLOOD ALT-64* AST-38 TotBili-0.3 DirBili-<0.2 IndBili-0.3 ___ 11:48AM BLOOD ALT-16 AST-12 ___ 02:00PM BLOOD ALT-22 AST-14 LD(LDH)-150 AlkPhos-75 TotBili-0.4 ___ 01:15PM BLOOD ___ ___ 08:45AM BLOOD ___ ___ 11:48AM BLOOD ___ ___ 02:00PM BLOOD ___ Medications on Admission: PNV Discharge Medications: 1. Leucovorin Calcium 10 mg PO ONCE Duration: 1 Dose RX *leucovorin calcium 10 mg 1 tablet(s) by mouth once Disp #*1 Tablet Refills:*0 2. Ondansetron 4 mg PO Q8H:PRN nausea RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*8 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Interstitial ectopic pregnancy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: TV OB US INDICATION: ___ with OSH ultrasound c/f interstitial pregnancy// assess for interstitial pregnancy LMP: Unsure TECHNIQUE: Transabdominal and transvaginal examinations were performed. Transvaginal exam was performed for better visualization of the embryo. COMPARISON: None. FINDINGS: There is a gestational sac identified at the periphery of the uterus on the left at fundus without visible surrounding myometrium, compatible with a left-sided interstitial ectopic pregnancy. The gestational sac contains a single live embryo with a crown-rump length of 8.5 mm representing a gestational age of 6 weeks and 6 days. Fetal heart motion is detected at 132 beats per minute. No evidence of an intrauterine gestational sac. The uterus is otherwise normal. The ovaries are normal. There is no free fluid. IMPRESSION: 1. Left-sided interstitial ectopic pregnancy with a single live embryo identified with a crown-rump length of 8.5 mm representing a gestational age of 6 weeks and 6 days. 2. No evidence of an intrauterine gestational sac. The uterus is otherwise normal. 3. The ovaries are normal. No free fluid. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 3:20 pm, 5 minutes after discovery of the findings. Radiology Report INDICATION: ___ G2P1 at 6w4d with L interstitial ectopic pregnancy// intra-sac ultrasound guided MTX TECHNIQUE: Ultrasound guided methotrexate injection COMPARISON: ULTRASOUND EXAMINATION ___ FINDINGS: Limited grayscale ultrasound imaging of the abdomen demonstrated a left sided ectopic interstitial pregnancy unchanged from prior study. PROCEDURE: The procedure, risks, benefits and alternatives were discussed with the patient and written informed consent was obtained. The procedure was requested by the OB GYN service specifically as an alternative to surgery to preserve fertility. 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. 18 gauge spinal needle was advanced into the gestational sac and 2 cc of fluid were aspirated. 25 mg of methotrexate were then injected. The patient tolerated the procedure satisfactorily without immediate complication. Estimated blood loss was minimal. Dr. ___ performed the procedure in consultation with Dr. ___ ___ and a member of the GYN team present. IMPRESSION: 1. Ultrasound-guided methotrexate injection into left interstitial ectopic pregnancy Radiology Report EXAMINATION: PELVIS, NON-OBSTETRIC INDICATION: ___ yo G2P1 with L interstitial ectopic pregnancy, on multi-dose methotrexate regimen // eval ectopic pregnancy 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: Ultrasound ___ ultrasound ___ FINDINGS: The uterus is anteverted and measures 9.6 x 4.8 x 7.8 cm. A left-sided ectopic, interstitial pregnancy is once again demonstrated however, the previously described embryonic pole and cardiac activity is no longer evident. Arterial and venous flow is demonstrated in conjunction with the gestational sac consistent with vascularized retained products of conception. Overall, the sac size has increased now measuring 4.5 x 3.4 x 3.8 cm, previously 3.6 x 3.4 x 3.7 cm. The ovaries are normal. There is no free fluid. IMPRESSION: Persistent vascularized gestational sac consistent with the known left-sided ectopic, interstitial pregnancy. Slightly increased in size when compared to prior examination however, with the previously described embryonic pole and cardiac activity no longer seen. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___ on the telephone on ___ at 9:58 am, 10 minutes after discovery of the findings. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Pregnant Diagnosed with Other ectopic pregnancy without intrauterine pregnancy temperature: 97.0 heartrate: 99.0 resprate: 18.0 o2sat: 100.0 sbp: 168.0 dbp: 84.0 level of pain: 0 level of acuity: 3.0

Ms. ___ was admitted to the gynecology team for management of her interstitial ectopic pregnancy. Discussed the management options of interstitial ectopic pregnancy, including IM MTX w/ intrasac MTX, vs. surgical management which involves a wedge resection of the cornua, with increased risk of hemorrhage and possible need for hysterectomy. The patient was hemodynamically stable, no abdominal pain or tenderness with unremarkable bimanual exam, and there was no indication for urgent surgical intervention. She received multi-dose methotrexate therapy with leucovorin rescue per ___ protocol. She also underwent an intra-gestational sac methotrexate injection on ___. Over the course of her treatment, her b-HCG failed to decline appropriately. She underwent a transvaginal ultrasound on ___, and it was determined that she did not need uterine artery embolization. She was discharged home with a plan for close follow up 2 and 5 days post-discharge, and b-HCG trending on ___ (day #14 of therapy) to discuss the plan going forwards.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Right knee pain and swelling Major Surgical or Invasive Procedure: Joint aspiration ___ History of Present Illness: Mr. ___ is a ___ year old male with a history of knee dislocation 2 weeks ago managed by Orthopedics at ___ who presents with right knee redness and swelling. Patient states that his knee swelling and redness is not any worse than it has been but his physical therapist recommended to be re-evaluated because his knee was not getting any better. He states he has been able to ambulate and place weight on his knee. He denies any fever, chills, nausea, vomiting, shortness of breath, chest pain. He received ancef at ___, and per the ortho note at ___ felt this likely represents multiple ligamentous injuries with possible infection and needs to be transferred back to ___ to be seen by knee specialist. Also of note, the patient states he drinks a bottle of wine per day, last drink at 10PM last night. He denies any prior withdrawal seizure but does say that he had one admission for alcohol withdrawal in the past. Also of note, the patient was recently admitted from ___ through ___ for ___ after his initial fall that led to his right knee dislocation. He apparently fell down a flight of stairs and landed on his right side on a concrete landing. He had a trauma evaluation that was negative at that time other than his right knee and right shoulder dislocations. Orthopedic surgery consulted and reduced both dislocations at the bedside. He also had mild rhabdomyolysis with a CK of 5000s and received IV fluids with improvement. That hospital stay was complicated by alcohol withdrawal. In the ED: - Initial vital signs were notable for: Temp 99.1 HR 108 BP 143/80 RR 18 02 94% RA - Exam notable for: Constitutional: In no acute distress HEENT: Normocephalic, atraumatic, pupils equal, round, reactive to light, EOMI Resp: Normal work of breathing, symmetric chest expansion, CTABL CV: Regular rate and rhythm, no rubs murmurs or gallops GI: Soft, nontender, nondistended, no rebound or guarding MSK: Swelling over right knee, scab intact, no drainages, right knee erythematous and tender to palpation, warm to touch, limited flexion. Psych: Normal mood, normal mentation - Labs were notable for: CBC; WBC 10.16 HR 11.8 Plt 549 BMP: Na 140 K 4.6 Cl 97 HC03 29 BUN 7 Cr. 0.69 COAGS:INR: 1.2 ___: 14.0 PTT: 27.9 - Studies performed include: Right Knee X-ray: ----------------- IMPRESSION: Mild prepatellar soft tissue swelling and small joint effusion. No fracture or dislocation. - Patient was given: > cefazolin 2 gram > doxycycline 100mg - Consults: ------------ Orthopedics: - labs: inflammatory markers WBC, CRP - Compression wrap Right knee - elevation and ice Right knee - antibiotics - overnight obs - close Sports Med follow up as scheduled Vitals on transfer: HR 96 BP 130/91 RR 18 96% RA Upon arrival to the floor, the patient said his that his right knee is painful overall but not much more than it is been lately. He also denies any new fevers or chills, cough, dysuria or frequency. Past Medical History: -Alcohol use disorder (prior DTs and seizures from alcohol withdrawal) -Hyperlipidemia Social History: ___ Family History: Both parents died from heart failure. No substance use history. Physical Exam: ADMISSION PHYSICAL EXAM: ___ 2346 Temp: 98.8 PO BP: 150/91 L Lying HR: 103 RR: 20 O2 sat: 94% O2 delivery: RA GENERAL: Overweight middle-aged appearing male lying in bed resting with headphones on awakes to my presence otherwise no pain or distress EYES: NCAT. PERRL Sclera anicteric and without injection. ENT: Moist mucous membranes. No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. MSK: Right knee is warm to the touch with large effusion that is mostly anterior with ballotable area on palpation anteriorly at the patellar area and medial to the patella, erythematous compared to the unaffected side, on the medial aspect of the patellar area there is a 2 cm scab over lesion without drainage SKIN: Warm and erythematous CN2-12 intact. ___ strength throughout. Normal sensation. AOx3. PSYCH: appropriate mood and affect DISCHARGE PHYSICAL EXAM: 24 HR Data (last updated ___ @ 1550) Temp: 98.6 (Tm 98.9), BP: 153/98 (125-170/85-119), HR: 87 (74-99), RR: 18 (___), O2 sat: 96% (95-97), O2 delivery: Ra, Wt: 238 lb/107.96 kg GEN: Well appearing, NAD CVD: RRR, no m/r/g PULM: CTAB ABD: Soft, non tender, non distended EXT: L leg w/ tense swelling over medial aspect of knee, small area of skin breakdown with surrounding erythematous changes Pertinent Results: LABS =============== ___ 06:03AM BLOOD WBC-7.5 RBC-3.37* Hgb-10.7* Hct-33.6* MCV-100* MCH-31.8 MCHC-31.8* RDW-15.8* RDWSD-57.9* Plt ___ ___ 06:03AM BLOOD Neuts-74.1* Lymphs-11.8* Monos-9.5 Eos-1.2 Baso-2.6* Im ___ AbsNeut-5.52 AbsLymp-0.88* AbsMono-0.71 AbsEos-0.09 AbsBaso-0.19* ___ 06:03AM BLOOD ___ PTT-27.2 ___ ___ 06:03AM BLOOD Glucose-104* UreaN-10 Creat-0.8 Na-140 K-4.1 Cl-96 HCO3-26 AnGap-18 ___ 06:03AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.1 ___ 06:03AM BLOOD CRP-48.5* ___ 10:21AM JOINT FLUID TNC-1613* ___ Polys-83* ___ Macro-15 ___ 10:21AM JOINT FLUID Crystal-NONE IMAGING ======== R Knee XR ___ Mild prepatellar soft tissue swelling and small joint effusion. No fracture or dislocation. ___ ___ 1. No evidence of DVT in the right lower extremity. 2. Heterogeneous fluid collection in the area of swelling in the medial right knee consistent with an evolving hematoma in the setting of prior trauma. MICROBIOLOGY ============== ___ 10:21 am JOINT FLUID Source: Knee. GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 2. FoLIC Acid 1 mg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain 5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 6. Senna 8.6 mg PO BID:PRN Constipation - First Line 7. Thiamine 100 mg PO DAILY 8. Simvastatin 40 mg PO QPM Discharge Medications: 1. Cephalexin 500 mg PO Q6H Duration: 6 Days RX *cephalexin 500 mg 1 capsule(s) by mouth every six (6) hours Disp #*24 Capsule Refills:*0 2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 3. FoLIC Acid 1 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain RX *oxycodone 5 mg 1 tablet(s) by mouth Every 4 hours as needed Disp #*10 Capsule Refills:*0 6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 7. Senna 8.6 mg PO BID:PRN Constipation - First Line 8. Simvastatin 40 mg PO QPM 9. Thiamine 100 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Superficial cellulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with right knee dislocation 2 weeks ago, continued swelling and redness// ?osteomyelitis, gas COMPARISON: None FINDINGS: AP, lateral and oblique views of the right knee were provided. There is no acute fracture or dislocation. There is a small joint effusion. No significant DJD. Mild prepatellar soft tissue edema is seen. No soft tissue gas. IMPRESSION: Mild prepatellar soft tissue swelling and small joint effusion. No fracture or dislocation. Radiology Report EXAMINATION: UNILAT LOWER EXT VEINS RIGHT INDICATION: ___ male who presented presently 2 weeks ago to the emergencydepartment and presumed alcohol withdrawal as well as rightshoulder and right patella dislocation which were reduced in the ED and he now presents to check in on right knee swelling.// Right Leg Venous Duplex Extremity Lower Unilateral Order (MAP or DVT). The Question is: Is there a DVT? TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the right lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, color flow, and spectral doppler of the right common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. There is a heterogeneous collection in the area of swelling in the medial right knee most consistent with an evolving hematoma. IMPRESSION: 1. No evidence of DVT in the right lower extremity. 2. Heterogeneous fluid collection in the area of swelling in the medial right knee consistent with an evolving hematoma in the setting of prior trauma. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: R Knee pain Diagnosed with Cellulitis of right lower limb temperature: 99.1 heartrate: 108.0 resprate: 18.0 o2sat: 94.0 sbp: 143.0 dbp: 80.0 level of pain: 8 level of acuity: 3.0

Mr. ___ is a ___ year old male with a history of knee dislocation 2 weeks ago managed by Orthopedics at ___ who presents with right knee redness and swelling. Joint aspirated and not consistent with septic arthritis. Presentation attributed to superficial cellulitis. Patient discharged with oral antibiotics and plans for close follow up.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Dilaudid / fentanyl / morphine / Lanacane Spray Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ w/ PMH cirrhosis, alcohol use disorder c/b chronic pancreatitis, anemia (baseline Hgb 8), cirrhosis, HTN, and GOUT presenting with acute pancreatitis. Patient states that he was in his usual state of health until this past ___, when he ate 1 pound of chocolate and ___ large bags of malted milk balls that he got at an ___ ___ sale. Since then, he has had significant burning epigastric pain which radiates into his back. He states that over the past day, this pain has gotten worse. He says that this may been exacerbated by the fact that he was taking a bowel prep for planned endoscopy and colonoscopy today to workup his chronic anemia. Because of his worsening pain, he presented to ___, where he was found to have an elevated white count and pancreatitis. A CT scan showed no abscess or complicated process occurring within the pancreas. The patient was treated with Zosyn, 2 L IV fluids, and transferred here for further evaluation and management. Mild nausea, no vomiting. No chest pain, no difficulty breathing. Patient otherwise feels well. No fevers, no chills, no weakness, no headache, no visual change, no sore throat, no chest pain, no difficulty breathing, no palpitations, no cough, no nausea, no vomiting, no diarrhea, no hematochezia, no melena, no dysuria, no arthralgias, no rash. Past Medical History: ?Kidney Disease - reports intermittent lab abnormalities with his kidney ?Liver Disease - has had abnormal liver labs ?Cardiac/valvular disease - states had echo ___ years ago, with valve issues and started on metop Pancreatitis HTN Gout Iron Deficiency Anemia Anxiety B/l Hip replacement Social History: ___ Family History: Father - unknown cancer, but aggressive (diagnosis -> death was 10 days) Mother - CHF Physical ___: ADMISSION EXAM: ==================== VITAL SIGNS: ___ 1216 Temp: 100.8 PO BP: 164/87 R Sitting HR: 82 RR: 18 O2 sat: 97% O2 delivery: Ra GENERAL: NAD. Lying comfortably in bed eating shaved ice. HEENT: Sclera icteric. EOMI. NECK: Supple. No JVD. CARDIAC: ___ systolic murmur heard best @ ___. Radiates to carotids. RRR. No other MRG. LUNGS: Diffusely ronchorous with mild wheezes throughout. ABDOMEN: + BS. Soft. TTP in epigastrum. No organomegaly. EXTREMITIES: WWP. NEUROLOGIC: CNII-XII intact. Moves all extremities. DISCHARGE EXAM: ================ Vitals: ___ Temp: 98.5 PO BP: 153/82 L Lying HR: 73 RR: 18 O2 sat: 97% O2 delivery: Ra HEENT: Sclera icteric. EOMI. NECK: Supple. No JVD. CARDIAC: ___ systolic murmur heard best @ ___. Radiates to carotids. RRR. No other MRG. LUNGS: clear to auscultation w/ only fiant wheeze ABDOMEN: + BS. Soft. Minimal TTP in epigastrum. No guarding or rebound. No organomegaly. EXTREMITIES: WWP. NEUROLOGIC: CNII-XII intact. Moves all extremities. Pertinent Results: ADMISSION LABS ==================== ___ 09:15PM BLOOD WBC-22.5* RBC-2.40* Hgb-7.5* Hct-23.7* MCV-99* MCH-31.3 MCHC-31.6* RDW-15.4 RDWSD-54.6* Plt ___ ___ 09:15PM BLOOD Glucose-139* UreaN-12 Creat-0.9 Na-139 K-4.2 Cl-105 HCO3-23 AnGap-11 ___ 09:15PM BLOOD ALT-27 AST-23 AlkPhos-231* Amylase-68 TotBili-1.1 ___ 09:15PM BLOOD Lipase-94* ___ 09:15PM RET AUT-1.9 ABS RET-0.05 ___ 09:15PM ___ PTT-26.6 ___ ___ 09:15PM PLT COUNT-135* ___ 09:15PM NEUTS-87.6* LYMPHS-5.4* MONOS-6.0 EOS-0.1* BASOS-0.1 IM ___ AbsNeut-19.69* AbsLymp-1.22 AbsMono-1.34* AbsEos-0.03* AbsBaso-0.02 ___ 09:15PM WBC-22.5* RBC-2.40* HGB-7.5* HCT-23.7* MCV-99* MCH-31.3 MCHC-31.6* RDW-15.4 RDWSD-54.6* ___ 09:15PM TRIGLYCER-61 HDL CHOL-63 CHOL/HDL-1.7 LDL(CALC)-34 ___ 09:15PM ALBUMIN-3.1* CALCIUM-7.9* PHOSPHATE-2.5* MAGNESIUM-1.6 CHOLEST-109 ___ 09:15PM cTropnT-<0.01 ___ 09:15PM LIPASE-94* ___ 09:15PM ALT(SGPT)-27 AST(SGOT)-23 ALK PHOS-231* AMYLASE-68 TOT BILI-1.1 ___ 09:15PM estGFR-Using this ___ 09:15PM GLUCOSE-139* UREA N-12 CREAT-0.9 SODIUM-139 POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-23 ANION GAP-11 ___ 11:11PM URINE RBC-5* WBC-1 BACTERIA-NONE YEAST-NONE EPI-<1 ___ 11:11PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 11:11PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 11:11PM URINE ___ ___ Course: ================= ___ 07:15AM BLOOD calTIBC-135* VitB12-773 Folate-7 Ferritn-1569* TRF-104* ___ 09:15PM BLOOD Triglyc-61 HDL-63 CHOL/HD-1.7 LDLcalc-34 ___ 07:15AM BLOOD calTIBC-135* VitB12-773 Folate-7 Ferritn-1569* TRF-104* ___ 07:15AM BLOOD Lipase-45 DISCHARGE LABS: ================== ___ 06:36AM BLOOD WBC-15.8* RBC-2.74* Hgb-8.4* Hct-26.1* MCV-95 MCH-30.7 MCHC-32.2 RDW-16.1* RDWSD-56.1* Plt ___ ___ 06:36AM BLOOD Plt ___ ___ 06:36AM BLOOD Glucose-124* UreaN-8 Creat-1.0 Na-141 K-3.9 Cl-104 HCO3-25 AnGap-12 ___ 06:36AM BLOOD ALT-11 AST-10 AlkPhos-233* TotBili-0.9 ___ 06:36AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.7 Imaging: ___ MRI==== UNDERLYING MEDICAL CONDITION: ___ year old man with MRI brain 1 month ago w/ asymmetric T2/FLAIR signal hyperintensity without enhancement or susceptibility artifact in the right globus pallidus requiring 1 month follow up. REASON FOR THIS EXAMINATION: Follow up of ___ MRI Brain CONTRAINDICATIONS FOR IV CONTRAST: None. Final Report EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD INDICATION: ___ year old man with MRI brain 1 month ago w/ asymmetric T2/FLAIR signal hyperintensity without enhancement or susceptibility artifact in the right globus pallidus requiring 1 month follow up.// Follow up of ___ MRI Brain 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: MR ___ ___. FINDINGS: There is evidence of prior ACDF at C3-4, partially visualized. Faint 1 cm T2/FLAIR hyperintensity right internal capsule, similar compared prior (12:13). No gradient abnormality, no abnormal enhancement or other corresponding signal abnormality. No enhancement to suggest capillary telangiectasia. Differential considerations include hamartoma there is history of NF1, low-grade glioma, less likely neuro degenerative, metabolic or toxic exposure Elsewhere, there is no evidence of infarction, hemorrhage, edema, mass, or mass effect. No abnormal enhancement. The ventricles and sulci are prominent, compatible with global parenchymal volume loss, mildly advanced for this patient's age. A few scattered small white matter FLAIR hyperintensities are nonspecific, unchanged prior, and could represent sequelae of early changes of chronic white matter microangiopathy, sequelae of migraines, other considerations are unlikely. Mild right maxillary sinus and ethmoid air cell mucosal thickening. No air-fluid levels. Remaining visualized paranasal sinuses are clear. Partial right mastoid effusion is unchanged from prior. Left mastoid appears clear. The globes and orbits are unremarkable. Major intracranial vascular flow voids are preserved. Right transverse sinus is diminutive; otherwise, major dural venous sinuses appear patent. IMPRESSION: 1. Stable right internal capsule 1 cm nonenhancing abnormality, differential considerations hamartoma if history of NF1, low-grade glioma, other considerations as above. 2. Otherwise, no acute intracranial abnormality. RECOMMENDATION(S): ___ month follow-up head MRI, as above. ___ Liver Ultrasound==== EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year old man with pancreatitis.// evaluate for gallstone, extra/intrahepatic ductal dilatation TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: Liver gallbladder ultrasound ___. FINDINGS: LIVER: The liver echotexture is coarsened, which is concerning for early cirrhosis. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is trace perihepatic ascites. BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 3 mm GALLBLADDER: There is no evidence of stones or gallbladder wall thickening. There is an unchanged 5 mm gallbladder polyp. PANCREAS: Pancreas is not visualized secondary to overlying bowel gas SPLEEN: Normal echogenicity. Trace perisplenic ascites. Spleen length: 7.9 cm KIDNEYS: Limited views of the right kidney shows no hydronephrosis. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. Coarsened hepatic echotexture, which is concerning for early cirrhosis. No evidence of solid liver lesions. The main portal vein is patent. 2. Trace perihepatic and perisplenic ascites. 3. Stable 5 mm gallbladder polyp. Followup ultrasound is recommended in one year. MICROBIOLOGY ================= ___ 9:00 pm BLOOD CULTURE Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Reported to and read back by ___ (___) @2120 ON ___. ___ 11:11 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year old man with pancreatitis.// evaluate for gallstone, extra/intrahepatic ductal dilatation TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: Liver gallbladder ultrasound ___. FINDINGS: LIVER: The liver echotexture is coarsened, which is concerning for early cirrhosis. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is trace perihepatic ascites. BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 3 mm GALLBLADDER: There is no evidence of stones or gallbladder wall thickening. There is an unchanged 5 mm gallbladder polyp. PANCREAS: Pancreas is not visualized secondary to overlying bowel gas SPLEEN: Normal echogenicity. Trace perisplenic ascites. Spleen length: 7.9 cm KIDNEYS: Limited views of the right kidney shows no hydronephrosis. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. Coarsened hepatic echotexture, which is concerning for early cirrhosis. No evidence of solid liver lesions. The main portal vein is patent. 2. Trace perihepatic and perisplenic ascites. 3. Stable 5 mm gallbladder polyp. Followup ultrasound is recommended in one year. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD INDICATION: ___ year old man with MRI brain 1 month ago w/ asymmetric T2/FLAIR signal hyperintensity without enhancement or susceptibility artifact in the right globus pallidus requiring 1 month follow up.// Follow up of ___ MRI Brain 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: MR head ___. FINDINGS: There is evidence of prior ACDF at C3-4, partially visualized. Faint 1 cm T2/FLAIR hyperintensity right internal capsule, similar compared prior (12:13). No gradient abnormality, no abnormal enhancement or other corresponding signal abnormality. No enhancement to suggest capillary telangiectasia. Differential considerations include hamartoma there is history of NF1, low-grade glioma, less likely neuro degenerative, metabolic or toxic exposure Elsewhere, there is no evidence of infarction, hemorrhage, edema, mass, or mass effect. No abnormal enhancement. The ventricles and sulci are prominent, compatible with global parenchymal volume loss, mildly advanced for this patient's age. A few scattered small white matter FLAIR hyperintensities are nonspecific, unchanged prior, and could represent sequelae of early changes of chronic white matter microangiopathy, sequelae of migraines, other considerations are unlikely. Mild right maxillary sinus and ethmoid air cell mucosal thickening. No air-fluid levels. Remaining visualized paranasal sinuses are clear. Partial right mastoid effusion is unchanged from prior. Left mastoid appears clear. The globes and orbits are unremarkable. Major intracranial vascular flow voids are preserved. Right transverse sinus is diminutive; otherwise, major dural venous sinuses appear patent. IMPRESSION: 1. Stable right internal capsule 1 cm nonenhancing abnormality, differential considerations hamartoma if history of NF1, low-grade glioma, other considerations as above. 2. Otherwise, no acute intracranial abnormality. RECOMMENDATION(S): ___ month follow-up head MRI, as above. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Abd pain, Pancreatitis, Transfer Diagnosed with Other chronic pancreatitis temperature: 100.6 heartrate: 100.0 resprate: 18.0 o2sat: 96.0 sbp: 138.0 dbp: 92.0 level of pain: 4 level of acuity: 3.0

___ w/ PMH cirrhosis, alcohol use disorder c/b chronic pancreatitis, anemia (baseline Hgb 8), cirrhosis, HTN, and GOUT presented with worsening epigastric abdominal pain found to have acute on chronic pancreatitis. #Acute on Chronic Pancreatitis 5 days prior to admission, patient states he ate 1 pound of chocolate and ___ large bags of malted milk balls that he got at an ___ sale. Following that, he had significant burning epigastric pain which radiated into his back. Because of his worsening pain, he presented to ___ ___ where he was found to have an elevated white count, low-grade fever and elevated lipase with CT evidence of acute pancreatitis. His CT scan did not show abscess or complicated process occurring within the pancreas. The patient was treated at ___ with Zosyn, 2 L IV fluids, and transferred to ___ for further evaluation and management. Aggressive IVF resuscitation was continued at ___. Amylase elevated at 68. TGs wnl. AST,ALT wnl. WBC 27, lactate 2.9. His pain was controlled with ___ oxycodone in addition to his home long acting medications. Diet was advanced as tolerated to a low fat diet and pain medications were reduced back to his home long acting regimen. #Normocytic Anemia Patient says he has had anemia for ___ years of unclear etiology. He has seen many doctors including ___ and ___ and has undergone thorough evaluation without discovering etiology. He has had many transfusions. He currently takes oral iron for reported iron deficiency anemia. He has had EGD and colonoscopies that were negative. Last ___ was ___ years ago, reportedly normal. Hgb 8.2 upon discharge on ___. Hgb 7.5 on admission to the floor. The patient's H/H was monitored and remained stable throughout admission. Iron studies showed a low iron/TIBC ratio, but a markedly elevated ferritin. He was not given IV iron for this reason as it was thought to all be an acute phase reaction. On ___, the patient's Hgb dropped to 6.8 in the setting of IVF administration and he was transfused with 1u pRBCs. His Hgb bumped appropriately to 8.6 the following day. Recommend outpatient follow up. # New diagnosis of ETOH cirrhosis: Newly diagnosed cirrhosis with a history of alcoholic fatty liver. Recently admitted to hepatology service in ___ for elevated LFTs, ultimately diagnosed with new cirrhosis. LFTs were normal during this admission and not consistent with decompensated cirrhosis. No ascites on exam, no asterixis. Needs close outpatient hepatology follow up. #Abnormal MRI Patient underwent MRI Brain during his ___ admission. At that time, MRI brain showed asymmetric T2/FLAIR signal hyperintensity without enhancement or susceptibility artifact in the right globus pallidus of unclear etiology (ddx included toxic or metabolic encephalopathy, encephalitis, or low-grade glioma, with late subacute to early chronic infarct). Patient had no neurologic deficits at that time. Radiology recommended follow-up imaging to resolution with contrast MRI in approximately 1 month. While he was admitted, repeat MRI was obtained that showed stable findings described as: internal capsule 1 cm nonenhancing abnormality, differential considerations hamartoma if history of NF1, low-grade glioma. Recommend repeat MRI in ___ months. # Coagulase negative staph in ___ blood culture bottles: Blood cultures drawn on admission. When culture result initially had GPCs, patient was started on IV vancomycin. IV vancomycin discontinued when speciated to coag negative staph consistent with likely skin contamination. No other blood cultures positive. Fevers resolved with treatment of pancreatitis as above. # Alcohol Use Disorder Patient has quit drinking alcohol since being told he has cirrhosis. He states he had two drinks for the ___ bowl but no other drinks since ___. # Valvular Disease Patient reports he had an echo on a previous admission where the "outflow valve" was seen to be defective. At this time he was started on metoprolol. His ___ systolic murmur at the RUSB may indicate aortic stenosis. Continued home metoprolol succinate. Recommend outpatient follow up. # Chronic low back pain: Takes oxycontin for ___ years. Continued on home OxyContin 40mg BID. # Anxiety: Continued home buspirone HCl 10mg BID. # Gout: Continued home allopurinol ___. # HTN: Continued home lisinopril 5mg. #Transitional Issues: ======================= [] Recommend close outpatient hepatology follow up for new diagnosis of cirrhosis. [] Repeat MRI brain in ___ months [] Consider repeat echo to evaluate for ?valvular disease given murmur on physical exam. HCP: ___ (wife) Phone: ___

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 pain Major Surgical or Invasive Procedure: Bone Marrow biopsy History of Present Illness: Mr. ___ is a ___ year old male with a history of poorly controlled HTN (secondary to medication non compliance) who initially presented with back pain, sciatica, found on MRI to have numerous lytic lesions in the spine, concerning for malignancy. Patient was interviewed with assistance from his wife. Patient was in usual state of health when noted indolent onset of back pain and sciatica. He was seen by a covering physician at his PCP's office and an MRI was performed. It showed numerous metastatic lesions, and thus he was sent in to the ED for further work up and urgent imaging. He was seen by spine and neurosurgery, and given that there was no cord compression they recommended no surgical intervention. Past Medical History: HTN CKD Social History: ___ Family History: No history of early CAD or malignancy Physical Exam: ADMISSION: Gen: NAD HEENT: NCAT, MMM, no scleral icterus CV: RRR, no mrg Resp: CTA ___ Abd: soft, nt, nd Ext: no CCE Neuro: no focal deficits, in tact sensation in the groin, intact muscle strength at ankles, knees, limited by pain at hip. Psych: euthymic DISCHARGE: Gen: NAD HEENT: NCAT, MMM, no scleral icterus CV: RRR, no mrg Resp: CTA ___ Abd: soft, nt, nd Ext: no CCE Neuro: no focal deficits, moves all 4 ext purposefully, no facial droop Psych: euthymic Pertinent Results: ADMISSION: ___ 07:00PM BLOOD WBC-6.1 RBC-4.07* Hgb-11.1* Hct-34.9* MCV-86 MCH-27.3 MCHC-31.8* RDW-16.0* RDWSD-49.6* Plt ___ ___ 07:00PM BLOOD Glucose-95 UreaN-23* Creat-1.4* Na-136 K-4.6 Cl-99 HCO3-25 AnGap-17 ___ 07:00PM BLOOD Neuts-56.6 ___ Monos-11.9 Eos-3.1 Baso-0.5 Im ___ AbsNeut-3.42 AbsLymp-1.67 AbsMono-0.72 AbsEos-0.19 AbsBaso-0.03 ___ 07:00PM BLOOD Albumin-3.5 Calcium-11.2* Phos-3.5 Mg-1.6 ___ 10:55AM BLOOD PSA-2.1 ___ 10:55AM BLOOD TotProt-9.8* Calcium-11.7* Phos-4.0 Mg-1.6 IMAGING: CT CHEST: IMPRESSION: 1. Innumerable expansile, heterogeneously enhancing soft tissue density masses resulting in expansion and destruction of nearly all imaged osseous structures of the thorax, including multiple vertebral bodies, detailed above. Notably, a large lesion results an osseous destruction of >50% of the T8 and T9 vertebral bodies anteriorly, better evaluated on recent MR total spine. Findings consistent with metastatic disease. 2. Multiple hypodense thyroid nodules measuring up to 19 mm. Recommend thyroid ultrasound on a nonurgent/routine basis, if/when clinically appropriate and if not previously known. 3. Mildly dilated main pulmonary suggestive of pulmonary hypertension. Moderate cardiomegaly. 4. Mild centrilobular and paraseptal emphysema. 5. Severe coronary artery calcification. 6. Please see separate report for subdiaphragmatic findings from same-day CT abdomen/pelvis. CT ABD/PELVIS: IMPRESSION: 1. Multiple osseous metastases. No obvious primary malignancy is seen on the study. 2. Healing pathologic fracture of the left inferior pubic ramus. MRI HEAD: IMPRESSION: 1. There is no MRI correlate to previously described subependymal hyperdense nodule of the frontal horn of the right lateral ventricle/right genu of the corpus callosum. There is no gradient echo susceptibility in the region to suggest hemorrhage nor abnormal enhancement. This may represent a calcified subependymoma. Close attention on followup examination is recommended. 2. There is no definite evidence for intracranial metastatic disease. 3. There is an enhancing left parietal calvarial lesion which appears to erodes through the outer table as well as a suspicious enhancing T1 hypointense lesion of the right clivus, concerning for metastatic osseous disease. There additional FLAIR hyperintense enhancing lesions scattered throughout the epiploic space corresponding to lucent lesions on CT head, which may represent any combination of additional lesions and venous lakes. 4. No acute infarct. Peripheral punctate foci of gradient echo susceptibility artifact likely representing sequela of prior microhemorrhage. MRI C,T,L SPINE IMPRESSION: 1. Diffuse presumably metastatic soft tissue lesions of the cervical, thoracic and lumbar spine involving the vertebral bodies, lateral and posterior elements. Many of these lesions are expansile demonstrating cortical erosion. 2. In the cervical spine, there is likely soft tissue extension into the left lateral C3 epidural space and in the thoracic spine, there is minimal soft tissue enhancement of the ventral T9 epidural space, without significant spinal canal narrowing secondary to metastatic disease. 3. In the lumbosacral spine, a dominant expansile left S1 and sacral iliac lesion severely compromises the left S2-S3 and S3-S4 neural foramina. 4. Superimposed degenerative changes as described above, most prominent at C3-C4 in the cervical spine where there is severe spinal canal narrowing, minimally remodeling the cord and at L3-L4 in the lumbar spine where there is severe spinal canal narrowing. Multilevel moderate to severe neural foraminal narrowing of the cervical and lumbar spine as described above. 5. Diffuse metastatic involvement of the ribs as described above. STIR hyperintense signal of the sternoclavicular junctions is identified, which may be degenerative in nature although underlying lesion cannot be excluded. There appears to be at least 1 pathologic fracture of the right posterior T10 rib. Further evaluation with CT thorax is recommended. CT HEAD: IMPRESSION: A 4 mm hyperdense potentially calcified or hemorrhagic lesion involving the body of the corpus callosum. Given history, MRI with contrast is suggested to further assess regarding the possibility of a mass lesion in this region in addition to the suspicious calvarial lesions. CXR: IMPRESSION: Pleural-based masslike opacity at the right lung base anteriorly for which chest CT is suggested. CT ABD PELVIS: IMPRESSION: 1. Multiple osseous metastases. No obvious primary malignancy is seen on the study. 2. Healing pathologic fracture of the left inferior pubic ramus. RECOMMENDATION(S): Multiple osseous lesions are suitable targets for percutaneous image guided biopsy if tissue sampling is needed. CT CHEST IMPRESSION: 1. Innumerable expansile, heterogeneously enhancing soft tissue density masses resulting in expansion and destruction of nearly all imaged osseous structures of the thorax, including multiple vertebral bodies, detailed above. Notably, a large lesion results an osseous destruction of >50% of the T8 and T9 vertebral bodies anteriorly, better evaluated on recent MR total spine. Findings consistent with metastatic disease. 2. Multiple hypodense thyroid nodules measuring up to 19 mm. Recommend thyroid ultrasound on a nonurgent/routine basis, if/when clinically appropriate and if not previously known. 3. Mildly dilated main pulmonary suggestive of pulmonary hypertension. Moderate cardiomegaly. 4. Mild centrilobular and paraseptal emphysema. 5. Severe coronary artery calcification. 6. Please see separate report for subdiaphragmatic findings from same-day CT abdomen/pelvis. RECOMMENDATION(S): Nonurgent/routine thyroid ultrasound, if/when clinically DISCHARGE: ___ 09:51AM BLOOD WBC-7.9 RBC-3.99* Hgb-10.9* Hct-34.3* MCV-86 MCH-27.3 MCHC-31.8* RDW-16.2* RDWSD-50.8* Plt ___ ___ 09:51AM BLOOD ___ ___ 09:51AM BLOOD Glucose-124* UreaN-29* Creat-1.3* Na-136 K-4.2 Cl-97 HCO3-29 AnGap-14 ___ 06:35AM BLOOD ALT-9 AST-24 AlkPhos-102 TotBili-0.4 ___ 09:51AM BLOOD Calcium-9.7 Phos-2.8 Mg-1.9 ___ 06:35AM BLOOD FreeKap-1280* ___ Fr K/L-116.4* IgG-464* IgA-4168* IgM-27* ___ 06:35AM BLOOD HCV Ab-NEGATIVE Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Chlorthalidone 25 mg PO DAILY 2. Metoprolol Succinate XL 100 mg PO DAILY 3. Amlodipine 10 mg PO DAILY Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Metoprolol Succinate XL 100 mg PO DAILY 3. Acetaminophen 325-650 mg PO/PR Q4H:PRN Pain RX *acetaminophen 325 mg ___ tablet(s) by mouth every six (6) hours Disp #*120 Tablet Refills:*0 4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain Do not drive, drink alcohol, or operate heavy machinery while taking RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*0 5. Chlorthalidone 25 mg PO DAILY 6. Rolling walker Length of need: 13 months Diagnosis: multiple myeloma C90.0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Multiple myeloma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD INDICATION: History: ___ with new malignancy w/ mets. possible hemorrhagic lesion on CT // hemorrhagic lesions? mets? TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of 8 mL of Gadavist intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: CT head without contrast of ___ FINDINGS: There is no MRI correlate to subependymal hyperdense nodule of the frontal horn of the right lateral ventricle seen on prior CT examination of ___. There is no associated gradient echo susceptibility in the region or abnormal enhancement. There are 2 nonenhancing FLAIR hyperintense white matter lesions of the left frontal coronal radiata and left periventricular white matter, which are nonspecific, but commonly seen in setting chronic microangiopathy in a patient of this age. There is no evidence for acute infarct or intracranial hemorrhage. There are scattered peripheral gradient echo susceptibility artifact punctate foci, which may represent sequela of prior micro hemorrhage. The sulci, ventricles cisterns are within expected limits given the degree of the patient's mild age related global cerebral volume loss. The major intracranial flow voids are preserved. The dural venous sinuses are patent. The paranasal sinuses are essentially clear. The orbits are unremarkable. There is trace fluid signal of the left mastoid tip. There is enhancing left parietal calvarial lesion which appears to erodes through the outer table (series 100 B, image 78) and a suspicious rounded enhancing T1 hypointense lesion of the right clivus (series 3, image 9; series 100b, image 35) both of which correspond to erosive lesions seen on head CT. There additional scattered FLAIR hyperintense enhancing lesions of the epiploic space, without definite erosion which may represent additional lesions and/or venous lakes. IMPRESSION: 1. There is no MRI correlate to previously described subependymal hyperdense nodule of the frontal horn of the right lateral ventricle/right genu of the corpus callosum. There is no gradient echo susceptibility in the region to suggest hemorrhage nor abnormal enhancement. This may represent a calcified subependymoma. Close attention on followup examination is recommended. 2. There is no definite evidence for intracranial metastatic disease. 3. There is an enhancing left parietal calvarial lesion which appears to erodes through the outer table as well as a suspicious enhancing T1 hypointense lesion of the right clivus, concerning for metastatic osseous disease. There additional FLAIR hyperintense enhancing lesions scattered throughout the epiploic space corresponding to lucent lesions on CT head, which may represent any combination of additional lesions and venous lakes. 4. No acute infarct. Peripheral punctate foci of gradient echo susceptibility artifact likely representing sequela of prior microhemorrhage. Radiology Report INDICATION: ___ year old man with new bony mets, pleural based mass on CXR, concern for malignancy // eval for intrathoracic malignancy, pleural based mass 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) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9 mGy-cm. 4) Stationary Acquisition 15.5 s, 0.2 cm; CTDIvol = 263.5 mGy (Body) DLP = 52.7 mGy-cm. 5) Spiral Acquisition 6.3 s, 74.1 cm; CTDIvol = 6.1 mGy (Body) DLP = 419.9 mGy-cm. 6) Spiral Acquisition 2.8 s, 35.1 cm; CTDIvol = 6.6 mGy (Body) DLP = 201.1 mGy-cm. Total DLP (Body) = 676 mGy-cm. COMPARISON: None. FINDINGS: LOWER CHEST: Please refer to concurrent chest CT for discussion of findings at the lung bases. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no hydronephrosis. Multiple simple cysts seen in both kidneys. The largest is in the right kidney interpolar region measuring 10.5 x 7.9 cm. 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. 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: 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: Multiple lucent osseous metastases are present, including in all lumbar vertebral bodies, right acetabulum, left sacrum, and left iliac wing. Many of these lesions contain a large soft tissue component. There is also a lucent lesions at the right inferior pubic ramus with a subacute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Multiple osseous metastases. No obvious primary malignancy is seen on the study. 2. Healing pathologic fracture of the left inferior pubic ramus. RECOMMENDATION(S): Multiple osseous lesions are suitable targets for percutaneous image guided biopsy if tissue sampling is needed. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 2:24 ___. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ man with new bony metastases, pleural-based mass on chest x-ray, concern for malignancy. TECHNIQUE: Multidetector helical scanning of the chest coordinated with intravenous infusion of nonionic iodinated contrast agent was 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: Total DLP (Body) = 676 mGy-cm. ** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND PELVIS WITH CONTRAST) COMPARISON: 1. Chest x-ray ___. 2. MR total spine ___. FINDINGS: Multiple hypodense thyroid nodules are identified, the largest of which measures 19 mm within the right thyroid lobe (series 4, image 10). The esophagus is within normal limits. There is no hiatus hernia. The aorta is normal in caliber throughout the chest. There is mild aortic arch calcification. There is a 2-vessel aortic arch, a normal anatomic variant, with all major branches appearing widely patent and unremarkable. There is a mildly dilated main pulmonary artery measuring 3.4 cm in diameter (series 4, image 28). There is severe coronary artery calcification. There is moderate cardiomegaly. The pericardium is unremarkable. There is no pericardial effusion. There is no mediastinal, hilar, or axillary lymphadenopathy. Respiratory motion artifact somewhat limits evaluation of the lung parenchyma. Mild centrilobular and paraseptal emphysema is most prominent at the right lung apex. Streaky opacities in the dependent portions of the lung bases are consistent with subsegmental atelectasis. Innumerable lucencies involving all visible osseous structures, including all ribs, the sternum, clavicles, and all imaged thoracolumbar vertebral bodies. The largest of these lesions display heterogeneously enhancing soft tissue density characteristics, with expansion and destruction of the involved adjacent bones. The largest such lesion arises from the right sixth (___) anterolateral rib, is rounded in morphology, and measures 5.2 x 4.6 x 3.8 cm, is relatively hyperenhancing with several internal foci of hypoenhancement (for example see series 5 image 205 and series 9, image 17). Similar large lesions demonstrate expansion and destruction of multilevel thoracic vertebral bodies. For example, a 5.4 x 4.8 x 7.2 cm lesion results in destruction of the anterior ___ of the T8 and the majority of the T9 vertebral body (see series 4, image 41 and series 9, image 33). Superiorly, a similar but smaller, approximately 3.6 x 3.2 x 2.6 cm enhancing lesion results in osseous destruction of at least of the anterior half of both the T4 and T5 vertebral bodies (see series 4, image 21 and series 9, image 33). Innumerable additional identical lesions are smaller. IMPRESSION: 1. Innumerable expansile, heterogeneously enhancing soft tissue density masses resulting in expansion and destruction of nearly all imaged osseous structures of the thorax, including multiple vertebral bodies, detailed above. Notably, a large lesion results an osseous destruction of >50% of the T8 and T9 vertebral bodies anteriorly, better evaluated on recent MR total spine. Findings consistent with metastatic disease. 2. Multiple hypodense thyroid nodules measuring up to 19 mm. Recommend thyroid ultrasound on a nonurgent/routine basis, if/when clinically appropriate and if not previously known. 3. Mildly dilated main pulmonary suggestive of pulmonary hypertension. Moderate cardiomegaly. 4. Mild centrilobular and paraseptal emphysema. 5. Severe coronary artery calcification. 6. Please see separate report for subdiaphragmatic findings from same-day CT abdomen/pelvis. RECOMMENDATION(S): Nonurgent/routine thyroid ultrasound, if/when clinically appropriate and if not previously performed. Radiology Report EXAMINATION: SKELETAL SURVEY (INCLUD LONG BONES) INDICATION: ___ year old man with likely multiple myeloma, hip pain // eval for areas of likely myeloma involvement TECHNIQUE: Two views of the T-spine, two views of the L-spine, AP view of the pelvis, single view of the humerus, two views of the femur is, single view of the skull COMPARISON: CT from ___ IMPRESSION: As seen on the CT, there is lytic osseous involvement of multiple regions of the skeleton including multiple vertebral bodies, the sacrum, humeri, femurs, pelvis, and skull. Given the diffuse osteopenia it is difficult to assess for alignment of the spine in the thoracic region. In the lumbar region there is mild anterolisthesis of L3 on L4 and moderate anterolisthesis of L4 and L5. There is disc space narrowing of L5-S1 with sclerosis. Anterior and lateral osteophytes are seen. There is residual contrast in the colon and in the bladder. Gender: M Race: BLACK/CARIBBEAN ISLAND Arrive by WALK IN Chief complaint: Abnormal MRI Diagnosed with Low back pain, Essential (primary) hypertension temperature: 100.2 heartrate: 80.0 resprate: 16.0 o2sat: 100.0 sbp: 157.0 dbp: 72.0 level of pain: 8-9 level of acuity: 2.0

Mr. ___ is a ___ year old male with a history of poorly controlled HTN (secondary to medication non compliance) who initially presented with back pain, sciatica, found on MRI to have numerous lytic lesions in the spine, concerning for multiple myeloma #multiple myeloma: given kidney disease, hypercalcemia, numerous lytic lesions and fractures, elevated total protein, elevated IgA. Oncology consulted. SPEP, UPEP, Kappa/lambda ratio ordered. Skeletal survey with numerous lesions. Has evidence of L pubic ramus fracture as well.Lytic osseous involvement of the left sacrum, right iliac bone, thoracolumbar spine, calvarium, bilateral femur, bilateral proximal humeri, right inferior pubic ramus -Dexamethasone 40mg PO received on ___ -had bone marrow biopsy on ___ -has appointment scheduled with Dr. ___ on ___ #Fever: unclear etiology. CT torso without source, UA negative, no skin lesions. NO leg swelling, tachypnea, hypoxia to expect VTE. Given relative immunosuppression, empirically started on ceftriaxone to cover for encapsulated organisms. Blood and urine cultures are NGTD. Abx discontinued on ___ -CTX 1g ___ -urine cx negative, blood cx NGTD #Hypercalcemia: of malignancy and metastases. Given pamidronate 60mg x 1 on ___. Ca 9.7 on day of discharge. #Back pain/leg pain: likely related to numerous bony metastatic lesions. Pamidronate will help,transitioned to oxycodone 5mg q4h prn pain. #HTN: Home medications were resumed on discharge. ___ consider switching to an agent other than chlorthalidone if CKD continues to progress. FEN: regular diet PPx: HSQ Code: full Dispo: HMED [x Discharge documentation reviewed, pt is stable for discharge [x] Time spent on discharge activity was greater than 30min. Electronically signed by ___, MD, pager ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: aspirin Attending: ___ Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ with h/o PVT on Coumadin, HCV cirrhosis, nonhodgkin's lymphoma s/p chemo in ___, who presents for right-sided chest and abdominal pain. The patient reports that he started feeling acute onset right-sided chest and abdominal pain 2 days ago, while he was lying down. No unusual activity preceded the pain. It does not radiate anywhere and is not associated with exertion. It is pleuritic and worsens with deep breathing. He endorses mild nausea but denies vomiting, and also denies fevers/chills, changes in bowel habits, dysuria, dyspnea, palpitations, dizziness, and syncope. Patient reports that he has never had pain like this before. In the ED, initial vitals were T 98.2 HR 105 BP 139/84 RR 16 O2 sat 98% RA. Labs were notable for platelets 56, at baseline, INR 2.7. Imaging was notable for abdominal US with cirrhotic liver, patent portal vein, no ascites. Hepatology was consulted and recommended admission to ___. Patient was given 4 mg IV morphine prior to transfer to the floor. Upon arrival to the floor, patient reports continue RUQ/R-sided chest pain. Also endorses mild anxiety about his health problems. ROS: (+) Per HPI. 10-point ROS reviewed and negative. Past Medical History: - Non-Hodgkin's lymphoma, s/p chemotherapy (CHOP ___ - Liver cirrhosis: From hepatitis C * Nonresponder x3 on sofosbuvir/ribavirin/Pegasys * Grade I varices (___) - Osteoarthritis - Depression and anxiety - Nephrolithiasis - Low back pain - GERD - History of various bone fractures Social History: ___ Family History: Father deceased; CAD w/ h/o MI and CHF. Physical Exam: ADMISSION PHYSICAL EXAM: ======================= VS: T 97.7 BP 107/72 HR 66 RR 20 O2 sat 95%RA GENERAL: Lying in bed, well-appearing, conversant, not in acute distress HEENT: normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, moist mucus membranes. NECK: Supple, no LAD, JVP flat. HEART: RRR, normal S1/S2, no murmurs rubs or gallops. TTP on right lateral ribcage. LUNGS: Clear to auscultation bilaterally, without wheezes or rhonchi. ABDOMEN: Normal bowel sounds, soft, non-distended, no organomegaly. Tender to deep palpation in RUQ without rebound or guarding. EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or edema. SKIN: No jaundice or rash. NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation, with strength ___ throughout. No asterixis. DISCHARGE PHYSICAL EXAM: ======================= VS: T 97.9, BP 119/69, HR 75, RR 18, SpO2 100/RA GENERAL: lying in bed, sleeping, easily awoke to voice. NAD. HEENT: no icterus HEART: RRR, S1+S2, no M/R/G. LUNGS: CTAB, no W/R/C. TTP on right lateral/anterior ribcage. ABDOMEN: non-distended, soft, non-tender. EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or edema. Pertinent Results: ADMISSION LABS: =============== ___ 12:25AM BLOOD WBC-4.2 RBC-4.51* Hgb-14.5 Hct-41.0 MCV-91 MCH-32.2* MCHC-35.4 RDW-13.6 RDWSD-45.0 Plt Ct-56* ___ 12:25AM BLOOD Neuts-47.9 ___ Monos-10.7 Eos-2.4 Baso-0.5 Im ___ AbsNeut-2.01 AbsLymp-1.61 AbsMono-0.45 AbsEos-0.10 AbsBaso-0.02 ___ 12:25AM BLOOD Glucose-93 UreaN-17 Creat-0.8 Na-143 K-4.2 Cl-104 HCO3-22 AnGap-17* ___ 12:25AM BLOOD ALT-28 AST-32 AlkPhos-91 TotBili-0.5 ___ 12:25AM BLOOD CK-MB-2 ___ 12:25AM BLOOD cTropnT-<0.01 ___ 12:25AM BLOOD Albumin-4.3 Calcium-9.3 Phos-3.3 Mg-2.0 ___ 12:28AM BLOOD Lactate-1.6 PERTINENT LABS/MICRO: ===================== ___ 12:25AM BLOOD Lipase-38 ___ 09:36AM BLOOD CK-MB-1 cTropnT-<0.01 ___ 12:28AM BLOOD Lactate-1.6 ___ urine culture: no growth ___: Blood culture x 2: NGTD DISCHARGE LABS: ================ ___ 09:36AM BLOOD WBC-3.5* RBC-4.12* Hgb-12.7* Hct-37.6* MCV-91 MCH-30.8 MCHC-33.8 RDW-13.4 RDWSD-44.6 Plt Ct-52* ___ 09:36AM BLOOD Glucose-94 UreaN-17 Creat-0.7 Na-145 K-4.2 Cl-107 HCO3-23 AnGap-15 ___ 09:36AM BLOOD ALT-26 AST-28 LD(LDH)-180 AlkPhos-68 TotBili-0.9 ___ 09:36AM BLOOD Calcium-8.6 Phos-2.9 Mg-1.9 IMAGING: ========= ___ Abd US w/ Doppler: 1. The main right and left portal veins demonstrate normal color flow. 2. Cirrhotic liver with 1.8 x 1.4 cm lesion in the right hepatic lobe, which likely corresponds with the lesion seen on prior MRI measuring 1.1 cm. Nonemergent follow-up imaging with dedicated liver MRI or CT is recommended for further evaluation. ___ CXR: No acute cardiopulmonary process. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Warfarin 5 mg PO 5X/WEEK (___) 2. Warfarin 7.5 mg PO 2X/WEEK (___) Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild DO NOT EXCEED TOTAL OF 2000mg IN 24 HOURS. 2. TraMADol 50 mg PO Q6H:PRN Pain - Moderate Duration: 4 Days RX *tramadol 50 mg One tablet(s) by mouth Once every six (6) hours Disp #*16 Tablet Refills:*0 3. Warfarin 5 mg PO 5X/WEEK (___) 4. Warfarin 7.5 mg PO 2X/WEEK (___) Discharge Disposition: Home Discharge Diagnosis: Costochondritis HCV cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: PA and lateral chest radiographs INDICATION: ___ with pleuritic chest pain. Evaluate for pneumonia. TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph from ___. FINDINGS: The lungs are well expanded and clear. Cardiomediastinal silhouette is within normal limits. No pleural effusion or pneumothorax. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: pvt? change in pvt? etiology of pain? TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen was performed. COMPARISON: Outside CT abdomen and pelvis from ___. MRI abdomen from ___ FINDINGS: Liver: The hepatic parenchyma is coarsened and nodular. The liver margin is nodular in keeping with cirrhosis. A hypoechoic 1.8 x 1.4 cm lesion in the right hepatic lobe likely corresponds to the lesion seen on prior MRI. There is no ascites. Bile ducts: There is no intrahepatic biliary ductal dilation. Gallbladder: The gallbladder is surgically absent. Pancreas: The imaged portion of the pancreas appears within normal limits, with portions of the pancreatic tail obscured by overlying bowel gas. Kidneys: Limited evaluation of the right kidney demonstrates no hydronephrosis. Doppler evaluation: The main portal vein is patent, with flow in the appropriate direction. Right and left portal veins are patent, with antegrade flow. IMPRESSION: 1. The main right and left portal veins demonstrate normal color flow. 2. Cirrhotic liver with 1.8 x 1.4 cm lesion in the right hepatic lobe, which likely corresponds with the lesion seen on prior MRI measuring 1.1 cm. Nonemergent follow-up imaging with dedicated liver MRI or CT is recommended for further evaluation. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: RUQ abdominal pain Diagnosed with Unspecified abdominal pain, Portal vein thrombosis temperature: 98.2 heartrate: 105.0 resprate: 16.0 o2sat: 98.0 sbp: 139.0 dbp: 84.0 level of pain: 6 level of acuity: 3.0

Mr. ___ is a ___ male with HCV cirrhosis and a portal vein thrombus (on warfarin) who presents with abdominal pain. #Rib pain: Presented with two days of right anterior lower rib pain that was pleuritic in nature and reproducible on palpation. No known trauma. Labs were overall unremarkable with stable thrombocytopenia. CXR was negative for pneumonia or rib fractures and RUQ US showed cirrhosis and a 1.8 x 1.4 cm lesion in the right hepatic lobe (seen on previous MRI). The pain was felt to be related to costochondritis. NSAIDs were contraindicated in this patient; thus, he was discharged with four days of tramadol. #HCV cirrhosis: MELD 18 on admission, but in setting of warfarin. No evidence of GIB, ascites, SBP, or encephalopathy. #Liver Lesion: Has been followed in the outpatient setting for a liver lesion concerning for HCC. Last MRI showed stable size of segment 5 liver lesion not meeting OPTN 5 criteria. Will need continued monitoring post discharge. #Portal vein thrombosis: He was continued on home warfarin. TRANSITIONAL ISSUES =================== [ ] Discharged with 4 days of tramadol [ ] Liver MRI on ___ for surveillance of mass [ ] INR 2.5 on discharge, warfarin regimen was not adjusted

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Chest pain Major Surgical or Invasive Procedure: ___ - Total arch? History of Present Illness: Mr. ___ is a ___ year old man with a history of depression and irritable bowel syndrome. He was in his usual state of health until the evening of ___ when he developed acute onset chest pain and pressure. He reported that earlier this evening while at home playing video games he became anxious and developed upper, central, chest pain while at rest. He has a difficult time describing the sensation but states it's constant, pressure, initially ___, and nonradiating. He stated that the pressure sensation never resolved but had decreased in intensity to ___. He denied any worsening of his chest pain with exertion. However, he stated he felt lightheaded with ambulation. He took 2 regular strength aspirin at home prior to arrival which did not alleviate his pain. He also endorsed associated blurred vision, shortness of breath, and palpitations with the onset of his symptoms, however these have since resolved. He presented to ___ and was noted to have a diastolic heart murmur. He underwent a chest CTA which revealed an aortic dissection through aortic valve and extending to iliac bifurcation. He was transferred to ___ for further care. He does not know of any family history of dissection, and has never been told he has Marfan's. The cardiac surgery service was consulted and he was taken emergently to the operating room. Past Medical History: Depression Irritable Bowel Syndrome Past Surgical History: Cyst removal from back, ___ Knee surgery at age ___ for a congenital bone abnormality Social History: ___ Family History: No history of premature coronary artery disease or aortic dissection. Physical Exam: Admission Exam: Vitals: T 97.8, HR 58, BP 96/52, RR 13, O2 98ra Gen: a&o x3, nad, CN ___ grossly intact, no focal neuro deficits Neck: bilateral carotid pulses palpable, right significantly decreased compared to left CV: rrr, grade ___ diastolic murmur Resp: cta bilat Abd: soft, NT, ND, +BS Extr: warm, bilateral radial/brachial pulses palpable, though right significantly decreased compared to left; fem/pop/dp/pt symmetric and palpable bilaterally Discharge Exam: VS: T 98.4 HR 79 BP 105/51 RR 19 O2sat 96%-RA Wt 94.6kg Preop: 90kg GEN: NAD Neuro: A&O x3, MAE-follows commands. Nonfocal exam CV: RRR -sharp click. Sternum-stable, incision CDI Pulm: CTA bilat Abdm: soft, NT/ND/+BS Ext: warm, well perfused, no edema Pertinent Results: Admission labs: ___ 04:45AM ___ PTT-31.0 ___ ___ 04:45AM PLT COUNT-179 ___ 04:45AM WBC-12.5* RBC-4.70 HGB-14.2 HCT-42.6 MCV-91 MCH-30.2 MCHC-33.4 RDW-13.8 ___ 04:45AM %HbA1c-5.1 eAG-100 ___ 04:45AM GLUCOSE-151* UREA N-24* CREAT-1.3* SODIUM-139 POTASSIUM-3.9 CHLORIDE-108 TOTAL CO2-21* ANION GAP-14 ___ 04:56AM LACTATE-2.9* Discharge Labs: ___ 05:50AM BLOOD WBC-12.5* RBC-2.78* Hgb-8.5* Hct-25.7* MCV-92 MCH-30.5 MCHC-33.0 RDW-14.6 Plt ___ ___ 05:50AM BLOOD Plt ___ ___ 05:50AM BLOOD ___ ___ 07:01AM BLOOD ___ ___ 05:50AM BLOOD Glucose-96 UreaN-26* Creat-1.0 Na-137 K-4.8 Cl-101 HCO3-27 AnGap-14 ___ 05:50AM BLOOD Mg-2.4 CTA Torso ___ Extensive aortic dissection extending from the aortic root (including the aortic valve) to the aortic bifurcation. Dilated aortic root and ascending aorta. The right carotid artery arises from the false lumen and is unopacified. The right kidney is slightly more opacified than the left indicating relative decrease in perfusion to the left kidney (both left renal arteries arise from the false lumen). Left common iliac artery aneurysm. Radiology Report CHEST (PA & LAT) Study Date of ___ 1:05 ___ Final Report: Small bilateral pleural effusion has probably decreased since ___, not evaluated previously with the lateral chest radiograph. Mild cardiomegaly stable. Lungs clear. No pneumothorax. ___. ___ ___ ECHOCARDIOGRAPHY REPORT Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: *5.7 cm <= 5.6 cm Left Ventricle - Ejection Fraction: >= 75% >= 55% Aorta - Annulus: 2.6 cm <= 3.0 cm Aorta - Sinus Level: *4.9 cm <= 3.6 cm Aorta - Ascending: *5.4 cm <= 3.4 cm Aorta - Descending Thoracic: *3.1 cm <= 2.5 cm Aortic Valve - Peak Gradient: 8 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 5 mm Hg Aortic Valve - LVOT diam: 2.4 cm Aortic Valve - Valve Area: 3.5 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: No spontaneous echo contrast or thrombus in the ___ or the RA/RAA. Good (>20 cm/s) ___ ejection velocity. All four pulmonary veins identified and enter the left atrium. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV cavity. Normal regional LV systolic function. Hyperdynamic LVEF >75%. RIGHT VENTRICLE: Normal RV systolic function. AORTA: Moderately dilated aorta at sinus level. Moderately dilated ascending aorta Mildly dilated descending aorta. Simple atheroma in descending aorta. Ascending aortic intimal flap/dissection.. Aortic arch intimal flap/dissection. Descending aorta intimal flap/aortic dissection. Flow in false lumen. AORTIC VALVE: Three aortic valve leaflets. No AS. Severe (4+) AR. Eccentric AR jet. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. ___ VALVE: Tricuspid valve not well visualized. Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. No PR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: Written informed consent was obtained from the patient. A TEE was performed in the location listed above. I certify I was present in compliance with ___ regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Conclusions PRE BYPASS No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). The right ventricle displays normal free wall contractility. The aortic root is moderately dilated at the sinus level. The ascending aorta is moderately dilated. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. A mobile density is seen in the ascending aorta consistent with an intimal flap/aortic dissection. The dissection extends through the arch and as far down the descending aorta as can be seen. There is flow in the false lumen. There are three aortic valve leaflets. There is no aortic valve stenosis. Severe (4+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a trivial/physiologic pericardial effusion. Dr. ___ was notified in person of the results in the operating room at the time of the study. POST BYPASS After first separation from bypass, the patient was placed back on bypas secondary to dislodgement of the right coronary button anastomosis. On second and final separation, the patient was in sinus rhythm and was receiving epinephrine by IV infusion. There was normal left ventricular systolic function with an ejection fraction of about 60%. The right ventricle was significantly dilated compared to prebypass exam. Right ventricular systolic function was low normal to mildly globally hypokinetic. The tricuspid regurgitation was in the trace to mild range. An ascending aortic graft was seen in situ with a composite bileaflet prosthesis in the aortic position. Both leaflets of the valve can be seen moving normally. The normal mild washing jets of aortic regurgitation are seen. The maximum gradient though the aortic valve was 8 mmHg with a mean gradient of 4 mmHg at a cardiac output of about 6.5 liters/minute. The effective valve area was about 2.9 cm2. The mitral regurgitation was in the trace to mild range. The descending thoracic aorta was unchanged from the prebypass exam. I certify that I was present for this procedure in compliance with ___ regulations. Electronically signed by ___, MD, Interpreting physician ___ ___ 19:09 Medications on Admission: Aspirin 325mg tablet prn headaches Bupropion 100mg tablet daily Discharge Medications: 1. Aspirin EC 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 2. Atorvastatin 40 mg PO DAILY RX *atorvastatin 40 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 3. BuPROPion 100 mg PO DAILY 4. CloniDINE 0.1 mg PO TID RX *clonidine HCl 0.1 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 5. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 6. Furosemide 20 mg PO DAILY Duration: 2 Weeks RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*14 Tablet Refills:*0 7. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4) hours Disp #*75 Tablet Refills:*0 8. Lisinopril 20 mg PO DAILY RX *lisinopril 20 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 9. Metoprolol Tartrate 100 mg PO TID RX *metoprolol tartrate 100 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*1 10. Potassium Chloride 20 mEq PO DAILY Duration: 2 Weeks RX *potassium chloride 20 mEq 1 tablet(s) by mouth once a day Disp #*14 Tablet Refills:*0 11. ___ MD to order daily dose PO DAILY target INR 2.5-3.5 RX *warfarin [Coumadin] 5 mg as directed by Dr ___ by mouth once a day Disp #*90 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Type A Aortic Dissection-s/p repair PMH: Depression Irritable Bowel Syndrome knee surgery Discharge Condition: Alert and oriented x3 nonfocal Ambulating with gait steady Sternal pain managed with Dilaudid and Tylenol Sternal Incision - healing well, no erythema or drainage Edema: none Followup Instructions: ___ Radiology Report INDICATION: History: ___ with cp // reread for aortic disection. TECHNIQUE: This is an outside hospital study for second read. MDCT axial images were acquired through abdomen and pelvis following intravenous. Coronal and sagittal reformations were performed and submitted to PACS for review. DOSE: This is an outside hospital study for second read. COMPARISON: None. FINDINGS: CHEST: The thyroid is unremarkable. There is no axillary or mediastinal or hilar lymphadenopathy. The airways are patent to the subsegmental level. The lungs are clear and there is no focal consolidation, pleural effusion or pneumothorax. No pericardial effusion. Heart size is normal. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There are several cysts throughout the liver. There are also subcentimeter hypodensities are too small to characterize. 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. The right kidney is slightly more opacified than the left indicating slight relative decrease in perfusion to the left kidney. There is no evidence of stones, focal renal lesions or hydronephrosis. There are no urothelial lesions in the kidneys or ureters. There is no perinephric abnormality. GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness and enhancement throughout. Scattered diverticula but otherwise the colon and rectum are within normal limits. Appendix has an appendicolith, has normal caliber without evidence of fat stranding. RETROPERITONEUM: There is no evidence of retroperitoneal and mesenteric lymphadenopathy. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: Reproductive organs are within normal limits BONES AND SOFT TISSUES: There is no evidence of worrisome lesions. Abdominal and pelvic wall is within normal limits. CTA: There is an extensive aortic dissection extending from the aortic root (including the aortic valve) to the aortic bifurcation. The aortic root and ascending aorta are dilated measuring up to 5.4 cm in diameter. The true and false lumen are opacified. The right subclavian, left subclavian, and left carotid arteries arise from the true lumen and are well opacified. The right carotid artery appears to arise from the false lumen and is non-opacified. It is difficult to the determine where the coronary arteries arise from however both are opacified. The celiac artery is opacified, and arises from the false lumen, the dissection flap extends very close to the celiac. The SMA, right renal artery, and ___ arise from the true lumen and are well opacified. There are 2 left renal arteries, both of which arise from the false lumen and remain opacified. The dissection flap ends at the aortic bifurcation. There is a 2.3 cm aneurysm of the left common iliac artery. IMPRESSION: Extensive aortic dissection extending from the aortic root (including the aortic valve) to the aortic bifurcation, detailed above. Dilated aortic root and ascending aorta. The right carotid artery arises from the false lumen and is unopacified. The right kidney is slightly more opacified than the left indicating relative decrease in perfusion to the left kidney (both left renal arteries arise from the false lumen). Left common iliac artery aneurysm. NOTIFICATION: These findings were discussed with Dr. ___ by Dr. ___ at 05:30 on ___ in person. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ male status post total arch replacement. TECHNIQUE: Portable AP radiograph of the chest from ___. COMPARISON: ___. FINDINGS: Endotracheal tube terminates at the level of the clavicles. A Swan-Ganz catheter is in place, terminating in the region of the pulmonic valve. Extensive coil metallic material projects over the mid mediastinum. Mediastinal drains are in place. The patient is status post aortic valve replacement. Surgical material projects over the right posterior second rib. There is new mediastinal widening, which is likely post surgical in nature. There is no pneumothorax. The lungs are clear. IMPRESSION: Lines and tubes in satisfactory position. Clear lungs. Radiology Report EXAMINATION: PORTABLE ABDOMEN INDICATION: ___ year old man with as above // check OGT placement-unable to see on CXR TECHNIQUE: Portable radiographs of the abdomen. COMPARISON: No prior examinations available for comparison. FINDINGS: There is a linear opacity which traverses the upper abdomen which may represent NG tube; however, extensive overlying support devices precludes definite identification of this as OG tube. Further, the OG tube is not seen on additional frontal images. Please obtain additional images for more definite localization and identification of OG tube. Otherwise, the images of the upper abdomen and chest show an ET tube with tip terminating 3.5 cm above the carina. There is a pulmonary artery catheter in the main pulmonary artery. Artificial aortic valve and surgical staples and wires are seen throughout the mediastinum. There is mediastinal widening consistent with recent surgery, and unchanged in comparison to chest x-ray obtained earlier on the same day. There may be left lower lobe basilar atelectasis obscuring the left hemidiaphragm. Otherwise, there are no focal lung consolidations. There is no pneumothorax or pleural effusion. There are no abnormally dilated loops of small or large bowel. There are no abnormal calcifications seen. There is no evidence of pneumatosis. IMPRESSION: 1. Extensive overlying support devices prevents identification and localization of NGT. Please obtain repeat imaging. 2. Possible left lower lobe subsegmental atelectasis, otherwise well-aerated lungs. 3. Unremarkable bowel gas pattern. Radiology Report EXAMINATION: CHEST (PORTABLE AP)CHEST (PORTABLE AP)i INDICATION: ___ year old man with as above // s/p repair of aortic disection w/hypoxia r/o effusion COMPARISON: Chest radiographs pre and postoperatively ___ and ___. IMPRESSION: Cardiomediastinal silhouette has a normal postoperative appearance unchanged since ___. Lungs are low in volume but clear. Midline and left pleural drains in place. No pneumothorax or appreciable pleural effusion. No pulmonary edema. Swan-Ganz catheter ends in the region of the pulmonic valve. ET tube in standard placement. Nasogastric tube ends in the upper portion of the nondistended stomach. Radiology Report EXAMINATION: CHEST RADIOGRAPHS INDICATION: Question retained sponges following sternal wound closure. TECHNIQUE: Chest, AP supine, two views. FINDINGS: There is no evidence of unanticipated radiodense foreign body. Sponges have been removed. Lines, tubes, and drains appear otherwise unchanged including endotracheal intubation, an orogastric tube, mediastinal drains, a left-sided chest tube, and a pulmonary venous catheter. The patient is status post aortic valve replacement. The cardiac, mediastinal and hilar contours appear unchanged. There is no definite pleural effusion or pneumothorax. Left basilar density is probably due to atelectasis and similar to the prior study. IMPRESSION: No evidence for unanticipated retained foreign body. Findings were discussed with Dr. ___ after the study by telephone. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man s/p AAA repair // eval for hypoxia etiology COMPARISON: ___ IMPRESSION: As compared to the previous radiograph, the Swan-Ganz catheter has been removed. The other monitoring and support devices, including the left chest tube, are in unchanged position. Minimal decrease in lung volumes with bilateral subtle homogeneous opacities at the lung bases, likely reflecting a combination of pleural effusions and atelectasis. Unchanged appearance of the mediastinum and the heart. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man s/p type A dissection repair // interval change TECHNIQUE: Portable chest film COMPARISON: Radiographs dating back to ___ FINDINGS: Left chest tube remains in place. ET tube terminates 5 cm above the carina. Median sternotomy clips and drains are unchanged in position. NG tube has migrated proximally since the prior examination, terminating near the cardia of the stomach with the port in the mid esophagus. Right layering mild to moderate pleural effusion with blurring of the right hemidiaphragm. There are prominent vascularity with horizontal linear opacities corresponding to mild interstitial edema, and interval finding. There is also a consolidation in the right lower lung which could be atelectasis or aspiration. The heart is moderately enlarged. IMPRESSION: Interval mild right-sided interstitial edema and layering right-sided mild to moderate pleural effusion. NG tube migrating proximal since the prior examination with the side port at the mid-esophagus; the NG tube can be advanced 15 cm. Right lower lung consolidation which could represent aspiration or atelectasis. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 12:13 ___, 1 minutes after discovery of the findings. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENTCHEST PORT. LINE PLACEMENTi INDICATION: ___ year old man s/p type A dissection repair-new cvl // assess line placement Contact name: ___, Phone: wer COMPARISON: Chest radiographs ___ through ___ at 08:14. IMPRESSION: Endotracheal tube has been advanced to standard position. Right jugular line ends in the mid SVC. Nasogastric drainage tube ends in the low esophagus as before and would need to be advanced at least 15 cm to move all side ports into the stomach. Newly inserted feeding tube passes into the stomach and out of view. Left pleural and midline drains in place. No pneumothorax pleural effusion or mediastinal widening. Normal postoperative appearance cardiac silhouette. Moderate bibasilar atelectasis is clearing Radiology Report EXAMINATION: CHEST (PORTABLE AP)CHEST (PORTABLE AP)i INDICATION: ___ year old man with aortic dissection // ?pleural effusion COMPARISON: Chest radiographs ___ through ___. IMPRESSION: Discrete consolidation, right lower lobe, worsened since ___, pneumonia into approved otherwise. Left infrahilar consolidation is typically due to atelectasis. No pneumothorax or left pleural effusion following removal of left pleural drain. Right internal jugular line ends in the low SVC. Normal postoperative cardiomediastinal silhouette. NOTIFICATION: Dr. ___ reported the findings to ___ by telephone on ___ at 12:02 ___, 10 minutes the initial attempt at paging the referring physician following discovery of the findings. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with s/p asc aorta replacement // hypoxia COMPARISON: ___ IMPRESSION: As compared to the previous radiograph, the pre-existing parenchymal opacities on the right have slightly increased in extent and severity. They are now located in the right perihilar regions. Retrocardiac atelectasis is unchanged. Moderate cardiomegaly. Status post valvular replacement. The right internal jugular vein catheter is of unchanged position. Radiology Report INDICATION: Status post ascending aorta replacement, evaluate perihilar opacity. TECHNIQUE: Bedside frontal chest radiograph. COMPARISON: Chest radiographs ___ and ___. FINDINGS: There has been near complete of the right perihilar opacities over the last 3 days. No new areas of consolidation worrisome for infection. Retrocardiac atelectasis persists. Trace bilateral pleural effusions are unchanged. Heart remains moderately enlarged. No pulmonary edema and no pneumothorax. A right internal jugular catheter courses into the mid SVC. Sternotomy wires and an aortic valve replacement are constant. IMPRESSION: Resolving right perihilar opacities without new areas of consolidation. Radiology Report EXAMINATION: CHEST (PA AND LAT)CHEST (PA AND LAT)i INDICATION: ___ year old man s/p Bentall // eval effusions COMPARISON: Chest radiographs ___ through ___ IMPRESSION: Small bilateral pleural effusion has probably decreased since ___, not evaluated previously with the lateral chest radiograph. Mild cardiomegaly stable. Lungs clear. No pneumothorax. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Chest pain Diagnosed with DISS THORACOABD AORTIC ANEURYSM temperature: nan heartrate: 58.0 resprate: nan o2sat: 98.0 sbp: 96.0 dbp: 52.0 level of pain: 4 level of acuity: 1.0

Mr ___ was transferred from an outside hospital with an typa A aortic dissection he was emergently brought to the operating room on ___ and underwent emergency repair of type A aortic dissection with Bentall procedure using a 25 mm ___ mechanical composite graft, and ascending aorta hemi arch replacement using a 28 mm Gelweave graft. Please see operative note for full details. He tolerated the procedure well, however he had significant bleeding issues intraoperatively and requiried multiple units of red cells an, platelets and fresh frozen plasma. Once the bleeding was somewhat minimized he was transferred to the CVICU chemically paralyzed and sedated with an open chest for recovery and invasive monitoring. He returned to the operating room the following day for: mediastinal washout and chest closure. He tolerated that procedure and again was transferred to the cardiac surgery ICU in stable condition. He was slowly weaned from pressors and was started on diuretics because of volume overload. He was finally able to wean from sedation, awoke neurologically intact and was extubated on POD 5. All tubes lines and drains were removed per cardiac suregry protocols without complication. Beta blockers were initiated and he continued diuresis toward his preoperative weight. He remained hemodynamically stable and was transferred to the telemetry floor for further recovery on POD8. Once on the floor he worked with nursing and physical therapy for assistance with strength and mobility. By the time of discharge on POD 12 he was ambulating freely, the wound was healing, and pain was controlled with Dilaudid and Tylenol. He was discharged home with physical therapy and visiting nurses in good condition. He is to follow up with Dr ___ in 1 month.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Hemopneumothorax Major Surgical or Invasive Procedure: None History of Present Illness: ___ hx AS/bicuspid aortic valve s/p repair/reconstruction ___, now ~4d after bicycle accident initially presenting to ___ where clavicular fracture, and rib fractures with pneumothorax reportedly diagnosed and managed conservatively without decompression, discharged HD2. Pt reports CT head/cspine negative. Seen by PCP today, where ___ CXR done noting hemopneumothorax prompting presentation to ___ ED. At time of consultation, pt AFVSS, Sa02 99rm air without dyspnea or increased work of breathing. CXR pa/l here notable for displaced L clavicular fracture, pneumothorax with apex down to 3rd rib, blunting of L costophrenic angle. Will plan for DART placement in ED, admission to trauma service for pain control. Past Medical History: PMH: AS, ascending aortic root aneurysm PSH: ___ ___ ___ ALL: NKDA ___: warfarin ___, metoprolol 25'', ASA 81 Social History: ___ Family History: Mother had two MI's in the past. Maternal grandmother with diabetes Physical Exam: VS: T 98.1, HR 80, BP 107/72, RR 18, SaO2 99%rm air GEN: A&Ox3, NAD HEENT: No scleral icterus, mucus membranes moist PULM: no respiratory distress, CTAB ABD: Soft, nondistended, nontender, no rebound or guarding Ext: No ___ edema, ___ warm and well perfused Pertinent Results: LABS: 10.2 142 / 100 / 14 4.5 >------< 187 ----------------< 123 AGap=14 30.4 3.9 / 32 / 0.9 estGFR: >75 N:56.9 L:24.4 M:13.6 E:4.2 Bas:0.7 PTT: 37.8 INR: 3.4 IMAGING: ___ CXR pa/l - Sternal wires and aortic valve replacement again seen. New since prior study is a moderate left apical pneumothorax with a small left pleural effusion. Displaced mid clavicular fracture. Given trauma, effusion concerning for a hemothorax. Chest xray ___ Very small left apical pneumothorax unchanged since ___, small bore pleural drainage catheter unchanged in position. Small left pleural effusion slightly decreased in the interim. Substantial left lower lobe atelectasis unchanged. Right lung clear. Heart size normal. Mild mediastinal leftward shift unchanged. Pelvis AP ___ No evidence of acute fracture or dislocation. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ with s/p chest tube // eval for ptx TECHNIQUE: Chest PA and lateral COMPARISON: Multiple prior radiographs most recent on ___ FINDINGS: The cardiomediastinal and hilar contours are stable. Sternal wires and an aortic valve replacement are again demonstrated. A left apical pneumothorax is decreased in size from ___ and is small. A small left-sided chest tube projects over the left hemi thorax. A displaced midclavicular fracture on the left is unchanged. A small left pleural effusion is minimally increased in size. Multiple left-sided rib fractures are identified. Of note, there is irregularity of the left eighth rib, suggesting possible osseous lesions/pathologic rib fracture. IMPRESSION: Small left apical pneumothorax is decreased from the prior exam. Small left pleural effusion is minimally increased in size. No other significant change. Multiple left-sided rib fractures are again seen as mentioned above including a possible osseous lesion affecting the left 8th rib. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ s/p fall from bicycle with L pneumothorax, interval dart placement now on water-seal. Please assess for interval change // ___ s/p fall from bicycle with L pneumothorax, interval dart placement now on water-seal. Please assess for interval change ___ s/p fall from bicycle with L pneumothorax, interval dart COMPARISON: Chest radiographs ___ and ___ at 05:10. IMPRESSION: Very small left apical pneumothorax unchanged since ___, small bore pleural drainage catheter unchanged in position. Small left pleural effusion slightly decreased in the interim. Substantial left lower lobe atelectasis unchanged. Right lung clear. Heart size normal. Mild mediastinal leftward shift unchanged. NOTIFICATION: Dr. ___ reported the findings to Dr ___ by telephone on ___ at 3:32 ___, 1 minutes after discovery of the findings. Radiology Report INDICATION: Trauma with multiple fractures. Assess a occult pelvic fracture. TECHNIQUE: Single AP radiograph of the pelvis and hips. FINDINGS: This examination is essentially normal with no fracture and the hips and SI joints are WNL. Unusual appearance of the lateral portion of the right femoral neck may reflect external rotation. IMPRESSION: No fracture. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man w/ L hemoptx, L clavicle fx, 1st rib fx // Is hemopneumothorax resolving with chest tube to water seal? TECHNIQUE: Chest PA and lateral COMPARISON: ___ FINDINGS: Left apical pneumothorax is small. The degree of pleural fluid at the left lung base is similar, small. Right lung is clear. Left lower lobe atelectasis, sternal wires, and aortic valve replacement are similar to the prior radiograph. Mildly displaced left mid-clavicular fracture is unchanged in alignment and displacement from the prior radiographs. Known 1st rib fracture is not well seen. IMPRESSION: Similar appearance compared to ___, with small left apical pneumothorax and small left pleural effusion. Radiology Report INDICATION: ___ year old man s/p fall, hemothorax, s/p chest tube removal // please eval for pneumothorax, please do CXR at 3pm TECHNIQUE: Portable AP upright view of the chest COMPARISON: ___ at 09:05 am FINDINGS: Cardiomediastinal silhouette stable. The left chest tube has been removed. Increased opacity at the left base may represent atelectasis. A small left pleural effusions unchanged. A very small left apical pneumothorax is unchanged. IMPRESSION: 1. Stable very small left apical pneumothorax. 2. Increased left basilar atelectasis. Small left pleural effusion is unchanged. Gender: M Race: WHITE - OTHER EUROPEAN Arrive by WALK IN Chief complaint: L Rib pain Diagnosed with TRAUM PNEUMOHEMOTHOR-CL, PED CYCL ACC-PED CYCLIST, ACTIVITIES INVOLVING BIKE RIDING temperature: 99.0 heartrate: 65.0 resprate: 18.0 o2sat: 96.0 sbp: 130.0 dbp: 84.0 level of pain: 1 level of acuity: 2.0

Patient was seen in ___ ED s/p blunt trauma to L chest 4 days prior to presentation, findings consistent with hemopneumothorax. Pigtail thoracostomy catheter was placed at the bedside in the ED and patient was admitted for pain control. Chest tube had sanguinous discharge and coumadin was held (INR 3.14 at admission). Patient was also found to have L clavicle fracture and L first rib fracture and was treated with NWB in sling to his left arm to stabilize the fractures. Patient was c/o hip pain and his pelvis AP revealed no evidence of acute fracture or dislocation. He did have L gluteal hematoma On HD 2, the chest tube was placed on waterseal and CXR revealed small pneumothorax unchanged from prior, small pleural effusion, LLL atelectasis. Patient was alert and oriented throughout hospitalization; pain was well-controlled, remained stable from a cardiovascular and pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. Regular diet was well tolerated. Patient's intake and output were closely monitored. His fever curves were closely watched for signs of infection, of which there were none. The patient's blood counts were closely watched for signs of bleeding, of which there were none. At the time of discharge on HD 2, patient's INR was 2.7, coumadin was restarted, he was doing well, afebrile, hemodynamically stable, tolerating regular diet, ambulating, voiding without assistance, pain was well controlled, and was discharged to home in a medically stable condition. The patient received discharge teaching and ___ instructions with understanding verbalized and agreement with the discharge plan to follow up in Ortho Trauma Clinic in 2 weeks.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / aspirin Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Per admitting resident: Ms. ___ patient ___ to the ___ service, is a ___ hx laparoscopic RNY gastric bypass ___ complicated course since requiring gastrostomy tube placement dependent on tube feeds for hypoglycemia, as well as treatment for marginal ulcers. She returns to the ED today with c/o ___ G-tube > epigastric/RUQ pain which began ___ days ago without any inciting event. She has had multiple recent admissions and ED visits for G-tube site pain, most recently on ___. She was evaluated in the ED and sent home when the pain resolved. She states that the pain has worsened the past 2 days. She states it's different from her previous episodes because of the epigastric and RUQ pain, similar to her former presentation when she had peptic ulcer. She has tried tylenol with little relief. She has not taken oxycodone, since she has run out. taking She has been able to stay on her TF at a continuous 40 cc/hr without vomiting, or diarrhea, and has had no problems with the tube feeds. She denies any blood per rectum or by mouth. She does note that the tube feed appears to leak around the tube. She has otherwise had no fevers, chills, chest pain, or shortness of breath. Of note, she is anxiously waiting to have her G-tube replaced ___ and wishes it could be done sooner. Past Medical History: 1. Obstructive sleep apnea, resolved. 2. Gastroesophageal reflux, resolved. 3. History of polycystic ovary disease. 4. History of fatty liver. 5. History of gastrojejunal anastomotic ulcer. 6. History of C. difficile colitis, ___. 7. Depression and anxiety. 8. Post-gastric bypass hypoglycemia. 9. Breath test positivity for bacterial overgrowth, ___. 10. MRSA positivity. Past Surgical History: 1. Right carpal tunnel surgery in ___. 2. Right shoulder surgery in ___. 3. Tubal ligation in ___. 4. Laparoscopic Roux-en-Y gastric bypass in ___. 5. Right internal jugular Hickman placed ___, status post removal. 6. Appendectomy. 7. Laparoscopic gastrostomy tube in ___, status post removal. 8. Interventional placed gastrostomy tube inadvertently placed in the Roux limb in ___, status post removal. 9. Laparoscopic converted to open gastrostomy tube placement in ___. Currently, tube is ___ MIC gastrostomy tube, 20 ___ with a ___ mL balloon. 10. Wound drainage and removal of foreign body (suture) from abdominal wall incision in ___. Social History: ___ Family History: Her family history is remarkable for obesity and CAD. Physical Exam: Neuro: alert and oriented x 3 Cardiac: regular rate and rhythm Resp: clear to auscultation, bilaterally Abd: soft, + tender to palpation, no rebound tenderness or guarding Wounds: g-tube insertion site without erythema or induration Ext: no edema Pertinent Results: ___ 05:05AM BLOOD WBC-5.5# RBC-3.72* Hgb-11.9* Hct-34.5* MCV-93 MCH-31.9 MCHC-34.5 RDW-14.3 Plt ___ ___ 05:00PM BLOOD WBC-11.4*# RBC-4.30 Hgb-13.9 Hct-40.1 MCV-93 MCH-32.2* MCHC-34.6 RDW-14.6 Plt ___ ___ 05:00PM BLOOD Neuts-70.8* ___ Monos-6.0 Eos-2.8 Baso-0.4 ___ 05:05AM BLOOD Glucose-80 UreaN-9 Creat-0.8 Na-142 K-4.0 Cl-106 HCO3-28 AnGap-12 ___ 05:00PM BLOOD Glucose-129* UreaN-9 Creat-0.8 Na-137 K-3.6 Cl-103 HCO3-25 AnGap-13 ___ 05:00PM BLOOD ALT-20 AST-21 AlkPhos-114* TotBili-0.2 ___ 05:00PM BLOOD Lipase-28 ___ 05:05AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.2 ___ 05:00PM BLOOD Albumin-4.4 ___ 06:00AM BLOOD Lactate-1.5 ___ 04:59PM BLOOD Lactate-3.1* ___: LIVER OR GALLBLADDER US (SINGLE ORGAN): IMPRESSION: No evidence of cholelithiasis or cholecystitis. Medications on Admission: abilify fluoxetine 60' rifaximin 550' Prevacid 30'' lorazepam 1''' ondansetron 4 q 8 hrs prn ambien 5' ferrous sulfate 325' MV'' oxycodone ___ mg q 6hrs prn Discharge Medications: 1. Abilify (ARIPiprazole) 1 mg/mL oral DAILY 2. Acetaminophen 650 mg PO Q6H:PRN pain 3. Fluoxetine 60 mg PO DAILY 4. OxycoDONE Liquid ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg/5 mL ___ ml by mouth every six (6) hours Refills:*0 5. Rifaximin 550 mg PO/NG BID 6. Sucralfate 1 gm PO QID RX *sucralfate 1 gram/10 mL 10 suspension(s) by mouth four times a day Refills:*0 7. Lansoprazole Oral Disintegrating Tab 30 mg PO BID 8. Lorazepam 1 mg PO TID 9. Ondansetron 4 mg PO Q8H:PRN nausea 10. Zolpidem Tartrate 5 mg PO QHS 11. Ferrous Sulfate 325 mg PO DAILY 12. Multivitamins W/minerals 1 TAB PO BID Discharge Disposition: Home Discharge Diagnosis: Abdominal pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ with RUQ pain and nausea // Eval for cholecystitis TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: CT of the abdomen and pelvis dated ___. FINDINGS: LIVER: The hepatic parenchyma appears within normal limits. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is 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. KIDNEYS: Limited views of the right kidney are unremarkable. RETROPERITONEUM: Visualized portions of aorta and IVC are within normal limits. IMPRESSION: No evidence of cholelithiasis or cholecystitis. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Abd pain Diagnosed with ABDOMINAL PAIN OTHER SPECIED temperature: 98.9 heartrate: 94.0 resprate: 16.0 o2sat: 100.0 sbp: 108.0 dbp: 86.0 level of pain: 8 level of acuity: 3.0

Ms. ___ presented to the hospital on ___ with abdominal pain, which she reported as right upper abdominal pain, which was different in nature from her chronic g-tube site pain. Upon arrival, she was maintained on bowel rest, given intravenous fluids and a pantoprazole gtt; a right upper quadrant ultrasound was obtained and not indicative of cholecystitis. She was subsequently admitted to the ___ service for ongoing observation and continued antiacid therapy given presumed recurrence of a marginal ulcer. On HD3, after the addition of sucralfate and continued intravenous pantoprazole, the patient's presenting pain improved significantly. She remained afebrile and hemodynamically stable and was tolerating enteral feedings and po water. She was subsequently discharged to home and will has g-tube revisional surgery scheduled for ___.

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: vaginal cuff dehiscence Major Surgical or Invasive Procedure: vaginal cuff repair History of Present Illness: ___ yo ___ s/p TLH for symptomatic fibroid uterus on ___. Today she presents from OSH with diffuse abdominal pain, nausea and vomiting and vaginal discharge. At 1130 pm she was having intercourse with her husband and she had sudden onset of sharp ___ abdominal pain and a large gush of clear fluid. The pain has continued and is diffuse, crampy and associated with nausea and emesis. She has continued to have nausea but only one further episode of emesis since then. She presented to an outside hospital ED where her WBC was 18. Her vital signs were: 98.4, 88, 18, 88/58, 100% RA. She received one dose of IV Zosyn, 8 mg of IV Zofran, and 2 mg of IV Dilaudid over 4 hours. Per patient report an ultrasound demonstrated loops of bowel in the vagina but these images were not available for my review. She was transferred to ___ for further management. Prior to this she was in her usual state of health. She had an otherwise uncomplicated post-op course. She denies any preceding pelvic pain, fevers, dyspareunia. She denies fevers, chills, feeling dizzy, lightheaded or short of breath. She denies any "pop" sensation. She was not using any sex toys. She denies vaginal bleeding. Past Medical History: POB: SVD X 2, uncomplicated. PGYN: fibroid uterus, denies STIs or abnormal paps PMH: denies any significant medical history. No h/o thromboembolic disease, HTN, asthma PSH: TLH ___ Social History: ___ Family History: She denies any family history of breast cancer, ovarian cancer, uterine cancer, or colon cancer. Physical Exam: Physical Exam on Discharge: VSS General: NAD, comfortable CV: RRR Pulm: Lungs clear to auscultation bilaterally Abd: Soft, mildly distended, +bs, nontender Ext: Warm well perfused, nontender to palpation Pertinent Results: ___ 12:20PM BLOOD WBC-19.6*# RBC-4.06*# Hgb-12.5# Hct-38.1# MCV-94 MCH-30.7 MCHC-32.7 RDW-12.1 Plt ___ ___ 05:49PM BLOOD WBC-20.8* RBC-4.14* Hgb-12.7 Hct-38.9 MCV-94 MCH-30.8 MCHC-32.8 RDW-12.7 Plt ___ ___ 06:10AM BLOOD WBC-11.7* RBC-3.55* Hgb-10.7* Hct-33.6* MCV-95 MCH-30.1 MCHC-31.8 RDW-12.8 Plt ___ ___ 05:50AM BLOOD WBC-7.7 RBC-3.41* Hgb-10.5* Hct-32.2* MCV-94 MCH-30.7 MCHC-32.5 RDW-12.8 Plt ___ Medications on Admission: None Discharge Medications: 1. oxycodone-acetaminophen ___ mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*60 Capsule(s)* Refills:*1* Discharge Disposition: Home Discharge Diagnosis: vaginal cuff dehiscence Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ woman status post total laparoscopic hysterectomy, now vaginal dehiscence. This is an outside study from ___. COMPARISON: CT of the abdomen and pelvis from ___. CT OF THE ABDOMEN: The lung bases are clear aside from minimal dependent atelectasis. Within the liver, there is a tiny 4-mm hypodensity at the dome and 2-mm hypodensity at the junctions of segments ___ likely cysts or hemangiomas. Otherwise, the liver is unremarkable. Gallbladder, spleen, pancreas, and bilateral adrenals are normal appearing. Bilateral kidneys enhance and excrete contrast symmetrically with no evidence of hydronephrosis, stones, or masses. Within the abdomen, the stomach and loops of small and large bowel are unremarkable. Appendix is unremarkable. CT OF THE PELVIS: Status post hysterectomy. There are air-fluid levels within a loop of ileum (2:66) around the presumed surgical site. There is pelvic free fluid along with more organized locular fluid (2:57) along the right pelvic sidewall without any rim enhancement measuring approximately 2.9 x 1.7 cm. The vagina is not fully evaluated on this CT, however no obvious evidence of dehiscence or loops of bowel within the vagina are noted. CT OF THE BONES: There is osteitis condensans of the sacroiliac joints. Otherwise, no suspicious lytic or sclerotic lesions. IMPRESSION: 1. No definite CT evidence of vaginal dehiscence reported on physical examination. Limitations noted above. 2. Pelvic free fluid, which along the right pelvic side wall may be loculated, without any evidence of abscess formation at this time. 3. Nonspecific air fluid levels in a loop of ileum. Findings discussed with Dr. ___ on ___ in the afternoon. Gender: F Race: ASIAN Arrive by AMBULANCE Chief complaint: VAGINAL WOUND DEHISSENCE Diagnosed with DISRUPTION OF EXTERNAL OPERATION (SURGICAL) WOUND, ABN REACT-PROCEDURE NOS temperature: 97.3 heartrate: 80.0 resprate: 16.0 o2sat: 97.0 sbp: 107.0 dbp: 70.0 level of pain: 2 level of acuity: 3.0

Ms ___ was admitted on ___ from an OSH with a vaginal cuff dehiscence. In the ED small bowel was visualized in the vagina, was easily reduced at which point a foley was placed and vagina was packed. Patient was then taken to the OR and underwent vaginal cuff repair. For full detail see operative note. Ms ___ recovered well in the PACU and was transferred to the floor in stable condition. Ms ___ WBC count on admission was elevated at 19.6. On POD 1 Ms ___ was tolerating PO, pain well controlled and tolerating regular diet. Her white count dropped to 11.7. She received 24 hours of Levo/flagyl. On POD 2 Ms ___ had met all post operative mile stones, her WBC count dropped to 7.7 and she was discharged in stable condition with follow up appointment scheduled with Dr. ___.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa(Sulfonamide Antibiotics) / hydrochlorothiazide / Quinidine-Quinine Analogues Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: ___ with history of refractory asthma (no hx of intubations), paroxysmal atrial fibrillation, who presents with cough and shortness of breath x 2 days: Pt presents with worsening shortness of breath and cough x 2 days. She reports that she had been doing well on the day of her recent discharge. However, the day PTA she noted increasing dry cough and chest tightness. She took her peak flow and it was 240 (baseline is 250). She took a neb and felt better. However, today she again noted worsening asthma symptoms that did not respond to 2 nebs. She presented to PCP and was referred in to ED. Pt thinks possible triggers for this episode could be the weather and exposure to a smoker on day PTA. She does feel that she might be developing a URI but has a nonproductive cough. She feels that her living conditions contribute to her symptoms as she is exposed to cigarette smoke, dust, mold, and has carpeting. She denies fevers, CP, sputum production, change in chronic leg swelling. She endorses passive SI and had thought about stopping her medicines as a way of committing suicide. She denies this now. She has no hx of prior SA. Of note, pt had recent hospitalization (___) for asthma exacerbation that was treated w/ prednisone 60mg. Lisinopril was discontinued given concern that it could be contributing to cough. SHe has been chronically on steroids since ___ and states the lowest she has been able to wean to is 20mg prednisone. She has been on pred 60 x 2 weeks now. In the ED, initial vitals were: 97.2 97 156/99 21 97% - Labs were significant for: leukocytosis to 18.8 with 77.7% PMNs, BUN 24, Cr 0.9, K 3.3. D-dimer negative. - Imaging revealed: CXR without acute intrathoracic process - Consults: Evaluated by ___ and provided with a letter for BHA. Pt expressed passive SI and was evaluated by psychiatry who felt she did not meet ___ criteria and recommended haldol QHS for sleep. - Peak flow was reportedly 210, 230 then after tx improved to 250. - The patient was given: azithromycin 500mg, ipratropium bromide neb x 2, levalbuterol neb x 2, haloperidol 1mg x1 Vitals prior to transfer were: 97.8 96 120/76 18 95% RA Upon arrival to the floor, pt confirms above history, she states she is feeling better both from an asthma standpoint and from psych perspective. She wants to defer prednisone dose until the morning. She feels sad about how sick she is but has hope that things will improve. Past Medical History: DM ASTHMA HYPERTENSION SPINAL STENOSIS ENDOMETRIAL POLYPS PULMONARY NODULE SYRINGOMYELIA DEPRESSION SLEEP APNEA GIB - gastric ulcer Social History: ___ Family History: Father deceased. COPD, Diabetes - Type I Mother ___ at ___ ___ - Type II; liver disease, rheumatoid arthritis Paternal Grandmother ___ - Type I Physical Exam: ======================= ADMISSION PHYSICAL EXAM: ======================= Vitals: 133.7kg, 97.9 150/80 98 18 93% on RA General: obese woman in no distress HEENT: Sclera anicteric, +thrush, oropharynx clear, EOMI, PERRL. Neck: Supple, obese, unable to assess JVP due to habitus. Buffalo hump present. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: good air movement. bilateral mild wheezing. breathing comfortably and able to speak in full sentences w/o pausing for a breath. No coughing during interview. Abdomen: Soft, non-distended, obese, mild RUQ tenderness. GU: No foley Ext: Warm, well perfused, pulses not palpable due to edema but feet are warm, pitting edema extending to knees and dependent areas on thighs Neuro: CNII-XII intact, A&OX3, gait deferred. ======================= DISCHARGE PHYSICAL EXAM: ======================= Vitals: T 97.7 145/68 RR 76 RR 18 100% on RA General: Obese woman in no distress HEENT: Sclera anicteric, +thrush, oropharynx clear, EOMI, PERRL. Neck: Supple, obese, unable to assess JVP due to habitus. Buffalo hump. CV: Distant heart sounds. Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Decreased air movement. Bilateral mild wheezing. Breathing comfortably and able to speak in full sentences w/o pausing for a breath. No coughing during interview. Abdomen: Soft, non-distended, nontender obese. Ext: Warm, well perfused, pulses not palpable due to edema but feet are warm, 3+ pitting edema extending to knees and dependent areas on thighs Neuro: CNII-XII intact, A&OX3, gait deferred. Pertinent Results: ============== ADMISSION LABS: ============== ___ WBC-18.8* RBC-4.46 Hgb-12.3 Hct-39.0 MCV-87 MCH-27.6 MCHC-31.5* RDW-20.2* RDWSD-63.4* Plt ___ ___ Neuts-77.7* Lymphs-15.3* Monos-5.8 Eos-0.3* Baso-0.2 Im ___ AbsNeut-14.58* AbsLymp-2.87 AbsMono-1.09* AbsEos-0.06 AbsBaso-0.04 ___ Glucose-84 UreaN-24* Creat-0.9 Na-144 K-3.3 Cl-103 HCO3-29 AnGap-15 ___ D-Dimer-<150 ================ PERTINENT RESULTS: ================ CXR (___): Lower lung volumes seen on the current frontal view. Right midlung linear opacities compatible surgical chain sutures from prior wedge resection. The lungs are clear without focal consolidation worrisome for infection, edema or effusion. The cardiomediastinal silhouette is stable. Moderate hiatal hernia is again noted. No acute osseous abnormalities. == ECG: NSR 87, normal axis, normal intervals, QTc 395, TWI III similar to prior. No ST changes. ============== DISCHARGE LABS: ============== ___ WBC-13.5* RBC-4.20 Hgb-11.4 Hct-37.2 MCV-89 MCH-27.1 MCHC-30.6* RDW-20.2* RDWSD-64.0* Plt ___ ___ Glucose-81 UreaN-22* Creat-1.0 Na-142 K-3.7 Cl-104 HCO3-29 AnGap-13 ___ Calcium-9.0 Phos-3.3 Mg-2.1 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Diltiazem Extended-Release 180 mg PO DAILY 2. Ferrous Sulfate 325 mg PO DAILY 3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 4. Furosemide 40 mg PO DAILY 5. Montelukast 10 mg PO DAILY 6. Nortriptyline 30 mg PO QHS 7. Omeprazole 20 mg PO Q12H 8. PredniSONE 60 mg PO DAILY 9. Warfarin 2.5 mg PO 3X/WEEK (___) 10. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN SOB 11. levalbuterol HCl 0.63 mg/3 mL INHALATION Q8H:PRN SOB 12. Cetirizine 10 mg PO DAILY 13. Multivitamins 1 TAB PO DAILY 14. Warfarin 3 mg PO 4X/WEEK (___) Discharge Medications: 1. Cetirizine 10 mg PO DAILY 2. Diltiazem Extended-Release 180 mg PO DAILY 3. Ferrous Sulfate 325 mg PO DAILY 4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 5. Furosemide 40 mg PO DAILY 6. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN SOB 7. Montelukast 10 mg PO DAILY 8. Nortriptyline 30 mg PO QHS 9. Omeprazole 20 mg PO Q12H 10. PredniSONE 60 mg PO DAILY 11. Warfarin 2.5 mg PO 3X/WEEK (___) 12. Warfarin 3 mg PO 4X/WEEK (___) 13. Azithromycin 250 mg PO Q24H RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*3 Tablet Refills:*0 14. Calcium Carbonate 1000 mg PO DAILY RX *calcium carbonate [Calcium 500] 500 mg calcium (1,250 mg) 2 tablet(s) by mouth once a day Disp #*60 Tablet Refills:*1 15. Dapsone 100 mg PO DAILY RX *dapsone 100 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 16. Nystatin Oral Suspension 5 mL PO QID RX *nystatin 100,000 unit/mL 5 mL by mouth four times a day Refills:*0 17. Vitamin D 400 UNIT PO DAILY RX *ergocalciferol (vitamin D2) 400 unit 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 18. Multivitamins 1 TAB PO DAILY 19. levalbuterol HCl 0.63 mg/3 mL INHALATION Q6H:PRN SOB Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis 1. Asthma/COPD exacerbation Secondary Diagnoses 1. Paroxysmal atrial fibrillation 2. Depression 3. Lower extremity edema 4. DM 2 5. GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with COPD/Asthma p/w exacerbation of the samee // eval for ptx TECHNIQUE: PA and lateral views the chest. COMPARISON: ___. FINDINGS: Lower lung volumes seen on the current frontal view. Right midlung linear opacities compatible surgical chain sutures from prior wedge resection. The lungs are clear without focal consolidation worrisome for infection, edema or effusion. The cardiomediastinal silhouette is stable. Moderate hiatal hernia is again noted. No acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary process. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Dyspnea Diagnosed with ASTHMA, CHRONIC OBSTRUCTIVE, WITH ACUTE EXACERBATION temperature: 97.2 heartrate: 97.0 resprate: 21.0 o2sat: 97.0 sbp: 156.0 dbp: 99.0 level of pain: 0 level of acuity: 3.0

Ms. ___ is a ___ woman with history of refractory asthma and multiple recent hospitalizations for asthma exacerbations with most recent discharge on ___ who presents with cough and shortness of breath x 2 days consistent with asthma/COPD exacerbation. ============ ACTIVE ISSUES: ============ # Asthma/COPD Exacerbation: The patient presented with 2 days of cough and shortness of breath after recent discharge on ___ for asthma/COPD exacerbation. She was continued on prednisone 60 mg PO daily, levalbuterol HCl 0.63 mg/3 mL inhalation Q6H:PRN SOB, Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN SOB, Montelukast 10 mg PO daily, Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID. She was given 2 doses of azithromycin, and discharged on azithromycin 250mg po x 3 additional days. She was instructed that she could take her levalbuterol inhaler up to every 6 hours for shortness of breath. At discharge, the patient was able to ambulate while maintaining her oxygen saturations at 94%. # Thrush: Due to using inhaled steroids. Patient discharged on nystatin oral solution. # Chronic steroid use: Patient reports an allergic reaction to atovaquone and has a history of rash to sulfa. She was started on dapsone 100mg po daily for PJP prophylaxis. She was also started on calcium and vitamin D . # Depression: Patient continues to have anxiety/irritability and poor sleep, likely in part due to steroids as well as difficulty coping with the stress of chronic illness. Denied SI. Evaluated by psych in the ED with diagnosis of mood anxiety disorder from six months of steroids vs. adjustment disorder. Continued nortriptyline 30 mg PO QHS. =============

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Hydrochlorothiazide / Heparin Agents / Vancomycin / Levofloxacin / Latex / Benadryl Decongestant / plastic tape / Sensipar / shellfish derived Attending: ___. Chief Complaint: Hemoptysis Major Surgical or Invasive Procedure: None. History of Present Illness: Mrs. ___ is a ___ year old female with complex PMH including ESRD on HD, HIV on HAART (CD4 ___, atrial fibrillation on warfarin, renal cell carcinoma s/p right nephrectomy (___), diastolic HF, pulmonary HTN who presents with hemoptysis and cough. Pt was at her baseline, but yesterday morning at 2:30, she had one episode of hemoptysis with a quarter-sized blood clot. She went back to sleep, and when she awoke, she coughed up pink sputum that since cleared. She endorsed chest tightness, shortness of breath, wheezing and chills. Pt has never coughed up blood like this ___ the past. The patient also had 1 episode of non-bloody vomiting yesterday morning with mild epigastric pain. She also has orthopnea. She endorses having a chronic cough that is both dry and productive x ___ year. Pt missed her dialysis on ___ because her ride did not show up. On a ___ schedule. She usually has 1 - 1.5L removed; and says she doesn't really get "very puffy." ___ the ED, initial vitals were: 99.1 86 162/86 16. Labs were significant for Cr 11.9, K 5.8, elevated LFTs, ___ 43000, INR 2.9, d-dimer negative, trop 0.04, lactate 2.0. Imaging revealed: CXR: Diffuse bilateral pulmonary opacities raise concern for severe pulmonary edema. The patient was given: ___ 18:01 IV Ondansetron 4 mg. She was seen by renal and HD was performed ___ the ED with ultrafiltration. She was also seen by IP who recommended CT chest. Vitals on transfer: 98.4 80 128/65 25 100% RA. Upon arrival to the floor, patient states that breathing has improved. Continues to have cough and wheezing. No CP, chest pressure or chest tightness at this time. Denies any more episodes of hemoptysis. REVIEW OF SYSTEMS: (+) Per HPI (-) Denies fever, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change ___ bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History: - Paroxysmal Atrial Fibrillation on warfarin. First diagnosed with PAF with RVR ___. Hx of TIA ___ ___ (negative MRI/MRA, but presented with transient R sided hemiparesis. ___ ___ underwent pulmonary venous ablation with cryoballoon which was initially successful but had reversion. Trialed dronaderone but this was stopped ___ concerns for NSIP. - Pulmonary hypertension - ESRD on HD at ___ (on HD since ___ via left arm bovine graft - TIA ___ - Raynaud's phenomenon - Hypertension - Left ventricular hypertrophy - Polycystic kidney disease - Atypical CP - cath ___ normal coronaries, negative stress ___ ___, and multiple CTA to rule out PEs. - S/p left open nephrectomy (___) Social History: ___ Family History: Mother died at ___. ___ side with numerous cancers. Father died at ___, history of diabetes ___ father's side of family. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== Vital Signs: T 98.7 BP 128/82 HR 82 RR 16 99%RA General: Alert, oriented, no acute distress; pleasant; spontaneous coughing. HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, JVP not elevated at 45 degrees, no LAD. Lungs: Basilar crackles, and mid lung rhonchi on Left; reduced air motion on Right lung, but no rhonchi or wheezes. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops. Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no HSM. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Without rashes or lesions. Neuro: ___ strength ___ upper and lower extremities. EOM intact. DISCHARGE PHYSICAL EXAM: ========================== Vital Signs: Tm 98.1 ___ 20 98% RA General: Alert, oriented;; pleasant; no spontaneous coughing. HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, JVP NOT elevated at 45 degrees, no LAD. Lungs: Minimal basilar crackles L lung, no expiratory wheezes or rhonchi. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops. Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no HSM. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Without rashes or lesions. Neuro: ___ strength ___ upper and lower extremities. EOM intact. Pertinent Results: ADMISSION LABS: ======================== ___ 04:55PM LACTATE-2.0 K+-5.8* ___ 04:51PM GLUCOSE-89 UREA N-80* CREAT-11.9*# SODIUM-135 POTASSIUM-6.9* CHLORIDE-93* TOTAL CO2-23 ANION GAP-26* ___ 04:51PM ALT(SGPT)-47* AST(SGOT)-45* ALK PHOS-209* TOT BILI-0.4 ___ 04:51PM LIPASE-91* ___ 04:51PM WBC-7.6 RBC-2.33* HGB-7.8* HCT-24.2* MCV-104* MCH-33.5* MCHC-32.2 RDW-14.8 RDWSD-56.1* ___ 04:51PM PLT COUNT-130*# ___ 04:51PM ___ PTT-46.0* ___ ___ 04:51PM cTropnT-0.04* ___ 04:51PM ___ IMAGING/STUDIES: ========================== CXR ___: Diffuse bilateral pulmonary opacities raise concern for severe pulmonary edema. Underlying infection, particularly ___ the left mid lung, not excluded. ECG: sinus, rate 78. no ST changes. CTA Chest ___: IMPRESSION: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Interval progression of interlobular septal thickening and diffuse ground-glass opacity compatible with pulmonary edema. 3. Slight interval decrease ___ bilateral pleural effusions. 4. Interval progression of peribronchovascular nodular ground-glass opacities, now with a morphology resembling "crazy paving." The constellation of findings suggests a complex differential. Findings including interlobular septal thickening, pleural effusions and a crazy paving appearance may be explained by pulmonary edema. Given history of HIV, the most probable differential is pneumocystis pneumonia given crazy paving appearance and interlobular septal thickening. Less likely is ___'s sarcoma which would explain crazy paving opacities and lymphadenopathy. 5. Prominent mediastinal lymph nodes have minimally decreased ___ size compared to the prior examination. 6. Renal osteodystrophy. 7. Diffuse bronchial wall thickening suggestive of chronic small airways disease. RECOMMENDATION(S): Recommend diuresis and empiric treatment for pneumocystis pneumonia with short-term interval followup imaging after completion of therapy. If findings persist, biopsy is recommended ___ order to exclude Kaposi's sarcoma. CT CHEST W/ CONTRAST ___: (Done immediately after HD session) IMPRESSION: 1.Significant improvement ___ bilateral ground glass opacities and pleural effusions. 2.Persistent confluent areas of consolidation may be related to the sequela of PCP, ___, or organizing pneumonia. Kaposi sarcoma is less likely given significant improvement. MICROBIOLOGY/CYTOLOGY: =============== ___ 9:50 am BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE TEST//LLL. GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final ___: NO GROWTH, <1000 CFU/ml. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final ___: TEST CANCELLED, PATIENT CREDITED. This is a low yield procedure based on our ___ studies. if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory (___). Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final ___: TEST CANCELLED, PATIENT CREDITED. DUPLICATE SPECIMEN. SPECIMEN COMBINED WITH SAMPLE # ___. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): 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. ___ 9:53 am BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE TEST. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS. RESPIRATORY CULTURE (Final ___: 10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final ___: TEST CANCELLED, PATIENT CREDITED. This is a low yield procedure based on our ___ studies. if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory (___). Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final ___: SPECIMEN COMBINED WITH SAMPLE # ___. NEGATIVE for Pneumocystis jirovecii (carinii). FUNGAL CULTURE (Preliminary): YEAST. NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): 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. CYTOLOGY ___: NEGATIVE FOR MALIGNANT CELLS. DISCHARGE LABS: ================ ___ 07:40AM BLOOD WBC-5.0 RBC-2.43* Hgb-7.9* Hct-25.2* MCV-104* MCH-32.5* MCHC-31.3* RDW-16.6* RDWSD-63.1* Plt ___ ___ 07:40AM BLOOD Plt ___ ___ 07:40AM BLOOD ___ PTT-40.7* ___ ___ 07:40AM BLOOD Glucose-77 UreaN-25* Creat-5.0*# Na-137 K-4.5 Cl-97 HCO3-30 AnGap-15 ___ 07:40AM BLOOD Calcium-9.6 Phos-2.5* Mg-2.1 Radiology Report EXAMINATION: Chest: Frontal and lateral views INDICATION: History: ___ with cough // r/o Pneumonia TECHNIQUE: Chest: Frontal and Lateral COMPARISON: ___ FINDINGS: There is extensive bilateral pulmonary opacities which may be due to severe pulmonary edema or infection. More confluent opacity in left mid lung raises concern for consolidation due to infection. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are stable. IMPRESSION: Diffuse bilateral pulmonary opacities raise concern for severe pulmonary edema. Underlying infection, particularly in the left mid lung, not excluded. Radiology Report EXAMINATION: CTA chest INDICATION: History of HIV with hemoptysis. TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of 100 cc of Omnipaque intravenous contrast. Reformatted coronal, sagittal, thin slice axial images, and oblique maximal intensity projection images were submitted to PACS and reviewed. DOSE: Acquisition sequence: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 0.8 mGy (Body) DLP = 0.4 mGy-cm. 4) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 0.8 mGy (Body) DLP = 0.4 mGy-cm. 5) Stationary Acquisition 1.5 s, 0.5 cm; CTDIvol = 2.4 mGy (Body) DLP = 1.2 mGy-cm. 6) Spiral Acquisition 4.1 s, 31.9 cm; CTDIvol = 6.7 mGy (Body) DLP = 213.3 mGy-cm. Total DLP (Body) = 215 mGy-cm. COMPARISON: CTA and CT chest examinations dating from ___ through ___. FINDINGS: Visualized portion of the thyroid is unremarkable. Heart size is normal without significant pericardial fluid. Thoracic aortic arch is normal caliber without evidence of dissection or aneurysm. Bovine aortic arch. Pulmonary arteries are normal caliber and there is no filling defect to the subsegmental level to suggest pulmonary embolus. Prominent left axillary lymph nodes measure up to 9 mm in short axis, unchanged. Prominent mediastinal lymph nodes measure up to 2.3 x 0.9 cm in the AP window, mildly decreased compared to prior examination. Small to moderate right pleural effusion is minimally decreased compared to prior examination. Small left-sided effusion has improved compared to the prior exam. Airways are patent to the subsegmental level. Airways appeared diffusely thickened. Diffuse interlobular septal thickening and ground-glass appearance is slightly worsened compared to the prior examination. Diffuse scattered areas of peribronchovascular nodular ground-glass opacity has worsened compared to the prior examination, most prominent in the superior lingular segment where ground-glass measures roughly 3.8 x 2.3 cm. These areas are ground-glass, particularly in the lingula demonstrate "crazy paving" morphology. Moderate linear left base atelectasis. Imaged upper abdomen is grossly unremarkable. Bones and soft tissues: Bones are diffusely sclerotic, unchanged. No suspicious focal bone lesion. IMPRESSION: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Interval progression of interlobular septal thickening and diffuse ground-glass opacity compatible with pulmonary edema. 3. Slight interval decrease in bilateral pleural effusions. 4. Interval progression of peribronchovascular nodular ground-glass opacities, now with a morphology resembling "crazy paving." The constellation of findings suggests a complex differential. Findings including interlobular septal thickening, pleural effusions and a crazy paving appearance may be explained by pulmonary edema. Given history of HIV, the most probable differential is pneumocystis pneumonia given crazy paving appearance and interlobular septal thickening. Less likely is ___'s sarcoma which would explain crazy paving opacities and lymphadenopathy. 5. Prominent mediastinal lymph nodes have minimally decreased in size compared to the prior examination. 6. Renal osteodystrophy. 7. Diffuse bronchial wall thickening suggestive of chronic small airways disease. RECOMMENDATION(S): Recommend diuresis and empiric treatment for pneumocystis pneumonia with short-term interval followup imaging after completion of therapy. If findings persist, biopsy is recommended in order to exclude ___'s sarcoma. NOTIFICATION: The of dated findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 14:30, 20 minutes after discovery of the findings. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with HIV on HAART with h/o PCP PNA now with fever // ?interval change TECHNIQUE: Portable AP chest radiograph. COMPARISON: Chest radiograph ___ FINDINGS: There are persistent bilateral airspace opacities, more confluent in the left mid lung. Aeration of the right lung appears to improved somewhat. Small left pleural effusion. No pneumothorax seen. IMPRESSION: Interval improvement in aeration of the right lung, persistent confluent opacity in the left mid lung suspicious for infection. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with HIV, ESRD on HD with SOB, fevers, hemoptysis. // new acute cardiopulmonary process? infection, increasing edema? IMPRESSION: Compared to the prior radiograph of 1 day earlier, diffuse alveolar and interstitial opacities have slightly worsened and continue to involve the left lung to a greater degree than the right. Small left pleural effusion and trace right pleural effusions are unchanged. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ year old woman with HIV, here with hemoptysis and chronic cough. // Is there underlying pathology under pulm edema? 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: Total DLP (Body) = 245 mGy-cm. COMPARISON: ___ FINDINGS: The thyroid is normal. Again noted are a number of borderline enlarged axillary, supraclavicular, mediastinal, and hilar lymph nodes. These are significantly improved in size since the prior examination. For example, one AP window lymph node that previously measured 23 x 9 mm now measures 18 x 7 mm. A subcarinal lymph node that was previously 1.8 cm in short axis is now 1.2 cm in short axis. A prominent right hilar lymph node measures and 1.1 cm. Aorta and pulmonary arteries are normal size. Cardiac configuration is normal. Mild coronary calcifications are noted. The airways are patent. Evaluation of the lungs shows significant improvement in diffuse, bilateral ground-glass opacities since the most recent examination. Interlobular septal thickening has also improved, corresponding to improved volume status. More confluent regions of consolidation are seen in the right lower lobe, which may be the sequela of prior PCP. Alternatively, this may represent an organizing pneumonia or bacterial superinfection. A right-sided pleural effusion has resolved. Persistent fluid is seen in the left major fissure. Left lower lobe and lingular atelectasis is noted. Evaluation of the bones shows prominent endplate densities, the so called "___ spine" which may be related to renal diease related hyperparathyroidism. Limited evaluation of the upper abdomen shows no significant abnormalities. IMPRESSION: 1. Significant improvement in bilateral ground glass opacities and pleural effusions. 2. Persistent confluent areas of consolidation may be related to the sequela of PCP, ___, or organizing pneumonia. Kaposi sarcoma is less likely given significant improvement. Gender: F Race: OTHER Arrive by AMBULANCE Chief complaint: Hemoptysis, Cough Diagnosed with Hemoptysis, Hypokalemia, Chronic kidney disease, unspecified temperature: 99.1 heartrate: 86.0 resprate: 16.0 o2sat: 100.0 sbp: 162.0 dbp: 86.0 level of pain: 0 level of acuity: 3.0

Patient is a ___ year old female with a h/o dCHF, ESRD on HD who presents with hemoptysis and SOB after recent missed HD session. ___ hospital stay complicated by fevers during. # Hemoptysis: Resolved. Patient has had episode of hemoptysis ___ the past, during admission ___ ___ though volume (quarter size clot x 1) was greater this time. At that time she was found to have parainfluenza type III and was treated supportively. Of note, the patient has had multiple admissions since ___ for respiratory decompensation of unknown etiology ___ the setting of a diagnosis of fibrotic nonspecific interstitial pneumonia. She has been treated for PCP ___ the past (although later was determined she never actually had PCP) and infection is certainly risk ___ this patient with ESRD and HIV. Given CXR, most likely cause is volume overload/pulm edema ___ the setting of INR of 2.9 and thrombocytopenia plt 130. CTA was negative for PE; did show significant pulmonary edema. HD schedule ___ continued, with some extra sessions. Fluid restriction to 1- 1.5 L. Patient had benefit from drier weight given that she seems to be accumulating fluid faster. Pulmonary consulted. Patient had bronchoscopy ___: Cytology was negative for malignant cells and 1+ gram positive rods and 1+ gram positive cocci ___ pairs. Pulmonologists did not believe biopsy was necessary. Repeat CT chest w/ contrast on ___: No malignancy or infectious process was appreciated on the dry CT chest. Reviewed her CT chest with radiology, it appears whenever she has an acute worsening of her pulmonary status she has severe volume overload on her CT. She has a few persistent confluent areas of consolidation on her CT after removing fluid but no areas are progressive and per discussion with radiology there was low concern for malignancy. See below. #Fevers: Pt had fever of 102.3 on AM of ___ fever on ___. Pt does not have a history of PCP; LDH 142. Aspergillus antigen negative. Patient likely had PNA on top of underlying pulmonary edema. Beta-glucan 88, however fungal infection not likely as fevers improved w/ Cefepime and BAL has been negative for fungal. Blood Cx ___: nothing growing to date. Cefepime started on ___ -> ___ (5 day course) for HCAP PNA. ID consulted. CD4 442, much improved from last (186 on ___. Viral load: < 20 copies. Bronchoscopy: 1+ GPRs, 1+ GPC ___ pairs. Ambulatory sats - 93-100% RA. Repeat CT chest w/ contrast: No malignancy or infectious process was appreciated on the dry CT chest. # Supratherapeutic INR: Unclear why INR increased to 4.1. Patient received ___ FFP units to reverse for bronchoscopy. Held Warfarin ___. Restarted Warfarin at 2.5mg. # Hypertension: On Metoprolol. Given hemoptysis and pulmonary edema, patient will benefit from improved BP control. Metoprolol was increased from 50mg to 75mg over the weekend for increased blood pressure/PVCs. Likely secondary to volume overload. Continue Metoprolol 75mg with outpatient titration. Continue HD. # Anemia: Patient had hgb drop from 7.8 -> 6.2 ___ HD ___ received 1 unit of RBCs (___), with bump to 9.6. Thought to be likely dilutional. However this AM she dropped from 9.6 -> 7.4. Patient denies bloody bowel movements, black/tarry BMs, dizziness, SOB. EGD done ___ ___ showed mod gastritis. Was due for colonoscopy ___ ___. Unlikely to be bleeding into lungs, given good clinical status. Could be secondary to HAART, however pt has been on this for years. Transfuse for hgb < 7. Retic index 0.4 on ___. Iron 36, ferritin 1746, TIBC 203, transferrin 156 - consistent with anemia of chronic disease. Nephrology reinitiated Epo. # Acute on chronic diastolic congestive heart failure: Dry weight 127 pounds. She is euvolemic on exam but shows significant pulmonary edema on CXR/CT. Coupled with elevated BNP, presentation is consistent with exacerbation. Most likely due to missed HD session on ___. Continue Metoprolol. Renal dialysis following. # ESRD: Secondary to polycystic kidneys and RCC. Anuric. Renal dialysis consulted. Continue Nephrocaps, phoslo. Patient was restarted on Epo. Will likely benefit from drier weight: 50.6kg. At this weight, patient had less cough, no hemoptysis. #Transaminitis: Resolved; likely due to volume overload/hemolyzed specimen. - No need to follow up.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: ? valve vegetation/thrombus Major Surgical or Invasive Procedure: TEE History of Present Illness: ___ h/o AVR/MVR in ___ (#21mm ___ Mechanical)/#29mm ___ Mechanical), SSS ___ DDD-PPM HCF, HTN, HLD, COPD, T2DM, p/w incidental ECHO findings of ?MV vegetation/thrombus. Patient went for routine twice a year ECHO today and noted ?MV vegetation/thrombus. Cardiologist referred patient to ED. Also had PPM intergated at cardiology office today and functioning appropriately. Reports fever (101) on sat, with persistent SOB at rest, and dry cough however these symptoms quickly resolved by ___. Has been feeling well since then without any sob, cp, diaphoresis, orthopnea, PND, lower extremity edema. He recently travelled to ___ and returned on ___. While in ___, he developed a erythematous papulomacular rash throughout his body after spending the day in the sun fishing. The rash was pruritic and he went to urgent care where he was given benadryl and prednisone for about 6 days with improvement of the rash. Denies facial edema, shortness of breath, hypotension. The rash progressed to small vesicles that popped and then skin peeling. Most of the rash is gone after 6 days, but he does have remnant skin peeling in his hands and some erythematous areas around his back, neck, and face. No sick contacts. No IVDU. In the ED, initial vitals were: 98.2 68 143/67 16 98% RA - Labs were significant for INR 3.5, lactate 1.8 - CXR showed no acute cardiopulmonary process - UA was negative - patient was admitted for TEE in AM Vitals prior to transfer were: 98.1 67 114/64 18 99% RA Upon arrival to the floor, patient has no complaints REVIEW OF SYSTEMS: (+) Per HPI (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History: -AS and insufficiency, MR ___ AVR/MVR in ___ (#21mm ___ Mechanical)/#29mm ___ Mechanical) -SSS ___ DDD-PPM -HTN -HLD -COPD -T2DM - OSA Social History: ___ Family History: Father had coronary artery bypass surgery in his ___ and died in his early ___. Physical Exam: ADMISSION PHYSICAL EXAM: ========================== Vitals: 97.9, 148/77, 74, 18, 96% RA General: Alert, oriented, comfortable, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur at RUSB and mitral area radiating through precardium, mechanical valve clicks, no rubs/gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII grossly intact, symmetric smile, no focal deficits SKIN: remnant erythematous rash on back, frontal neck area, sides of head. Skin peeling in b/l hands from areas of blister. No splinter hemorrhage, ___ lesions, ___ nodes DISCHARGE PHYSICAL EXAM: ========================== VS: 98.3 131/58 60 18 100RA Weight: 90.8 <- 91.4 <- 91.4 <- 91.1 <- 92.2 <- 92.0 <- 92.8 kg I/O: -/1000 General: Alert, oriented, comfortable, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur at RUSB and mitral area radiating through precardium, mechanical valve clicks, no rubs/gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII grossly intact, symmetric smile, no focal deficits SKIN: remnant erythematous rash on back, frontal neck area, sides of head, improving. Skin peeling in b/l hands from areas of blister. No splinter hemorrhage, ___ lesions, ___ nodes Pertinent Results: ADMISSION LABS: ====================== ___ 02:50PM BLOOD WBC-5.2 RBC-4.77 Hgb-13.2*# Hct-40.9# MCV-86 MCH-27.7 MCHC-32.3 RDW-14.5 RDWSD-44.6 Plt ___ ___ 02:50PM BLOOD Neuts-53.5 ___ Monos-11.7 Eos-8.5* Baso-1.0 Im ___ AbsNeut-2.76 AbsLymp-1.26 AbsMono-0.60 AbsEos-0.44 AbsBaso-0.05 ___ 02:50PM BLOOD ___ PTT-45.0* ___ ___ 02:50PM BLOOD Glucose-184* UreaN-15 Creat-0.8 Na-137 K-3.8 Cl-99 HCO3-29 AnGap-13 ___ 07:30AM BLOOD Calcium-9.4 Phos-3.0 Mg-1.4* ___ 03:28PM BLOOD Lactate-1.8 DISCHARGE LBAS: ====================== ___ 09:30AM BLOOD WBC-5.6 RBC-4.79 Hgb-13.3* Hct-41.3 MCV-86 MCH-27.8 MCHC-32.2 RDW-14.2 RDWSD-44.4 Plt ___ ___ 09:30AM BLOOD ___ PTT-130.3* ___ ___ 06:52AM BLOOD Glucose-235* UreaN-15 Creat-0.9 Na-137 K-4.3 Cl-102 HCO3-29 AnGap-10 ___ 06:52AM BLOOD Calcium-9.5 Phos-3.2 Mg-2.0 ___ 06:52AM BLOOD CRP-6.3* STUDIES: ====================== + TTE ___: The left atrium is moderately dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is normal (Biplane LVEF 57%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. A bileaflet aortic valve prosthesis is present. The transaortic gradient is higher than expected for this type of prosthesis. Moderate (2+) aortic regurgitation is seen. A bileaflet mitral valve prosthesis is present. The mitral prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. There is a small hypermobile echodensity attached to the posterior aspect of the mitral prosthesis (LV side). In the differential diagnosis: suture, thrombus, vegetation. Mild mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Small echodensity attached to the posterior aspect of a well seated bileaflet mitral valve prosthesis with differential diagnosis described above. Mild mitral regurgitation (possibly underestimated due to shadowing). Normal transmitral gradients. Well seated bileaflet aortic valve prosthesis with moderate (possibly a combination of central and paravalvular) aortic regurgitation and higher than expected transaortic gradients. Preserved biventricular systolic function. Mild pulmonary artery systolic hypertension. + TEE ___: The left atrium is elongated. The right atrium is dilated. No mass or thrombus is seen in the right atrium or right atrial appendage. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. A bileaflet aortic valve prosthesis is present. The aortic valve prosthesis leaflets appear to move normally. The prosthetic aortic valve leaflets are mildly thickened. A mild-moderate paravalvular aortic valve leak is probably present (best seen in clips 67 to 71). No masses or vegetations are seen on the aortic valve. A well seated bileaflet mitral valve prosthesis is present. The motion of the mitral valve prosthetic leaflets appears normal. There is a small hypermobile echodensity seen attached to the posterior aspect of the mitral prosthesis (LV side) suggestive of a thorn chord or suture (less likely vegetation). Trivial mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: No valvular, prosthetic or lead-related vegetations identified. Small echodensity associated with the bileaflet mitral valve prosthesis is more suggestive of a suture or thorn chord, although repeat TEE recommended if clinically indicated (fever, bacteremia etc) to exclude interval development of endocarditis. Well seated bileaflet aortic valve prosthesis with mild-moderate paravalvular leak. Compared to the prior intraoperative TEE dated ___, the mitral echodensity is new. There is slightly more paravalvular aortic regurgitation (mild previously). Medications on Admission: The Preadmission Medication list is accurate and complete. 1. atorvastatin 80 mg oral QHS 2. Aspirin 81 mg PO DAILY 3. FoLIC Acid 1 mg PO DAILY 4. Thiamine 100 mg PO DAILY 5. Lisinopril 20 mg PO DAILY 6. Hydrochlorothiazide 25 mg PO DAILY 7. Fenofibrate 67 mg PO DAILY 8. GlipiZIDE 10 mg PO BID 9. MetFORMIN (Glucophage) 1000 mg PO BID 10. Metoprolol Succinate XL 200 mg PO QAM 11. Metoprolol Succinate XL 100 mg PO QPM 12. Diltiazem Extended-Release 240 mg PO DAILY 13. Warfarin 5 mg PO 6X/WEEK (___) 14. Glargine 25 Units Bedtime 15. Warfarin 7.5 mg PO 1X/WEEK (MO) Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. atorvastatin 80 mg oral QHS 3. Diltiazem Extended-Release 240 mg PO DAILY 4. FoLIC Acid 1 mg PO DAILY 5. Hydrochlorothiazide 25 mg PO DAILY 6. Glargine 25 Units Bedtime 7. Lisinopril 20 mg PO DAILY 8. Metoprolol Succinate XL 200 mg PO QAM 9. Metoprolol Succinate XL 100 mg PO QPM 10. Thiamine 100 mg PO DAILY 11. Warfarin 5 mg PO 6X/WEEK (___) 12. Warfarin 7.5 mg PO 1X/WEEK (MO) 13. GlipiZIDE 10 mg PO BID 14. MetFORMIN (Glucophage) 1000 mg PO BID 15. Fenofibrate 67 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Prosthetic mitral valve Warfarin management 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 CHF, w/ mech AV/MV, SSS s/p pacemaker, presents w/ ? endocarditis, also c/o fever, cough over the weekend // eval for PNA or other acute cardiopulmonary pathology TECHNIQUE: Chest: Frontal and Lateral COMPARISON: ___ FINDINGS: Dual lead left-sided pacer is stable in position. The patient is status post median sternotomy and cardiac valve replacements. Cardiac and mediastinal silhouettes are stable. Slight prominence of the hila is stable. No focal consolidation is seen. There is no pleural effusion or pneumothorax. IMPRESSION: No significant interval change from ___. No acute cardiopulmonary process. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abnormal echo Diagnosed with FEVER, UNSPECIFIED, LONG TERM USE ANTIGOAGULANT, HEART VALVE REPLAC NEC temperature: 98.2 heartrate: 68.0 resprate: 16.0 o2sat: 98.0 sbp: 143.0 dbp: 67.0 level of pain: 0 level of acuity: 2.0

___ M with PMH of AVR/MVR in ___ (#21mm ___ ___, SSS ___ DDD-PPM in ___, HTN, HLD, COPD, and T2DM that presents with incidental TTE findings of ?MV vegetation/thrombus. # MV echodensity: Patient does not fulfill Duke's criteria for endocarditis (only one major criteria - ECHO findings). Patient did have severe skin reaction after sun exposure in ___ leading to blisters and skin peeling, which may have led to possible point of entry for skin bacteria. He went to an Urgent Care in ___ on ___ with a diffuse maculopapular rash, sore throat, and fever to 102.6F and was given a course of Azithromycin and 1g Ceftriaxone. Pt also had fever to ___, SOB at rest, dry cough, night sweats, and chills four days prior to admission, but symptoms completely resolved three days prior to admission. No fevers while in-house. CXR, UA, urine cx, and blood cultures x3 negative. Blood cultures x2 pending on discharge. Repeat TTE in-house showed normal EF (57%) and a small echodensity attached to the posterior aspect of a well seated bileaflet mitral valve prosthesis. TEE ___ showed small echodensity associated with the bileaflet mitral valve prosthesis that is more suggestive of a suture. He had no infectious symptoms and was discharged with plan for repeat TTE at next cardiology appointment. Patient's Warfarin dose was held in the ER, which caused his INR to be sub-therapeutic after admission. His home Warfarin regimen was restarted, and he was on a heparin gtt until his Warfarin level was therapeutic. INR on discharge 2.9. #IDDM: Patient's home doses of glargine, glipizide, and metformin were continued for his T2DM. #HTN: Home lisinopril, HCTZ, metoprolol, and diltiazem doses were continued. #Hyperlipidemia: Home atorvastatin, fenofibrate, and baby ASA were continued.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: adhesive tape / iodine Attending: ___. Chief Complaint: AMS/?Seizure Major Surgical or Invasive Procedure: Colon CA s/p ? partial colectomy L frontal CVA HTN PVD TIA Atrial fibrillation History of Present Illness: Four of patient's children are at bedside providing history. ___ with PMH left frontal cva, htn, pvd, tia, colon cancer, a. fib on coumadin presenting with altered mental status and seizure, fever to 101.6 at ___. Patient had a fall yesterday morning with head strike to fridge as she was carrying her laundry. Patient lives on her own and is independent in ADLs. She sustained bruising to ribs, wrists, and her buttock. She told her family later that she felt her feet fall out from underneath her as she fell. At that time, she called Lifeline- EMS came and evaluated the patient but did not send her to ___. The remainder of the day she was with family. Her family reports that she was able to ambulate after fall but appeared to have some cognitive slowing - she would repeat her stories every ten minutes. Two to three times, she also would stare directly at her children as they were talking but would not respond to what they were saying. That evening, her son stayed with her and noted that Ms. ___ was physically slow. The next morning, he noted that she had soiled herself. When he saw her, her feet were grounded and she was not responsive to the things he was saying. She seemed to stare through his eyes and would not communicate. She did make her bed and recognized a telephone ring. Her son was concerned and brought her to ___. Outside hospital patient had a negative head CT scan but did have a witnessed tonic-clonic seizure in the emergency department. Patient received 2mg Ativan and 1g dilantin and the patient was postictal. She also recevid a total of 20mg diltaizem for afib. PR temperature was 101.6. Noted to have a tremor in right hand. Patient was evaluated by neurology at an outside hospital and recommended continuous EEG. In the ___, initial vitals were: 98.9 102 129/70 16 99% 15L Non-Rebreather Patient was given Vanc 1g, ceftriaxone 2g, ampicillin 1g, acyclovir 600mg there On the floor, patient is somnolent and states the number 61 when I ask her if she knows where she is. She denies any pian. Review of systems: Unable to assess given patient is responding to my questions only intermittently. (+) Per HPI Past Medical History: Colon CA L frontal CVA HTN PVD TIA Atrial fibrillation Social History: ___ Family History: n/c Physical Exam: ADMISSION PHYSICAL EXAM Vitals: T98.1 BP121/54 HR118 RR16 98%4L General: Alert, not oriented, no acute distress, somnolent HEENT: Sclera anicteric, MMM, dry mmm, EOMI, PERRL Neck: Supple, JVP not elevated, no LAD CV: stystolic murmur, normal S1 + S2, no rubs, gallops Lungs: Clear to auscultation bilaterally but with minimal effort Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: foley in place draining clear dark urine Ext: Warm, well perfused, varicose veins, 2+ pulses, no clubbing, cyanosis or edema Neuro: unable to assess strength/sensation secondary to patient somnolence s/p bz administration. Skin: bruising on left buttock Rectum: with bright red blood and external hemorrhoids noted DISCHARGE PHYSICAL EXAM Vitals: 97.9 HR83 BP 148/79 RR 17 97RA General: Alert, oriented to self, hospital, ___, no acute distress HEENT: Sclera anicteric, MMM, EOMI, PERRL Neck: Supple, JVP not elevated, no LAD CV: systolic murmur, normal S1 + S2, no 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, varicose veins, 2+ pulses, no clubbing, cyanosis or edema Neuro: follows commands/squeezes fingers Pertinent Results: ADMISSION LABS ___ 05:50PM BLOOD WBC-13.1* RBC-4.68 Hgb-13.5 Hct-41.4 MCV-89 MCH-28.8 MCHC-32.6 RDW-13.6 Plt ___ ___ 05:50PM BLOOD Neuts-82.8* Lymphs-12.8* Monos-4.1 Eos-0 Baso-0.3 ___ 05:50PM BLOOD Plt ___ ___ 05:50PM BLOOD Glucose-118* UreaN-13 Creat-0.7 Na-139 K-3.3 Cl-98 HCO3-30 AnGap-14 ___ 05:56PM BLOOD ___ pO2-68* pCO2-42 pH-7.47* calTCO2-31* Base XS-6 Urinanalysis ___ 05:50PM URINE Color-Straw Appear-Clear Sp ___ ___ 05:50PM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-TR Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD ___ 05:50PM URINE RBC-16* WBC-47* Bacteri-FEW Yeast-NONE Epi-0 PERTINENT IMAGING ___ CXR IMPRESSION: Ill-defined opacity projecting over the left mid-to-lower lung may be due to pleural effusion with overlying atelectasis, new since the study earlier today; underlying consolidation not excluded. Cardiomegaly. No definite overt pulmonary edema. PERTINENT MICROBIOLOGY ___ Blood cx X 2 pending ___ Urine cx negative DISCHARGE LABS on day of discharge lab appears to be hemoconcentrated. ___ 05:00AM BLOOD WBC-11.3* RBC-4.89 Hgb-14.0 Hct-44.5 MCV-91 MCH-28.7 MCHC-31.5 RDW-13.9 Plt ___ ___ 05:00AM BLOOD Glucose-86 UreaN-14 Creat-0.8 Na-143 K-4.4 Cl-100 HCO3-34* AnGap-13 ___ 05:00AM BLOOD Calcium-9.1 Phos-2.4* Mg-1.9 =========== EEG: FINDINGS: CONTINUOUS EEG: The background activity shows an asymmetric posterior dominant rhythm of approximately 9 Hz seen over the right hemisphere, with slower frequencies in the theta range seen over the left temporal, parietal, and occipital regions. Additionally, there are occasional episodes of semirhythmic delta seen over the left hemisphere. There is diffuse beta seen throughout the record, with some loss of beta over the left hemisphere as well as loss of faster frequencies over the left hemisphere. SLEEP: The patient progresses from wakefulness to stage 2, then slow wave sleep at appropriate times with the loss of spindle activity also seen over the left hemisphere during stage II sleep. PUSHBUTTON ACTIVATIONS: There are no pushbutton activations. SPIKE DETECTION PROGRAMS: There are several automated spike detections, which are predominantly for sharply contoured theta rhythms, as well as beta activity. There are also detections for vertex waves. Others are for electrode and movement artifact. There are no epileptiform discharges. SEIZURE DETECTION PROGRAMS: There are several automated seizure detections, which are mostly for sharply contoured theta and alpha frequencies. There are no electrographic seizures. QUANTITATIVE EEG: Trend analysis is performed with Persyst Magic Marker software. Panels included automated seizure detection, rhythmic run detection and display, color spectral density array, absolute and relative asymmetry indices, asymmetry spectrogram, amplitude integrated EEG, burst suppression ratio, envelope trend, and alpha delta ratios. Segments showing abnormal trends are reviewed, and the FFT spectrogram confirmed the finding of diminished faster frequencies seen over the left hemisphere as well as increased power in the delta frequency range over the left hemisphere. CARDIAC MONITOR: ___ an irregular rhythm with a rate of approximately 70-80 bpm. IMPRESSION: This is an abnormal continuous ICU monitoring study because of focal slowing seen over the left temporal, parietal and occipital regions with the occasional periods of semirhythmic delta seen over the left hemisphere and loss of fast frequencies. This is indicative of a focal subcortical dysfunction over the left hemisphere. There is diffuse beta seen throughout the record. This can be seen in the setting of benzodiazepine or barbiturate use. There are no epileptiform discharges and no electrographic seizures. INTERPRETED BY: ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Warfarin 5 mg PO 2X/WEEK (MO,FR) 2. Warfarin 2.5 mg PO 5X/WEEK (___) 3. Metoprolol Succinate XL 50 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Prazosin 1 mg PO DAILY 6. Hydrochlorothiazide 25 mg PO DAILY 7. Detrol LA (tolterodine) 4 mg oral daily 8. Aspirin 81 mg PO DAILY 9. cilostazol 50 mg oral daily 10. alendronate 70 mg oral weekly 11. Verapamil SR 120 mg PO Q24H Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Hydrochlorothiazide 25 mg PO DAILY 3. Metoprolol Succinate XL 50 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Prazosin 1 mg PO DAILY 6. Verapamil SR 120 mg PO Q24H 7. Acetaminophen 650 mg PO TID Please do not take more than 3 grams a day. RX *acetaminophen 650 mg 1 tablet extended release(s) by mouth every 8 hours for pain Disp #*28 Tablet Refills:*0 8. alendronate 70 mg oral weekly 9. cilostazol 50 mg ORAL DAILY 10. Detrol LA (tolterodine) 4 mg oral daily 11. LeVETiracetam 500 mg PO BID 12. Warfarin 2.5 mg PO DAILY please check INR on ___. to be readjusted by MD. 13. Outpatient Lab Work Please check CBC with differential as well as INR for ___ Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnosis: urinary tract infection, seizure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAM: Chest, single frontal view. CLINICAL INFORMATION: Altered mental status. ___ at ___, 11:35 a.m. FINDINGS: Single AP upright portable view of the chest was obtained. The cardiac silhouette remains enlarged. Hazy opacity projecting over the left mid-to-lower lung may be due to a small pleural effusion with atelectasis. Underlying consolidation is not excluded in the appropriate clinical setting. Dedicated PA and lateral views would be helpful for further evaluation. The cardiac silhouette remains enlarged. The aortic knob is calcified. No definite pulmonary edema is seen. IMPRESSION: Ill-defined opacity projecting over the left mid-to-lower lung may be due to pleural effusion with overlying atelectasis, new since the study earlier today; underlying consolidation not excluded. Cardiomegaly. No definite overt pulmonary edema. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: s/p Fall, Unresponsive Diagnosed with OTHER FORMS OF EPILEPSY AND RECURRENT SEIZURES, WITHOUT MENTION OF INTRACTABLE EPILEPSY temperature: 98.9 heartrate: 102.0 resprate: 16.0 o2sat: 99.0 sbp: 129.0 dbp: 70.0 level of pain: 0 level of acuity: 2.0

___ with PMH left frontal cva, htn, pvd, tia, colon cancer, a. fib on coumadin presenting with altered mental status and seizure. # Altered mental status: Pt presented with altered mental status with orientation to self only. Patient may be altered secondary to infectious delirium, stroke, post-ictal state, antiepileptic medications, ativan. She may also be clouded by old left frontal stroke secondary to reprogression of old left frontal stroke though there is no evidence of this on CT imaging from OSH. Infectious delirium thought to be secondary to uti seen on u/a. Lumbar puncture was not pursued secondary to low suspicion for meningitis. Empiric antibiotics were narrowed from vanc, ceftriaxone, amp, acyclovir to ceftriaxone to treat uti. Pt finished 3 day course of ceftriaxone for UTI. 24 hour EEG indicated no epileptiform discharges and no electrographic seizures. On day of discharge, pt is oriented to self, place (hospital) and month/year, consistent with baseline. # Seizure, resolved: Multiple etiologies for seizure including infection causing a decrease in seizure threshold. Patient also has a history of prior stroke which could also result in decreased seizure threshold. As noted by neurology, seizure is likely arising from site of prior stroke in left frontal lobe as indicated by right sided rhythmic movements and right sided gaze deviation seen in ___. EEG with no evidence of continous seizures. Neurology recommended keppra 500mg BID on discharge. She will be followed up in neurology clinic at which time antiepileptics medications will be readdressed. # Atrial fibrillation with RVR: INR 4.5 at ___ but 2.2 here. Patient did have asymptomatic afib with RVR during hospitalization in the setting of missing 2 doses of her metop/verapamil. This resolved with IV metoprolol push and home dose of po metoprolol succinate. Will continue home dose metop on discharge. Coumadin was resumed at 2.5mg daily prior to discharge (previously was 2.5mg daily with 5mg twice per week). Pt should have INR checked on ___ post discharge and readjusted as necessary by PCP. # UTI- on ceftriaxone during hospital stay. Transitioned to levofloxacin on discharge. She did have a slight leukocytosis to 11.2 on day of d/c, so please recheck CBC on ___ to trend. Her entire CBC did appear hemoconcentrated, however, and she appeared well and afebrile so she was discharged. # Blood per rectum: hemorrhoids vs colonic infection/polyps. Patient does have history of colon cancer which could indicate presentation of malignancy, but less likely. Consider colonoscopy outpatient. H/H remained stable throughout hospitalization. CHRONIC ISSUES # GERD: continued omeprazole. # HTN: blood pressures remained stable. Continued hctz during hospitalization. TRANSITIONAL ISSUES # CODE: FULL CODE # CONTACT: ___ sons ___ ___ # PENDING: BCX, EEG # ISSUES TO DISCUSS AT F/U - consider outpatient colonsocopy given BRPBR on admit - please consider increasing frequency or dose of metoprolol and verapamil and readjusting as needed to further control a. fib is necessary. - please check CBC with diff as well as INR on ___ and trend leukocytosis - please check INR on ___ - Patient was started on keppra 500mg BID and she should continue taking these medications until she sees her neurologist in ___.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Tramadol Attending: ___. Chief Complaint: Squamous Cell Carcinoma Right Shin, Cellulitis Shin Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old Male with history of multiple skin cancers including SCC, Melanomas, non-healing leg wounds who presents with concerns of a right shin skin cancer. The patient is under care of Dr. ___ dermatology, and was in fact scheduled for clinic this upcoming week. The patient complains of a left shin painful swelling, with concerns for an infected squamous cell carcinoma. The patient states it has been red and swollen for approximately 3 weeks for which his PCP started cefadroxil which ended on ___. The patient denies fever or chills. He was seen by his ___ office NP the day prior to admission, who did not feel it was significantly infected, and the he continue his baseline mipirocin. In the ___ ED his initial vitals 97.8, 125/55, 56, 18, 97%. Patient given IV Vancomycin in the ED. Past Medical History: ___: -dyslipidemia -hypertension -single chamber pacemaker. -systolic and diastolic CHF, EF 35% -CAD s/p large inferolateral MI ___ s/p ___ -___ dementia -Chronic microvascular cerebral ischemia -Peripheral neuropathy -Cervical myelopathy -Lumbar spinal stenosis -s/p multiple laminectomies and spinal fusion -Atrial fibrillation -Pulmonary emboli in ___ -Bovine aortic arch -Mild pulmonary arterial hypertension -Hematochezia d/t internal hemorrhoids -Colonic polyp and diverticulosis -C. diff colitis ___ -Melanoma on left cheek s/p excision . PAST SURGICAL HISTORY: -s/p hemorrhoidectomy in ___, mult bandings since then -s/p TURP in ___ -s/p L2 laminectomy and foraminotomies at ___ -s/p Right total knee replacement in ___ -s/p Right inguinal hernia repair -s/p removal of basal cell CA skin lesions on scalp, legs, and arms -s/p removal of squamous cell CA skin lesions on right leg in ___. Social History: ___ Family History: Father died at ___ due to abdominal aortic aneurysm. Mother died at ___ of "stomach" cancer. Fraternal twin sister died at ___ of lymphoma. Physical Exam: ROS: GEN: - fevers, - Chills, - Weight Loss EYES: - Photophobia, - Visual Changes HEENT: - Oral/Gum bleeding CARDIAC: - Chest Pain, - Palpitations, - Edema GI: - Nausea, - Vomiting, - Diarrhea, - Abdominal Pain, - Constipation, - Hematochezia PULM: - Dyspnea, - Cough, - Hemoptysis HEME: - Bleeding, - Lymphadenopathy GU: - Dysuria, - hematuria, - Incontinence SKIN: - Rash ENDO: - Heat/Cold Intolerance MSK: - Myalgia, - Arthralgia, - Back Pain NEURO: - Numbness, - Weakness, - Vertigo, - Headache ADMISSION PHYSICAL EXAM: VSS: 97.7, 107/80, 53, 20, 96% GEN: NAD Pain: ___ HEENT: EOMI, MMM, - OP Lesions PUL: CTA B/L COR: RRR, S1/S2, - MRG ABD: NT/ND, +BS, - CVAT EXT: - CC, trace edema b/l, chronic stasis b/l NEURO: CAOx3, Non-Focal DERM: crusted 1.5cm left shin lesion concerning for ___ with central clot, team was able to express tiny amount of purulent material earlier. DISCHARGE EXAM: Vitals: 98.1 96/48 55 18 95%RA Otherwise unchanged Pertinent Results: ADMISSION LABS: ___ 12:15PM BLOOD WBC-8.8 RBC-3.44* Hgb-10.4* Hct-33.6* MCV-98 MCH-30.2 MCHC-31.0* RDW-16.0* RDWSD-56.7* Plt ___ ___ 12:15PM BLOOD Neuts-66.3 Lymphs-15.8* Monos-12.8 Eos-4.3 Baso-0.5 Im ___ AbsNeut-5.84 AbsLymp-1.39 AbsMono-1.13* AbsEos-0.38 AbsBaso-0.04 ___ 12:15PM BLOOD Glucose-155* UreaN-28* Creat-1.4* Na-136 K-5.9* Cl-100 HCO3-25 AnGap-17 DISCHARGE LABS: ___ 05:00AM BLOOD WBC-7.2 RBC-3.24* Hgb-9.7* Hct-31.4* MCV-97 MCH-29.9 MCHC-30.9* RDW-15.9* RDWSD-56.9* Plt ___ ___ 05:00AM BLOOD Glucose-156* UreaN-26* Creat-1.4* Na-140 K-3.5 Cl-101 HCO3-28 AnGap-15 ___ 05:00AM BLOOD Calcium-9.2 Phos-3.3 Mg-2.3 MICRO: none IMAGING: Left leg ___: No evidence of deep venous thrombosis in the left lower extremity veins Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 80 mg PO QPM 2. Digoxin 0.125 mg PO DAILY 3. Donepezil 10 mg PO QHS 4. Finasteride 5 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Spironolactone 12.5 mg PO DAILY 7. Torsemide 80 mg PO QAM 8. Acetaminophen 500 mg PO Q6H:PRN pain 9. Aspirin 81 mg PO DAILY 10. Vitamin D ___ UNIT PO DAILY 11. Cyanocobalamin 500 mcg PO DAILY 12. Ferrous Sulfate 325 mg PO DAILY 13. Multivitamins W/minerals 1 TAB PO DAILY 14. Vitamin E 400 UNIT PO DAILY 15. Sarna Lotion 1 Appl TP BID:PRN back itch Discharge Medications: 1. Acetaminophen 500 mg PO Q6H:PRN pain 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Cyanocobalamin 500 mcg PO DAILY 5. Digoxin 0.125 mg PO DAILY 6. Donepezil 10 mg PO QHS 7. Ferrous Sulfate 325 mg PO DAILY 8. Finasteride 5 mg PO DAILY 9. Multivitamins W/minerals 1 TAB PO DAILY 10. Omeprazole 20 mg PO DAILY 11. Sarna Lotion 1 Appl TP BID:PRN back itch 12. Spironolactone 12.5 mg PO DAILY 13. Torsemide 80 mg PO QAM 14. Vitamin D ___ UNIT PO DAILY 15. Vitamin E 400 UNIT PO DAILY 16. Amoxicillin-Clavulanic Acid ___ mg PO Q12H cellulitis Duration: 5 Days RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet by mouth two times per day Disp #*10 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: Cellulitis Secondary Diagnosis: Venous stasis 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: UNILAT LOWER EXT VEINS LEFT INDICATION: ___ with 3 weeks progressive swelling, pain, redness of LLE, evaluate for DVT. TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the left lower extremity veins. COMPARISON: Prior DVT study dated ___. FINDINGS: There is normal compressibility, flow, and augmentation of the left common femoral, femoral, and popliteal veins. Normal color flow is demonstrated in the posterior tibial and peroneal veins. Duplication of the mid superficial femoral vein system is incidentally noted. 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. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: L Leg pain Diagnosed with Cellulitis of left lower limb temperature: 97.8 heartrate: 56.0 resprate: 18.0 o2sat: 97.0 sbp: 125.0 dbp: 55.0 level of pain: 10 level of acuity: 3.0

___ male with Alzheimer's disease, atrial fibrillation, not on anticoagulation, HFpEF, pulmonary hypertension, h/o GI bleed, GERD and cervical radicular myelopathy presenting with 3 weeks progressive pain, swelling, and redness on LLE, recently treated by PCP with oral antibiotics, presenting for expedited dermatology evaluation. ACTIVE ISSUES 1. Leg Cellulitis with Squamous Cell Carcinoma: Explained to patient that dermatology biopsy/excision is not urgent and did not require hospitalization. Patient was admitted from the ED for cellulitis but it was felt pt did not need aggressive IV antibiotics. He was given a prescription for Augmentin to last until his dermatology appointment on ___. He will follow up with dermatology as previously scheduled. Patient with history of non-healing wounds, and will likely require wound care ___ long term. CHRONIC ISSUES 2. Chronic Diastolic CHF: Euvolemic during admission. Discharge weight: 79 kgs. - Continued torsemide 3. CAD: No chest pain. - Aspirin and Plavix continued 4. Hyperlipidemia - Atorvastatin continued. 5. Lumbar Stenosis - Chronic Percocet held while in house - Tylenol and Lidoderm with relief 6. Alzheimer's Dementia -Donepezil and Memantine continued 7. BPH without Obstruction - Finasteride continued 8. CKD Stage 3 - Renally dosed medications - Avoided nephrotoxins

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: meperidine Attending: ___ Chief Complaint: Fall Mild TBI Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ female on Plavix for cardiac stents who presents to ___ on ___ with a mild TBI. Patient was walking in her neighbor's driveway when she tripped and fell, striking her head. Denies LOC. Was able to get up herself and presented to OSH ED with R forehead laceration. NCHCT was performed which showed small L frontal SAH. The patient was transferred to ___ for further evalution. Past Medical History: HTN HLD Cardiac stent x ___ yrs on Plavix Social History: ___ Family History: N/A Physical Exam: Exam on admission: O: T: 98.1 BP: 126/80 HR: 71 RR: 18 O2 Sat: 100% RA GCS at the scene: 15 GCS upon Neurosurgery Evaluation: Airway: [ ]Intubated [x]Not intubated Eye Opening: [ ]1 Does not open eyes [ ]2 Opens eyes to painful stimuli [ ]3 Opens eyes to voice [x]4 Opens eyes spontaneously Verbal: [ ]1 Makes no sounds [ ]2 Incomprehensible sounds [ ]3 Inappropriate words [ ]4 Confused, disoriented [x]5 Oriented Motor: [ ]1 No movement [ ]2 Extension to painful stimuli (decerebrate response) [ ]3 Abnormal flexion to painful stimuli (decorticate response) [ ___ Flexion/ withdrawal to painful stimuli [ ]5 Localizes to painful stimuli [x]6 Obeys commands Exam: Gen: WD/WN, comfortable, NAD. HEENT: R forehead laceration with DSD Neck: Supple Extrem: warm and well perfused Neuro: Mental Status: Awake, alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech is fluent with good comprehension. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4mm to 3mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Intact to light touch Exam on discharge: ___ x 3. NAD. PERRLA. CN II-XII intact. LS clear. RRR. Abdomen soft, NTND. ___ BUE and BLE. No drift. Pertinent Results: ___ Head CT Two smaqll foci of hyperdense tSAH within the left frontal lobe without mass effect or MLS. She show mild redistribution and no interval increase in the size of hemorrhage. Medications on Admission: Atorvastatin 80mg daily Plavix 75mg daily diltiazem ER (dose unknown) Lisinopril 10mg daily Metoprolol 125mg PO BID Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Atorvastatin 80 mg PO QPM 3. Diltiazem Extended-Release 300 mg PO DAILY 4. Lisinopril 10 mg PO DAILY 5. Metoprolol Tartrate 100 mg PO BID 6. Plavix 75mg daily - may restart this medication on ___ Discharge Disposition: Home Discharge Diagnosis: Traumatic Subarachnoid Hemorrhage 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 woman with small L frontal tSAH s/p fall// Please perform ___ @ 5am. Evaluate stability of tSAH TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 6.4 s, 16.1 cm; CTDIvol = 55.7 mGy (Head) DLP = 897.1 mGy-cm. Total DLP (Head) = 897 mGy-cm. COMPARISON: None available. FINDINGS: Again seen are small amounts of left frontal subarachnoid hemorrhage. No new hemorrhages identified.. There is no evidence infarction. Prominence of the ventricle and sulci is compatible with age related involutional changes. The basilar cisterns appear patent. There is a small amount of air inferiorly in the right orbit. This, along with hyperdense fluid in the maxillary sinus suggests an orbital floor fracture, although the fracture itself is not identified on this study. Otherwise, the remaining visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: Unchanged small amount of left frontal subarachnoid hemorrhage. No new hemorrhage is identified. No evidence of infarction mass effect or edema. Findings suggesting right orbital floor fracture with right maxillary sinus hemorrhage. NOTIFICATION: The findings of right intraorbital air and hyperdense fluid in the right maxillary sinus suggesting an orbital floor fracture entered in the Radiology department non urgent critical imaging findings system 10:30 ___ immediately upon reviewing the images by D. Hackney. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: s/p Fall, SAH, Transfer Diagnosed with Traum subrac hem w/o loss of consciousness, init, Fall same lev from slip/trip w/o strike against object, init temperature: 98.1 heartrate: 71.0 resprate: 18.0 o2sat: 100.0 sbp: 126.0 dbp: 80.0 level of pain: 0 level of acuity: 2.0

#Fall/Mild TBI/tSAH: ___ yo patient presents after a trip and fall. Heac CT at OSH showed small tSAH in the left frontal lobe. She was Neurologically intact with GCS of 15. Her exam was stable on ED evaluation and she was admitted to the floor given her history of Plavix use. Repeat CT is stable as is her exam. She was discharged home on ___. She may restart Plavix on ___.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Weakness, fatigue, intoxication Major Surgical or Invasive Procedure: None History of Present Illness: ___ with a history of DM and EtOH use, who presents intoxicated, with a chief complaint of fatigue, intoxication, failure to thrive. He is accompanied by his wife who provides most of the history and has most of the concerns. She reports that for the last year, and especially the last month, he has had a steady decline, both mentally and physically. He has been increasingly weak, appetite is poor, he is always in bed. He was laid off from his job several months ago, and his wife wonders if he is depressed. However, he has also been confused, saying "incoherent things," mumbling, and doing this even when he is not drunk. He can no longer balance a check book, but was once a very intelligent man. His wife wonders if there is something else going on that is not solely EtOH related. Otherwise, he did have one fall yesterday. He has had decreased urinary output per her wife. He had one episode of "dark" stool on ___, no BM's since, no hematochezia or rectal bleeding. He has been globally weak with trouble walking. He has had no fever, chills, CP, SOB, cough, abd pain, nausea, vomiting, diarrhea, joint pain, headache, neck pain, or incontinence. He returned from from ___ yesterday with his wife. He was very confused on the ride home. He reports drinking wine earlier today prior to his wife bringing him to the ED for failure to thrive. The patient is without specific complaints at this time. ED Course notable for: -Initially hypotensive, 76/47, with Lactate of 5.1 -Given 3L IVF, Vancomycin, Zosyn -Lactate improved to 4.0 after the first 2 liters of fluid -He was agitated, confused, and intoxicated. Received IV Ativan and IM Haldol. -Bedside US showed compressible IVC, no pericardial effusion, grossly normal EF On arrival to the MICU, he was without complaint and SBP was in the 100-110's. He did have some dizziness after standing up to urinate Past Medical History: Diabetes Type 2 on oral agents Hypertension Hyperlipidemia Obesity Hemochromatosis carrier Social History: ___ ___ History: -Mother: obesity -Father: died at ___ of cerebral hemorrhage, h/o HTN -2 sisters both with depression Physical Exam: ADMISSION EXAM: =========================== GENERAL: Clinically intoxicated. NAD. Resting in bed. HEENT: Sclera anicteric, MM dry, oropharynx clear NECK: supple, no stiffness, full ROM LUNGS: Clear to auscultation anteriorly, no wheezes, rales, rhonchi CV: Regular rate and rhythm ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, no edema SKIN: Warm and dry NEURO: No asterixis. Moving all extremities. 3 beats nystagmus on lateral gaze bilaterally. Unable to comply with full exam. DISCHARGE EXAM ====================== VITALS: ___ 1531 Temp: 99 PO BP: 111/72 HR: 119 RR: 16 O2 sat: 94% O2 delivery: ra GENERAL: AOx3. Interactive. Comfortable. NAD. HEENT: Normocephalic, atraumatic. Pupils equal, round, and reactive bilaterally. CARDIAC: Distant heart sounds, ___ systolic ejection murmur heard best at LSB. LUNGS: CTAB ABDOMEN: Normal bowels sounds, ND, NT EXTREMITIES: Compression stockings in place. B/l waffle boots. SKIN: WWP. L heel pressure wound appears to be healing. NEUROLOGIC: CN II-XII intact. Sensation intact throughout. Strength ___ in upper extremities. Strength ___ with lower extremity flexion, ___ lower extremity extension. Pertinent Results: ADMISSION LABS: =================== ___ 05:15PM BLOOD WBC-5.8 RBC-3.50* Hgb-11.2* Hct-33.5* MCV-96 MCH-32.0 MCHC-33.4 RDW-14.6 RDWSD-51.5* Plt ___ ___ 05:15PM BLOOD Neuts-60.5 ___ Monos-17.4* Eos-1.4 Baso-0.5 Im ___ AbsNeut-3.51 AbsLymp-1.13* AbsMono-1.01* AbsEos-0.08 AbsBaso-0.03 ___ 05:15PM BLOOD Glucose-95 UreaN-13 Creat-1.2 Na-132* K-4.5 Cl-93* HCO3-15* AnGap-24* ___ 05:15PM BLOOD ALT-44* AST-89* CK(CPK)-111 AlkPhos-88 TotBili-0.5 ___ 05:15PM BLOOD ___ PTT-27.6 ___ ___ 05:15PM BLOOD Lipase-23 ___ 05:15PM BLOOD cTropnT-0.02* ___ 05:15PM BLOOD CK-MB-2 ___ 05:15PM BLOOD Albumin-3.8 Calcium-9.0 Phos-3.8 Mg-1.5* ___ 05:26PM BLOOD Lactate-5.1* IMAGING: ================= CXR ___ No acute cardiopulmonary process. CT Head ___ No acute intracranial process. Global volume loss out of proportion to patient's age. White matter hypodensities, likely sequela of chronic small vessel disease. CT C-Spine ___ No cervical spine fracture or malalignment. CT Abdomen and Pelvis ___. No acute intra-abdominal or intrapelvic process. 2. Healing posterior right twelfth rib fracture. ___ ___ 1. No evidence of deep venous thrombosis in the right or left lower extremity veins. 2. Incidentally noted is extensive calcification of the arterial vasculature. MRI BRAIN ___. No evidence of an intracranial mass or acute intracranial abnormalities. 2. Extensive supratentorial white matter and pontine T2/FLAIR signal abnormalities are nonspecific but likely sequela of chronic small vessel ischemic disease in this age group. 3. Advanced global cerebral parenchymal volume loss, greater than expected for age. Disproportionately severe volume loss in the right medial temporal lobe compared to the left, of uncertain etiology and clinical significance. Only mild cerebellar volume loss. TTE ___ The left atrial volume index is normal. There is normal left ventricular wall thickness with a normal cavity size. There is normal regional left ventricular systolic function. Quantitative biplane left ventricular ejection fraction is 63 %. Left ventricular cardiac index is normal (>2.5 L/min/m2). There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. 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 structurally normal with no mitral valve prolapse. There is severe mitral annular calcification. There is mild mitral stenosis from the prominent mitral annular calcification. There is mild [1+] mitral regurgitation. Due to acoustic shadowing, the severity of mitral regurgitation could be UNDERestimated. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. The estimated pulmonary artery systolic pressure is high normal. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal biventricular wall thicknesses, cavity sizes, and regional/ global systolic function. Mild mitral regurgitation with normal valve morphology. Mild functional mitral stenosis. ___ ECHO: Suboptimal image quality. Normal biventricular wall thicknesses, cavity sizes, and regional/ global systolic function. Mild mitral regurgitation with normal valve morphology. Mild functional mitral stenosis. CTA CHest ___: 1. No evidence of pulmonary embolism or acute aortic syndrome. 2. Minimal areas of ___ nodularity with largest isolated nodule measuring up to 5 mm in the posterior right upper lobe along with single trace area of mixed ground-glass attenuation in the left lung apex are nonspecific, though could represent trace areas of inflammation/infection or sequela of prior infection. 3. Trace right greater than left pleural effusions. 4. Otherwise no large areas of dense consolidation to suggest a severe pneumonia. ___: No acute fracture or malalignment of the lumbar spine. No evidence of infection or paravertebral soft tissue abnormality ___ RUQ US: 1. Echogenic liver consistent with steatosis. Other forms of liver disease and more advanced liver disease including steatohepatitis or significant hepatic fibrosis/cirrhosis cannot be excluded on this study. 2. Technically limited study due to inability of patient to breath hold, otherwise main patent portal vein. ___ CT AP No evidence of acute intra-abdominal or intrapelvic abnormality which would correlate with patient's reported symptoms. MRI Cervical and Lumbar: 1. No evidence to suggest discitis myelitis. No prevertebral or epidural collections identified. 2. No abnormal signal or enhancement of the cervical cord, visualized portions of the thoracic cord, terminal cord, conus medullaris or cauda equina. 3. No high-grade spinal canal or neural foraminal narrowing. Degenerative changes as described above. In the cervical spine, degenerative findings are most prominent at C5-C6 where there is moderate left neural foraminal narrowing. In the lumbar spine degenerative changes are most prominent at L5-S1 where there is moderate right neural foraminal narrowing. 4. There is STIR hyperintense signal of the cervical and lumbar paraspinal muscles, nonspecific, but may represent strain versus myositis. 5. Additional findings as described above. MRI T Spine: 1. Limited examination due to patient motion. 2. The signal intensity throughout the thoracic spinal cord is normal with no evidence of focal or diffuse lesions. There is no evidence of abnormal enhancement after contrast administration 3. No high-grade spinal canal or neural foraminal stenosis. 4. No epidural paraspinal collections. No findings to suggest ___ discitis. 5. Moderate right-sided pleural effusion. MRI HEAD: Small 6 mm foci of mildly slow diffusion in the right cerebellar hemisphere with associated T2 and FLAIR hyperintense signal change suggesting a late acute to subacute infarct. This was not present on prior MRI brain done ___. No hemorrhagic transformation. No enhancement. Rest of the intracranial findings as detailed above are unchanged compared to prior imaging. ECHO ___: : Suboptimal image quality. No 2D echocardiographic evidence for endocarditis or pathologic flow. No LV thrombus or mass seen. ___ Carotid Series: Bilateral plaque, right worse than left. Less than 40% stenosis in the internal carotid arteries bilaterally. INTERVAL LABS ===================== ___ 03:33AM BLOOD ALT-40 AST-87* AlkPhos-76 TotBili-0.5 ___ 05:00AM BLOOD ALT-43* AST-72* LD(LDH)-239 AlkPhos-88 TotBili-0.6 DirBili-0.3 IndBili-0.3 ___ 05:36AM BLOOD ALT-45* AST-78* AlkPhos-103 TotBili-0.7 ___ 05:15PM BLOOD calTIBC-230* VitB12-197* Ferritn-488* TRF-177* ___ 05:30AM BLOOD %HbA1c-6.3* eAG-134* ___ 05:15PM BLOOD TSH-2.0 ___ 05:15PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG ___ 08:17PM BLOOD Lactate-4.0* ___ 06:54AM BLOOD Lactate-1.0 MICROBIOLOGY ===================== RPR - negative URINE CULTURE (Final ___: NO GROWTH. All blood cultures - No growth CYTOLOGY REPORT - Final SPECIMEN(S) SUBMITTED: CEREBROSPINAL FLUID DIAGNOSIS: Cerebrospinal Fluid, Lumbar Puncture: NEGATIVE FOR MALIGNANT CELLS. - Lymphocytes and monocytes. Time Taken Not Noted Log-In Date/Time: ___ 11:22 am CSF;SPINAL FLUID Source: LP. **FINAL REPORT ___ Enterovirus Culture (Final ___: No Enterovirus isolated. Time Taken Not Noted Log-In Date/Time: ___ 11:22 am CSF;SPINAL FLUID Source: LP. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final ___: NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST CULTURE (Preliminary): The sensitivity of an AFB smear on CSF is very low.. If present, AFB may take ___ weeks to grow.. Time Taken Not Noted Log-In Date/Time: ___ 11:22 am CSF;SPINAL FLUID Source: LP. **FINAL REPORT ___ CRYPTOCOCCAL ANTIGEN (Final ___: CRYPTOCOCCAL ANTIGEN NOT DETECTED. (Reference Range-Negative). Test performed by Lateral Flow Assay. Results should be evaluated in light of culture results and clinical presentation. ___ 5:30 am Blood (LYME) **FINAL REPORT ___ Lyme IgG (Final ___: NEGATIVE BY EIA. (Reference Range-Negative). Lyme IgM (Final ___: NEGATIVE BY EIA. (Reference Range-Negative). Negative results do not rule out B. burg___ infection. Patients in early stages of infection or on antibiotic therapy may not produce detectable levels of antibody. ___ 6:00 pm STOOL CONSISTENCY: NOT APPLICABLE 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). ___ 10:25 am URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 3:33 am SEROLOGY/BLOOD Source: Venipuncture. **FINAL REPORT ___ RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE. Reference Range: Non-Reactive. DISCHARGE LABS ========================= ___ 05:10AM BLOOD WBC-8.0 RBC-3.38* Hgb-10.1* Hct-31.3* MCV-93 MCH-29.9 MCHC-32.3 RDW-15.6* RDWSD-53.1* Plt ___ ___ 05:35AM BLOOD Neuts-55.3 Lymphs-17.0* Monos-18.8* Eos-7.5* Baso-0.6 Im ___ AbsNeut-2.74 AbsLymp-0.84* AbsMono-0.93* AbsEos-0.37 AbsBaso-0.03 ___ 05:10AM BLOOD Glucose-106* UreaN-4* Creat-0.7 Na-140 K-4.4 Cl-101 HCO3-24 AnGap-15 ___ 05:35AM BLOOD ALT-31 AST-34 AlkPhos-182* TotBili-0.4 ___ 05:35AM BLOOD Albumin-2.4* Calcium-8.3* Phos-3.4 Mg-1.7 ___ 05:15PM BLOOD calTIBC-230* VitB12-197* Ferritn-488* TRF-177* ___ 05:10AM BLOOD %HbA1c-6.0 eAG-126 Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Atorvastatin 20 mg PO QPM 2. amLODIPine 5 mg PO DAILY 3. GlipiZIDE XL 5 mg PO DAILY 4. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY 5. Aspirin 81 mg PO DAILY Discharge Medications: 1. Clopidogrel 75 mg PO DAILY end date ___ 2. Cyanocobalamin 1000 mcg PO DAILY 3. FoLIC Acid 1 mg PO DAILY 4. Mirtazapine 15 mg PO QHS 5. Multivitamins W/minerals 1 TAB PO DAILY 6. Thiamine 100 mg PO DAILY 7. Atorvastatin 40 mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do not restart amLODIPine until your doctor says to resume taking it. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnoses ================= Dehydration Lactic acidosis Hypotension Severe cognitive impairment B12 deficiency Alcohol use disorder Subacute R cerebellar infarct Secondary diagnoses ================== Type 2 Diabetes Alcohol withdrawal Pancytopenia Refeeding syndrome Transaminitis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ year old man with fever, tachycardia// rule out DVT in bilateral lower extremity TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: No relevant comparisons identified FINDINGS: There is normal compressibility, flow, and augmentation of the bilateral common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. Incidentally noted is extensive calcification of the arterial vasculature. IMPRESSION: 1. No evidence of deep venous thrombosis in the right or left lower extremity veins. 2. Incidentally noted is extensive calcification of the arterial vasculature. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with fever// eval for pneumonia eval for pneumonia IMPRESSION: Comparison to ___. Lung volumes have minimally increased, with a subsequent increase in radiodensity of the lung parenchyma. However, there is no evidence of focal parenchymal opacities suggesting pneumonia. No pulmonary edema. Borderline size of the heart. Elongation of the descending aorta. Radiology Report EXAMINATION: CT L-SPINE W/ CONTRAST Q332 CT SPINE INDICATION: ___ year old man with man with alcohol use disorder, chronic cognitive decline, with new low grade fevers, tachycardia, unclear source, eval for PE as well// eval for gross signs of infection, understand MRI is ideal for this, but patient going down for CTA of chest and would prefer evaluating L spine at this time as well, thanks! eval for gross signs of infection, understand MRI is ideal f TECHNIQUE: Non-contrast helical multidetector CT was performed after the intravenous administration of mL 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 4.3 s, 34.4 cm; CTDIvol = 27.2 mGy (Body) DLP = 934.4 mGy-cm. Total DLP (Body) = 934 mGy-cm. COMPARISON: ___ CT abdomen pelvis with IV contrast FINDINGS: Alignment of the lumbar spine is normal.No fractures are identified. There is mild degenerative changes including a left L5-S1 anterolateral bridging osteophyte. There is mild-to-moderate disc space narrowing at L5-S1 and mild disc space narrowing at L4-L5. Small disc bulges are seen diffusely, which appear to indent the thecal sac, though do not obviously appear to cause significant canal stenosis. There is no evidence of severe spinal canal or neural foraminal stenosis within confines of CT. There is no prevertebral soft tissue swelling. There is no evidence of infection or neoplasm. There is no abnormal enhancement on post contrast imaging. Prominent aortoiliac atherosclerotic vascular calcifications are noted. The visualized retroperitoneum is otherwise grossly unremarkable. IMPRESSION: No acute fracture or malalignment of the lumbar spine. No evidence of infection or paravertebral soft tissue abnormality. Radiology Report EXAMINATION: CTA chest INDICATION: ___ year old man with man with alcohol use disorder, chronic cognitive decline, with new low grade fevers, tachycardia, unclear source, eval for PE as well// eval for infection, PE TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of intravenous contrast. Reformatted coronal, sagittal, thin slice axial images, and oblique maximal intensity projection images were submitted to PACS and reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 2.4 s, 31.9 cm; CTDIvol = 14.7 mGy (Body) DLP = 469.2 mGy-cm. 2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7 mGy-cm. 3) Stationary Acquisition 1.8 s, 0.5 cm; CTDIvol = 9.9 mGy (Body) DLP = 5.0 mGy-cm. Total DLP (Body) = 476 mGy-cm. COMPARISON: Chest radiograph ___. FINDINGS: The thyroid gland is grossly unremarkable. Heart size is borderline with trace likely physiologic pericardial fluid. Thoracic aorta is normal caliber with only trace atherosclerotic calcification. There is no dissection or aneurysm formation. The pulmonary arteries are normal caliber and there is no filling defect to the subsegmental level. There is no supraclavicular, axillary, hilar, or mediastinal lymphadenopathy by CT size criteria. There are tiny right greater than left pleural effusions with mild dependent atelectasis. Minimal areas of ___ nodularity are located peripherally in the right upper lobe. The largest nodular component measures 5 mm. Trace areas of mixed ground-glass are also noted in the left lung apex. Otherwise no suspicious focal consolidation or isolated suspicious pulmonary nodules are identified. Although this study is not tailored for subdiaphragmatic analysis, the visualized upper abdomen demonstrates no gross acute abnormality. There are chronic healed fractures of the bilateral lateral sixth ribs. Thoracic cage is intact without acute fracture or suspicious focal bone lesion. IMPRESSION: 1. No evidence of pulmonary embolism or acute aortic syndrome. 2. Minimal areas of ___ nodularity with largest isolated nodule measuring up to 5 mm in the posterior right upper lobe along with single trace area of mixed ground-glass attenuation in the left lung apex are nonspecific, though could represent trace areas of inflammation/infection or sequela of prior infection. 3. Trace right greater than left pleural effusions. 4. Otherwise no large areas of dense consolidation to suggest a severe pneumonia. Radiology Report EXAMINATION: DUPLEX DOPPLER LIVER INDICATION: Evaluate cause of rising LFTs, evaluate for portal vein thrombosis. TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen was performed. COMPARISON: CT abdomen from ___. FINDINGS: The staged study was technically limited due to inability of the patient to breath hold. Liver: The hepatic parenchyma is diffusely echogenic. No focal liver lesions are identified. There is no ascites. Bile ducts: There is no intrahepatic biliary ductal dilation. The common hepatic duct measures 2 mm. Gallbladder: The gallbladder appears within normal limits, without intraluminal calculi. Spleen: The spleen demonstrates normal echotexture, and measures 11 cm. Doppler evaluation: The main portal vein is patent, with flow in the appropriate direction. Main portal vein velocity is approximately 22 cm/sec. Right and left portal veins are not well seen. IMPRESSION: 1. Echogenic liver consistent with steatosis. Other forms of liver disease and more advanced liver disease including steatohepatitis or significant hepatic fibrosis/cirrhosis cannot be excluded on this study. 2. Technically limited study due to inability of patient to breath hold, otherwise main patent portal vein. Radiology Report EXAMINATION: CT ABDOMEN AND PELVIS WITH CONTRAST INDICATION: ___ year old man with ongoing infection, fevers, unclear source. Evaluation for source of infection. TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 3.9 s, 52.2 cm; CTDIvol = 21.7 mGy (Body) DLP = 1,133.4 mGy-cm. 2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7 mGy-cm. 3) Stationary Acquisition 7.2 s, 0.5 cm; CTDIvol = 40.2 mGy (Body) DLP = 20.1 mGy-cm. Total DLP (Body) = 1,155 mGy-cm. COMPARISON: Comparison to CT abdomen/pelvis from ___. FINDINGS: LOWER CHEST: Trace right greater than left pleural effusions. Visualized lung fields are otherwise within normal limits. There is no evidence of pleural or pericardial effusion. Extensive mitral annular calcifications are again 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: 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. Subcentimeter hypodensity in the left lower renal pole is too small to characterize, however likely represents a simple renal cyst. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. Diverticulosis of the 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. Extensive atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Healing right eleventh and twelfth rib fractures are again noted. SOFT TISSUES: A right inguinal hernia containing fat is noted. IMPRESSION: No evidence of acute intra-abdominal or intrapelvic abnormality which would correlate with patient's reported symptoms. Radiology Report EXAMINATION: MRI CERVICAL AND LUMBAR PT23 MR SPINE INDICATION: ___ year old man with ams, fever, neck rigidity, diffuse clonus// per neuro c/f cervical or lumbar process per neuro c/f cervical or lumbar process 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 abdomen pelvis with contrast of ___, MRI head with without contrast of ___, cervical spine CT of ___. FINDINGS: CERVICAL: Cervical alignment is anatomic. Vertebral body heights are preserved. No focal suspicious marrow lesion. Mixed ___ 1 and 2 C6-C7 endplate changes are identified. Degenerative loss of disc height and signal is noted at C6-C7. The visualized posterior fossa is unremarkable. There is no evidence of abnormal signal or enhancement of the cervical and visualized upper thoracic cord. No epidural collections. C2-C3 through C4-C5: Mild degenerative changes do not result in high-grade spinal canal or neural foraminal narrowing. C5-C6: A small central protrusion results in mild spinal canal narrowing. Uncovertebral and facet arthropathy results in moderate left and mild right neural foraminal narrowing. C6-C7: Small central protrusion and thickening of ligamentum flavum results in mild spinal canal narrowing. Uncovertebral and facet arthropathy results in mild bilateral neural foraminal narrowing. C7-T1: Unremarkable. Mild STIR hyperintense signal of the paraspinal muscles is identified without focal collection, which may represent strain or myositis. LUMBAR: Counting from C2, there is lumbarization of S1 with a well-formed S1-S2 disc. 2 mm retrolisthesis of L5 on S1 is unchanged from prior exam. Otherwise, lumbar alignment is anatomic. No focal suspicious marrow lesions. Vertebral body heights are preserved. Degenerative loss of disc height at L5-S1 is mild. The conus medullaris terminates at the L2 superior endplate, within expected limits. There is no abnormal signal or enhancement of the terminal cord, conus medullaris or cauda equina. No epidural collections are identified. L1-L2 through L4-L5: Mild degenerative changes not significantly narrow the spinal canal or neural foramina. L5-S1: A broad disc bulge crowds the subarticular zones contacting but not posterior displacing the traversing nerve roots. In combination with prominent epidural fat this results in moderate spinal canal narrowing. Loss of disc height and facet osteophytes results in mild left and moderate right neural foraminal narrowing. On the right, prominent facet arthropathy with a posteriorly projecting 1.1 cm synovial cyst is identified. S1-S2: No significant spinal canal or neural foraminal narrowing. OTHER: Right much greater than left STIR hyperintense signal of the paraspinal muscles is identified without focal collection, which may represent muscle strain versus myositis. Prominent subcutaneous dependent edema is also identified. The remainder of the visualized prevertebral and paraspinal soft tissues are unremarkable. IMPRESSION: 1. No evidence to suggest discitis myelitis. No prevertebral or epidural collections identified. 2. No abnormal signal or enhancement of the cervical cord, visualized portions of the thoracic cord, terminal cord, conus medullaris or cauda equina. 3. No high-grade spinal canal or neural foraminal narrowing. Degenerative changes as described above. In the cervical spine, degenerative findings are most prominent at C5-C6 where there is moderate left neural foraminal narrowing. In the lumbar spine degenerative changes are most prominent at L5-S1 where there is moderate right neural foraminal narrowing. 4. There is STIR hyperintense signal of the cervical and lumbar paraspinal muscles, nonspecific, but may represent strain versus myositis. 5. Additional findings as described above. Radiology Report EXAMINATION: LUMBAR PUNCTURE (W/ FLUORO) N8 RF SPINE INDICATION: ___ year old man with subacute on chronic cognitive decline, with acute cognitive worsening/delirium and high fevers up to 104, pan-scanned unclear source, labs ordered// LP please. attempted at bedside for +1.5 hours yesterday, two attendings unable to get it, ?scoliosis. TECHNIQUE: After informed consent was obtained from the patient's healthcare proxy 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 L2-L3. Approximately 5 cc of 1% lidocaine was administered for local anesthesia. Under fluoroscopic guidance, a 20 gauge, 15 cm spinal needle was inserted into the thecal sac. There was good return of clear CSF. 27 mL of CSF were collected in 5 tubes and sent for requested analysis. COMPARISON: None. FINDINGS: 27 mL of CSF were collected in 5 tubes. IMPRESSION: Lumbar puncture at L2-L3 without complication. 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: MR ___ ANDW/O CONTRAST T___ MR SPINE. INDICATION: ___ year old man with AMS and fever of unknown origin.//? abscess. TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique, followed by axial T2 imaging. This was followed by sagittal and axial T1 images obtained after the uneventful intravenous administration of 8 mL of Gadavist contrast agent. COMPARISON: Prior cervical and lumbar spine done ___ at 00:26. FINDINGS: The study is degraded by motion artifact. The thoracic spine alignment appears maintained. The signal intensity throughout the thoracic spinal cord is normal with no evidence of focal or diffuse lesions. The conus medullaris terminates at the level of T12-L1 and is unremarkable. There is no evidence of abnormal enhancement after contrast administration No acute vertebral body fractures. Benign lesion (Hemangioma or focal fatty lesion) in the right aspect of the L2 vertebral body. No epidural paraspinal collections. Small T8-9 and T9-10 facet joint effusions. No surrounding soft tissue edema. Extra-spinal: Moderate right-sided pleural effusion. IMPRESSION: 1. Limited examination due to patient motion. 2. The signal intensity throughout the thoracic spinal cord is normal with no evidence of focal or diffuse lesions. There is no evidence of abnormal enhancement after contrast administration 3. No high-grade spinal canal or neural foraminal stenosis. 4. No epidural paraspinal collections. No findings to suggest ___ discitis. 5. Moderate right-sided pleural effusion. Radiology Report EXAMINATION: UNILAT UP EXT VEINS US RIGHT INDICATION: ___ year old man with fevers of unknown origin, currently afebrile on broad spec abx, has erythematous cord at previous IV site on RUE.// RUE ?DVT, ?infxn/abscess, ?thrombophlebitis TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper extremity veins. COMPARISON: None. FINDINGS: There is normal flow with respiratory variation in the right subclavian vein. The right internal jugular and axillary veins are patent, show normal color flow and compressibility. The right brachial, basilic, and the proximal and mid cephalic veins are patent, compressible and show normal color flow and augmentation. There is a nonocclusive thrombus in the distal right cephalic vein at the antecubital fossa. IMPRESSION: No DVT. Nonocclusive thrombus in the distal right cephalic vein at the antecubital fossa. The remaining upper extremity veins are patent. Radiology Report EXAMINATION: AP portable chest radiograph. INDICATION: ___ year old man with fevers of unknown origin, currently afebrile on broad spec abx, mild DIB with end expiratory wheezes.// ?pulm edema, ?pna TECHNIQUE: AP portable chest radiograph. COMPARISON: Reference is made to the CT chest dated ___ as well as multiple prior studies dating back to ___. FINDINGS: In comparison to the prior radiograph dated ___, lung volumes remain low. There is no focal consolidation to suggest pneumonia. Pulmonary vasculature is within normal limits without evidence of pulmonary edema. There are trace bilateral pleural effusions. Cardiac silhouette is enlarged but unchanged when accounting for differences in patient positioning. IMPRESSION: Low lung volumes with trace bilateral pleural effusions. No evidence of pulmonary edema or pneumonia. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD INDICATION: ___ year old man with EtOh abuse, Vitamin B12 deficiency, chronic cognitive decline with fevers of unknown origin and continued lower extremity weakness.// ?encephalopathy ?lower extremity weakness 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: Prior MRI head done ___ FINDINGS: The study is degraded by motion artifact. Small 6 mm foci of mildly slow diffusion in the right cerebellar hemisphere (series 6, image 8) with associated T2 and FLAIR hyperintense signal change suggesting a late acute to subacute infarct. This was not present on prior MR brain done ___. No hemorrhagic transformation. No enhancement. There is no evidence of mass or hemorrhage. Moderate periventricular and deep white matter T2 and FLAIR hyperintense changes most likely representing sequela of microangiopathy appear similar compared to prior imaging. Advanced generalized cerebral atrophy is unchanged compared to prior. There is disproportionate medial temporal lobe atrophy (right more than left) which appear similar compared to prior imaging. The orbits appear normal. Minimal mucosal thickening involving the paranasal sinuses. The intracranial arteries demonstrate normal T2 flow void. The pituitary appears normal. The craniocervical junction appears normal. IMPRESSION: Small 6 mm foci of mildly slow diffusion in the right cerebellar hemisphere with associated T2 and FLAIR hyperintense signal change suggesting a late acute to subacute infarct. This was not present on prior MRI brain done ___. No hemorrhagic transformation. No enhancement. Rest of the intracranial findings as detailed above are unchanged compared to prior imaging. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ ___ on the telephone on ___ at 12:40 am, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK INDICATION: ___ year old man with recent fevers of unknown origin, encephalopathy, b/l ___ weakness, recent finding of subacute cerebellar infarct.// ?evidence of further infarct or vessel narrowing per neuro recs TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 747.3 mGy-cm. 2) Spiral Acquisition 4.8 s, 38.0 cm; CTDIvol = 13.3 mGy (Body) DLP = 504.0 mGy-cm. 3) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5 mGy-cm. 4) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 23.8 mGy (Body) DLP = 11.9 mGy-cm. Total DLP (Body) = 517 mGy-cm. Total DLP (Head) = 747 mGy-cm. COMPARISON: Prior MR done ___ FINDINGS: CT HEAD WITHOUT CONTRAST: Known right cerebellar late acute to subacute infarct was better visualized on prior MRI. No hemorrhagic transformation. No evidence of acute large territory infarct. White matter hypodense changes most likely representing sequela of microangiopathy. Disproportionate medial temporal lobe atrophy (right more than left) is similar compared to prior. The ventricles and sulci are normal in size and configuration. Th minimal mucosal thickening involving the paranasal sinuses. The visualized portion of the orbits are unremarkable. CTA HEAD: Moderate calcific atherosclerotic changes of the carotid siphons bilateral, but no marked stenosis. The vessels of the circle of ___ and their principal intracranial branches are patent without marked stenosis, occlusion, or aneurysm formation. Hypoplastic right A1 segment. Fetal type origin of the right PCA. The dural venous sinuses are patent. CTA NECK: Moderate atherosclerotic changes of the carotid bulbs bilateral with minimal to no proximal right ICA and no left proximal ICA stenosis by NASCET criteria. The vertebral arteries are patent bilateral. Dominant left vertebral artery. Diminutive right V4 segment. OTHER: Small left and small to moderate right pleural effusion. 5 mm sub solid left upper lobe pulmonary nodule. The visualized portion of the thyroid gland is within normal limits. There is no lymphadenopathy by CT size criteria. The visualized aerodigestive tract is grossly unremarkable. IMPRESSION: 1. Known right cerebellar late acute to subacute infarct was better visualized on prior MRI. No hemorrhagic transformation. 2. No intracranial arterial aneurysm or occlusion. 3. Moderate atherosclerotic changes of the carotid bulbs bilateral with minimal to no proximal right ICA and no left proximal ICA stenosis by NASCET criteria. The vertebral arteries are patent bilateral. Dominant left vertebral artery. Diminutive right V4 segment. 4. Small left and small to moderate right pleural effusion. 5. 5 mm sub solid left upper lobe pulmonary nodule. Please see recommendations below. 6. Additional findings as noted above. RECOMMENDATION(S): For an incidentally detected single ground-glass nodule smaller than 6mm, no CT follow-up is recommended. See the ___ ___ Society Guidelines for the Management of Pulmonary Nodules Incidentally Detected on CT" for comments and reference: ___ Radiology Report EXAMINATION: Carotid Doppler Ultrasound INDICATION: ___ m hx T2DM, HTN, HLP with subacute infarction of cerebellum// b/l. ?stenosis TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound imaging of the carotid arteries was obtained. COMPARISON: None FINDINGS: RIGHT: The right carotid vasculature has moderate heterogeneous, echogenic atherosclerotic plaque. The peak systolic velocity in the right common carotid artery is 42 cm/sec. The peak systolic velocities in the proximal, mid, and distal right internal carotid artery are 36, 38, and 47 cm/sec, respectively. The peak end diastolic velocity in the right internal carotid artery is 23 cm/sec. The ICA/CCA ratio is 1.1. The external carotid artery has peak systolic velocity of 33 cm/sec. The vertebral artery is patent with antegrade flow. LEFT: The left carotid vasculature has mild, heterogeneous, echogenic atherosclerotic plaque. The peak systolic velocity in the left common carotid artery is 55 cm/sec. The peak systolic velocities in the proximal, mid, and distal left internal carotid artery are 44, 54, and 41 cm/sec, respectively. The peak end diastolic velocity in the left internal carotid artery is 26 cm/sec. The ICA/CCA ratio is 1.0. The external carotid artery has peak systolic velocity of 26 cm/sec. The vertebral artery is patent with antegrade flow. IMPRESSION: Bilateral plaque, right worse than left. Less than 40% stenosis in the internal carotid arteries bilaterally. Radiology Report INDICATION: ___ with hypotension and intoxication// ?pneumonia TECHNIQUE: Single portable view of the chest. COMPARISON: None. FINDINGS: The lungs are clear. There is no consolidation, effusion, or edema. The cardiomediastinal silhouette is within normal limits for technique. No acute osseous abnormalities deformities of the lateral sixth ribs bilaterally suggests chronic fractures. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ with AMS, fall// eval for SDH or other ICH TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained without intravenous contrast. Coronal and sagittal reformats were also performed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 16.2 cm; CTDIvol = 49.4 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: None. FINDINGS: There is no intra-axial or extra-axial hemorrhage, mass, midline shift, or acute major vascular territorial infarct. Periventricular and subcortical white matter hypodensities are likely sequela of chronic small vessel disease. Ventricles and sulci are enlarged compatible with global volume loss. Atherosclerotic calcifications noted within the intracranial ICAs and vertebral arteries. Included paranasal sinuses and mastoids are clear noting poor pneumatization of the mastoids bilaterally. Skull and extracranial soft tissues are unremarkable. IMPRESSION: No acute intracranial process. Global volume loss out of proportion to patient's age. White matter hypodensities, likely sequela of chronic small vessel disease. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: ___ with fall// eval for fracture TECHNIQUE: Contiguous axial images obtained through the cervical spine without intravenous contrast. Coronal and sagittal reformats were reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.3 s, 20.8 cm; CTDIvol = 22.6 mGy (Body) DLP = 469.2 mGy-cm. 2) Sequenced Acquisition 0.5 s, 2.0 cm; CTDIvol = 15.0 mGy (Body) DLP = 30.0 mGy-cm. 3) Sequenced Acquisition 0.5 s, 2.0 cm; CTDIvol = 15.0 mGy (Body) DLP = 30.0 mGy-cm. Total DLP (Body) = 529 mGy-cm. COMPARISON: None. FINDINGS: Alignment is normal. No fractures are identified.Degenerative changes are notable for intervertebral disc height loss and uncovertebral joint hypertrophy at C5-6 and C6-7 though without significant canal or foraminal narrowing.There is no prevertebral edema. The thyroid and included lung apices are unremarkable. Atherosclerotic calcifications seen in the common carotid arteries and at the carotid bulbs. IMPRESSION: No cervical spine fracture or malalignment. Radiology Report EXAMINATION: CT abdomen pelvis with contrast INDICATION: ___ with elevated lactate, hypotensionNO_PO contrast// eval for intrabdominal infection TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 6.5 s, 0.5 cm; CTDIvol = 31.3 mGy (Body) DLP = 15.6 mGy-cm. 2) Spiral Acquisition 6.6 s, 51.6 cm; CTDIvol = 21.8 mGy (Body) DLP = 1,124.1 mGy-cm. Total DLP (Body) = 1,140 mGy-cm. COMPARISON: CT abdomen dated ___. FINDINGS: LOWER CHEST: Aside from bibasilar dependent atelectasis, the visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. Extensive mitral annular 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: 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. Subcentimeter hypodensity in the left lower pole is too small to characterize, but statistically likely represents a simple cyst. There is no evidence of suspicious 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. Colon is notable for diverticulosis without diverticulitis. 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 is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. There are prior right eleventh and twelfth rib fractures. SOFT TISSUES: Right inguinal hernia containing fat is noted. IMPRESSION: No acute intra-abdominal or intrapelvic process. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with fever, concern for sepsis// eval for pneumonia TECHNIQUE: Portable AP chest COMPARISON: Chest radiograph ___ FINDINGS: Lungs are clear without focal consolidation, pleural effusion, or pneumothorax. The cardiomediastinal silhouette is stable. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD INDICATION: ___ year old man with several years of cognitive decline, worsening over the last several months possibly secondary to known alcohol use, with evidence of global volume loss on head CT. Evaluate for evidence of prior ischemic events, intra-cranial lesion, etiology of encephalopathy. TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of intravenous contrast (9 cc Gadavist), axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: CT head ___. FINDINGS: Postcontrast MP RAGE images are moderately limited by motion artifacts. Postcontrast axial T1 weighted images and several other sequences are mildly limited by motion artifacts. There is no evidence for an enhancing mass, acute infarction, edema, or blood products. Extensive confluent T2/FLAIR hyperintensities in the periventricular and deep white matter of the cerebral hemispheres and central pons, as well as discrete foci of T2/FLAIR hyperintensity in the subcortical white matter of the cerebral hemispheres, are nonspecific but likely sequela of chronic small vessel ischemic disease in this age group. There is advance global cerebral parenchymal volume loss, greater than expected for the patient's age, with disproportionately severe right medial temporal volume loss compared to the left. There is only mild volume loss in the cerebellum, despite the reported history of alcohol use. Major arterial flow voids are grossly preserved. Dural venous sinuses appear patent on postcontrast MP RAGE images. There is mild mucosal thickening throughout the paranasal sinuses. Bilateral mastoids are underpneumatized, with near complete opacification of the pneumatized left mastoid air cells and mild mucosal thickening versus trace fluid within the pneumatized right mastoid air cells, as seen on the recent head CT. IMPRESSION: 1. No evidence of an intracranial mass or acute intracranial abnormalities. 2. Extensive supratentorial white matter and pontine T2/FLAIR signal abnormalities are nonspecific but likely sequela of chronic small vessel ischemic disease in this age group. 3. Advanced global cerebral parenchymal volume loss, greater than expected for age. Disproportionately severe volume loss in the right medial temporal lobe compared to the left, of uncertain etiology and clinical significance. Only mild cerebellar volume loss. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: BRBPR Diagnosed with Altered mental status, unspecified, Hypotension, unspecified, Fall on same level, unspecified, initial encounter temperature: 99.0 heartrate: 105.0 resprate: 16.0 o2sat: 100.0 sbp: 76.0 dbp: 47.0 level of pain: 0 level of acuity: 1.0

Patient Summary for Admission: Mr. ___ is a ___ year old man with EtOH use disorder and T2DM who presented with weakness, fatigue, and the setting of subacute cognitive decline and general failure to thrive. At the time of admission the patient was found to be hypotensive, intoxicated, with a lactic acidosis and initially admitted to ICU. He was resuscitated with IVF and then on the floor underwent workup for cognitive decline that was felt to be multifactorial (alcohol, B12 deficiency, chronic small vessel disease, depression). He was discharged to rehab after his daughter was appointed his guardian. ACUTE ISSUES ======================= # Cognitive Decline: The patient presented with years of worsening cognitive decline described by multiple falls, impulsiveness, general worsening of executive functioning and self care. He notably was previously high functioning (MBA). Over the recent years his alcohol intake has increased and he has been eating less as result of drinking more. MOCA 13 during admission. There was no evidence of ___'s encephalopathy on exam; the patient had no observed nystagmus or ataxia and did not appear to be confabulating as his reported history was in keeping with collateral information. However, given his prior alcohol use history, he was treated empirically with thiamine. He had volume loss on CT head and MRI, consistent with microvascular ischemia or possibly Alzheimer's dementia. TSH normal. RPR negative. B12 low. Cognitive decline was felt to be multifactorial: vascular dementia, alcohol, depression, B12 deficiency all contributing. For possible vascular dementia he was treated with aspirin and high dose statin. He was started on oral and IM B12 repletion. Patient became significantly deconditioned during hospitalization. He was also found to have suffered a R cerebellar infarct althoug chronicity unclear. Given inability to care for self or make decisions guardianship was pursued and his daughter ___ was appointed guardian. Given his deconditioning and recent cerebellar infarct, he was discharged to a stroke rehabilitation center. #Deconditioning. During hospitalization initially patient was seen to be walking around the floor. Later noted to be max assist to get from bed to commode when. Likely deconditioning given bed/chair alarm and may be secondary to haldol. CK normal. Haldol was discontinued. Patient later found to have suffered a subacute R cerebellar infarct as disused above with recommendation for discharge to stroke rehabilitation center. #Hypotension: On admission differential diagnosis included infection (though no obvious source), hypovolemia (very poor PO intake and EtOH use), bleed (reported dark stool). Cardiogenic was less likely as patient without cardiac history and bedside US reportedly normal. CXR without sign of PTX. Improved with IV fluids supporting hypovolemia as primary driver. Initially treated with broad spectrum antibiotics but discontinued given no clear source of infection. LENIs were obtained to rule out clot given immobility at home as the cause of fever which were negative for DVT. # Fever # Lethargy Later in hospitalization patient began spiking fevers with a Tmax of 104.9F. Also with increased in WBC count to 9.8 (previously leukopenic), tachycardia and with worsening control of blood sugars all concerning for infection. CXR was negative for pneumonia. Patient with several episodes of incontinence (although not entirely new for patient) raising suspicion for UTI. Given decreased movement ___ also with urinary incontinence raises concern for cord compression however strength is present and intact with plantar flexion/dorsiflexion and urinary incontinence is not new for patient making this much less likely on the differential. Lethargy may be extrapyramidal symptoms from Haldol (bradykinesia) but given fever raises concern for infection. He became very altered during his Tmax of 104.9 and c/o neck stiffness and tenderness which was c/f meningitis. An LP was performed but was CSF results did not reveal any signs of meningeal infection. Later an MRI of his head was performed of his brain which revealed a subacute infarct of the R cerebellum. # Lactic acidosis: Likely from hypovolemia, resolved with fluids. # Intoxication, EtOH use disorder: # Alcohol withdrawal: As above, patient with significant alcohol use disorder. He was drinking "many" glasses of wine and brandy throughout the day, and his wife shares she only realized how much he was drinking (and not eating) over the past few months. On admission he was on CIWA scale and treated with diazepam for withdrawal. He only required two doses of diazepam and later in hospitalization was not scoring on CIWA thus it was discontinued. He was treated with high dose thiamine, MVI and folic acid. SW was consulted, but patient did not recognized his drinking as a problem. #Pancytopenia. Likely in the setting of alcohol suppressing the bone marrow and nutritional deficiencies, particularly B12. CT abdomen/pelvis without any signs of cirrhosis. With B12 injections both leukopenia and thrombocytopenia resolved. Was still mildly anemic at discharge. # B12 Deficiency: B12 was low at 197, s/p IM repletion x3 ___, ___. Unclear etiology, likely a component of nutritional deficiency given alcohol use and poor PO intake. Intrinsic factor blocking antibody was negative. # Nutritional status # Refeeding syndrome Required significant repletion of phos, K and Mg initially. Likely in the setting of poor po intake and alcohol use. Nutrition recommended consideration of tube feeds given poor PO intake. Patient was provided with ensure enlive TID and encouraged to take PO. # Elevated LFT's: CT Abdomen without any obvious hepatobiliary abnormality. Likely EtOH related. Hepatitis B and C negative, although patient not immune to hepatitis B. Recommend ongoing cessation of alcohol and outpatient follow-up. # ___ Swelling. Symmetric ___ swelling noted while on medicine floor. ___ negative. Minimal protein in urine, low serum albumin. Likely iatrogenic in the setting of low intravascular oncotic pressures and volume resuscitation earlier in admission for hypotension. Pitting edema resolved with compression stockings. TTE overall unremarkable. CHRONIC ISSUES ================ # Type 2 Diabetes: Held metformin and glipizide while in-house. A1C 6.3%. Treated with insulin sliding scale while hospitalized. At discharge these medications were discontinued. TRANSITIONAL ISSUES ==================== [ ] Pending labs at discharge: ___ 11:20 PARANEOPLASTIC AUTOANTIBODY EVALUATION, CSF (cerebrospinal fluid (csf)) ___ 11:20 ARBOVIRUS ANTIBODY IGM AND IGG (cerebrospinal fluid (csf)) Microbiology ___ 11:22 CSF;SPINAL FLUID FUNGAL CULTURE; ACID FAST CULTURE [ ] 1000 mcg IM/SC B12 injections monthly, next injection due ___. [ ] GI referral as appropriate for evaluation of B12 deficiency. [ ] Patient should undergo extensive neuropsychiatric testing once the patient's Vitamin B12 has been repleted, referral to be made by PCP. [ ] Consider treatment for depression with therapy if indicated. [ ] Follow up CBC to ensure pancytopenia is resolving with B12 repletion. [ ] Consider RUQUS or fibroscan to look for evidence of cirrhosis secondary to alcohol use. [ ] Consider holding metformin (can lower B12) and given lactic acidosis on admission in the setting of poor PO intake. [ ] Outpatient psych/social work for management of his alcohol use disorder, as this is certainly contributing to his cognitive dysfunction. [ ] Admission to stroke rehabilitation s/p R cerebellar infarct patient referred for stroke follow up at time of discharge. [ ] Mirtazapine started on ___ for a trial of 2 weeks to evaluate for effect on appetite if weight not increasing with supplementation should be discontinued. [] A1c on ___ 6/0% as a result Metformin and Glipizide were held on discharge. [] Patient with deep tissue injury on ___ and patient should have waffle boots and elevated feet. # Communication: HCP: Wife ___ ___, Daughter ___ (PCT on ___ 10) ___ # Code: Full, confirmed

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: left lower extremity rest pain, left first toe ischemia Major Surgical or Invasive Procedure: ___: 1. Ultrasound-guided access to the right common femoral artery. 2. Selective catheterization of the left external iliac artery, ___ order vessel. 3. Abdominal aortogram. 4. Left lower extremity diagnostic angiogram with CO2 and one-third Visipaque. History of Present Illness: Mr. ___ is a ___ year-old man w/ stable stage IV CKD referred from his home vascular surgeon for further evaluation of left ___ toe ischemia. The patient and wife report he has been noticing discoloration and pain in his left first toe for months. Over the past few days however, the pain has increased to a point where he is unable to sleep. The pain in constant, though worse when he has his legs elevated. He also reports bilateral lower extremity edema, worse than his baseline. The day of presentation, he was seen by his home vascular surgeon as an outpatient. Given that his presentation will likely require angiogram in the setting of stage IV CKD, he was referred to ___ for further management. Currently, Mr. ___ complains of continued left first toe pain. Other than his pain and edema as described above, he is at his baseline and denies all other complains, including fever/chills. Past Medical History: AFIB, PACER/defib placed ___, s/p CABG x3 vessels ___, Chronic Renal Failure, Anemia, NIDDM, HTN, High Cholesterol, Obstructive sleep apnea on CPAP at night at home, Lumbar stenosis Social History: ___ Family History: significant for mother and father with heart disease Physical Exam: VITALS: Temp 97.6, HR 78, BP 105/52, RR 18, SpO2 98% on room air GEN: NAD, well appearing and comfortable HEENT: NCAT, EOMI, no scleral icterus CV: Irregularly Irregular rhythm, heart sounds distant on auscultation and difficult to assess RESP: CTAB, breathing comfortably on room air GI: soft, non-TTP, no R/G/D EXT: warm and well perfused, there is noticeable atrophy in the bilateral calf muscles (Left > Right) with ___ and DP pulses obvious on Doppler exam, the left great toe is slightly purple in appearance with no ulcers, wounds or sores Pertinent Results: LABWORK: ___ IMAGING: ___ LLE duplex: Findings duplex evaluation was performed the right lower extremity. Significant calcified plaque makes the interpretation difficult. Velocities are 73 in the common femoral the but become decreased at the popliteal. Impression somewhat difficult to interpret duplex due to significant calcification of patent proximal right lower extremity arterial system. Distally there appears to be occlusion. ___ ABI/PVR: Doppler evaluation was performed of both lower extremities. Segmental pressures are not accurate due to noncompressible vessels. All waveforms are monophasic. Pulse volume recordings show significant dampening starting at the thigh level and are essentially flat line at the left ankle and metatarsal. Impression significant multi segmental bilateral occlusive disease ___ CTA Aorta with bilateral runoff: 1. Extensive diffuse atherosclerotic calcification, limiting evaluation of the arteries in the lower extremities. 2. The left anterior and posterior tibial arteries are occluded with single vessel runoff to the wide, reconstitution of the dorsalis pedis artery, likely from collateral flow. 3. The right superficial femoral artery is occluded with reconstitution of the popliteal artery from collateral flow. 4. Right anterior tibial artery is occluded with 2 vessel runoff, reconstitution of the dorsalis pedis artery. 5. Rim calcified left adrenal lesion may represent prior hemorrhage. Correlate with prior imaging if available. 6. Mild right inguinal hematoma secondary to recent procedure, no contrast intravasation or pseudoaneurysm. ___ Right groin ultrasound: IMPRESSION: Ill-defined 7.5 x 3.5 x 3.4 cm avascular heterogeneous fluid collection in the right groin, consistent with hematoma. No AVF or pseudoaneurysm identified. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Doxazosin 4 mg PO DAILY 3. Indapamide 1.25 mg PO EVERY OTHER DAY 4. Klor-Con M20 (potassium chloride) 20 mEq oral DAILY 5. Furosemide 40 mg PO DAILY 6. Omeprazole 20 mg PO QHS 7. Atorvastatin 80 mg PO QPM 8. Vitamin D ___ UNIT PO 2X PER MONTH 9. GlipiZIDE 2.5 mg PO BID 10. Febuxostat 40 mg PO DAILY 11. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 12. Metoprolol Succinate XL 100 mg PO DAILY 13. Fenofibrate 54 mg PO DAILY 14. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 15. ___ MD to order daily dose PO DAILY16 16. Cyanocobalamin 1000 mcg PO DAILY 17. Fish Oil (Omega 3) 4000 mg PO DAILY 18. Vitamin E 400 UNIT PO DAILY 19. FoLIC Acid 1 mg PO DAILY 20. Epoetin ___ ___ U SC 1X/MONTH Discharge Medications: 1. Acetaminophen 650 mg PO Q8H RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by mouth every eight (8) hours Disp #*24 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*10 Capsule Refills:*0 3. Polyethylene Glycol 17 g PO DAILY constipation RX *polyethylene glycol 3350 [Miralax] 17 gram 1 packet by mouth daily Disp #*10 Packet Refills:*0 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 80 mg PO QPM 6. Cyanocobalamin 1000 mcg PO DAILY 7. Doxazosin 4 mg PO DAILY 8. Epoetin ___ ___ U SC 1X/MONTH 9. Febuxostat 40 mg PO DAILY 10. Fenofibrate 54 mg PO DAILY 11. Fish Oil (Omega 3) 4000 mg PO DAILY 12. FoLIC Acid 1 mg PO DAILY 13. Furosemide 40 mg PO DAILY 14. GlipiZIDE 2.5 mg PO BID 15. Indapamide 1.25 mg PO EVERY OTHER DAY 16. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 17. Klor-Con M20 (potassium chloride) 20 mEq oral DAILY 18. Metoprolol Succinate XL 100 mg PO DAILY 19. Omeprazole 20 mg PO QHS 20. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 21. Vitamin D ___ UNIT PO 2X PER MONTH 22. Vitamin E 400 UNIT PO DAILY 23. ___ MD to order daily dose PO DAILY16 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Left Great Toe Ischemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report Study arterial Doppler lower extremity Reason ischemia Findings duplex evaluation was performed the right lower extremity. Significant calcified plaque makes the interpretation difficult. Velocities are 73 in the common femoral the but become decreased at the popliteal. Impression somewhat difficult to interpret duplex due to significant calcification of patent proximal right lower extremity arterial system. Distally there appears to be occlusion. Radiology Report Study arterial Doppler lower extremity Reason left foot ulcer Doppler evaluation was performed of both lower extremities. Segmental pressures are not accurate due to noncompressible vessels. All waveforms are monophasic. Pulse volume recordings show significant dampening starting at the thigh level and are essentially flat line at the left ankle and metatarsal. Impression significant multi segmental bilateral occlusive disease Radiology Report EXAMINATION: CHEST (PRE-OP PA AND LAT) INDICATION: ___ year old man with left toe ischemia for angiogram // preop CXR TOE PAIN IMPRESSION: In comparison with the study of ___, there is little change. Again there is elevation of the left hemidiaphragmatic contour with blunting of the costophrenic angle. Pacer device remains in place. No evidence of acute pneumonia or vascular congestion. Radiology Report EXAMINATION: CTA AORTA/BIFEM/ILIAC RUNOFF W/WANDWO C AND RECONS INDICATION: ___ year old man hx stage IV CKD, CAD, PAD p/w left first toe ischemia, s/p LLE angio with ___ high creatinine, failure to adequately visualize vessels // ___ year old man hx stage IV CKD, CAD, PAD p/w left first toe ischemia, s/p LLE angio with ___ high creatinine, failure to adequately visualize vessels 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: 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: None. FINDINGS: VASCULAR: Extensive diffuse atherosclerotic plaque is demonstrated. The abdominal aorta and demonstrates mild fusiform abdominal aortic ectasia measuring up to 3.6 cm. At the upper margin of the aneurysm, there is small air bubble within the anterior wall of the aortic aneurysm, which may be related to recent procedure, or is iatrogenic. There are no adjacent inflammatory change. The celiac artery is patent. Calcification is noted at the origin and along the SMA, vessel is narrowed more distally. Extensive atherosclerotic plaque is noted involving the origins of the renal arteries bilaterally. Atherosclerotic calcification is noted of the iliac arteries. There is mild-to-moderate narrowing of the distal left common iliac artery, left external iliac artery is small in caliber and patent. Left internal iliac artery is patent. Right common iliac artery is mildly narrowed. Right internal iliac artery is patent. The right external iliac arteries mildly narrowed. Right lower extremity: There is right groin hematoma measuring 5.8 cm by 1.8 cm, likely from recent procedure. No evidence of contrast extravasation or pseudoaneurysm. Right common femoral artery is mildly narrowed. The right superficial femoral artery is completely occluded at its origin and is very small in caliber, and there is reconstitution of the right popliteal artery, from collateral vessels. The deep femoral artery is patent. The right anterior tibial artery is occluded just beyond its origin. Dorsalis pedis artery is heavily calcified, it does not appear patent in few small noncalcified segments. The peroneal arteries is patent, demonstrate severe atherosclerotic calcification. Posterior tibial artery is heavily calcified, is probably patent. The right plantar artery appears patent. Left lower extremity: There is mild narrowing of the left common femoral artery. The left superficial femoral artery and popliteal arteries demonstrate demonstrate severe atherosclerotic narrowing but likely remain patent. The deep femoral artery is severely atherosclerotic and patent. The anterior and posterior tibial arteries are occluded. The peroneal artery appears patent and continues into the plantar aspect of the foot. There is reconstitution of the dorsalis pedis artery, likely from collateral flow. The left plantar artery appears occluded. Multiple surgical clips are noted along the right medial thigh, likely from saphenous vein harvesting. LOWER CHEST: Minimal atelectasis is noted in the lung bases. There is no pleural or pericardial effusion. Extensive coronary artery calcification. Pacemaker lead is noted in the right ventricle. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits, without stones or gallbladder wall thickening. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: A rim calcified lesion is noted in the left adrenal gland measuring 3.4 x 3.6 cm. Right adrenal gland is normal. URINARY: The kidneys bilaterally are atrophic. No renal masses or hydronephrosis. Small benign simple cyst left kidney. GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness and enhancement throughout. Sigmoid colonic diverticulosis. Appendix contains air, has normal caliber without evidence of fat stranding. There is no evidence of mesenteric lymphadenopathy. RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Sternotomy wires are demonstrated. SOFT TISSUES: Stranding and fluid noted in the right inguinal region is consistent with recent angiogram. Soft tissue within the left lower anterior abdominal wall which may relate to gynecomastia. IMPRESSION: 1. Extensive diffuse atherosclerotic calcification, limiting evaluation of the arteries in the lower extremities. 2. The left anterior and posterior tibial arteries are occluded with single vessel runoff to the wide, reconstitution of the dorsalis pedis artery, likely from collateral flow. 3. The right superficial femoral artery is occluded with reconstitution of the popliteal artery from collateral flow. 4. Right anterior tibial artery is occluded with 2 vessel runoff, reconstitution of the dorsalis pedis artery. 5. Rim calcified left adrenal lesion may represent prior hemorrhage. Correlate with prior imaging if available. 6. Mild right inguinal hematoma secondary to recent procedure, no contrast intravasation or pseudoaneurysm. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with new fevers and tachycardia // fever workup fever workup IMPRESSION: Compared to chest radiographs ___. No evidence of pneumonia. Elevation left hemidiaphragm is chronic. Borderline enlargement cardiac silhouette unchanged. No appreciable pleural effusion. Transvenous right ventricular pacer defibrillator lead in place unchanged. Radiology Report EXAMINATION: ART DUP EXT LO UNI;F/U RIGHT INDICATION: ___ year old man with large R groin hematoma and Hct drop // evaluate for pseudoaneurysm, AVF, bleed TECHNIQUE: Grayscale ultrasound images were obtained of the superficial tissues of the right groin. COMPARISON: CTA aorta, bifem and iliac dated ___. FINDINGS: Transverse and sagittal images were obtained of the right groin. Superficial to the femoral vessels, there is a large ill-defined heterogeneous fluid collection without internal vascularity measuring 3.5 x 3.4 x 7.5 cm, consistent with known hematoma. No pseudoaneurysm or arteriovenous fistula identified. Doppler evaluation of the right common femoral and superficial femoral vessels demonstrates normal waveforms with wall-to-wall flow. IMPRESSION: Ill-defined 7.5 x 3.5 x 3.4 cm avascular heterogeneous fluid collection in the right groin, consistent with hematoma. No AVF or pseudoaneurysm identified. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Leg swelling, L Foot pain Diagnosed with Peripheral vascular disease, unspecified temperature: 97.6 heartrate: 80.0 resprate: 18.0 o2sat: 98.0 sbp: 140.0 dbp: 74.0 level of pain: 10 level of acuity: 2.0

The patient was admitted to the vascular surgery service after presenting with left foot rest pain and an ischemic-appearing left foot with rubor. Non-invasive studies were performed on HD2, which demonstrated left ABIs: ___ 0.17; DP 0.79. He was started on a heparin drip once his INR was <2 (on home coumadin for afib) and was taken to the operating room on HD3 for left lower extremity angiogram with a mixture of CO2 and contrast given his history of severe CKD. This did not allow for adequate visualization of his vessels so he underwent post-operative CTA imaging with pre and post-hydration to protect his renal function per the nephrology team's recommendations. Postoperatively, he had stable signals in the right and left feet though was noted to have a hematoma at the right groin site; his heparin drip was therefore held and restarted the next day after the hematoma was noted to be stable. The CTA demonstrated occlusion of the right SFA as well as occlusion of the DP, AT, and ___ with collateralization. He was thought to require a left femoral endarterectomy with possible iliac stent placement and surgical planning was pursued. On POD2, he was noted to be in afib with rvr and have elevated troponins. Notably, he was asymptomatic during this event and normotensive. His troponins were trended and peaked at 1.68; his CM-MB peaked at 15 and was noted to downtrend. The cardiology service was consulted and recommended increasing his home metoprolol dosing. He was kept inhouse awaiting a pre-operative cardiac catheterization as part of a cardiac clearance work-up. On POD5, he was noted to be increasingly tachycardic with a Hct drop to 20.7. He underwent ultrasound of his right groin which demonstrated a 7.5cm stable hematoma and no evidence of pseudoaneurysm. He was tranfused 2 units of pRBCs with appropriate increase in his hematocrit and improved hemodynamics. Ultimately, his cardiac catheterization was cancelled due to concerns that it was very high risk given his CKD and access issues. Cardiology also felt the catheterization would offer very minimal benefit given that the troponin elevation event likely represented a demand ischemia rather than a true NSTEMI requiring intervention. He was noted to be high risk for surgery by cardiology but it was decided to proceed with scheduling as no intervention was suggested to improve this risk. Throughout his hospital stay, he persistently complained of severe pain in his left foot that required IV pain medicine. By POD___-9, he starting reporting improvement in his left foot such that he felt able to be discharged home on an oral regimen. At this time, a heparin bridge to coumadin was started in preparation for discharge home to follow up for his surgery as an outpatient. Also of note, the nephrology team was consulted and followed the patient throuhgout his workup. They were involved in pre/posthydration decisions prior to contrast loading and determined that the patient had no need for hemodialysis. His creatinine returned to 2.9 at time of discharge from a peak of 4.3. During the period of POD10-11, we began to discuss the tentative plan for a Left CIA Stent and a Left Femoral Endarterectomy. We discussed the plan with the patient who deferred medical decision making to his wife. After extensive discussion with his wife, we determined that the wife would ultimately like for the patient to be DNR/DNI status, although she did express interest in the patient having the surgery and desire to make him Full Code for the ___ period. We consulted the Geriatric Service, who saw the patient and confirmed the HCP status of the wife, who completed a MOLST form. After discussion with the vascular surgery team, we decided to hold off on any intervention during this admission but to follow Mr. ___ closely as an outpatient and to re-evaluate his operative potential during his scheduled follow up appointment in two weeks. The family was comfortable with this decision but inquired about his pain control at home. They reported they were just prescribed Ultram by another provider and were contempt using that medication to control his pain. All discharge instructions and outpatient follow up plans were discussed with the patient and his family who were comfortable with the plan.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: Keflex / Penicillins / shellfish derived Attending: ___. Chief Complaint: Hydrocephalus Major Surgical or Invasive Procedure: lumbar puncture ___ History of Present Illness: Mr. ___ is a ___ year-old man with a history of DM, HTN, disc herniation s/p spinal surgery, and recent diagnosis of hepatocellular carcinoma with mets to the lungs, who was transferred to ___ ED from ___ after fall due to bilateral leg weakness and lightheadedness. The patient has been experiencing chronic back pain in the mid back. He reportedly had a disc herniation, for which he underwent spinal surgery. However, his back pain has continued to persist to today. He also has longstanding hip pain, and a diabetic neuropathy causing burning in both legs. Within the last month, pt was diagnosed with hepatocellular carcinoma with metastasis to the lungs. Due to his falls and recently diagnosed Hepatocellular carcinoma and metastasis to the lung, the patient was transferred here to ___ for questionable mets to the spine. The patient also states that he's had gate instability over the last year and urinary hesitancy and urgency over the last 4 months. He also stated that many years ago he (he can't remember how long) was told that he had "water in his brain" but he didn't believe it at the time. Per Neurology note: Within the past few days, pt has had intermittent nausea and lightheadedness, both when standing and lying down. Yesterday, after spending the day outside, pt stood up from sitting, felt worsening nausea and lightheadedness, as well as leg weakness, and fell. He did not lose consciousness or strike his head. He had two such falls. After falling, he noted a sharp/aching pain in the lower extremities, extending from the buttocks to the calves bilaterally. He reports an unusual sensation in his feet (which he reports as a "hard" or "waxy" feeling) but is unsure when it began. Past Medical History: - Hepatocellular carcinoma with mets to lungs, recently diagnosed, not yet treated - Diabetes mellitus - HTN - HLD - GERD - Chronic back pain; disc herniation s/p spinal surgery - s/p left partial knee replacement - s/p hand surgery - s/p appendectomy Social History: ___ Family History: Neck cancer in mother Lung cancer in maternal uncle ___ cancer in maternal great-grandfather ___ in maternal relatives Physical Exam: On admission: PHYSICAL EXAMINATION Vitals: 36.8 105 150/75 18 97% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: ___ EOMs I 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. Recall: ___ objects at 5 minutes. 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. 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 Toes downgoing bilaterall - Coordination - No dysmetria with finger to nose testing bilaterally. - Gait - Unstable station Pertinent Results: LABS: ___ 11:30AM URINE COLOR-DkAmb APPEAR-Hazy SP ___ ___ 11:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN->12 PH-6.0 LEUK-TR ___ 11:30AM URINE RBC-2 WBC-6* BACTERIA-NONE YEAST-NONE EPI-2 ___ 11:30AM URINE HYALINE-59* ___ 04:35AM GLUCOSE-134* UREA N-24* CREAT-0.7 SODIUM-136 POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-24 ANION GAP-16 ___ 04:35AM ALT(SGPT)-41* AST(SGOT)-117* ALK PHOS-267* TOT BILI-2.2* ___ 04:35AM WBC-14.3* RBC-3.55* HGB-11.3* HCT-35.0* MCV-99* MCH-31.9 MCHC-32.4 RDW-14.1 ___ 04:35AM NEUTS-75.2* LYMPHS-15.9* MONOS-7.4 EOS-1.1 BASOS-0.4 ___ 04:35AM PLT COUNT-204 ___ MRI C/T/L spine: No abnormal cord signal or evidence of cord impingement. Some canal narrowing is seen at C3-4 due to posterior disc bulge. IMAGING: ___ CT Head: Severe noncommunicating hydrocephalus. No evidence of herniation. Neurosurgical consultation advised, consider ventriculostomy catheter placement. ___ MRI Brain: Severe hydrocephalus without an obstructing lesion identified. Findings are consistent with communicating hydrocephalus such as normal pressure hydrocephalus. CYTOLOGY: NEGATIVE FOR MALIGNANT CELLS Medications on Admission: The Preadmission Medication list is accurate and complete. 1. GlipiZIDE XL 10 mg PO DAILY 2. Gabapentin 1200 mg PO BID 3. Lisinopril 40 mg PO DAILY 4. Atorvastatin 20 mg PO DAILY 5. Docusate Sodium 100 mg PO BID:PRN constipation 6. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H 7. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 8. Metoprolol Succinate XL 50 mg PO DAILY 9. Levemir FlexPen 30 Units Bedtime 10. MetFORMIN (Glucophage) 1000 mg PO BID 11. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO Q6H:PRN pain 12. Pantoprazole 40 mg PO Q24H 13. Amitriptyline 25 mg PO HS 14. Hydrochlorothiazide 25 mg PO DAILY 15. Cyclobenzaprine 10 mg PO TID:PRN pain 16. Pioglitazone 30 mg PO DAILY Discharge Medications: 1. Atorvastatin 20 mg PO DAILY 2. Gabapentin 1200 mg PO BID 3. Levemir FlexPen 30 Units Bedtime 4. Lisinopril 40 mg PO DAILY 5. MetFORMIN (Glucophage) 1000 mg PO BID 6. Metoprolol Succinate XL 50 mg PO DAILY 7. Amitriptyline 25 mg PO HS 8. Cyclobenzaprine 10 mg PO TID:PRN pain 9. Hydrochlorothiazide 25 mg PO DAILY 10. Pantoprazole 40 mg PO Q24H 11. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO Q6H:PRN pain 12. Pioglitazone 30 mg PO DAILY 13. GlipiZIDE XL 10 mg PO DAILY 14. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 15. Docusate Sodium 100 mg PO BID:PRN constipation 16. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: Communicating Hydrocephalus Discharge Condition: Level of Consciousness: Alert and interactive. Mental Status: Confused - sometimes. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: MRI CERVICAL, THORACIC, AND LUMBAR INDICATION: History: ___ with recent diagnosis of hepatic CA presenting with back pain and weakness of lower extremities // Any metastases? TECHNIQUE: Sagittal T2, STIR, T1 pre and postcontrast sequences of the cervical, thoracic and lumbar spine with axial T2 and T1 pre and postcontrast sequences of the cervical, thoracic and lumbar spine following administration of 14 cc Gadavist. COMPARISON: Chest radiograph of ___. CT abdomen of ___. MRI abdomen of ___ FINDINGS: Cervical spine: There is mild straightening of the normal cervical lordosis. The patient is status post anterior plate and screw fixation of C5 and 6. There is mild loss of disc height at C3-4, with associated ___ 2 endplate changes. ___ 2 endplate changes at C6-7 is also seen. Otherwise, the remainder of the disc heights are preserved. Vertebral body heights, allowing for postsurgical changes at C5-6 are also preserved. Disc and vertebral body heights at the remainder levels are unremarkable. The visualized posterior fossa is unremarkable. No cord signal abnormalities of the cervical spine. No abnormal leptomeningeal enhancement. C2-3: Unremarkable. C3-4: There is a large posterior disc osteophyte complex and moderate bilateral uncovertebral arthropathy, which results in moderate spinal canal narrowing. The disc osteophyte complex remodels the ventral aspect of the cord without underlying cord signal changes. There is mild to moderate bilateral neural foraminal narrowing. C4-5 through C7-T1: No significant spinal canal or neural foraminal narrowing. Thoracic spine: There is preservation of the normal lumbar lordosis. Mild multilevel degenerative marginal osteophytes are noted. Disc and vertebral body heights are preserved. No suspicious marrow signal. No signal abnormalities of the visualized cord. No abnormal leptomeningeal enhancement. There is moderate facet arthropathy at T10-11 resulting in mild spinal canal narrowing. There is also mild bilateral neural foraminal narrowing. Otherwise, there is no significant spinal canal or neural foraminal narrowing at the remainder levels. There are multiple pulmonary nodules in the bilateral lung bases, consistent with metastatic disease. In addition, there is a nodule arising from the lateral limb of the left adrenal gland, measuring approximately 2.8 cm, larger when compared to prior CT of ___, also likely representing metastatic disease. Lumbar spine: There is straightening of the normal lumbar lordosis. The patient is status post posterior fusion spanning L4 through S1, with right laminectomy at L5 and bilateral bone grafting at L4. There is severe loss of disc height at L5-S1 and 5-6 mm retrolisthesis of L5 on S1. Disc desiccation and mild loss of disc height at L3-4 and L4-5 is noted. The remainder of the disc heights of the lumbar spine is preserved. Vertebral body heights are maintained. The conus terminates at the inferior endplate of L1. No signal abnormalities of the visualized cord. There are ___ 2 endplate changes at L4 and L5. No suspicious marrow signal. L1-2 through L2-3: No significant spinal canal or neural foraminal narrowing. L3-4: There is a moderate size posterior disk bulge with central annular fissure, more prominent on the left as well as moderate bilateral facet arthropathy and infolding ligamentum flavum. This results in moderate to severe spinal canal narrowing, moderate left neural foraminal narrowing and mild right neural foraminal narrowing. There is crowding of the left subarticular recess which contacts and likely displaces the traversing nerve root. L4-5: There is a small posterior disc bulge as well as in mild to moderate bilateral facet arthropathy and infolding with the flavum, resulting in moderate spinal canal narrowing and mild bilateral neural foraminal narrowing. L5-S1: There is a small posterior disc bulge. There is mild spinal canal narrowing secondary to retrolisthesis of L5 on S1. There is mild bilateral neural foraminal narrowing. There is bilateral defects of the ileum from prior osteotomy. IMPRESSION: 1. Multilevel degenerative changes described above, most severe at C3-4 where there is moderate spinal canal narrowing with mild remodeling of the ventral aspect of the cord without underlying cord compression or abnormal signal and L4-5 through L5-S1, where there is mild to moderate spinal canal narrowing. 2. The patient is status post anterior fusion spanning C5 and 6 as well as posterior fusion of L5 through S1. 3. Incompletely characterized are multiple bibasilar pulmonary lesions and an enlarging left adrenal lesion, consistent with patient's known metastatic disease. Radiology Report INDICATION: History: ___ with weakness // ?pna TECHNIQUE: PA and lateral images of the chest. COMPARISON: Comparison is made with chest radiographs from ___. FINDINGS: The lungs are well expanded and clear. On the lateral images there is a small region of consolidation in the anterior aspect of the lower lobes. Lateral images also demonstrate a possible nodule above the aortic arch. There is no pleural effusion or pneumothorax. The cardiomediastinal silhouette is unremarkable. IMPRESSION: 1. Small region of consolidation in the anterior aspect of the lower lobes. 2. Possible nodule above the aortic arch. Old studies would be helpful for comparison, but if these are unavailable CT is recommended for further evaluation. Radiology Report INDICATION: ___ male with unsteady gait and ___ weakness, evaluate for for signs of hydrocephalus versus infarct. TECHNIQUE: Helical axial MDCT images were obtained through the brain without the administration of IV contrast. Reformatted images in coronal and sagittal axes were generated. DOSE: DLP: 892 mGy-cm COMPARISON: None available FINDINGS: There is no evidence of acute major vascular territorial infarction, intracranial hemorrhage, or edema. There is severe hydrocephalus with enlargement of the lateral ventricles, third and fourth ventricles without evidence of obstruction or transependymal migration of CSF. The basal cisterns are patent, cerebral sulci remain conspicuous though may be partially effaced, and there is preservation of gray-white matter differentiation. There is no acute fracture. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. IMPRESSION: Severe noncommunicating hydrocephalus. No evidence of herniation. Neurosurgical consultation advised, consider ventriculostomy catheter placement. NOTIFICATION: Findings were discussed with Dr. ___ by Dr. ___ the telephone on ___ at 11:50, 5 minutes and fibula. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST INDICATION: ___ year old man with hydrocephalus, metastatic HCC // eval for any signs of leptomeningeal enhancement to suggest metastatis, or any other metastatic parenchymal lesions, explanation for hydrocephalus TECHNIQUE: MRI of the brain is performed and includes the following sequences: sagittal T-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: CT head ___ FINDINGS: There is moderate hydrocephalus with moderate dilation of the lateral ventricles including the temporal horns and third and fourth ventricles along with mildly dilated cerebral aqueduct. The ventricular dilation is out of proportion to the size of the sulci, which appear normal in size. Minimal periventricular hyperintense signal is seen, which can relate to CSF seepage. There is slightly lobulated contour of the lateral ventricles along the lateral aspect, with indentation on and thinning of the corpus callosum. No obstructing lesion seen. No abnormal enhancement noted in the brain parenchyma or in the meninges. There is no acute infarction, intracranial hemorrhage, extracerebral fluid collection, midline shift or mass effect. No diffusion abnormalities are detected. The cerebral volume is appropriate for the patient's stated age. The major vascular flow voids are maintained. There is no evidence of abnormal enhancement. Sella, pineal gland and the craniocervical junction regions are unremarkable. The orbits are unremarkable, the paranasal sinuses and mastoid air cells are grossly clear ; minimal fluid noted in the right mastoid air cells. IMPRESSION: Moderate hydrocephalus out of proportion to normal sulcal size without an obstructing lesion identified. No abnormal parenchymal or leptomeningeal enhancement. Findings are consistent with communicating hydrocephalus such as normal pressure hydrocephalus. Clinical correlation is recommended for further management. Radiology Report EXAMINATION: CHEST RADIOGRAPH ___ INDICATION: ___ year old man who is pre-op for OR // pre-operative planning Surg: ___ (VP shunt) TECHNIQUE: Single upright AP view of the chest. COMPARISON: Comparison is made to a prior study from yesterday morning. FINDINGS: The lung volumes are slightly lower compared to the prior study, with persistent mild bibasilar opacities, possibly atelectasis. The cardiomediastinal silhouette is stable. There is no pneumothorax or overt pulmonary edema. IMPRESSION: No significant change in appearance of the chest since the prior study. Radiology Report EXAMINATION: Fluoroscopic guided lumbar puncture INDICATION: ___ year old man with normal pressure hydrocephalus and recent diagnosis of hepatocellular carcinoma. // needs large volume lumbar puncture, basic studies, cytology (ordered) TECHNIQUE: Fluoroscopic guided lumbar puncture COMPARISON: MRI head and entire spine ___ FINDINGS: The risks, benefits, and alternatives to the procedure were explained to the patient and informed consent was obtained. A preprocedure time-out was performed confirming the patient's identity, relevant history, and labs. The patient was placed in prone position. The lower back was prepped and draped in sterile fashion. A preprocedural scout film demonstrated spinal fusion hardware at L4-S1. The L4-5 interspace was selected and local anesthesia utilizing 5 cc of 1% lidocaine was administered. A 22 gauge spinal needle was inserted under fluoroscopic guidance. The position of the needle was confirmed utilizing fluoroscopy and an image was saved to PACS. The opening pressure was 19 cm of water. 30 cc of clear colorless cerebrospinal fluid was removed. The needle was subsequently removed. There were no immediate complications. The CSF was sent to the laboratory in 4 tubes and a separate ___ container for cytology. This procedure was performed by Dr. ___ (neuroradiology fellow) and Dr. ___ (neuroradiology attending). Dr. ___ was present during the entire procedure. IMPRESSION: Successfully performed high-volume lumbar puncture. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Lower back pain, Neck pain Diagnosed with LUMBAGO temperature: 36.8 heartrate: 105.0 resprate: 18.0 o2sat: 97.0 sbp: 150.0 dbp: 75.0 level of pain: 9 level of acuity: 3.0

___ is a ___ year old man with a new diagnosis of metastatic hepatocellular carcinoma, who presented after a fall. He was found to have enlarged ventricles on brain imaging. In combination with a history of declining cognitive function and incontinence, his presentation is concerning for normal pressure hydrocephalus (NPH) and he was admitted to neurology for further workup.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Diagnostic paracentesis History of Present Illness: Mrs ___ is a ___ female who has decompensated liver cirrhosis secondary to NASH with hepatic encephalopathy, ascites, portal hypertension with esophageal varices and a portal vein thrombosis, on liver transplant list who presents with abdominal pain. She c/o intermittent epigastric pain x 1 day. +nausea, no emesis. +chills, subjective fever and feels weak. Of note, she was recently discharged from on ___ after eval for lethargy/gait imbalance, which was felt to be secondary to orthostatic hypotension vs neurological origin, but had resolved on discharge. No diarrhea/recent sick contacts/rash/RUQ pain/CP/SOB/neuro sxs. Says last BM was well formed last ___ with no blood or melena. . In the ED, initial vitals were 99.4 99 150/90 18 100% RA. Labs showed CBC/coags stable from ___, LFTs/lipase nl, Tbili stable. Diagnostic paracentesis was attempted and failed. CT a/p showed Increased right colonic wall thickening due to portal colopathy vs infectious or ischemic colitis.Right portal vein not visualized, may represent extension of portal vein thombosis. She was given 4mg IV morphine prior to the paracentesis. Percocet was also given for abdominal pain, as well as IV Zofran. BC x2 drawn and IV Flagyl and IV Cipro given. Most Recent Vitals prior to transfer: 98.8, 88, 143/77, 98 RA, 18 Past Medical History: # type 2 diabetes. # NASH Cirrhosis complicated by: -- esophageal varices (two cords of grade one varices) with prior banding procedures. -- portal vein and splenic vein thrombosis, chronic, nonocclusive -- ascites --SBP early ___ -- reactivated on transplant list ___ # iron deficiency anemia # migraine headaches # hypercholesterolemia # psoriatic arthritis # History of positive PPD s/p INH therapy. # Psoriasis Social History: ___ Family History: Mother with previous CVA. Father has DM2 and prostate cancer. Physical Exam: Adm PE: VS: 99.8, 149/63, 84, 20, 100RA GENERAL: comfortable, appropriate, NAD HEENT: PERRL, EOMI. MM dry, OP clear. NECK: Supple with no JVD, LAD. No thyromegaly. CARDIAC: RRR, nl S1 S2, no MRG. LUNGS: CTAB, no rales, wheezes or rhonchi. ABDOMEN: Soft, non-tender, mild distension. + prominent ventral hernia EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 1+ edema. NEURO: oriented x3, no asterixis . Discharge PE: VS: 97.7 (98.9) 115/60 76 100%RA GENERAL: comfortable, appropriate, NAD HEENT: MMM, OP clear. CARDIAC: RRR, no MRG. LUNGS: CTAB, no rales, wheezes or rhonchi. ABDOMEN: Soft, mildly tender, mild distension. + prominent umbilical hernia EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 1+ edema b/l ___. NEURO: oriented x3, no asterixis SKIN: Diffuse dyspigmented patches scattered throughout entire body Pertinent Results: Adm labs: ___ 08:15AM BLOOD WBC-3.7*# RBC-3.08* Hgb-8.5* Hct-26.9* MCV-88 MCH-27.6 MCHC-31.6 RDW-20.3* Plt Ct-50* ___ 08:15AM BLOOD Neuts-78.3* Lymphs-14.1* Monos-3.7 Eos-3.7 Baso-0.2 ___ 08:37AM BLOOD ___ PTT-32.2 ___ ___ 08:15AM BLOOD Glucose-113* UreaN-12 Creat-0.8 Na-137 K-3.7 Cl-106 HCO3-23 AnGap-12 ___ 08:15AM BLOOD ALT-24 AST-38 AlkPhos-87 TotBili-2.4* ___ 06:32AM BLOOD Albumin-3.5 Calcium-8.4 Phos-2.3* Mg-1.7 ___ 04:45PM ASCITES TotPro-1.3 Glucose-240 LD(LDH)-73 ___ 04:45PM ASCITES WBC-3475* ___ Polys-79* Lymphs-4* Monos-3* Macroph-14* . Micro: ___ 12:40 pm BLOOD CULTURE SET#2. ESCHERICHIA COLI. FINAL SENSITIVITIES. _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ 4 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . ___ UCx: Yeast ___ 12:23 pm STOOL CONSISTENCY: FORMED Source: Stool. FECAL CULTURE (Pending): CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ___: Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). . ___ 3:38 pm PERITONEAL FLUID PERITONEAL FLUID. GRAM STAIN (Final ___: 4+ (>10 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 (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. . ___ - ___ BCx: No growth at discharge x 6 total sets. . Imaging: ___. Increased right colonic wall thickening, maybe due to portal colopathy but infectious or ischemic colitis cannot be excluded. No obvious thromboembolus in mesenteric vessels. 2. Chronic thrombosis of the main portal vein extending to the left portal vein, with non-visualization of the right portal vein. This may be due to the timing of image acquisition or progression of portal vein thrombosis. If clinically indicated, consider Doppler ultrasound study of the liver. 3. Hepatic cirrhosis with sequelae of portal hypertension including ascites, splenomegaly, and extensive mesenteric varicosity. 4. Large but stable umbilical hernia containing multiple loops of non-obstructed small bowel, free fluid, and omentum/mesentery. . ___ ___ guided paracentesis: IMPRESSION: Successful ultrasound-guided diagnostic paracentesis . Discharge labs: ___ 05:55AM BLOOD WBC-1.2* RBC-2.60* Hgb-7.2* Hct-23.6* MCV-91 MCH-27.7 MCHC-30.6* RDW-21.7* Plt Ct-43* ___ 05:40AM BLOOD Neuts-51 Bands-7* ___ Monos-3 Eos-7* Baso-1 Atyps-4* ___ Myelos-0 ___ 05:55AM BLOOD ___ PTT-34.0 ___ ___ 05:55AM BLOOD ___ ___ ___ 05:55AM BLOOD Glucose-96 UreaN-14 Creat-0.8 Na-136 K-3.7 Cl-105 HCO3-24 AnGap-11 ___ 05:55AM BLOOD ALT-10 AST-29 LD(LDH)-183 AlkPhos-52 TotBili-1.3 ___ 05:55AM BLOOD Calcium-8.8 Phos-2.6* Mg-1.9 Medications on Admission: BETAMETHASONE DIPROPIONATE - 0.05 % Lotion - apply bid to psoriasis on weekends avoid face-folds-genitals CALCIPOTRIENE [DOVONEX] - 0.005 % Cream - apply to psoriasis twice a day to psoriasis ___ through ___ DESONIDE - 0.05 % Cream - apply once a day to folds/genitals for psoriasis as needed for ___ days then stop ETANERCEPT [ENBREL] - 50 mg/mL (0.98 mL) Syringe - 50 mg subcut q week DX ___ FUROSEMIDE - 40 mg Tablet - 1 Tablet(s) by mouth in the am INSULIN LISPRO PROTAM & LISPRO [HUMALOG MIX 75-25] - 100 unit/mL (75-25) Suspension - 55U twice a day KETOCONAZOLE [NIZORAL] - 2 % Shampoo - wash hair as directed daily LACTULOSE - 10 gram/15 mL Solution - 15 ml(s) by mouth three times a day with orange flavoring LUMBAR OR ABDOMINAL CORSET - - use as directed back pain, abd pain; abdominal hernia icd9:789.00 NADOLOL - 20 mg Tablet - 1 Tablet(s) by mouth once a day PRAVASTATIN 10mg daily RIFAXIMIN [XIFAXAN] - 550 mg Tablet - one Tablet(s) by mouth twice a day SPIRONOLACTONE - 100 mg Tablet - 1 Tablet(s) by mouth once a day TRIAMCINOLONE ACETONIDE - 0.1 % Ointment - apply twice a day to psoriasis on arms/legs/back/chest for ___ days per month as needed avoid face,folds,genitals Medications - OTC ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) CALCIUM CARBONATE-VITAMIN D3 - 600 mg (1,500 mg)-400 unit Tablet - 1 Tablet(s) by mouth once daily FERROUS SULFATE - 325 mg (65 mg iron) Tablet - 1 Tablet(s) by mouth once a day GUAIFENESIN - 100 mg/5 mL Liquid - 5 mL(s) by mouth every ___ hours as needed for cough Discharge Medications: 1. betamethasone dipropionate 0.05 % Lotion Sig: One (1) Appl Topical BID (2 times a day): apply bid to psoriasis on weekends avoid face-folds genitals . 2. calcipotriene 0.005 % Cream Sig: One (1) Appl Topical BID (2 times a day): ___ through ___. 3. ketoconazole 2 % Shampoo Sig: One (1) Topical once a day. 4. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO TID (3 times a day). 5. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. triamcinolone acetonide 0.1 % Ointment Sig: One (1) Topical twice a day: apply twice a day to psoriasis on arms/legs/back/chest for ___ days per month as needed avoid face,folds,genitals. 9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit Tablet Sig: One (1) Tablet PO once a day. 11. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Insulin Continue your home insulin dosing; which you reported to be NPH 55u with breakfast, and 25u with dinner; and humalog sliding scale 13. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 14. spironolactone 100 mg Tablet Sig: One (1) Tablet PO once a day. 15. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): For 14 day total course, started on ___. Disp:*qs Tablet(s)* Refills:*0* 16. Outpatient Lab Work Please obtain a CBC with differential on ___ or ___ ___ and have the results sent to Dr. ___ ___ ___ Discharge Disposition: Home Discharge Diagnosis: Spontaneous bacterial peritonitis E. coli bacteremia Pancytopenia Cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Epigastric pain in patient with end-stage renal disease and known portal vein thrombosis. COMPARISON: Liver ultrasound from ___, CT abdomen from ___, and MRI abdomen ___. TECHNIQUE: Multidetector CT-acquired axial images from the lung bases to the pubic symphysis were displayed with 5-mm slice thickness. Image acquisition was performed after IV contrast administration. PO contrast was not given. Multiplanar reformation was performed to generate sagittal and coronal image series. ABDOMEN: There is minimal left basilar atelectasis as well as coronary arterial calcifications. The lower chest is otherwise unremarkable. The liver has a macronodular contour, consistent with known history of cirrhosis. The gallbladder is absent. No focal liver lesions are seen. There is thrombosis in the main portal vein, which appears chronic given its calcified rim, which extends into the porta hepatis and undergoes cavernous change at the origin of the occluded left portal vein (2:14, 24). The splenic vein and SMV appear patent. The left portal vein is not well seen which is a new finding from the prior ultrasound on ___, when flow was demonstrated. The pancreas and adrenal glands appear normal. There is stable splenomegaly as well as ascites. The bilateral kidneys enhance normally and excrete contrast symmetrically. There is a small hiatal hernia. The stomach and proximal duodenum are decompressed, limiting evaluation. There is a large but stable umbilical hernia with multiple loops of unobstructed small bowel and mesentery along with ascitic fluid within the hernia sac. The abdominal loops of small and large bowel feature no wall thickening or dilation. There is diffuse mesenteric vessel varicosity, unchanged from the prior studies. There is no intra-abdominal free air. No lymphadenopathy is identified. There are atherosclerotic calcifications within the abdominal aorta, but the main branches are patent. PELVIS: Increased bowel wall thickening is noted of the right hemicolon when compared to the prior cross-sectional studies (2:45). The transverse and descending colon are normal. There is sigmoid diverticulosis without diverticulitis. There is no pelvic abscess or lymphadenopathy. The normal appendix is visualized. The uterus, bladder, and adnexa appear normal. BONE WINDOWS: There is no acute fracture, malalignment, or lesion concerning for malignancy. Incidental note is made of an L5 pars defect. IMPRESSION: 1. Increased right colonic wall thickening, maybe due to portal colopathy but infectious or ischemic colitis cannot be excluded. No obvious thromboembolus in mesenteric vessels. 2. Chronic thrombosis of the main portal vein extending to the left portal vein, with non-visualization of the right portal vein. This may be due to the timing of image acquisition or progression of portal vein thrombosis. If clinically indicated, consider Doppler ultrasound study of the liver. 3. Hepatic cirrhosis with sequelae of portal hypertension including ascites, splenomegaly, and extensive mesenteric varicosity. 4. Large but stable umbilical hernia containing multiple loops of non-obstructed small bowel, free fluid, and omentum/mesentery. Radiology Report PROCEDURE: Ultrasound-guided diagnostic paracentesis. INDICATION: ___ female with history of cirrhosis and ascites presenting with abdominal pain. Request ultrasound-guided diagnostic paracentesis to evaluate for spontaneous bacterial preitonitis. OPERATORS: Dr. ___ imaging fellow) and Dr. ___ (radiology attending). Dr. ___ was present for the entire duration of the procedure. COMPARISON: Previous CT abdomen and pelvis dated ___. PROCEDURE: After explaining the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was brought to the ultrasound suite and was laid supine on the table. Preprocedure timeout was performed using three unique patient identifiers as per standard ___ protocol. Limited preprocedure sonographic images of the abdomen was performed for purposes of location of the largest ascitic fluid pocket. The largest pocket was localized to the right upper quadrant of the abdomen. The overlying skin was prepped and draped in the usual sterile fashion. 1% buffered lidocaine solution was used to anesthetise the skin, subcutaneous soft tissues and parietal peritoneum. Under sonographic guidance, a 22-gauge needle was advanced into the peritoneal cavity, there was immediate return of darkish straw-colored ascitic fluid. Approximately 20 mL of the fluid was drained. The obtained sample was sent for further microbiological analysis. The patient tolerated the procedure well without any immediate periprocedural complications. IMPRESSION: Successful ultrasound-guided diagnostic paracentesis. Microbiological results pending at this time. Gender: F Race: HISPANIC OR LATINO Arrive by WALK IN Chief complaint: ABD PAIN, NAUSEA Diagnosed with ABDOMINAL PAIN RLQ, CIRRHOSIS OF LIVER NOS, DIABETES UNCOMPL ADULT temperature: 99.4 heartrate: 99.0 resprate: 18.0 o2sat: 100.0 sbp: 150.0 dbp: 90.0 level of pain: 5 level of acuity: 3.0

Summary: ___ woman with NASH cirrhosis complicated by hepatic encephalopathy, ascites, portal hypertension with esophageal varices and a portal vein thrombosis, admitted for SBP. . # SBP and associated e coli bacteremia: Not suspected to be secondary peritonitis after a work-up for this was unrevealing. Treated with Ceftriaxone for 4 days, which was halted secondary to pancytopenia, with an ANC at discharge of 610. ID was consulted and recommended switching to Ciprofloxacin 500 mg po q12 hours for total 14 day antibiotic course from ___ (first day of clear cultures). Surveillance blood cultures, peritoneal cultures, and stool cultures had been sent, which were not growing anything at the time of discharge will need follow-up as an outpatient. . # Pancytopenia: Time-course correlates with ceftriaxone, which was subsequently changed to ciprofloxacin. However, other etiologies are possible, including marrow suppression from e-coli bacteremia. Now stabilized, and some lines trending up. ___ 610. Enbrel was held given neutropenia. Patient was carefully counseled to watch for fever at home, and to immediately call her outpatient physicians or go to the emergency room for a temperature >100.4. She was scheduled for follow-up 3d post discharge for PCP appointment and repeat count check. ID did not recommend listing pancytopenia as an adverse reaction of ceftriaxone in the patient's record, as they did not feel confident this medication was to blame. . # NASH Cirrhosis: Decompensated. continued lactulose and rifaximin for encephalopathy. Initially held and later restarted lasix and spironolactone. continued nadolol for varices . # Psoriasis with psoriatic arthritis: Currently relatively few lesions, and she feels her current regimen controls her symptoms well. Minimal arthritis pain. continued topical regimen, but held Enbrel in setting of neutropenia and infection. . # Diabetes: continued home regimen (per pt's report of her home doses which was different than listed in OMR). . # History of possible TIA: On 325mg daily ASA; Deferred to primary outpatient providers. . # Health maintenance: continued calcium, iron, vitamin D . ==========

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: PLASTIC Allergies: Penicillins / clindamycin Attending: ___ Chief Complaint: Right hand pain Major Surgical or Invasive Procedure: Pain clinic: stellate ganglion block History of Present Illness: ___ y/o M s/p multiple wrist surgeries with multiple surgeons for symptoms started by either a scaphoid fracture or scapholunate reconstruction, and due to collapse and interval arthritis, he went on to a carpal fusion finally, and on ___ a partial wrist arthrodesis. He presents to the ED with ___ pain and swelling, as well as numbness and hyperesthesia over his wrist, thumb, second and third digit. He had no trauma to his hand and did not overuse his hand. In the Ed, he is in severe pain (___) and very uncomfortable. Past Medical History: PMH/PSH: Multiple procedures on R wrist Social History: ___ Family History: Non contributory. Physical Exam: AVSS General: Appears to uncomfortable and in pain, A&O x3. Abd: S, NT, ND P: Breathing comfortably on RA, CTAB. CV: RRR, ulnar and radial pulses palpable. Extremities: R wrist immobile (unchanged from baseline). Numbness and hyperesthesia wrist, thumb, ___ and ___ digit palmar and dorsal in median and radial nerve distribution. Skin mottling over incision. L arm, wrist and digits normal ROM, sensation. No erythema or signs of infection. Tinel sign negative. Medications on Admission: Neurontin 200mg QHS, Lyrica 75mg QHS Discharge Medications: 1. Acetaminophen 650 mg PO Q6H RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*20 Capsule Refills:*0 3. Gabapentin 600 mg PO TID 4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills:*0 5. Ibuprofen 800 mg PO Q8H RX *ibuprofen 800 mg 1 tablet(s) by mouth every eight (8) hours Disp #*42 Tablet Refills:*0 6. Lorazepam 0.5-1 mg PO QHS:PRN insomnia RX *lorazepam 0.5 mg ___ tablets by mouth every six (6) hours Disp #*30 Tablet Refills:*1 7. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*14 Capsule Refills:*1 Discharge Disposition: Home Discharge Diagnosis: Right wrist neuropathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: DX HAND AND WRIST INDICATION: History: ___ with right wrist pain and TTP. unable to move fingers*** WARNING *** Multiple patients with same last name! // eval for fracture/dislocation eval for fracture/dislocation eval for fracture/dislocation TECHNIQUE: Right hand, three views, and right wrist, three views. COMPARISON: Right wrist radiograph dated ___. FINDINGS: The patient is status post resection of the entire proximal carpal row, placement of screws transfixing the distal radius to the distal carpal row and placement of bone graft material. Overall the appearance is unchanged. There is no evidence of acute fracture. Mild degenerative changes are seen at the first MCP joint and the CMC joints. IMPRESSION: No significant interval change. No acute fracture. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ in personon ___ at 5:36 ___, 2 minutes after discovery of the findings. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with Desat s/p stellate ganglion block // Desat s/p stellate ganglion block Desat s/p stellate ganglion block IMPRESSION: In comparison with the study of ___, there is little change and no evidence of acute cardiopulmonary disease. Cardiac silhouette is within normal limits and there is no evidence of vascular congestion, pleural effusion, or acute focal pneumonia. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: R Wrist pain Diagnosed with Pain in right wrist, Pain in right hand temperature: 97.7 heartrate: 86.0 resprate: 18.0 o2sat: 100.0 sbp: 138.0 dbp: 111.0 level of pain: 9 level of acuity: 3.0

The patient was admitted to the plastic surgery service on ___ for observation and treatment of severe right hand pain. The patient tolerated the procedure well. . Neuro: A chronic pain service consult was obtained and recommendations were followed including increasing home neurontin dose, adding toradol, and adding opioid pain medication. Patient reported some relief but also had periods of "shooting, shock like pain" radiating from a focal point of radial side of wrist (radial neuropathy). Patient became increasingly anxious with episodes of pain and was given Ativan prn. Patient reported good effect with Ativan both for anxiety and assisting with pain control. In further review with patient and discussing symptoms, it was agreed that patient would undergo a repeat stellate ganglion injection of hydrocortisone by the Chronic Pain Service. This was completed prior to discharge home and patient will follow up with Dr. ___ CPS to discuss outcome of procedure and effect on radial neuropathy. . CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. . Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. . GI/GU: The patient tolerated a regular diet. He was also started on a bowel regimen to encourage bowel movement. Voiding spontaneously. . At the time of discharge on hospital day#4, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was controlled.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: CARDIOTHORACIC Allergies: NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / Phenergan Attending: ___. Chief Complaint: spontaneous pneumothorax Major Surgical or Invasive Procedure: ___ Right pigtail catheter placement ___ Intrabronchial valve placement in right upper lobe take off History of Present Illness: Dr. ___ is a ___ year old female known to the Thoracic Surgery service since ___ after undergoing a VATS right upper and right lower lobe wedge resection for metastatic renal cell cancer. She developed increased SOB and chest pain yesterday and came to the ER. A CXR showed a large right pneumothorax. The IP service placed a pigtail catheter and her CXR today shows partial resolution of the PTX. She was admitted to the ICU for management of the chest tube and close observation. Past Medical History: PAST MEDICAL HISTORY: Renal cell Ca ___ Lupus since ___ Tx for active nephritis in ___ Biventricular dysfunction ?___ chemo (EF~30%) with resultant HF ___ Post-obstructive PNA with sepsis ___ Past Surgical History Open left knee arthroscopy ___ Hysterectomy with BSO in ___ Left nepgrectomy ___ Portacath ___ VATS RU, RL wedge Bx ___ Social History: ___ Family History: negative for kidney, bladder cancer Physical Exam: Temp: 99 HR: 90 BP: 90/60 RR: 18 O2 2L Sat:100% GENERAL [] WN/WD [x] NAD [x] AAO [ ] abnormal findings: HEENT [x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric [x] OP/NP mucosa normal [x] Tongue midline [x] Palate symmetric [x] Neck supple/NT/without mass [x] Trachea midline [x] Thyroid nl size/contour [ ] Abnormal findings: RESPIRATORY [] CTA/P [x] Excursion normal [x] No fremitus [x] No egophony [x] No spine/CVAT [x] Abnormal findings: diminished at both bases CARDIOVASCULAR [x] RRR [x] No m/r/g [x] No JVD [x] PMI nl [x] No edema [x] Peripheral pulses nl [x] No abd/carotid bruit [ ] Abnormal findings: GI [x] Soft [x] NT [x] ND [x] No mass/HSM [x] No hernia [ ] Abnormal findings: J tube in place, site clear GU [x] Deferred [ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE [ ] Abnormal findings: NEURO [x] Strength intact/symmetric [x] Sensation intact/ symmetric [x] Reflexes nl [x] No facial asymmetry [x] Cognition intact [x] Cranial nerves intact [ ] Abnormal findings: MS [x] No clubbing [x] No cyanosis [x] No edema [x] Gait nl [x] No tenderness [x] Tone/align/ROM nl [x] Palpation nl [x] Nails nl [ ] Abnormal findings: LYMPH NODES [x] Cervical nl [x] Supraclavicular nl [x] Axillary nl [x] Inguinal nl [ ] Abnormal findings: SKIN [x] No rashes/lesions/ulcers [x] No induration/nodules/tightening [ ] Abnormal findings: PSYCHIATRIC [x] Nl judgment/insight [x] Nl memory [x] Nl mood/affect [ ] Abnormal findings: Pertinent Results: ___ 06:14PM BLOOD WBC-13.6* RBC-3.14* Hgb-8.3* Hct-24.9* MCV-79* MCH-26.5* MCHC-33.4 RDW-18.2* Plt ___ ___ 05:03AM BLOOD Glucose-93 UreaN-17 Creat-0.8 Na-136 K-4.3 Cl-96 HCO3-33* AnGap-11 WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct ___ 06:02 12.4* 2.91* 7.5* 23.0* 79* 26.0* 32.8 17.8* 598* Source: Line-port ___ 05:52 18.5* 2.94* 7.7* 23.4* 79* 26.3* 33.2 17.9* 579* Source: Line-portacath ___ 05:14 18.8* 2.85* 7.6* 22.6* 79* 26.7* 33.7 18.1* 587* Source: Line-port ___ 05:33 13.4* 2.85* 7.5* 22.6* 80* 26.4* 33.2 18.1* 649* Source: Line-port ___ 03:41 11.9* 2.97* 7.8* 23.6* 79* 26.2* 33.0 18.1* 666* Source: Line-chest port ___ 18:14 13.6* 3.14* 8.3* 24.9* 79* 26.5* 33.4 18.2* 770* Source: Line-central ___ 05:03 10.1 3.08* 8.3* 24.4* 79* 27.0 34.1 17.9* 774 Glucose UreaN Creat Na K Cl HCO3 AnGap ___ 06:02 105 20 0.8 134 4.4 94* 31 13 Source: Line-port; TROUGH ___ 05:52 106 21* 0.9 136 4.3 96 31 13 Source: Line-portacath ___ 05:14 99 22* 0.9 132* 4.5 92* 32 13 Source: Line-port ___ 05:33 108 21* 0.9 136 4.6 95* 32 14 Source: Line-port ___ 03:41 103 18 0.9 134 3.5 94* 33* 11 Source: Line-chest port ___ 18:14 99 18 0.9 135 4.0 94* 34* 11 ___ 8:41 pm PLEURAL FLUID PLEURAL FLUID. **FINAL REPORT ___ GRAM STAIN (Final ___: 4+ (>10 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 ___: Reported to and read back by ___. ___ ___ 12:56PM. Due to mixed bacterial types [>=3] an abbreviated workup is performed; all organisms will be identified and reported but only select isolates will have sensitivities performed. Work-up of organism(s) listed below discontinued (excepted screened organisms) due to the presence of mixed bacterial flora detected after further incubation. RARE GROWTH MIXED BACTERIAL FLORA ( >=3 COLONY TYPES) CONSISTENT WITH OROPHARYNGEAL FLORA. ENTEROCOCCUS SP.. RARE GROWTH. Daptomycin PER ___ ___ ___. Daptomycin IS SENSITIVE AT 0.047 MCG/ML PERFORMED BY ETEST. STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. OXACILLIN Sensitivity testing confirmed by Sensititre. GRAM POSITIVE BACTERIA. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | STAPHYLOCOCCUS, COAGULASE NEGATIVE | | AMPICILLIN------------ <=2 S CLINDAMYCIN----------- R DAPTOMYCIN------------ S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.5 S OXACILLIN------------- <=0.25 S PENICILLIN G---------- 0.25 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ <=0.5 S 1 S ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. ___ CYTOLOGY REPORT - Final Specimen(s) Submitted: PLEURAL FLUID Diagnosis SUSPICIOUS FOR MALIGNANCY. Rare highly atypical cells, suspicious for involvement by patient's known malignant neoplasm. Note: Select slides from the patient's kidney resection ___ were reviewed for morphologic comparison. ___ CXR : Moderate right pneumothorax, new from prior, no signs of tension. Opacities within the right upper lung and left lung appear unchanged and could represent pneumonia and/or metastatic disease ___ Chest CT : 1. No residual right pleural effusion. Small pneumothorax. 2. Cavitation of ischemic, right upper lobe, post-obstructive pneumonia. 3. Small left pleural effusion with improved aeration of the left lower lobe. 4. No significant interval change in diffuse calcified pulmonary metastases. ___ CXR : Small right basal pneumothorax has decreased compared to ___, with the basal pleural pigtail catheter unchanged in position along the mediastinum. Consolidation in the largely cavitated right upper lobe has remained stable. There are no new findings in the lungs aside from multiple metastases. Small left pleural effusion stable. Heart size normal. Left subclavian line ends in the SVC. Endobronchial valve projects over the right upper lobe bronchus, but cannot be localized with conventional radiographs. ___ CXR : AP single view of the chest has been obtained with patient in semi-upright position. Comparison is made with the next preceding similar study of ___. The findings are completely unaltered. The previously described parenchymal densities with spontaneous air bronchogram in the right upper lobe area remains fully unchanged. No evidence of new pulmonary abnormalities and unchanged position of left-sided subclavian approach central venous line. Medications on Admission: _1. Commode for bedside 2. Oxygen ___ Litres continuous via NC. 3. Vancomycin 750 mg IV Q 24H Continue until ___ 4. 2Cal HN @ 30cc/HR per G-tube 5. infinity pump 6. 500ml feeding bags 7. ___ button/extension 8. Acetaminophen 325-650 mg PO Q4H:PRN pain 9. Amlodipine 10 mg PO DAILY HOLD for SBP < 90 10. axitinib 5 mg Oral BID 11. Bisacodyl ___AILY:PRN constipation 12. Docusate Sodium 200 mg PO BID 13. Estradiol 1 mg PO DAILY 14. Fentanyl Patch 12 mcg/h TP Q72H 15. Fentanyl Patch 50 mcg/h TP Q72H 16. Lorazepam 0.5 mg PO Q6H:PRN nausea/anxiety 17. Metoclopramide 5 mg PO BID 18. PredniSONE 5 mg PO DAILY 19. TraMADOL (Ultram) 50-75 mg PO Q6H:PRN pain 20. Carvedilol 25 mg PO BID Hold for SBP< 90, HR< 55 21. DiphenhydrAMINE 12.5 mg PO HS:PRN Itchiness 22. Heparin 5000 UNIT SC BID 23. Pantoprazole 40 mg PO Q12H 24. Valsartan 320 mg PO DAILY 25. Torsemide 20 mg PO DAILY 26. Ondansetron 8 mg PO Q8H:PRN nausea 27. Ranitidine 300 mg PO HS 28. Scopolamine Patch 1 PTCH TD Q72H:PRN nausea 29. Lidocaine-Prilocaine 1 Appl TP PRN port access 30. Benzonatate 100 mg PO TID 31. Simvastatin 20 mg PO DAILY 32. darbepoetin alfa in polysorbat 500 mcg/mL Injection q3 weeks 33. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain 34. ertapenem 1 gram Injection QD 35. ertapenem 1 gram Injection QD Discharge Medications: 1. Acetaminophen (Liquid) 1000 mg PO Q6H:PRN pain 2. Carvedilol 6.25 mg PO BID RX *carvedilol 6.25 mg 1 tablet(s) by mouth twice a day Disp #*120 Tablet Refills:*3 3. Estradiol 1 mg PO DAILY 4. Fentanyl Patch 100 mcg/h TD Q72H RX *fentanyl 100 mcg/hour 1 patch Q 72 hrs Disp #*20 Transdermal Patch Refills:*3 5. Heparin 5000 UNIT SC BID 6. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain 7. Metoclopramide 5 mg PO TID 8. Pantoprazole 40 mg PO Q12H 9. PredniSONE 5 mg PO DAILY 10. Ranitidine 300 mg PO HS 11. Torsemide 10 mg PO DAILY RX *torsemide 10 mg 1 tablet(s) by mouth once a day Disp #*60 Tablet Refills:*3 12. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain 13. Valsartan 160 mg PO BID RX *valsartan [Diovan] 160 mg 1 tablet(s) by mouth twice a day Disp #*120 Tablet Refills:*3 14. Vancomycin 500 mg IV Q 24H Last dose ___ RX *vancomycin 500 mg 500 mg once a day Disp #*8 Syringe Refills:*0 15. darbepoetin alfa in polysorbat 500 mcg/mL Injection Q 3 weeks anemia 16. LOPERamide 2 mg PO QID:PRN diarrhea 17. Ondansetron 4 mg PO Q8H:PRN nausea 18. Simvastatin 20 mg PO DAILY 19. Tizanidine 4 mg PO Q6H:PRN muscle spasm 20. Polyethylene Glycol 17 g PO DAILY 21. Amlodipine 5 mg PO DAILY RX *amlodipine 5 mg 1 tablet(s) by mouth once a day Disp #*60 Tablet Refills:*3 22. axitinib 5 mg Oral BID 23. Respiraory Therapy O2 at ___ liters/min via NC continuous during the day Pulse dose for portability 35% humidified open face tent at HS Room air saturation 88% Dx Metastatic renal cell Ca, Pneumonia Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: Metastatic renal cell carcinoma Pneumonia Persistent air leak Right empyema Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report CHEST RADIOGRAPH PERFORMED ON ___. COMPARISON: Prior exams dated ___ and ___. CLINICAL HISTORY: ___ female with renal cancer and lung metastasis with recent right upper lobe pneumonia, here with dyspnea, question interval change. FINDINGS: Portable AP upright chest radiograph provided. There is a new moderate-sized right pneumothorax, predominantly localizing to the right lower lung. There is persistent opacity within the right upper lobe, which could represent residual pneumonia. In addition, subtle vague opacities are seen in the left lung, which represents nodules or multifocal consolidation. There is a Port-A-Cath residing in the left chest wall with tip in the region of the low SVC. Catheter tubing project over the upper abdomen. IMPRESSION: Moderate right pneumothorax, new from prior, no signs of tension. Opacities within the right upper lung and left lung appear unchanged and could represent pneumonia and/or metastatic disease. Findings were flagged on the ED dashboard at the time of initial review. Radiology Report CHEST RADIOGRAPH INDICATION: Pneumothorax, status post chest tube, evaluation. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, the patient has received a right-sided chest tube. The lung is now substantially better inflated but a small pneumothorax persists at the lung bases and in the lateral aspects of the right lung. The extensive parenchymal opacities in the right apex and in the retrocardiac lung areas persist in unchanged manner. The Port-A-Cath in the left pectoral region is also unchanged. Radiology Report CHEST RADIOGRAPH INDICATION: Pneumothorax, status post pigtail catheter. Evaluation. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, there is no relevant change. Right pigtail catheter in situ. Mild remnant right pneumothorax without evidence of tension. Unchanged appearance of the left lung. Radiology Report INDICATION: Widely metastatic renal cell carcinoma with tachypnea and pigtail drain in place. Evaluation for residual effusion. TECHNIQUE: MDCT images were obtained from the thoracic inlet to the upper abdomen without intravenous contrast. Coronal and sagittal reformations as well as axial MIPs were prepared. COMPARISON: CTA chest, ___. FINDINGS: Right-sided pigtail drain is in the posterior costophrenic sulcus with a small pneumothorax. There is no residual effusion. Small non-hemorrhagic pleural effusion on the left has decreased from ___ and atelectasis in the left lower lobe has improved. The 3.9 x 2.7 cm obstructive right hilar mass still nearly occludes the right upper lobe bronchus and its pulmonary artery branch (2:19). Right upper lobe consolidation described on ___ has necrosed and and a large 3.9 x 2.4 cm cavitation has developed (4:67). Aeration of the remaining portions of the right upper lobe has slightly improved. Left-sided Port-A-Cath tip terminates at the cavoatrial junction. Numerous calcified pulmonary masses and nodules representing metastatic renal cell carcinoma are unchanged in size from the most recent CT. Small focus of air in the pulmonary outflow tract is likely from infusion (2:26). There is no pericardial effusion, and the heart is normal in size. There are no pathologically enlarged supraclavicular or axillary lymph nodes by size criteria. This exam is not tailored for subdiaphragmatic evaluation, but 2.1 x 1.4 cm calcified mass in the liver also represents metastasis (2:40). OSSEOUS STRUCTURES: There is no lytic or blastic lesion worrisome for metastasis. IMPRESSION: 1. No residual right pleural effusion. Small pneumothorax. 2. Cavitation of ischemic, right upper lobe, post-obstructive pneumonia. 3. Small left pleural effusion with improved aeration of the left lower lobe. 4. No significant interval change in diffuse calcified pulmonary metastases. Radiology Report INDICATION: Widely metastatic renal cell carcinoma with right upper lobe cavitation. Reevaluation of right chest tube. COMPARISON: CT chest, ___. Chest radiographs from ___. FINDINGS: Portable AP chest radiograph. Left-sided Port-A-Cath and right-sided pleural pigtail drain are in stable position. There is no pneumothorax. Again noted is the right upper lobe consolidation, shown to be cavitating on yesterday's CT. Numerous focal opacities correspond to calcified pulmonary metastases. Left pleural effusion remains small. Radiology Report AP CHEST, 11:12 A.M. ON ___ HISTORY: ___ woman with metastatic renal cell carcinoma and a right pneumothorax. Pigtail pleural drain. IMPRESSION: AP chest compared to ___ at 7:17 a.m.: Moderate-to-large right pneumothorax has not improved since 7:17 a.m., basal pigtail pleural drain still in place. Severe consolidation, right upper lobe, longstanding. Left basal mass and pleural effusion, difficult to separate, with probable increase in pleural fluid volume since ___. Left subclavian infusion port ends low in the SVC. Radiology Report HISTORY: Short of breath. Chest tube to suction. CHEST, SINGLE AP PORTABLE VIEW. ___. A right pigtail catheter is again seen medially at the base of the right lung. There is a large pneumothorax at the base of the right lung, larger than on ___. The lung is retracted superiorly, with chain sutures noted at the inferior edge of the lung. Again seen is a dense patchy opacity in the right upper zone which is apparently longstanding and similar to the prior film. Also again seen is a small nodular opacity in the lower portion of the retracted right lung, unchanged. There is a small-to-moderate left effusion, slightly larger, with patchy opacity in the mid and lower zones of the left lung. The parenchymal opacities appear slightly improved. A left-sided indwelling catheter is present, with lead tip over the SVC/RA junction. IMPRESSION: Relatively largepneumothorax at the base of the right lung, larger than on ___. Right-sided pleural catheter appears unchanged. Please see report of follow-up film which shows interval improvement in the ptx. Radiology Report HISTORY: Increased pneumothorax on waterseal, now back on suction. CHEST, SINGLE AP PORTABLE VIEW. ___ at 10:14 a.m. Compared with the prior study, the pneumothorax at the right lung base has decreased considerably in size. However, a significant pneumothorax remains visible there. Otherwise, I doubt significant interval change. Radiology Report CHEST RADIOGRAPH INDICATION: Pneumothorax, position of pigtail catheter. COMPARISON: ___. FINDINGS: As compared to the previous examination, the position of the right pigtail catheter is virtually unchanged. Also unchanged is the dimension of the known right pneumothorax, predominating at the lung bases and the lateral lung aspect. There is unchanged mild flattening of the right hemidiaphragm. On the left, the extent of a pre-existing retrocardiac atelectasis has minimally increased. No other changes are present. Radiology Report AP CHEST, 11:05 A.M., ___ HISTORY: Check pneumothorax. IMPRESSION: AP chest compared to ___: Large right pneumothorax, predominantly basal, unchanged since ___, despite stable position of the pigtail catheter projecting over the right lung base medially. Residual cavitary consolidation at the right lung apex, large partially calcified metastases, all recently unchanged. Moderate left pleural effusion varies slightly from day to day. Heart size normal. Left subclavian infusion port ends at the superior cavoatrial junction. Radiology Report AP CHEST, 11:04 A.M., ___ HISTORY: A ___ woman with pneumothorax, question interval change. Moderate-to-right pneumothorax has been relatively stable in volume since decreasing between radiographs on ___. Basal pleural pigtail catheter unchanged in position. The largely cavitated, consolidated right upper lobe is relatively stable in appearance. Mild edema present on the ___ has improved. Multiple pulmonary metastases, some substantially calcified would not be expected to change. Tiny left pleural effusion stable. Heart size normal. Left subclavian infusion port ends at the level 6.5 cm below the carina and would need to be withdrawn 2 cm to position it low in the SVC. Radiology Report CHEST RADIOGRAPH INDICATION: Chest tube put to suction. COMPARISON: ___, 11:04. FINDINGS: As compared to the previous radiograph, the right pigtail catheter has been pulled back on suction. There is improved expansion of the right lung. However, a right basal pneumothorax with a diameter of approximately 5 mm is still visible. Slight depression of the right hemidiaphragm has resolved in the interval. Unchanged are the opacities seen in the right lung apex and in the left perihilar areas as well as the left lung bases. Unchanged appearance of the cardiac silhouette. Radiology Report AP CHEST, 9:00 A.M., ___ HISTORY: Right upper lobe endobronchial valve placement. Assess for possible pneumothorax. IMPRESSION: AP chest compared to ___: Small right basal pneumothorax has decreased compared to ___, with the basal pleural pigtail catheter unchanged in position along the mediastinum. Consolidation in the largely cavitated right upper lobe has remained stable. There are no new findings in the lungs aside from multiple metastases. Small left pleural effusion stable. Heart size normal. Left subclavian line ends in the SVC. Endobronchial valve projects over the right upper lobe bronchus, but cannot be localized with conventional radiographs. Radiology Report CHEST ON ___ HISTORY: Pleural effusion, . REFERENCE EXAM: ___ at 0900. FINDINGS: Compared to the prior study, there is no significant interval change. Radiology Report CHEST, ___ HISTORY: Followup right pneumothorax. FINDINGS: Compared to the prior study, there has been interval slight decrease in the size of the pneumothorax. It can still be seen inferiorly and superiorly, however. Other changes in the right lung are similar. There is increased alveolar infiltrate on the left. The right pigtail chest tube is unchanged. The left subclavian line with tip in the right atrium is unchanged. Radiology Report CHEST ON ___ HISTORY: Right pneumothorax. FINDINGS: The right-sided pigtail catheter is again seen. There is increased size of the right pneumothorax best visualized inferiorly. The remainder of the appearance of the lungs are unchanged. Radiology Report STUDY: AP chest, ___. CLINICAL HISTORY: ___ woman with metastatic renal cell cancer. Assess pneumothorax. FINDINGS: Comparison is made to previous study from ___. The right basilar pneumothorax is not longer seen. There is again seen a pigtail catheter at the right base, which is unchanged in position. There are areas of consolidation throughout both lung fields, but worse within the right upper lobe where there is also volume loss with areas of cavitation. They are stable. The left-sided Port-A-Cath has its distal lead tip at the distal SVC, unchanged in position. Radiology Report STUDY: AP chest ___. CLINICAL HISTORY: ___ woman with endobronchial valve, now with clamped chest tube. FINDINGS: Comparison is made to previous study from five hours earlier. No pneumothoraces are seen. There is again seen a right-sided pigtail catheter. There are also areas of consolidation throughout both lung fields, worse within the right upper lobe where there is also cavitation. Findings appear stable. Radiology Report STUDY: AP chest, ___. CLINICAL HISTORY: ___ woman with followup chest tube adjustment. FINDINGS: Comparison is made to previous study from ___ at 10:31 a.m. There has been removal of the pigtail catheter at the right lung base. There remain airspace opacities, most confluent within the upper lobes and a cavitating region in the right upper lobe, stable. There is an unchanged left-sided Port-A-Cath with the distal lead tip at the cavoatrial junction. Radiology Report TYPE OF EXAMINATION: Chest AP portable single view. INDICATION: ___ female patient with metastatic renal cell carcinoma, white blood count 18,000, recent pneumonia, check for interval change. FINDINGS: AP single view of the chest has been obtained with patient in semi-upright position. Comparison is made with the next preceding similar study of ___. The findings are completely unaltered. The previously described parenchymal densities with spontaneous air bronchogram in the right upper lobe area remains fully unchanged. No evidence of new pulmonary abnormalities and unchanged position of left-sided subclavian approach central venous line. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Dyspnea Diagnosed with OTHER PNEUMOTHORAX, SECONDARY MALIG NEO LUNG, HX OF KIDNEY MALIGNANCY, SYST LUPUS ERYTHEMATOSUS temperature: 98.3 heartrate: 94.0 resprate: 32.0 o2sat: 100.0 sbp: 114.0 dbp: 69.0 level of pain: nan level of acuity: 1.0

Dr. ___ was admitted to the Thoracic Surgery service for management of her pigtail catheter. It was kept to -10 of suction, however she continued to have an air leak. We attempted to put this to water seal to see if the lack of suction would help to seal the leak, but both times the leak persisted and her lung began to collapse, requiring being put back to suction twice. Because of this persistent air leak, it was decided by IP that she would be trialed on an intrabronchial valve in her right upper lobe in order to selectively isolate and not airate the leaking parenchyma. It was decided by the patient, her husband, and IP to stop her tyrosine kinase inhibitor 2 days pre-operatively in hopes that this would help promote more effective healing. Post procedurally she was stable, but transferred to the CVICU. The leak appeared smaller post-operatively. From an infectious disease standpoint she was continued on meropenem and vancomycin which she was on prior to admission for pneumonia. Her pleural fluid was sent for culture and grew enterococcus and MSSA. The infectious disease service followed her closely. Her WBC rose to 18K following removal of her chest tube but her chest xray did not change nor did she have a temperature spike. The Rheumatology service evaluated her to assure that her leukocytosis was not from active lupus and that was ruled out as her complement levels were normal. Her WBC eventually decreased to 12K. The Meropenum was stopped on ___ and her Vancomycin will continue through ___. The dose was decreased to 500 mg daily as her trough on 750 mg daily was elevated. Her trough on 500 mg daily is 18 as of ___. Physical Therapy worked with her while she was inpatient to help prevent deconditioning. She was also seen by nutrition who confirmed that her tube feeding was givng her adequate nutrition, and that she should continue to intake PO for pleasure. She was also seen by palliative care, who had been previously following her, who agreed with her plan of care and symptom management. They did not have any specific pain recommendations at this time, but will continue to follow her and provide support. She was discharged home on ___ with ___ services for IV Vancomycin, follow up blood work, tube feedings and medication review. She will follow up with Dr. ___ Interventiomal ___ in a few weeks with a chest xray prior as well as follow up with Oncology and Infectious Disease.

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: UROLOGY Allergies: Sulfa (Sulfonamide Antibiotics) / Penicillins Attending: ___. Chief Complaint: Failure to thrive Wound infection Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo M with recent radical right nephrectomy on ___ who presented to ED with failure to thrive, poor oral intake since surgery, and two atraumatic falls ("sliding off of new bed"). In the ED, he was found to have erythemta around his midline incision, and was treated with vancomycin. He was admitted for antibiotics, IVFs and strengthening. Past Medical History: PMH: BPH/LUTS Incontinence CVA ___ Carotid stenosis LLL lung VATS resection HTN Depression polymyalgia rheumatica melanoma skin SCC, BCC Inguinal hernia C3 fracture Cataracts OSA HYPERTENSION - ESSENTIAL DEPRESSIVE DISORDER POLYMYALGIA RHEUMATICA CANCER - SKIN, SQUAMOUS CELL VITREOUS DEGENERATION MELANOMA, ___, IN-SITU, LT FOREARM, ___, LUNG, rt temple, ___ HERNIA - INGUINAL CATARACT - CORTICAL SENILE BASAL CELL CARCINOMA, ant scalp STROKE COLONIC ADENOMAS FRACTURE OF CERVICAL VERTEBRA, C3 CAROTID ARTERY STENOSIS / OCCLUSION LENTIGO MALIGNA Cataract, nuclear sclerotic senile Sleep apnea, moderate Vitamin B 12 deficiency LBBB (left bundle branch block) Renal mass Social History: ___ Family History: Non-contributory Physical Exam: AVSS Elderly male, pleasant, NAD Unlabored breathing RRR Abdomen soft NTTP, incisions with dermabond. Midline incision with mild erythema, significantly improved, no fluctuance or discharge. Foley catheter in place draining clear yellow with slight pink tinge Ext WWP Pertinent Results: ___ 06:27AM BLOOD WBC-12.3* RBC-4.57* Hgb-14.6 Hct-41.2 MCV-90 MCH-31.9 MCHC-35.4* RDW-13.0 Plt ___ ___ 02:20AM BLOOD WBC-19.0*# RBC-4.64 Hgb-14.5 Hct-41.8 MCV-90 MCH-31.2 MCHC-34.7 RDW-13.0 Plt ___ ___ 02:20AM BLOOD Neuts-86.2* Lymphs-8.9* Monos-4.1 Eos-0.6 Baso-0.2 ___ 06:27AM BLOOD Glucose-96 UreaN-20 Creat-1.6* Na-134 K-4.1 Cl-98 HCO3-28 AnGap-12 ___ 03:40PM BLOOD Glucose-109* UreaN-21* Creat-1.6* Na-134 K-4.1 Cl-95* HCO3-29 AnGap-14 ___ 03:40PM BLOOD Calcium-9.2 Mg-2.1 ___ 02:20AM BLOOD Calcium-8.9 Phos-2.8 Mg-1.8 ___ 4:10 am URINE URINE CULTURE (Preliminary): GRAM NEGATIVE ROD(S). 10,000-100,000 ORGANISMS/ML.. Blood cultures x 2 pending Imaging: CT A/P: INDICATION: ___ man with recent nephrectomy, presenting with cellulitis at the abdominal incision site. COMPARISON: None. TECHNIQUE: MDCT-acquired axial images of the abdomen and pelvis were obtained after administration of enteric contrast only. Coronal and sagittal reformatted images prepared and reviewed. FINDINGS: There is bilateral lower lobe atelectasis as well as a surgical suture line from prior lung resection on the left. There are trace bilateral pleural effusions as well as a region of calcification in the posterior left pleura (2:2). There are coronary arterial calcifications. Lower chest is otherwise unremarkable. ABDOMEN: Evaluation is limited by lack of intravenous contrast. Diffuse hypoattenuation of the liver consistent with hepatic steatosis is noted. There are no focal liver lesions. The gallbladder contains a small gallstone but is otherwise normal. There is no intra- or extra-hepatic bile duct dilation. The spleen contains a linear region of capsular calcification (2:29). The spleen is otherwise unremarkable. The pancreas and adrenal glands are normal. The patient is status post right nephrectomy. There is no mass or fluid collection at the nephrectomy site. The left kidney is without stones or hydronephrosis or mass. There is a small hiatal hernia with possible asymmetric wall thickening or mixing artifact. The stomach, small bowel, and large bowel are of normal caliber, without wall thickening or mass. The abdominal aorta is normal in caliber. There are scattered atherosclerotic calcifications. There is no ascites, pneumoperitoneum, or fluid collection. There is no lymphadenopathy. The inferior vena cava is relatively collapsed, which may indicate hypovolemic state. Beneath the incision there is subcutaneous fat stranding along with small locules of fluid. The largest is located superiorly, measuring 2.2 x 3.2 cm (2:54). This collection involves the right rectus muscle which is enlarged compared to the left. There is no evidence of intraperitoneal fluid collection or dehiscence. PELVIS: There is a urethral catheter in place. The prostate is enlarged and the bladder is relatively collapsed, with asymmetric thickening of the superior wall. The rectum is unremarkable. There is no pelvic free fluid, mass, or lymphadenopathy. MUSCULOSKELETAL: There are no destructive lesions concerning for malignancy or infection. IMPRESSION: 1. Superficial subcutaneous fat stranding and small locules of fluid beneath the incision site. An additional 2 x 3 cm fluid collection involves the right rectus muscle, which is enlarged. Although many of these findings may be explained by post-operative change, in the setting of cellulitis on examination, infection should be suspected, alongside possible myositis of the right rectus muscle. No evidence of wound dehiscence. 2. No intraperitoneal or retroperitoneal abnormality fluid collection. 3. Hepatic steatosis and cholecystitis without evidence of cholelithiasis. The study and the report were reviewed by the staff radiologist. Medications on Admission: Atenolol 25 mg PO DAILY Finasteride 5 mg PO DAILY Hydrochlorothiazide 25 mg PO DAILY Simvastatin 10 mg PO DAILY Tamsulosin 0.4 mg PO HS Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever do not exceed greater than 4 grams daily 2. Atenolol 25 mg PO DAILY 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 4. Finasteride 5 mg PO DAILY 5. Hydrochlorothiazide 25 mg PO DAILY 6. Senna 2 TAB PO HS RX *sennosides [senna] 8.6 mg 1 capsule by mouth at bedtime Disp #*30 Capsule Refills:*0 7. Simvastatin 10 mg PO DAILY 8. Tamsulosin 0.4 mg PO HS 9. Aspirin 81 mg PO DAILY 10. Dipyridamole 200 mg PO BID do not resume until after foley catheter is removed 11. Cephalexin changed to Levaquin 250mg daily - see addendum Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Failure to thrive Wound infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ man with recent nephrectomy, presenting with cellulitis at the abdominal incision site. COMPARISON: None. TECHNIQUE: MDCT-acquired axial images of the abdomen and pelvis were obtained after administration of enteric contrast only. Coronal and sagittal reformatted images prepared and reviewed. FINDINGS: There is bilateral lower lobe atelectasis as well as a surgical suture line from prior lung resection on the left. There are trace bilateral pleural effusions as well as a region of calcification in the posterior left pleura (2:2). There are coronary arterial calcifications. Lower chest is otherwise unremarkable. ABDOMEN: Evaluation is limited by lack of intravenous contrast. Diffuse hypoattenuation of the liver consistent with hepatic steatosis is noted. There are no focal liver lesions. The gallbladder contains a small gallstone but is otherwise normal. There is no intra- or extra-hepatic bile duct dilation. The spleen contains a linear region of capsular calcification (2:29). The spleen is otherwise unremarkable. The pancreas and adrenal glands are normal. The patient is status post right nephrectomy. There is no mass or fluid collection at the nephrectomy site. The left kidney is without stones or hydronephrosis or mass. There is a small hiatal hernia with possible asymmetric wall thickening or mixing artifact. The stomach, small bowel, and large bowel are of normal caliber, without wall thickening or mass. The abdominal aorta is normal in caliber. There are scattered atherosclerotic calcifications. There is no ascites, pneumoperitoneum, or fluid collection. There is no lymphadenopathy. The inferior vena cava is relatively collapsed, which may indicate hypovolemic state. Beneath the incision there is subcutaneous fat stranding along with small locules of fluid. The largest is located superiorly, measuring 2.2 x 3.2 cm (2:54). This collection involves the right rectus muscle which is enlarged compared to the left. There is no evidence of intraperitoneal fluid collection or dehiscence. PELVIS: There is a urethral catheter in place. The prostate is enlarged and the bladder is relatively collapsed, with asymmetric thickening of the superior wall. The rectum is unremarkable. There is no pelvic free fluid, mass, or lymphadenopathy. MUSCULOSKELETAL: There are no destructive lesions concerning for malignancy or infection. IMPRESSION: 1. Superficial subcutaneous fat stranding and small locules of fluid beneath the incision site. An additional 2 x 3 cm fluid collection involves the right rectus muscle, which is enlarged. Although many of these findings may be explained by post-operative change, in the setting of cellulitis on examination, infection should be suspected, alongside possible myositis of the right rectus muscle. No evidence of wound dehiscence. 2. No intraperitoneal or retroperitoneal abnormality fluid collection. 3. Hepatic steatosis and cholecystitis without evidence of cholelithiasis. Radiology Report HISTORY: Leukocytosis in a patient status post recent nephrectomy. COMPARISON: CT of the abdomen and pelvis performed earlier the same date. Chest radiograph from ___. FINDINGS: Chest, semi-upright AP. There are linear opacities in the left lower lobe with blunting of the costophrenic angles, which is explained by scarring and pleural calcifications seen on the CT. The lungs are otherwise clear. The hilar and cardiomediastinal contours are normal. There is no pneumothorax or pleural effusion. Pulmonary vascularity is normal. IMPRESSION: No evidence of pneumonia. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: WEAKNESS Diagnosed with OTHER POST-OP INFECTION, ABN REACT-SURG PROC NEC, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA temperature: 98.2 heartrate: 61.0 resprate: 16.0 o2sat: 98.0 sbp: 120.0 dbp: 80.0 level of pain: 0 level of acuity: 2.0

THe patient was admitted to the urology service. He was placed on Clindamycin, IV Fluids, and serial labs were checked. His electrolytes normalized by HD #1. His creatinine was stable at 1.6 (postoperative baseline 1.4). He was seen by physical therapy and he was able to ambulate with assistance and a walker. On HD 2, his wound infection appeared improved. Upon discharge, he was afebrile with stable vital signs, he was tolerating a regular diet with improved appetite, he ambulated with assistance, was producing adequate urine output, and he did not have any pain. He was discharged with a course of antibiotics for cellulitis and for his urinary tract infection (urine culture sensitivities pending).

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: SOB, left rib pain Major Surgical or Invasive Procedure: None. History of Present Illness: ___ with history of COPD, recently diagnosed CAP s/p levofloxacin and currently on azithromycin presenting with ongoing SOB and pleuritic left sided chest pain found to have multifocal pneumonia. Patient reports he has had approximately 6 weeks of symptoms of SOB. Initially seen at ___ where he was admitted to for 3 days and treated initially for pneumonia with levaquin then discharged only on treatment for COPD exacerbation with prolonged taper. Followed up with PCP who felt he did have a RUQ pneumonia and was treated with 7 days of levoflox. Had elevated D-dimer for which he had CTA which was negative for PE. His symptoms did not improve and he ended up having a second CTA on ___ which again showed RUL consolidation. He was referred to pulmonary whom he saw on ___ who noted he had ongoing mucus and secretions and started him on azithromycin for ___t 500mg daily. Today, patient had persistent SOB and DOE with new pleuritic left chest pain prompting evaluation at the ED. He also notes ongoing low grade fevers (100 degrees F). Has had productive cough. 50lb weight loss over the last ___ years, no recent change. In the ED, initial vitals were: 99.3 104 150/87 20 98%RA Exam notable for: mild diffuse decreased breath sound. Left chest was reproducible on palpation. Labs notable for: WBC 15.8 with 84% polys, negative trop, Cr 0.9, BNP 37, lactate of 2.2. EKG: 99 bpm, no ischemia, sinus, normal int Imaging notable for: -CXR with right si -CTA Chest: No e/o PE or aortic abnormality, new LUL consolidation, unchanged RUL consolidation and reactive mediastinal lymphadenopathy suggesting spread of multifocal pneumonia. Severe centrilobular emphysema and pulmonary arterial hypertension. Patient was given: 1L NS, 1g Ceftriaxone ED team spoke to Dr. ___ agreed with admission to medicine for IV antibiotics given failure of outpatient CAP treatment. On the floor, patient describes low grade fevers, cough and left sided pleuritic chest pain laterally. Denies wheezing. Notes SOB with exertion. Cough productive of white sputum Past Medical History: COPD Spiculated right upper lobe lung nodule H/o clostridium difficile GERD Colonic Adenoma Social History: ___ Family History: Father with CAD, lung cancer, Mother with CAD, CHF, Sister with hypertension. Physical Exam: ADMISSION PHYSICAL EXAM: Vital Signs: 98.6 152/86 103 18 96%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MM slightly dry, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated CV: Regular rate and rhythm, distant heart sounds, no appreciable murmurs Lungs: Good air movement throughout with course breath sounds at right base Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, Moving all 4 extremities DISCHARGE PHYSICAL EXAM: VS - Tc 98.1 HR 77-110 BP ___ RR ___, O2 sat 93-96%RA General: well appearing, NAD , speaking in full sentences HEENT: Head normocephalic, atraumatic, sclera anicteric, MMM, EOMI Neck: Supple, No LAD CV: rrr, no m/r/g, distant heart sounds Lungs: Breathing comfortably, decreased breath sounds bilaterally, inspiratory crackles in lower lobes bilaterally Abdomen: soft, nontender, nondistended GU: deferred Ext: warm and well perfused, distal pulses strong Neuro: grossly normal Pertinent Results: ADMISSION LABS: ___:50PM BLOOD WBC-15.8*# RBC-5.59 Hgb-15.6 Hct-47.2 MCV-84 MCH-27.9 MCHC-33.1 RDW-13.3 RDWSD-40.7 Plt ___ ___ 02:50PM BLOOD Neuts-84.6* Lymphs-6.1* Monos-6.7 Eos-1.5 Baso-0.4 Im ___ AbsNeut-13.39*# AbsLymp-0.96* AbsMono-1.06* AbsEos-0.23 AbsBaso-0.07 ___ 02:50PM BLOOD Plt ___ ___ 02:50PM BLOOD Glucose-141* UreaN-12 Creat-0.9 Na-139 K-3.9 Cl-100 HCO3-25 AnGap-18 ___ 02:50PM BLOOD proBNP-37 ___ 02:50PM BLOOD cTropnT-<0.01 ___ 07:32AM BLOOD Calcium-9.0 Phos-2.7 Mg-1.9 ___ 06:38PM BLOOD Lactate-2.2* MICRO: ___: 3x Concentrated sputum smears negative for Tb MTb Direct Amplification Test: Negative ___: Legionella Antigen: Negative ___: MRSA screen negative ___ Blood cultures: PENDING IMAGING: ___ CTX IMPRESSION: Comparison to ___. Moderate overinflation on the lateral radiograph. In the interval, there are newly occurred both alveolar and interstitial opacities in the right lung apex, the right middle lobe and the left perihilar lung regions. Multifocal pneumonia is the most likely differential diagnosis. However, given the slightly rounded appearance of a component of the right upper lobe opacity, complete resolution must be confirmed radiographically, to exclude the presence of a neoplasm. No cardiomegaly. No pleural effusions. ___ CTA 1. No evidence of pulmonary embolism or aortic abnormality. 2. New left upper lobe consolidation in the setting of an unchanged right upper lobe consolidation and reactive mediastinal lymphadenopathy suggests spread of multifocal pneumonia. 3. Severe centrilobular emphysema and pulmonary arterial hypertension. DISCHARGE LABS: ___ 05:00AM BLOOD WBC-9.8 RBC-4.82 Hgb-13.2* Hct-39.9* MCV-83 MCH-27.4 MCHC-33.1 RDW-12.8 RDWSD-38.5 Plt ___ ___ 05:00AM BLOOD Plt ___ ___ 05:00AM BLOOD Glucose-156* UreaN-11 Creat-0.7 Na-136 K-4.6 Cl-100 HCO3-26 AnGap-15 ___ 05:00AM BLOOD Calcium-9.4 Phos-3.5 Mg-2.2 ___ 05:00AM BLOOD HIV Ab-Negative Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 2. Azithromycin 500 mg PO Q24H 3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 4. Pantoprazole 40 mg PO Q24H 5. Ranitidine 150 mg PO DAILY 6. Tiotropium Bromide 1 CAP IH DAILY 7. TraZODone 100 mg PO QHS 8. Docusate Sodium 300 mg PO ___ TIMES PER WEEK 9. Polyethylene Glycol 17 g PO ___ TIMES PER WEEK 10. Acetaminophen 1000 mg PO BID:PRN Pain - Mild Discharge Medications: 1. Benzonatate 100 mg PO TID:PRN cough RX *benzonatate 100 mg 1 capsule(s) by mouth 3 times per day as needed Disp #*10 Capsule Refills:*0 2. CefTAZidime 2 g IV Q12H RX *ceftazidime-dextrose (iso-osm) [Fortaz in dextrose 5 %] 2 gram/50 mL 2 g IV every twelve (12) hours Disp #*9 Intravenous Bag Refills:*0 3. PredniSONE 40 mg PO DAILY Duration: 5 Days RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*8 Tablet Refills:*0 4. Acetaminophen 1000 mg PO BID:PRN Pain - Mild 5. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 6. Docusate Sodium 300 mg PO ___ TIMES PER WEEK 7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 8. Pantoprazole 40 mg PO Q24H 9. Polyethylene Glycol 17 g PO ___ TIMES PER WEEK 10. Ranitidine 150 mg PO DAILY 11. Tiotropium Bromide 1 CAP IH DAILY 12. TraZODone 100 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Healthcare Associated Pneumonia Secondary Diagnoses: Gastro-esophageal reflux Chronic Obstructive Pulmonary Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with sob and rib pain // pna? pna? IMPRESSION: Comparison to ___. Moderate overinflation on the lateral radiograph. In the interval, there are newly occurred both alveolar and interstitial opacities in the right lung apex, the right middle lobe and the left perihilar lung regions. Multifocal pneumonia is the most likely differential diagnosis. However, given the slightly rounded appearance of a component of the right upper lobe opacity, complete resolution must be confirmed radiographically, to exclude the presence of a neoplasm. No cardiomegaly. No pleural effusions. Radiology Report EXAMINATION: CTA CHEST WITH CONTRAST INDICATION: ___ with shortness of breath and new chest pain on left side away from known pneumonia on right, 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) Stationary Acquisition 2.5 s, 0.5 cm; CTDIvol = 7.6 mGy (Body) DLP = 3.8 mGy-cm. 2) Spiral Acquisition 5.1 s, 39.9 cm; CTDIvol = 14.7 mGy (Body) DLP = 587.9 mGy-cm. Total DLP (Body) = 592 mGy-cm. COMPARISON: Prior chest CTAs dated ___ and ___. FINDINGS: HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the subsegmental level without filling defect to indicate a pulmonary embolus. Dilatation of the left and right pulmonary arteries measuring 3.4 and 3.1 cm, respectively, suggests underlying pulmonary arterial hypertension. The thoracic aorta is normal in caliber without evidence of dissection or intramural hematoma. The heart, pericardium, and great vessels are within normal limits. No pericardial effusion is seen. AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar lymphadenopathy is present. Mildly prominent lymph nodes are unchanged from the prior study and likely reactive. No mediastinal mass. PLEURAL SPACES: No pleural effusion or pneumothorax. LUNGS/AIRWAYS: A large right upper lobe consolidation is similar to the prior study of ___. New focal areas of consolidation are noted within the left upper lobe (3:101, 172). There is severe centrilobular emphysema. 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: No suspicious osseous abnormality is seen.? There is no acute fracture. IMPRESSION: 1. No evidence of pulmonary embolism or aortic abnormality. 2. New left upper lobe consolidation in the setting of an unchanged right upper lobe consolidation suggests spread of multifocal pneumonia. 3. Severe centrilobular emphysema and pulmonary arterial hypertension. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: L Rib pain, Dyspnea Diagnosed with Pneumonia, unspecified organism temperature: 99.3 heartrate: 104.0 resprate: 20.0 o2sat: 98.0 sbp: 150.0 dbp: 87.0 level of pain: 3 level of acuity: 3.0

The patient is a ___ year-old male with a history of COPD and recent diagnosis of community acquired pneumonia (status-post 7 days of levofloxacin and 4 days of azithromycin) who presents with continued SOB and dyspnea on exertion. He was found to have bilateral upper lobe multifocal pneumonia, and improved after treatment for healthcare-associated pneumonia. He was discharged home with midline on IV ceftazadime.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Penicillins Attending: ___. Chief Complaint: Rule out compartment syndrome Major Surgical or Invasive Procedure: none History of Present Illness: ___ s/p blow to right calf with swollen painful leg. A friend was performing a somersault maneuver and accidentally kicked the patient in the right calf area at about 6pm last evening. Initially only minor pain, but worsened to the point where he had difficulty bearing weight. Currently has no numbness or tingling in his toes and his pain is well controlled after 1 percocet. Past Medical History: ADHD Social History: ___ Family History: non-contributory Physical Exam: AFVSS NAD, A&Ox3 RLE: wwp, compartments soft and compressible, no pain w/ passive stretch, SILT s/s/sp/dp/t; 2+DP, ___ ___ Radiology Report INDICATION: Hit in the right lower extremity with pain and swelling. Evaluate for fracture. COMPARISONS: Tibia, fibula radiographs ___. Three views of the right knee (4 radiographs) are normal. No fracture or effusion. Radiology Report INDICATION: Upper medial right calf swelling after being kicked. Evaluate for hematoma. COMPARISONS: None. TECHNIQUE: Targeted Grayscale and Doppler ultrasound images were acquired over the right and left calves. FINDINGS: In the area of concern in the right medial calf, there is a moderate amount of subcutaneous edema and swelling. The soft tissues are more edematous in comparison to normal soft tissues in the left calf. There is no discrete fluid collection to suggest an organized hematoma. IMPRESSION: No evidence of a discrete fluid collection to suggest an organized hematoma. Moderate soft tissue edema and swelling. Radiology Report INDICATION: Direct kick to the calf. Evaluate for fracture. COMPARISONS: None. FINDINGS: Two views of the knee and two views of the tibia/fibula were obtained. There is no evidence of fracture or dislocation. There are no significant degenerative changes. The soft tissues are unremarkable without evidence of radiopaque foreign bodies or subcutaneous gas. IMPRESSION: No evidence of fracture or dislocation. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: R CALF CRAMP Diagnosed with PAIN IN LIMB temperature: 98.0 heartrate: 82.0 resprate: 14.0 o2sat: 100.0 sbp: 127.0 dbp: 72.0 level of pain: 7 level of acuity: 4.0

The patient was admitted to the orthopaedic surgery service on ___ with RLE hematoma. Pt was admitted to rule out compartment syndrome. He was checked every ___ hours. His pain was controlled with PO pain meds and his compartments became increasingly compressible during his stay. He had no ___ deficits. He worked with ___, WBAT RLE prior to discharge. Neuro: post-operatively, patient's pain was controlled oxycodone with good effect and adequate pain control. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. Hematology: The patient was hemodynamically stable. Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. GI/GU: A po diet was tolerated well. Patient was also started on a bowel regimen to encourage bowel movement. Intake and output were closely monitored. At the time of discharge on HD#2 the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The incision was clean, dry, and intact without evidence of erythema or drainage; the extremity was NVI distally throughout. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge and the patient expressed readiness for discharge. The patient will follow up with Orthopaedic Surgeons in ___ per his father (a doctor himself).

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins Attending: ___ Chief Complaint: Flu-like symptoms and jaundice Major Surgical or Invasive Procedure: MRCP RUQ ultrasound History of Present Illness: ___ female with history of Hep C+, opioid abuse on ___ transferred from ___ for cholecystitis vs possible cholangitis vs hepatitis. She presents with a chief complaint of 9 days of RUQ abdominal pain, nausea, vomiting, dark urine, subjective fevers, and chills. The patient initially thought she was experiencing the flu. She now complains of ___ RUQ abdominal pain accompanied by nausea, but also reports that she is hungry and is angry that she hasn't been given anything to eat. She has an ultrasound performed at the OSH which showed diffuse GB wall thickening and a common bile duct of 9mm and a sonographic ___ sign. She has a known history of treatment naive Hepatitis C (secondary to IV drug use) and her labs at the OSH revealed severe transaminitis and bilirubinemia (direct). At the OSH she received a dose of Levaquin and a dose of Flagyl prior to her transfer to ___. Denies diarrhea, ETOH or recreational drugs including MDMA, Cocain, Psilocybin mushroom. Pt states she took no more than two tylenol. She denies any recent unprotected sex. Since admission to ___ on ___, had elevated LFTs (ALT/AST ___ -> 1823/701 today), alk phos 328, Tbili 7.2 -> 7.5 (9.8 at OSH), dbili 6.3. MRCP - no evidence of stones or obstructing mass, showed hepatomegaly, evidence of hepatitis. LFTs have trended down, bili has remained elevated, transamnitis per hepatology recs. She was started on cipro/flagyl empirically. Was febrile on admission, but afebrile now. VSS. Past Medical History: hepatitis C h/o IVDA Opioid abuse on methadone maintenance Social History: ___ Family History: Father - melanoma Mother - hypertension Brothers (identical twins) - ___ deletion syndrome Physical Exam: Admission: VS: T 98.2 BP 110/74 - 112/63, HR 50-58, O2 Sat 99% RA General: Obese young woman lying comfortably in bed HEENT: MMM, PERRL, no scleral icterus Neck: supple CV: RRR, no murmurs, rubs, gallops Lungs: CTAB Abdomen: soft, mildly tender to palpation R>L Back: mild tenderness to palpation on lower right Ext: warm, well-perfused, +pulses bilaterally Neuro: A&Ox3, CNII-XII grossly intact, no asterixis Skin: warm, dry, no rashes or lesions or evidence of IV injections, no stigmata of liver disease Discharge: VS: T 98.1 BP 90-100s/50-60s, HR 50-80s, RR ___ 98% RA General: Obese young woman lying comfortably in bed HEENT: MMM, PERRL, no scleral icterus Neck: supple CV: RRR, no murmurs, rubs, gallops Lungs: CTAB, mild pain in chest with deep inspiration Abdomen: soft, much less tender to palpation R>L this morning Ext: warm, well-perfused, +pulses bilaterally Neuro: A&Ox3, CNII-XII grossly intact, no asterixis Skin: warm, dry, no rashes or lesions or evidence of IV injections Pertinent Results: Admission labs: ___ BLOOD WBC-4.8 RBC-3.94 Hgb-12.0 Hct-35.8 MCV-91 MCH-30.5 MCHC-33.5 RDW-12.8 RDWSD-41.9 Plt Ct-94* ___ BLOOD Neuts-24* Bands-0 Lymphs-62* Monos-1* Eos-3 Baso-1 ___ Metas-1* Myelos-1* Other-7* AbsNeut-1.70 AbsLymp-4.40* AbsMono-0.07* AbsEos-0.21 AbsBaso-0.07 ___ BLOOD ___ PTT-29.7 ___ ___ 02:20AM BLOOD Glucose-101* UreaN-7 Creat-0.5 Na-135 K-3.7 Cl-100 HCO3-25 AnGap-14 ___ 02:20AM BLOOD ALT-2638* ___ AlkPhos-328* TotBili-7.2* DirBili-6.3* IndBili-0.9 ___ 01:10PM BLOOD ALT-2515* AST-1417* AlkPhos-373* TotBili-7.6* DirBili-6.3* IndBili-1.3 ___ 05:05AM BLOOD ALT-1823* AST-701* AlkPhos-355* TotBili-7.5* DirBili-6.3* IndBili-1.2 ___ 02:20AM BLOOD Calcium-7.7* Phos-2.4* Mg-1.8 ___ 01:10PM BLOOD Albumin-3.3* Calcium-8.1* Phos-2.7 Mg-2.1 ___ 08:54PM BLOOD Lactate-1.4 Discharge labs: ___ 05:40AM BLOOD WBC-6.3 RBC-3.87* Hgb-11.9 Hct-36.3 MCV-94 MCH-30.7 MCHC-32.8 RDW-14.1 RDWSD-47.7* Plt ___ ___ 05:40AM BLOOD Plt ___ ___ 05:40AM BLOOD Glucose-115* UreaN-9 Creat-0.6 Na-140 K-3.9 Cl-103 HCO3-27 AnGap-14 ___ 05:40AM BLOOD ALT-868* AST-131* AlkPhos-315* TotBili-3.2* ___ 05:05AM BLOOD Lipase-14 GGT-461* ___ 05:40AM BLOOD Albumin-3.4* Calcium-8.8 Phos-4.0 Mg-2.0 ___ 05:40AM BLOOD HBcAb-PND ___ 05:05AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HAV Ab-NEGATIVE IgM HAV-NEGATIVE ___ 05:05AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE ___ 05:05AM BLOOD ___ ___ 05:05AM BLOOD IgG-940 IgA-158 IgM-192 ___ 05:05AM BLOOD tTG-IgA-3 ___ 08:54PM BLOOD Lactate-1.4 ___ 06:18AM BLOOD HEPATITIS E ANTIBODY (IGG)-PND ___ 06:18AM BLOOD CERULOPLASMIN-PND ___ 01:10PM BLOOD HERPES SIMPLEX VIRUS 1 AND 2 (IGG)-Test ___ 05:05AM BLOOD HEPATITIS E ANTIBODY (IGM)-PND IMAGING: RUQ U/S (OSH) - 8mm duct and presence of stones in the gb MRCP - no evidence of stones or obstructing mass, showed hepatomegaly, evidence of hepatitis. RUQ U/S (___) 1. Patent hepatic vasculature with appropriate flow directions. 2. Mild gallbladder wall thickening, decreased when compared to prior examination. No gallstones. 3. Splenomegaly. 4. Mildly ectatic common bile duct to 6 mm, slightly decreased when compared to prior examinations. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 600 mg PO QID 2. Amphetamine-Dextroamphetamine 20 mg PO BID 3. Sertraline 100 mg PO DAILY 4. Methadone 67 mg PO DAILY Discharge Medications: 1. Gabapentin 600 mg PO TID 2. Methadone 67 mg PO QAM 3. Amphetamine-Dextroamphetamine 20 mg PO BID 4. Fluoxetine 20 mg PO DAILY RX *fluoxetine 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*1 5. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN low back pain Duration: 5 Days RX *oxycodone 5 mg 1 tablet(s) by mouth q8h prn Disp #*8 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary: Acute hepatitis, etiology undetermined (likely medication-related) Secondary: Depression Methadone maintenance Discharge Condition: Mental Status: Confused - intermittently (baseline per patient s/p overdose) Level of Consciousness: Alert and interactive. Followup Instructions: ___ Radiology Report INDICATION: ___ h/o HCV ___ IV drug use) p/w RUQ pain and fevers x9d, transaminitis, and Tbili 7.8 // Evidence of stones or mass obstruction TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were acquired in a 1.5 T magnet. Intravenous contrast: None. Only of the scout images and taste sequence were performed at which time patient did not wish to continue with exam. COMPARISON: Reference abdominal ultrasound dated ___. FINDINGS: Study limited as only coronal haste sequence was performed prior to patient refusing to continue the exam. Lower Thorax: There is a right pleural effusion. Liver: Limited evaluation of the liver demonstrates a paddle megaly and periportal edema. There is trace perihepatic ascites. Biliary: No intrahepatic biliary dilatation. The gallbladder is decompressed with marked gallbladder wall edema. The common bile duct measures 6 mm and appears to taper to the ampulla with no stone visualized on this limited exam. Pancreas: The pancreas demonstrates no T2 signal abnormalities with normal caliber of the pancreatic duct. Spleen: The spleen is enlarged measuring 16 cm in craniocaudal dimension. Adrenal Glands: Limited views of the adrenal glands are unremarkable. Kidneys: Limited views of the kidneys demonstrate no hydronephrosis or masses Gastrointestinal Tract: Visualized loops of small and large bowel are normal in caliber with no obstruction. Lymph Nodes: No definite retroperitoneal or mesenteric lymphadenopathy. Vasculature: The abdominal aorta is normal in caliber. IMPRESSION: Limited study as only the coronal haste sequence was performed prior to patient refusing to continue exam. 1. Normal appearance of the common bile duct which appears to taper to the ampulla without definite stone or obstructing mass. 2. Hepatomegaly, periportal edema, trace ascites and splenomegaly likely related to hepatitis. 3. Decompressed gallbladder with marked gallbladder wall edema likely reactive such as in the setting of hepatitis. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: Request RUQ with dopplers, eval liver parenchyma, portal vein TECHNIQUE: Gray scale, color and spectral Doppler evaluation of the abdomen was performed. COMPARISON: Limited MRCP sequences rounds ___, ultrasound of the abdomen from ___. FINDINGS: Liver: The hepatic parenchyma is within normal limits. Nofocal liver lesions are identified. There is no ascites. Bile ducts: There is no intrahepatic biliary ductal dilation. The common hepatic duct measures 6 mm. Gallbladder: There is mild gallbladder wall thickening and decreased compared to prior examinations measuring up to 3 mm. No stones. Pancreas: Imaged portion of the pancreas appears within normal limits, with portions of the pancreatic tail obscured by overlying bowel gas. Spleen: The spleen demonstrates normal echotexture, and measures 15.3 cm. Kidneys: The kidneys appear overall similar in size and appearance to priors. No stones, masses or hydronephrosis are identified in either kidney. Doppler evaluation: The main portal vein is patent, with flow in the appropriate direction. Main portal vein velocity is 11.9 cm/sec. Right and left portal veins are patent, with antegrade flow. The main hepatic artery is patent, with appropriate waveform. Right, middle and left hepatic veins are patent, with appropriate waveforms. Splenic vein and superior mesenteric vein are patent, with antegrade flow. IMPRESSION: 1. Patent hepatic vasculature with appropriate flow directions. 2. Mild gallbladder wall thickening, decreased when compared to prior examination. No gallstones. 3. Splenomegaly. 4. Mildly ectatic common bile duct to 6 mm, slightly decreased when compared to prior examinations. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: RUQ abdominal pain, Transfer Diagnosed with ABDOMINAL PAIN RUQ temperature: 97.9 heartrate: 66.0 resprate: 16.0 o2sat: 97.0 sbp: 104.0 dbp: 62.0 level of pain: 8 level of acuity: 3.0

___ y/o F hx IV drug abuse, HCV (treatment naive), methadone maintenance p/w 11 days of flu-like sx and jaundice, found to have transaminitis and evidence of gallbladder wall thickening but no stone or obstructing mass and found to have hepatitis on imaging, transfered to ET for further w/u of acute hepatitis. # Acute hepatitis - Abd pain, jaundice in setting of untreated HCV and hx IVDU. Poor short term memory but per pt mental status not off baseline; do not suspect encephalopathy. On admission to surgery service initially, antibiotics were continued with cipro/flagyl given concern for acute cystitis vs cholangitis based on OSH abdominal ultrasound showing gallbladder wall thickening. However MRCP here showed no biliary stones or obstructing mass. Patient was transferred to ___ hepatorenal service on ___ and antibiotics were discontinued given absence of fever, WBC and normal vitals making hepatitis more likely than acute cholecystitis or cholangitis. LFTs elevated to 1000-2000s, downtrending. Tbili remained elevated, alk phos in 300s. Differential for etiology of hepatitis includes drug-induced (most likely given mixed hepatic/cholestatic picture, severity of transaminitis, and hx of sertraline as well as frequent supplement use) vs infectious vs autoimmune vs alcoholic (denies) vs other toxin induced (denies.) Abdominal ultrasound on ___ revealed patent hepatic vasculature, mild gallbladder wall thickening and mildly ectatic common bile duct but decreased, and splenomegaly. By time of admission to ___, pt was never febrile and vital signs stable; by discharge, abdominal pain and nausea also significantly improved and labs had downtrended (ALT/AST to 868/161 from ___ on admission, alk phos to 315 from peak 373, tbili 3.2 from peak 7.6.) Serologic w/u thus far has revealed immunization for hepatitis B, other hepatitis (A, C viral load, E) CMV, and EBV labs pending, and autoimmune w/u so far negative (AMA, ___, smooth, IgG, IgA, IgM, tTG-IgA) with ceruloplasmin still pending. Patient does have ongoing lower back pain on discharge that she says started at the same time as her admission for transaminitis. Lipase negative. ___ have musculoskeletal component and recommend outpatient follow up. Treated pain with opioids; given on methadone, initially required IV morphine for pain, then transitioned to oxycodone. # NUTRITION: Initially NPO, advanced to clears, then to regular diet. Tolerated well. # RENAL: Normal renal function with BUN/Cr ___ on discharge.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: confusion Major Surgical or Invasive Procedure: none History of Present Illness: ___ w/PMH stroke, HTN, DMII, and HLD, p/w altered mental status. Family noted that he was not answering questions appropriately, and was speaking nonsensically. Similar prior episodes were the result of either hypoglycemia or UTI, so they brought him to the ED. A fingerstick at home > 400. . In the ED, initial VS 98.1, 82, 16, 150/71, 100% RA. Exam was nonfocal initially as patient was not answering all questions appropriately, but otherwise neurologic exam was nonfocal. No head imaging obtained. CXR unremarkable. UA positive, so he received CFTX and 2L NS --> MS subsequently improved. Transfer vitals were 98.4 76nsr 154/74 17 100%RA. . By the time he arrived on the floor he was mentating well, answering questions appropriately, and felt fine. Family agreed that he was back to baseline. Reported he was having urinary frequency, urgency, dysuria, incontinence, and suprapubic pain. No fever or chills, no back pain. Daughter cares for him at home and says recurrent UTIs are an ongoing problem. Not aware of any problems with prostate, but he does take finasteride and previously took tamsulosin (she thinks it was discontinued recently). Has not seen his PCP since ___. . REVIEW OF SYSTEMS: Denies night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia. Past Medical History: 1. CVA ___ following colonoscopy presenting with slurred speech, leg weakness, dizziness. Has L facial droop ___ stroke. 2. HTN 3. Type II DM complicated by neuropathy, L eye blindness ___ retinopathy, nephropathy (Cr baseline 1.5-1.7). 4. Anemia: thought hypoproliferative ___ chronic kidney disease. Has been on darbepoetin shots in the past. 5. Hypercholesterolemia 6. s/p bicycle accident c metal plate in head 7. PVD: ___ digit, right foot amputated ___ years prior 8. Glaucoma 9. CAD. No previous stress. ECHO ___ showing EF 50% 10. Small stroke ___ Social History: ___ Family History: Mother died in her ___ from stroke. HTN and DM run in the family. Physical Exam: ADMISSION EXAM VS 97.8 167/79 74 18 100%/RA GENERAL - Alert, interactive, pleasant male sitting up in chair NAD HEENT - PERRL, EOMI, sclerae anicteric, MMM, OP clear NECK - Supple, no thyromegaly, no carotid bruits HEART - PMI non-displaced, RRR, nl S1-S2, no MRG LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use ABDOMEN - NABS, soft/NT/ND, no masses or HSM, +suprapubic tenderness EXTREMITIES - WWP, no c/c/e, 1+ bilateral edema - missing ___ digit on right foot NEURO - awake, A&Ox3, CNs II-XII intact except mild L lip droop and leftward eye deviation/disconjugate gaze; muscle strength ___ throughout; sensation grossly intact; cerebellar exam intact; days of week backwards with 1 mistake; months backwards until ___. Clock draw w/all numbers on right half. . DISCHARGE EXAM VS 98.2 145/60 80 16 100/RA ___ 90 GENERAL - Alert, interactive, pleasant male sitting up in chair NAD HEENT - PERRL, EOMI, sclerae anicteric, MMM, OP clear (neuro as below) NECK - Supple, no thyromegaly, no carotid bruits HEART - PMI non-displaced, RRR, nl S1-S2, no MRG LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no suprapubic tenderness EXTREMITIES - WWP, no c/c/e, 1+ bilateral edema, R foot ___ digit amputated NEURO - awake, A&Ox2 (self, hospital, not year), CNs II-XII intact except mild L lip droop and leftward eye deviation/disconjugate gaze; muscle strength ___ throughout; sensation grossly intact; cerebellar exam intact; days of week backwards consistently; gait stable with walker and/or daughter's assistance. Pertinent Results: ADMISSION LABS ___ 07:44PM WBC-3.8* RBC-3.57* HGB-11.1* HCT-30.4* MCV-85 MCH-31.1 MCHC-36.6* RDW-14.0 ___ 07:44PM PLT COUNT-195 ___ 07:44PM ___ PTT-33.0 ___ ___ 07:44PM GLUCOSE-387* LACTATE-2.6* NA+-135 K+-4.0 CL--99 TCO2-25 . ADMISSION URINALYSIS ___ 09:00PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 09:00PM URINE BLOOD-LG NITRITE-POS PROTEIN-TR GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR ___ 09:00PM URINE RBC-18* WBC-34* BACTERIA-FEW YEAST-NONE EPI-0 . DISCHARGE LABS ___ 06:05AM BLOOD WBC-4.0 RBC-3.47* Hgb-10.3* Hct-28.9* MCV-83 MCH-29.8 MCHC-35.8* RDW-14.2 Plt ___ ___ 03:30PM BLOOD UreaN-25* Creat-1.6* Na-139 K-4.0 Cl-106 ___ 06:05AM BLOOD Calcium-8.9 Phos-4.0 Mg-2.0 . MICRO ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. WORK -UP PER ___. ___ PAGER ___. STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000 ORGANISMS/ML.. 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. STAPHYLOCOCCUS, COAGULASE NEGATIVE. ~7000/ML. ___ MORPHOLOGY. 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. STAPHYLOCOCCUS, COAGULASE NEGATIVE. ~4000/ML. ___ MORPHOLOGY. 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 in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | STAPHYLOCOCCUS, COAGULASE NEGATIVE | | STAPHYLOCOCCUS, COAGULASE N | | | GENTAMICIN------------ <=0.5 S <=0.5 S <=0.5 S LEVOFLOXACIN----------<=0.12 S <=0.12 S <=0.12 S NITROFURANTOIN-------- <=16 S <=16 S <=16 S OXACILLIN-------------<=0.25 S <=0.25 S <=0.25 S TETRACYCLINE---------- 2 S 2 S 2 S VANCOMYCIN------------ 2 S 2 S 2 S . ___ BLOOD CULTURES - NGTD . IMAGING ___ CXR FINDINGS: AP portable upright chest radiograph was obtained. The lungs appear clear bilaterally without signs of pneumonia or CHF. A dense nodule in the left mid lung is most compatible with a calcified granuloma. No large effusion or pneumothorax is seen. Heart size is normal. Mediastinal contour is unremarkable. No definite bony abnormality is seen. IMPRESSION: No acute findings in the chest. Medications on Admission: 1. insulin glargine 100 unit/mL Cartridge 17 units at bedtime 2. dipyridamole-aspirin 200-25 mg BID 3. pravastatin 20 mg x 2 DAILY 4. finasteride 5 mg Tablet DAILY 5. amlodipine 10 mg Tablet QD 6. tamsulosin 0.4 mg Capsule, QD (daughter thinks stopped recently) Discharge Medications: 1. insulin glargine 100 unit/mL Cartridge Sig: Nineteen (19) units Subcutaneous at bedtime. 2. dipyridamole-aspirin 200-25 mg Cap, ER Multiphase 12 hr Sig: One (1) Cap PO BID (2 times a day). 3. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Flomax 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO once a day. Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2* 7. Humalog 100 unit/mL Cartridge Sig: as directed Subcutaneous QAC: Check blood sugar by fingerstick before each meal. If sugar is 150-200, inject 2 units. For sugar 201-250, inject 4 units. 251-300, 6 units. 301-350, 8 units. 351-400, 10 units. Greater than 400, inject 10 units and call your doctor. . Disp:*2 cartridges* Refills:*2* 8. Cipro 500 mg Tablet Sig: One (1) Tablet PO QAM for 3 days. Disp:*3 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Urinary tract infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report CHEST RADIOGRAPH PERFORMED ON ___ COMPARISON: None. CLINICAL HISTORY: Altered mental status, assess for acute intrathoracic process. FINDINGS: AP portable upright chest radiograph was obtained. The lungs appear clear bilaterally without signs of pneumonia or CHF. A dense nodule in the left mid lung is most compatible with a calcified granuloma. No large effusion or pneumothorax is seen. Heart size is normal. Mediastinal contour is unremarkable. No definite bony abnormality is seen. IMPRESSION: No acute findings in the chest. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: MENTAL STATUS CHANGES Diagnosed with URIN TRACT INFECTION NOS, ALTERED MENTAL STATUS temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: nan

___ w/hx CVA, HTN, DMII, BPH and frequent UTIs p/w AMS, found to have positive UA and rapid improvement in MS with IVF and 1 dose CFTX in the ED; admitted for intravenous antibiotics and management of recurrent UTI. . # AMS Family reported confusion at home. No new focal neurologic signs or symptoms suggestive of TIA or CVA. History not consistent with seizure either. MS cleared with IVF and antibiotics for UTI, confirming UTI as his underlying problem. On HD1, family confirmed team's impression that he was "better than baseline." . # CYSTITIS UA was positive for nitrites, leukesterase, bacteria and WBCs in the ED so he was started on ceftriaxone IV. History also consistent w/UTI including dysuria, frequency, urge incontinence, and suprapubic pain. These resolved with antibiotics. Continued to receive IV ceftriaxone until his urine cultures grew 3 morphologies of pan-sensitive coag-negative staph. Transitioned to PO cipro for a 7-day course. . # Acute-on-Chronic kidney injury Underlying known diabetic nephropathy with baseline Cr 1.5-1.7. Creatinine at 1.8 on admission. Renal function improved with IVF and treatment of UTI. Discharge Cr 1.6. . # Hx BPH By verbal report from his PCP's office, his last medication list update there was ___ and at that time he was taking finasteride and flomax for BPH. BPH could predispose him to frequent UTIs, especially if untreated, which we suspect since his pill collection from home did not include either of these two medications. Daughter thinks they were discontinued during a recent admission. Finasteride and flomax were restarted. He was referred to urology for follow-up. . # DM type II Hyperglycemic prior to arrival in ED. Home qHS long-acting insulin increased from 17U to 19U, with better glucose control thereafter. . # Hx CVA No new focal exam findings, and AMS cleared w/fluids and treatment for UTI, which is not c/w intracranial process. L lip droop and L prosthetic eye deviation, unchanged to prior as confirmed by family. We felt there was no indication for head imaging at this time. Continued Aggrenox. . # HLD Continued pravastatin. . # HTN Continued amlodipine. . TRANSITIONAL ISSUES 1. BPH- needs Urology f/u to address issue of recurrent UTIs, treatment options 2. FREQUENT UTIS - Review UTI warning signs/symptoms with patient and family 3. CHRONIC RENAL FAILURE- Recommended nephrology follow-up 4. DIABETES - review/adjust insulin regimen, check A1c

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: Endoscopy ___ History of Present Illness: ___ gentleman with h/o abnormal liver chemistry tests thought related to fatty liver disease (Recent fibroscan 6, minimal fibrosis, no decompensated liver disease), who presents today with multiple episodes of dark emesis and nausea on the morning of ___, concerning for acute upper GI bleed. The patient reports that he has been drinking alcohol (approximately 2 drinks per day) but has not for the last few days. He reports that he has had 20 episodes of emesis for the past 2 days. He reports that the emesis is black. He denies any hematochezia or melena. Of note, the patient saw his outpatient hepatologist on ___, at which time he failed to mention these episodes of emesis. Per Dr. ___, the patient has had intermittent thrombocytopenia and possible portal hypertension noted on endoscopy and colonoscopy in the form of small rectal varices and portal gastropathy, apparently requiring APC for angioectasias. Per hepatology notes, it is not entirely clear whether he does in fact have advanced liver disease. Abdominal imaging showed nodular liver suggestive of cirrhosis, but he has not had evidence of portal hypertension and does not have splenomegaly. He had a Fibroscan in ___ which showed stage ___ fibrosis. FibroScan on ___ had a score of 6 again suggesting minimal fibrosis. Patient went home after clinic with plan for return visit to discuss possible liver biopsy. In the ED initial vitals: 99 94 144/104 20 93% RA - Exam notable for: epigastric abdominal pain, brown, guaiac negative stool - ECG showing NSR with PACs. - Labs notable for K 3.0, creatinine 2.1 (up from 1.1), LFT's wnl, WBC 14.5 (77%N), bicarb 34, AG 18, INR 1.1 - Patient was given: Zofran 4 mg, 1 L NS, CTX 1g, pantoprazole 80 mg then drip, Lorazepam 1 mg. -Patient was seen by hepatology who recommended admission to ET - Vitals prior to transfer: 95 132/92 19 100% RA On the floor, the patient reports that he is feeling well overall. He reports that his nausea and vomiting have improved significantly but he continues to have intermittent small amounts of black emesis with no blood. He denies sick contacts, recent travel, diarrhea, blood in stool. Past Medical History: COLONIC POLYPS: adenomas repeat colonscopy ___ DIABETES MELLITUS: not insulin dependent H PYLORI: treated ANGIOECTASIAS:seen on small bowel enterscopy; treated with Argon Plasma Cauterization ALCOHOL ABUSE ANEMIA HYPERLIPIDEMIA Social History: ___ Family History: patient does not know if there is family history of GI or liver disease. father died at age ___. mother died at ___ Physical Exam: Admission: VITAL SIGNS 99.4 PO 130 / 86 L Lying 94 20 96 RA GENERAL Lying comfortably in bed. IN NAD, asking for water to drink. HEENT: MMM, no oral lesions NECK: Supple, no LAD CARDIAC RRR no M/R/G PULMONARY CTAB, no w/r/r ABDOMEN: TTP in epigastrium. Normal BS EXTREMITIES - No peripheral edema. Warm, well perfused SKIN No obvious lesions NEUROLOGIC CN ___ grossly intact. Strength ___ symmetric, intact PSYCHIATRIC - Mood, affect normal Discharge: VITAL SIGNS 99.4 PO 130 / 86 L Lying 94 20 96 RA GENERAL Lying comfortably in bed. IN NAD, asking for water to drink. HEENT: MMM, no oral lesions NECK: Supple, no LAD CARDIAC RRR no M/R/G PULMONARY CTAB, no w/r/r ABDOMEN: TTP in epigastrium. Normal BS EXTREMITIES - No peripheral edema. Warm, well perfused SKIN No obvious lesions NEUROLOGIC CN ___ grossly intact. Strength ___ symmetric, intact PSYCHIATRIC - Mood, affect normal Pertinent Results: Admission: ___ 09:56PM WBC-13.0* RBC-3.82*# HGB-11.7*# HCT-34.2* MCV-90 MCH-30.6 MCHC-34.2 RDW-12.2 RDWSD-39.8 ___ 09:56PM PLT COUNT-138* ___ 12:10PM ___ PTT-28.2 ___ ___ 11:02AM GLUCOSE-281* UREA N-24* CREAT-2.1* SODIUM-133 POTASSIUM-3.0* CHLORIDE-81* TOTAL CO2-34* ANION GAP-21* ___ 11:02AM ALT(SGPT)-28 AST(SGOT)-24 ALK PHOS-69 TOT BILI-1.2 ___ 11:02AM LIPASE-22 ___ 11:02AM ALBUMIN-5.1 CALCIUM-11.6* PHOSPHATE-5.6* MAGNESIUM-1.7 ___ 11:02AM WBC-14.5* RBC-5.10 HGB-15.4 HCT-43.8 MCV-86 MCH-30.2 MCHC-35.2 RDW-11.9 RDWSD-37.1 ___ 11:02AM NEUTS-77.7* LYMPHS-12.0* MONOS-9.8 EOS-0.0* BASOS-0.1 IM ___ AbsNeut-11.23* AbsLymp-1.73 AbsMono-1.42* AbsEos-0.00* AbsBaso-0.02 ___ 11:02AM PLT COUNT-186 ___ 10:00AM UREA N-12 CREAT-1.1 ___ 10:00AM estGFR-Using this ___ 10:00AM ALT(SGPT)-33 AST(SGOT)-32 ALK PHOS-69 TOT BILI-1.4 ___ 10:00AM ALBUMIN-4.9 ___ 10:00AM AFP-2.5 ___ 10:00AM WBC-11.7*# RBC-4.99 HGB-14.9 HCT-43.8 MCV-88 MCH-29.9 MCHC-34.0 RDW-12.3 RDWSD-39.2 ___ 10:00AM PLT COUNT-184 ___ 10:00AM ___ Discharge: ___ 07:10AM BLOOD WBC-8.8 RBC-3.91* Hgb-12.0* Hct-35.1* MCV-90 MCH-30.7 MCHC-34.2 RDW-12.2 RDWSD-40.1 Plt ___ ___ 11:02AM BLOOD Neuts-77.7* Lymphs-12.0* Monos-9.8 Eos-0.0* Baso-0.1 Im ___ AbsNeut-11.23* AbsLymp-1.73 AbsMono-1.42* AbsEos-0.00* AbsBaso-0.02 ___ 07:10AM BLOOD Plt ___ ___ 07:10AM BLOOD ___ PTT-26.6 ___ ___ 07:10AM BLOOD Glucose-176* UreaN-15 Creat-1.0# Na-134 K-3.7 Cl-94* HCO3-28 AnGap-16 ___ 07:10AM BLOOD ALT-18 AST-23 LD(LDH)-136 AlkPhos-50 TotBili-1.4 ___ 07:10AM BLOOD Albumin-3.7 Calcium-8.0* Phos-2.3* Mg-1.7 Imaging: EGD ___: Esophagus: Mucosa: Esophagitis was seen. Protruding Lesions 1 cords of grade I varices were seen in the esophagus. Stomach: Mucosa: Erythema and congestion of the mucosa with no bleeding were noted in the stomach body and fundus. These findings are compatible with portal hypertensive gastropathy. Duodenum: Mucosa: Normal mucosa was noted. Impression: Esophagitis Esophageal varices Erythema and congestion in the stomach body and fundus compatible with portal hypertensive gastropathy Normal mucosa in the duodenum Otherwise normal EGD to third part of the duodenum Micro: none Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 2. Pravastatin 40 mg PO QPM 3. Multivitamins 1 TAB PO DAILY 4. Omeprazole 20 mg PO DAILY 5. TraZODone 100 mg PO QHS:PRN insomnia 6. GlipiZIDE XL 2.5 mg PO DAILY 7. FoLIC Acid 1 mg PO DAILY 8. Thiamine 50 mg PO DAILY Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*10 Tablet Refills:*0 2. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. GlipiZIDE XL 2.5 mg PO DAILY RX *glipizide 2.5 mg 2.5 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. MetFORMIN XR (Glucophage XR) 1000 mg PO BID RX *metformin 1,000 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 6. Multivitamins 1 TAB PO DAILY RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 7. Pravastatin 40 mg PO QPM RX *pravastatin 40 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet Refills:*0 8. Thiamine 50 mg PO DAILY RX *thiamine HCl (vitamin B1) 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 9. TraZODone 100 mg PO QHS:PRN insomnia RX *trazodone 100 mg 1 tablet(s) by mouth QHS:PRN Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary: Hematemesis ___ gastritis, portal gastropathy Secondary: Fatty liver disease, ___, DM, EtOH abuse Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: DUPLEX DOPP ABD/PEL INDICATION: ___ year old man with h/o fatty liver, presenting with GI bleeding // evidence of PVT. Characterization of fibrosis in liver TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: MRI liver on ___ an ultrasound on ___. FINDINGS: LIVER: The liver is diffusely echogenic. The contour of the liver is smooth. There is a 1 cm hyperechoic focus adjacent to the portal vein may reflect an area of focal fat or hemangioma. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 3 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, measuring 9.3 cm. KIDNEYS: Limited views of the right kidney show no hydronephrosis. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 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. No definite focal hepatic lesions are identified. A 1 cm hyperechoic area adjacent to the portal vein may reflect an area of focal fat or a small hemangioma. Consider evaluation with nonurgent, contrast-enhanced MRI when clinically appropriate given background of cirrhosis. Gender: M Race: BLACK/CAPE VERDEAN Arrive by AMBULANCE Chief complaint: Abd pain, Vomiting Diagnosed with Hematemesis, Acute kidney failure, unspecified temperature: 99.0 heartrate: 94.0 resprate: 20.0 o2sat: 93.0 sbp: 144.0 dbp: 104.0 level of pain: 10 level of acuity: 2.0

___ gentleman with h/o abnormal liver chemistry tests thought related to fatty liver disease (Recent fibroscan 6, minimal fibrosis, no decompensated liver disease), who presented to ___ with multiple episodes of dark emesis and nausea on the morning of ___, concerning for acute upper GI bleed. #Upper GI bleeding: presenting with 20 episodes of emesis associated with black coloration prior to admission. On previous EGD there was esophagitis, gastritis, and mild portal gastropathy. Additionally, the bleeding might have all been triggered by wretching causing a ___ tear. The patient had an EGD on ___ which showed gastritis and portal gastropathy. He was initially started on an octreotide and protonix gtt and eventually this was discontinued. He was discharged on ciprofloxacin 500 mg BID for 5 days, and PPI 40 mg BID. He initially received one dose of IV ceftriaxone for GI bleeding but antibiotics were continued on discharge with po ciprofloxacin for total of 5 day course (___). His nausea improved and he did not have any further hematemesis prior to discharge. #Fatty liver disease: Per last Hepatology note, no evidence of true cirrhosis or liver failure. Never had decompensation with the exception of mild portal gastropathy. Liver USN with dopplers showed patent portal vein and echogenic liver consistent with steatosis with small lesions that should be characterized with eventual MRI. ___: creatinine up to 2.1 on admission from baseline of 1.1. Improved to 1.0 with fluid resuscitation. #Leukocytosis, nausea/vomiting: resolved on Hospital day 2. Now normal at 8.0. #DM: Continued home glipizide and metformin at discharge. Patient admits that he has not been taking metformin given GI upset for last two weeks. Also has not been taking glipizide and other pills since he ran out a few days ago. We will refill his prescriptions and he will follow up with his PCP. #EtOH abuse: currently drinks 2 beers or 2 "nips" but has not had a drink for two days. He denies ever having withdrawal symptoms when he tries not to drink. ___ ordered but patient did not show signs of withdrawal.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: tachypnea Major Surgical or Invasive Procedure: Intubation Pericardiocentesis PEG tube placement History of Present Illness: ___ with ?CHF, hx of prostate cancer presents from his nursing home with tachypnea to the ___ and fevers. History unable to be obtained from patient. He was reportedly wheezing and dyspneic. Initial vitals from EMS were 101.6 154/78 HR 122 RR 40, with ___ 216. Per EMS was febrile to 104 with adequate BPs, pulse ox 97%. In the ED, initial VS were: 104.4 100 129/72 38 100%. He was awake, but lethargic. He came in with a foley. Received tylenol and albuterol/ipratroprium neb He was seen by respiratory, who intubated the pt secondary to his tachypnea with vent settings: Assist control, Vt 500, RR 12, PEEP 5, FIO2 100%. Reportedly easy intubation with etomidate and succinylcholine and started on fentanyl and midazolam drip, with ETT 7.5, taped at 21 at teeth. He wsa guveb CXR showed large left pleural effusion with possiblity of LLL consolidation. He was given 1.5LNS and started on vancomycin and zosyn. He was noted to have a bruise on his head that has reportedly been there for the past week. CT Head was obtained, which per preliminary report, showed large right subdural hemorrhage with leftward subfalcine herniation. Neurosurgery was consulted who felt this may have been acute on chronic subdural hemorrhage, but given poor MS at baseline, did not feel he was a surgical candidate. Urinalysis suggestive of urinary tract infection. He was intubated secondary to his tachypnea, though his oxygen saturations were okay. He was withdrawing to pain but was not much more responsive than that. His vent settings upon transfer were AC, FiO2 40%, Vt 500, R 12, PEEP 5. His BPs had been stable (129/72) up until intubation, when he was noted to be auto-PEEPing and his systolics dropped to 79 systolic and levo 0.1 was started. Central line was placed in the ED. Cultures were sent as well. Labs from ___ showed WBC 5.2, HCT 32.0, and Plts 88, with Cr 1.2 - CT HEAD- LARGE RIGHT EPIDURAL/SUBDURAL BLEED WITH MIDLINE SHIFT. Neurosurgery was consulted and felt there was no operative option for this tpatient. On arrival to the MICU, pt is intubated and sedated. No further history is obtainable. He does not respond to commands. Past Medical History: -HTN -Bradycardia -Afib on ASA -Prostate CA s/p radiation -s/p injury from fall Social History: ___ Family History: Noncontributory Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: BP: P: R: 18 O2: General: intubated and sedated HEENT: Sclera anicteric, dry MM, pupils minimally reactive, large right sided bruise Neck: supple, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally on anterior exam, no wheezes, rales, ronchi 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 Neuro: sedated, no purposeful movements DISCHARGE PHYSICAL EXAM: VS: Tmax 99.5 Tcurrent 98.1 BP 169/88 HR ___ RR ___ O2sat 99%RA Gen: Lying in bed on left side, not moving spontaneously HEENT: right periorbital hematoma Resp: tachypneic, breath sounds improved but still decreased on left compared to right CV: RRR w/o murmurs/rubs/gallops Abd: PEG in place and is clean/dry/intact, soft, bowel sounds present, no rigidity/guarding Ext: warm & well perfused Mental status: arouses minimally to deep pain only CN: does not open eyes spontaneously, when eyes are pried open they are dysconjugate and appear to be roving with left gaze preference, mild left nasolabial fold flattening, weak gag present, cough observed Motor: spasticity left > right, weakly withdraws right arm and stiffens left arm to pain, triple flexion to pain in both legs Sensory: groans to pain in all extremities Reflexes: Toes extensor bilaterally but right >> left Pertinent Results: ADMISSION LABS: ___ 03:47PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 03:47PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG ___ 09:49AM TYPE-ART RATES-14/ TIDAL VOL-500 O2-100 PO2-461* PCO2-38 PH-7.39 TOTAL CO2-24 BASE XS--1 AADO2-216 REQ O2-44 -ASSIST/CON INTUBATED-INTUBATED ___ 08:02AM ___ TEMP-40.2 PO2-141* PCO2-36 PH-7.45 TOTAL CO2-26 BASE XS-2 INTUBATED-NOT INTUBA COMMENTS-GREENTOP ___ 08:02AM LACTATE-2.3* ___ 07:50AM GLUCOSE-245* UREA N-33* CREAT-1.4* SODIUM-138 POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-23 ANION GAP-17 ___ 07:50AM ALT(SGPT)-18 AST(SGOT)-21 ALK PHOS-95 TOT BILI-0.8 ___ 07:50AM LIPASE-17 ___ 07:50AM ALBUMIN-3.1* ___ 07:50AM WBC-7.3 RBC-2.90* HGB-9.5* HCT-27.9* MCV-96 MCH-32.8* MCHC-34.1 RDW-16.7* ___ 07:50AM NEUTS-81.4* LYMPHS-14.9* MONOS-3.1 EOS-0.3 BASOS-0.2 ___ 07:50AM ___ PTT-28.0 ___ CT Head ___: FINDINGS: Motion artifact slightly limits evaluation, particularly at the skull base. There is a large predominantly hyperdense right subdural hemorrhage tracking along the entire right cerebral convexity and along the tentorium and falx, measuring up to 19 mm in thickness, with 13 mm leftward shift of normally midline structures. There is mild effacement of the sulci of the right and effacement of the right lateral ventricle, most notably in the region of the occipital horn. The basal cisterns appear patent with crowding in the region of the right uncus. There is preservation of gray-white matter differentiation. Underlying ventricular and sulcal prominence suggests age-related involutional changes. White matter hypodensity is likely secondary to sequela of chronic small vessel ischemic disease with a large lacune centered in the left external capsule. Right frontal subgaleal hematoma is seen. An osteoma projects into the frontal sinus on the left. There is partial opacification of the ethmoid air cells, left sphenoid sinus, and mucus retention cyst formation in the right maxillary sinus. The visualized portions of the mastoid air cells appear well aerated. Dense arterial calcifications are seen. No acute bony abnormality is detected. IMPRESSION: Large right subdural hemorrhage with leftward subfalcine herniation. CXR ___: FINDINGS: There is a large left pleural effusion with overlying atelectasis, other underlying alveolar processes cannot be excluded. There is a small right pleural effusion. Pulmonary vascular prominence is seen, likely exaggerated by low lung volumes, without overt pulmonary edema. Linear density projecting over the left upper lung field likely represents atelectasis. No pneumothorax is seen on this single view. Heart size is difficult to evaluate in the setting of overlying large pleural effusion. IMPRESSION: Large left pleural effusion with underlying consolidation, which most likely represents atelectasis, but pneumonia, aspiration, and hemorrhage cannot be excluded. CXR ___: FINDINGS: There has been interval intubation with endotracheal tube tip projecting approximately 3.5 cm above the carina. An esophageal catheter courses below the diaphragm with tip projecting over the left upper quadrant, likely within the stomach. There is a large left pleural effusion and small right pleural effusion, as seen previously, with underlying left lower lung consolidation. No pneumothorax is detected on this single supine view. Pulmonary vascular prominence persists without radiographic evidence for overt pulmonary edema. Heart size is difficult to evaluate in the setting of overlying pleural effusion. IMPRESSION: Interval intubation and placement of an esophageal catheter in standard positions. CXR ___: Comparison is made with prior study ___. NG tube tip is out of view below the diaphragm. ET tube tip is in standard position 6.4 cm above the carina. Moderate cardiomegaly and tortuous aorta are stable. Right subclavian catheter tip is at the cavoatrial junction or upper right atrium. There is no pneumothorax. Bibasilar opacities, larger on the left side, are a combination of small effusions and adjacent atelectasis. Left perihilar atelectases are unchanged. There is mild stable vascular congestion. EEG ___: FINDINGS: ABNORMALITY #1: Throughout the record, the background voltages were markedly diminished broadly over the right side. ABNORMALITY #2: There was also prominent delta slowing on the right side. ABNORMALITY #3: There were several sharp waves in the left temporal region. ABNORMALITY #4: The background rhythm was disorganized and often mildly slow, typically in the ___ Hz range. It was seen better on the left side. HYPERVENTILATION: Could not be performed. INTERMITTENT PHOTIC STIMULATION: Could not be performed. SLEEP: No normal waking or sleeping patterns were evident CARDIAC MONITOR: Showed a generally regular rhythm but with frequent and multifocal PVCs. IMPRESSION: Abnormal EEG due to the slow background, signifying a mild encephalopathy, and the diminished background voltages over the right side suggesting material interposed between the cortical surface at recording electrodes (such as a subdural fluid), occasional leftsided focal slowing, and the infrequent left temporal sharp waves, the voltage asymmetry is compatible with the history of SDH. The slowing of background suggests an encephalopathy. The sharp waves did not have following slow waves and did not appear repetitively. CXR ___: IMPRESSION: AP chest compared to ___: There is both more atelectasis and more left pleural effusion, at least moderate in volume, compared to ___. Right lung is grossly clear, though showing vascular congestion. There is no pulmonary edema in the right lung or pleural effusion. No pneumothorax. Right subclavian line ends close to the superior cavoatrial junction and a nasogastric tube passes into the stomach and out of view. Dr. ___ is paged at 8:25 a.m., one minute following recognition of the findings. EEG ___: FINDINGS: CONTINUOUS EEG RECORDING: Began at 16:15 on the afternoon of ___ ___ and continued through 7 the next morning. Throughout the record, the background remained slow, reaching a ___ Hz maximum. There were also bursts of generalized slowing and occasional suppressive burst with attenuation of the background in all areas for one second or so. Also, background voltages were significantly lower over the entire right hemisphere. Finally, there were frequent sharp waves in the left temporal region but without following slow waves and without rapid repetition. SPIKE DETECTION PROGRAMS: Showed the same left temporal sharp waves described above. SEIZURE DETECTION PROGRAMS: Showed no electrographic seizures. PUSHBUTTON ACTIVATIONS: There were none. SLEEP: No normal sleep patterns appeared. CARDIAC MONITOR: Showed a generally regular, wide complex rhythm with occasional PVCs. IMPRESSION: This telemetry showed a slow background indicating a widespread encephalopathy. The background was significantly lower and voltage over the right side, suggesting the presence of material interposed between the recording electrodes and the cortical surface, e.g. subdural fluid. There were occasional sharp waves in the left temporal region but no sharp and slow wave complexes are repetitive discharges. There were no electrographic seizures. LENIs ___: FINDINGS: Duplex evaluation of the bilateral lower extremity veins. There is normal wall-to-wall flow, compression and augmentation of the right common femoral, proximal femoral, mid femoral, distal femoral, popliteal, posterior tibial and peroneal veins. There is normal wall-to-wall flow, compression and augmentation of the left common femoral, left proximal superficial femoral, mid femoral, distal femoral veins. Of note, there is a clot involving the left proximal greater saphenous vein without extension into the superficial femoral vein or common femoral vein. Additionally, there is aneurysmal dilatation of the left popliteal vein without evidence of intrinsic clot. The aneurysmal dilatation measures up to 2 cm in the AP dimension. The remainder of the left calf veins including the posterior tibial and peroneal veins are patent with wall-to-wall flow and compression. IMPRESSION: 1. No evidence of deep venous thrombosis in the bilateral lower extremities. 2. Small clot is noted in the proximal left greater saphenous vein, near the junction with the common femoral vein, but without evidence of extension into the left superficial femoral or common femoral veins. 3. Aneurysmal dilatation of the left popliteal vein without evidence of intrinsic clot. CT Head ___: FINDINGS: Duplex evaluation of the bilateral lower extremity veins. There is normal wall-to-wall flow, compression and augmentation of the right common femoral, proximal femoral, mid femoral, distal femoral, popliteal, posterior tibial and peroneal veins. There is normal wall-to-wall flow, compression and augmentation of the left common femoral, left proximal superficial femoral, mid femoral, distal femoral veins. Of note, there is a clot involving the left proximal greater saphenous vein without extension into the superficial femoral vein or common femoral vein. Additionally, there is aneurysmal dilatation of the left popliteal vein without evidence of intrinsic clot. The aneurysmal dilatation measures up to 2 cm in the AP dimension. The remainder of the left calf veins including the posterior tibial and peroneal veins are patent with wall-to-wall flow and compression. IMPRESSION: 1. No evidence of deep venous thrombosis in the bilateral lower extremities. 2. Small clot is noted in the proximal left greater saphenous vein, near the junction with the common femoral vein, but without evidence of extension into the left superficial femoral or common femoral veins. 3. Aneurysmal dilatation of the left popliteal vein without evidence of intrinsic clot. CXR ___: COMPARISON: Multiple chest radiographs, the latest from ___. ONE VIEW OF THE CHEST: The lungs show severe left lower lobe opacity with an associated effusion. The right lung shows a small effusion. A right subclavian catheter terminates with its tip in the right atrium. An NG tube terminates with its tip overlying the mid mediastinum. IMPRESSION: 1. NG tube should be advanced by 20 cm for optimal position. 2. Unchanged severe left lower lobe atelectasis with an associated effusion. EEG ___: FINDINGS: CONTINUOUS EEG RECORDING: Began at 7:01 on the morning of ___ ___ and continued until 16:10 that afternoon. Throughout, it showed a disorganized and moderately slow background on the left side typically reaching a 7 Hz frequency posteriorly. There were also several sharp waves in the left temporal region. Background voltages over the right side were markedly diminished, as on the previous recording. SPIKE DETECTION PROGRAMS: Showed the same left temporal sharp waves, but there were no spike or sharp and slow wave complexes or repetitive discharges. SEIZURE DETECTION PROGRAMS: Showed no electrographic seizures. PUSHBUTTON ACTIVATIONS: There were none. SLEEP: No normal waking or sleep patterns were evident. CARDIAC MONITOR: Showed a frequently regular rhythm with several PVCs. IMPRESSION: This telemetry showed a continued slow background over the left side indicating an encephalopathy. There were frequent sharp waves in the left temporal region but no spike or sharp and slow wave complexes and no repetitive discharges. The background voltages over the right side were markedly reduced. All of these findings are continuations of the same from the previous recording. CXR ___: IMPRESSION: AP chest compared to ___: A new large pneumoperitoneum, do not have an obvious explanation unless the patient has undergone intervening abdominal surgery or placement of an enterostomy tube. Dr. ___ was paged at 9:40 a.m., 1 minute following recognition of the findings. Severe cardiomegaly is chronic. Moderate left pleural effusion has recurred. Left lower lobe is consolidated either chronic atelectasis or pneumonia. CT Head ___: COMPARISON: Prior head CT from ___. FINDINGS: Again noted is a large right subdural hematoma tracking along the entire right cerebral convexity. Density changes are consistent with the evolution of subdural hematomas. Shift of the normally midline structures measures 13.4 mm. In comparison to prior examination, there is a 1 mm increase in the leftward shift of the midline structures; previously measuring 12.2 mm. There is increased effacement of the right cerebral convexity sulci. The gray-white matter differentiation is preserved. There is underlying prominence of the ventricles and sulci, likely age related. A focus of hypodensity is again seen in the left external capsule and is compatible with prior lacunar infarct. Periventricular white matter hypodensities are consistent with chronic small vessel ischemic disease. There is no evidence of fracture. There is opacification of the right mastoid air cells and mucosal thickening in the right maxillary sinus. An osteoma is noted in the left frontal sinus. CONCLUSION: Increased mass effect of right subdural hematoma with increased right sulcal effacement and equivocal leftward shift of normally midline structures. TTE ___: Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 4.0 cm <= 4.0 cm Left Atrium - Four Chamber Length: *7.0 cm <= 5.2 cm Right Atrium - Four Chamber Length: *7.1 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: *1.8 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.7 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.2 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.0 cm Left Ventricle - Fractional Shortening: 0.29 >= 0.29 Left Ventricle - Ejection Fraction: 50% to 55% >= 55% Left Ventricle - Stroke Volume: 38 ml/beat Left Ventricle - Cardiac Output: 2.75 L/min Left Ventricle - Cardiac Index: *1.62 >= 2.0 L/min/M2 Aorta - Sinus Level: 3.1 cm <= 3.6 cm Aorta - Ascending: *3.9 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.6 m/sec <= 2.0 m/sec Aortic Valve - Mean Gradient: 11 mm Hg Aortic Valve - LVOT VTI: 12 Aortic Valve - LVOT diam: 2.0 cm Mitral Valve - E Wave: 0.7 m/sec Mitral Valve - A Wave: 0.4 m/sec Mitral Valve - E/A ratio: 1.75 Mitral Valve - E Wave deceleration time: 248 ms 140-250 ms TR Gradient (+ RA = PASP): *41 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. LEFT VENTRICLE: Severe symmetric LVH. Low normal LVEF. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size. Borderline normal RV systolic function. [Intrinsic RV systolic function likely more depressed given the severity of TR]. AORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Severe [4+] TR. Moderate PA systolic hypertension. Given severity of TR, PASP may be underestimated due to elevated RA pressure. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: Moderate pericardial effusion. Effusion circumferential. No echocardiographic signs of tamponade. Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. GENERAL COMMENTS: Suboptimal image quality - poor subcostal views. Left pleural effusion. Conclusions The left atrium is elongated. The right atrium is markedly dilated. There is severe symmetric left ventricular hypertrophy. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size is normal. with borderline normal free wall function. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The tricuspid valve leaflets are mildly thickened. Severe [4+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is a moderate sized pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. CXR ___: IMPRESSION: AP chest compared to ___ through ___: Large pneumoperitoneum may have improved slightly. Severe enlargement of the cardiac silhouette, consistent with cardiomegaly and/or pericardial effusion, has increased since ___, but is unchanged since ___ and there may now be a moderate-to-large left pleural effusion. Atelectasis is present at both lung bases. Upper lobes show mild vascular congestion but no edema. Left PIC line ends at the junction of brachiocephalic veins. No pneumothorax. CXR ___: FINDINGS: As compared to the previous radiograph, there is unchanged evidence of free subdiaphragmatic air. Massive cardiomegaly and signs of moderate pulmonary edema have slightly increased in the interval. Also increased is a left pleural effusion and subsequent areas of atelectasis in the left lung. No pneumothorax. LENIs ___: FINDINGS: There is normal wall-to-wall flow, compression and augmentation of the right common femoral, proximal, mid, and distal superficial femoral, and popliteal veins. Normal color flow and compressibility were seen in the right posterior tibial and peroneal veins. There is also normal wall-to-wall flow and compression in the left common femoral, mid, and distal superficial femoral veins. There is an acute expansile hypoechoic non-occlusive thrombus involving the left greater saphenous vein at the junction, without extension into the common femoral vein. There is also an acute expansile non-occlusive thrombus at the left popliteal vein above the knee. The remainder of the left calf veins including the posterior tibial and peroneal veins are patent with wall-to-wall flow and compression. IMPRESSION: 1. Expansile hypoechoic non-occlusive thrombus at the left greater saphenous vein junction without extension to the common femoral vein. 2. Expansile hypoechoic non-occlusive thrombus in the left popliteal vein above the knee. CT Abdomen prelim read ___: 1. Large left and moderate right nonhemorrhagic pleural effusions and overlying atelectasis. 2. Moderate nonhemorrhagic pericardial effusion. 3. Severe coronary calcifications. 4. Large volume pneumoperitoneum persists after PEG placement on ___. Extensive streak artifact limits evaluation of the percutaneous gastrostomy site. However the large volume of air adjacent to this site suggest that there might be a leak. In addition, there are several small foci of high density material in the peritoneal cavity concerning for a small amount of extra-luminal oral contrast (2:77, 602b:31, 602b:39 5. Numerous large right renal cysts. Atrophic left kidney 6. Severe intimal hematoma vs thrombosed circumferencial dissection of the infrarenal abdominal aorta causes severe luminal narrowing from 2.4 cm diameter to 0.8 cm (2:68). The heavily calcified iliac arteries appear patent. PEG tube study ___: FINDINGS: Residual barium is seen within the large bowel. There is a relative paucity of air in the small bowel. There is a nonobstructive bowel gas pattern. 30 cc of Optiray was injected in to a PEG tube which is in place. Contrast is seen opacifying the distal stomach as well as the proximal duodenum and there is no evidence of extraluminal contrast to suggest leak. IMPRESSION: Nonobstructive bowel gas pattern. PEG tube in place without suggestion of leak. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Prazosin 2 mg PO DAILY 2. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 3. Aspirin 325 mg PO DAILY 4. Nitroglycerin SL 0.3 mg SL TID:PRN chest pain Every 5 minutes x 3 5. Pravastatin 20 mg PO DAILY 6. HumuLIN 70/30 *NF* (insulin NPH & regular human) 12 Units Subcutaneous QAM 7. HumuLIN R *NF* (insulin regular human) ___ Units Injection QPM 8. Multivitamins 1 TAB PO DAILY 9. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 10. Calcitriol 0.25 mcg PO DAILY 11. Docusate Sodium 100 mg PO BID 12. Amlodipine 10 mg PO DAILY 13. Lisinopril 40 mg PO DAILY 14. Linezolid ___ mg PO Q12H UTI Duration: 2 Days Until ___ for 14 day course for UTI at ___. Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q3H:PRN wheezing/dyspnea 2. Famotidine 20 mg PO BID 3. Fluconazole 200 mg PO Q24H 4. Furosemide 20 mg PO DAILY 5. Heparin 5000 UNIT SC TID 6. Glargine 16 Units Breakfast 7. LeVETiracetam 500 mg IV BID 8. Miconazole Powder 2% 1 Appl TP QID:PRN rash 9. Morphine Sulfate 0.5-1 mg IV Q4H:PRN respiratory distress, tachypnea with RR > 40 10. Calcitriol 0.25 mcg PO DAILY 11. Multivitamins 1 TAB PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Subdural hemorrhage Respiratory failure Sepsis Seizures Congestive Heart Failure Pleural Effusions Pericardial Effusion Atrial Fibrillation Funguria Diabetes Mellitus Melena Acute Kidney Injury DVT (Deep Venous Thrombosis) Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic and not arousable. Activity Status: Bedbound. Followup Instructions: ___ Radiology Report SINGLE FRONTAL VIEW OF THE CHEST. REASON FOR EXAM: Intubated patient, patient with severe head bleed, assess NG tube. Comparison is made with prior study ___. NG tube tip is out of view below the diaphragm. ET tube tip is in standard position 6.4 cm above the carina. Moderate cardiomegaly and tortuous aorta are stable. Right subclavian catheter tip is at the cavoatrial junction or upper right atrium. There is no pneumothorax. Bibasilar opacities, larger on the left side, are a combination of small effusions and adjacent atelectasis. Left perihilar atelectases are unchanged. There is mild stable vascular congestion. Radiology Report AP CHEST, 2:34 A.M. ON ___ HISTORY: ___ man with acute and chronic tachypnea. Evaluate chest process. IMPRESSION: AP chest compared to ___: There is both more atelectasis and more left pleural effusion, at least moderate in volume, compared to ___. Right lung is grossly clear, though showing vascular congestion. There is no pulmonary edema in the right lung or pleural effusion. No pneumothorax. Right subclavian line ends close to the superior cavoatrial junction and a nasogastric tube passes into the stomach and out of view. Dr. ___ is paged at 8:25 a.m., one minute following recognition of the findings. Radiology Report TYPE OF EXAMINATION: Chest AP portable single view. INDICATION: ___ male patient status post left-sided thoracocentesis, evaluate for pneumothorax and interval change. FINDINGS: AP single view of the chest has been obtained with patient in semi-upright position. Comparison is made with the next preceding similar study obtained 10 hours earlier during the same day. In the interval, a left-sided thoracocentesis has been performed resulting in diminished density on the left base overlying the enlarged cardiac silhouette. Pulmonary vasculature in the left-sided hemithorax can be identified and is not congested. There is no evidence of remaining pneumothorax in the apical area. Right-sided hemithorax is unchanged with unaltered position of previously described right-sided subclavian approach central venous line. ___ was paged for stat report at 2:45 p.m. Radiology Report BILATERAL LOWER EXTREMITY DVT ULTRASOUND INDICATION: ___ man with SDH, immobile, now with daily fevers, evaluate for DVT. TECHNIQUE: Sonographic gray-scale and Doppler images of the lower extremity veins were performed. FINDINGS: Duplex evaluation of the bilateral lower extremity veins. There is normal wall-to-wall flow, compression and augmentation of the right common femoral, proximal femoral, mid femoral, distal femoral, popliteal, posterior tibial and peroneal veins. There is normal wall-to-wall flow, compression and augmentation of the left common femoral, left proximal superficial femoral, mid femoral, distal femoral veins. Of note, there is a clot involving the left proximal greater saphenous vein without extension into the superficial femoral vein or common femoral vein. Additionally, there is aneurysmal dilatation of the left popliteal vein without evidence of intrinsic clot. The aneurysmal dilatation measures up to 2 cm in the AP dimension. The remainder of the left calf veins including the posterior tibial and peroneal veins are patent with wall-to-wall flow and compression. IMPRESSION: 1. No evidence of deep venous thrombosis in the bilateral lower extremities. 2. Small clot is noted in the proximal left greater saphenous vein, near the junction with the common femoral vein, but without evidence of extension into the left superficial femoral or common femoral veins. 3. Aneurysmal dilatation of the left popliteal vein without evidence of intrinsic clot. CRITICAL RESULTS: The above findings were verbally communicated by telephone to the patient's nursing unit. Nurse, ___, verbalized understanding of results at 4:53 p.m. on ___. Radiology Report INDICATION: ___ male with subdural hematoma, now on mannitol; evaluate for progression. COMPARISONS: Head NECT ___, 0815 hours. TECHNIQUE: Continuous axial sections were obtained through the brain without the administration of IV contrast. DLP: 1287.72 mGy-cm. CTDIvol: 57.81 mGy. FINDINGS: The skull base was re-imaged secondary to motion artifact on the initial scan. Again, there is a large predominantly hyperdense right subdural hematoma which tracks along the entire right cerebral convexity, including the tentorium and falx. The maximum depth on the prior study was 19 mm and on this study, it now measures 17.6 mm at the level of the sylvian fissure. There is 12.2 mm of leftward shift of the normally midline structures, previously 13 mm. Mild effacement of the right lateral ventricle, particularly in the occipital horn, as well as effacement of the right cerebral convexity sulci appears unchanged from prior. The previous hypodense foci within the hematoma on the earlier scan now appear slightly more hyperdense, suggesting interval bleeding versus redistribution of blood products. The gray-white matter differentiation is preserved and the basal cisterns remain patent. Underlying prominence of the ventricles and sulci likely relates to age-related volume loss. Confluent periventricular white matter hypodensities are likely sequela of chronic small vessel ischemic disease. A focus of hypodensity seen in the left external capsule is compatible with a prior lacunar infarct. The right frontal scalp subgaleal hematoma is unchanged. There is no fracture seen. Redemonstrated are mild mucosal thickening in the right maxillary sinus and an osteoma in the left frontal sinus. Partial opacification of the mastoid air cells remains unchanged. Dense calcifications are noted within the carotid siphons and right vertebral artery. IMPRESSION: Increased density within a large right subdural hematoma, suggestive of either interval re-bleeding versus redistribution. There has been no increase in the overall size of the hematoma, with slight decrease in the degree of leftward shift of the normally midline structures. COMMENT: These findings were discussed with Dr. ___ at 1133 hours on ___ by telephone at the time of their discovery. Radiology Report INDICATION: Subdural hematoma, congestive heart failure and recent pneumonia. Question NG tube position. COMPARISON: Multiple chest radiographs, the latest from ___. ONE VIEW OF THE CHEST: The lungs show severe left lower lobe opacity with an associated effusion. The right lung shows a small effusion. A right subclavian catheter terminates with its tip in the right atrium. An NG tube terminates with its tip overlying the mid mediastinum. IMPRESSION: 1. NG tube should be advanced by 20 cm for optimal position. 2. Unchanged severe left lower lobe atelectasis with an associated effusion. These findings were communicated via telephone to ___ via telephone at 3:36 p.m. on ___. Radiology Report INDICATION: Question NG tube placement. COMPARISON: Chest radiograph from ___ at 3:00 p.m. ONE VIEW OF THE CHEST: The NG tube is noted to be in the stomach. The remaining radiographic findings are unchanged. Radiology Report TYPE OF EXAMINATION: Chest AP portable single view. INDICATION: ___ male patient with left-sided PICC line, confirm tip position, contact ___ ___. FINDINGS: A left-sided PICC line has been placed and reaches well into the right of the midline. The line terminates overlying the right atrial structures and withdrawal by 4 cm is recommended so to terminate in the mid-to-lower third of the SVC. No pneumothorax or any other placement-related complication. Cardiac enlargement and pulmonary congestive pattern as before. Page was placed at 2:10 p.m. Radiology Report AP CHEST, 1:35 A.M., ___ HISTORY: ___ man with possible CHF, effusions and atelectasis. Persistent tachypnea. IMPRESSION: AP chest compared to ___: A new large pneumoperitoneum, do not have an obvious explanation unless the patient has undergone intervening abdominal surgery or placement of an enterostomy tube. Dr. ___ was paged at 9:40 a.m., 1 minute following recognition of the findings. Severe cardiomegaly is chronic. Moderate left pleural effusion has recurred. Left lower lobe is consolidated either chronic atelectasis or pneumonia. Radiology Report INDICATION: ___ male patient with right subdural hematoma. Study requested for evaluation of shift/herniation. TECHNIQUE: Contiguous axial images were obtained through the brain. No contrast was administered. TOTAL EXAM DLP: 936.52 mGy-cm. CTDIvol: 56.54 mGy. COMPARISON: Prior head CT from ___. FINDINGS: Again noted is a large right subdural hematoma tracking along the entire right cerebral convexity. Density changes are consistent with the evolution of subdural hematomas. Shift of the normally midline structures measures 13.4 mm. In comparison to prior examination, there is a 1 mm increase in the leftward shift of the midline structures; previously measuring 12.2 mm. There is increased effacement of the right cerebral convexity sulci. The gray-white matter differentiation is preserved. There is underlying prominence of the ventricles and sulci, likely age related. A focus of hypodensity is again seen in the left external capsule and is compatible with prior lacunar infarct. Periventricular white matter hypodensities are consistent with chronic small vessel ischemic disease. There is no evidence of fracture. There is opacification of the right mastoid air cells and mucosal thickening in the right maxillary sinus. An osteoma is noted in the left frontal sinus. CONCLUSION: Increased mass effect of right subdural hematoma with increased right sulcal effacement and equivocal leftward shift of normally midline structures. Radiology Report AP CHEST, 8:09 P.M., ___ HISTORY: ___ man with pleural and pericardial effusions. Worsening respiratory distress. IMPRESSION: AP chest compared to ___ through ___: Large pneumoperitoneum may have improved slightly. Severe enlargement of the cardiac silhouette, consistent with cardiomegaly and/or pericardial effusion, has increased since ___, but is unchanged since ___ and there may now be a moderate-to-large left pleural effusion. Atelectasis is present at both lung bases. Upper lobes show mild vascular congestion but no edema. Left PIC line ends at the junction of brachiocephalic veins. No pneumothorax. Radiology Report CHEST RADIOGRAPH INDICATION: Fever, questionable pneumonia. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, there is unchanged evidence of free subdiaphragmatic air. Massive cardiomegaly and signs of moderate pulmonary edema have slightly increased in the interval. Also increased is a left pleural effusion and subsequent areas of atelectasis in the left lung. No pneumothorax. Radiology Report INDICATION: ___ male with a history of subdural hemorrhage and fevers presents with O2 desaturations concerning for PE, who now presents for evaluation for DVT. COMPARISON: Lower extremity ultrasound from ___. TECHNIQUE: Grayscale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. FINDINGS: There is normal wall-to-wall flow, compression and augmentation of the right common femoral, proximal, mid, and distal superficial femoral, and popliteal veins. Normal color flow and compressibility were seen in the right posterior tibial and peroneal veins. There is also normal wall-to-wall flow and compression in the left common femoral, mid, and distal superficial femoral veins. There is an acute expansile hypoechoic non-occlusive thrombus involving the left greater saphenous vein at the junction, without extension into the common femoral vein. There is also an acute expansile non-occlusive thrombus at the left popliteal vein above the knee. The remainder of the left calf veins including the posterior tibial and peroneal veins are patent with wall-to-wall flow and compression. IMPRESSION: 1. Expansile hypoechoic non-occlusive thrombus at the left greater saphenous vein junction without extension to the common femoral vein. 2. Expansile hypoechoic non-occlusive thrombus in the left popliteal vein above the knee. These findings were verbally communicated by Dr. ___ to Dr. ___, pager number ___, at 5:02 p.m. by telephone, approximately 10 minutes after the discovery of the findings. Radiology Report CT TORSO HISTORY: Fever. COMPARISONS: Chest radiograph from ___, but no prior CT imaging of the torso. TECHNIQUE: Multidetector CT images of the chest, abdomen, and pelvis were obtained with oral and intravenous contrast, and sagittal and coronal reformations were also performed. DLP: 1044.1 mGy-cm. FINDINGS: CT CHEST: The heart is mild to moderately enlarged. There are calcifications among the coronary arteries as well as the aortic and mitral valves. Patchy vascular calcifications are present along the aorta. There is a small pericardial effusion. There is a moderate right-sided pleural effusion and a moderate to large left-sided pleural effusion. The left lower lobe is essentially collapsed and significant lingular atelectasis is also present. Chest findings are compatible with the result of recent prior radiography. Although a pleural effusion appears more conspicuous on the left on the scout view, this apparent difference may be due to differences in positioning. CT ABDOMEN: There is a moderate-to-large quantity of pneumoperitoneum. A gastrostomy tube is somewhat difficult to assess due to streak artifacts from an overlying left arm, but positioning appears intraluminal. The quantity of air is somewhat prominent given the period of time which has elapsed since placement of the tube, although it does not necessarily connote an ongoing leak. It is noted that no discrete fluid collection is visualized. In the dome of the right lobe, a very small hypodense focus measuring 7 mm in diameter is too small to characterize. A dependent hyperdense focus of 7 mm in diameter within the gallbladder is probably due to a gallstone rather than a polyp. The spleen is normal in size and appearance. The pancreas is atrophic with dilatation of the pancreatic duct within the tail to nearly 8 mm in diameter. There is a fairly abrupt termination of the dilated duct at the level of the pancreatic body where no discrete mass can be discerned. Each adrenal gland appears mildly thickened, including a nodule along the anterior limb of the left adrenal, which is nonspecific, measuring up to 16 x 9 mm in axial ___ (2:55). In the right kidney, there are several simple cysts as well as small hypodense foci that are too small to characterize. In the upper pole of the left kidney, which is markedly atrophic, there is a hyperdense lesion measuring 21 mm in diameter, which is concerning for a neoplasm, although it is potentially due to a hemorrhagic cyst. Its density measures 70 Ho___ units on post-contrast imaging. Additional hypodense foci are mostly too small to characterize, but a large simple cyst is noted along the lower pole measuring up to 57 mm in diameter. Along the anterior margin of the lower pole, a 15 mm diameter heterogeneous but predominantly low-density lesion is suspected to represent a complex cystic lesion, but relatively small. The stomach is nondilated. There is no obstruction. Contrast passes freely through the small bowel into the colon. There is moderate sigmoid diverticulosis without evidence for inflammation. The rectum shows mild wall thickening and there is apparently incontinence with spillage of enteric contrast from the anus directly visualized on this examination. It is also difficult to exclude the possibility of a rectal mass, although an inflammatory process seems more likely, of uncertain chronicity. CT PELVIS: A Foley catheter is present within a collapsed bladder. The prostate, if present, is quite small and there may be a urethral diverticulum (2:109) to the left of midline measuring about 8 mm in diameter. There is a left common iliac stent. The lower abdominal aorta is markedly thickened and mildly ectatic measuring up to 32 x 36 mm in axial ___ with considerable calcification. The lumen narrows to as little as 11 x 7 mm in axial ___. Contents of wall thickening are of intermediate density. There is likely stenosis of the left renal artery, but not well characterized with non-angiographic technique and there is probably mild right-sided renal artery stenosis. On the right, there is stenosis of the right superficial femoral artery and possibly occlusion at the origin of the deep branch. The left superficial femoral artery appears occluded. There are septations across the narrowed part of the aorta which could be viewed as chronic dissection flaps, but the etiology of the appearance is probably due to large ulcerating atherosclerotic plaques. In the setting of fever, it is difficult to completely exclude a mycotic aneurysm but without robust enhancement or fat stranding, and with evidence for extensive atherosclerotic change, it seems less likely than a noninfectious cause. BONE WINDOWS: The bones appear demineralized. There are no suspicious lytic or blastic lesions. Moderate degenerative changes are present along the lower lumbar spine. There is a prior fracture of the right proximal humerus with displacement and overlap of fragments as well as callus formation. There has also been a prior right distal radius fracture with incomplete healing, noting that the right arm is partly within the field of view. Similarly, there has also been a distal radius fracture on the left, which is not as well characterized. There is a moderate compression deformity of the T12 vertebral bod, which appears likely chronic, without retropulsion. IMPRESSION: 1. Substantial pleural effusions with associated volume loss in the lingula and left lower lobe, the latter almost fully collapsed. Superimposed pneumonia is a potential consideration in the appropriate clinical setting, however. 2. Severe atherosclerotic change including coronary artery calcifications and marked narrowing of the infrarenal abdominal aorta with large ulcerating soft tissue plaques. The etiology is likely atherosclerosis. The possibility of a mycotic aneurysm could be considered, but the appearance and location are typical for atherosclerotic change and there are no signs such as brisk enhancement or fat stranding to indicate infection. It may be helpful, if available, however, correlate with any prior imaging, which may be available to assess the significance of the findings, however. 3. Fairly large amount of pneumoperitoneum, but without fluid collection. In the early post-procedure course, this appearance may be within normal limits, but is prominent. Accordingly, recent or ongoing leakage of air from the stomach is difficult to exclude. Followup radiographs may be helpful in order to assess for whether the quantity of air is increasing or decreasing, which may be helpful clinically. 4. There is no evidence of contrast extravasation. 5. Dilatation of the distal pancreatic duct with a relatively rapid cutoff in the pancreatic body. Although there is no mass demonstrated, the possibility of a subtle obstructing neoplasm or benign stricture could be considered and if clinically indicated, followup imaging could be pursued or further characterization with MR imaging is needed clinically, provided the patient is able to tolerate the examination. 6. Suspicious lesion in the upper pole of the left kidney, hemorrhagic cyst versus neoplasm. This appearance could also be assessed with MR or ultrasound may be of value in assessing further. 7. Marked left renal atrophy. Dr. ___ the preliminary findings with Dr. ___ at 8:10 p.m. by telephone. Dr. ___ the final report with Dr. ___ on ___ including recommendations regarding suspicious pancreatic and left renal findings. Radiology Report HISTORY: ___ man with subdural hematoma status post PEG placement with persistent pneumoperitoneum and suggestion of contrast leak on prior CT. COMPARISON: CT torso, ___. FINDINGS: Residual barium is seen within the large bowel. There is a relative paucity of air in the small bowel. There is a nonobstructive bowel gas pattern. 30 cc of Optiray was injected in to a PEG tube which is in place. Contrast is seen opacifying the distal stomach as well as the proximal duodenum and there is no evidence of extraluminal contrast to suggest leak. IMPRESSION: Nonobstructive bowel gas pattern. PEG tube in place without suggestion of leak. Radiology Report INDICATION: ___ male with signs of head trauma. COMPARISON: None available. TECHNIQUE: Axial CT images through the head were acquired without intravenous contrast. Coronal, sagittal, and thin slice bone reconstructed images were created and reviewed. FINDINGS: Motion artifact slightly limits evaluation, particularly at the skull base. There is a large predominantly hyperdense right subdural hemorrhage tracking along the entire right cerebral convexity and along the tentorium and falx, measuring up to 19 mm in thickness, with 13 mm leftward shift of normally midline structures. There is mild effacement of the sulci of the right and effacement of the right lateral ventricle, most notably in the region of the occipital horn. The basal cisterns appear patent with crowding in the region of the right uncus. There is preservation of gray-white matter differentiation. Underlying ventricular and sulcal prominence suggests age-related involutional changes. White matter hypodensity is likely secondary to sequela of chronic small vessel ischemic disease with a large lacune centered in the left external capsule. Right frontal subgaleal hematoma is seen. An osteoma projects into the frontal sinus on the left. There is partial opacification of the ethmoid air cells, left sphenoid sinus, and mucus retention cyst formation in the right maxillary sinus. The visualized portions of the mastoid air cells appear well aerated. Dense arterial calcifications are seen. No acute bony abnormality is detected. IMPRESSION: Large right subdural hemorrhage with leftward subfalcine herniation. Findings reported to ___ by ___ by telephone at 9:18 a.m. on ___ at the time of discovery of these findings. Radiology Report INDICATION: ___ male with fever and cough. COMPARISON: None available. TECHNIQUE: Single frontal chest radiograph was obtained portably with the patient in a semi-erect position. FINDINGS: There is a large left pleural effusion with overlying atelectasis, other underlying alveolar processes cannot be excluded. There is a small right pleural effusion. Pulmonary vascular prominence is seen, likely exaggerated by low lung volumes, without overt pulmonary edema. Linear density projecting over the left upper lung field likely represents atelectasis. No pneumothorax is seen on this single view. Heart size is difficult to evaluate in the setting of overlying large pleural effusion. IMPRESSION: Large left pleural effusion with underlying consolidation, which most likely represents atelectasis, but pneumonia, aspiration, and hemorrhage cannot be excluded. Findings reported to ___ by ___ by telephone at 10:03 a.m. on ___ at the time of discovery of these findings. Radiology Report INDICATION: ___ male status post intubation. COMPARISON: ___ at 8:00 a.m. TECHNIQUE: Single frontal chest radiograph was obtained portably with the patient in a supine position. FINDINGS: There has been interval intubation with endotracheal tube tip projecting approximately 3.5 cm above the carina. An esophageal catheter courses below the diaphragm with tip projecting over the left upper quadrant, likely within the stomach. There is a large left pleural effusion and small right pleural effusion, as seen previously, with underlying left lower lung consolidation. No pneumothorax is detected on this single supine view. Pulmonary vascular prominence persists without radiographic evidence for overt pulmonary edema. Heart size is difficult to evaluate in the setting of overlying pleural effusion. IMPRESSION: Interval intubation and placement of an esophageal catheter in standard positions. Radiology Report TYPE OF EXAMINATION: Chest AP portable single view. INDICATION: ___ male patient with pneumonia and subdural hematoma with new right subclavian central venous line placement. Check position. Contact Dr. ___ ___. AP single view of the chest has been obtained with patient in sitting semi-upright position. Comparison is made with the next preceding similar study of ___. The patient remains intubated, the ETT in unchanged position. The same holds for previously described NG line. A new right subclavian central venous line has been placed, seen to overlie the right mediastinal structures some 7 cm below carina. This projects also in the possible upper portion of the right atrium. It is recommended to withdraw the line by 4 cm to be in safe SVC position. ___ was paged at ___ at 4:50 p.m. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: DYSPNEA Diagnosed with SEPTICEMIA NOS, SEVERE SEPSIS , ACCIDENT NOS, SUBDURAL HEMORRHAGE temperature: 104.4 heartrate: 100.0 resprate: 38.0 o2sat: 100.0 sbp: 129.0 dbp: 72.0 level of pain: unable level of acuity: 1.0

___ with ?CHF, hx of prostate cancer presents from his nursing home with tachypnea to the ___ and fevers found to have severe cerebral hemorrhage. # Neuro: Acute holohemispheric SDH, poor mental status, seizures - Has midline shift with subfalcine herniation. Not a surgical candidate per neurosurgery. Given that surgery is not an option, with his severe injury, unlikely that other treatments such as mannitol and hyperventilation will be useful in setting of not being able to evaucate hematoma. Following successful extubation on ___ he reportedly was able to communicate, although his speech was very difficult to comprehend. Given he no longer required ICU level care, and his primary active issue was neurologic, he was called out and transfered to the neurology service. Throughout his hospitalization under the care of the neurology service, pt's mental status remained poor. His eyes remained closed throughout almost the entirety of his stay although he spontaneously opened them once or twice. No verbal output was elicited although pt transiently followed some very simple verbal commands such as showing two fingers. On ___ he was started on mannitol given that neurosurgery recommended no surgical intervention. He was also started on phenytoin prophylaxis. Multiple CT heads were obtained that did not show improvement of subdural hematoma despite treatment with mannitol first followed by a course of prednisone; both therapies were stopped as ineffective. EEG monitoring was ordered given the concern for subclinical seizures, and did not show epileptiform activity, so phenytoin prophylaxis was stopped. However, as pt was later observed to have some right arm jerking consistent with seizure activity, he was started on levetiracetam. Neurosurgery was consulted three times during this admission, and a second opinion was also obtained from ___ neurosurgery; each time, the decision was made that Mr. ___ would require a major neurologic surgery involving hemicraniectomy, and that because of his frail state and age, this surgery would not be offered. Amantadine was tried for a 7-day course to attempt to improve alertness, but had no discernable effect, so it was stopped. # PNA/sepsis - Febrile and infiltrate with effusion on CXR. As the patient came in from a nursing home, he therefore required HCAP coverage. He was treated with vanc/cefepime beginning on ___, on ___ he was switched to vanc/pip-tazo/azithro given concern that he continued to be febrile. # Respiratory failure - Was intubated given tachypnea and concern he would tire out. Likely etiology is a combination of pneumonia and increased intracranial pressures from hemorrhage. He was successfully extubated on ___. After his extubation, pt remained tachypneic with ___ Stokes respirations. Respiratory distress was treated with PRN furosemide when there was evidence of pulmonary edema, albuterol nebs. After discussion with daughter ___, PRN morphine at a dose of 0.5-1 mg was added for respiratory rate > 40. # Hypotension - Upon initial presentation his hypotension was likely a combination of infection and hemorrhage. He required support with pressors briefly during his hospital course. He subsequently developed hypertension while in the ICU, which resolved with his home dose of lisinopril. On the neurology floor, pt was for the most part normotensive or mildly hypertensive. SBP was maintained < 160 mmHg in light of SDH, for the most part without PRNs. There were several episodes of transient hypotension that responded to fluid boluses. #CHF - Mildly reduced ejection fraction. Fluid balance was tenuous, and pt had multiple episodes of pulmonary edema during this hospitalization that responded to furosemide IV 20 mg. He will be discharged on a standing dose of furosemide 20 mg PO daily. # A fib - Currently rate controlled in a fib. His aspirin was held in the setting of SDH, as were nodal agents while on pressors. # Endo/diabetes - His sugars were monitored and insulin was administered with a basal/bolus measurement on a sliding scale. # ID - Given that he continued to have a fever, on ___ his peripheral line was pulled. He was also treated with miconazole powder for a fungal infection in his perineal region. On ___ he was again switched to vanc/pip-tazo/tobramycin because he was again febrile. Pt was maintained on this course throughout the majority of his admission, as each time an attempt was made to decrease antibiotic coverage, he spiked new fevers. A source of infection was not identified, although one single blood culture grew coag-negative staph (likely a contaminant). At the time of discharge, pt has been afebrile for > 72 hours, and has been gradually weaned off antibiotics (tobramycin stopped on ___, vancomycin on ___ and pip-tazo on ___. Fluconazole was initiated for persistent funguria despite Foley exchange for a 14-day course ___. #DVTs - In light of the large SDH with mass effect, pt was not started on DVT prophylaxis. LENIs on ___ demonstrated to DVTs in left leg. Decision was made to initiate prophylactic heparin ___ut forego therapeutic anticoagulation. This decision was discussed with HCP ___. #GI/nutrition: s/p PEG tube placement, transiently w/melenous stools (which now appear to have resolved, likely were secondary to PEG). Also w/persistent pneumoperitoneum attributed to PEG placement, but this was assessed clinically by surgery service and also there was no PEG tube leak on tube study. In light of the intracranial bleed and episodes of melena, famotidine stress ulcer prophylaxis will be continued on discharge. - #renal/GU: New ___ during this admission, may have been secondary to tobramycin or overdiuresis. Urine lytes borderline intrarenal, eos negative. Currently generally improving with some creatinine fluctuations (Cr 1.7 at discharge). -# Disposition: In light of his poor prognosis, pt was changed to DNR status during intubation. After extubation, daughter and HCP ___ wished pt to have a full code status again although it was explained to her that Mr. ___ has a severe neurologic injury, from which he is extremely unlikely to recover. She stated that she would want him to live regardless of how much he is suffering. Palliative care, the chaplaincy, and the ethics consult team were involved to help mediate, and ___ changed her mind later during this admission, deciding that DNR/DNI would be appropriate. At this point, patient is DNR/DNI and has an unrecoverable neurologic condition, for which we cannot offer any further surgical or medical options. His daughter and HCP ___ wishes to continue the current regimen of medications. However, should his status deteriorate, it is very unlikely that he would benefit from rehospitalizaton.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Simvastatin / Amlodipine Attending: ___. Chief Complaint: dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: ___ h/o bronchiectasis, ?COPD, ?chronic ___ presents with 2 week hx of cough productive of sputum. On ___ of last week she woke up with a raspy throat and raspy chest, nasal congestion, rhinorrhea, sore throat. The phlegm was bothering her, so she had to sleep in a recliner. She has some baseline shortness of breath, which is has been a little worse with wheezing. She took her albuterol two to three times a day and it helped a lot. Phlegm transitioned from white to yellow. Her PCP prescribed ___ prednisone burst which she started to taper yesterday (Z-pak also finished) and SOB got worse. Pt denies chest pain, endorses intermittent chest tightness lasting minutes recently, + DOE and ___ pillow orthopnea worse in the last week. No fevers, chills, palpitations or chest pressure. Pt also reports that she does not reliably take her lasix, though she reports no known cardiac history and that it is for leg swelling. No other recent dietary changes. On arrival to the ED, initial vitals were: 98 74 180/62 22 97% RA. Labs notable for WBC 3.4 with 78N, Glc 276, BUN 28, Cr 1.1 (baseline), lactate 2.4, proBNP 260, TroT <.01 x1. CXR, EKG unremarkable. She was given albuterol nebs x2, ipratropium neb x1, ASA 325mg, lisinopril 20mg PO x1, lasix 40mg IV x1 with 600cc UOP, Levofloxacin 750mg IV. VS at transfer: 99.2 149/74 70 14 96% RA. Currently, she reports breathing is feeling better. Denies CP or palps, no F/C. Past Medical History: BRONCHIECTASIS W/ RECURRENT PNAs ? COPD ? CHRONIC DIASTOLIC CHF CHRONIC RHINITIS GLUCOSE INTOLERANCE HYPERLIPIDEMIA HYPERTENSION S/P HYSTERECTOMY S/P B/L KNEE REPLACEMENT OBSTRUCTIVE SLEEP APNEA OSTEOPENIA PAGET'S DISEASE SPINAL MENINGIOMA S/P RESECTION Social History: ___ Family History: Mother with CAD. No other known lung or cardiac FH. Physical Exam: VS - 97.9 160/84 72 14 94% RA General: well-appearing woman, appears younger than stated age, NAD, speaking in full sentences HEENT: MMM, OP clear, Mallampati 3 Neck: supple, JVP=10cm CV: RRR, no murmurs or rubs Lungs: Poor air entry throughout, mild bibasilar crackles, faint end exp wheezes scattered Abdomen: soft, NTND, +BS GU: deferred Ext: warm, 1+ pitting edema b/l to knee Neuro: CN ___ intact and symmetric, motor ___ throughout Skin: no rashes Discharge exam same as above except Lungs: moderate air entry throughout with mild end expiratory wheezes throughout. Pertinent Results: ___ 11:28PM CK-MB-3 cTropnT-<0.01 ___ 01:50PM cTropnT-<0.01 ___ 01:50PM proBNP-260 ___ 01:50PM WBC-3.4* RBC-4.46 HGB-13.8 HCT-41.5 MCV-93 MCH-31.0 MCHC-33.3 RDW-12.5 ___ 07:30AM BLOOD WBC-4.9 RBC-4.33 Hgb-13.2 Hct-39.2 MCV-91 MCH-30.6 MCHC-33.7 RDW-12.3 Plt ___ ___ 07:30AM BLOOD Glucose-117* UreaN-30* Creat-1.3* Na-141 K-3.4 Cl-103 HCO3-26 AnGap-15 ___ 07:45AM BLOOD CK-MB-3 cTropnT-<0.01 ___ 11:28PM BLOOD CK-MB-3 cTropnT-<0.01 CXR ___: No acute cardiopulmonary process or significant change since the prior study. LLE US ___: No evidence of DVT in the left lower extremity. TTE ___: The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). 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 aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate (___) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. Mild aortic regurgitation. Mild-moderate mitral regurgitation. Mild pulmonary hypertension. Compared with the prior study (images reviewed) of ___, the severity of mitral regurgitation is slightly increased. Biventricular systolic function remains preserved with similar PA systolic pressure. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 20 mg PO BID Hold for SBP<100 2. Lorazepam 0.5 mg PO DAILY:PRN insomnia, anxiety Hold for sedation, RR<10 3. albuterol sulfate *NF* 90 mcg/actuation Inhalation QID:PRN wheeze 4. Furosemide 20 mg PO BID 5. Atenolol 50 mg PO DAILY Hold for SBP<100, HR<55 6. Potassium Chloride 20 mEq PO DAILY Hold for K > 7. PredniSONE 40 mg PO TAPER AS DIRECTED 40mg on ___ & ___ 30mg on ___ and ___, 20mg on ___ and ___, and 10mg on ___ and ___ Discharge Medications: 1. Furosemide 20 mg PO BID 2. Lisinopril 20 mg PO BID 3. Lorazepam 0.5 mg PO DAILY:PRN insomnia, anxiety 4. Guaifenesin ___ mL PO Q6H:PRN cough 5. Metoprolol Tartrate 25 mg PO BID 6. albuterol sulfate *NF* 90 mcg/actuation Inhalation QID:PRN wheeze 7. Potassium Chloride 20 mEq PO DAILY Hold for K > 8. PredniSONE 20 MG PO DAILY Duration: 3 Days 9. PredniSONE 10 MG PO DAILY Duration: 3 Days 10. PredniSONE 5 MG PO DAILY Duration: 3 Days Discharge Disposition: Home Discharge Diagnosis: Bronchiectasis Reactive airway disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report HISTORY: ___ female with CHF, COPD cough and orthopnea. Question CHF versus pneumonia. COMPARISON: Chest radiograph ___. FINDINGS: PA and lateral chest radiographs were provided. Compared to the prior radiograph there has been no significant change. There is no focal consolidation, pleural effusion or pneumothorax. There is no evidence of pulmonary edema. Minimal atelectasis is present in the right lower lobe. The heart size is mildly prominent but stable. Calcification of the aortic arch is noted. The imaged upper abdomen is unremarkable. Bones are intact. IMPRESSION: No acute cardiopulmonary process or significant change since the prior study. Radiology Report HISTORY: ___ man with left lower extremity greater than right lower extremity swelling. Evaluate for DVT. COMPARISON: None. FINDINGS: Gray scale and color Doppler ultrasound was performed of the bilateral common femoral veins and the left superficial femoral, popliteal, posterior tibial and peroneal veins. There is normal flow, augmentation and compressibility. IMPRESSION: No evidence of DVT in the left lower extremity. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: COUGH, SHORTNESS OF BREATH Diagnosed with OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION temperature: 98.0 heartrate: 74.0 resprate: 22.0 o2sat: 97.0 sbp: 180.0 dbp: 62.0 level of pain: 0 level of acuity: 2.0

___ with bronchiectasis who presents with SOB s/p failed azithromycin course, concerning for PNA vs. bronchiectasis. #Dyspnea: Dyspnea persisted and mildly improved from admission by discharge. Negative EKG, CXR, enzymes, and essentially unchanged TTE made bronchiectasis the most likely etiology. Pt remained stable on room air, and on day of discharge pt. maintained an O2Sat of 95% on ambulation with minimal dyspnea on exertion. Pt was maintained with q4h duonebs and prednisone(40mg daily with begin taper to 20mg on day of discharge). #Lower extremity edema: Pt concerned for L>R increased LLE edema, venous ultrasound of LLE performed and was normal. #HTN: At discharge was normotensive, Atenolol changed to Metoprolol during stay.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Cymbalta / Prozac Attending: ___. Chief Complaint: malnutrition, severe anorexia Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ homeless man presenting with eating disorder. He has had multiple admissions for anorexia at ___ (most recently from ___ and ___. He reports progressive symptoms of fatigue, dyspnea with exertion, lightheadedness and presyncope when he has not eaten and his "sugar is low". He states he's had these symptoms over the course the past several weeks. He denies any symptoms currently. He has been attempting to increase his weight with protein bars and other high-calorie foods but has been unsuccessful. He admits to restricting and not having access to food. He is homeless and spends nights couch surfing or sleeping in libraries. Of note, he reports that he has a court date today for trespassing (sleeping in an appropriate area), states that missing persons report was filed for him by his father. In the ED, he denied suicidal ideation, auditory or visual hallucinations. He denies binging or purging. Of note, during his last ___ admission, his initial weight was 41.6 kg (91 lbs) and his discharge weight was 53.5 kg (117 lbs). During that admission, he failed multiple meals, occasionally needing an NG tube placement. He also had a pancytopenia with ANC 590 on admission. He had a negative infectious work-up was negative and his ANC improved. His course was also complicated by orthostatic hypotension. He also had a transaminitis which also improved with feeding. There was also an attempt to get a ___ certification to give the patient olanzapine which he had been refusing. He was discharged to a Behavioral ___ Facility ___ In the ED, initial vitals: T: 98.6 HR: 53 BP: 93/57 RR: 18 Sp02:100% RA Labs were significant for: - CBC: WBC 2.2 (ANC of 760, 53% lymphs) H/H 10.6/30.5, Platelets 137. -LFTS: ALT 74 AST 556, Amylase, 167, Lipase 177 - UA with trace protein. - Urine Culture pending Imaging showed: -___ CXR PA/LAT: FINDINGS: The lungs are clear without focal consolidation. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are unremarkable. IMPRESSION: No acute cardiopulmonary process. - EKG notable for sinus bradycardia (49 bpm), flat T wave in V1, Qtc 466 In the ED, he received nothing Vitals prior to transfer: HR: 49 BP: 90/47 RR: 12 Sp02: 98% RA Past Medical History: Malnutrition complicated by pancytopenia Anorexia nervosa Obsessive Compulsive Disorder Social History: ___ Family History: Paternal grandparents both with OCD; Grandmother with eating disorder-abused laxatives and diuretics; Brother with depression; ___ any family members with suicide attempts or addictions. No family h/o CAD/MI. Thyroid cancer (PGF), stomach cancer (uncle). Physical Exam: ADMISSION PHYSICAL EXAM: VS: 97.3 PO 99 / 62 L Sitting 50 18 100 RA Weight: 42.3 kg Gen: No acute distress, prefers to stand, cachectic HEENT: EOMI, PERRL, no LAD, moist mucus membranes CV: Bradycardia, no murmurs, rubs, gallops, 2+ peripheral pulses bilaterally Pulm: CTAB, no wheeze, rales, rhonchi Abd: NTTP, NBS GU: No foley in place Ext: Cold, mottling skin, compression stocking on with dry flaking skin under. No clear edema. Skin: Very pale, no bruises on chest or back. Neuro: CN II-XII intact, ___ strength bilateral upper and lower extremities. Psych: Pleasant and cooperative. DISCHARGE EXAM: Vitals: 97.8 PO 98 / 64 73 18 99 RA Weight: 52.43 kg General: Thin man in no distress, ambulating around his room. HEENT: sclera anicteric, MMM COR: RRR, no murmurs Lungs: CTAB ABD: soft, nontender, nondistended Ext: No cyanosis, stable 1+ lower extremity edema extending to the knee, TEDs in place Neuro: CNs2-12 intact, motor function grossly normal Pertinent Results: Admission labs --------------- ___ 06:30AM BLOOD WBC-2.2* RBC-3.47* Hgb-10.3* Hct-30.5* MCV-88# MCH-29.7 MCHC-33.8 RDW-17.2* RDWSD-54.2* Plt ___ ___ 06:30AM BLOOD Neuts-34.5 Lymphs-53.2* Monos-10.9 Eos-0.9* Baso-0.0 Im ___ AbsNeut-0.76*# AbsLymp-1.17* AbsMono-0.24 AbsEos-0.02* AbsBaso-0.00* ___ 06:30AM BLOOD Glucose-83 UreaN-41* Creat-0.5 Na-141 K-3.5 Cl-103 HCO3-23 AnGap-19 ___ 06:30AM BLOOD ALT-74* AST-56* AlkPhos-96 Amylase-167* TotBili-0.3 Pertinent labs ---------------- ___ 06:32AM BLOOD VitB12-1247* Folate-12 ___ 06:30AM BLOOD TSH-2.2 ___ 06:32AM BLOOD 25VitD-20* Studies: ------------- ___ CXR FINDINGS: The lungs are clear without focal consolidation. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are unremarkable. IMPRESSION: No acute cardiopulmonary process. Discharge labs ---------------- ___ 08:40AM BLOOD WBC-2.5* RBC-3.48*# Hgb-10.5*# Hct-33.3*# MCV-96 MCH-30.2 MCHC-31.5* RDW-18.8* RDWSD-66.5* Plt ___ ___ 08:40AM BLOOD Glucose-82 UreaN-30* Creat-0.5 Na-141 K-4.6 Cl-100 HCO3-26 AnGap-20 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. FLUoxetine 20 mg PO DAILY RX *fluoxetine 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Multivitamins W/minerals 1 TAB PO DAILY RX *multivitamin,tx-minerals 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Thiamine 100 mg PO DAILY RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Pancytopenia bradycardia Anorexia nervosa 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 eating d/o // Eval for acute process TECHNIQUE: Chest: Frontal and Lateral COMPARISON: Chest radiograph on ___ FINDINGS: The lungs are clear without focal consolidation. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are unremarkable. IMPRESSION: No acute cardiopulmonary process. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Anorexia Diagnosed with Anorexia nervosa, unspecified temperature: 98.6 heartrate: 53.0 resprate: 18.0 o2sat: 100.0 sbp: 93.0 dbp: 57.0 level of pain: 0 level of acuity: 2.0

Mr. ___ is a ___ year old man with a history of anorexia nervosa who presents with dyspnea on exertion, lightheadedness, and presycnopal symptoms and has had a course complicated by electrolyte deficiencies, bradycardia, and pancytopenia. Now gaining weight and medically stable for discharge to eating disorder program. # Anorexia nervosa: Patient presented to ED with symptoms of weakness and DOE requesting admission for management of eating disorder. He has had multiple previous admission. He was found to be pancytopenic and bradycardic on admission, which was consistent with previous admissions. His admission weight was 94 lbs (IBW is 144). He was started on eating disorder protocol and generally did well with it. At discharge his weight is 115.6 lbs (52.4 kg). Psychiatry was involved with his care and started him on fluoxetine. He was told that if he refused the medication that they will file for ___ guardianship for his father, and was willing to take fluoxetine after that point. # Right arm cellulitis: from IV site, completed 1 week course of clinda with resolution of infection. # Cytopenias: From malnutrition. Consistent previous. Improving at discahrge. His discharge Hb was 10.5. #Court Date: Noted to have a court-date for trespassing on the date of admission ___. SW sent a letter to the court explaining the circumstances. This was rescheduled to ___.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Pre-syncope, nausea, vomiting Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ male psychiatrist with hx CAD s/p MI in ___ s/p 3V CABG, C diff colitis in ___, who presented with acute onset lightheadedness, nausea, vomiting, and diaphoresis. At approximately 3:30 ___ on ___, he was seeing patients at ___ when the patient had sudden onset of dizziness, diaphoresis, nausea, and NBNB emesis. This episode happened after seeing a difficult patient in clinic. He put his head down on the table and felt that the world went sideways. He denied any chest pain or shortness of breath during the acute onset or currently when seen. He also endorsed a frontal mild headache. He reported chronic tension headaches, though this one feels somewhat different. He reported history of typical migraines as a child. He denied abdominal pan, fevers, chills, cough, diarrhea, constipation. His wife had previous URI/ILI but now doing ok. Per PCP, he has not had cardiac complaints over the last year. In the ED, initial vital signs were: 96.0 52 122/74 16 98% RA - Labs were notable for: WBC 11.9 (84N), Hgb 14.5, plt 183 Lactate:1.3 Trop <0.01 BNP 170 LFTs nml - CXR showed no acute cardiopulmonary process - The patient was given: ___ 18:45 IV Ondansetron 4 mg ___ 18:45 IVF 1000 mL NS Started 125 mL/hr ___ 21:18 IV Metoclopramide 10 mg ___ 21:18 PO/NG DiphenhydrAMINE 25 mg He was seen by Dr. ___ in the ED). He was admitted to medicine for observation. Vitals prior to transfer were: 98.1 56 115/65 22 98% RA Upon arrival to the floor, patient endorsed continued nausea, though somewhat improved. He is tolerating PO water and crackers. Persistent mild to moderate headache in the forehead/retroorbital region. Past Medical History: - C diff colitis diagnosed ___ and treated with 2 weeks of flagyl - CAD s/p MI in ___ - Hypercholesterolemia - Polymyalgia rheumatica - Recurrent sinusitis - Cubital fossa syndrome on left side with residual tingling in left ___ and ___ digits - Injury to the left knee with resulting atrophy of muscles in the ___ - s/p L4-L5 herniated disc - s/p ruptured Achilles tendon - Herniorrhaphy (several) - CABG - 3V CABG with one arterial and two grafts (Left internal mammary artery bypassed to the left anterior descending; sequential aorta coronary saphenous vein bypass graft to the second and third obtuse marginal arteries) - s/p appendectomy Social History: ___ Family History: Mother died of colon cancer. Father and brother MI, both at age ___. Sister and his three children are in good health. Physical Exam: PHYSICAL EXAMINATION ON ADMISSION: ================================== VITALS: 98.7 118/68 60 18 100(1L) GENERAL: Pleasant, appears uncomfortable, lying in bed holding emesis basin. HEENT - normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear. NECK: Supple, no LAD, no thyromegaly, JVP flat. CARDIAC: Bradycardic RRR, normal S1/S2, no murmurs rubs or gallops. PULMONARY: Clear to auscultation bilaterally, without wheezes or rhonchi. ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, no organomegaly. EXTREMITIES: Warm, well-perfused. Trace edema bilaterally. SKIN: Without rash. NEUROLOGIC: A&Ox3, CN II-XII normal, normal sensation, with strength ___ throughout, coordination within normal of limits. PHYSICAL EXAMINATION ON DISCHARGE: ================================== VITALS: 98.5 120/68 60 18 100% RA GENERAL: Pleasant, appears uncomfortable, lying in bed holding emesis basin. HEENT - normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear. NECK: Supple, no LAD, no thyromegaly, JVP flat. CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops. PULMONARY: Clear to auscultation bilaterally, without wheezes or rhonchi. ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, no organomegaly. EXTREMITIES: Warm, well-perfused. Trace edema bilaterally. SKIN: Without rash. NEUROLOGIC: A&Ox3, CN II-XII normal, normal sensation, with strength ___ throughout, coordination within normal of limits. Pertinent Results: LABS ON ADMISSION: ================== ___ 06:45PM BLOOD WBC-11.9*# RBC-4.81 Hgb-14.5 Hct-42.6 MCV-89 MCH-30.1 MCHC-34.0 RDW-13.1 RDWSD-42.3 Plt ___ ___ 06:45PM BLOOD Neuts-83.7* Lymphs-8.3* Monos-6.4 Eos-0.9* Baso-0.3 Im ___ AbsNeut-9.92* AbsLymp-0.99* AbsMono-0.76 AbsEos-0.11 AbsBaso-0.03 ___ 06:45PM BLOOD ___ PTT-34.5 ___ ___ 06:45PM BLOOD Plt ___ ___ 06:45PM BLOOD Glucose-111* UreaN-23* Creat-1.0 Na-140 K-4.5 Cl-104 HCO3-25 AnGap-16 ___ 06:45PM BLOOD ALT-20 AST-22 LD(LDH)-178 CK(CPK)-92 AlkPhos-71 TotBili-0.3 ___ 06:45PM BLOOD CK-MB-5 cTropnT-<0.01 proBNP-170 ___ 06:45PM BLOOD Albumin-4.2 Calcium-9.4 Phos-2.7 Mg-1.8 ___ 06:55PM BLOOD Lactate-1.3 LABS ON DISCHARGE: ================== ___ 06:45AM BLOOD WBC-6.0 RBC-4.39* Hgb-13.2* Hct-39.6* MCV-90 MCH-30.1 MCHC-33.3 RDW-13.3 RDWSD-43.5 Plt ___ ___ 06:45AM BLOOD Plt ___ ___ 06:45AM BLOOD Glucose-75 UreaN-19 Creat-1.0 Na-144 K-4.0 Cl-107 HCO3-28 AnGap-13 ___ 06:45AM BLOOD CK-MB-5 cTropnT-<0.01 ___ 06:45AM BLOOD Calcium-8.8 Phos-3.6 Mg-1.8 ___ CXR: No acute cardiopulmonary process ___ CT HEAD WITHOUT CONTRAST: No acute intracranial process. Of note MRI would be more sensitive for detection of acute ischemia EKG: Sinus rhythm, rate 47. PR 253. QTC 449. New complete RBBB, old inferoposterior MI. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Rosuvastatin Calcium 20 mg PO QPM 3. Metoprolol Succinate XL 25 mg PO DAILY 4. Enalapril Maleate 2.5 mg PO DAILY 5. Zolpidem Tartrate ___ mg PO QHS Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Enalapril Maleate 2.5 mg PO DAILY 3. Rosuvastatin Calcium 20 mg PO QPM 4. Zolpidem Tartrate ___ mg PO QHS Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: Vasovagal episode Sinus bradycardia SECONDARY DIAGNOSES: CAD Insomnia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with CAD s/p CABG with acute onset nausea, vomiting, diaphoresis and bradycardia with new O2 requirement // eval for infiltrate, effusion, edema TECHNIQUE: Single portable view of the chest. COMPARISON: ___. FINDINGS: Lower lung volumes seen on the current exam with secondary bibasilar atelectasis. Superiorly, the lungs are clear and there is no edema. Tortuous course of the thoracic aorta, particularly at the arch is similar to prior. Median sternotomy wires and mediastinal clips are again noted. Cardiac silhouette is within normal limits. No acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with history of CAD now with sudden onset nausea and vertigo. Evaluate for acute intracranial hemorrhage or large territorial infarct. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 16.5 cm; CTDIvol = 48.8 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: ___ noncontrast brain MRI. FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. There is prominence of the ventricles and sulci suggestive of involutional changes. There is no evidence of fracture. There is an approximately 9 (AP) x 15 (TV) x 15 (SI) mm right occipital calvarium well-circumscribed lesion with sclerotic margin and approximately 3.1 mm central lucency, with no evidence of cortical breakthrough and no evidence of associated soft tissue mass (see 3: 27- 33, 601b:99, 602b:40 ). Allowing for difference in technique, this lesion is grossly stable compared to the ___ prior MRI (see 03:37 02:11 5:77 on prior MRI). The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. No acute intracranial abnormality. 2. Please note MRI of the brain is more sensitive for the detection of acute infarct. 3. Probable right occipital calvarial osteoid osteoma, grossly stable compared to ___ prior brain MRI as described. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Dizziness, Lightheaded, Vomiting Diagnosed with Nausea with vomiting, unspecified temperature: 96.0 heartrate: 52.0 resprate: 16.0 o2sat: 98.0 sbp: 122.0 dbp: 74.0 level of pain: 0 level of acuity: 2.0

___ with history of CAD s/p MI in ___ s/p ___ CABG who presented with sudden onset of lightheadedness, headache, and nausea/vomiting, highly suggestive of a vasovagal episode. # Lightheadedness: The sudden onset of lightheadedness, headache, and nausea/vomiting in context of bradycardia was suggestive of a high vagal tone. He has a history of migraines with vomiting, though this has not happened for many years. CT head without contrast did not show any intracranial bleed. His symptoms improved without any intervention. He was able to ambulate without difficulty on the day of discharge. # Bradycardia: He had a few episodes of HR in the ___, and was mostly in the ___. Bradycardia was likely secondary to nausea/vomiting with vagal response as above, however may have underlying conduction disease as he was found to have 1st degree AV block and RBBB (present also on an ECG done by his PCP ___ ___. Troponins were negative x2. We held metoprolol after discussion with primary cardiologist. # CAD: We continued aspirin 81mg, crestor 20 mg QHS, and enalapril. We held metoprolol succinate ER 25 mg given new bradycardia. # Insomnia: We continued Zolpidem ___ QHS PRN. ***TRANSITIONAL ISSUES:*** - We stopped metoprolol due to bradycardia (HR mostly around 50, but a few episodes in the ___, consider restarting the metoprolol if patient experiences angina - Monitor for recurrence of symptoms of high vagal tone (nausea, vomiting, lightheadedness) # CONTACT: ___ (wife) ___ # CODE STATUS: Full confirmed

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: headache and transient R facial droop Major Surgical or Invasive Procedure: Lumbar Puncture History of Present Illness: Mr. ___ is a ___ year old right-handed man who presents with thunderclap headache four times in past week, associated with coitus or exertion, and transient R facial droop. The patient typically has only very rare and "normal" mild headaches that resolve with OTC medications. He had acute onset of thunderclap worst headache of life 8 days prior to presentation during sexual intercourse, before orgasm. The headache was a pinpoint of ___ sharp pain above right eye that spread over the same area, it was maximal intensity at onset, associated with nausea. No other associated symptoms or neuro deficits (no vision changes, no vertigo, no sensory changes or focal weakness, no language deficits). The pain lasted severely for 30 minutes then gradually decreased in intensity to ___. It remained as a dull, pressure headache in the R frontal area, persisted constantly before a couple of days until the next severe headache. The next severe headache occurred a couple of days later, in the same situation, and was the same quality, location, and intensity, again with no other associated symptoms. It lasted longer this time, about 2 hours, and again dulled slowly. The next severe headache occured 3 days prior to presentation. This time, it occurred just at the beginning of sexual activity (earlier than prior episodes). The headache again started above the R eye, but this time spread over the area above and behind the L eye. There was more nausea, and pain lasted even longer, about 3 to 4 hours. The pain diminished as in prior episodes, but was ___ and moderately uncomfortable. He had difficulty sleeping, and it hurt to lie on right side of his head. Today, at 3pm, the patient was bending over cleaning tires when another severe headache began suddenly. This was located above and behind both eyes, and was the worst yet in intensity. He vomited within 30 seconds of pain onset. For the first time he had photophobia. He was able to drive himself to OSH ED, but noticed his R face looked different when he glanced in rearview mirror. He described that the R eye and corner of mouth looked to be drooping downward. There may have been ptosis. No R arm/hand symptoms. Pt drove to ___. Facial weakness is not reported in ED notes. Pt does not know how long it lasted. CT was negative, pt initially refused LP. He was transferred for imaging and neuro eval. On arrival to ___, he had no focal neuro deficits. LP had 3 WBC, 0 RBC, opening pressure was 28 with legs bent and closing pressure was 21 with legs bent. Pt has been afebrile. Of note, pt c/o neck stiffness since the first bad headache. He is able to turn neck, and denies neck pain. Past Medical History: - past alcohol abuse, sober since ___ when he attended detox program Social History: ___ Family History: paternal uncle had cerebral aneurysm, mother has phlebitis, no h/o stroke, migraine. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 98.2 P:80 R: 16 BP:163/112 SaO2:100/RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx, no tenderness to palpation of posterior neck Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Speech was not dysarthric. Able to follow both midline and appendicular commands. 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 3 to 2mm and brisk. VFF to confrontation. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Normal saccades. No diplopia. V: Facial sensation intact to light touch, pinprick. VII: No facial droop, upper and lower facial musculature full strength and symmetric. No ptosis. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline with normal quick lateral movements. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, proprioception throughout. No extinction to DSS. Intact cortical sensory modalities (graphethesia, topognosis) -DTRs: brisk throughout, no Hoffmans or clonus. Bi Tri ___ Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was mute bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: deferred given just post-LP DISCHARGE PHYSICAL EXAM: Vitals: T: 98.6 P:80's R: 16 BP:140-150's/80's SaO2:100/RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx, no tenderness to palpation of posterior neck Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Speech was not dysarthric. Able to follow both midline and appendicular commands. 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 3 to 2mm and brisk. VFF to confrontation. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Normal saccades. No diplopia. V: Facial sensation intact to light touch, pinprick. VII: No facial droop, upper and lower facial musculature full strength and symmetric. No ptosis. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline with normal quick lateral movements. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, proprioception throughout. No extinction to DSS. Intact cortical sensory modalities (graphethesia, topognosis) -DTRs: brisk throughout, no Hoffmans or clonus. Bi Tri ___ Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was mute bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: good initiation, narrow based, good arm swing, Romberg negative, Pertinent Results: ADMISSION LABS: ___ 07:00PM BLOOD WBC-8.2 RBC-5.15 Hgb-16.2 Hct-48.3 MCV-94 MCH-31.4 MCHC-33.4 RDW-14.2 Plt ___ ___ 07:00PM BLOOD Neuts-82.7* Lymphs-12.5* Monos-2.8 Eos-1.5 Baso-0.5 ___ 07:00PM BLOOD Glucose-139* UreaN-17 Creat-1.1 Na-139 K-4.4 Cl-103 HCO3-24 AnGap-16 DISCHARGE LABS - not done given that patient's exam was normal REPORTS: CTA HEAD AND NECK ___: PRELIM IMPRESSION: 1. No acute intracranial abnormality. 2. CTA of the head and neck shows no flow-limiting stenosis, occlusion, or aneurysm formation. MRV ___: PRELIM IMPRESSION: Limited MR venogram images demonstrating normal dural venous sinuses without evidence of venous sinus thrombosis. Medications on Admission: None Discharge Medications: 1. verapamil 240 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. Disp:*30 Tablet Extended Rel 24 hr(s)* Refills:*6* 2. indomethacin 25 mg Capsule Sig: One (1) Capsule PO once a day as needed for ___ minutes prior to sexual activity. Disp:*20 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Coital Headaches Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ man with headache, persistent after medical treatment. COMPARISON: CTA of the head and neck, ___. TECHNIQUE: Time-of-flight MR venogram images of the head were obtained with multiplanar reformats. FINDINGS: The superior and inferior sagittal, straight, bilateral transverse and sigmoid sinuses and proximal internal jugular veins demonstrate normal flow-signal. Left transverse sinus is mildly hypoplastic. The principal deep cerebral veins demonstrate normal flow-signal. IMPRESSION: Limited MR venogram images demonstrating normal dural venous sinuses without evidence of cerebral venous thrombosis. N.B. This study adds little to the recent cranial CTA, which demonstrated patent majory dural venous sinuses and deep cerebral veins. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: H/A X 1 WEEK Diagnosed with HEADACHE, FACIAL WEAKNESS temperature: 98.2 heartrate: 80.0 resprate: 20.0 o2sat: 100.0 sbp: 163.0 dbp: 112.0 level of pain: 8 level of acuity: 2.0

___ yo RHM with PMHx of alcohol abuse, now sober who presents with thunderclap headache four times in week PTA, associated with coitus or exertion, and possible transient R facial droop. His CTA and LP were reassuring with regards to an aneurysm. He was admitted for further workup and treatment of his headache. . # NEURO: We got an MRV while he was here to ensure that he did not have a venous clot, and this was also negative. We started him on verapamil 80mg TID while here, and he was discharged on 240mg ER QD. We treated his headache with toradol, compazine and valium with some effect, but by the day of discharge he was much improved with just the verapamil. We also sent him home with indomethacin to use prior to sexual activity to prevent the onset of further coital headaches. . # CARDS: Patient's BP was elevated to the 150-160/80's while he was here. This improved to an SBP in the 140's with verapamil. He may require further antihypertensive medications in the future if his BP continues to be so elevated.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Univasc / Amlodipine / Norvasc / Cromolyn Attending: ___. Chief Complaint: LLE wound bleeding Major Surgical or Invasive Procedure: NONE History of Present Illness: ___ with refractory asthma, AVR with mechanical prosthesis on enoxaparin, CHF, HTN, T2DM who presents with bleeding from chronic wound ___ to non-uremic calciphylaxsis. Patient reports that she was in her USOH until yesterday evening when she began having bleeding from her L leg lesion. She denies trauma to the area and reports this degree of bleeding had not occured before. She wrapped the wound but the bleeding did not stop. She decided early this AM to come into the emergency department. In the ED, initial vital signs were 97.6 103 134/76 16 100%. Her initial evaluation was notable for the following: - Exam: ___ ulcer with pungent smell and ? purulent drainage. - Labs: CBC with WBC 14 (84% pmns), Hgb 8.9 (baseline Hgb ___ chemistry unremarkable, lactate normal. - Studies: XR L distal extremity without e/o osteomyelitis. - Interventions: vancomycin 1g - Consults: none Decision was made to admit to medicine for intravenous antibiotics and consideration of wound debridement. On transfer, VS were 98.1 93 130/66 16 99% RA. Upon arrival to the floor, the patient recounts the history above. Of note, the patient was admitted from ___ for painful necrotic lesions along her lower legs eventually diagnosed as a non-uremic calciphylaxsis. Malignancy workup with CT torso was unrevealing. Antiphospholipid antibodies returned negative. She recieved wound care and pain control. She was initiated on sodium thiosulfate infusions which were continued after discharge. In the interval since her discharge, the patient has been visited for wound care via ___ services and recieved 7 of 16 doses of sodium thiosulfate. Past Medical History: AVR with mechanical valve, on lovenox Diastolic heart failure Heart block with a pacemaker Hypertension Diabetes, longstanding, poorly controlled (last A1C 10.6) Obesity Asthma GERD Depression Hyperlipidemia Social History: ___ Family History: Significant for HTN in multiple family members. ___ cancer in two sister (dx at age ___). Brother deceased from ___. Physical Exam: ADMISSION: Vitals: 98.5 143/96 90 20 100%RA General: Obese woman laying in hospital bed HEENT: NCAT EOMI MMM Neck: supple, full ROM, no cervical LAD CV: RRR Mechanical S2 w/ systolic murmur Lungs: CTAB Abdomen: +BS soft NT/ND GU: No CVA tenderness Ext: No c/c/e. Large, open wound on left leg with dark circular area centrally surrounded by fibrinous tissue. Borders non-erythematous, no apparent discharge. Smaller, dark circular lesion just below on left leg and another with well healed scab along R thigh. Neuro: AAOx3 Skin: Per above, otherwise warm and dry. DISCHARGE: Vitals: 97.4 136/82 98 20 97%RA General: Obese woman laying in hospital bed HEENT: NCAT EOMI MMM Neck: supple, full ROM, no cervical LAD CV: RRR Mechanical S2 w/ systolic murmur Lungs: CTAB Abdomen: +BS soft NT/ND GU: No CVA tenderness Ext: No c/c/e. Large, open wound on left leg with dark circular area centrally surrounded by fibrinous tissue. Borders non-erythematous, no apparent discharge. Smaller, dark circular lesion just below on left leg and another with well healed scab along R thigh. Neuro: AAOx3 Skin: Per above, otherwise warm and dry Pertinent Results: ADMISSION: ___ 08:05AM BLOOD WBC-14.1* RBC-3.07* Hgb-8.9* Hct-25.5* MCV-83 MCH-28.9 MCHC-34.8 RDW-17.1* Plt ___ ___ 08:05AM BLOOD Neuts-83.6* Lymphs-11.7* Monos-4.2 Eos-0.4 Baso-0.2 ___ 08:05AM BLOOD ___ PTT-28.5 ___ ___ 08:05AM BLOOD Plt ___ ___ 08:05AM BLOOD Glucose-207* UreaN-25* Creat-1.1 Na-136 K-3.6 Cl-98 HCO3-25 AnGap-17 ___ 08:05AM BLOOD Calcium-9.2 Phos-3.5 Mg-1.5* ___ 08:11AM BLOOD Lactate-1.8 DISCHARGE: ___ 06:25AM BLOOD WBC-12.6* RBC-3.23* Hgb-9.0* Hct-27.0* MCV-83 MCH-27.9 MCHC-33.4 RDW-17.2* Plt ___ ___ 06:25AM BLOOD Plt ___ ___ 06:25AM BLOOD ___ PTT-32.9 ___ ___ 06:25AM BLOOD Glucose-136* UreaN-21* Creat-1.1 Na-140 K-3.7 Cl-100 HCO3-29 AnGap-15 ___ 06:25AM BLOOD Calcium-9.1 Phos-4.7* Mg-2.9* ___ L Tib/fib AP IMPRESSION: No radiographic evidence for osteomyelitis. Large soft tissue defect involving the posteromedial proximal/mid leg. ___ CXR IMPRESSION: Right PICC terminates in mid SVC. No radiographic evidence of pneumonia. Radiology Report INDICATION: History: ___ with infected wound to left lower leg. TECHNIQUE: Left tibia and fibula, two views COMPARISON: ___ FINDINGS: Large soft tissue defect is seen involving the medial and posterior aspect of the left leg at the level of the proximal/ mid tibia. No subcutaneous gas or radiopaque foreign body is present. No osseous destruction or periosteal new bone formation is present. There is no acute fracture. Large plantar and dorsal calcaneal enthesophytes are noted. There diffuse vascular calcifications. Moderate degenerative changes are seen within the imaged knee with osteophytic spurring and subchondral sclerosis. No concerning lytic or sclerotic osseous abnormality is visualized. IMPRESSION: No radiographic evidence for osteomyelitis. Large soft tissue defect involving the posteromedial proximal/mid leg. Radiology Report INDICATION: ___ year old woman with PICC in place, recent leukocytosis // ?PICC Placement, ?acute intrapulmonary process EXAMINATION: CHEST (PORTABLE AP) TECHNIQUE: Portable Chest radiograph, frontal view COMPARISON: Chest radiograph ___ FINDINGS: Right PICC terminates in mid SVC. Left pectoral pacemaker has its leads terminating in right atrium and right ventricle. Cardiac silhouette is mildly enlarged. Prosthetic heart valve and median sternotomy wires are in unchanged position. There is no consolidation, pleural effusion, or pneumothorax. IMPRESSION: Right PICC terminates in mid SVC. No radiographic evidence of pneumonia. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Laceration Diagnosed with OTHER POST-OP INFECTION, ABN REACT-PROCEDURE NOS temperature: 97.6 heartrate: 103.0 resprate: 16.0 o2sat: 100.0 sbp: 134.0 dbp: 76.0 level of pain: 4 level of acuity: 3.0

___ with refractory asthma, AVR with mechanical prosthesis on enoxaparin, CHF, HTN, T2DM presented with bleeding from chronic wound ___ to non-uremic calciphylaxsis. Initial concern for infection and patient provided single dose of Vancomycin 1 g IV in ED, but examination made concern for superinfection less likely. Patient monitored overnight and remained without systemic or local signs of acute infection. Wound care evaluated patient and made new recommendations for care, which were translated to ___ services. Case discussed with primary care physican who was in agreement of plan and will ___ as outpatient. #LLE drainage Patient reports interval improvement in pain and exam without erythema or appearance of gross infection on arrival to floor. Treated for presumed superinfection of wound in ED. Without systemic signs of infection outside of mild leukocytosis in the setting of steroid use which is relatively decreased from last check. Patient maintained on bactrim prophylaxis at home. Given history of bleeding which ceded after hours, may have been a result of subtle trauma in the setting of anticoagulation. Repeat CBC in AM of hospital day 2 stable and patient had no further signs of infection. After discussion with outpatient provider, decided on no current need for further antibiotic treatment. Helped coordinate outpatient provider ___ with PCP. #Anemia Normocytic. Likely setting of acute blood loss from leg trauma. Repeat CBC in AM stable. CHRONIC ISSUES # Aortic valve replacement: cont enoxaparin 100 sc BID . We understood that this anticoagulant choice was made prior to hospitalization given possible issues with coumadin and her calciphylaxis. # Heart block: s/p PPM placement. sees ___ cardiology. no need for telemetry at present. # dCHF: cont torsemide 20/day, metoprolol # HTN: cont losartan # ASCVD: cont asa 81, atorva 20 # T2DM: hold metformin, glipizide; cont glargine 17u qhs; HISS # Asthma: continue home albuterol, budesonide-formoterol, montelukast; cont duoneb q6h prn. cont pred 20/day, cont tmp-smx ppx. # Chronic cough: cont benzonatate, guaifenesin # Allergies (nasal/ophthalmic): cont fluticasone, beclomethasone spray, cetirizine, ketotifen eye gtt, artificial tears # GERD: cont omeprazole, ondansetron for nausea # Depression/Anxiety: cont duloxetine, lorazepam # Pain: cont oxycodone 10 q12, cont hydromorphone 4mg q4-q6 prn for pain not controlled by oxycodone TRANSITIONAL ISSUES -Anticoagulation: patient placed on lovenox given concern for warfarin-associated worsening of skin changes, however, shots have caused brusing skin changes. Ongoing discussion between PCP, cardiology regarding choice of anticoagulation for AVR. Patient and daughter to obtain second opinion from hematology/oncology this coming ___. # Code Status: Full code (confirmed) # Emergency Contact: daughter/HCP ___ ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: nausea, vomiting, diarrhea Major Surgical or Invasive Procedure: none History of Present Illness: ___ pmhx of hypothyroid, HTN, GERD, recent diagnosis of GBS iso PNA s/p plex and IVIG who presents from rehab with new fever, nausea, abd pain and worsening of his ascending weakness. Admitted ___ with ascending weakness and sensory loss s/p 5x IVIG treatments. He was stabilized and discharged to rehab. At rehab he was doing well making progress with walker and abilty to ambulate until ___. But therafter starting ___ he has regressed in his strength. On the day of presentation to ED he said he started to feel warm and unwell. Reports diarrhea, n/v, but otherwise denies HA, photophobia, neck rigidity. He was found to have fever of 103 and transferred to the ED. In the ED, initial vitals were: 103.9, HR 137, 139/83, 16, 98% RA Exam notable for: - decreased ___ strength compared to discharge Labs notable for: - leukocytosis - lactate 4.9 -> 2.1 with IVF - clean U/A, flu neg Patient Given: - IV abx for prelim diverticulitis read, but overread without - IVF - Home medications Neurology was consulted who agreed there was increased weakness in comparison to discharge. Will follow and reassess as infection is stabilized the role of IVIG. Vitals on Transfer: 98.8, 98, 126/82, 15, 96% RA On the floor, he confirms the above history. He says that he has 1 day of feeling unwell, 2 episodes of diarrhea day prior to presentation, nothing since. Nausea, 1 episode vomiting of yellow fluids but nothing since. Has residual mild diffuse/suprapubic abdominal discomfort. No prandial nature. Past Medical History: HTN GERD Hypothyroidism - GBS iso PNA Social History: ___ Family History: No known family history of neurologic disease. No known family history of autoimmune disease, including T1DM, thyroid disease, RA, MS, lupus, IBD. Physical Exam: PHYSICAL EXAM: Vital Signs: 99.0, 148/77, 95, 18, 98% Ra GEN: Laying in bed, flat affect HEENT: Neck supple, MM tacky/dry CV: RRR nl s1/s2 no mrg PULM: CTA b/l GI: Obese, soft, ND, mild diffuse tenderness greatest suprapubic EXT: trace pitting edema to mid shin NEURO: B/l ___ weakness, ___, roughly equal/symmetric, decreased sensation b/l feet, unable to elicit extremity reflexes DISCHARGE PHYSICAL EXAM: 24 HR Data (last updated ___ @ 1038) Temp: 98.6 (Tm 99.7), BP: 129/79 (119-159/66-94), HR: 94 (91-98), RR: 18 (___), O2 sat: 96% (96-99), O2 delivery: Ra GEN: Laying in bed, comfortable, NAD HEENT: Neck supple, MMM CV: RRR nl s1/s2 no mrg PULM: CTA b/l GI: Obese, soft, ND, non-tender EXT: trace pitting edema to mid shin NEURO: ___ strength in upper extremities, CN II-XII intact, B/l ___ weakness, ___, roughly equal/symmetric, decreased sensation b/l feet to above the knee, unable to elicit extremity reflexes Pertinent Results: ADMISSION LABS: ============= ___ 04:57PM BLOOD WBC-13.3* RBC-5.51 Hgb-15.9 Hct-48.2 MCV-88 MCH-28.9 MCHC-33.0 RDW-13.3 RDWSD-42.6 Plt ___ ___ 04:57PM BLOOD Neuts-92.8* Lymphs-3.2* Monos-3.2* Eos-0.1* Baso-0.2 Im ___ AbsNeut-12.35* AbsLymp-0.43* AbsMono-0.43 AbsEos-0.01* AbsBaso-0.02 ___ 04:57PM BLOOD Glucose-127* UreaN-15 Creat-1.1 Na-139 K-5.3 Cl-100 HCO3-23 AnGap-16 ___ 04:57PM BLOOD ALT-16 AST-32 AlkPhos-116 TotBili-0.8 ___ 04:57PM BLOOD Albumin-3.8 Calcium-9.0 Phos-4.2 Mg-1.8 DISCHARGE LABS: ============== ___ 07:11AM BLOOD WBC-5.6 RBC-4.61 Hgb-13.2* Hct-41.1 MCV-89 MCH-28.6 MCHC-32.1 RDW-13.2 RDWSD-43.4 Plt ___ ___ 11:43AM BLOOD Neuts-76.7* Lymphs-13.6* Monos-9.0 Eos-0.0* Baso-0.2 Im ___ AbsNeut-4.34 AbsLymp-0.77* AbsMono-0.51 AbsEos-0.00* AbsBaso-0.01 ___ 07:11AM BLOOD Glucose-95 UreaN-16 Creat-0.9 Na-141 K-4.3 Cl-105 HCO3-25 AnGap-11 ___ 11:43AM BLOOD ALT-11 AST-12 LD(LDH)-103 AlkPhos-87 TotBili-0.6 ___ 07:11AM BLOOD Calcium-8.6 Phos-4.6* Mg-1.9 RELEVANT IMAGING: ================ ___ MRI IMPRESSION: 1. Unchanged faint enhancement of the cauda equina nerve roots, without thickening. 2. Unchanged degenerative changes of the lower lumbar spine. ___ CXR IMPRESSION: No acute cardiopulmonary process. No focal consolidation to suggest pneumonia. ___ CT abdomen IMPRESSION: 1. Fluid-filled non-dilated loops of small bowel, cecum and ascending colon, likely representing a viral gastroenteritis. No evidence of obstruction. The appendix is not visualized but there is no secondary sign of acute appendicitis. 2. Mild colonic diverticulosis without evidence of diverticulitis. 3. Hepatic steatosis. NOTIFICATION: The updated findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 8:18 am, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: MR ___ AND W/O CONTRAST T___ MR SPINE INDICATION: ___ year old man with recent diagnosis of GBS with new worsening of symptoms. Per discussion with neurology, would like to verify that there is no new pathology to explain weakness given unusual nature of recurring GBS so soon after prior insult// Would like lumbar-sacral spine MRI w w/o contrastQ: any new pathology to explain weakness TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique, followed by axial T2 imaging. This was followed by sagittal and axial T1 images obtained after the uneventful intravenous administration of Ga___ contrast agent. COMPARISON: MRI lumbar spine with and without contrast ___. FINDINGS: Although no thickening of the nerve roots is seen, faint enhancement is re-demonstrated (09:36), unchanged. There is mild retrolisthesis of L4-5. The bone marrow signal is within normal limits. The cord terminates at L1 and is unremarkable. Disc desiccation and loss of disc height are seen involving the lower lumbar spine. T11-T12: No spinal canal or foraminal narrowing. T12-L1: No spinal canal or foraminal narrowing. L1-L2: No spinal canal or foraminal narrowing. L2-L3: No spinal canal or foraminal narrowing. L3-L4: Mild disc bulge, bilateral facet osteophytes and effusions, thickening of the ligamentum flavum, no spinal canal narrowing, mild bilateral foraminal narrowing, unchanged. L4-L5: Disc bulge, thickening of the ligamentum flavum, bilateral facet osteophytes and effusions, no spinal canal narrowing, mild to moderate right and mild left foraminal narrowing, unchanged. L5-S1: Disc bulge, thickening of the ligamentum flavum, bilateral facet osteophytes, left facet effusion, no spinal canal narrowing, moderate bilateral foraminal narrowing, mass-effect on the exiting right L5 nerve root from facet, unchanged. IMPRESSION: 1. Unchanged faint enhancement of the cauda equina nerve roots, without thickening. 2. Unchanged degenerative changes of the lower lumbar spine. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Fever Diagnosed with Fever, unspecified temperature: 103.9 heartrate: 137.0 resprate: 16.0 o2sat: 98.0 sbp: 139.0 dbp: 83.0 level of pain: 0 level of acuity: 1.0

___ pmhx of hypothyroid, HTN, GERD, recent diagnosis of GBS iso PNA s/p plex and IVIG who presents from rehab with new fever, nausea, abd pain and worsening of his ascending weakness. #Norovirus Improved w/ 1 formed BM on ___. He was given supportive care and no antibiotics. # GBS Neurology re-evaluated on ___ felt that exam same or somewhat improved. No need for IVIG at this time. They checked in with Dr. ___ outpatient neurologist who agreed with the decision to not treat. # HTN - Home HCTZ -> DC and attempted low dose amlodipine 5mg - ok to allow some permissive hypertension likely in setting of some possible autonomic dysfunction w/ his GBS # Hypothyroidsim - Home levothyroxine # Dssesthesia and ___ - home Lyrica, gabapentin, nortriptyline

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: NONE History of Present Illness: ___ is a ___ year old female with history of hypothyroidism, HTN, prior Lyme disease (___), and recent orthopedic evaluation for severe right rotator cuff arthropathy with surgery planned for ___, who was brought to the ED after being found at a bus station, disoriented, clutching her head, and yellowing "oh god". Per the patient's son at bedside, ___ is in exceptionally good health at baseline. She lives independently in her own home on ___, still drives, and worked as a ___ until she retired ___ years ago. She has a history of recurrent headache and eye pain due to particles in her left artificial cornea. He spoke with her over the phone last night, and she appeared at her baseline, complaining of a headache but expressing no other concerns. She came to ___ via bus this morning in anticipation of reverse total right shoulder replacement scheduled for ___. She was found altered at the station, clutching her head and stating "oh god", so EMS was called, and she was brought to the ED. On arrival to the ED, she remained altered with eye closure, somnolence, arouses but is irritable, saying "two" and "get out of here", responds appropriately saying ___ to noxious stimuli. In the ED, initial vitals were: T 98, HR 90, BP 138/102, Sat 100% RA Exam notable for: Sleeping, arouses but keeps her eyes closed, does not answer questions, doesn't follow commands. Moving all four extremities spontaneously. Briskly withdraws to noxious stimuli and yells. Labs notable for: - WBC 8.3 - Na 122, Cr 0.6 - Serum osm 265 - Lactate 1.4 - UNa 100, Uosm 387 - UA neg leuks/nitrites, 10 ketones Imaging was notable for: - NCHCT: No acute vascular territorial infarction or intracranial hemorrhage. - CTA Head: Probable infundibula of b/l posterior communicating arteries, otherwise normal circle of ___ vasculature. Patent dural venous sinuses. - CTA Neck: Abrupt narrowing of right V2 segment of vertebral artery, most likely due to facet arthropathy. No e/o dissection. Moderate atherosclerotic calcification of aortic arch, great vessels, b/l ICA near bifurcation. No e/o stenosis or occlusion. - CXR: Ill-defined consolidation in the right midlung which could represent a focus of infection. No pleural effusion or pneumothorax. Consults: - Ophtho: Consulted given pt's h/o L eye HSV keratitis, to see if L eye pain could be contributing to her current AMS. On limited exam, no e/o infection, corneal abrasion, or intraocular infection. Sutures appear intact. They removed and washed her contact lens. - Neuro: presentation c/w global encephalopathy without focal features. Recommended cEEG while sodium is correcting. Further workup if mental status does not improve despite adequate sodium correction. Patient was given: - IV Lorazepam 2 mg - IV Haloperidol 5 mg - IV Morphine Sulfate 2 mg - IVF NS 1L - IV Ceftriaxone 1g LP was attempted, but unable to perform after multiple tries. Upon arrival to the floor, the patient's son endorsed the story above. The patient withdrew to sternal rub, but otherwise kept her eyes tightly closed and did not follow commands. ROS: Positive per HPI. Remaining 10 point ROS reviewed and negative Past Medical History: - Hypothyroidism - s/p corneal replacement - OA - significant R rotator cuff arthropathy Social History: ___ Family History: Not pertinent to presenting problem. Physical Exam: ADMISSION PHYSICAL EXAM: =========================== VITAL SIGNS: T 99.9, BP 142/70, HR 94, RR 18, Sat 94% RA GENERAL: Lying in bed with eyes tightly closed. HEENT: artificial left cornea. Pupils 1mm and faintly reactive. NECK: no nuchal rigidity CARDIAC: RRR. Normal S1 and S2. No murmurs. LUNGS: No increased work of breathing on RA. Exam limited due to poor inspiratory effort, but decreased breath sounds at bilateral bases. ABDOMEN: Soft, NTND. EXTREMITIES: WWP. No ___ edema. NEUROLOGIC: Somnolent, briefly arousing to sternal rub, not following commands. No visible facial droop. Moving all 4 extremities. SKIN: Scattered ecchymoses of anterior lower legs. DISCHARGE PHYSICAL EXAM: =========================== VITAL SIGNS: 24 HR Data (last updated ___ @ 551) Temp: 98.0 (Tm 98.1), BP: 151/80 (119-162/69-80), HR: 78 (78-85), RR: 18 (___), O2 sat: 96% (94-98), O2 delivery: Ra, Wt: 102.29 lb/46.4 kg GENERAL: Lying in bed, conversant, NAD. HEENT: artificial left cornea. Pupils 1mm and faintly reactive. NECK: no nuchal rigidity CARDIAC: RRR. Normal S1 and S2. No murmurs. LUNGS: No increased work of breathing on RA. Exam limited due to poor inspiratory effort, but decreased breath sounds at bilateral bases. ABDOMEN: Soft, NTND. EXTREMITIES: WWP. No ___ edema. NEUROLOGIC: Awake, AOx3, no focal neurologic deficits, moving all four extremities with purpose. SKIN: Scattered ecchymoses of anterior lower legs. Pertinent Results: ADMISSION LABS: ================= ___ 02:34PM BLOOD WBC-8.3 RBC-4.20 Hgb-12.8 Hct-37.1 MCV-88 MCH-30.5 MCHC-34.5 RDW-12.6 RDWSD-40.9 Plt ___ ___ 02:34PM BLOOD Neuts-85.6* Lymphs-10.9* Monos-2.8* Eos-0.0* Baso-0.2 Im ___ AbsNeut-7.08* AbsLymp-0.90* AbsMono-0.23 AbsEos-0.00* AbsBaso-0.02 ___ 02:34PM BLOOD Glucose-126* UreaN-9 Creat-0.6 Na-122* K-3.9 Cl-82* HCO3-24 AnGap-16 ___ 02:34PM BLOOD ALT-12 AST-21 AlkPhos-73 TotBili-0.6 ___ 02:34PM BLOOD Lipase-17 ___ 02:34PM BLOOD cTropnT-<0.01 ___ 02:34PM BLOOD Albumin-4.5 Calcium-9.0 Phos-2.7 Mg-1.7 ___ 02:34PM BLOOD Osmolal-265* PERTINENT/DISCHARGE LABS: ======================== ___ 09:30AM BLOOD WBC-7.5 RBC-4.07 Hgb-12.5 Hct-36.4 MCV-89 MCH-30.7 MCHC-34.3 RDW-13.3 RDWSD-43.7 Plt ___ ___ 06:38PM BLOOD Glucose-111* UreaN-8 Creat-0.6 Na-124* K-6.4* Cl-88* HCO3-23 AnGap-13 ___ 11:00PM BLOOD Glucose-106* UreaN-9 Creat-0.6 Na-128* K-3.4* Cl-91* HCO3-23 AnGap-14 ___ 09:30AM BLOOD Glucose-122* UreaN-15 Creat-0.9 Na-129* K-3.5 Cl-94* HCO3-21* AnGap-14 ___ 07:30AM BLOOD Glucose-96 UreaN-13 Creat-0.6 Na-135 K-3.7 Cl-96 HCO3-24 AnGap-15 ___ 06:38PM BLOOD TSH-1.5 IMAGING/RESULTS: ================== EEG ___: IMPRESSION: This is an abnormal continuous EEG monitoring study because of diffuse background slowing with occasional triphasic appearing waveforms consistent with a mild encephalopathy. This finding is nonspecific in regards to etiology but can be seen in the setting of metabolic derangements such as this clinical setting. It can also be seen in the setting of infection, anoxia, and toxic/medication effect. There is also excessive beta activity, which can be seen in the setting of medication effect, such as benzodiazepenes. There are no areas of prominent focal slowing, no definite epileptiform-appearing discharges, no electrographic seizures, and no pushbutton activations. CT HEAD W/O CONTRAST ___: IMPRESSION: 1. No acute vascular territorial infarction or intracranial hemorrhage. CTA HEAD AND NECK ___: IMPRESSION: 1. Small infundibula of the bilateral posterior communicating arteries, at the intersection with the internal carotid arteries. Otherwise, no evidence of stenosis, occlusion, or aneurysm of the intracranial arteries. Patent dural venous sinuses. 2. An abrupt, focal narrowing of the right V2 segment of the vertebral artery is most likely due to facet arthropathy. No evidence of dissection. Otherwise, no evidence of stenosis or occlusion of the bilateral carotid and vertebral arteries. CXR ___: IMPRESSION: Suspected right lower lung pneumonia. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 50 mcg PO DAILY 2. losartan-hydrochlorothiazide 50-12.5 mg oral daily 3. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID 4. Timolol Maleate 0.5% 1 DROP LEFT EYE BID 5. moxifloxacin 0.5 % ophthalmic (eye) QID Discharge Medications: 1. Azithromycin 250 mg PO DAILY Duration: 3 Doses RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*2 Tablet Refills:*0 2. Cefpodoxime Proxetil 400 mg PO Q12H RX *cefpodoxime 200 mg 2 tablet(s) by mouth every twelve (12) hours Disp #*12 Tablet Refills:*0 RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp #*8 Tablet Refills:*0 3. Levothyroxine Sodium 50 mcg PO DAILY 4. moxifloxacin 0.5 % ophthalmic (eye) QID 5. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID 6. Timolol Maleate 0.5% 1 DROP LEFT EYE BID 7. HELD- losartan-hydrochlorothiazide 50-12.5 mg oral daily This medication was held. Do not restart losartan-hydrochlorothiazide until you see your doctor Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES: Hyponatremia Altered mental status Community acquired pneumonia Headache SECONDARY DIAGNOSES: Hypertension Hypothyroidism Right rotator cuff arthropathy Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ with confusion, severe headache, hypertension// please evaluate for intracranial hemorrhage TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 802.7 mGy-cm. 2) Sequenced Acquisition 4.0 s, 4.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 200.7 mGy-cm. Total DLP (Head) = 1,003 mGy-cm. COMPARISON: None. FINDINGS: There is no evidence of acute large vascular territorial infarction,hemorrhage,edema, or mass. Periventricular and subcortical white matter hypodensities are nonspecific, likely related to small vessel ischemic disease in a patient of this age. There is prominence of the ventricles and sulci suggestive of involutional changes. Calcifications are seen along bilateral carotid siphons. There is no evidence of fracture. There is mild mucosal thickening of the ethmoid air cells. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits show bilateral lens replacement. A metallic structure is seen along the anterior left globe, likely postsurgical. IMPRESSION: 1. No acute vascular territorial infarction or intracranial hemorrhage. Radiology Report EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK INDICATION: ___ with altered mental status. Evaluate for stroke, bleed, aneurysm or dissection. TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 54.5 mGy (Head) DLP = 27.2 mGy-cm. 2) Spiral Acquisition 4.9 s, 38.4 cm; CTDIvol = 30.9 mGy (Head) DLP = 1,186.3 mGy-cm. 3) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 49.0 mGy (Head) DLP = 24.5 mGy-cm. 4) Stationary Acquisition 6.5 s, 0.5 cm; CTDIvol = 70.8 mGy (Head) DLP = 35.4 mGy-cm. 5) Spiral Acquisition 3.2 s, 25.5 cm; CTDIvol = 30.4 mGy (Head) DLP = 774.1 mGy-cm. Total DLP (Head) = 2,048 mGy-cm. COMPARISON: Head CT ___. FINDINGS: CTA HEAD: Small infundibula of the bilateral posterior communicating arteries, at the intersection with the internal carotid arteries. Otherwise, the vessels of the circle of ___ and their principal intracranial branches appear normal without stenosis, occlusion oraneurysm greater than 3 mm. The dural venous sinuses are patent. CTA NECK: An abrupt, focal narrowing of the right V2 segment of the vertebral artery (2:137) is most likely due to facet arthropathy. No evidence of dissection. Otherwise, the carotid and vertebral arteries and their major branches appear normal with no evidence of stenosisorocclusion. Moderate atherosclerotic calcification of the aortic arch and great vessels. Moderate atherosclerotic calcification of the bilateral internal carotid arteries, near the bifurcation. OTHER: The visualized portion of the lungs are clear. The visualized portion of the thyroid gland is within normal limits. There is no lymphadenopathy by CT size criteria. IMPRESSION: 1. Small infundibula of the bilateral posterior communicating arteries, at the intersection with the internal carotid arteries. Otherwise, no evidence of stenosis, occlusion, or aneurysm of the intracranial arteries. Patent dural venous sinuses. 2. An abrupt, focal narrowing of the right V2 segment of the vertebral artery is most likely due to facet arthropathy. No evidence of dissection. Otherwise, no evidence of stenosis or occlusion of the bilateral carotid and vertebral arteries. Radiology Report INDICATION: History: ___ with altered mental state s, cough// Pneumonia TECHNIQUE: AP portable chest radiograph COMPARISON: None FINDINGS: There is an ill-defined consolidation in the right midlung which could represent a focus of infection. No pleural effusion or pneumothorax identified. The size of the cardiac silhouette is within normal limits. Tortuosity of the thoracic aorta as well as thoracic aortic calcification are present. IMPRESSION: Suspected right lower lung pneumonia. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Altered mental status Diagnosed with Altered mental status, unspecified temperature: 98.0 heartrate: 90.0 resprate: 16.0 o2sat: 100.0 sbp: 138.0 dbp: 102.0 level of pain: uta level of acuity: 1.0

Ms. ___ is a ___ with h/o hypothyroidism and severe right rotator cuff arthropathy who presented with AMS and headache and found to have hyponatremia to 122 and right lower lobe lung infiltrate c/f PNA. # Altered mental status Per son, patient functional at baseline, living alone and independent in all IADLs. Patient presented to the ED with new altered mental status. Work up with CT head and EEG without any abnormalities. CTA of the head/neck with small infundibula of the bilateral posterior communicating arteries, at the intersection with the internal carotid arteries and an abrupt, focal narrowing of the right V2 segment of the vertebral arteyr, most likely due to facet arthropathy. No evidence of dissection. She was evaluated by neurology who did not feel this explained her symptoms. Etiology was felt to be related to hyponatremia and pneumonia. Her mental status has improved with correction of sodium. However, there were still concerns about her ability to care for herself at home. OT was consulted and performed MOCA where she scored ___. It was recommended that patient be discharged with 24 hour care. Plan to discharge her to live with her son. # Hyponatremia Patient presented with Na of 122, down from 136 five days prior. The etiology of this is most likely SIADH given UNa > 100 and UOsm > 300. SIADH is likely being driven by RLL consolidation given normal TSH. Possible component of hypovolemia as patient also received 1L NS in ED. Patient was placed on 1.5L fluid restriction and her Na trended upward with treatment of pneumonia. Her mental status improved with resolution of hyponatremia. Her discharge Na is 135. She should have a repeat BMP with ___ this week. TSH was 1.5. Cortisol was 7.1 but difficult to interpret as it was drawn in the evening. # Community Acquired Pneumonia Patient noted to have consolidation on CXR. She denies any recent cough or fevers. However, given radiography and concerns for SIADH, patient was treated for community acquired pneumonia. She was initially treated with ceftriaxone/azithromycin before transitioning to cefpodoxime/azithromycin to complete a 5 day course. Last day of antibiotics is ___. # Headache, resolved # History of HSV keratitis requiring corneal transplant Patient with reported history of HSV keratitis requiring corneal transplant. Per patient's son, she has periodic headaches associated with buildup of debris in between contact lens cleaning. Had headache at time of presentation. Ophthalmology was consulted and cleaned her left eye. Patient denied any further headaches. She was continued on home moxifloxacin, prednisolone, and timolol drops. She should follow up with her ophthalmologist at ___ after discharge. ====================

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Sulfa (Sulfonamide Antibiotics) / Penicillins Attending: ___ Chief Complaint: R ankle pain Major Surgical or Invasive Procedure: ORIF R ankle History of Present Illness: Ms. ___ is a ___ with HTN who is transferred from OSH with right ankle pain and deformity following fall. Patient, who endorses drinking alcohol earlier in the evening, reports slipping on bathroom floor at approximately midnight prior to presentation. She is unsure of exact mechanics of fall, but noted immediate right ankle pain and deformity. She denies prodromal symptoms, HS, LOC. She was initially taken to OSH, where likely ankle fracture-disloaction was noted clinically but not reduced. Transferred to ___ ED for further management. At time of presentation, patient denies paresthesias or numbness at right foot, either currently or at any point subsequent to injury. Denies any other pain or complaints. Past Medical History: HTN Social History: ___ Family History: nc Physical Exam: Admission PE: Vitals: 97.4 90 109/59 18 96% +C collar Appears uncomfortable but in no acute distress Respirations non-labored RRR RLE: Obvious deformity at R ankle Skin is tented but intact over bony prominence at anteromedial ankle. Mild swelling. Small areas of ecchymosis over deformity. No areas of deformity or TTP over knee, thigh, or hip; compartments of thigh and lower leg are soft and compressible Palpable DP pulse, dopplerable biphasic ___ pulse Sensation intact in sural, saphenous, deep and superficial peroneal, and tibial distributions Fires ___, TA, ___ Discharge PE: AVSS NAD RLE: Splint c/d/i, nvid. Pertinent Results: ___ 07:30AM BLOOD WBC-20.6*# RBC-3.85* Hgb-12.1 Hct-35.7* MCV-93 MCH-31.4 MCHC-33.8 RDW-13.0 Plt ___ Medications on Admission: HCTZ Losartan Diltiazem Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Aspirin 81 mg PO DAILY 3. Calcium Carbonate 500 mg PO QD 4. Diltiazem Extended-Release 240 mg PO DAILY 5. Docusate Sodium 100 mg PO BID:PRN constipation 6. Enoxaparin Sodium 40 mg SC QPM Duration: 14 Days Start: Today - ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 40 mg sc at bedtime Disp #*14 Syringe Refills:*0 7. Fexofenadine 60 mg PO QD 8. Hydrochlorothiazide 25 mg PO DAILY 9. Losartan Potassium 100 mg PO DAILY 10. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Breakthrough pain Decrease dosage as soon as possible. RX *oxycodone 5 mg ___ tablet(s) by mouth q4h prn Disp #*60 Tablet Refills:*0 11. Senna 8.6 mg PO BID:PRN constipation Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: R ankle fracture Discharge Condition: Improved. AO3. NWB RLE. Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: History: ___ with fall with +ETOH and headstrike // eval trauma TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed images were obtained. DOSE: DLP: 780 mGy-cm CTDI: 54 mGy COMPARISON: None. FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass effect. The ventricles and sulci are normal in size and configuration. Mild prominence of ventricles and sulci is consistent with age related involutional changes. Mild periventricular white matter hypodensities are likely the sequela of 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 hemorrhage or mass effect or acute fracture. Other details as above. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: History: ___ with fall with +ETOH and headstrike // eval trauma eval trauma TECHNIQUE: Contiguous axial images were obtained. Sagittal and coronal reformatted images were generated. No contrast was administered. CTDIvol: 846 mGy DLP: 37 mGy-cm COMPARISON: None. FINDINGS: Reversal of cervical lordosis with kyphosis from C4-C6 levels. No acute fractures are identified. There are multifactorial, multilevel moderate degenerative changes, with intervertebral disc space narrowing and osteophytosis and uncovertebral and facet degenerative changes. Posterior osteophytosis is most prominent at the C4-C5, C5-C6, and C6-C7 levels, causing mild to moderate central canal narrowing. There is moderate to severe multilevel neural foraminal narrowing from C3-C7 levels some deformity on the nerves. No prevertebral swelling noted. Prominent anterior osteophytes are noted at C4-5 C5-6 and T1-T2 level causing mild displacement of the anterior longitudinal ligament. Vascular calcifications are noted in the carotid arteries on both sides. Thyroid is unremarkable. Included lung apices are grossly clear. IMPRESSION: 1. No acute fracture or subluxation. 2. Moderate multilevel degenerative changes causing at least mild to moderate central canal narrowing from C4-C7 and moderate to severe foraminal narrowing from C3-C7 levels with some deformity on the nerves. Correlate clinically to decide on the need for further workup. Other details as above. Radiology Report INDICATION: ___ with fall and displaced ankle fx, post reduction. COMPARISON: Outside hospital right ankle radiograph ___. TECHNIQUE AP oblique and lateral view of the right ankle. FINDINGS: An overlying cast obscures fine bony detail. Since prior, there has been marked interval improvement in the alignment of the ankle mortise. There is a fracture through the medial and posterior malleolus. Additionally, there is a obliquely oriented displaced fracture of the distal fibula. No additional fractures identified. IMPRESSION: Marked interval improvement in alignment of the ankle compared to outside hospital radiograph. Re- demonstrated fractures of the medial and posterior malleolus and distal fibula. Radiology Report INDICATION: Right ankle ORIF. COMPARISON: None. TECHNIQUE: 11 spot fluoroscopic images were obtained intraoperatively without the presence of a radiologist. Total fluoroscopic time was 17 seconds. IMPRESSION: Right ankle internal fixation hardware and surgical instrumentation are demonstrated. Please refer to the operative note for further details. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: s/p Fall Diagnosed with FX TRIMALLEOLAR-CLOSED, UNSPECIFIED FALL, HYPERTENSION NOS temperature: 97.4 heartrate: 90.0 resprate: 18.0 o2sat: 96.0 sbp: 109.0 dbp: 59.0 level of pain: 0 level of acuity: 3.0

The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have R ankle fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for R ankle ORIF, which the patient tolerated well (for full details please see the separately dictated operative report). The patient was taken from the OR to the PACU in stable condition and after recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given perioperative antibiotics and anticoagulation per routine. The patients home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient was afebrile with stable vital signs that were within normal limits, pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is NWB in the RL extremity, and will be discharged on lovenox for DVT prophylaxis. The patient will follow up in two weeks per routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course, and all questions were answered prior to discharge.

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Cefaclor / Compazine / Cipro / morphine / Reglan / OxyContin / Percocet Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old woman with anxiety, depression, PTSD from prior sexual abuse, chronic abdominal and pelvic pain s/p TLH BSO (___) with normal pathology, and s/p recent EGD and colonoscopy with normal biopsies, who presented with worsening abdominal and pelvic pain not controlled on home narcotic regimen. She notes being pain-free following her most recent outpatient pain appointment at ___ (Dr. ___ on ___ with trigger point injections at the sites of her abdominal pain. She noted that she did not need her home Dilaudid for the past 5 days following the trigger point injections because she was feeling well. On ___, one day prior to admission, her pain acutely worsened. She tried treating this at home with dilaudid, gabapentin, acetaminophen, and ibuprofen, but was unable to control her pain on this regimen. She initially presented to the ___ clinic on ___ and was given IV Dilaudid and Zofran. She was then transferred to the ___ as this is where she receives her primary care. In the ED, initial VS were 96.8 64 110/70 16 100%RA. Labs and urinalysis were unremarkable. She received fluids, Dilaudid 1 mg x 3, Zofran 4 mg IV x 1, and was sent to the floor for pain management. Of note, she is constipated at baseline and has been taking multiple herbal remidies that her friend formulates, including albizia, botswala, lavender passion flower, and epsom salt baths, that she started about two weeks ago and have been working well. She did note one episode of non-bloody diarrhea the day prior to admission. In addition to her chronic lower abdominal and epigastric pain, she notes vaginal throbbing that has worsened over the past day. She denies fevers, vaginal bleeding, vaginal discharge, vomiting, dysuria, hematuria, recent sezual contact, or trauma. On transfer vitals were 97.4 73 88/48 15 97% on RA. On arrival to the floor, patient was sleepy after having received dilaudid in the ED and reported improvement in her abdominal pain to ___ from ___ in the ED. REVIEW OF SYSTEMS: Denies fever, chills, night sweats, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, vomiting, blood in her stools, dysuria, or hematuria. All other 10-system review negative in detail. Past Medical History: - Chronic pelvic pain s/p TLH BSO (___) with normal pathology, s/p ___ (___) with normal pathology - Depression - Anxiety - PTSD from prior sexual trauma - History of anorexia/bulemia - Migraine headaches - Fibroadenomas of the breast s/p resection - Hypothyroidism - Pelvic floor dysfunction, urinary retention often requiring straight catheterization - Reactive chemical gastropathy followed by GI - Possible interstitial cystitis Social History: ___ Family History: Paternal aunt with ___, paternal uncle with vasculitis, mother HTN, high chol, Father high chol, graves, gallstones, colitis, M-GMA HTN and alzheimers, P-PGA died of colon cancer, Pat GMA died aortic dissection, Pat GPA died pancreatic cancer. Physical Exam: ADMISSION PHYSICAL EXAM: VS - 97.8 96/61 64 20 98% RA GEN - Alert, sleepy, NAD HEENT - NCAT, dry MM, EOMI, sclera anicteric, OC/OP clear NECK - supple, no JVD, no LAD PULM - CTAB, no w/r/r CV - RRR, S1/S2, no m/r/g ABD - Soft, nondistended, normoactive bowel sounds, tenderness to palpation on left lower quadrant and epigastrium that is not present when pressing with the stethoscope, no rebound or guarding. EXT - WWP, no c/c/e, 2+ pulses palpable bilaterally NEURO - CN II-XII intact, motor function grossly normal SKIN - no ulcers or lesions DISCHARGE PHYSICAL EXAM: VS - 98.0 87/54 -> 92/54 58 20 99%RA GEN - Awake, alert, NAD HEENT - NCAT, MMM, EOMI, sclera anicteric, OC/OP clear NECK - supple, no JVD, no LAD PULM - CTAB, no w/r/r CV - RRR, S1/S2, no m/r/g ABD - Soft, nondistended, normoactive bowel sounds, tenderness to palpation on left lower quadrant and epigastrium that is not present when pressing with the stethoscope, no rebound or guarding. EXT - WWP, no c/c/e, 2+ pulses palpable bilaterally NEURO - CN II-XII intact, motor function grossly normal SKIN - no ulcers or lesions Pertinent Results: On admission: ___ 06:00AM BLOOD WBC-6.8 RBC-4.19* Hgb-12.4 Hct-37.7 MCV-90 MCH-29.5 MCHC-32.9 RDW-13.5 Plt ___ ___ 06:00AM BLOOD Neuts-58.1 ___ Monos-5.0 Eos-1.3 Baso-1.1 ___ 06:00AM BLOOD Glucose-127* UreaN-9 Creat-0.6 Na-138 K-3.7 Cl-106 HCO3-22 AnGap-14 On discharge: ___ 09:10AM BLOOD WBC-4.6 RBC-4.00* Hgb-11.9* Hct-34.9* MCV-87 MCH-29.9 MCHC-34.2 RDW-13.5 Plt ___ ___ 09:10AM BLOOD Glucose-105* UreaN-5* Creat-0.7 Na-138 K-3.7 Cl-104 HCO3-25 AnGap-13 ___ 09:10AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.0 Micro: None Studies: ___ KUB: No evidence of obstruction. Moderate amount of stool is seen throughout the colon. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q6H:PRN pain 2. Citalopram 30 mg PO DAILY 3. Clonazepam 0.5 mg PO QHS 4. Gabapentin 800 mg PO BID 5. HYDROmorphone (Dilaudid) 2 mg PO TID:PRN pain 6. Levothyroxine Sodium 150 mcg PO 1X/WEEK (___) 7. Levothyroxine Sodium 100 mcg PO 6X/WEEK (___) 8. Ondansetron 8 mg PO Q8H:PRN nausea 9. Oxybutynin 5 mg PO BID 10. Propranolol 160 mg PO QHS 11. Tizanidine 2 mg PO QHS 12. Zovia ___ (28) *NF* (ethynodiol diac-eth estradiol) ___ mg-mcg Oral daily 13. Citracal + D *NF* (calcium phosphate-vitamin D3) 250 mg calcium- 250 unit Oral daily 14. naratriptan *NF* 1 mg ORAL AS NEEDED migraines Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN pain 2. Citalopram 30 mg PO DAILY 3. Citracal + D *NF* (calcium phosphate-vitamin D3) 250 mg calcium- 250 unit Oral daily 4. Clonazepam 0.5 mg PO QHS 5. Gabapentin 800 mg PO BID 6. HYDROmorphone (Dilaudid) 1 mg PO TID:PRN pain 7. Levothyroxine Sodium 150 mcg PO 1X/WEEK (___) 8. Levothyroxine Sodium 100 mcg PO 6X/WEEK (___) 9. naratriptan *NF* 1 mg ORAL AS NEEDED migraines 10. Ondansetron 8 mg PO Q8H:PRN nausea 11. Oxybutynin 5 mg PO BID 12. Propranolol 160 mg PO QHS 13. Tizanidine 2 mg PO QHS 14. Zovia ___ (28) *NF* (ethynodiol diac-eth estradiol) ___ mg-mcg Oral daily 15. Docusate Sodium 100 mg PO BID 16. Ibuprofen 800 mg PO Q8H:PRN pain 17. Senna 1 TAB PO BID:PRN constipation Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: - Chronic pelvic pain Secondary diagnoses: - Depression, Anxiety, PTSD from prior sexual trauma - History of anorexia/bulemia - Migraine headaches - Hypothyroidism - Pelvic floor dysfunction, urinary retention often requiring straight catheterization - Reactive chemical gastropathy followed by GI - Possible interstitial cystitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ female with a history of constipation and abdominal pain. Rule out obstruction. COMPARISON: Abdominal radiographs from ___, ___, and CT abdomen and pelvis from ___. FINDINGS: The bowel gas pattern is unremarkable. There is a moderate amount of stool throughout the colon. There is no pneumatosis or free air. There are no distended loops of bowel. The visualized osseous structures are unremarkable. IMPRESSION: No evidence of obstruction. Moderate amount of stool is seen throughout the colon. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: ABDOMINAL PAIN Diagnosed with OTHER CHRONIC PAIN , ABDOMINAL PAIN UNSPEC SITE temperature: 96.8 heartrate: 64.0 resprate: 16.0 o2sat: 100.0 sbp: 110.0 dbp: 70.0 level of pain: 9 level of acuity: 3.0

___ year old woman with anxiety, depression, PTSD from prior sexual abuse, chronic abdominal and pelvic pain s/p TLH BSO (___) with normal pathology, and s/p recent EGD and colonoscopy with normal biopsies, who presented with worsening abdominal and pelvic pain not controlled on home narcotic regimen. # Abdominal Pain: She presented with one day of acutely worsening chronic abdominal/pelvic pain in the setting of not taking home narcotics for the past several days. She is s/p TAH/BSO with pathology with negative pathology for endometriosis. Negative GI workup thus far including EGD and colonoscopy with normal biopsies in ___. Differential includes neuropathic pain, opioid hyperalgesia, and constipation. There is almost certainly a psychogenic overlay with her ongoing symptoms, especially in the context of her history of mental illness. In speaking with outpatient pain department at ___, we transitioned her to her home regimen including acetaminophen, gabapentin 800 mg PO BID, dilaudid 2 mg PO TID prn, tizanidine 2 mg PO QHS, with close outpatient follow up. # s/p TLH/BSO: Obtained in the setting of chronic pelvic pain. Was counseled extensively aginst this procedure, but patient insisted. Pathology was negative for endometriosis. She is now on hormone supplements. Review of systems positive for vaginal throbbing, and it is unclear if this is related to recent surgery or hormone deficiencies, but she should continue to be monitored with close gynecology follow up. She was continued on Zovia and citalopram for hormone replacement. # Constipation: Patient reports history of constipation in the setting of narcotic use. On prior admission, she was constipated for many days and required an aggressive bowel regimen. A KUB was obtained which revealed moderate stool within the colon and no evidence of obstruction. She was continued on colace and senna. She noted recently taking multiple herbal remidies including passion flower which has been reported to have interactions with opioids and can increase the pain threshold. She was counseled to discontinue use of these supplements given these risks. # Cystitis: Stable. She was continued on oxybutynin 5 mg PO BID. # Depression/anxiety/PTSD: Extensive psychiatric history which is likely playing a role in her chronic pain syndrome. She was continued on her home clonazepam 0.5 mg PO QHS and propanolol 160 mg PO QHS. # Hypothyroidism: Stable. Continued home levothyroxine. # Migraine headaches: Stable. Continued naratriptan 1 mg PO prn. # Urinary Retention: She has had issues in the past with urinary retention and was felt to be related to narcotics. She was scheduled for uro/gyn follow up but missed the appointment. She no longer requires indwelling foley catheter and is urinating well. # Transitional issues: - Code status: Full (confirmed ___ - Emergency contact: Mother ___ (cell ___ - Patient counseled to discontinue use herbal supplements for constipation as increased pain threshold has been noted with some of her supplements. - She should continue to have outpatient pain follow up. - Encourage outpatient uro/gyn follow up if symptoms of urinary retention recur.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Vecuronium / Succinylcholine Bromide / lidocaine / Zofran (as hydrochloride) Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ___: Ultra-sound guided percutaneous cholecystostomy tube History of Present Illness: Mr. ___ is a ___ year old male who presents on ___ with complaints of abdominal pain. Patient states that he has had intermittent abdominal pain, gradual in onset, sharp in character, moderate in duration, for several days preceding the presentation day, first starting in the lower abdomen, now in the upper abdomen and with radiation to R flank. No urinary symptoms. +vomiting, had normal BM yesterday. Pt has hx of kidney stones but states that this feels different. ROS negative for fever/chills or other constitutional sxs, headache, Palpitations or chest pain, SOB, cough, sputum or other URI sxs. Denies black or bloody stools, dysuria / hematuria / frequency. Past Medical History: Past Medical History: HTN heart murmur (per patient) GERD anxiety mild depression osteoarthritis Surgical History: R rotator cuff surgery today He has had a patellar debridement in the 1970s for the left knee. Past Medical History: HTN heart murmur Surgical History: R rotator cuff surgery today He has had a patellar debridement in the 1970s for the left knee. Social History: ___ Family History: cancer, diabetes, neurologic disease, and gastrointestinal problems. Physical Exam: Admission PE: ___ Gen: sitting in bed comfortable Chest: Clear to auscultation bilaterally all lung fields Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, Nondistended, mild TTP RUQ w/ perc site CDI Extr/Back: no ___ edema, warm well perfused Neuro: A&Ox4, MAES Discharge PE: ___ Vitals: 98.2, 80, 141/70, 18, 96% on RA Gen: NAD, well appearing man Lungs: LSCTAB Cardiac: S1, S2, RRR, Abd: Soft, mildly distended, mildly tender in RUQ at drain site, RUQ ___ drain intact with bilous drainage Extrm: warm, well perfused, + PP, no edema Neuro: Alert and oriented X3, MAE to command, PERRL Pertinent Results: ___ 11:47AM LACTATE-2.5* ___ 11:54AM VoidSpec-DUPLICATE ___ 12:15PM ___ ___ 12:15PM PLT COUNT-191 ___ 12:15PM NEUTS-84.4* LYMPHS-7.9* MONOS-7.3 EOS-0.3 BASOS-0.1 ___ 12:15PM WBC-12.5*# RBC-4.81 HGB-13.3* HCT-40.8 MCV-85 MCH-27.6 MCHC-32.6 RDW-13.7 ___ 12:15PM ALBUMIN-4.3 ___ 12:15PM ALT(SGPT)-39 AST(SGOT)-38 ALK PHOS-40 TOT BILI-0.7 ___ 12:15PM GLUCOSE-141* UREA N-11 CREAT-0.7 SODIUM-136 POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-27 ANION GAP-15 ___ 01:40PM URINE MUCOUS-RARE ___ 01:40PM URINE RBC-8* WBC-0 BACTERIA-NONE YEAST-NONE EPI-1 ___ 01:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-8.0 LEUK-NEG ___ CT ABD/PELVIS: 1. Distended gallbladder with wall edema and extensive surrounding fat stranding is consistent with acute cholecystitis. No radiopaque gallstones identified. Findings can be confirmed with ultrasound if needed. 2. Normal appendix. No renal, bladder, or ureteral calculi identified. ___: Ultra Sound Guided ___ Procedure: An 8 gauge ___ ___ pigtail catheter was easily advanced into the gallbladder lumen under ultrasound guidance. The pigtail catheter was deployed. 70 cc of bilious fluid were drained. The final image demonstrates a pigtail catheter within the gallbladder lumen. Medications on Admission: 3. Acetaminophen 1000 mg PO Q8H 4. Amitriptyline 25 mg PO HS 5. Amlodipine 2.5 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Atenolol 25 mg PO DAILY 8. Cyclobenzaprine 5 mg PO TID:PRN pain 9. Finasteride 5 mg PO DAILY 10. Fluticasone Propionate NASAL 1 SPRY NU DAILY 11. Gabapentin 600 mg PO HS 12. Hydrochlorothiazide 12.5 mg PO DAILY 13. Nabumetone 500 mg PO BID 14. Tamsulosin 0.4 mg PO DAILY Discharge Medications: 1. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain Duration: 7 Days RX *oxycodone 5 mg 1 capsule(s) by mouth four times a day Disp #*30 Capsule Refills:*0 RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID constipation Duration: 7 Days RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*14 Capsule Refills:*0 3. Acetaminophen 1000 mg PO Q8H 4. Amitriptyline 25 mg PO HS 5. Amlodipine 2.5 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Atenolol 25 mg PO DAILY 8. Cyclobenzaprine 5 mg PO TID:PRN pain 9. Finasteride 5 mg PO DAILY 10. Fluticasone Propionate NASAL 1 SPRY NU DAILY 11. Gabapentin 600 mg PO HS 12. Hydrochlorothiazide 12.5 mg PO DAILY 13. Nabumetone 500 mg PO BID 14. Tamsulosin 0.4 mg PO DAILY 15. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 14 Days RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 pill by mouth twice a day Disp #*28 Tablet Refills:*0 16. Pravastatin 40 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Acute cholecystitis Discharge Condition: Discharge condition: Improved Ambulating well Mentating appropriately Followup Instructions: ___ Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ man with history of kidney stones here with abdominal pain radiating to R flank with tenderness to palpation of the RUQ and RLQ. TECHNIQUE: MDCT images were obtained from the lung bases to the pubic symphysis without the administration of intravenous contrast. Axial images were interpreted in conjunction with coronal and sagittal reformats. DLP: 1044 mGy-cm COMPARISON: None available. FINDINGS: There is minimal bibasilar atelectasis. The heart is normal in size and there is no evidence of pericardial effusion. ABDOMEN: The examination is limited secondary to the lack of intravenous contrast. Within this limitation, the non-contrast enhanced appearance of the liver, spleen, pancreas, and adrenal glands are unremarkable. The gallbladder is distended with gallbladder wall edema and extensive surrounding fat stranding (02:34). No radiopaque gallstones are identified. There is no intra or extrahepatic biliary duct dilation. There are no renal, ureteral, or bladder calculi identified. There is no hydronephrosis. There is a small hiatal hernia. The stomach is decompressed. There is prominence of multiple loops of small bowel including a fecalized loop in the lower abdomen, likely reflecting slow flow (2:83). The appendix is well visualized and normal. There is no retroperitoneal or mesenteric lymphadenopathy by CT size criteria. There is no abdominal free air. There is no abdominal aortic aneurysm. PELVIS: The bladder is well distended and normal in appearance. There is no pelvic side-wall or inguinal lymphadenopathy by CT size criteria. No free pelvic fluid is identified. OSSEOUS STRUCTURES: There are multilevel degenerative changes of the lumbar spine with endplate sclerosis most pronounced at L4-5 and L5-S1. No focal lytic or sclerotic lesion concerning for malignancy. IMPRESSION: 1. Distended gallbladder with wall edema and extensive surrounding fat stranding is consistent with acute cholecystitis. No radiopaque gallstones identified. Findings can be confirmed with ultrasound if needed. 2. Normal appendix. No renal, bladder, or ureteral calculi identified. Radiology Report EXAMINATION: US INTERVENTIONAL PROCEDURE INDICATION: ___ year old man with acute cholecystitis symptomatic for 5 days // Percutaneous cholecystostomy TECHNIQUE: Grey scale and color Doppler ultrasound images were obtained. COMPARISON: CT of the abdomen and pelvis ___. OPERATORS: Dr. ___ Fellow, Dr. ___ Dr. ___ ___. PROCEDURE: The procedure including risks, benefits, and alternatives were explained to the patient, and after detailed discussion, informed written consent was obtained. A pre-procedural time out was performed using three unique patient identifiers utilizing the ___ protocol. Focused ultrasound of the right upper quadrant of the abdomen was performed demonstratingthe distended gallbladder with marked and gallbladder wall thickening, moderate pericholecystic fluid and multiple shadowing gallstones. A sonographic ___ sign was present. The skin was marked for targeting of the gallbladder. The skin, soft tissues, and liver capsule were infiltrated with 3 cc of p2% Chloroprocaine as the patient has a lidocaine allergy. Ultrasound guided percutaneous cholecystostomy placement was attempted, however was unsuccessful on tbe first attempt as the pigtail could not be deployed within the gallbladder lumen. 2 mL of bilious aspirate was obtained during the procedure. The patient experienced right shoulder pain. The procedure was delayed until the pain mitigated. A postprocedural chest x-ray demonstrated no pneumothorax. The procedure was again attempted. An 8 gauge ___ ___ pigtail catheter was easily advanced into the gallbladder lumen under ultrasound guidance. The pigtail catheter was deployed. 70 cc of bilious fluid were drained. The final image demonstrates a pigtail catheter within the gallbladder lumen. Moderate sedation was provided by administering divided doses of 3 mg Versed and 150 mcg fentanyl throughout the total intra-service time of 40 minutes during the first attempt. During the second attempt, divided doses of 1.5 mg Versed and 75 mcg Fentanyl was administered during a total intraservice time of 8 minutes. The patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. The attending Dr. ___ was present throughout the procedure. FINDINGS: Findings consistent with acute on chronic cholecystitis. IMPRESSION: Sonographic guided percutaneous cholecystostomy tube placement. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: SOB, RT SHOULDER PAIN ?PTX IMPRESSION: In comparison with the study of ___, there are lower lung volumes. Dense streaks of atelectasis are seen at both bases. No evidence of pulmonary vascular congestion. Radiology Report EXAMINATION: ABDOMEN (SUPINE AND ERECT) INDICATION: ___ year old man with ileus, last BM prior to admission, on bowel regimen, distended, has not yet stooled. // obstuction obstuction IMPRESSION: No previous images. There are dilated loops of small bowel with minimal depression at there are dilated loops of predominantly small bowel with relative paucity of large bowel gas. This raises the possibility of early or partial small bowel obstruction. If this is a serious clinical concern, CT would be the next imaging procedure. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Abd pain Diagnosed with ACUTE CHOLECYSTITIS temperature: 99.0 heartrate: 90.0 resprate: 18.0 o2sat: 97.0 sbp: 167.0 dbp: 97.0 level of pain: 10 level of acuity: 3.0

Mr. ___ is a ___ y.o. who was admitted to the ___ on ___ with complaints right upper quadrant abdominal pain that had progressed over a few days prior to admission. CT ABD/Pelvis revealed a distended gallbladder with wall edema and extensive surrounding fat stranding consistent with acute cholecystitis. He was hemodynamically stable and afebrile with a WBC of 12.5 on admission. The patient was made NPO with intravenous fluid and started on Unasyn for antibioitc coverage. On ___, he underwent placement of an ultrasound guided cholecystostomy tube. The patient tolerated the procedure well and remained hemodynamically stable. On ___, the patient reported no bowel movement since admission and had a distended abdomen without peritoneal signs on physical exam. He was started on a bowel regimen and was able to pass flatus and stool later that evening. At this time he was transistioned to an Augmentin in preparation for antibiotic coverage at discharge. He tolerated this well. On ___, the day of discharge, the patient's pain was well controlled on oxycodone. He was tolerating a regular diet without nausea, vomitting or abdominal pain. His ___ drain remained patent in his RUQ and continued to have bilous output. The patient voided without problem. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. He was educated on ___ drain care at the time of discharge and will have a ___ evlauate him at home. He will follow-up in the ___ clinic as listed below for drain evaluation and planning for interval cholecystectomy.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: malaise and abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo F end stage renal dz, htn, hypothroid, hld who presents with ___ days of N/V and diarrhea. Per daughter pt is not at baseline and has been having hallucinations "someone trying to shoot her." She also decribed increasing cough above her baseline that is non-productive. She has also been feeling that she is weak all over and more confused with some difficulty walking. She also complains of whole body aches. She was unable to go to dialysis today (usually TThSa) because she felt too weak. Her daughter is a ___ and provides most of the history, she lives with her son and is normally very indepdent. She continues to make some urine. Subjective fevers at home. She has been having increasing difficulty swallowing per family and coughs frequently when taking PO. She denies any current CP, HA, brbpr, or hemetemesis, difficulty swallowing/difficulty taking PO. In the ED, initial VS were: 19:30 98 78 154/82 18 99% RA. The patient remained afebrile with HR in the ___. Her Blood pressure emained elevated around 150s/80s. She remained >97% O2 saturation. One 18g and one 22g were placed. She remained alert and oriented x3. She has a fistula in her L arm. Her initial exam was reportedly notable only for crackles in the lungs, but a repeat exam revealed diffuse abdominal tenderness. Thus, the patient underwent CT abdomen and pelvis, which did not reveal acute pathology. She also was felt to have a swollen leg, and so underwent CTA, which did not show PE. Her CXR did not show a clear source of infection. Bedside echo was reportedly without signs of cardiogenic shock. The patient received Vancomycin, zosyn, flagyl, 500ml NS, ___, thiamine. Nephrology was consulted for HD, and were aware of dye load given with CTA. She was found to have an elevated lactate in the ED, which increased to 5.6 but then began to trend down to 5.0 with IVF (she got 1800cc total). She also had a gap of 18. The patient was noted to also have a normal chemistry otherwise except for her elevated creatinine. She had a slight leukocytosis with normal differential. Her hematocrit and platelets were normal. She did have a slight elevation in her ALT and AST, her INR was elevated to 1.4. Her troponin was elevated to 0.04 with normal CK/MB. UA was obtained. A RIJ was placed and was oozing. On arrival to the MICU, the patient says that she feels well, she says that she feels much better than prior. In speaking to her daughter, she brought her into the hospital for concern for weakness, deconditioned. Unable to eat. Forgetting her dialysis day. Hallucinating. The patient is in the middle of moving from one apartment to another. The cough is nagging and constant, the daughter says that this interferes with her sleep. She endorsed coughing to the point of vomiting. Past Medical History: - hypertension, - end-stage renal disease on hemodialysis, (TThSa via left brachiocephalic AVF made in ___ - congestive heart failure (systolic EF 50% in ___, - hyperlipidemia, - osteoarthritis, - depression, - anemia,secondary versus tertiary hyperparathyroidism, - recently developing dementia. Social History: ___ Family History: non-contributory Physical Exam: ADMISSION PHYSICAL General: AOx3 HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL CV: Regular rate and rhythm, normal S1 + S2, no rubs Lungs: bilateral crackles. Air movement bilaterally. Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 4+/5 strength upper/lower extremities, grossly normal sensation, gait deferred, finger-to-nose intact with mild intention tremor DISCHARGE PHYSICAL Alert & oriented x3, pleasant, but forgetful. Gait stable using walker. Left brachiocephalic fistula intact, +bruit Pertinent Results: ADMISSION LABS ___ 09:35PM WBC-11.9*# RBC-3.59* HGB-11.0* HCT-34.8* MCV-97 MCH-30.7 MCHC-31.7 RDW-17.9* ___ 09:35PM NEUTS-55.6 ___ MONOS-7.0 EOS-2.0 BASOS-0.7 ___ 09:35PM ALBUMIN-4.0 CALCIUM-9.3 PHOSPHATE-2.8 MAGNESIUM-2.0 ___ 09:35PM CK-MB-3 cTropnT-0.04* ___ 09:35PM LIPASE-57 ___ 09:35PM ALT(SGPT)-43* AST(SGOT)-43* CK(CPK)-71 ALK PHOS-101 TOT BILI-0.4 ___ 09:35PM GLUCOSE-146* UREA N-41* CREAT-6.2*# SODIUM-139 POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-24 ANION GAP-22* ___ 09:40PM LACTATE-3.8* ___ 09:50PM ___ PTT-29.3 ___ LACTATE: ___ 01:39 1.8 ___ 16:16 3.0* ___ 13:10 8.2*1 ___ 10:08 7.0*1 ___ 09:43 88 7.0*1 ___ 06:42 5.2*2 ___ 03:55 5.0*3 ___ 00:47 5.6* CARDIAC ENZYMES CK 71 MB 3 TropT 0.04 ___ 15:48 3 0.04*1 ___ 21:35 3 0.04*1 MICROBIOLOGY: ___ 11:27PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 11:27PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-300 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-2* PH-5.5 LEUK-NEG ___ 11:27PM URINE RBC-<1 WBC-2 BACTERIA-FEW YEAST-NONE EPI-1 ___ 11:27PM URINE HYALINE-16* ___ 11:27PM URINE MUCOUS-RARE ___ SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-FINAL INPATIENT ___ IMMUNOLOGY HCV VIRAL LOAD-PENDING INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT ___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL; LEGIONELLA CULTURE-PRELIMINARY; FUNGAL CULTURE-PRELIMINARY INPATIENT ___ MRSA SCREEN MRSA SCREEN-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY WARD ___ URINE URINE CULTURE-FINAL; Legionella Urinary Antigen -FINAL EMERGENCY WARD ___ BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY WARD URINE TOXICOLOGY: ___ 11:27PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 03:48PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 03:48PM ACETONE-TRACE OSMOLAL-290 IMAGING/STUDIES: ECG: NSR @ 67 bpm, leftward axis and LAFB, ___, LVH, TWI laterally, flattened Ts II, poor R-wave progression. Compared to ECG from ___, appears similar. ___ CHEST X-RAY: Consistent with pulmonary vascular congestion. Frontal and lateral views of the chest were obtained. The cardiac silhouette remains enlarged. Prominence of the pulmonary arteries is stable. There is mild left base streaky atelectasis/scarring. There is minimal pulmonary vascular congestion. Mediastinal contours are stable. No large pleural effusion or pneumothorax. ___ CHEST X-RAY: IMPRESSION: Status post right IJ central line placement without evidence of complication; worsening heart failure. ___ ECHO: Mildly dilated LA and moderately dilated RA. Estimated RA pressure at least 15 mmHg. LV size borderline dilated. LV systoli function severely depressed (LVEF 20%) with akinesis of the apex and distal LV segments and moderate hypokinesis remaining seg. Moderate LV thrombus seen. RV mildly dilated with mild free wall hypokinesis. Mod-severe MR and mod-severe TR. Severe PA systolic HTN (TR gradient 60). No pericardial effusion. ___ CT chest/abdomen/pelvis w/ contrast: 1. No PE or aortic dissection. 2. Cardiomegaly and pulmonary edema. 3. Heterogeneous nodule of the left lobe of the thyroid as described above. 4. Atrophic kidneys with multiple indeterminate lesions, some of which are cysts, but many of which are incompletely characterized, so RCC cannot be excluded; MR may be considered for further characterization. 5. Descending and sigmoid colonic diverticulosis without diverticulitis. 6. Periportal edema and decompressed gallbladder with wall edema, which is a nonspecific finding and may reflect CHF, hyperproteinemia, or hepatic dysfunction. 7. Small amount of free fluid in the pelvis, possibly reactive. 8. Benign-appearing but indeterminate lytic lesion in the right iliac bone without evidence of cortical disruption. ___ CT HEAD IMPRESSION: Minimal cavernous carotid atheromatous disease, otherwise normal ___ CARDIAC STRESS IMPRESSION: No significant ST segment changes or anginal symptoms. Blunted hemodynamic response to regadenoson. Nuclear report sent separately. ___ PHARMACOLOGIC STRESS IMPRESSION: 1. No reversible or fixed myocardial perfusion defects. 2. Severely enlarged left ventricular cavity size. 3. Decreased left ventricular function with calculated EF of 24% and diffuse hypokinesia. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Acetaminophen 650 mg PO Q6H:PRN pain <4 g per day. Please tell ___ if given for T>100.5 2. Simvastatin 20 mg PO DAILY 3. sevelamer CARBONATE 1600 mg PO TID W/MEALS 4. Omeprazole 40 mg PO DAILY 5. Sertraline 150 mg PO DAILY 6. Levothyroxine Sodium 88 mcg PO DAILY 7. Nephrocaps 1 CAP PO DAILY 8. Lidocaine-Prilocaine 1 Appl TP PRN with HD access 9. Metoprolol Tartrate 75 mg PO BID 10. Valsartan 160 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain <4 g per day. Please tell ___ if given for T>100.5 2. Levothyroxine Sodium 88 mcg PO DAILY 3. Metoprolol Tartrate 75 mg PO BID 4. Nephrocaps 1 CAP PO DAILY 5. Omeprazole 40 mg PO DAILY 6. Sertraline 150 mg PO DAILY 7. Simvastatin 20 mg PO DAILY 8. Valsartan 160 mg PO DAILY 9. Thiamine 100 mg PO DAILY RX *thiamine HCl 100 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet Refills:*11 10. Lidocaine-Prilocaine 1 Appl TP PRN with HD access 11. sevelamer CARBONATE 1600 mg PO TID W/MEALS 12. Benzonatate 100 mg PO TID:PRN cough RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day Disp #*30 Capsule Refills:*3 13. Warfarin 4 mg PO DAILY16 RX *warfarin 1 mg 4 tablet(s) by mouth DAILY Disp #*120 Tablet Refills:*0 14. Outpatient Lab Work 428.0 Congestive heart failure Please check INR on or before ___. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY: Congestive heart failure, lactic acidosis, left ventricular thrombus SECONDARY: Hypertension, end-stage renal disease, hypothyroidism, anemia 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 HISTORY: ___ female with fever, leukocytosis, elevated lactate, and tenderness to palpation. STUDY: CT of the torso with contrast. Although the patient's creatinine was 6.2, the patient is on dialysis and renal team is aware and plans for dialysis after the scan. 100 mL of Omnipaque intravenous contrast was administered without adverse reaction or complication. Images were acquired in the arterial phase. Images were then acquired in the chest, abdomen, and pelvis. Coronal and sagittal reformatted images were also generated. COMPARISON: None. FINDINGS: CHEST: The visualized portion of the thyroid demonstrates a heterogeneous 1.8 x 1.3 cm nodule in the left lobe of thyroid (2:7). No axillary, hilar, or mediastinal lymphadenopathy is noted. The aorta is of a normal caliber along its course without evidence of dissection or intramural hematoma; incidental note is made of a common origin of the brachiocephalic and left common carotid arteries, a normal variant. The pulmonary arterial trunk is of a normal caliber and there are no filling defects to the subsegmental level. The heart size is large, but there is no pericardial effusion. Small bilateral pleural effusions are present, but they are nonhemorrhagic in nature and minimal associated atelectasis is present. Scattered areas of ground-glass opacity are most compatible with pulmonary edema. ABDOMEN: Within the limits of early phase scan, the liver shows no focal lesion and mild-to-moderate periportal edema. Contrast is seen refluxing into the hepatic veins, raising the possibility of hepatic congestion. The gallbladder is decompressed, but shows moderate wall edema/pericholecystic fluid. No calcified stones are noted. The spleen is normal in size. The pancreas and adrenal glands show no masses or nodules. The kidneys enhance symmetrically but are atrophic. Both kidneys demonstrate multiple hypodense exophytic indeterminate lesions, some of which are cysts, but some of which have more mass-like or have more soft tissue-like densities. Neither kidney demonstrates hydronephrosis. The small and large bowel shows no evidence of obstruction or wall edema. There is no pneumatosis or portal venous gas. Scattered diverticula are present along the descending and sigmoid colon. There is no free air or lymphadenopathy. The abdominal aorta is of normal caliber along its course. The celiac and SMA are widely patent. The renal arteries and ___ are not narrowed. PELVIS: The bladder, uterus, and rectum appear unremarkable. Small amount of free fluid is present in the pelvis. Sigmoid diverticulosis is present without evidence of diverticulitis. No lymphadenopathy is seen. BONES: A lucent lesion with a sclerotic rim is present in the right iliac bone measuring 15 x 13 mm in the coronal plane (601B:49), and is benign-appearing. Mild-to-moderate multilevel degenerative changes are present throughout the thoracolumbar spine. IMPRESSION: 1. No PE or aortic dissection. 2. Cardiomegaly and pulmonary edema. 3. Heterogeneous nodule of the left lobe of the thyroid as described above. Ultrasound may be considered as clinically indicated. 4. Atrophic kidneys with multiple indeterminate lesions, some of which are cysts, but many of which are incompletely characterized, so RCC cannot be excluded; MR may be considered for further characterization. 5. Descending and sigmoid colonic diverticulosis without diverticulitis. 6. Periportal edema and decompressed gallbladder with wall edema, which is a nonspecific finding and may reflect CHF, hyperproteinemia, or hepatic dysfunction. 7. Small amount of free fluid in the pelvis, possibly reactive. 8. Benign-appearing but indeterminate lytic lesion in the right iliac bone without evidence of cortical disruption. Radiology Report HISTORY: ___ female with right IJ line placed. STUDY: Portable semi-upright AP chest radiograph. COMPARISON: ___. FINDINGS: Moderate cardiomegaly is chronic. Mild edema has developed over the past six hours, following engorged hilar and peripheral pulmonary vasculature. Retrocardiac atelectasis is present. There is no pneumothorax. There is no pleural effusion or apical cap. There has been interval placement of a triple-lumen central venous catheter from a right IJ approach. Mild S-shaped scoliosis is present in the thoracolumbar spine. IMPRESSION: Status post right IJ central line placement without evidence of complication; worsening heart failure. Radiology Report HISTORY: ___ female with one month of slowly progressive altered mental status, and new finding of an LV thrombus. COMPARISON: Non-contrast head CT from ___ TECHNIQUE: ___ MDCT axial images of the brain were obtained without intravenous contrast. NON-CONTRAST HEAD CT: There is no evidence of hemorrhage, mass, mass effect, or infarction. No focal hypodensity is identified to suggest embolic phenomenon. The ventricles and sulci are normal in size and configuration. There is minimal calcification of the cavernous carotid arteries. There is no shift of the usually midline structures. Suprasellar and basilar cisterns are widely patent. There is no evidence of fracture. The visualized paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: Minimal cavernous carotid atheromatous disease, otherwise normal study. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: VOMITING/DIARRHEA,COUGH Diagnosed with SEMICOMA/STUPOR, ACIDOSIS, END STAGE RENAL DISEASE, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE temperature: 98.0 heartrate: 78.0 resprate: 18.0 o2sat: 99.0 sbp: 154.0 dbp: 82.0 level of pain: 13 level of acuity: 3.0

___ yo woman with ESRD on dialysis, HTN, admitted for 6 weeks of worsening cough, posttussive emesis, waxing and waning mental status, found to have elevated lactate as high as 8 and new echo with dramatically reduced EF, 3+ TR/MR, mild RV failure, pulmonary hypertension, and LV thrombus. # CHF: Pt was found to have new biventricular heart failure (EF 20%) on echo with LV thrombus. ___ TTE which showed systolic dysfunction with EF of 45-50%. DDx includes recent silent MI (unlikely given lack of qwaves) or balanced ischemia from 3 vessel disease since stress MIBI was negative (patient is not a good candidate for CABG per discussion with family, nephrologist), chronic deterioration of hypertensive cardiomyopathy, or amyloid cardiomyopathy. Trop 0.04 in ED without EKG changes, and remained stable. P-MIBI ___ showed no reversible or fixed myocardial perfusion defects, diffuse hypokinesia, EF 24%. Based on this interpretation, we cannot rule out balanced ischemia, but since patient not candidate for CABG, it was agreed upon that cardiac catheterization was not necessary. Per Dr. ___ heart failure may be due to amyloid cardiomyopathy. - CT of head was negative for any intracranial process, so patient was given heparin bolus and heparin gtt was started for LV thrombus, until therapeutic on warfarin. - Continued home valsartan, started metoprolol at decreased dose (25mg TID) then uptitrated as tolerated back to home dose - Cont simvastatin 20 mg PO/NG DAILY - Cannot get spironolactone given ESRD - Continue HD for fluid removal qSaTuThu - Thiamine levels were not drawn prior to starting IV thiamine, empirically treating with daily thiamine supplementation as wet beri-beri is on the differential for cardiomyopathy with elevated lactate. - Consider outpatient workup of amyloid cardiomyopathy. If cardiac amyloid were present, most likely this would be from ESRD or senile, but have not yet ruled out light chain amyloid. As outpatient, could get SPEP/UPEP, serum light chains, and immunofixation, but deferred as inpaitnet. # LV thrombus: Apical hypokinesis and severely depressed LV function likely cause. - Heparin gtt bridge until therapeutic on warfarin # Elevated lactate: Rose to lactate of 8 on day of admission and then decreased to 1.8 with HD. Etiology of lactate elevation is unclear. - Normal serum osms. VBG (pH. 7.45, CO2 40). - There has been no known infectious process. No leukocytosis, CXR showed no consolidation, UA negative, blood cultures no growth. Got Vanc, cefepime, levofloxacin for one day but was discontinued on HD2 because no evidence of infection. Continued azithromycin for 4 days for possible atypical pneumonia vs pertussis given history of 6 weeks of severe cough with post-tussive emesis - HIV pending at time of discharge - Hep serologies pending at time of discharge - CT abd/pelvis negative for bowel ischemia, transplant surgery saw and felt no surgical issues - LV dysfunction without hypotension unlikely to cause this kind of lactate elevation. - Other etiologies include toxic ingestions: Patient has arthritis and dementia but does not endorse taking increased amounts of over the counter pain medications such as tyelenol or aspirin. LFTS only mildly elevated. Sertraline toxicity has been seen in a case study in rats to cause mitochondrial dysfunction and a lactic acidosis so this is a possibility. Sertraline was held per toxicology recommendations, but restarted with no new elevation in lactate. No blood in stool to suggest iron or colchicine ingestion. Negative serum tox screen. - Thiamine deficiency can also cause a lactic acidosis. Thiamine empirically repleted. # Cough: Cough for a few months with some emesis after coughing fits. Cough improved with diuresis, most likely etiology is pulmonary edema. Also possibly viral or pertussis given increased incidence recently. Sent serum studies for pertussis to state since swab will be negative 6 weeks out. Rec'd azithromycin ___. Infection control stated that patient does not need to be on droplet precautions because onset was 6 weeks ago and cough is improved. # AMS: Was brought in with confusion by her daughter that had been worsening over the days before admission. Improved during hospitalization but the patient per report has some baseline dementia. # ESRD on HD ___ schedule: When she was admitted she had missed a day of dialysis because of fatigue. On ___ she received dialysis and then received a partial dialysis on ___ to get her back on schedule. Received dialysis ___ prior to discharge. # HTN: Kept on home valsartan. Lopressor restarted on ___ and uptitrated back to her home dose on ___. # HLD: Kept on home dose of simvastatin # Osteoarthritis: Home tylenol was discontinued because of concern for toxicity while in the hospital. # Hypothyroidism: TSH 5.0 and free T4 0.99. Kept on home levothyroxine. # Depression: Held home sertraline in hospital for concern of toxicity and contribution of lactic acidosis. Restarted without any increase in lactate. # Anemia: HCT remained stable around 34.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ___ Attending: ___ Chief Complaint: chest pressure Major Surgical or Invasive Procedure: DCCV ___ at OSH History of Present Illness: Mr. ___ is a ___ with PMH significant for CAD s/p CABG, 4 stents, htn, afib on xarelto presenting with chest pressure. Patient was in his usual state of health until around 2pm today when he noted sudden onset of substernal chest pressure as he was working on the deck. He took SL nitro which eased the pain slightly but it did not go away. He quickly presented to ___ ___ for evaluation. The pain was nonradiating and not associated with exertion. He denied SOB, cough, diaphoresis, N/V. At the OSH, he was found to be in atrial fibrillation/flutter and was cardioverted with return to normal sinus rhythm. His pain resolved after this and has not returned. Of note, patient had a positive stress test in ___ which showed a medium sized perfusion defect in the territory of the LAD. Reportedly his first set of cardiac enzymes at 1630 were negative. Cardiology consult at ___ recommended transfer to ___ for likely admission and cardiac catheterization given presenting symptoms and recent positive stress test. In the ED, initial vitals were: 98.8, 90, 148/56, 16, 99% ra. Labs were notable for troponin 0.03. Imaging included lower extremity doppler which showed no DVT. On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. All of the other review of systems were negative. Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. PVD with LLE claudication and s/p R fem-pop 2. Arthritis 3. LBBB 4. HTN 5. hyperlipidemia 6. Gout 7. Headaches 8. Lower back pain s/p lower lumbar laminectomy and fusion of L1 and S1 ___ 9. CAD s/p CABG ___, DESx3 in ___ 10. NSTEMI ___ s/p CABG ___. PE/DVT at ___ ___ on Rivaroxaban 12. Anxiety 13. invasive squamous cell carcinoma on the left mid arm Social History: ___ Family History: Mother passed at ___ and father passed at ___ from coronary artery disease Physical Exam: ON ADMISSION VS: 98.3 140/72 94 18 95% RA 90.7kg General: well appearing mildly anxious man in NAD HEENT: NCAT, EOMI, PERRL, OP clear Neck: no elevation in JVP CV: normal rate, reg rhythm, +systolic murmur and LLSB Lungs: CTAB, no w/r/r Abdomen: soft, NTND, NABS Ext: wwp, 1+ pitting edema at ankles in LLE Neuro: no focal deficits Skin: no rashes ON D/C Tm 97.8 BP 121-128/62-74 HR 65-69 RR 20 96 % RA General: nad HEENT: ncat, op clear Neck: no jvp elevation, no thyromegaly CV: RRR S1 and S2, ___ systolic murmuer LUSB Lungs: CTAB, no w/r/r Abdomen: soft, NTND, NABS Ext: wwp, 1+ pitting edema at ankles in LLE Neuro: no focal deficits Skin: no rashes Pertinent Results: ON ADMISSION ___ 10:03PM ___ PTT-28.5 ___ ___ 10:03PM PLT COUNT-191 ___ 10:03PM NEUTS-78.7* LYMPHS-14.0* MONOS-6.5 EOS-0.5 BASOS-0.3 ___ 10:03PM WBC-12.2* RBC-4.49* HGB-13.8* HCT-39.6* MCV-88 MCH-30.8 MCHC-34.9 RDW-16.3* ___ 10:03PM cTropnT-0.03* ___ 10:03PM estGFR-Using this ___ 10:03PM GLUCOSE-101* UREA N-14 CREAT-0.8 SODIUM-142 POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-22 ANION GAP-17 CXR ___ FINDINGS: The patient is status post coronary artery bypass graft surgery. The cardiac, mediastinal and hilar contours appear stable. There is no pleural effusion or pneumothorax. The lungs appear clear. IMPRESSION: No evidence of acute cardiopulmonary disease. ___ EXAMINATION: UNILAT LOWER EXT VEINS LEFT INDICATION: ___ male with left lower extremity swelling, evaluate for DVT. TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the left lower extremity veins. COMPARISON: Bilateral lower extremity Dopplers from ___ FINDINGS: There is normal compressibility, flow and augmentation of the left common femoral, superficial femoral, and popliteal veins. Visualization of the calf veins was limited. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. There is a structure within the left thigh resembling the fem pop graft which is appears occluded. IMPRESSION: 1. Limited evaluation of the calf veins. No evidence of deep venous thrombosis in the visualized left lower extremity veins. 2. Structure within the left thigh resembling the fem-pop graft which appears occluded. ON D/C ___ 07:25AM BLOOD WBC-8.1 RBC-4.43* Hgb-13.6* Hct-39.2* MCV-89 MCH-30.6 MCHC-34.6 RDW-16.1* Plt ___ ___ 07:25AM BLOOD Plt ___ ___ 07:25AM BLOOD Glucose-102* UreaN-12 Creat-0.7 Na-141 K-4.3 Cl-108 HCO3-25 AnGap-12 ___ 07:25AM BLOOD Calcium-8.9 Phos-3.1 Mg-1.9 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325-650 mg PO Q6H:PRN pain 2. Amlodipine 10 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Clopidogrel 75 mg PO DAILY 5. Docusate Sodium 100 mg PO QHS 6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 7. Lisinopril 10 mg PO DAILY 8. Metoprolol Tartrate 50 mg PO BID 9. Rivaroxaban 20 mg PO DAILY 10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 11. ALPRAZolam 0.5 mg PO BID Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain 2. ALPRAZolam 0.5 mg PO BID 3. Amlodipine 10 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. Clopidogrel 75 mg PO DAILY 6. Docusate Sodium 100 mg PO QHS 7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 8. Lisinopril 10 mg PO DAILY 9. Metoprolol Tartrate 50 mg PO BID 10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 11. Rivaroxaban 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Atrial fibrillation Atrial flutter Coronary artery disease status post CABG Peripheral vascular disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: UNILAT LOWER EXT VEINS LEFT INDICATION: ___ male with left lower extremity swelling, evaluate for DVT. TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the left lower extremity veins. COMPARISON: Bilateral lower extremity Dopplers from ___ FINDINGS: There is normal compressibility, flow and augmentation of the left common femoral, superficial femoral, and popliteal veins. Visualization of the calf veins was limited. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. There is a structure within the left thigh resembling the fem pop graft which is appears occluded. IMPRESSION: 1. Limited evaluation of the calf veins. No evidence of deep venous thrombosis in the visualized left lower extremity veins. 2. Structure within the left thigh resembling the fem-pop graft which appears occluded. Radiology Report EXAMINATION: CHEST RADIOGRAPHS INDICATION: Chest pain. TECHNIQUE: Chest, PA and lateral. COMPARISON: ___. FINDINGS: The patient is status post coronary artery bypass graft surgery. The cardiac, mediastinal and hilar contours appear stable. There is no pleural effusion or pneumothorax. The lungs appear clear. IMPRESSION: No evidence of acute cardiopulmonary disease. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: ATRIAL FLUTTER, CARDIOVERSION, Transfer Diagnosed with ATRIAL FLUTTER, CHEST PAIN NOS temperature: 98.8 heartrate: 90.0 resprate: 16.0 o2sat: 99.0 sbp: 148.0 dbp: 56.0 level of pain: 0 level of acuity: 2.0

Mr. ___ is a ___ with PMH significant for CAD s/p CABG, 4 stents, htn, afib on xarelto who presented with chest pressure and pain, was found to be in aflutter, and had symptom resolve after 100 J DCCV at OSH. Patient was in his usual state of health until around 2pm prior to admission when he noted sudden onset of substernal chest pressure as he was working on the deck. He took SL nitro which eased the pain slightly but it did not go away. He quickly presented to ___ for evaluation. The pain was nonradiating and not associated with exertion. He denied SOB, cough, diaphoresis, nausea or vomiting. At the OSH, he was found to be in atrial fibrillation/flutter and was cardioverted (100 J) with return to normal sinus rhythm. His pain resolved after this and did not return. Of note, patient had a positive stress test in ___ which showed a medium sized perfusion defect in the territory of the LAD, and cath that showed severe native 3VD, and at that time was medically managed. Cardiology consult at ___ recommended transfer to ___ for likely admission and cardiac catheterization given presenting symptoms and recent positive stress test. At ___, patient continued to have no pain and prior cardiac cath on ___ was reviewed. Given ___ known 3VD CAD, lack of pain after cardioversion, and decision to continue medical management after ___ cath, decision was made to continue patient on medrical management, as there was question of whether there would be any new intervenable lesions, as ___ symptosm resolved after resolution aflutter above. Of note, during initial admission to hospital, patient had ___ U/S of left leg due to slight swelling (which patient noted was baseline) which showed no DVT, but showed questionable occlusion of fem pop bypass. Patient denied any pain, and had no poikilothermia, or parathesias of left leg, and had intact sensation, and both DP and ___ pulse of left leg were dopplerable. As such, no further action was taken in regards to left leg, but team scheduled patient to F/U with Dr. ___, ___ prior vascular surgeon, as an outpatient. #Chest pain/CAD: question of demand ischemia in setting of tachycardia from his afib. The patient was currently pain free during hospital stay. First set of cardiac enzymes negative, second and thurs set mild elevation of 0.03, and EKG is unchanged from prior. He was monitored in the hospital overnight with no events and dced with his home medical regimen for his CAD. #Afib: cardioverted at ___ with return to sinus. Continued home metoprolol and rivoraxaban. #HTN: continued home beta blocker, amlodipine, lisinopril #HLD: high dose atorvastatin for now while ruling out for ACS #H/O PE/DVT: continued rivaroxaban. Per patient, had discussion with cardiologist 2 weeks prior and decision was made to continue rivoraxaban despite history of DVT back in ___. # Hx fem/pop bypass / Left leg swelling: patient had ___ U/S of left leg due to slight swelling (which patient noted was baseline) which showed no DVT, but showed questionable occlusion of fem pop bypass. Patient denied any pain, poikilothermia, or parathesias of left leg, and had intact sensation, and both DP and ___ pulse of left leg were dopplerable. As such, no further action was taken in regards to left leg, but team scheduled patient to F/U with Dr. ___ prior vascular surgeon, as an outpatient. TRANSITIONAL ISSUES -Patient to F/U cardiologist regarding anticoagulation above (on rivoraxaban) and recent successful DCCV. Home meds unchanged on D/C. -Regarding incidental finding on LLE U/S above (possible fem pop occlusion, but no evidence on exam and dopplerable ___ and DP pulses), patient to F/U with Dr. ___ vascular surgery.

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: Vaginal bleeding, Fever Major Surgical or Invasive Procedure: Manual vacuum aspiration History of Present Illness: CC: pain, bleeding HPI: ___ yo G4P1 at ___ weeks who presents with vaginal bleeding and malaise. She had an early OB visit on ___ at which time TVUS showed: Single intrauterine gestational sac, with no embryo or yolk sac seen. Later that day she developed vaginal bleeding and cramping. On ___ she presented to ___ for rhogam given RH negative. Today she has felt overall unwell and sick. Her bleeding has picked up today and she is having more pain and passing large clots. She denies feeling lightheaded or dizzy. Denies dysuria or frequency or back pain. She had a low grade temp of 100.0 at home earlier this week. This was a desired pregnancy. Past Medical History: OB: G4P1 - SVD x1 - SAB x1 - TAB x1 GYN: - Denies STIs - LMP: Not sure, ? ___, around 8 weeks per patient PMH: Denies PSH: Denies Meds: - PNV ALL: NKDA Social History: ___ Family History: Noncontributory Physical Exam: INITIAL EXAM Exam: Vitals: 100.3 92 126/86 18 100% RA General: eyes closed, fatigued Resp: breathing comfortably Abd: soft, voluntary gurading, no rebound, mild lower middle abdominal tenderness, not an acute abdomen Pelvic: normal external genitalia, vaginal vault with 2 scopettes of blood, ~10 mL, no purulent discharge or products of conception, cervical oz partially open, no CMT, moderate uterine tenderness, exam limited due to discomfort and anxiety ================= DISCHARGE EXAM Vital signs: ___ ___ Temp: 98.5 PO BP: 100/58 HR: 71 RR: 16 O2 sat: 100% O2 delivery: RA ___ 0005 Temp: 98.8 PO BP: 98/68 HR: 80 RR: 16 O2 sat: 99% O2 delivery: RA General: NAD, comfortable CV: RRR Lungs: normal work of breathing, CTAB Abdomen: soft, non-distended, mild fundal tenderness, no rebound/guarding GU: pad with minimal spotting Extremities: no edema, no TTP, pneumoboots in place bilaterally Pertinent Results: ___ 12:12AM BLOOD WBC-20.1* RBC-3.75* Hgb-11.6 Hct-35.2 MCV-94 MCH-30.9 MCHC-33.0 RDW-12.3 RDWSD-42.5 Plt ___ ___ 12:12AM BLOOD Neuts-81.4* Lymphs-11.6* Monos-5.6 Eos-0.7* Baso-0.1 Im ___ AbsNeut-16.41* AbsLymp-2.33 AbsMono-1.12* AbsEos-0.14 AbsBaso-0.02 ___ 01:05PM BLOOD WBC-22.5* RBC-3.46* Hgb-10.9* Hct-32.0* MCV-93 MCH-31.5 MCHC-34.1 RDW-12.2 RDWSD-41.1 Plt ___ ___ 01:05PM BLOOD Neuts-83.4* Lymphs-10.4* Monos-5.2 Eos-0.2* Baso-0.2 Im ___ AbsNeut-18.77* AbsLymp-2.33 AbsMono-1.17* AbsEos-0.05 AbsBaso-0.04 ___ 06:40AM BLOOD WBC-9.5 RBC-3.28* Hgb-10.2* Hct-31.0* MCV-95 MCH-31.1 MCHC-32.9 RDW-12.2 RDWSD-42.5 Plt ___ ___ 07:10AM BLOOD Neuts-38.5 ___ Monos-13.6* Eos-4.6 Baso-0.2 Im ___ AbsNeut-1.93 AbsLymp-2.14 AbsMono-0.68 AbsEos-0.23 AbsBaso-0.01 ___ 07:10AM BLOOD WBC-5.0 RBC-3.30* Hgb-10.2* Hct-31.3* MCV-95 MCH-30.9 MCHC-32.6 RDW-12.4 RDWSD-43.6 Plt ___ ___ 12:12AM BLOOD Glucose-95 UreaN-12 Creat-0.6 Na-140 K-4.0 Cl-103 HCO3-24 AnGap-13 ___ 12:12AM BLOOD ALT-19 AST-18 AlkPhos-78 TotBili-0.4 ___ 12:12AM BLOOD Albumin-3.9 Calcium-8.9 Phos-3.0 Mg-1.5* ___ 12:12AM BLOOD ___ ___ 02:27AM BLOOD Lactate-0.82 Medications on Admission: PNV Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth twice a day Disp #*27 Tablet Refills:*0 2. Doxycycline Hyclate 100 mg PO Q12H RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day Disp #*27 Capsule Refills:*0 3. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*42 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Septic abortion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: EARLY OB US <14WEEKS INDICATION: History: ___ with + home pregnancy test// r/o ectopic LMP: Unknown. 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: ___ early OB ultrasound. FINDINGS: The uterus is anteverted. The endometrium is heterogeneous and vascular. Within the lower uterine segment is an elongated 1.9 x 0.8 x 0.4 cm hypoechoic cystic structure with an echogenic rim representing the previously seen small intrauterine gestational sac seen on most recent prior ___ early OB ultrasound. No yolk sac or embryo is identified. The ovaries are normal. There is small free fluid. IMPRESSION: Intrauterine elongated cystic structure positioned low within the lower uterine segment represents the gestational sac seen in most recent prior ultrasound. However no embryo or yolk sac is seen. Findings are consistent with spontaneous abortion in progress. Correlate with serial HCG. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Pregnant, Vaginal bleeding Diagnosed with Sepsis following complete or unsp spontaneous abortion temperature: 100.3 heartrate: 92.0 resprate: 18.0 o2sat: 100.0 sbp: 126.0 dbp: 86.0 level of pain: 8 level of acuity: 3.0

On ___, Ms. ___ was admitted to the gynecology service after undergoing a manual vacuum aspiration for a septic abortion. Her hospital course is summarized by problem below: *) Septic abortion: At initial presentation, she was febrile with a Tmax of 102.3 on ___. Her labs were notable for a significant leukocytosis which peaked at 22.5 on ___. She underwent a bedside manual vacuum aspiration by GYN while still in the ED and tolerated the procedure well. A bedside transabdominal ultrasound after the procedure showed a thin endometrial stripe without evidence of retained products of conception. Given her Rh negative blood type, she was administered Rhogam. She was empirically treated with IV ampicillin/gentamicin/clindamycin (___) for presumed septic abortion. On ___, she was transitioned to PO doxycycline/Augmentin to complete a 14 day antibiotic course. Her leukocytosis resolved with a WBC of 5.0 on ___. Her BCx were negative. *) Possible UTI: Her initial UA was notable for large blood and leukocytes with negative nitrites. Given her equivocal UA and lack of dysuria, treatment was deferred pending the results of her UCx. Her UCx grew >100,000 CFUs of Group A Strep. She was started on PO Augmentin/Doxycycline for coverage of Group A strep UTI vs septic abortion as etiology of fever. She had clinically improved and had remained afebrile for 48 hours on hospital day 3 and was discharged home on PO antibiotics with outpatient follow up scheduled.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: aspirin / Demerol / Floxin / fluconazole / Motrin / acetaminophen Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: ___: 1. Right iliac vein and IVC venogram. 2. Infrarenal Denali IVC filter deployment. 3. Post-filter placement venogram. 4. Cholangiogram through the 3 external biliary drains, and contrast injection into the percutaneous cholecystostomy drain. 5. Removal of 1 of the right-sided external biliary drains. ___ 1. Patent CBD stents with successful removal of right anterior and left external anchor biliary drains. Gel-Foam embolization the tract was performed. 2. Successful exchange of existing cholecystostomy catheter with new 8 ___ all-purpose drainage catheter. History of Present Illness: The patient is a ___ with a history of non resectable hilar cholangiocarcinoma c/b recurrent ascending cholangitis s/p b/l PDBD and perc chole tube placement, s/p biliary stenting on ___, remote colon CA s/p partial colectomy, HTN, HLD, DM, diastolic CHF, COPD who presented to ___ for acute onset shortness of breath this am. She underwent chest CT and was found to have saddle pulmonary embolism within the main pulmonary artery extending into the right and left pulmonary arteries. At that point she was transferred to ___. In ED she remained hemodynamically stable on ___ l nasal cannula and reported no chest pain or shortness of breath. She denies fever/chills at home. Past Medical History: PAST MEDICAL HISTORY: - DM - asthma, on daily prednisone - thyroid nodules, currently being monitored with ultrasound - paroxysmal afib, not on anticoagulation - hx pancreatic cyst - remote history of colon CA status post partial colectomy in ___ - atrial fibrillation - hypertriglyceridemia - hearing loss - adrenal insufficiency, iatrogenic - peripheral neuropathy - CKD stage II - IPMN, being monitored with regular MRI, most recent in ___ PAST SURGICAL HISTORY: - laparoscopic right colectomy with ileocolonic anastomosis - bilateral oophorectomy in ___. - PTBD x 2 placed ___ - percutaneous cholecystostomy tube placed ___ Social History: ___ Family History: Denies family history of CA. Mother and father with heart disease Physical Exam: VS 98.2 76 110/60 16 93% RA Gen: A&O x3, NAD CV: RRR Pulm: CTAB GI: Soft, NTND. Percutaneous cholecystostomy tube in place and to drainage bag. Site appears C/D/I. Ext: WWP Pertinent Results: ___ CTPA ___: Embolism within the main pulmonary artery extending into the right and left pulmonary arteries, segmental and subsegmental branches resulting in right heart strain. ___ ECG: Sinus rhythm. There is diffuse ST-T wave abnormalities. Cannot rule out underlying myocardial ischemia. There is also prominent early R wave progression. Compared to the previous tracing of ___ wave abnormalities, particularly in the anterolateral leads are new. Clinical correlation is suggested. ___ ___: IMPRESSION: 1. Acute deep venous thrombosis in the right popliteal vein the extending into the right peroneal and posterior tibial veins. 2. No left-sided acute deep venous thrombosis, although visualization of the calf veins is limited. 3. Extensive bilateral subcutaneous edema. ___ ECHOCARDIOGRAM: Conclusions: The left atrium is elongated. Normal left ventricular wall thickness, cavity size, and regional/global systolic function (biplane LVEF = 67 %). The estimated cardiac index is depressed (<2.0L/min/m2). The right ventricular cavity is mildly dilated with borderline normal free wall function. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) 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. The tricuspid valve leaflets are moderately thickened. There is a large echogenic mass (1.5cm) on he anterior tricuspid valve leaflet with highly mobile 1.5 cm extension of the mass on the RA side of the valve. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Large echogenic structure on the tircuspid valve most c/w a vegetation. Moderate to severe tricuspid regurgitation. Moderate pulmonary artery systolic hypertension. ___ IVC FILTER: FINDINGS: 1. Patent normal sized, non-duplicated IVC with 3 right-sided renal veins and 1 left-sided renal vein and no evidence of a clot. 2. Successful deployment of an infra-renal Denali IVC filter. 3. One of the external right-sided biliary drains had become dislodged from the liver, and was removed after it was gently injected with contrast to confirm position. 4. Injection of the other 3 drainage catheters confirmed appropriate positioning. IMPRESSION: Successful deployment of a Denali IVC filter. Successful removal of a dislodged external right biliary drain. Medications on Admission: Albuterol 2 puffs q6prn Symbicort 160 mcg-4.5 2 puffs'' Diltiazem HCl 60' Fexofenadine 180' Furosemide 20' Glipizide 5' Glargine 15 units SC qHS Humalog 100 unit/mL SC per ISS bid with lunch & supper Ipratropium-Albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL nebs bid prn Lisinopril 20 mg qd Singulair 10 mg qHS Oxycodone 5 mg qd prn Prednisone 15 mg qd (tapering dose) Ranitidine 150 mg qd Simvastatin 20 mg qHS Sotalol 80 mg bid Trazodone 25 mg qHS Calcium Carbonate-Vitamin D3 - Dosage uncertain Flonase 50mcg IH 2 sprays IN qd prn Humulin ___ 15 units SC before b/f Centrum Silver Women 8 mg iron-400 mcg-300 mcg qd Omega-3 fatty acids-fish oil 360mg-1,200 mg bid Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 2. Diltiazem 30 mg PO BID 3. Docusate Sodium 100 mg PO BID 4. Fluticasone Propionate NASAL 2 SPRY NU DAILY 5. Furosemide 20 mg PO DAILY take as needed 6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth q4 Disp #*30 Tablet Refills:*0 7. PredniSONE 15 mg PO DAILY 8. Ranitidine 150 mg PO DAILY 9. Senna 8.6 mg PO BID 10. Sotalol 80 mg PO BID 11. Vancomycin Oral Liquid ___ mg PO Q6H last dose on ___ 12. Fexofenadine 180 mg PO DAILY 13. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 14. Simvastatin 20 mg PO QPM 15. Calcium 500 With D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral DAILY 16. Centrum Silver Women (multivit-min-iron-FA-lutein) 8 mg iron-400 mcg-300 mcg oral DAILY 17. omega 3-dha-epa-fish oil (omega 3-dha-epa-fish oil;<br>omega-3s-dha-epa-fish oil) 360-1,200 mg oral BID 18. Glargine 15 Units Bedtime Humulin ___ 15 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 19. Warfarin 3 mg PO ONCE Duration: 1 Dose RX *warfarin 3 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: 1. Hilar cholangiocarcinoma 2. Saddle pulmonary emboli 3. Deep vein thrombosis 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: BILAT LOWER EXT VEINS INDICATION: ___ year old woman with bilateral PEs, evaluate for lower extremity DVTs. TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: None. FINDINGS: Right lower extremity: There is normal compressibility, flow, and augmentation of the left common femoral and femoral veins. The right popliteal vein is distended with echogenic intraluminal thrombus with no demonstrable color flow or compressibility. Acute deep venous thrombosis extends into right peroneal and posterior tibial veins. Extensive associated subcutaneous edema is noted. Left lower extremity: There is normal compressibility, flow, and augmentation of the left common femoral, femoral, and popliteal veins. The posterior tibial and peroneal veins are not well demonstrated. Extensive subcutaneous edema is noted. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: 1. Acute deep venous thrombosis in the right popliteal vein the extending into the right peroneal and posterior tibial veins. 2. No left-sided acute deep venous thrombosis, although visualization of the calf veins is limited. 3. Extensive bilateral subcutaneous edema. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 9:30 ___, 15 minutes after discovery of the findings. Radiology Report INDICATION: ___ year old woman with bilateral PEs and right popliteal DVT // place IVC filter COMPARISON: CTs ___ 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: Sedation was provided by administrating divided doses of 0mcg of fentanyl and 1 mg of midazolam. The patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: 1 mg versed, 1% lidocaine CONTRAST: 45 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 3.9 min, 83 mGy PROCEDURE: 1. Right iliac vein and IVC venogram. 2. Infrarenal Denali IVC filter deployment. 3. Post-filter placement venogram. 4. Cholangiogram through the 3 external biliary drains, and contrast injection into the percutaneous cholecystostomy drain. 5. Removal of 1 of the right-sided external biliary drains. 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 neck was prepped and draped in the usual sterile fashion. Under ultrasound and fluoroscopic guidance, the patent and compressible Right internal jugular vein was punctured using a 21G micropuncture needle. Ultrasound images of the access was stored on PACS. A ___ wire was advanced through the micropuncture sheath into the inferior vena cava. A 5 ___ sheath was exchanged for the micropuncture sheath. After the inner dilator was removed, an Omniflush catheter was advanced over the wire into the IVC. The ___ wire was advanced into the right common iliac vein and the catheter tip was advanced into the right common iliac vein. A right common iliac and inferior vena cava venogram was performed. Based on the results of the venogram, detailed below, a decision was made to place a Denali retrievable filter. The catheter and sheath were removed over the wire and the sheath of a Denali filter was advanced over the wire into the IVC past the take-off of the renal vessels. An Denali vena cava filter was advanced until the cranial tip was at the level of the inferior margin of the lower renal vein. The sheath was then withdrawn until the filter was deployed. The wire and loading device were then removed through the sheath and a repeat contrast injection was performed, confirming appropriate filter positioning. The final image was stored on PACS. The sheath was removed and pressure was held for 10 minutes, at which point hemostasis was achieved. A sterile dressing was applied. It was noted that one of the external biliary drains projected outside the liver. Contrast injection was performed through the drain, which confirmed inappropriate location. It was noted from the records that this particular tube had not drained bile recently. The suture was cut, and the hub of the catheter was removed. The tube was then gently removed from the skin. A sterile dressing was applied. The other 3 drains were injected with contrast, confirming appropriate position. The patient tolerated the procedure well and there were no immediate post procedure complications. FINDINGS: 1. Patent normal sized, non-duplicated IVC with 3 right-sided renal veins and 1 left-sided renal vein and no evidence of a clot. 2. Successful deployment of an infra-renal Denali IVC filter. 3. One of the external right-sided biliary drains had become dislodged from the liver, and was removed after it was gently injected with contrast to confirm position. 4. Injection of the other 3 drainage catheters confirmed appropriate positioning. IMPRESSION: Successful deployment of a Denali IVC filter. Successful removal of a dislodged external right biliary drain. RECOMMENDATION(S): This IVC filter is removable, and can be removed with the patient no longer needs it. Radiology Report INDICATION: ___ year old woman with hilar cholangiocarcinoma with multiple PTBDs now with inrernal stents. // please evaluate patency of the biliary stents and remove external drains. COMPARISON: ___ TECHNIQUE: OPERATORS: Dr. ___, Interventional Radiology Fellow and Dr. ___, attending radiologist performed the procedure. Dr. ___ ___ personally supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 50 mcg of fentanyl and 1 mg of midazolam throughout the total intra-service time of 31 mis during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site MEDICATIONS: Fentanyl, Versed, ceftriaxone CONTRAST: 35 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 6.8 min, 14 mGy PROCEDURE: 1. Over-the-wire cholangiogram through existing right anterior percutaneous transhepatic biliary drainage access. 2. Removal of right anterior percutaneous transhepatic biliary drainage catheter with Gel-Foam embolization of the tract. 3. Over-the-wire cholangiogram through existing left percutaneous transhepatic biliary drainage access. 4. Removal of the left percutaneous transhepatic biliary drainage catheter with Gel-Foam embolization of the tract. 5. Cholecystogram 6. Exchange of cholecystostomy with a new 8 ___ all-purpose drainage catheter. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The right and mid abdomen was prepped and draped in the usual sterile fashion. Initial scout images showed biliary drain in the appropriate position. Both tubes were injected with dilute contrast. The images were stored on PACS. Following the subcutaneous injection of 1% lidocaine and instillation of lidocaine jelly into the skin site, the right anterior catheter was cut and a ___ wire was advanced through the catheter into the biliary tree. The catheter was removed over the wire. An 8 ___ by 25 cm sheath was advanced over the wire. A pull back cholangiogram was then performed with findings as outlined below. After appropriate positioning of the sheath, within the liver tract, 2 Gel-Foam pledgets were deployed with subsequent removal of the sheath. Attention was then turned to the left percutaneous transhepatic biliary access. Following the subcutaneous injection of 1% lidocaine and instillation of lidocaine jelly into the skin site, the left catheter was cut and ___ wire was advanced through the catheter into the biliary tree. The catheter was removed over the wire. An 8 ___ by 10 cm sheath was advanced over the wire. A pull back cholangiogram was then performed with findings as outlined below. After appropriate positioning of the sheath, within the liver tract, 2 Gel-Foam pledgets were deployed with subsequent removal of the sheath. Examinatin of the cholecystostomy tube showed that the hub was cracked. The cholecystostomy tube was injected with dilute contrast. The catheter was cut. A stiff Glidewire was advanced through the cholecystostomy tube and coiled into the gallbladder lumen. The catheter was removed over the wire. A new 8 ___ all-purpose drainage catheter was advanced into the gallbladder lumen. The wire and inner stiffener were removed. The loop was formed and locked. The catheter was flushed. Dilute contrast was injected confirm position. A stat lock device and suture were used to secure the catheter. A sterile dressing was applied. The patient tolerated the procedure well and there were no immediate post-procedure complications. FINDINGS: 1. Right anterior and left biliary access cholangiograms demonstrate patent biliary stents with prompt flow of contrast through the biliary stent into the small bowel. 2. Successful removal of the left and right anterior biliary external anchor drains with subsequent Gel-Foam embolization of the tract. 3. Cholecystogram demonstrates multiple gallstones within the gallbladder. No contrast flows into the common bile duct, suggesting continued cystic duct obstruction. 4. Successful exchange of 8 ___ cholecystostomy tube with a new 8 ___ all-purpose drainage catheter. IMPRESSION: 1. Patent CBD stents with successful removal of right anterior and left external anchor biliary drains. Gel-Foam embolization the tract was performed. 2. Successful exchange of existing cholecystostomy catheter with new 8 ___ all-purpose drainage catheter. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Dyspnea, PE, Transfer Diagnosed with Saddle embolus of pulmonary artery w/o acute cor pulmonale temperature: 98.5 heartrate: nan resprate: 18.0 o2sat: 98.0 sbp: 105.0 dbp: 71.0 level of pain: 1 level of acuity: 1.0

Ms. ___ with unresectable cholangiocarcinoma was transferred to the Surgical Oncology Service from OSH with new saddle PE. MASCOT was consulted on admission and systemic thrombolysis was not recommended by the team. Patient was started on Heparin drip and was admitted in ICU. LENIs done, revealed clot in right popliteal vein. Patient's PTBDs and perc. chole tube were initially left open to gravity drainage. She was started on Cefepime after her bile cultures was positive for GNRs, she was continued on PO Vancomycin for C.diff colitis. On HD 2, patient was noticed decreased PLT and HIT was sent, patient was transitioned to Bivalrudin. She underwent IVC filter placement on ___ and cholangiogram. Her right posterior PTBD was also removed on ___. On HD 3, patient's HIT was negative, she was transitioned back to Heparin drip and started on Coumadin. On HD 4, patient's right anterior and left lateral PTBDs were capped with LFTs stable afterwards, percutaneous cholecystostomy tube was left to gravity drainage. She was transferred to the floor. On ___, her heparin gtt was discontinued and she was started on Lovenox to Coumadin bridge with appropriate dosing throughout the rest of her hospitalization for INR goal of ___. Patient had CyberKnife Radiation teaching session by Rad/Onc, and plan to start radiation treatment next week. On ___, she underwent a cholangiogram and removal of her remaining 2 PTBDs and exchange of her perc chole tube which was still left to gravity. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. She was discharged on Coumadin with instructions to have her INR checked on ___ and with scheduled followup with her PCP for anticoagulation management. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: ___ Toe Pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with history of HTN, HLD, pHTN, PAD, CAD, s/p SFA to DP bypass on ___ with composite vein for thrombosed L pop pseudoaneurysm, complicated by occlusion of graft and unsuccessful attempt at revascularization on ___ now presenting with unrelenting LLE ischemic rest pain, more severe at his ___ left toe. He denies any bruising but does note mild redness of the dorsal aspect of that left ___ toe. Pain of that LLE improves with dangling feet and standing. Oxycodone tablets he was given post-angio have modest effect but do not resolve the pain. He denies fevers/chills, SOB, CP, or nausea/vomiting. (+) per HPI (-) Denies fevers chills, night sweats, unexplained weight loss, fatigue/malaise/lethargy, changes in appetite, trouble with sleep, pruritis, jaundice, rashes, bleeding, easy bruising, headache, dizziness, vertigo, syncope, weakness, paresthesias, nausea, vomiting, hematemesis, bloating, cramping, melena, BRBPR, dysphagia, chest pain, shortness of breath, cough, edema, urinary frequency, urgency Past Medical History: HTN, HLD, Pulmonary HTN, Popliteal Artery Aneurysm, Peripheral Arterial Disease, and CAD. Social History: ___ Family History: Denies CAD, DM, malignancy or aneurysms Past Surgical History: ___ LLE angio ___ LLE SFA to DP bypass ___ LLE angio Physical Exam: VITALS: Temp 98.6, HR 76, BP 145/84, RR 18, SpO2 94% GEN: NAD, well appearing HEENT: NCAT, EOMI, no scleral icterus CV: RRR, no murmurs or rubs, radial pulses 2+ b/l RESP: CTAB, breathing comfortably on room air GI: soft, non-TTP, +BS, no R/G/D EXT: warm, there is a 1x1 cm dry, superficial ulcer on the tip and plantar surface of the ___ left toe with no erythema, purulence or bleeding; there is an overlying eschar PULSES: R: p/d/d/d L: d/d/faint d/ Pertinent Results: ___ 08:00AM BLOOD WBC-7.4 RBC-5.02 Hgb-15.5 Hct-47.3 MCV-94 MCH-30.9 MCHC-32.8 RDW-12.1 RDWSD-41.9 Plt ___ ___ 03:27AM BLOOD WBC-5.9 RBC-4.92 Hgb-15.1 Hct-47.0 MCV-96 MCH-30.7 MCHC-32.1 RDW-12.0 RDWSD-42.2 Plt ___ ___ 03:27AM BLOOD Neuts-46.8 ___ Monos-9.0 Eos-2.0 Baso-0.7 Im ___ AbsNeut-2.77 AbsLymp-2.44 AbsMono-0.53 AbsEos-0.12 AbsBaso-0.04 ___ 08:00AM BLOOD Glucose-92 UreaN-15 Creat-1.2 Na-139 K-3.8 Cl-99 HCO3-25 AnGap-19 ___ 08:00AM BLOOD Calcium-9.7 Phos-4.2 Mg-2.0 LEFT FOOT XR: ___ No fracture, dislocation, or radiographic evidence of osteomyelitis. Moderate osteoarthritis worst at the first MTP. Medications on Admission: Medications - Prescription IBUPROFEN - ibuprofen 600 mg tablet. 1 tablet(s) by mouth every 6- 8 hours as needed PRN - (Prescribed by Other Provider) LISINOPRIL - lisinopril 10 mg tablet. 1 tablet(s) by mouth daily - (Prescribed by Other Provider) METOPROLOL SUCCINATE - metoprolol succinate ER 50 mg tablet,extended release 24 hr. 1 tablet(s) by mouth DAILY - (Prescribed by Other Provider) Medications - OTC ASPIRIN - aspirin 500 mg tablet,delayed release. 1 tablet(s) by mouth every 8 hours for pain PRN - (Prescribed by Other Provider) ASPIRIN [ASPIR-81] - Aspir-81 81 mg tablet,delayed release. 1 tablet(s) by mouth DAILY - (Prescribed by Other Provider) Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Severe RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 3. Aspirin 81 mg PO DAILY 4. Lisinopril 10 mg PO DAILY 5. Metoprolol Succinate XL 50 mg PO DAILY 6. Simvastatin 20 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Peripheral Vascular Disease Non-Healing Toe Ulcer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: FOOT AP,LAT AND OBL LEFT INDICATION: ___ man with left fourth toe pain, history of peripheral vascular disease, evaluate for evidence of acute infectious process. TECHNIQUE: 3 nonweightbearing views of left foot. COMPARISON: None available. FINDINGS: There is no evidence of fracture or dislocation. There is patchy diffuse subjective osseous demineralization. Moderate osteoarthritis is most pronounced at the first MTP. There is no evidence of subcutaneous emphysema or osteolysis to suggest osteomyelitis. A fragmented os peroneum is noted. No evidence of ankle effusion. ___ fat pad is intact. No worrisome focal lytic or sclerotic osseous lesion is seen. Vascular calcifications are seen throughout the left foot. IMPRESSION: No fracture, dislocation, or radiographic evidence of osteomyelitis. Moderate osteoarthritis worst at the first MTP. Gender: M Race: HISPANIC/LATINO - DOMINICAN Arrive by WALK IN Chief complaint: Toe pain Diagnosed with Peripheral vascular disease, unspecified temperature: 99.0 heartrate: 84.0 resprate: 18.0 o2sat: 100.0 sbp: 131.0 dbp: 71.0 level of pain: 9 level of acuity: 2.0

Mr. ___ was admitted to the ___ ___ control of his pain secondary to a non-healing toe ulcer from his substantial peripheral vascular disease. He was admitted to the vascular surgery service for observation and his pain was controlled with additional pain medications. Upon further discussion and review of his previous imaging with Dr. ___ vascular team decided that we would discharge the patient home with the appropriate pain control and see him in clinic in 10 days. Due to his substantial vascular occlusive disease in his left lower extremity, we will consider direct pedal access and retrograde access into his occluded bifurcation region. Dr. ___ will ultimately make this decision on follow up. Patient was discharged with the appropriate medications and follow up instructions.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Ataxia, altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old female with h/o transverse colon cancer - ___ positive LNs) s/p resection and chemotherapy along with history of papillary thyroid cancer, s/p radioactive iodine treatment in ___ and now with active refractory IgA myeloma with pancytopenia currently due for cycle 2 of CyBorD. She presented to he primary oncologist- Dr. ___ ___ office on the day of presentation with failure to thrive and frequent falls which lead Dr. ___ to seek medical admission. In the ED she triggered for altered mental status. (Triage Vitals: 99.2 94 121/45 18 96%) Radiology Studies: Head CT negative, CXR: COPD with tiny bilateral effusions. Possible pulmonary arterial hypertension accounting for the relative enlargement of the hilar vascular structures. Upon arrival to the floor she denies pain. She notes that she may be having some difficulty breathing. Apart from that she is unable to give a history. Her limited ROS is negative except as described above because of her delirium. Past Medical History: PAST ONCOLOGY HISTORY - Taken from Dr. ___ notes: The patient is a ___ with a history of transverse colon cancer, presented with perforation and abscess, T4-N2 tumor, ___ positive nodes, was resected in ___ by Dr. ___. She had a CEA which was 5.7.Plan for FOLFOX 6,then switched to ___ secondary toxicity. This was completed ___. Re-anastomosis in ___. Last colonoscopy with Dr. ___ at ___ ___ showed adenomas. Repeat in ___ years was recommended. The patient also has a history of papillary thyroid cancer, s/p radioactive iodine treatment ___. She is currently on thyroid replacement. ___: Back pain, MRI showed expansile lytic lesion right sacrum at S2-3. CT scans and bone scan negative for additional disease. PET scan was negative for additional areas of disease given history of thyroid and colon cancer. ___: Biopsy +plasma cell dyscrasia ___ plasma cells. Very poor and hypocellular specimen however. ___: COmpleted XRT to right sacral mass. 5010Gy with Dr. ___. ___: Started weekly velcade and Decadron (velcade 1.3mg/m2 SQ ) ___: transition to Revlimid 15mg days ___ cycle, monthly Zometa ___: Started Cy/Bor/D at ___ for rise in IgA, pancytopenia. ___: Hosp'd CCH for FFT, CHF, pneumonia. ECHO showed rt heart failure and pulmonary HTN. Fat pad bx neg for amyloid. Given Vel/Dex while hosp'd as plts very low. ___: Cytoxan held. Given Vel/Dex. Other PMH: Hypertension, Gastroesophageal Reflux Disease PSH: colon surgery for cancer with colostomy, reversal colostomy, Bilateral eye cataract extraction, right shoulder rotator cuff repair, left knee scope Social History: ___ Family History: Her mother died of an MI. She is unable to state details regarding her father's health. Physical Exam: ADMISSION: 98.2 120/50 p95-100 R18 96%RA General: Very cachectic elderly female, weak, lying in bed HEENT: left suborbital ecchymosis Neck: Supple with full ROM. No meningismus CV: S1, S2 regular. JVP elevated to 10cm Lungs: bibasilar faint crackles. Abdomen: soft, nontender, nondistended Ext: 1+ pitting edema bilaterally Neuro: Oriented to name. Cannot name hospital. Knows she's in ___. Severe speech latency and word finding difficulties. Unable to spell WORLD fwds or backwords. Alert. EOMI. Motor strength ___ to proximal muscles in UE and ___ bilaterally. ___ ankle and wrist extension and flexion. Symmetric, with no focal deficits. Gait deferred. No truncal ataxia. No pronator drift. No asterixis. Skin: Ecchymosis in multiple areas, including arms, face, and back DISCHARGE: Vitals: 97.6 119/61 94 16 94% RA General: Very thin elderly female, weak, lying in bed HEENT: Left suborbital ecchymosis, Right eye non-reactive, L eye reactive to light Neck: Supple with full ROM. No meningismus CV: S1, S2 regular. JVP at 7 cm Lungs: Clear to auscultation this morning Abdomen: Soft, normoactive BS, no TTP Ext: No ___ edema Neuro: Alert and oriented to self, ___, oriented to date and year but not month (thought ___. Able to say days of the week backwards. Significant word finding difficulty Motor strength ___ to proximal muscles in UE and ___ bilaterally. ___ ankle and wrist extension and flexion. Symmetric, with no focal deficits. Skin: Ecchymosis in multiple areas, including arms, face, and back Pertinent Results: ADMISSION LABS ___ 11:45PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 11:45PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-6.0 LEUK-NEG ___ 11:45PM URINE RBC-4* WBC-2 BACTERIA-NONE YEAST-NONE EPI-1 ___ 11:45PM URINE MUCOUS-RARE ___ 11:45PM URINE MUCOUS-RARE ON ADMISSION: ___ 07:57PM GLUCOSE-112* UREA N-16 CREAT-0.8 SODIUM-138 POTASSIUM-4.7 CHLORIDE-104 TOTAL CO2-23 ANION GAP-16 ___ 07:57PM estGFR-Using this ___ 07:57PM ALT(SGPT)-21 AST(SGOT)-35 ALK PHOS-63 TOT BILI-1.0 ___ 07:57PM LIPASE-38 ___ 07:57PM proBNP-6555* ___ 07:57PM ALBUMIN-3.3* CALCIUM-8.7 PHOSPHATE-3.1 MAGNESIUM-2.4 ___ 07:57PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 07:57PM LACTATE-1.4 ___ 07:57PM WBC-5.2 RBC-2.74*# HGB-8.8*# HCT-27.8*# MCV-101* MCH-32.0 MCHC-31.6 RDW-21.3* ___ 07:57PM NEUTS-56 BANDS-0 ___ MONOS-8 EOS-2 BASOS-0 ATYPS-3* ___ MYELOS-2* NUC RBCS-9* OTHER-2* ___ 07:57PM HYPOCHROM-NORMAL ANISOCYT-3+ POIKILOCY-1+ MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL SPHEROCYT-OCCASIONAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL TEARDROP-OCCASIONAL ___ 07:57PM PLT SMR-VERY LOW PLT COUNT-52* DISCHARGE LABS ___ 07:25AM BLOOD WBC-5.6 RBC-2.60* Hgb-8.6* Hct-26.2* MCV-101* MCH-33.1* MCHC-32.8 RDW-22.1* Plt Ct-53* ___ 07:25AM BLOOD Plt Ct-53* ___ 07:25AM BLOOD Glucose-89 UreaN-15 Creat-0.9 Na-139 K-4.6 Cl-109* HCO3-21* AnGap-14 ___ 07:25AM BLOOD Calcium-8.3* Phos-4.9* Mg-2.3 ___ 06:00AM BLOOD SerVisc-2.1* ___ 07:05AM BLOOD ALT-21 AST-20 AlkPhos-69 TotBili-1.0 ___ 07:57PM BLOOD Lipase-38 ___ 06:00AM BLOOD CK-MB-4 cTropnT-<0.01 ___ 07:57PM BLOOD proBNP-6555* ___ 07:57PM BLOOD VitB12-256 Hapto-82 ___ 06:15AM BLOOD Ammonia-68* ___ 07:57PM BLOOD TSH-4.0 ___ 07:57PM BLOOD T4-5.7 T3-76* ___ 06:00AM BLOOD Cortsol-11.3 ___ 06:00AM BLOOD CEA-2.2 ___ 07:57PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 07:57PM BLOOD Lactate-1.4 Echo ___ Recent echo at ___ which was negative for changes c/w amyloid- EF = 60% and + mild-to-moderate mitral regurgitation/mild tricuspid regurgitation present/Estimated PA systolic pressure, mildly increased at 34 mmHg above RA pressure. ECG; sinus tach at 100 bpm, low voltages, no acute changes. MRI C-T-L Spine FINDINGS: There is mild thoracolumbar scoliosis. There is retrolisthesis of T12 on L1 and L1 on L2. Alignment of the lumbar spine is otherwise normal. There is no evidence of spinal bone destruction. There are large bilateral pleural effusions. There are changes of degenerative disc disease in the cervical spine with mild canal narrowing but no evidence of spinal cord compression. Degenerative changes in the thoracic spineproduce no encroachment on the spinal canal. In the lumbar spine comment degenerative changes from L2-L5 narrow the spinal canal. These are incompletely evaluated in the absence of axial images. Based on the sagittal images alone, it appears there may be moderate and perhaps severe spinal stenosis at L3-4 and at L4-5. IMPRESSION: No evidence of spinal cord compression. CT HEAD W/O CONTRAST ___: FINDINGS: There is no acute hemorrhage, edema or shift of the midline structures. Prominence of the ventricles and sulci is consistent with global age involutional changes. Scattered periventricular white matter hypodensities, while nonspecific, are presumably sequela from chronic small vessel ischemic disease. The gray-white matter differentiation is preserved, without evidence for an acute territorial vascular infarction. The basal cisterns remain patent. The included paranasal sinuses and mastoid air cells are well aerated. The imaged lenses and globes are normal. The soft tissues and calvarium are unremarkable. Calcifications are noted within the carotid siphons. IMPRESSION: No acute intracranial process. CXR ___ FINDINGS: PA and lateral views of the chest were provided. The lungs are hyperinflated with widened AP diameter of the chest, which likely reflects underlying COPD. There is blunting of the CP angles bilaterally which is compatible with small pleural effusion. Relative prominence of the hilar vascular structures raises potential concern for pulmonary arterial hypertension. Please correlate clinically. The heart size is within normal limits. The mediastinal contour appears normal. There is no pneumothorax. Bony structures are intact. IMPRESSION: COPD with tiny bilateral effusions. Possible pulmonary arterial hypertension accounting for the relative enlargement of the hilar vascular structures. 24 HR EEG ___: CONTINUOUS EEG: The background activity is abnormal. At times, there is a 7.0-7.5 Hz theta rhythm posteriorly. This is not a continuous rhythm. It is interrupted by irregular generalized and occasionally paroxysmal-appearing slowing. The more paroxysmal activity is midline and central and often appears as a triphasic wave. No clear spikes are associated with them. There appears to be slightly greater slowing over the left hemisphere seen mainly on the spectrogram. SPIKE DETECTION PROGRAMS: There were numerous automated spike detections for the paroxysmal triphasic-appearing waves. There were no epileptiform discharges. SEIZURE DETECTION PROGRAMS: There were no automated seizure detections. There were no electrographic seizures. QUANTITATIVE EEG: Trend analysis was performed with Persyst Magic Marker software. Panels included automated seizure detection, rhythmic run detection and display, color spectral density array, absolute and relative asymmetry indices, asymmetry spectrogram, amplitude integrated EEG, burst suppression ratio, envelope trend, and alpha delta ratios. Segments showing abnormal trends were reviewed and showed the mild hemispheric asymmetry suggesting slightly greater left hemisphere pathology. PUSHBUTTON ACTIVATIONS: There were no pushbutton activations. SLEEP: While there was no clear cycling into deeper stages of sleep, there did appear, on occasion, to be some in regular moderate to high amplitude generalized slowing associated clinically with the patient being asleep. This suggests at least some slow wave sleep remnants. CARDIAC MONITOR: Showed a generally regular rhythm with an average rate of 60-80 bpm. IMPRESSION: This is an abnormal continuous ICU monitoring study because of the presence of background slowing with intermittent paroxysmal triphasic waves. This is most compatible with a metabolic encephalopathy. However, there did appear to be slightly greater slowing broadly across the left hemisphere. It is possible there is also structural pathology within the left hemisphere. No clear interictal discharges or more sustained seizure events were detected or recorded. MRI HEAD ___ FINDINGS: The study is compared with the recent NECT dated ___. There is scattered, both discrete and confluent T2-/FLAIR-hyperintensity in bihemispheric subcortical, deep and periventricular white matter, likely representing the sequelae of chronic small vessel ischemic disease, as on the CT. There is no focus of slow diffusion to suggest either acute ischemia or malignant involvement. The principal intracranial vascular flow voids, including those of the dural venous sinuses, are preserved and these structures enhance normally. There is no pathologic parenchymal, leptomeningeal or dural focus of enhancement. There is moderate prominence of the extra-axial CSF spaces, the cortical sulci and fissures and the ventricles and cisterns, representing global atrophy, with a prominent central component and an "etat crible" appearance. There is no intra- or extra-axial hemorrhage or space-occupying lesion. The sella, parasellar region and remainder of the skull base are unremarkable. There is evidence of bilateral ocular lens surgery. The included paranasal sinuses and mastoid air cells are grossly clear. The calvarial, clival and included upper cervical vertebral bone marrow is uniformly T1-hypointense, likely related to the underlying myeloma. IMPRESSION: 1. No acute intracranial abnormality. 2. No space-occupying lesion or pathologic enhancement. 3. Moderate global atrophy with prominent central component, and sequelae of chronic small vessel ischemic disease. 4. Diffuse bone marrow T1-hypointensity, reflecting myelomatous involvement. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Docusate Sodium 100 mg PO BID 3. Furosemide 40 mg PO DAILY 4. Fluoxetine 10 mg PO DAILY 5. BuPROPion (Sustained Release) 450 mg PO QAM 6. Acyclovir 800 mg PO Q12H 7. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 8. Aspirin 81 mg PO DAILY 9. Levothyroxine Sodium 125 mcg PO DAILY 10. Lorazepam 0.75 mg PO HS:PRN insomnia 11. Magnesium Oxide 400 mg PO DAILY 12. Potassium Chloride 20 mEq PO BID 13. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 14. Pregabalin 75 mg PO BID Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Acyclovir 800 mg PO Q8H 3. Aspirin 81 mg PO DAILY 4. BuPROPion (Sustained Release) 150 mg PO QAM 5. Docusate Sodium 100 mg PO BID 6. Fluoxetine 10 mg PO DAILY 7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 8. Levothyroxine Sodium 125 mcg PO DAILY 9. Potassium Chloride 20 mEq PO BID 10. Pregabalin 75 mg PO BID 11. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB/wheezing 12. Cyanocobalamin 250 mcg PO DAILY 13. Ondansetron 4 mg PO Q8H:PRN nausea 14. Senna 1 TAB PO BID:PRN constipation 15. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 16. Furosemide 40 mg PO DAILY 17. Magnesium Oxide 400 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY: Failure to thrive, Encephalopathy/Dementia, Polypharmacy, B12 Deficiency Anemia SECONDARY: IgA Multiple myeloma 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 HISTORY: Altered mental status. Evaluate for intracerebral hemorrhage. TECHNIQUE: Continuous axial sections were acquired through the brain without administration IV contrast. Coronal and sagittal reformations were provided and reviewed. DLP: 1153.83 mGy/cm. CTDIvol: 126.7 mGy. COMPARISON: None. FINDINGS: There is no acute hemorrhage, edema or shift of the midline structures. Prominence of the ventricles and sulci is consistent with global age involutional changes. Scattered periventricular white matter hypodensities, while nonspecific, are presumably sequela from chronic small vessel ischemic disease. The gray-white matter differentiation is preserved, without evidence for an acute territorial vascular infarction. The basal cisterns remain patent. The included paranasal sinuses and mastoid air cells are well aerated. The imaged lenses and globes are normal. The soft tissues and calvarium are unremarkable. Calcifications are noted within the carotid siphons. IMPRESSION: No acute intracranial process. Radiology Report CHEST RADIOGRAPH PERFORMED ON ___. COMPARISON: None. CLINICAL HISTORY: Altered mental status, assess for acute intrathoracic process. FINDINGS: PA and lateral views of the chest were provided. The lungs are hyperinflated with widened AP diameter of the chest, which likely reflects underlying COPD. There is blunting of the CP angles bilaterally which is compatible with small pleural effusion. Relative prominence of the hilar vascular structures raises potential concern for pulmonary arterial hypertension. Please correlate clinically. The heart size is within normal limits. The mediastinal contour appears normal. There is no pneumothorax. Bony structures are intact. IMPRESSION: COPD with tiny bilateral effusions. Possible pulmonary arterial hypertension accounting for the relative enlargement of the hilar vascular structures. Radiology Report HISTORY: Poorly controlled myeloma. TECHNIQUE: Sagittal imaging was performed with T2-T1, and T2 weighted ideal technique. No contrast was administered. COMPARISON: Lumbar spine MR ___. FINDINGS: There is mild thoracolumbar scoliosis. There is retrolisthesis of T12 on L1 and L1 on L2. Alignment of the lumbar spine is otherwise normal. There is no evidence of spinal bone destruction. There are large bilateral pleural effusions. There are changes of degenerative disc disease in the cervical spine with mild canal narrowing but no evidence of spinal cord compression. Degenerative changes in the thoracic spine produce no encroachment on the spinal canal. In the lumbar spine comment degenerative changes from L2-L5 narrow the spinal canal. These are incompletely evaluated in the absence of axial images. Based on the sagittal images alone, it appears there may be moderate and perhaps severe spinal stenosis at L3-4 and at L4-5. IMPRESSION: No evidence of spinal cord compression. Lumbar spine degenerative disc disease with spinal canal stenosis. This is incompletely evaluated, but appears to be most prominent from L2-L5. Radiology Report MR EXAMINATION OF BRAIN WITHOUT AND WITH CONTRAST, ___ HISTORY: ___ female with IgA myeloma presenting with word finding difficulty, mental slowing and failure to thrive, and epileptiform discharges on EEG; ? evidence of mass lesion. TECHNIQUE: Routine ___ enhanced MR examination, comprising axial T1-weighted FLAIR FSE sequences, pre- and post-, and T1-weighted axial SE and sagittal MP-RAGE sequences, post-contrast administration, the latter with axial and coronal reformations. FINDINGS: The study is compared with the recent NECT dated ___. There is scattered, both discrete and confluent T2-/FLAIR-hyperintensity in bihemispheric subcortical, deep and periventricular white matter, likely representing the sequelae of chronic small vessel ischemic disease, as on the CT. There is no focus of slow diffusion to suggest either acute ischemia or malignant involvement. The principal intracranial vascular flow voids, including those of the dural venous sinuses, are preserved and these structures enhance normally. There is no pathologic parenchymal, leptomeningeal or dural focus of enhancement. There is moderate prominence of the extra-axial CSF spaces, the cortical sulci and fissures and the ventricles and cisterns, representing global atrophy, with a prominent central component and an "etat crible" appearance. There is no intra- or extra-axial hemorrhage or space-occupying lesion. The sella, parasellar region and remainder of the skull base are unremarkable. There is evidence of bilateral ocular lens surgery. The included paranasal sinuses and mastoid air cells are grossly clear. The calvarial, clival and included upper cervical vertebral bone marrow is uniformly T1-hypointense, likely related to the underlying myeloma. IMPRESSION: 1. No acute intracranial abnormality. 2. No space-occupying lesion or pathologic enhancement. 3. Moderate global atrophy with prominent central component, and sequelae of chronic small vessel ischemic disease. 4. Diffuse bone marrow T1-hypointensity, reflecting myelomatous involvement. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: FOR EVAL Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, DEFICIENCY ANEMIA NOS, MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION, HYPERTENSION NOS, HX OF COLONIC MALIGNANCY temperature: 99.2 heartrate: 94.0 resprate: 18.0 o2sat: 96.0 sbp: 121.0 dbp: 45.0 level of pain: 13 level of acuity: 1.0

Ms. ___ is a ___ year old woman with a history of colon cancer in remission s/p resection, papillary thyroid cancer s/p ablation, and currently undergoing chemo for IgA Myeloma with cytoxan, velcade, and decadron who presents with altered mental status, frequent falls, failure to thrive. # Encephalopathy - Patient presented with subacute mental status decline x 2 months characterized by increased word finding difficulties. These changes were noted to start at approximately the same time that the patient was started on Decadron. Dexamethasone-induced mental status changes are considered possible, especially given how small this patient is and the time course of her symptoms. Her EEG revealed asymmetric slowing over the left lateral temporal region compatible with possibly vascular or structural abnormality also associated with epileptic discharges. Neurology was consulted and upon review of her MRI there was no underlying structural abnormality as the cause of the EEG findings. Given that she did not have any clinical or definite electrographic seizures there was no indication to start an antiepileptic. An infectious workup of her symptoms was negative. Electrolytes, AM cortisol, and TSH were within normal limtits. Toxicology screen was negative (though would not detect home lorazepam usage). Ammonia level only slightly elevated and the slight elevation would not be expected to cause her symptoms. RPR was negative. Serum viscosity also slightly above normal limits, though again the levels would not be expected to cause her presentation. CEA was obtained to rule out recurrence of her colon cancer and was within normal limits. B12 levels were low and she was started on B12 supplementation. She will continue cyanocobalamin on discharge. # Recurrent falls: The etiology is likely multifactorial and related to atrophic changes noted on her MRI brain combined with failure to thrive. The patient lives alone and per her brother may not be receiving adequate nutrition at home or taking her medications appropriately. There is no evidence of structural heart disease on ___ ECHO. Her orthostatics were negative. Telemetry revealed no evidence of arrhythmia. She did not present with clinical or definite electrographic seizures. MRI did not reveal intracranial structural abnormalities to account for her symptoms and her physical exam did not reveal focal abnormalities. MRI pan-spine without spinal cord lesions, though did have stenosis and degenerative discs. She will be discharged to undergo physical rehabilitation. # B12 deficiency anemia: MCV high, B12 level 256, and hypersegmented neutrophils on peripheral smear. Patient given 1000mcg B12 IM x 5 days during her stay in addition to oral tablets. Hemoglobin was stable this admission. # Polypharmacy: We were unable to reconcile patient's home medications, as it seems she, her family, or her ___ providers could not verify what she is actually taking. We stopped lorazepam indefinitely, reduced her bupropion, and simplified her regimen as best possible. More of her medications may be able to be stopped. ***Strongly suggest thorough medication reconciliation (have her bring in every pill bottle in her home), and reducing/avoiding deliriogenic medications or complex regimens (such as Fluoxetine only on ___ and ___. # Acute ?diastolic CHF exacerbation: On admission, patient was volume overloaded on exam with elevated BNP. Outpatient records indicate a recent normal ECHO and even workup for amyloid disease in the heart (negative). However she does have past exacerbations of heart failure. Here, 40mg of IV lasix resulted in robust diuresis and some reflex tachycardia, so in the future recommend starting with 20mg IV furosemide. She was restarted on home furosemide 40mg PO by discharge. She was breathing comfortably throughout her stay.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Right subclavian CVL placement History of Present Illness: ___ y/o M with hx Clostridium difficile (2 courses of PO vanco, last completed 1 week ago) and CABG at ___ (___) presenting from ___ with hypotension s/p fall. Patient s/p fall earlier today, which was heard but not witnessed by wife. Patient recalled the entire event and denies LOC, neck pain, chest pain, SOB, dizziness, or lightheadedness at the time of the event. He did report a head strike. He reports taking ASA before going to ___. Of note, patient reports significant diarrhea over the past 24 hours despite finishing an C diff treatment one week prior. He had been feeling weak over the past several days. While at ___, patient c/o chest pain and his pressures dropped into the ___. EKG showed new T wave inversions in V2-V6. He was given a IVF bolus and placed on Levophed. Central line was placed. His chest pain and EKG changes resolved prior to arrival at ___. His troponin there was 0.05. He was started on IV ceftriaxone and vancomycin. . Upon arrival to ___, the patient's vital signs were 98, 98, 117/52, 16, 99%. CXRs were unremarkable. CT head and neck were negative. Patient continued to receive IVF and Levophed. He was started on PO vancomycin and a tetanus shot was administered. . On the floor, patient is asymptomatic. He denies having any more chest pain. His BP was stable on Levophed. Past Medical History: CAD s/p CABG (___) Stable Angina (diagnosed by stress test at ___ Hypertension Vertigo Basal cell carcinoma Social History: ___ Family History: Father died of MI at age ___. Mother died at age ___ of stroke. Son had 3 stents placed in his ___. Physical Exam: On admission: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . On discharge: Vitals- 97.6 147/78 92 18 99%RA I/O: this morning 200/850, BMx2; yesterday ___/___, BMx8 General- Alert, oriented, no acute distress HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple Lungs- Clear to auscultation bilaterally, no wheezes, rales, ronchi CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding Ext- warm, well perfused, no clubbing, cyanosis or edema . Pertinent Results: ====================== Labs: ====================== ___ 10:30PM BLOOD WBC-19.6*# RBC-3.77*# Hgb-11.1* Hct-35.2*# MCV-94 MCH-29.6 MCHC-31.6 RDW-15.1 Plt ___ ___ 07:50AM BLOOD WBC-7.7 RBC-3.88* Hgb-11.4* Hct-36.0* MCV-93 MCH-29.3 MCHC-31.6 RDW-15.4 Plt ___ ___ 10:30PM BLOOD Neuts-91.0* Lymphs-3.8* Monos-4.7 Eos-0.1 Baso-0.3 ___ 10:30PM BLOOD ___ PTT-35.4 ___ ___ 07:00AM BLOOD ___ PTT-32.3 ___ ___ 10:30PM BLOOD Glucose-89 UreaN-32* Creat-1.3* Na-137 K-3.5 Cl-108 HCO3-18* AnGap-15 ___ 07:50AM BLOOD Glucose-100 UreaN-5* Creat-0.7 Na-140 K-3.3 Cl-104 HCO3-22 AnGap-17 ___ 04:08AM BLOOD CK(CPK)-81 ___ 10:30PM BLOOD cTropnT-0.02* ___ 04:08AM BLOOD CK-MB-11* MB Indx-13.6* cTropnT-0.12* ___ 03:00PM BLOOD CK-MB-7 cTropnT-0.10* ___ 04:08AM BLOOD Calcium-7.5* Phos-3.2 Mg-1.6 ___ 07:50AM BLOOD Calcium-8.0* Phos-3.7 Mg-1.7 ___ 09:52AM BLOOD Type-CENTRAL VE Temp-36.6 Rates-/16 pO2-40* pCO2-32* pH-7.42 calTCO2-21 Base XS--2 Intubat-NOT INTUBA ___ 10:48PM BLOOD Lactate-2.5* ___ 04:52AM BLOOD Lactate-3.3* ___ 03:04PM BLOOD Lactate-2.0 ====================== Micro: ====================== ___ blood cultures negative ___ 6:35 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Reported to and read back by ___ ___ ___ ST 15:16. CLOSTRIDIUM DIFFICILE. Positive for toxigenic C. difficile by the Illumigene DNA amplification. (Reference Range-Negative). ___ MRSA screen - POSITIVE ====================== Imaging: ====================== ___ CT HEAD: IMPRESSION: No acute intracranial process. . ___ CT C SPINE IMPRESSION: No evidence of fracture or malalignment. Multilevel degenerative changes. . ABDOMEN (SUPINE & ERECT) Study Date of ___ 1:10 AM IMPRESSION: No evidence of megacolon or obstruction. Cholelithiasis. . Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Metoprolol Tartrate 25 mg PO TID Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Metoprolol Tartrate 25 mg PO TID 3. Vancomycin Oral Liquid ___ mg PO SEE INSTRUCTIONS c diff Duration: 86 Doses q6h x 14days; q12h x 7d; q24h x 7d; every other day x 8d (4 doses); every 3 days x 15d (5 doses) RX *vancomycin [Vancocin] 125 mg 1 capsule(s) by mouth see instructions Disp #*86 Capsule Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: C diff Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HEAD CT WITHOUT CONTRAST: ___. HISTORY: ___ male status post fall with head strike. COMPARISON: None. TECHNIQUE: Contiguous axial images obtained from skull base to vertex without intravenous contrast. Coronal and sagittal reformats were reviewed. FINDINGS: There is no acute intra-axial or extra-axial hemorrhage, mass, midline shift, or territorial infarct. Periventricular and subcortical white matter hypodensities are most likely sequela of chronic small vessel disease. The gray-white matter differentiation is preserved. Ventricles and sulci are symmetric and unremarkable. The basilar cisterns are patent. The paranasal sinuses and mastoids are clear. The skull and extracranial soft tissues are unremarkable. Lenses have been replaced bilaterally. Globes are otherwise unremarkable. IMPRESSION: No acute intracranial process. Radiology Report INDICATION: ___ male status post fall with head strike. Question intracranial hemorrhage and fracture. COMPARISONS: None. TECHNIQUE: MDCT axial images were obtained through the cervical spine without the administration of intravenous contrast material. Coronal and sagittal reformats were completed. DLP: 886.4 mGy-cm. CTDIvol: 37.2 mGy. FINDINGS: There is no evidence of fracture, malalignment or prevertebral soft tissue swelling. Vertebral body heights are maintained. There are multilevel degenerative changes with disc space narrowing. A small disc bulge at C3-C4 causes mild central canal narrowing. There is left sided neural foraminal narrowing at every level from C2 to C6 and right sided narrowing at C3-4 and C4-5. The outline of the thecal sac is preserved. The thyroid gland has a tiny hypodensity within the left lobe. The soft tissues are otherwise unremarkable. There is scarring at the lung apices. There are calcifications over the carotid siphons bilaterally. The visualized paranasal sinuses are clear. There is cerumen within the external auditory canals bilaterally. IMPRESSION: No evidence of fracture or malalignment. Multilevel degenerative changes. Radiology Report INDICATION: History of c-diff and sepsis. Question megacolon. COMPARISONS: None. FINDINGS: Portable supine and left lateral decubitus radiographs were provided. There is a non-obstructive bowel gas pattern and no evidence of free air. Air is present within the rectum. A large gallstone is present. The lung bases are clear. The bones are intact. IMPRESSION: No evidence of megacolon or obstruction. Cholelithiasis. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: SYNCOPE Diagnosed with NONINF GASTROENTERIT NEC, CHEST PAIN NOS, SYNCOPE AND COLLAPSE, TETANUS TOXOID INOCULAT temperature: 98.0 heartrate: 98.0 resprate: 16.0 o2sat: 99.0 sbp: 117.0 dbp: 52.0 level of pain: 0 level of acuity: 1.0

___ man with a h/o C diff, CABG in ___, hypertension, vertigo, prior basal cell carcinoma, and other issues admitted with hypotension, diarrhea, and recurrent C diff, initially requiring MICU admission. # C diff / shock. Hypovolemia vs sepsis ___ severe, complicated C diff. This was the patient's third occurance of C diff, and he had recently completed a course of PO vancomycin one week prior to admission. Initial c diff presentation was s/p CABG 2 months prior. Patient with ___ SIRS criteria on presentation in ED, with WBC 19.6 and HR 98. Blood pressure was controlled with IVF and Levophed drip. Patient started on IV vancomycin, IV ceftriaxone, and IV Flagyl in the ED, and was given PO vancomycin upon arrival to the unit. Patient was eventually weaned from pressors and transferred to the floor. On the floor, pt remained afebrile and HD stable. Stool output decreased and leukocytosis resolved; IV flagyl was discontinued and PO vancomycin dose was decreased. Pt was taken off IV fluids. Pt to complete long (~7 week) PO vancomycin taper per ID recommendation and will follow up with ID. . # Chest pain / EKG changes. Patient had c/o chest pain at ___ and had some T wave inversions that correlated with his drop in pressure; those resolved fairly soon afterward. Patient had a history of stable angina. His initial troponin was 0.05, repeat in BIDMCED downtrending to 0.02. He did transiently had an increase in his troponin to 0.12, but he soon thereafter downtrended. He was transiently started on heparin drip in the interim. He did not experience any other chest pain during hospitalization. Felt likely due to demand ischemia. Once blood pressure recovered, was continued on home metoprolol as well as aspirin. . # Anemia: Likely due to inflammation in the setting of C diff infection and IVF resuscitation. No symptoms or signs of active blood loss. Hct improved gollowing admission. . # Hyponatremia: Likely due to volume resuscitation with LR; improved prior to discharge. . # Coagulopathy: His INR was elevated to 2.0 for unclear reasons – possibly decreased vitamin K in the setting of c diff and copious diarrhea. INR corrected to 1.3 after receiving Vitamin K doses. . #HTN: Continued on metoprolol once blood pressure recovered. .

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Ceftriaxone / Strawberry / Bleach Attending: ___. Chief Complaint: adominal pain, leaking HD artieral port. Major Surgical or Invasive Procedure: Hemodialysis Catheter Replacement History of Present Illness: Ms. ___ is a ___ female with history of morbid obesity, end-stage renal disease on HD ___, pulmonary hypertension, diabetes, dCHF, and prior DVTs on chronic warfarin who presents with abdominal pain. Pt reports diffuse lower abdominal pain and nausea starting on ___, two days prior to admission. The patient describes the pain as pressure on her right side with radiation to the suprapubic region. The pain continued and peaked today with a sensation of constipation. She reports no BM since ___, though she usually only has hard stool pellets every 3 days. In the ED, initial VS: Labs notable for: WBC 8.9, K 7.4 (non-hemolyzed), INR 2.3, ALT 38, AST 87, AP 205. Imaging with unremarkable CXR and CT ab/pelvis. Given hyperkalemia in anuric pt, she underwent HD with minimal fluid removed. Post-HD, the femoral tunneled line was noted to have leaking port from malfunctioning clamp on arteral (red) port. A ___ clamp was placed, and ___ was consulted with plans to replace line in AM oin ___. Pt. received levofloxacin 500mg IV and home ___ meds while in the ED. Upon arrival to the floor, VS: 98.5F, 104/50, 92, 16, 98% 2L nc. Pt reports that she feels hungry and thirsty. She began to pass significant amounts of flatus while in HD and her abdominal pain is significantly better. ROS: (+) per HPI (-) fever, chills, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, vomiting, diarrhea, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: diastolic CHF, DVT's (bilateral IJ, bilateral legs), atrial tachycardia, PAD, OSA, hyperlipidemia, HTN, R breast mass PSH: R femoral endarterectomy ___, LUE AV fistula/revision/removal ___, R AKA ___ Social History: ___ Family History: Two children with asthma. Strong family hx of cancer (many uncles / aunts with lung cancer, father had prostate cancer, mother has HCC ___ alcoholic hepatitis) Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 110kg (dry weight appears to be around 105kg), T 98.4, HR ___, BP 115/38, 20, 99 on 2L (home O2) General: obese woman in bed in no acute distress HEENT: PERRL, coated tongue, moist mucous membranes CV: RRR, normal s1, s2, no m/r/g Lungs: clear to auscultation bilaterally, though limited based on body habitus Abdomen: soft, distended, umbilical hernia, mild tenderness to palpation throughout, no ___ sign, no guarding Ext: R above the knee amputation, L leg with no edema. Access: L femoral tunneled HD line without erythema, exudate, or tenderness, arterial port clamped DISCHARGE PHYSICAL EXAM: Vitals: T: 98.5 ___ HR ___ 20 100% 2L General: Alert, oriented x3 HEENT: Sclera anicteric, MMM Lungs: No increased work of breathing, fair air exchange, no wheezes, rales or rhonchi. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Soft, obese, tender in the RLQ and LLQ. Ext: R AKA, warm, well perfused, 2+ pulse, no clubbing, cyanosis or edema. Neuro: AAOx3 Access: L femoral tunneled HD line without erythema, exuadate, or tenderness. Pertinent Results: ADMISSION LABS: ___ 04:30PM UREA N-11 ___ 11:45AM SODIUM-129* POTASSIUM-7.4* CHLORIDE-93* ___ 10:43AM LACTATE-2.6* K+-6.8* ___ 10:03AM K+-6.6* ___ 07:30AM GLUCOSE-141* UREA N-66* CREAT-6.9*# SODIUM-131* POTASSIUM-9.0* CHLORIDE-93* TOTAL CO2-23 ANION GAP-24* ___ 07:30AM estGFR-Using this ___ 07:30AM ALT(SGPT)-38 AST(SGOT)-87* ALK PHOS-205* TOT BILI-0.4 ___ 07:30AM ALBUMIN-3.9 CALCIUM-9.2 PHOSPHATE-5.9* MAGNESIUM-2.6 ___ 07:30AM WBC-8.9# RBC-3.74* HGB-12.2 HCT-39.8 MCV-106* MCH-32.6* MCHC-30.7* RDW-14.8 RDWSD-57.7* ___ 07:30AM NEUTS-76.2* LYMPHS-15.6* MONOS-6.4 EOS-1.0 BASOS-0.3 IM ___ AbsNeut-6.74* AbsLymp-1.38 AbsMono-0.57 AbsEos-0.09 AbsBaso-0.03 ___ 07:30AM PLT COUNT-276 ___ 07:30AM ___ PERTINENT RESULTS: VANC TROUGHS: ___ 07:00AM BLOOD Vanco-7.3* ___ 09:15PM BLOOD Vanco-17.7 ___ 07:15AM BLOOD Vanco-18.1 ___ 07:45AM BLOOD Vanco-14.3 ___ 06:29AM BLOOD Vanco-16.7 ___ 06:20AM BLOOD Vanco-20.4* ___ 05:50AM BLOOD Vanco-19.4 ___ 06:40AM BLOOD VitB12-976* ___ 06:07AM BLOOD Cortsol-9.9 INRS: ___ 07:00AM BLOOD ___ PTT-36.8* ___ ___ 09:15PM BLOOD ___ PTT-37.8* ___ ___ 07:15AM BLOOD ___ PTT-39.7* ___ ___ 07:15AM BLOOD ___ PTT-39.7* ___ ___ 07:14AM BLOOD ___ PTT-38.5* ___ ___ 06:29AM BLOOD ___ PTT-41.6* ___ ___ 07:09AM BLOOD ___ PTT-37.6* ___ ___ 09:30AM BLOOD ___ PTT-36.7* ___ ___ 06:29AM BLOOD ___ PTT-37.4* ___ ___ 11:15AM BLOOD ___ PTT-36.2 ___ ___ 06:20AM BLOOD ___ PTT-38.2* ___ ___ 05:50AM BLOOD ___ PTT-38.4* ___ ___ 06:00AM BLOOD ___ PTT-36.9* ___ ___ 07:30AM BLOOD ___ DISCHARGE LABS: ___ 07:00AM BLOOD WBC-7.5 RBC-3.04* Hgb-9.8* Hct-32.7* MCV-108* MCH-32.2* MCHC-30.0* RDW-14.0 RDWSD-54.4* Plt ___ ___ 07:00AM BLOOD Plt ___ ___ 07:00AM BLOOD ___ PTT-36.8* ___ ___ 07:00AM BLOOD Glucose-213* UreaN-29* Creat-4.5*# Na-132* K-3.7 Cl-90* HCO3-26 AnGap-20 ___ 07:00AM BLOOD Calcium-9.1 Phos-3.9 Mg-2.0 ___ 07:00AM BLOOD Vanco-7.3* PERTINENT IMAGING: ___ CT ABDOMEN/PELVIS W/ CONTRAST IMPRESSION: Nonacute CT of the abdomen and pelvis, without evidence of small bowel obstruction, diverticulitis, or appendicitis. No drainable fluid collection. ___ TUNNEL DIALYSIS REPLACE IMPRESSION: Successful exchange of a 43 cm tip to cuff length tunneled dialysis line. The tip of the catheter terminates in the suprarenal IVC. The catheter is ready for use. MICROBIOLOGY: ___ 12:29 pm BLOOD CULTURE Source: Line-HD. **FINAL REPORT ___ Blood Culture, Routine (Final ___: STREPTOCOCCUS GALLOLYTICUS SSP PASTEURIANUS. FINAL SENSITIVITIES. VANCOMYCIN MIC<=0.12MCG/ML. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STREPTOCOCCUS GALLOLYTICUS SSP PASTEURIANUS | CLINDAMYCIN----------- 0.5 I ERYTHROMYCIN----------<=0.12 S PENICILLIN G---------- 0.12 S VANCOMYCIN------------ S Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Reported to and read back by ___ ___ 9:35AM. BLOOD CULTURES ___ NO GROWTH Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amiodarone 200 mg PO DAILY 2. Nephrocaps 1 CAP PO DAILY 3. Cinacalcet 60 mg PO DAILY 4. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin 5. Paroxetine 40 mg PO DAILY 6. sevelamer CARBONATE 1600 mg PO TID W/MEALS 7. Warfarin 5 mg PO DAILY16 8. Bisacodyl 10 mg PO DAILY:PRN constipation 9. Senna 8.6 mg PO BID 10. Docusate Sodium 200 mg PO BID 11. Omeprazole 20 mg PO DAILY 12. Lubiprostone 8 mcg PO BID MWFSUN 13. Nepro Carb Steady (nut.tx.impaired renal fxn,soy) 120 mL oral BID 14. Magnesium Citrate 300 mL PO 1X/WEEK (___) 15. Prochlorperazine 25 mg PR Q12H:PRN nausea/vomiting 16. Simethicone 80 mg PO QID:PRN gas 17. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheeze 18. Calcium Carbonate 500 mg PO QID:PRN heartburn 19. Bisacodyl 10 mg PR QHS:PRN constipation 20. DiphenhydrAMINE 25 mg PO BID:PRN itch 21. Acetaminophen 500 mg PO Q4H:PRN pain Discharge Medications: 1. Outpatient Lab Work ICD9 code: ___ bacteremia ALL LAB RESULTS SHOULD BE SENT TO: ATTN: ___ CLINIC - FAX: ___ WEEKLY LABS: CBC with differential, BUN, Cr, ESR, CRP THREE TIMES WEEKLY: Vancomycin random level prior to HD for goal trough ___. 2. Acetaminophen 500 mg PO Q6H:PRN pain 3. Amiodarone 200 mg PO DAILY 4. Bisacodyl 10 mg PO DAILY:PRN constipation 5. Bisacodyl 10 mg PR QHS:PRN constipation 6. Cinacalcet 60 mg PO DAILY 7. Docusate Sodium 200 mg PO BID 8. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin 9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheeze 10. Nephrocaps 1 CAP PO DAILY 11. Omeprazole 20 mg PO DAILY 12. Paroxetine 40 mg PO DAILY 13. Senna 8.6 mg PO BID 14. sevelamer CARBONATE 1600 mg PO TID W/MEALS 15. Vancomycin 1000 mg IV HD PROTOCOL 16. Calcium Carbonate 500 mg PO QID:PRN heartburn 17. DiphenhydrAMINE 25 mg PO BID:PRN itch 18. Lubiprostone 8 mcg PO BID MWFSUN 19. Magnesium Citrate 300 mL PO 1X/WEEK (___) 20. Nepro Carb Steady (nut.tx.impaired renal fxn,soy) 120 mL oral BID 21. Prochlorperazine 25 mg PR Q12H:PRN nausea/vomiting 22. Simethicone 80 mg PO QID:PRN gas Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnoses: Abdominal pain, Malfunctioning Left Femoral Tunnel Dialysis Catheter, Positive Blood Culture Secondary Diagnoses: ESRD, IDDM, Bilateral ___ DVTs, Pulmonary HTN 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 AP AND LATERAL INDICATION: ___ with ESRD on dialysis, DM, who presents with abdominal pain. Rule out pneumonia. TECHNIQUE: Chest AP and lateral COMPARISON: Chest radiograph from ___ and ___. Correlation with CT Abd and pelvis from the same day. FINDINGS: Compared to the prior radiograph, lung volumes remain low. Streaky opacity in the left lung base is likely atelectasis, and similar to the prior radiograph. No focal opacity identified at the left lung base on concurrent CT. Moderate cardiomegaly is unchanged. The mediastinal and hilar contours are stable. No pneumothorax is identified. IMPRESSION: No focal consolidation concerning for pneumonia. Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ with 5 days progressive abd pain. IDDM dialysis, peritoneal exam + guarding concern for SBO or diverticulitis. R/o intra-abdominal infection/ abscess. TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Coronal and sagittal reformations were performed and reviewed on PACS. No oral contrast was administered. DOSE: Total DLP (Body) = 930 mGy-cm. IV Contrast: 150 mL Omnipaque COMPARISON: CT abdomen and pelvis from ___ and ___. FINDINGS: LOWER CHEST: There is bibasilar atelectasis, but no pleural effusion 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 bilateral native kidneys are atrophic, but enhance symmetrically without suspicious focal lesion or hydronephrosis. Tiny bilateral hypodensities, too small to characterize, are unchanged. GASTROINTESTINAL: The stomach is unremarkable. Incidental note is made of a duodenal diverticulum (2:39). Small bowel loops demonstrate normal caliber, wall thickness and enhancement throughout. Incidentally noted ascending colonic diverticula, without evidence of diverticulitis, noted. Colon and rectum are within normal limits. Appendix contains air, has normal caliber without evidence of fat stranding. There is no evidence of mesenteric lymphadenopathy. There is a very small amount of ascites (601b:27). RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. There is moderate calcium burden in the abdominal aorta. Extensive atherosclerotic calcification at the origin of the SMA is again seen. Asymmetric ill-defined irregularity of the right common femoral vein is again identified, but unchanged since ___. The left common femoral approach venous dialysis catheter terminates in the hepatic IVC. PELVIS: The urinary bladder is decompressed. The distal ureters are unremarkable. There is no evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: An enlarged fibroid uterus with numerous dystrophic calcifications is stable in appearance. BONES AND SOFT TISSUES: Unchanged degenerative changes are seen in the lumbar spine. Abdominal and pelvic wall is within normal limits. IMPRESSION: Nonacute CT of the abdomen and pelvis, without evidence of small bowel obstruction, diverticulitis, or appendicitis. No drainable fluid collection. Radiology Report INDICATION: ___ history of morbid obesity, end-stage renal disease on HD ___, pulmonary hypertension, diabetes, dCHF, and prior DVTs on chronic warfarin presents with abdominal pain found to be hyperkalemic requiring urgent dialysis and also with leaking arterial HD port. // leaking femoral arterial HD port COMPARISON: CT of the abdomen pelvis from ___. TECHNIQUE: OPERATOR: Dr. ___ radiology attending) performed the procedure. ANESTHESIA: Moderate sedation could not be provided due to the patient's low blood pressure. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: Per nursing staff. CONTRAST: 30 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 20 min, 275 mGy PROCEDURE: 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 left groin was prepped and draped in the usual sterile fashion. After injection of local lidocaine at the entry site of the current tunneled catheter into the left common femoral vein, a small skin incision was made. A stiff wire was introduced through the existing tunneled catheter. And the tunneled catheter removed using traction. The wire was then removed from the tunnel and pulled out close to the venotomy. Over the wire, first a dialysis catheter with of the IP port and then a temporary dialysis catheter were advanced. No blood return was noted through either lumen of both catheters. A venogram through the catheter in the left common iliac vein showed clot extending up to the junction of the common iliac vein and IVC. The IVC itself was patent. Since the temporary dialysis catheters were 2 short, the decision was placed to replace a 43 cm tip to cuff tunneled double lumen dialysis catheter. A 43 cm tip to cuff length catheter was selected. The catheter was tunneled from the entry site towards the venotomy site from where it was brought out using a tunneling device. 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 catheter was threaded into the right side of the heart with the tip in the suprarenal IVC. The sheath was then peeled away. The catheter was sutured in place with 0 silk sutures. ___ subcuticular Vicryl sutures and Steri-strips were also used to close the venotomy incision site. Final spot fluoroscopic image demonstrating good alignment of the catheter and no kinking. The tip is in the right atrium. The catheter was flushed and both lumens were capped. Sterile dressings were applied. The patient tolerated the procedure well. FINDINGS: Venogram of left common iliac vein showing occlusion of the left common iliac and external iliac veins. The IVC itself is patent. Chronic Occlusion of the left common iliac and left external iliac veins prevent placement of temporary dialysis catheters. Successful replacement of existing tunneled 43 cm tip to cuff dialysis catheter with a new 43 cm tip to cuff dialysis catheter through the same tunnel and venotomy. IMPRESSION: Successful exchange of a 43 cm tip to cuff length tunneled dialysis line. The tip of the catheter terminates in the suprarenal IVC. The catheter is ready for use. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Abd pain Diagnosed with ABDOMINAL PAIN GENERALIZED, END STAGE RENAL DISEASE temperature: 98.8 heartrate: 58.0 resprate: 16.0 o2sat: 100.0 sbp: 132.0 dbp: 84.0 level of pain: 5 level of acuity: 3.0

SUMMARY: ___ history of morbid obesity, end-stage renal disease on HD ___, pulmonary hypertension, diabetes, dCHF, and prior DVTs on chronic warfarin presents with abdominal pain found to be hyperkalemic requiring urgent dialysis and also with leaking arterial HD port. She was also found to have one positive blood culture off the HD port with GPCs in clusters and chains shown to be S. Gallolyticus. She was treated with vancomycin for the bacteremia, bowel regimen for constipation and the port was replaced. Her course was notable for asymptomatic hypotension and aymptomatic new junctional rhythm.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Bee Pollens / Penicillins / Bactrim Attending: ___. Chief Complaint: Cough Major Surgical or Invasive Procedure: None History of Present Illness: HPI: This is an ___ M with history of CAD s/p CABG x3, CKD, anemia, HTN, HLD, BPH, AS (s/p TAVR in ___ and Afib (on coumadin) who presented to ___ for cough and was transferred for further evaluation. Has had cough for 1 week - productive of yellow or brown sputum, particularly worsening over the past 2 days. Associated with nasal congestion for ___ days and rhinorrhea. Wife reports he began to get sick 10 days ago, chills yesterday. He has had low-grade fevers to a high of ___ F. He denies chest pain, abdominal pain, vomiting, diarrhea, dysuria, hematuria, rashes, joint pains, increasing lower extremity edema, orthopnea. He does have baseline dyspnea on exertion. Patient reports urgent care gave him "a shot of penicillin and a shot of steroids" and told him to go to the emergency department. Patient is on steroids chronically for skin rash. Patient very attentive to his weight, weighing himself daily; stays at 161lb; does not feel he has lost dry weight. Taking torsemide 20 daily without interruption. No orthopnea, weight gain, ___ edema. Hositalization records from ___ and ___ reviewed and summarized as follows: ___ presentation with DOE, found to be volume up, diuresed with Lasix 40 IV effective dose; also that admission with a questionable RLL pneumonia similar to today. DC weight from ___ was In ED: VS: afebrile, HR 97-->76, 116/56, RR 18, 99% RA ED Exam: comfortable, diffuse rhonchi, 1+ edema bilaterally Labs: wbc 13, hb 10 (b/l ___, plt 95; INR 2.1 (on Coumadin), Cr 2.0 (b/l 2.0) other BMP unremarkable; BNp 46k (though chronically elevated to ___, lact 1.2; flu A & B neg, trop 0.05 Blood cx x2 sent Imaging: CXR with RLL infiltrate Received: ctx 1g, azithro 500 ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: CAD s/p CABG x 3 CKD Chronic iron-deficiency anemia HTN HLD BPH AS s/p TAVR (___) HFrEF (EF 28% ___ Afib on Coumadin Lower extremity rash, c/w eczema (on prednisone) Syncope s/p ILR Social History: ___ Family History: Brother; CVA Brother had MI in his late ___ Mother: CVA, CHF Reviewed and found to be not relevant to this illness/reason for hospitalization. Physical Exam: ADMISSION: ========= VITALS: Afebrile and vital signs significant stable GENERAL: Alert and in no apparent distress; normal WOB, speaking full sentences EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVP. No ___ or presacral edema. RESP: Right lung CTA, mild end expiratory rales in left lung, no egophany. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. 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: =========== Vitals: 98.2 BP:125/61 HR: 74 18 94 RA VITALS: Afebrile and vital signs significant stable GENERAL: Alert and in no apparent distress; normal WOB, speaking full sentences EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVP. No ___ or presacral edema. RESP: Right lung CTA, mild end expiratory rales in left lung base. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Pertinent Results: ADMISSION: =========== ___ 10:34PM BLOOD WBC-13.6* RBC-3.25* Hgb-10.2* Hct-32.1* MCV-99* MCH-31.4 MCHC-31.8* RDW-15.1 RDWSD-55.3* Plt Ct-95* ___ 10:34PM BLOOD Neuts-96.1* Lymphs-1.3* Monos-1.8* Eos-0.0* Baso-0.1 Im ___ AbsNeut-13.04* AbsLymp-0.17* AbsMono-0.24 AbsEos-0.00* AbsBaso-0.02 ___ 10:34PM BLOOD ___ PTT-36.6* ___ ___ 10:34PM BLOOD Glucose-137* UreaN-59* Creat-2.0* Na-138 K-4.0 Cl-99 HCO3-23 AnGap-16 ___ 10:34PM BLOOD ALT-24 AST-20 CK(CPK)-50 AlkPhos-76 TotBili-0.8 ___ 10:34PM BLOOD CK-MB-2 cTropnT-0.05* ___ ___ 05:30AM BLOOD cTropnT-0.04* ___ 10:34PM BLOOD Albumin-3.7 Calcium-8.5 Phos-3.5 Mg-1.8 ___ 10:44PM BLOOD Lactate-1.2 DISCHARGE: ========== XXXX Flu A/B: negative Strep pneumo: pending Legionella: pending UA: neg blood, neg nit, lg ___, 0 RBCs, 0 WBCs, no bact UCx (___): pending BCx (___): pending x 2 ___ labs: --------- Hgb 9.5 (___) -> 10.6 (___) Plt 116 (___) Cr 2.0 IMAGING: ======== CXR (___): 1. Bibasilar peribronchial cuffing and infiltrates, most prominent at the left lower lobe, concerning for pneumonia. 2. Interval decrease in trace pulmonary vascular congestion. 3. Status post TAVR and leadless pacing device placement. EKG (___): Afib, LBBB, QRS 176, QTC 505 (449 accounting for LBBB), similar to ___ CXR ___, OSH): Bilateral prominent perihilar and lower lobe airspace and interstitial opacities which are new compared to ___ years prior. Differential considerations include atypical PNA, atypical appearance of consolidative pneumonia, interstitial lung disease process. Pulmonary edema is also a consideration although less likely given lack of a fissural thickening and lack of Kerly B lines. TTE (___): Well seated Evolut TAVR with normal gradient and trace aortic regurgitation. Severe pulmonary artery systolic hypertension. Moderate to severe mitral regurgitation. Mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic dysfunction most suggestive of multivessel coronoary artery disease or other diffuse process (EF 28%). Right ventricular cavity dilation with free wall hypokinesis. Compared with the prior TTE (images reviewed) of ___ , the left ventricular systolic function is now more depressed and the severity of mitral regurgitation and the estimated PA systolic pressure are now greater. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 10 mg PO QPM 3. PARoxetine 10 mg PO DAILY 4. PredniSONE 10 mg PO DAILY 5. Terazosin 5 mg PO QHS 6. Torsemide 20 mg PO DAILY 7. Warfarin 5 mg PO DAILY16 8. Acetaminophen 1000 mg PO Q 8 HOURS PRN Pain - Mild 9. Sacubitril-Valsartan (49mg-51mg) 1 TAB PO BID Discharge Disposition: Home Discharge Diagnosis: Primary: Pneumonia Secondary: HFrEF Atrial fibrillation AS s/p TAVR CAD s/p CABG Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man with CHF, s/p TAVR p/w cough and leukocytosis.// Please evaluate for PNA vs edema TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph at outside facility dated ___ FINDINGS: Compared to radiograph dated ___, there is interval decrease in the now trace pulmonary vascular congestion. There is bibasilar peribronchial cuffing and infiltrates, most prominent at the left lower lobe, concerning for developing pneumonia. There is no pleural effusion or pneumothorax. There is no mediastinal widening. Otherwise, the heart size is likely within normal limits. Status post TAVR with expected changes. 7 intact sternotomy wire seen. There is a leadless pacing device projecting over the left atrium. There are moderate degenerative changes of the thoracic spine. IMPRESSION: 1. Bibasilar peribronchial cuffing and infiltrates, most prominent at the left lower lobe, concerning for pneumonia. 2. Interval decrease in trace pulmonary vascular congestion. 3. Status post TAVR and leadless pacing device placement. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 3:44 pm, 5 minutes after discovery of the findings. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Cough, Dyspnea Diagnosed with Pneumonia, unspecified organism temperature: 98.7 heartrate: 97.0 resprate: 18.0 o2sat: 99.0 sbp: 116.0 dbp: 56.0 level of pain: 0 level of acuity: 3.0

___ with history of CAD s/p CABG x3, HFrEF (EF 28% ___, CKD (b/l Cr 2.0), iron-def anemia, HTN, HLD, BPH, AS (s/p TAVR in ___, syncope s/p ILR, Afib (on coumadin), lower extremity rash (on prednisone taper) p/w cough and low-grade fever, found to have CAP. # Cough: # Leukocytosis: # Community-acquired PNA: P/w cough, low-grade fever, and leukocytosis with CXR suggestive of multifocal PNA. No hypoxia, and no recent hospitalizations to suggest resistant organisms. Flu A/B negative. At slightly higher risk given recent steroid use (initiated prednisone taper ___, currently on 10mg daily). He was treated with CTX/azithromycin on admission with improvement in his cough and resolution of his leukocytosis. BCx NGTD and Strep pneumo/legionella antigens pending at the time of discharge. He was transitioned to oral cefpodoxime/azithromycin to complete a course through ___. # Troponin elevation: # HFrEF: # CAD s/p CABG (___): # AS s/p TAVR (___): # Severe pHTN: Patient is followed by primary cardiologist Dr. ___ at ___ ___ and by Dr. ___ at ___ for his TAVR. He is s/p CABG ___ with non-intervenable CAD on cath in ___ per Dr. ___ ___ note. Last TTE ___ revealed iCMP with EF 28%, depressed from 40% in ___ unclear whether further w/u was performed to explain this decrement. Patient presents with BNP >40K (chronically elevated, likely secondary to severe pHTN vs recently initiated Entresto, which can reportedly elevate proBNP), but appeared clinically euvolemic with weight at baseline (160lbs) and CXR without pulmonary edema. Mild troponin elevated to 0.05 on admission and downtrended to 0.04, likely demand ischemia in setting of known CAD and CKD; low suspicion for ACS in absence of angina. He was continued on his home torsemide 20mg daily, Entresto, and ASA 81mg. Weight 157lbs on discharge. He will ___ with Dr. ___ ___. # Thrombocytopenia: Plt 95 on admission in setting of chronic thrombocytopenia ___ on review of ___ records). Suspect secondary to infection. Nl fibrinogen and absence of schistocytes argues against DIC. Plt 97 on discharge. Would benefit from repeat CBC at PCP ___. # Iron deficiency anemia: At baseline Hgb ___, attributed to iron deficiency. No evidence of bleeding or hemolysis. Hgb 10.5 on discharge. Further management of iron deficiency as outpatient. # CKD stage III: Cr at baseline (2.0). # Atrial fibrillation: INR therapeutic. Rate well controlled off beta-blockade. Home coumadin 5mg daily was continued. INR 2.1at discharge. He was instructed to have an INR check on ___ given possible fluctuations with concurrent antibiotics (to be followed by Dr. ___. # HTN: Continued home torsemide. Was previously on amlodipine, which had been d/c'd as outpatient. # Chronic lower extremity rash, possible eczema: Longstanding issue, previously trialed on cyclosporine and MTX. Improved with recent initiation of prednisone 40mg daily on ___, which he is now tapering. Followed by derm. He was discharged on his scheduled prednisone taper, with the first day of 10mg daily ___. He will ___ with his outpatient dermatologist. # Hx syncope: ILR from ___ admission with falls. Followed by EP at ___ with no further episodes. # BPH: Continued home terazosin. # Depression: Continued home paroxetine. # HLD: Continued home atorvastatin. ** TRANSITIONAL ** [ ] continue cefepime and azithromycin through ___ [ ] CBC at PCP ___ to assess for improvement in thrombocytopenia [ ] ___ BCx, Strep/legionella Ag pending at discharge [ ] check INR on ___ and adjust coumadin as needed [ ] ___ with dermatology for management of eczema; discharged on previously scheduled prednisone taper # Contacts/HCP/Surrogate and Communication: ___ (daughter, a ___) ___ # Code Status/ACP: DNR/DNI (confirmed)

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Headache, altered mental status Major Surgical or Invasive Procedure: Cerebral angiogram ___ History of Present Illness: EU Critical ___, AKA ___, is a ___ man who was transferred from an outside hospital after an evaluation for altered mental status revealed a large left parietal intraparenchymal hemorrhage. The history is limited as the patient is currently intubated. Most of the data is gathered from the patient's chart. According to the records, the patient was found wandering around his apartment building shirtless and confused. Neighbors called EMS. On arrival to ___ the patient was unable to provide details about his presentation. However he was reported to be alert and oriented to person, time, place. He is from ___, and came to the ___ ___ years ago, studying ___ at ___. Initial evaluation revealed blood pressure of 124/67 pulse of 67, and a temperature of 99.3. He is not in any apparent distress. General exam was reportedly unremarkable. Neurologic exam revealed right pronator drift, decreased sensation to light touch in the right upper extremity and lower extremity. Otherwise full strength. CT of the head revealed a large left parietal intraparenchymal hemorrhage, with a midline shift 4 mm. neurosurgery was consulted. Labs were notable for elevated white count to 13.5, hemoglobin of 14.6, platelet of 240. Basic metabolic panel was remarkable for potassium of 3.5, but normal sodium. Creatinine was 0.9. UA was negative. Tox screen for both serum and urine was normal. There were no LFT abnormalities. Coags were not performed. The patient was intubated for airway protection. He was given 1 g of Keppra as well as 100 mg of mannitol. He was started on propofol drip as well as fentanyl boluses. He was subsequently transferred to ___ for further management. Past Medical History: previously healthy Social History: ___ Family History: Notable for diabetes in his father, but negative for stroke or intracranial hemorrhage. No family history of CTD. Physical Exam: ADMISSION EXAM ============== Performed 15 minutes after discontinuation of propofol Vitals: T: 98.6 HR: 58 BP: 107/66 RR: 17 SaO2: 100% on mechanical ventilation breathing over the set rate General: Intubated HEENT: NCAT, no oropharyngeal lesions, neck supple ___: RRR, no M/R/G Pulmonary: CTAB, no crackles or wheezes Abdomen: Soft, NT, ND, +BS, no guarding Extremities: Warm, no edema Neurologic Examination: - Mental status: Off propofol, the patient is able to open eyes to command. He follows axial and appendicular commands and is able to show thumbs up on both hands. He is able to nod yes to his name. - Cranial Nerves: PERRL 4->2 brisk. He has intact vestibular ocular reflex. Intact corneals bilaterally. Positive cough. - Sensorimotor: He was observed to be moving all 4 extremities off of the plane of the bed spontaneously, as well as to command. The right side appears to be slightly less brisk than the left. Withdraws to noxious in all 4 limbs. - Reflexes: [Bic] [Tri] [___] [Quad] [Gastroc] L 2+ 2+ 2+ 2+ 1 R 2+ 2+ 2+ 2+ 1 Plantar response flexor bilaterally - Coordination/gait: deferred DISCHARGE EXAM ============== Vitals: 98.0 ___ / ___ R ___ General: no acute distress HEENT: NCAT, no oropharyngeal lesions, neck supple Pulmonary: breathing comfortably on RA Neurologic Examination: - Mental status: Oriented to month, year and situation. He follows axial and appendicular commands. Does have some slight delayed speech. Naming low and high frequency objects. - Cranial Nerves: right pupil 3>2 bilaterally, no nystagmus, VFF to finger, slight right NLFF, symmetric activation. Facial sensation intact. Palate symmetric. - Sensorimotor: Full strength. mild right pronation, no drift. - Coordination: no dysmetria Pertinent Results: ADMISSION LABS ============== ___ 12:55PM SODIUM-144 ___ 12:55PM OSMOLAL-293 ___ 09:25AM TSH-1.5 ___ 06:13AM GLUCOSE-100 UREA N-13 CREAT-0.7 SODIUM-139 POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-22 ANION GAP-16 ___ 06:13AM ALT(SGPT)-17 AST(SGOT)-28 LD(LDH)-263* CK(CPK)-1635* ALK PHOS-76 TOT BILI-1.1 ___ 06:13AM CK-MB-4 cTropnT-<0.01 ___ 06:13AM CK-MB-4 cTropnT-<0.01 ___ 06:13AM %HbA1c-5.2 eAG-103 ___ 06:13AM TRIGLYCER-92 HDL CHOL-78 CHOL/HDL-1.8 LDL(CALC)-48 ___ 06:13AM TSH-2.2 ___ 06:13AM WBC-10.7* RBC-4.58* HGB-13.8 HCT-40.0 MCV-87 MCH-30.1 MCHC-34.5 RDW-11.8 RDWSD-37.6 ___ 06:13AM PLT COUNT-223 ___ 06:13AM ___ PTT-28.7 ___ ___ 03:54AM URINE HOURS-RANDOM ___ 03:54AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG ___ 03:54AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 03:54AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* GLUCOSE-NEG KETONE-TR* BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-NEG ___ 03:54AM URINE RBC-3* WBC-<1 BACTERIA-NONE YEAST-NONE EPI-0 ___ 03:47AM GLUCOSE-114* UREA N-15 CREAT-0.8 SODIUM-133 POTASSIUM-3.6 CHLORIDE-97 TOTAL CO2-22 ANION GAP-14 ___ 03:47AM OSMOLAL-298 ___ 03:47AM WBC-11.9* RBC-4.34* HGB-12.9* HCT-37.8* MCV-87 MCH-29.7 MCHC-34.1 RDW-11.9 RDWSD-37.7 ___ 03:47AM NEUTS-87.7* LYMPHS-6.6* MONOS-4.9* EOS-0.1* BASOS-0.3 IM ___ AbsNeut-10.45* AbsLymp-0.79* AbsMono-0.58 AbsEos-0.01* AbsBaso-0.04 ___ 03:47AM PLT COUNT-214 ___ 03:47AM ___ PTT-25.1 ___ IMAGING: ======== ___ CT/A head and neck NECT: A 5.4 x 4.0 cm left parieto-occipital intraparenchymal hemorrhage is grossly unchanged (02:20). There is surrounding vasogenic edema. There is approximately 4 mm of rightward midline shift. Hyperdense foci in some of the left frontal sulci may reflect areas of subarachnoid hemorrhage. (For example 02:24). There is no evidence of acute infarct. CTA head: There ___ striation of the right M1 segment. The vessels of the circle ___ and their major branches appear patent without evidence of stenosis, occlusion or aneurysm formation. CTA neck: The carotid arteries are patent from their origin without evidence of stenosis, dissection or occlusion. The vertebral arteries are patent from their origins without evidence of stenosis, dissection or occlusion. ___ Renal US:1. Normal renal ultrasound. 2. No sonographic evidence of renal artery stenosis. 3. Note is made that the urinary bladder is distended despite the presence of a Foley catheter. ___ MRI head:1. Stable acute 5.1 cm parenchymal hematoma centered on left parietal lobe. Suggestion of minimal enhancement along the anterosuperior margin of hematoma. Occult vascular malformation should be considered. Neoplasm is less likely. Consider drug screen. Follow-up exam in 3 months without and with gadolinium recommended. ___ Cerebral angio Early draining vein associated with the left parietal occipital artery best seen on lateral imaging. This is concerning for a small micro AVM. Plan to follow-up with an MRI in 1 month. ___: Groin ultrasound 1. No evidence of pseudoaneurysm, or AV fistula. 2. A 4.0 cm hematoma is identified within the superficial soft tissues of the right groin with no drainable fluid collection. INTERVAL LABS: ============== ___ 05:26AM BLOOD WBC-7.5 RBC-4.29* Hgb-12.8* Hct-37.3* MCV-87 MCH-29.8 MCHC-34.3 RDW-11.8 RDWSD-37.2 Plt ___ ___ 05:26AM BLOOD Glucose-106* UreaN-8 Creat-0.7 Na-137 K-3.4 Cl-97 HCO3-25 AnGap-15 ___ 06:25AM BLOOD CK(CPK)-994* ___ 05:26AM BLOOD Calcium-9.1 Phos-3.1 Mg-2.0 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 2. Gabapentin 100 mg PO TID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Intracranial hemorrhage Right groin hematoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK INDICATION: History: ___ with head bleed// evaluate for intracranial vessels, aneurysm TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of 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 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 802.7 mGy-cm. 2) Stationary Acquisition 6.5 s, 0.5 cm; CTDIvol = 70.8 mGy (Head) DLP = 35.4 mGy-cm. 3) Spiral Acquisition 5.6 s, 44.2 cm; CTDIvol = 31.1 mGy (Head) DLP = 1,376.4 mGy-cm. Total DLP (Head) = 2,215 mGy-cm. COMPARISON: ___ MR head without contrast ___ CT head without contrast FINDINGS: CT HEAD WITHOUT CONTRAST: There is a large acute intraparenchymal hemorrhage centered within the left parietal lobe that measures approximately 4 cm in diameter with associated vasogenic edema. No definite intraventricular or subarachnoid blood products are identified. There is local mass effect, however no midline shift or herniation. The ventricles, sulci, and cisterns are otherwise normal in appearance. The paranasal sinuses, middle ear cavities, and mastoid air cells are clear. The orbits are unremarkable. CTA HEAD: The internal carotid arteries, anterior and middle cerebral arteries are patent without stenosis. Incidental note is made of a fenestration within the proximal right M1 segment. The posterior cerebral arteries are patent without stenosis. The right and left posterior communicating arteries are patent. The intracranial vertebral arteries and basilar artery are patent without stenosis. There may be areas of mild narrowing within the intracranial arteries, however no high-grade stenosis or proximal occlusion. No aneurysm greater than 2 mm or vascular malformation is identified CTA NECK: There is a beaded appearance of the right and left internal and external carotid arteries with sparing of the carotid bulbs. This is most consistent with type 1 (medial fibroplasia) fibromuscular dysplasia. The extracranial vertebral arteries appear relatively spared. There is no occlusion, extracranial dissection, or high-grade stenosis by NASCET criteria. OTHER: No cervical enlarged lymph nodes are identified. The visualized lung apices are clear. IMPRESSION: Large parietal lobe acute intraparenchymal hemorrhage with associated vasogenic edema, without appreciable progression from a ___ head CT. No underlying vascular malformation or aneurysm greater than 2 mm is identified. The intraparenchymal hemorrhage may be related to a ruptured aneurysm or dissection given the beaded appearance of the extracranial carotid arteries, consistent with type 1 (medial fibroplasia) fibromuscular dysplasia. NOTIFICATION: The findings were discussed with ___, N.P. by ___ ___, D.O. on the telephone on ___ at 2:25 pm, 10 minutes after discovery of the findings. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST ___ MR HEAD INDICATION: ___ year old man with left parietal IPH, unclear etiology// eval for underlying lesions TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of mL of Gadavist intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: CTA head neck ___ 04:32, head CT ___ 01:45 FINDINGS: There is 5.1 cm x 3.6 cm by 4.2 cm acute parenchymal hematoma is involving left parietal lobe the, similar in size compared to prior. There is mild to moderate surrounding edema. There is no no evidence of subarachnoid or intraventricular extension. There is mild crowding of cerebellar tonsils at foramen magnum, with extension of 1-2 mm below foramen magnum, similar compared with CTA. This faint punctate focus of enhancement along the superomedial margin of parenchymal hematoma post gadolinium axial spin echo image slice 20, and few linear serpiginous foci of enhancement are suggested on axial post gadolinium MP rage images along the anterior superior margin of hematoma, which may be too early for enhancement associated with the subacute hematoma which typically happens more in subacute phase. The underlying vascular malformation, potentially compressed by hematoma cannot be excluded. Neoplasm is unlikely. The underlying dural venous sinuses are patent. There is no evidence of PRES. There is no hydrocephalus. Efface suprasellar cistern, partial effacement of perimesencephalic cisterns, more prominent on the left. There is minimal left temporal horn trapping, similar to prior. Intracranial vascular flow voids are preserved. Clear paranasal sinuses, mastoid air cells. IMPRESSION: 1. Stable acute 5.1 cm parenchymal hematoma centered on left parietal lobe. Suggestion of minimal enhancement along the anterosuperior margin of hematoma. Occult vascular malformation should be considered. Neoplasm is less likely. Consider drug screen. Follow-up exam in 3 months without and with gadolinium recommended. RECOMMENDATION(S): MRI brain without and with gadolinium in 3 months. Drug screen. Radiology Report EXAMINATION: US RENAL ARTERY DOPPLER INDICATION: ___ year old man with IPH// assess renal artery hypertension TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: None. FINDINGS: The right kidney measures 10.6 cm. The left kidney measures 11.2 cm. There is no hydronephrosis, stones, or masses bilaterally. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. The bladder is moderately well distended despite the presence of a Foley catheter which appears to be appropriately placed. DOPPLER EXAMINATION: Appropriate arterial waveforms with sharp upstrokes are seen in the main renal artery bilaterally. Peak systolic flow in the right main renal artery measures 88 cm/sec and within the left main renal artery measures 51 cm/sec. Resistive indices of the intraparenchymal arteries range from 0.58 to 0.61 in the right kidney and from 0.54 to 0.56 in the left kidney. The renal vein is patent bilaterally. IMPRESSION: 1. Normal renal ultrasound. 2. No sonographic evidence of renal artery stenosis. 3. Note is made that the urinary bladder is distended despite the presence of a Foley catheter. Radiology Report EXAMINATION: Diagnostic cerebral angiogram During the procedure the following vessels were selectively catheterized angiograms were performed: Right common carotid artery Left vertebral artery Right internal carotid artery Right external carotid artery Right common femoral artery INDICATION: This is a ___ Asian male who presented after an episode of confusion and was found have all left parietal occipital hematoma. CTA was unrevealing. Angiogram was undertaken to rule out vascular etiology. ANESTHESIA: The patient did not require moderate sedation. He received a total of 100 mcg of fentanyl during the procedure. His hemodynamic parameters were monitored throughout the course the procedure. TECHNIQUE: Diagnostic cerebral angiogram COMPARISON: ___ CTA PROCEDURE: The patient was identified and brought to the neuro radiology suite. He was transferred to the fluoroscopic table supine. Moderate sedation was administered. Bilateral groins were prepped and draped in standard sterile fashion. A time-out was performed. The right common femoral artery was identified using anatomic local radiographic landmarks. The right common femoral artery was accessed using standard micropuncture technique after infiltration of local anesthetic. A short 5 ___ sheath was introduced, connected to continuous heparinized saline flush, and secured. A berenstein diagnostic was introduced and connected to continuous heparinized saline flush and the power injector. Was advanced over 038 glidewire through the aorta into the aortic arch. It was used to select the right common carotid artery. The wire was removed and vessel patency was confirmed via hand injection. intracranial AP and lateral as well as high magnification oblique views were obtained. Next the catheter was withdrawn back into the aortic arch. Was advanced over the wire into the left subclavian artery. The wire was removed and contrast possible used to identify the proximity of the vertebral artery origin and a road map was performed. The vertebral artery was selected using roadmap guidance over the 038 glidewire. The wire was removed and vessel patency was confirmed via hand injection. Standard AP and lateral views of the posterior circulation were obtained. Catheter was again withdrawn the aortic arch. It was advanced over the wire into left common carotid artery. The wire was removed and a roadmap of the bifurcation was performed. The catheter was advanced into the internal carotid artery over the wire using roadmap guidance. The wire was removed and vessel patency was confirmed via hand injection. AP and lateral as well as high magnification oblique views were obtained of the intracranial circulation. The catheter was then withdrawn to the common carotid artery again and a new roadmap was performed. Catheter was advanced over the 038 glidewire into the external carotid artery. The wire was removed and vessel patency was confirmed via hand injection. Standard AP and lateral views of the intracranial circulation were obtained. Next the diagnostic 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 ___ Angio-Seal. The patient was removed from the fluoroscopy table remained at his 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: Vessel caliber smooth and regular. There is opacification of the anterior middle cerebral arteries and their distal branches. There is filling of the distal external carotid artery branches. There is no aneurysm or AVM. The venous phase is unremarkable. Left vertebral artery: Vessel caliber smooth and regular. There is opacification of the basilar as well as the bilateral posterior cerebral arteries and bilateral superior cerebellar arteries. There is reflux into the right vertebral artery and ___. There is an early draining vein on the left that appears to arise near the parietal occipital artery and travels toward the sagittal sinus. This is best demonstrated on lateral views. There is no evidence of aneurysm. Left external carotid artery. Vessel caliber smooth and regular. There is filling of the distal external carotid artery branches. There is no evidence of aneurysm or AV shunting. Left internal carotid artery: Vessel caliber smooth and regular. There is opacification of the anterior marrow middle cerebral arteries and their distal territories. There is cross-filling across the anterior communicating artery to the right A2 segment. There is no evidence of aneurysm or AVM. The venous phase is unremarkable. Right common femoral artery: Arteriotomy is above the bifurcation. There is good distal runoff. There is no evidence of dissection. IMPRESSION: Early draining vein associated with the left parietal occipital artery best seen on lateral imaging. This is concerning for a small micro AVM. Plan to follow-up with an MRI in 1 month. RECOMMENDATION(S): 1. If the patient has returned to school at ___ weakened arrange follow-up at that time there. No additional nurse surgical intervention at this time for his acute hemorrhage. Radiology Report EXAMINATION: FEMORAL VASCULAR US RIGHT INDICATION: ___ year old man with IPH s/p cerebral angiogram ___ now with large right groin hematoma.// ___ year old man with IPH s/p cerebral angiogram ___ now with large right groin hematoma. TECHNIQUE: Grayscale, color, and spectral Doppler evaluation of the right groin COMPARISON: None FINDINGS: Normal color flow and spectral Doppler waveforms are present in the right common femoral artery and vein. There is no evidence of pseudoaneurysm, or arteriovenous fistula. A hematoma measuring 4.0 x 1.8 cm is identified within the superficial soft tissues of the right groin. No drainable fluid collection is identified. IMPRESSION: 1. No evidence of pseudoaneurysm, or AV fistula. 2. A 4.0 cm hematoma is identified within the superficial soft tissues of the right groin with no drainable fluid collection. Gender: M Race: UNKNOWN Arrive by UNKNOWN Chief complaint: ICH, Transfer Diagnosed with Nontraumatic intracranial hemorrhage, unspecified temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: uta level of acuity: 1.0

___, is a ___ man who presented after being 5.4 x 4.0 cm left parieto-occipital intraparenchymal hemorrhage possibly secondary to micro-AVM. # Left parietooccipital intraparenchymal hemorrhage He presented after being found confused and wandering at his apartment complex. Neurologic exam revealed right pronator drift, decreased sensation to light touch in the right upper extremity and lower extremity, but he was otherwise full strength. Negative lab w/u including negative serum tox, urine tox. CT of the head revealed a large left parietal intraparenchymal hemorrhage, with a midline shift 4 mm. He was initially intubated for airway protection and admitted to neuro ICU with mannitol and HTS. He was extubated within 24 hours. CTA and MRI w/ contrast with no evidence of AVM or underlying mass. There was some concern for fibromuscular dysplasia given ribbed appearance of bilateral carotids, but this was ultimately felt to be due to pulse artifact. Conventional angio ___ with possible micro AVM due to early filling vein on the left, possibly a draining vein. No family history of aneurysm, AVM, ICH per family and no family history of CTD. No personal history of hypertension and no hypertension throughout his stay. He had a renal u/s which was negative for renal artery stenosis. His exam was significant for mild anisocoria (resolved at discharge), slight right nasolabial fold flattening, right lower quadrantanopsia with extinguishing in the right upper quadrant with double simultaneous stimulation (resolved at discharge), as well as mild pronation of the right hand at times. He had no weakness or sensory change on confrontational testing. He will need follow-up MRI 1 month post discharge for further characterization of AVM. This has been scheduled for ___. He was evaluated by ___ who recommended rehab on discharge. # CK elevation CK elevated to ~4000. Etiology may have been shaking movements observed with propofol infusion on admission. No further episodes and CK trended down with fluids. # Right groin hematoma Cerebral angiogram complicated by right groin hematoma confirmed by ultrasound. No aneurysm or pseudoaneurysm identified. Distal pulses remained intact and H/H stable. AHA/ASA Core Measures for Intracerebral Hemorrhage 1. Dysphagia screening before any PO intake? (x) Yes - () No 2. DVT Prophylaxis administered? (x) Yes - () No 3. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker] 4. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 5. Assessment for rehabilitation and/or rehab services considered? (x) Yes - () No TRANSITIONAL ISSUES: ==================== [] Repeat MRI in one month for possible AVM, scheduled for ___ [] Please continue speech therapy as an outpatient [] Stop gabapentin and acetaminophen if it is no longer needed for headache

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: facial redness and swelling Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ yr old man with RA on biweekly etanercept who presents with 5 days of facial redness and swelling not improving on clindamycin. A week and a half before presentation, Mr. ___ had a few days of "flu-like symptoms" with fevers, chills, myalgias, and URI symptoms, which resolved on their own. 5 days prior to presentation, he noted a gritty feeling in his left eye and erythema of his lower eyelid, which spread to involve the left cheek. He also noted development of several "cold sores" on his nose and upper lip that he described as erytematous bumps, that subsequently blistered and scabbed over. He did not have blurry vision, diplopia, pain with eye movements, new floaters or flashing lights. Denied pain over the erythematous area, except when palpated. He was started on clindamycin by his PCP the day prior to presentation, but erythema continued to spread, so he was sent to the ED for further eval. In the ED, he was afebrile with tmax 99.8. WBC was 14, lactate 1.2, normal chem7. Fluorescene eye exam was benign. CT showed ___ cellultis without post-septal spread. Pt received vancomycin x1, developed pruritis which resolved with benadryl, and was transferred to the floor. On the floor this AM, pt denies blurry vision, new floaters, flashing lights, eye pain, pain with eye movement. Pt only reports some double vision on left lateral gaze. Past Medical History: Rheumatoid arthritis Pilonidal cyst Anxiety Social History: ___ Family History: non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS - 97.9 110/58 ___ 18 97% RA General: well-appearing man in NAD lying comfortably in bed HEENT: Erythema extending from the lower left eyelid over the entire left cheek, with patchy redness over the bridge of the nose. No upper eyelid involvement. Scabbed over sores noted on left nare, left lip. Lower eyelid is edematous and difficult to retract. No proptosis. OP clear. EOM intact, no pain with EOM. +diplopia with far left end-gaze. VF full. Tender to palpation over erythematous area. Neck: nontender, supple, fullness of anterior cervical LNs bilaterally but without discrete LAD. CV: RRR no m/r/g Lungs: CTAB Abdomen: soft nontender nondistended GU: deferred Ext: wwp Neuro: PERRL. EOM intact. +diplopia with far left end-gaze. VF full. Facial musculature symmetric. Palate elevates symmetrically. Skin: no rashes, aside from facial erythema as noted above DISCHARGE PHYSICAL EXAM: ======================== VS: 98.1 ___ ___ RA General: well-appearing man in NAD lying comfortably in bed HEENT: Minimal erythema and edema of the left cheek, much improved from prior, with dry peeling skin. Scabbed over sores noted on left nare, left lip. No proptosis. OP clear. EOM intact, no pain with EOM. VF full. Neck: nontender, supple, fullness of anterior cervical LNs bilaterally but without discrete LAD. CV: RRR no m/r/g Lungs: CTAB Abdomen: soft nontender nondistended GU: deferred Ext: wwp Neuro: PERRL. EOM intact. VF full. No diplopia. Facial musculature symmetric. Palate elevates symmetrically. Skin: no rashes, aside from facial erythema as noted above Pertinent Results: ADMISSION LABS: =============== ___ 11:05AM BLOOD WBC-15.1*# RBC-4.98 Hgb-15.0 Hct-43.8 MCV-88 MCH-30.2 MCHC-34.3 RDW-12.8 Plt ___ ___ 11:05AM BLOOD Neuts-78.2* Lymphs-14.4* Monos-5.9 Eos-1.0 Baso-0.5 ___ 11:05AM BLOOD Plt ___ ___ 02:00PM BLOOD Glucose-88 UreaN-18 Creat-0.9 Na-136 K-4.1 Cl-99 HCO3-24 AnGap-17 ___ 07:00AM BLOOD Calcium-9.2 Phos-3.5 Mg-2.1 ___ 02:10PM BLOOD Lactate-1.2 DISCHARGE LABS: =============== ___ 06:30AM BLOOD WBC-9.3 RBC-4.50* Hgb-13.6* Hct-39.5* MCV-88 MCH-30.2 MCHC-34.5 RDW-12.1 Plt ___ ___ 06:30AM BLOOD Glucose-83 UreaN-15 Creat-0.9 Na-140 K-4.8 Cl-103 HCO3-31 AnGap-11 IMAGING: ======== CT SINUS/MANDIBLE/MAXILLA:1. Fat stranding, skin thickening and soft tissue edema overlying the left inferior periorbital region, anterior to the maxillary sinus, and extending anterior and lateral to the left mandible. There is no evidence of retrobulbar or post-septal spread. This is consistent with left periorbital and facial cellulitis. No abscess is identified. 2. Mild sinus disease. MICROBIOLOGY: ___ BLOOD CULTURES X2: pending Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lorazepam 0.5 mg PO HS:PRN insomnia 2. etanercept unknown subcutaneous weekly Discharge Medications: 1. Lorazepam 0.5 mg PO HS:PRN insomnia 2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 3. Erythromycin 0.5% Ophth Oint 0.5 in LEFT EYE BID RX *erythromycin 5 mg/gram (0.5 %) 0.5 (One half) in ophth twice a day Disp #*1 Tube Refills:*0 4. Cephalexin 500 mg PO Q6H RX *cephalexin 500 mg 1 tablet(s) by mouth every six (6) hours Disp #*28 Capsule Refills:*0 5. Sulfameth/Trimethoprim DS 1 TAB PO BID RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY # Preseptal cellulitis SECONDARY # Rheumatoid arthritis on Etanercept Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Diffuse rapidly expanding left maxillary and periorbital erythema and swelling. Evaluate for evidence of orbital cellulitis. COMPARISONS: None. TECHNIQUE: Contiguous axial MDCT images were obtained through the facial bones after the administration of IV contrast. Sagittal and coronal reformatted images were obtained and reviewed. TOTAL DLP: 597.32 mGy-cm. FINDINGS: There is soft tissue edema and fat stranding along the left face anterior to the left maxillary sinus and extending minimally into the fat overlying the left side of the mandible. There is no rim-enhancing fluid collection to suggest an abscess. There is evidence of skin thickening and edema. The edema also extends slightly anterior in the lower periorbital region. There is no evidence of extension into the retrobulbar fat or post-septal space. There is no retrobulbar or post-septal fat stranding or fluid. The left extraocular muscles are normal and symmetric. The orbits are intact. There is no evidence of a lens dislocation or vitreous hemorrhage. There is a small amount of mucosal thickening in the bilateral maxillary sinuses with a small retention cyst in the right maxillary sinus. There is minimal mucosal thickening in the ethmoidal air cells. The frontal sinus and sphenoid sinus are clear. The bilateral ostiomeatal units are patent. There is no evidence of a fracture. The cribriform plates and lamina papyracea are intact. There is slight rightward deviation of the nasal septum. The mastoid air cells and middle ear cavities are clear. Soft tissue in the left external ear cavity likely represents cerumen. There is no evidence of a periapical lucency. There is no osseous erosion or destruction to suggest underlying osteomyelitis. The imaged portions of the brain are normal. The ventricles and sulci are normal in size. In the right parotid gland, there is a 7 mm slightly hyperdense rounded nodule (3, 78), which likely represents an intraparotid lymph node. Prominent cervical lymph nodes on the left are likely reactive, though none meet criteria for pathologic enlargement. The cervical vasculature is normal in caliber. There is no significant atherosclerotic calcification. IMPRESSION: 1. Fat stranding, skin thickening and soft tissue edema overlying the left inferior periorbital region, anterior to the maxillary sinus, and extending anterior and lateral to the left mandible. There is no evidence of retrobulbar or post-septal spread. This is consistent with left periorbital and facial cellulitis. No abscess is identified. 2. Mild sinus disease. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: L FACIAL CELLULITIS Diagnosed with ORBITAL CELLULITIS temperature: 97.9 heartrate: 107.0 resprate: 20.0 o2sat: 98.0 sbp: 122.0 dbp: 70.0 level of pain: 0 level of acuity: 3.0

___ yr old man with RA on etanercept who presents with 5 days of facial redness and swelling not improving on clindamycin, found to have periorbital and facial cellulitis without post septal involvement.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Erythromycin Base / Iodine / Aspirin / Motrin / Prilosec / Zestril / Shellfish Derived Attending: ___ Chief Complaint: increased drainage around chest tube for persistent right pneumothorax Major Surgical or Invasive Procedure: none History of Present Illness: She is s/p MI MV repair on ___ which was complicated by a pneumothorax, at which time a chest tube was placed by thoracic surgery. Postoperatively the patient has had a persistent R air leak. She was discharged to home with a pneumostat on the Right and continued to have pain at the chest tube site but noted good continued activity. The patient was due to follow up with Dr. ___ coming week, but last night he had temps up to approx 101 last ___ and had new, clear, non-foul smelling drainage from the chest tube. The visiting nurse came this AM and saw that a suture had pulled through and that clear, non-malodorous fluid was leaking around the tube. The ___ advised the patient to come to the ED at which time Thoracic surgery was called by cardiac surgery to call to evaluate the patient. A call at this time found the patient already in the ED. On evaluation the patient's Right sided chest tube was found to be loose, though not free, and a ___ suture was placed steriley at the bedside to close the lateral space and further secure the tube. During workup it was discovered that the patient had a WBC of 14K, a temperature of ___ F reported at home and a CXR demonstrating possible new bilateral pleural effusions. She denies new cough, fatigue, DOE, or pain. She denies redness or fluctuance at any incsions sites. Past Medical History: Past Medical History: 1. Asthma, since age ___, intubated once in the ___ 2. Osteoporosis 3. Recurrent sinus infections 4. Possible sleep apnea 5. GERD 6. Allergic rhinitis 7. MV prolapse ___ on echo 8. h/o dysplastic nevus 9. h/o atypical ductal hyperplasia of breast ___ Past Surgical History: 1. Rhinoplasty at ___ years old 2. Endoscopic sinus surgery in ___ in late ___-early ___ with septoplasty 3. ___ Endoscopic fieberoptic revision ethmoidectomy, sphenoideotomy, frontal sinusotomy, and widening of maxillary sinus ostia. 4. ___ CT-guided revision of endoscopic bilateral total ethmoidectomies, maxillary antrostomies, frontal sinusotomies, and sphenoidotomies. 5. Dysplastic nevus excision ___ 6. Left breast biospy ___ 7. Lipoma excision ___ Social History: ___ Family History: Mother with h/o breast cancer in her early ___ treated with lumpectomy and XRT. Also with h/o endocarditis and now s/p MVR, HTN. Father with h/o sinus problems (not treated), HTN. One younger sister with h/o allergies. MGM with h/o CAD. Physical Exam: Physical Exam temp: 98.6 BP:103/62 HR: 78 RR: 18 98% sat on RA Height: 62 inches Weight: 112 lbs BSA: 1.50 m2 General: WDWN in NAD Skin: Warm [X] Dry [X] intact [X] HEENT: NCAT, PERRLA, EOMI, Sclera anicteric, OP benign. Teeth in good repair. Neck: Supple [X] Full ROM [X] No JVD Chest: Lungs clear bilaterally [X] R chest tube in place, well healing mini thorocotomy. Pneumostat demonstrates persistent air leak. Appropriately TTP, no erythema, no fluctuance or purulent drainage. Scant serous drainage noted in pneumostat. Heart: RRR, Nl S1-S2, III/VI holosystolic murmur heard best at LMSB and apex. Radiates to carotids Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds +[X] Extremities: Warm [X], well-perfused [X] No Edema. Groin incison evaluated and without evidence of erythema or fluctuance. Appropriately TTP Varicosities: None [X] Neuro: Grossly intact [X] Pulses: Femoral Right:2 Left:2 DP Right:2 Left:2 ___ Right:2 Left:2 Radial Right:2 Left:2 Pertinent Results: ___ 07:10AM BLOOD WBC-9.5 RBC-3.45* Hgb-11.2* Hct-34.3* MCV-100* MCH-32.5* MCHC-32.6 RDW-12.6 Plt ___ ___ 01:57PM BLOOD WBC-14.1*# RBC-3.41* Hgb-11.1* Hct-34.2* MCV-100* MCH-32.6* MCHC-32.5 RDW-13.0 Plt ___ ___ 01:57PM BLOOD ___ PTT-29.5 ___ ___ 01:57PM BLOOD Glucose-88 UreaN-16 Creat-0.7 Na-135 K-3.8 Cl-97 HCO3-26 AnGap-16 ___ ___ F ___ ___ Radiology Report CHEST (PA & LAT) Study Date of ___ 12:51 ___ ___ CSURG FA6A ___ 12:51 ___ CHEST (PA & LAT) Clip # ___ Reason: ?PTX-CT clamped****At 12:30 please UNDERLYING MEDICAL CONDITION: ___ year old woman with s/p mini MVR/PTX REASON FOR THIS EXAMINATION: ?PTX-CT clamped****At 12:30 please Final Report PA AND LATERAL CHEST, ___ COMPARISON: ___ radiograph. FINDINGS: Right chest tube remains in place with persistent very small right apical pneumothorax. Configuration of right basilar hydropneumothorax component is slightly different, with apparent slight increase in amount of pleural fluid and probably decreased in extent of pleural gas in this region. On the left, there is a questionable increase in size of a small-to-moderate left pleural effusion. Otherwise, no relevant short interval change since the recent study. ___. ___ ___: MON ___ 3:13 ___ Imaging Lab There is no report history available for viewing. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Alendronate Sodium 70 mg PO QSUN 2. Citalopram 20 mg PO DAILY 3. Dulera (mometasone-formoterol) 200-5 mcg/actuation inhalation bid 4. Citracal + D (calcium phosphate-vitamin D3) 250 mg calcium- 250 unit oral daily 5. Fish Oil (Omega 3) 1000 mg PO BID 6. itraconazole 10 mg/mL oral daily 7. Multivitamins 1 TAB PO DAILY 8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation q6h prn sob 9. Pulmicort (budesonide) 0.25 mg/2 mL INHALATION DAILY 10. Vagifem (estradiol) 10 mcg vaginal 2x/week 11. Vitamin D ___ UNIT PO DAILY 12. Acetaminophen 1000 mg PO Q6H Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN fever 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 3. Alendronate Sodium 70 mg PO QSUN 4. Citalopram 30 mg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Dulera (mometasone-formoterol) 200-5 mcg/actuation inhalation bid 7. Multivitamins 1 TAB PO DAILY 8. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain 9. Citracal + D (calcium phosphate-vitamin D3) 250 mg calcium- 250 unit oral daily 10. Fish Oil (Omega 3) 1000 mg PO BID 11. itraconazole 10 mg/mL oral daily 12. Pulmicort (budesonide) 0.25 mg/2 mL INHALATION DAILY 13. Vagifem (estradiol) 10 mcg vaginal 2x/week 14. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: increased drainage around chest tube which Secondary: Mitral valve prolapse s/p mitral valve repair Pneumothorax with associated subcutaneous emphysema Preop noted QTC prolongation resolved secondary medication (celexa) Sinusitis present preop completed antibiotic course Mechanical vision distortion Secondary Diagnosis - Asthma, since age ___, intubated once in the ___ - Osteoporosis - Recurrent sinus infections - Sleep apnea - GERD - Allergic rhinitis - history of dysplastic nevus - history of atypical ductal hyperplasia of breast ___ Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesia Incisions: Thoracotomy - healing well, serosanguinous drainage Groin Right - healing well, no erythema or drainage No Edema Followup Instructions: ___ Radiology Report HISTORY: ___ female with chest tube in place and open wound. Evaluation for pneumothorax. COMPARISON: Comparison is made to multiple prior chest radiographs, including most recent from ___ and ___. FINDINGS: PA and lateral views of the chest demonstrate a small residual pneumothorax, present at the right lung apex, as well as at the right lung base, with a right-sided chest tube, directed towards the apex in a similar position compared to the prior studies. The degree of subcutaneous emphysema along the right lateral chest wall and abdominal wall as well as the left lateral chest wall has improved since the prior study. The overall lung volumes are slightly lower than on the prior study, with mild atelectasis bilaterally, with persistent small bilateral pleural effusions. There is no evidence of tension or mediastinal shift, and the heart size is stable. A prosthetic mitral ring is unchanged in position. IMPRESSION: Small residual right apical and basal pneumothorax, with chest tube in place. Small bilateral pleural effusions and mild bibasilar atelectasis. Radiology Report PA AND LATERAL CHEST, ___ COMPARISON: ___ radiograph. FINDINGS: Right chest tube remains in place with persistent very small right apical pneumothorax. Configuration of right basilar hydropneumothorax component is slightly different, with apparent slight increase in amount of pleural fluid and probably decreased in extent of pleural gas in this region. On the left, there is a questionable increase in size of a small-to-moderate left pleural effusion. Otherwise, no relevant short interval change since the recent study. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with s/p CT DCd // ? PTX TECHNIQUE: Chest PA and lateral COMPARISON: Multiple chest radiographs the most recent on ___ at 12:53 FINDINGS: There has been interval removal of a right chest tube. There is a small right basilar hydro pneumothorax. Left retrocardiac area appears worse from the prior exam. No other significant change. IMPRESSION: 1. Small right basilar hydropneumothorax. 2. Left retrocardiac opacity appears worse from the prior exam and likely reflects a combination of pleural effusion and adajcent atelectasis and/or consolidation. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Wound eval Diagnosed with FEVER, UNSPECIFIED temperature: 98.8 heartrate: 74.0 resprate: 14.0 o2sat: 95.0 sbp: 113.0 dbp: 62.0 level of pain: 6 level of acuity: 3.0

___ year old female s/p MI MV repair on ___ with R chest tube placed for persistent pneumothorax, has remained on pleurostat for persistent air leak. Ms. ___ had one low grade temp (101 F) last night and also spontaneous increasing clear drainage. On ___ she presented to the ED for evaluation of her right pneumostat by the Thoracic team. Upon their evaluation the chest tube was noted to still be secured to her chest wall,though loose. She also had a WBC of 14 and new bilateral pleural effusions on CXR. She was admitted to ___ 6 for further work up. Thoracic secured chest tube at bedside sterile with single ___ nylon suture and closed space lateral to tube. She was given Levaquin for presumed pneumonia. Chest tube was placed to pleurevac. Thoracic surgery followed. HD #3 the chest tube was placed to water seal and clamped. CXR showed stable small right pnuemothorax. Thoracic team discontinued the right pleurestat tube. CXR was repeated and right pneumothorax was stable. Thoracic cleared the pt for discharge to home with follow up with ___ advised in 1 week along with CXR prior to clinic visit. Her leukocytosis improved with incentive spirometry and pt did not have a pneumonia. She was discharged to home with ___ services and follow up appoinments advised.

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Cellulitis Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ lady from the ___ with HTN, DM2, CAD, CVA, chronic venous stasis, and PVD with claudication who was referred to the ED due to a leg ulcer. . For ___ years she has had issues with blateral leg swelling and chronic venous stasis. The legs always look reddish with brawny disoloration and thickening of the skin. She has also had issues with claudication for many years, having required a right iliac stent in the past. She has leg pain behind her calves at rest which gets worse with walking. Her right leg is usually slightly bigger and more painful than the left one. . On ___, six days prior to presentation) she was at an appointment and she rubbed the back of her left lower leg against something sharp, causing a small abrasion. She did not think much of it. She has sensation in her feet and only noticed slightly more pain than usual. Denies pus/drainage at the site. She had an appointment to see a Vacscular Surgeon ___ ___ yesterday, where she had arterial/vacular studies done (see below). He pointed out her wound and she realized that the abrasion was bigger than before, and was ulcerated. He was concerned for infection so he started her on PO Bactrim and advised her to go to the ED. . In the ED, initial VS were: T 97, HR 65, BP 178/57, RR 15, O2 sat 100% RA. Her exam demonstrated good perfusion, good pulses. Labs remarkable for BUN/Cr ___, glucose 46, bicarb 20, WBC 12.6. Patient was given Vancomycin for cellulitis. She was given juice and food for relative hypoglycemia. She was admitted to Medicine for cellulitis. VS prior to transfer were: T 97.5, HR 59, BP 151/64, RR 16, O2 sat 99% RA. . On the floor, patient is comfortable. Denies any fevers or chills. Says that her legs look the way they always to, except for the wound on her left calf. Currently she has pain in both legs and also a burning sensation around the area of the wound. Past Medical History: -CAD s/p MI s/p BMS to RCA in ___ (___) -PVD s/p R Iliac stent -s/p CVA -DM -HTN -CHF -CKD (unknown baseline) -HLD -Tobaccoism -GERD Social History: ___ Family History: Father died of MI at age ___. Mother died of MI at age ___. 2 sons have DM2 and HTN. Cousin and aunt have colon cancer. Physical Exam: ON ADMISSION: VS - Temp 96.6F, BP 181/122, HR 73, R 20, O2-sat 100% RA, ___ 288 GENERAL - well-appearing obese lady in NAD, comfortable HEENT - EOMI, sclerae anicteric, MMM NECK - supple, no JVD LUNGS - CTA bilaterally HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - obese but nondistended, (+) bowel sounds, no tenderness to palpation EXTREMITIES - warm legs but cool feet; 1+ DP pulses bilaterally; R>L size; both legs with brawny stasis dermatitis inferiorly and reddish hue superiorly but no warmth/no plaque/no demarcated area of erythema and no streaking of skin; posterior to the left leg there is a 6cm x 3cm superficial ulceration with clean erythematous base and no surrounding erythema LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait . ON DISCHARGE: VS - Temp 98.6 , BP 145/90, HR 65, R 20, O2-sat 100% RA, GENERAL - well-appearing obese lady in NAD, comfortable HEENT - EOMI, sclerae anicteric, MMM NECK - supple, no JVD LUNGS - CTA bilaterally HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - obese but nondistended, (+) bowel sounds, no tenderness to palpation EXTREMITIES - warm legs but cool feet; 1+ DP pulses bilaterally; R>L size; both legs with brawny stasis dermatitis inferiorly and reddish hue superiorly but no warmth/no plaque/no demarcated area of erythema and no streaking of skin; posterior to the left leg there is a 6cm x 3cm superficial ulceration with clean erythematous base and no surrounding erythema LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait Pertinent Results: ADMISSION LABS: ___ 02:40PM BLOOD WBC-12.6* RBC-4.10* Hgb-12.0 Hct-35.9* MCV-88 MCH-29.4 MCHC-33.5 RDW-13.3 Plt ___ ___ 02:40PM BLOOD Glucose-46* UreaN-30* Creat-2.6*# Na-139 K-4.0 Cl-107 HCO3-20* AnGap-16 ___ 07:05AM BLOOD Calcium-8.2* Phos-4.5 Mg-2.1 ___ 10:07AM URINE Hours-RANDOM UreaN-262 Creat-39 Na-60 K-13 Cl-39 DISCHARGE LABS: ___ 08:25AM BLOOD WBC-7.3 RBC-3.74* Hgb-11.0* Hct-33.3* MCV-89 MCH-29.3 MCHC-32.9 RDW-13.1 Plt ___ ___ 08:25AM BLOOD Glucose-88 UreaN-39* Creat-3.0* Na-140 K-5.2* Cl-111* HCO3-22 AnGap-12 ___ 08:25AM BLOOD Calcium-8.4 Phos-4.7* Mg-2.2 ___ 08:25AM BLOOD Vanco-13.3 IMAGING: Renal US: FINDINGS: Note is made that this is a limited study due to the patient's body habitus and her limited ability to hold her breath. The right kidney measures 10.6 cm and the left kidney measures 10.5 cm. There is no hydronephrosis. Several small parapelvic cysts are seen in the hilum of the left kidney measuring up to 1.2 cm in diameter. A tiny simple cyst is seen at the lower pole of the left kidney measuring 1.0 x 1.0 x 0.8 cm. There is a non-obstructing stone measuring 9 mm seen in the collecting system of the left kidney. A small non-obstructing stone is seen at the lower pole of the right kidney measuring 0.8 cm. The pre-void bladder is partially distended and is unremarkable. DOPPLER EXAMINATION: Due to the patient's body habitus and her inability to hold her breath, the Doppler examination is severely limited. There is arterial and venous flow identified within each of the kidneys. No further assessment for renal artery stenosis can be made. IMPRESSION: 1. Arterial and venous flow documented within each kidney. However, no further Doppler assessment can be made due to the patient's body habitus and her inability to hold her breath. 2. No hydronephrosis. Small simple cyst seen in the left kidney and one non-obstructing stone seen in each of the kidneys. EKG: Artifact is present. Sinus rhythm. Non-diagnostic Q waves in the inferior leads. There is a late transition with small R waves in the anterior leads consistent with possible myocardial infarction. Non-specific ST-T wave changes. Compared to the previous tracing of ___-T wave changes are new. Medications on Admission: Aspir-81 81 mg daily Plavix 75 mg daily Nifedipine ER 90 mg daily Losartan 100 mg daily Metoprolol succinate 100 mg daily Torsemide 20 mg daily Glipizide 5 mg daily Gabapentin 300 mg TID Lexapro 10 mg daily Loratidine 10mg daily Famotidine 20 mg daily Folic acid 1 mg daily Ferrous sulfate 325 mg daily Vitamin B-12 1,000 mcg daily Acetaminophen 500 mg Q6H PRN Bactrim DS 800 mg-160 mg BID [since ___ Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 8. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 10. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. nifedipine 90 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO DAILY (Daily). 12. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 13. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. insulin NPH & regular human 100 unit/mL (70-30) Suspension Sig: ___ Subcutaneous twice a day. 15. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 8 days. Disp:*16 Tablet(s)* Refills:*0* 16. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 8 days. Disp:*16 Tablet(s)* Refills:*0* 17. losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 18. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:*30 Patch 24 hr(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Cellulitis Chronic Kidney Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report ARTERIAL DOPPLER LOWER EXTREMITY REASON: Ulceration. Doppler evaluation was performed of both lower extremity arterial systems at rest. All waveforms are monophasic bilaterally from the femoral to dorsalis pedis artery. The ABI on the right is 0.53, on the left 0.52. Pulse volume recordings show dropoff the right thigh compared to left with further dropoff distally. IMPRESSION: Significant bilateral occlusive disease multisegmental, likely proximal component as well as a tibial component. Radiology Report INDICATION: A ___ female with chronic renal failure and peripheral vascular and arterial disease, evaluate renal vasculature and for obstruction. COMPARISON: No previous exam for comparison. FINDINGS: Note is made that this is a limited study due to the patient's body habitus and her limited ability to hold her breath. The right kidney measures 10.6 cm and the left kidney measures 10.5 cm. There is no hydronephrosis. Several small parapelvic cysts are seen in the hilum of the left kidney measuring up to 1.2 cm in diameter. A tiny simple cyst is seen at the lower pole of the left kidney measuring 1.0 x 1.0 x 0.8 cm. There is a non-obstructing stone measuring 9 mm seen in the collecting system of the left kidney. A small non-obstructing stone is seen at the lower pole of the right kidney measuring 0.8 cm. The pre-void bladder is partially distended and is unremarkable. DOPPLER EXAMINATION: Due to the patient's body habitus and her inability to hold her breath, the Doppler examination is severely limited. There is arterial and venous flow identified within each of the kidneys. No further assessment for renal artery stenosis can be made. IMPRESSION: 1. Arterial and venous flow documented within each kidney. However, no further Doppler assessment can be made due to the patient's body habitus and her inability to hold her breath. 2. No hydronephrosis. Small simple cyst seen in the left kidney and one non-obstructing stone seen in each of the kidneys. Gender: F Race: HISPANIC/LATINO - DOMINICAN Arrive by WALK IN Chief complaint: LOWER EXTREMITY REDNESS Diagnosed with PERIPH VASCULAR DIS NOS, VENOUS INSUFFICIENCY NOS, ULCER OF CALF, NIDDM UNCONTROLLED temperature: 97.0 heartrate: 65.0 resprate: 15.0 o2sat: 100.0 sbp: 178.0 dbp: 57.0 level of pain: 0 level of acuity: 3.0

___ yo woman w/ DM, HTN, HL, PVD and PAD who is s/p prior arterial bypass and angioplasty who presents from vascular surgery clinic with an errythematous superficial lesion on her left leg concerning for cellulitis. Paitent recieved IV vanc/zosyn while inpatient and was transitioned to oral bactrim/augmentin after evaluation by vascular surgery who felt patient did not require debridement or revascularization. #. Left calf ulcer: Patient developed lesion after scraping her leg a week prior, she was seen by her vascular surgeon who sent her to the emergency department with concern for a cellulitis. The lesion was errythematous, painful and swollen, but patient had doppleralbe pulses distally. Patient was started on IV vanc/zosyn which improvment in the surrounding swelling and errythema. Patient was seen by vascular surgery who felt patient did not require debridement or revascularization after reviewing the patient's non-invasive studies and given improvement in cellulitis and ulcer in house with antibiotics and careful wound care by our wound care RNs. Patient was transitioned to PO bactrim and augmentin to complete a ___s an outpatient. She was instructed on how to care for the ulcer at home, and will follow up with her PCP and ___ surgeon. . # CKD: Patient presented with a creatinine of 3.0 up from a baseline of 2.0 per the ___ labs from several months prior. Her creatinine was not fluid responsive and Renal US did not show any flow assymetry or obstruction. This was felt to be from a worsening of her chronic illness, her medications were renally dosed and patient restarted on her home losartan 100 mg and lasix 20 mg prior to discharge. . #. CAD: Stable, EKG without signs of ischemia. Continued on ASA, Plavix, beta blocker and atorvastatin. . #. DM2: Stable, though with frequent AM hypoglycemia (to the ___ on her home dose of novalog 70/30 20 units Qam and 15 units QPM with a regular insulin sliding scale. . #. PVD: stable, continued on home ASA, Plavix, atorvastatin. . #. HTN: stable, continued on home Nifedipine, Metoprolol, losartan and lasix. .

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Cephalosporins / Aztreonam / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / Reglan Attending: ___. Chief Complaint: Nausea Major Surgical or Invasive Procedure: Tunneled dialysis line through IJ placed ___ History of Present Illness: ___ hx DMII, PVD, CKDV, MCI, gastroparesis presents for two week history of nausea and vomiting with diarrhea. Was seen in ED one month ago for similar symptoms, was told to f/u with PCP regarding gastroparesis but does not have a PCP. Ran out of reglan 1.5 months ago. Does note endorse new onset burning pain with urination. Has stopped taking gabapentin due to sleepiness, otherwise denies changes in medications. In regards to her renal disease, the patient is known by the renal service a ___. CKD stage 5 is presumably from diabetes and hypertension, baseline cr around ___. She had a R UE basilic AVF placed by Dr. ___ on ___, but missed multiple follow up appointments and did not have superficialization of the fistula procedure and has declined dialysis. Historically she does not want to take extra medications because could not olerate (vit D, sodium bicarbonate), but that if the medicationis good for her kidney she may try. In addition, in previous discussions, she is not ready for transplant. In regards to her history of gasteroperesis though to be secondary to diabetes. She was last seen by GI at ___ in ___. She had a gastric emptying study performed in ___ showing she has gasteroparesis. At that time, she is continued to suffer from complications of diabetes and is unlikely to have had substantial improvement in her gastroparesis. Likely further limiting her motility is the fact she is now confined to a wheelchair. At that time, GI felt that a further workup was not warranted and began metoclopramide 5 mg to be taken 3 times a day, 30 minutes before meals as well as beginning a bowel regimen to encourage bowel movements. In the ED, initial VS were: T 97.8 HR 90 BP133/70 RR16 O2100% RA Exam notable for: GEN: A&Ox3, NAD, wheelchair bound due to R-BKA CV: Regular rate, no murmurs or rubs appreciated Pulm: Normal pulmonary effort, CTAB Abd: Mildly distended, diffusely tender, worst to RUQ and RLQ. Pain does not radiate upon palpation. Positive bowel sounds. GU: Bilateral flank pain ECG: Labs showed: Cr 11.2, BUN 87 K 5.2, ALT/AST ___ ALP 176 WBC 11.6 H/H 11.6/33.0 Imaging showed: Bedside renal ultrasounds show no obvious hydronephrosis, normal appearing renal pelvis b/l. Bedside abdomen ultrasound shows no obvious signs of obstruction. CT Abd/Pelvis w/o contrast: 1. Mild wall thickening of the right colon suggestive of colitis, possibly infectious or inflammatory in etiology. 2. 3.1 cm right adnexal cyst with layering hyperdense component, likely compatible with a hemorrhagic cyst. 3. Small amount of free fluid in the pelvis. Consults: ___ female with past medical history of diabetes mellitus, type 2 c/b neuropathy, nephropathy, gastroparesis, CKD stage V who has refused dialysis, previously on fludrocortisone for hyperkalemia management but ___ stopped due to nausea, HTN, PVD, asthma, gastroparesis, mild cognitive impairment, anemia, and HLD who presented with a 2-day of history of nausea and vomiting. Renal was consulted for CKD stage 5. Per note from ___, previously refused dialysis and transplant consideration. -per discussion with ED, no concern for volume overload, still makes good amount of urine. electrolytes acceptable range. -start sodium bicarb 650mg tid -we will see patient in the AM. -there is no acute indication for dialysis tonight. Patient received: 1L NS Zofran 4mg X2 Cipro 400mg Flagyl 500mg Labetalol 10mg Morphine 2mg Transfer VS were: T 98.0 HR94 BP186/76 RR18 O2100% RA On arrival to the floor, patient reports having nausea for the past 2 weeks. She states she has been having BM. She did not describe these BM to me. Her last BM was on the day of admission. She denied blood. She did vomit in the ED. Otherwise she states she has mild abdominal pain. She denies any pelvic pain, or discharge her her vagina. Past Medical History: PMH: DM2 c/b gastroparesis/neuropathy/foot ulcer in RLE/nephropathy HTN hypercholesterolemia PVD asthma CKD stage V (refuses HD) obesity chronic cognitive deficits anemia s/p R BKA . Social History: ___ ___ History: Diabetes in her mother, and 5 of her 6 siblings. Per patient report, mother died while on hemodialysis. Physical Exam: ADMISSION PHYSICAL EXAM: ========================== VS: ___ 0004 Temp: 97.6 PO BP: 189/103 HR: 87 RR: 18 O2 sat: 100% O2 delivery: RA GENERAL: NAD NECK: supple, no LAD CV: RRR, S1/S2, no murmurs, PULM: CTAB, no wheezes, GI: abdomen soft, nondistended, mild tenderness in Left upper and lower quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no edema DISCHARGE PHYSICAL EXAM: =========================== 24 HR Data (last updated ___ @ 012) Temp: 97.2 (Tm 98.5), BP: 155/87 (139-183/64-87), HR: 91 (82-98), RR: 18, O2 sat: 97% (96-99), O2 delivery: RA GENERAL: Laying in bed, NAD, very happy. HEENT: AT/NC, anicteric sclera, MMM CV: RRR, S1/S2, II/VI systolic over LSB, no gallops or rubs PULM: CTAB, breathing comfortably without use of accessory muscles GI: BS present, nontender, nondistended EXTREMITIES: no cyanosis, clubbing, or edema, R BKA NEURO: Alert, moving extremities with purpose, leans to the side freely without assistance DERM: Warm and well perfused, no excoriations or lesions, no rashes. Tunneled RIJ line in dressing in place, c/d/I without overlying erythema. Pertinent Results: ___ 10:40PM GLUCOSE-88 UREA N-78* CREAT-10.3* SODIUM-142 POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-14* ANION GAP-22* ___ 12:23PM ___ PO2-37* PCO2-41 PH-7.27* TOTAL CO2-20* BASE XS--8 ___ 12:23PM LACTATE-1.3 K+-5.0 ___ 12:20PM GLUCOSE-222* UREA N-87* CREAT-11.2*# SODIUM-137 POTASSIUM-5.2 CHLORIDE-96 TOTAL CO2-17* ANION GAP-24* ___ 12:20PM ALT(SGPT)-41* AST(SGOT)-25 ALK PHOS-176* TOT BILI-0.5 ___ 12:20PM ALBUMIN-4.8 ___ 12:20PM LIPASE-90* ___ 12:20PM HCG-<5 ___ 12:20PM WBC-11.6* RBC-4.12 HGB-11.6 HCT-33.0* MCV-80* MCH-28.2 MCHC-35.2 RDW-15.0 RDWSD-43.1 DISCHARGE LABS: =================== ___ 06:10AM BLOOD WBC-10.3* RBC-3.03* Hgb-8.5* Hct-24.7* MCV-82 MCH-28.1 MCHC-34.4 RDW-15.4 RDWSD-45.4 Plt ___ ___ 06:10AM BLOOD ___ PTT-25.4 ___ ___ 06:10AM BLOOD Glucose-247* UreaN-22* Creat-5.0*# Na-140 K-4.4 Cl-104 HCO3-23 AnGap-13 ___ 07:25AM BLOOD ALT-22 AST-22 AlkPhos-128* TotBili-0.4 ___ 06:10AM BLOOD Calcium-7.4* Phos-3.9 Mg-1.7 ___ 06:56AM BLOOD HCV Ab-NEG Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB 2. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QFRI hypertension 3. Epoetin Alfa 4000 UNIT IV ASDIR 4. gabapentin 250 mg/5 mL oral QHS 5. GlipiZIDE 2.5 mg PO BID 6. Metoclopramide 5 mg PO QIDACHS 7. NIFEdipine (Extended Release) 60 mg PO DAILY 8. Vitamin D ___ UNIT PO DAILY Discharge Medications: 1. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD QMON Put patch in the same location on your body, change 1x per week. 2. Nephrocaps 1 CAP PO DAILY RX *B complex with C#20-folic acid ___ Caps] 1 mg 1 capsule(s) by mouth once daily Disp #*30 Capsule Refills:*0 3. sevelamer CARBONATE 800 mg PO TID W/MEALS RX *sevelamer carbonate 800 mg 1 tablet(s) by mouth TID with meals Disp #*90 Tablet Refills:*0 4. NIFEdipine (Extended Release) 90 mg PO DAILY RX *nifedipine 90 mg 1 tablet(s) by mouth once daily Disp #*30 Tablet Refills:*0 5. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB 6. Epoetin Alfa 4000 UNIT IV ASDIR 7. gabapentin 300 mg/6 mL (6 mL) oral QHS 8. GlipiZIDE 2.5 mg PO BID 9. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: CKD 5 with dialysis Infectious colitis 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: VENOUS MAPPING FOR DIALYSIS ACCESS INDICATION: ___ year old woman with ESRD// please perform vein mapping for HD AV fistula planning TECHNIQUE: Real-time grayscale and Doppler ultrasound imaging of both cephalic veins, radial artery, brachial artery, basilic vein and subclavian veins was performed. COMPARISON: None FINDINGS: RIGHT: Normal venous flow in the right subclavian vein. The basilic vein measures: Proximal arm: 0.28 at a depth of 0.78 cm Mid arm: 0.29 cm at a depth of 1.18 cm Distal arm: 0.26 cm and a depth of 1.26 cm Antecubital fossa: 0.18 cm at a depth of 0.60 cm The cephalic vein measures: Wrist: 0.12 cm at a depth of 0.56 cm Mid forearm: 0.19 cm at a depth of 0.66 cm Antecubital fossa: 0.17 cm at a depth of 0.71 cm Distal arm: 0.17 cm at a depth of 0.18 cm Mid arm: 0.16 cm and a depth of is 0.24 cm Proximal arm: 0.11 cm at a depth of 0.41 cm The right brachial artery measures 0.14 cm with mild arterial calcification with poor peak systolic velocity tracing, but likely normal. The right radial artery measures 0.14 cm with mild calcification, normal peak systolic velocity. LEFT: Normal venous phasic flow in the Left subclavian vein. The basilic vein measures: Proximal arm: 0.31 cm and a depth of 0.8 cm Mid arm: 0.29 cm and at the 0.90 cm Distal arm: 0.35 cm and a depth of 0.81 cm Antecubital fossa: 0.34 cm at those 0.86 cm Cephalic vein measures: Wrist: 0.20 cm at a depth of 0.43 cm Mid forearm: 0.20 cm at the 0.67 cm Antecubital fossa: Partial thrombosis Distal arm/antecubital fossa: 0.26 cm and a depth of 0.59 cm without thrombus Mid arm: 0.22 cm at a depth of 0.74 cm The Left brachial artery measures 0.34 cm without significant calcification, normal peak systolic velocity. Left radial artery measures 0.20 cm without significant calcification, normal peak systolic velocities. IMPRESSION: Partial thrombosis of the Left cephalic vein at the antecubital fossa. Patent Left basilic vein with measurements as above. Patent right cephalic and basilic veins with measurements as above. Small caliber right brachial artery. Radiology Report EXAMINATION: CT ABDOMEN AND PELVIS WITHOUT CONTRAST INDICATION: History: ___ DMII CKDV gastroparesis with 2 week history abdominal pain, diarrhea. Evaluation for acute intra-abdominal process. TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired without intravenous contrast. Non-contrast scan has several limitations in detecting vascular and parenchymal organ abnormalities, including tumor detection. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 6.7 s, 53.1 cm; CTDIvol = 15.1 mGy (Body) DLP = 803.6 mGy-cm. Total DLP (Body) = 804 mGy-cm. COMPARISON: Comparison to CT abdomen/pelvis 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 homogeneous attenuation throughout. There is no evidence of focal lesions within the limitations of an unenhanced scan. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is surgically absent. PANCREAS: 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. There is no nephrolithiasis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber and wall thickness throughout. Mild thickening of the right colon is suggestive of colitis, possibly infectious or inflammatory (02:34). Remainder of the colon and rectum appear unremarkable. The appendix is normal. PELVIS: The urinary bladder and distal ureters are unremarkable. There is a small amount of free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus is within normal limits. There is a right adnexal cyst with layering hyperdense component, measuring 3.1 x 2.3 cm (2:72) and likely compatible with hemorrhagic cyst. 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: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Mild wall thickening of the right colon suggestive of colitis, possibly infectious or inflammatory in etiology. 2. 3.1 cm right adnexal cyst with layering hyperdense component, likely compatible with a hemorrhagic cyst. 3. Small amount of free fluid in the pelvis. Radiology Report INDICATION: ___ year old woman with ESRD, needs somewhat urgent dialysis.// needs semi-urgent HD tunnel line placement COMPARISON: Chest radiograph dated ___ 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 75mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service time of 30 min during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: CONTRAST: 0 ml of Optiray contrast FLUOROSCOPY TIME AND DOSE: 1.5 min, 1 mGy PROCEDURE: 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 left upper chest was prepped and draped in the usual sterile fashion. Under continuous ultrasound guidance, the patent left internal jugular vein was compressible and accessed using a micropuncture needle. Permanent ultrasound images were obtained before and after intravenous access, which confirmed vein patency. Subsequently a Nitinol wire was passed into the right atrium using fluoroscopic guidance. The needle was exchanged for a micropuncture sheath. The Nitinol wire was removed and a short ___ wire was advanced to make appropriate measurements for catheter length. The ___ wire was then passed distally into the IVC. Next, attention was turned towards creation of a tunnel over the upper anterior chest wall. After instilling superficial and deeper local anesthesia using lidocaine mixed with epinephrine, a small skin incision was made at the tunnel entry site. A 23cm tip-to-cuff length catheter was selected. The catheter was tunneled from the entry site towards the venotomy site from where it was brought out using a tunneling device. 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 catheter was threaded into the right side of the heart with the tip in the right atrium. The sheath was then peeled away. The catheter was sutured in place with 0 silk sutures. Steri-strips were also used to close the venotomy incision site. Final spot fluoroscopic image demonstrating good alignment of the catheter and no kinking. The tip is in the right atrium. The catheter was flushed and both lumens were capped. Sterile dressings were applied. The patient tolerated the procedure well. FINDINGS: Patent left internal jugular vein. Final fluoroscopic image showing dialysis catheter with tip terminating in the right atrium. IMPRESSION: Successful placement of a 23cm tip-to-cuff length tunneled dialysis line. The tip of the catheter terminates in the right atrium. The catheter is ready for use. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with shortness of breath. Evaluation for edema or consolidation. TECHNIQUE: Chest PA and lateral COMPARISON: Comparison to radiograph from ___. FINDINGS: Interval placement of a left internal jugular central venous catheter, with tip terminating in the proximal right atrium. Mild cardiomegaly is stable. Slightly low lung volumes contribute to crowding of bronchovascular markings. Lungs are clear without evidence of focal consolidation. No pleural effusion or pneumothorax is seen. Surgical clips are seen in the right upper quadrant, compatible with prior cholecystectomy. IMPRESSION: No acute cardiopulmonary abnormality. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Abd pain, Diarrhea Diagnosed with Acute kidney failure, unspecified temperature: 97.8 heartrate: 90.0 resprate: 16.0 o2sat: 100.0 sbp: 133.0 dbp: 70.0 level of pain: 3 level of acuity: 3.0

___ hx DMII, PVD, CKDV, MCI, gastroparesis presents for two week history of nausea and vomiting with diarrhea. Was seen in ED one month ago for similar symptoms, and was told to f/u with PCP regarding gastroparesis but does not have a PCP. She ran out of reglan 1.5 months ago. Her N/V was at first believed to be d/t a gastroparesis flare i/s/o taking less Reglan. On admission she was found to have ___ with Cr 11 up from baseline of 8, metabolic acidosis, and uremia. She was given IV fluids and nausea managed w/ IV Zofran, reglan, and ativan but persisted. A gastric motility study was also non-diagnostic due to the patient's immediate emesis. GI was consulted and recommended EGD, which the patient declined, while inpatient. Nephrology was consulted for initiation of hemodialysis on day of admission, however pt initially refused due to prior experiences with family members on dialysis. After 2 days of intractable N/V, continued HTN, and worsening metabolic condition, pt agreed to begin hemodialysis and a tunneled catheter was placed in the LIJ on ___. On ___, Ms. ___ experienced what is believed to be a dystonic reaction to IV reglan (despite being home med) with neck stiffness and tongue protrusion, and was ___ transferred to the ICU for monitoring of airway protection. She had no airway concerns while in the ICU and was transitioned back to the medical floor within 24 hours. She began hemodialysis on ___ with subsequent decline in her Cr to ~5. Her anion gap began to diminish following the initiation of hemodialysis, and the patient began to tolerate PO intake of food, beverage, and medications without symptoms. She was discharged ___ after being scheduled to continue HD on an outpatient basis.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Cardiac catheterization ___ - thrombectomy and bare metal stent placement to proximal LAD History of Present Illness: Mr. ___ is an ___ y/o male with a history of CAD s/p PCI to ___ ___, Sick Sinus Syndrome s/p PPM who presented to ___ the night of ___ with chest pain. Patient states that he was having substernal chest pain most of the night with associated diaphoresis. He denies radiation to jaw or extremities, no nasuea/vomiting, no numbness/tingling, lightheadedness or dizziness. EKG at OSH were remarkable for paced rhythm with LV bundle branch block. He was admitted to OSH for monitoring, given aspirin, and his troponins trended 0.04-->5.59-->21.01, he was transferred here for catheterization. In the ED vitals were 98.4, 60, 185/88, 16, 99% 2L NC. Labs were significant for troponin here was 4.08 and BUN/Cr: 37/1.9, H/H: 9.5/28.8. For BP control, he was started on a nitro drip at 1mcg/kg/min. His BP ranged from 160's-180's so he received hydral 5mg IV, and metoprolol 5mg IV with minimal effect. He was given nitro paste and morphine for Chest pain. Heparin drip was started, cardiology was consulted and he was taken emergently to the cath lab. In the cath lab for his NSTEMI he was underwent angiography and was found to have 3 vessel disease with a culprit lesion in the LAD. Thrombectomy was performed and a bare metal stent was placed in the proximal LAD. He was started on Eptifibatide for 18 hours, ASA and Plavix. Transferred to the CCU CP free and stable, on nitro drip for pressures, will monitor overnight On review of systems, he denies any prior history of deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, cough, hemoptysis. He denies recent fevers, chills or rigors. . Per chart, prior history of TIA and retinal vein occlusion. All of the other review of systems were negative. . Cardiac review of systems is notable for chest pain, and absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: Diabetes Dyslipidemia Hypertension - not on lisonpril d/t hyperkalemia CAD s/p PERCUTANEOUS CORONARY INTERVENTIONS: ___ LAD AND LCFX STENTS AT ___ ___ complicated by contrast induced nephropathy PACING/ICD for heart block, generator change ___ ___ Primary hyperparathyroidism treated with sensipar CKD III Vitamin D Deficiency GASTRITIS - endoscopy ___ "mild erosive gastritis" and hiatal hernia CAROTID ARTERY STENOSIS / OCCLUSION TIA retinal venous occlusion, branch HYPERPARATHYROIDISM GLAUCOMA ASSOC W VASC DISORDER, chronic angle closure and open angle Cataracts DIVERTICULITIS MENIERE'S DISEASE and hearing loss (conductive and sensorineural) PROTEINURIA ANXIETY DISORDER POSITIVE PPD BPH s/p TURP Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Father had a stroke. otherwise non-contributory. Physical Exam: On admission: ED vitals were 98.4, 60, 185/88, 16, 99% 2L NC GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple, JVP not assessed since lying flat. CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. coarse crackles on left. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. PULSES: dopplerable DP and ___ pulses bilaterally, 2+ radial pulses bilaterally On discharge: Vitals 98.9 159/76 60 18 98%RA HEENT: NCAT CV: RRR no m/r/g Chest: compromised somewhat by poor patient cooperation but I was able to appreciate some L>R crackles at the bases Abd: NT/ND, BS+ Ext: WWP Pertinent Results: Admission Labs ___ 02:10PM BLOOD WBC-8.3 RBC-2.99* Hgb-9.5* Hct-28.8* MCV-96 MCH-31.7 MCHC-32.9 RDW-13.4 Plt ___ ___ 02:10PM BLOOD ___ PTT-150* ___ ___ 02:10PM BLOOD Glucose-108* UreaN-37* Creat-1.9* Na-136 K-4.2 Cl-107 HCO3-20* AnGap-13 ___ 09:43PM BLOOD CK-MB-43* MB Indx-6.0 ___ 02:10PM BLOOD cTropnT-4.08* Discharge Labs: ___ 06:00AM BLOOD WBC-6.8 RBC-3.03* Hgb-9.4* Hct-28.2* MCV-93 MCH-30.9 MCHC-33.3 RDW-14.2 Plt ___ ___ 06:22AM BLOOD Hct-27.2* ___ 06:22AM BLOOD UreaN-30* Creat-2.2* Na-137 K-4.1 Cl-107 Studies: EKG on admission: V-paced rhythm with LBBB morphology, rate 60bpm CARDIAC CATH ___: -ASSESSMENT 1.NSTEMI with ongoing pain 2.Three vessel coronary artery disease with culprit lesion in LAD 3.Successful bare metal stent in proximal LAD -RECOMMENDATIONS 1.Aspirin 325 mg daily for one month 2.Plavix 75 mg daily 3.IV eptifibatide for 18 hours CXR ___: LUL infiltrate CXR ___: bibasilar atelectasis, with interval improvement in left mid lung airspace abnormality consistent with improved aspiration pneumonitis. Echo ___: Normal biventricular cavity sizes with preserved global biventricular systolic function with LV regional wall motion abnormalities as above. Mild aortic regurgitation. Mild mitral regurgitation. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientFamily/CaregiverAtrius. 1. NIFEdipine CR 60 mg PO DAILY Start: In am hold for SBP <100 2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID 3. Simvastatin 20 mg PO ___ Start: In am 4. Timolol Maleate 0.5% 1 DROP RIGHT EYE QID Start: In am 5. FoLIC Acid 2 mg PO DAILY Start: In am 6. Cinacalcet 30 mg PO DAILY Start: In am 7. Atropine Sulfate Ophth 1% 1 DROP RIGHT EYE BID Start: In am 8. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID Start: In am 9. Omeprazole 20 mg PO BID 10. bimatoprost *NF* 0.03 % ___ 11. Metoprolol Tartrate 25 mg PO DAILY:PRN for SBP > 140 Start: In am 12. Vitamin D Dose is Unknown PO DAILY Start: In am 13. Nitroglycerin SL 0.4 mg SL PRN for chest pain 14. Lorazepam 0.5 mg PO BID:PRN anxiety 15. Ferrous Sulfate 325 mg PO 3X/WEEK (___) Start: In am 16. Aspirin 81 mg PO DAILY 17. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE DAILY Start: In am 18. Vigamox *NF* (moxifloxacin) 0.5 % Right eye ___ 19. Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE BID Start: In am Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. bimatoprost *NF* 0.03 % ___ 3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID 4. Cinacalcet 30 mg PO DAILY 5. Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE BID 6. Ferrous Sulfate 325 mg PO 3X/WEEK (___) 7. FoLIC Acid 2 mg PO DAILY 8. Lorazepam 0.5 mg PO BID:PRN anxiety 9. NIFEdipine CR 60 mg PO DAILY hold for SBP <100 10. Cefpodoxime Proxetil 400 mg PO Q24H RX *cefpodoxime 200 mg 2 Tablet(s) by mouth dialy Disp #*6 Unit Refills:*0 11. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 Tablet(s) by mouth Daily Disp #*28 Unit Refills:*3 12. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE DAILY 13. Nitroglycerin SL 0.4 mg SL PRN for chest pain 14. Omeprazole 20 mg PO BID 15. Simvastatin 20 mg PO ___ 16. Vitamin D 800 UNIT PO DAILY 17. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 18. Metoprolol Tartrate 50 mg PO BID RX *metoprolol tartrate 50 mg 1 Tablet(s) by mouth twice a day Disp #*56 Unit Refills:*3 19. Atropine Sulfate Ophth 1% 1 DROP RIGHT EYE BID 20. Polyethylene Glycol 17 g PO DAILY:PRN constipation 21. Ranitidine 150 mg PO BID:PRN reflux Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Principal diagnosis: NSTEMI (heart attack) Secondary diagnoses: Coronary Artery Disease Community Acquired Pneumonia GI bleed - hematemesis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report CHEST ON ___ HISTORY: Stent to proximal LAD with cough and vomiting, question aspiration. There is a dual-lead pacemaker. The heart is upper limits normal in size. There is a hazy alveolar infiltrate in the left mid lung. There is mild pulmonary vascular re-distribution. There is a small right effusion. IMPRESSION: Left mid lung infiltrate. Radiology Report HISTORY: ___ male with pneumonia, question CHF. COMPARISON: ___. FINDINGS: There is interval improvement in airspace opacity in the left mid lung, likely from improvement in aspiration pneumonitis. The lungs demonstrate bibasilar atelectasis, left greater than right, new from prior without effusion or pneumothorax. Right parahilar airspace opacity likely reflects aspiration. The pulmonary vasculature remains normal. The cardiac silhouette is normal in size, and the aortic contour is tortuous with note of atherosclerotic calcification. A two-lead left chest pacemaker is unchanged. IMPRESSION: Bibasilar atelectasis, with interval improvement in left mid lung airspace abnormality consistent with improved aspiration pneumonitis. There is new bibasilar atelectasis and right parahilar airspace opacity . Gender: M Race: ASIAN Arrive by AMBULANCE Chief complaint: CP Diagnosed with INTERMED CORONARY SYND, CARDIAC PACEMAKER STATUS temperature: 98.4 heartrate: 60.0 resprate: 16.0 o2sat: 99.0 sbp: 185.0 dbp: 88.0 level of pain: nan level of acuity: 2.0

Mr. ___ is an ___ y/o male with a history of CAD s/p PCI (___), SSS s/p PPM who presented an OSH, transferred here for NSTEMI, taken to cath lab and had a stent placed to ___ LAD, hospital course complicated by hematemesis and community acquired pneumonia.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: fever, cough, hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old male w/ hx of HLD p/w 1 week of cough, dyspnea and dark urine. He states that he has had intermittent chills/fevers/night sweats with about one week of cough without production of sputum. His dypsnea is not exacerbated by exertion. He notes that the had muscle/joint aches leading up to the cough. He also had n/v with two episodes of emesis as well as diarrhea over the last two days but denies abd pain. He notes significant reduction in PO intake associated with some intermittent lightheadedness. He denies chest pain, leg swelling. He states that he has travelled, stating that he has not ever left the ___. He denies any family with recent travel or illness and denies recent hospitalizations or medical treatment. He was seen at his PCP's office and found to be hypoxic to 89 so was sent to the ED. In the ED initial vitals were: 99.9 96 135/85 18 96% 2L. He was treated with CTX and doxycycline in the ED with vitals prior to transfer were: 98.5 96 128/81 18 93% RA. On the floor, patient notes mild shortness of breath improved with 2L O2 by nasal cannula. Past Medical History: Colon adenoma R thigh lipoma HLD Hx gastric ulcer Rotator cuff repair x2 Right elbow bone chip removal Social History: ___ Family History: Father died elderly of pneumonia, mother died at ___ of unknown cancer, sister died of unknown cancer, brother died lung ca. 1 brother with copd. 8 sons, 1 daughter are well. Physical Exam: Admission Physical Exam: Vitals - T: 99 BP: 152/73 HR: 94 RR: 24 02 sat: 92%RA GENERAL: Well appearing man lying in bed in NAD HEENT: EOMI, PERRL, anicteric sclera, MMM NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: Crackles on L from base to mid-lung field, breathing comfortably without use of accessory muscles, no dullness to percussion ABDOMEN: Soft but mildly distended, +BS, nontender in all quadrants, no rebound/guarding EXTREMITIES: Warm and well perfused, no cyanosis, clubbing or edema PULSES: 2+ DP pulses bilaterally NEURO: AAOx3, motor and sensory exam grossly intact LYMPH NODES: No cervical, axillary, or inguinal LAD Discharge Physical Exam: PE 98.6 98.5 134/85 81 20 93RA(90-94) General- Alert, oriented, NAD HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- L side crackles from base up to mid lung and R upper lung decreased breath sounds, dullness, CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- no foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal Pertinent Results: ___ 08:10AM BLOOD WBC-11.1* RBC-4.90 Hgb-12.4* Hct-40.4 MCV-82 MCH-25.4* MCHC-30.8* RDW-14.9 Plt ___ ___ 07:55AM BLOOD WBC-11.2* RBC-4.65 Hgb-12.3* Hct-39.3* MCV-85 MCH-26.6* MCHC-31.4 RDW-15.1 Plt ___ ___ 08:30AM BLOOD WBC-12.8* RBC-4.76 Hgb-12.2* Hct-39.3* MCV-83 MCH-25.7* MCHC-31.1 RDW-14.9 Plt ___ ___ 04:49PM BLOOD WBC-13.9*# RBC-4.94 Hgb-13.3* Hct-41.0 MCV-83 MCH-26.9* MCHC-32.4 RDW-15.0 Plt ___ ___ 04:49PM BLOOD Neuts-79.3* Lymphs-15.1* Monos-4.9 Eos-0.1 Baso-0.5 ___ 08:10AM BLOOD Glucose-110* UreaN-11 Creat-0.8 Na-141 K-3.9 Cl-102 HCO3-31 AnGap-12 ___ 07:55AM BLOOD Glucose-111* UreaN-13 Creat-0.9 Na-141 K-3.9 Cl-103 HCO3-31 AnGap-11 ___ 08:30AM BLOOD Glucose-100 UreaN-16 Creat-1.1 Na-139 K-4.4 Cl-103 HCO3-28 AnGap-12 ___ 04:49PM BLOOD Glucose-125* UreaN-17 Creat-1.4* Na-139 K-4.1 Cl-100 HCO3-27 AnGap-16 ___ 08:10AM BLOOD ALT-59* AST-73* LD(___)-277* ___ 07:55AM BLOOD ALT-58* AST-74* CK(CPK)-177 AlkPhos-111 ___ 08:30AM BLOOD ALT-65* AST-106* LD(___)-361* AlkPhos-110 TotBili-0.4 ___ 04:49PM BLOOD CK(CPK)-721* ___ 04:49PM BLOOD cTropnT-<0.01 ___ 04:49PM BLOOD CK-MB-3 ___ 08:10AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.2 ___ 08:30AM BLOOD TotProt-5.2* Albumin-2.9* Globuln-2.3 Calcium-8.6 Phos-2.7 Mg-2.3 ___ 08:30AM BLOOD Hapto-438* ___ 02:50AM URINE Color-Yellow Appear-Clear Sp ___ ___ 12:03PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 02:50AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 12:03PM URINE Blood-LG Nitrite-NEG Protein->600 Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-4* pH-6.5 Leuks-NEG ___ 02:50AM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE Epi-<1 ___ 12:03PM URINE RBC-4* WBC-6* Bacteri-FEW Yeast-NONE Epi-0 ___ 10:48AM URINE Hours-RANDOM Creat-147 TotProt-85 Prot/Cr-0.6* ___ 2:50 am SPUTUM Source: Expectorated. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ___ 4:10 pm SPUTUM Source: Expectorated. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ___ 9:38 am SPUTUM Source: Expectorated. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Naproxen 1250 mg PO EVERY OTHER DAY 2. Aspirin 81 mg PO DAILY 3. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Vitamin D 1000 UNIT PO DAILY 3. Azithromycin 500 mg PO Q24H RX *azithromycin 500 mg 1 tablet(s) by mouth daily Disp #*2 Tablet Refills:*0 4. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 4 Days RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp #*16 Tablet Refills:*0 5. Acetaminophen 650 mg PO Q6H:PRN pain Discharge Disposition: Home Discharge Diagnosis: Pneumonia, community-acquired Acute renal failure/ AIN 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: None. FINDINGS: Heart size is normal. Mediastinal and hilar contours are unremarkable. There is no pulmonary edema. Consolidative opacities are seen within the left lower lobe and right upper lobe compatible with multifocal pneumonia. No pleural effusion or pneumothorax is identified. There are no acute osseous abnormalities. Surgical anchors are seen within the right humeral head. IMPRESSION: Multifocal pneumonia. Follow up radiographs after treatment are recommended to ensure resolution of this finding. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Cough, Dyspnea Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED temperature: 99.9 heartrate: 96.0 resprate: 18.0 o2sat: 96.0 sbp: 135.0 dbp: 85.0 level of pain: 0 level of acuity: 3.0

#CAP/?TB: Patient presented with two weeks of fevers/chills/joint pains, a week of cough with progressive dyspnea, left sided crackles on exam, and was found to have leukocytosis, and multifocal opacities on CXR without recent health-care contact consistent with community acquired pneumonia. Urine legionella was negative. He was started on ceftraixone and azithro. Patient improved quickly and was dicharged on cepodoxime and azithro. Given the hx of two weeks of fever/chills/night sweats and hx of incarceration, there was initial concern for TB. Patient subsequently ruled out with three AFP negative smears. ___: Patient with Cr 1.4 (from baseline 1.2) with dark urine and UA with SG 1.039 likely evidence of hypovolemia in the setting of poor PO intake and fevers. 1L LR on admission. resolved. # Nephropathy: ___ w/ large blood & protein, small bili on initial UA. Spot protein/Cr 0.6, non nephrotic range proteinuira, most likely NSAID induced acute interstitial nephritis given hx of significant NSAID use(6 naproxen every other day for 4 months). Repeat UA unremarkable. ___ resolved. ================================= Transitional issues ================================= - continue Azithromycin 500mg through ___ - continue Cefpodoxime through ___ - PPD needs to be read ___ afternoon at ___ (form provided) - Follow up final blood and sputum cultures

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: NG tube placement ___ Paracentesis ___ Paracentesis ___ History of Present Illness: Mr. ___ is a ___ year old male with history of EtOH cirrhosis (Child Class C, MELD 23) diuretic refractory ascites s/p TIPS ___, recent umbilical hernia repair with mesh ___ who presents with encephalopathy. Per patient's wife the patient was discharged from hospital on ___ (post umbilical hernia repair) and noted he was tired and wanted to sleep. He was in pain but did not want to take further pain medications due to nausea. Also did not want to take anything in by mouth due to his nausea. Over the day yesterday, he continued to not eat or drink anything and also did not take any of his medications including lactulose. His wife noted drainage from his recent surgical wound that was clear to blood tinged. The patient's wife spoke with a nurse over the phone who advised her to clean the area with warm water and to place clean gauze over it which she did. Around midnight, the patient was up and wandering around and at times aggressive, which is not his norm. The patient's wife again called the nurse at about midnight and explained altered mental status at which point it was suggested to take patient to the emergency room for further evaluation. Patient transferred to ___ from an outside hospital where he presented with with altered mental status and lethargy had negative CT head, was given lactulose, and transfered to ___ for further evaluation. Vitals in the ED significant for Temp 98.6, BP 104/61, HR 98, RR 18, 99% RA. Head CT obtained at OSH that was negative. RUQ US obtained which showed slightly high velocity mid-tips but otherwise patent TIPS. Diagnostic paracentesis obtained ruling out SBP though did show evidence of peritonitis. Patient started on IV ceftriaxone 2 grams (given recent umbilical hernia repair 4 days prior and SBP), given 60 ml of lactuose, 1L NS, and rifaxamin. NG tube placed. Infectious work up initiated with including urine and blood cultures pending. Transplant surgery evaluated patient and will follow patient while in hospital. On arrival to ___ 10, patient complaining of abdominal pain and nausea, fever, chills, or SOB. Attention is otherwise very poor and patient unable to follow commands. Unable to obtain full ROS due to patient's altered mental status. Past Medical History: - Alcoholic cirrhosis c/b diuretic refractory ascites s/p TIPS ___ - grade I varices (___) - Hypertension --not on antihypertensives - Internal Hemorrhoids - Umbillical hernia s/p repair ___ - H/o right inguinal hernia repair ___ - h/o cataract surgery Social History: ___ Family History: - No family history of liver disease - Mother died at ___ of ovarian cancer - Father diet at ___ of an MI - Siblings with diabetes Physical Exam: PHYSICAL EXAM ON ADMISSION: ============================= VS: Temp 98.2, BP 149/93, HR 76, RR 20, 99% RA General: NG tube in place, EOMI, ___ (left pupil slightly less reactive than right, but pupils symmetric) Oriented to self and place. Does not know date. Unable to assess for asterexis due to inability to follow commands. Intermittent hiccups HEENT: EOMI, ___ CV: RRR, no murmurs Lungs: clear to ausculation bilaterally Abdomen: Abdominal binder in place. Dressing from recent surgery c/d/i. Abdominal bulging and distended at site of dressing. Tender to palpation but no rebound or guarding Ext: 2+ peripheral pulses, no edema Neuro: CN II-XII intact, strenght exam limited by patient's ability to follow commands but grossly moving all extremties Skin: no rash PHYSICAL EXAM ON DISCHARGE: ============================= HYSICAL EXAMINATION: VS: 97.8, BP 124/69, HR 71, RR 18, 100% RA General: Oriented to place, date, location EOMI, ___ (left pupil slightly less reactive than right, but pupils symmetric) Oriented to self and place. No asterexis HEENT: EOMI, ___ CV: RRR, no murmurs Lungs: clear to ausculation bilaterally Abdomen: Abdominal binder in place. Dressing from recent surgery c/d/i. Diminished abdominal distention at site of dressing. c/d/i. Non-temder to palpation. Ext: 2+ peripheral pulses, no edema Neuro: CN II-XII intact Skin: no rash Pertinent Results: LABS ON ADMISSION: ================== ___ 11:00AM BLOOD WBC-4.4# RBC-2.88* Hgb-10.5* Hct-29.7* MCV-103* MCH-36.4* MCHC-35.2* RDW-15.5 Plt Ct-62* ___ 11:00AM BLOOD Neuts-56 Bands-1 ___ Monos-20* Eos-2 Baso-0 Atyps-2* ___ Myelos-0 ___ 06:11AM BLOOD Glucose-97 UreaN-58* Creat-1.6* Na-134 K-5.0 Cl-102 HCO3-20* AnGap-17 ___ 06:11AM BLOOD ALT-17 AST-59* AlkPhos-42 TotBili-3.6* ___ 06:11AM BLOOD cTropnT-<0.01 ___ 06:23AM BLOOD Lactate-3.2* Micro: ====== ___ 2:51 pm PERITONEAL FLUID PERITONEAL FLUID. GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): LABS ON DISCHARGE: ==================== ___ 05:30AM BLOOD Glucose-105* UreaN-17 Creat-0.9 Na-140 K-3.7 Cl-110* HCO3-19* AnGap-15 ___ 05:30AM BLOOD ALT-11 AST-26 AlkPhos-42 TotBili-3.3* ___ 05:30AM BLOOD Calcium-8.8 Phos-2.1* Mg-2.0 STUDIES: =========== RUQ US ___: IMPRESSION: 1. Patent TIPS. Slightly high velocity within the mid tips which could represent a stenosis recommend followup ultrasound in 2 months. 2. Cirrhotic liver with large volume ascites, not significantly improved from pre TIPS ultrasound. CXR ___: IMPRESSION: NOTIFICATION: Large intra-abdominal free air, likely secondary to recent surgery. No evidence of pneumonia. CT abdomen with contrast ___: IMPRESSION: 1. Moderate ascites throughout the abdomen with pneumoperitoneum. While this raises suspicion for enteric leak, there is no extravasation of oral contrast, which has passed to the level of the sigmoid colon, and the finding could be postoperative in nature. Prior umbilical hernia repair with ascites fluid and pneumoperitoneum tracking into the anterior abdominal wall just deep to the surgical incision. 2. Small bilateral pleural effusions and bibasilar atelectasis. 3. Hepatic cirrhosis with patent TIPS. The right anterior portal vein is not well visualized by CT and thrombosis cannot be excluded. However, it is noted that the vein was patent on ultrasound of ___ and could simply be diminutive. 4. Pancreas divisum. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Rifaximin 550 mg PO BID 2. Lactulose 30 mL PO TID 3. Vitamin D 50,000 UNIT PO 1X/WEEK (FR) 4. Spironolactone 50 mg PO DAILY 5. Furosemide 20 mg PO DAILY 6. Thiamine 100 mg PO DAILY 7. FoLIC Acid 1 mg PO DAILY Discharge Medications: 1. Lactulose 30 mL PO TID Please take this and ensure you have at least 4 bowel movements per day. RX *lactulose 20 gram/30 mL 30 ml by mouth three times daily Refills:*0 2. Rifaximin 550 mg PO BID 3. FoLIC Acid 1 mg PO DAILY 4. Spironolactone 50 mg PO DAILY 5. Thiamine 100 mg PO DAILY 6. Vitamin D 50,000 UNIT PO 1X/WEEK (FR) 7. Ciprofloxacin HCl 750 mg PO Q12H RX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*5 Tablet Refills:*0 8. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*7 Tablet Refills:*0 9. Outpatient Lab Work Please draw CBC and chem-10 on ___ amd fax results to attn Dr. ___ at ___. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Encephalopathy Secondary Bacterial Peritonitis Pneumoperitoneum Secondary: Umbillical hernia s/p repair ___ Alcoholic cirrhosis Diuretic refractory ascites s/p TIPS ___ Grade I varices (___) Hypertension Internal Hemorrhoids H/o right inguinal hernia repair ___ h/o cataract surgery Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with recent hernia repair, with altered mental status, evaluate for pneumonia.. COMPARISON: None Available. TECHNIQUE Portable AP view of the chest. FINDINGS: Large intra-abdominal free air. Lung volumes are low without focal consolidation. Relative crowding of the interstitial markings and bronchovascular structures likely secondary to low lung volumes. Cardiomediastinal silhouette is normal. There is no pneumothorax or pleural effusion. No acute osseous abnormalities seen. IMPRESSION: Large intra-abdominal free air, likely secondary to recent surgery. No evidence of pneumonia. NOTIFICATION: Large intra-abdominal free air, likely secondary to recent surgery. No evidence of pneumonia. *** ED URGENT ATTENTION *** Findings discussed with Dr. ___ by Dr. ___ telephone on ___ at 06:30, 1 min after they were made. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ with TIPS, AMS // ?shunt patency TECHNIQUE: Grey scale, color, and spectral Doppler ultrasound images of the abdomen were obtained. COMPARISON: Abdominal ultrasound ___. FINDINGS: The liver appears diffusely coarsened and nodular consistent with known cirrhosis. No focal liver lesions are identified. There is large volume ascites. The spleen measures 11.7 cm. The gallbladder is normal without wall thickening or distention. The main portal vein is patent with hepatopetal flow and a velocity of 41 cm/ cm/sec. The TIPS is patent and demonstrates wall-to-wall flow with velocities of 75 cm/second, 230 cm/second, and 190 cm/sec in the proximal, mid, and distal portions respectively. Flow within the left portal vein is towards the TIPS shunt. Flow within the right anterior and right posterior portal vein is towards the TIPS. Appropriate flow is seen in the hepatic veins and IVC. IMPRESSION: 1. Patent TIPS. Slightly high velocity within the mid tips which could represent a stenosis recommend followup ultrasound in 2 months. 2. Cirrhotic liver with large volume ascites, not significantly improved from pre TIPS ultrasound. NOTIFICATION: Updated findings were discussed with Dr. ___ by Dr. ___ on ___ at 09:50, 10 min after they were made. Radiology Report EXAMINATION: Chest radiograph INDICATION: NG tube placement TECHNIQUE: Single frontal chest radiograph COMPARISON: ___ 06:13 FINDINGS: NG tube tip terminates in the distal stomach. Slightly improved aeration of the lungs. Large free peritoneal air is re- demonstrated. No other relevant change. IMPRESSION: NG tube tip terminates in the distal stomach. Otherwise no relevant change from recent prior. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man with alcoholic cirrhosis s/p recent umbilical hernia repair with subdiagphragmatic free air // Evaluate for worsening free air. TECHNIQUE: Single frontal view of the chest COMPARISON: ___ IMPRESSION: Large pneumoperitoneum is grossly unchanged. Cardiomediastinal contours are unchanged. Bilateral effusions are small. The lungs are grossly clear. NG tube tip is in the stomach Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man with recent umbilical hernia repair // Evaluate for progression of free air COMPARISON: Chest radiograph ___ FINDINGS: PA and lateral views of the chest provided. Interval removal of an orogastric tube. On the lateral view there is poor definition of vessels. No pneumothorax. There is significantly more free air under the right and left hemidiaphragm. Small, bilateral pleural effusions and associated atelectasis are mildly worsened. Hilar and cardiomediastinal contours are normal. IMPRESSION: 1. There is significantly more free air under the right and left hemidiaphragm. 2. On the lateral view, there is poor definition of vessels projecting over the left lower lobe. In the appropriate clinical setting, this may represent superimposed pneumonia. 3. Small, bilateral pleural effusions and associated atelectasis are mildly worsened. NOTIFICATION: Lateral view, poor deifniton of vessels in app clinical setting superimposed consolidation Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ year old man with cirrhosis recent umbilical hernia repair with bacterial peritonitis and worsening free air on CXR // Evaluate for intrabdominal process contributing to worsening free air/perforationEvaluate with IV and PO contrast TECHNIQUE: MDCT scanning was performed from the lung bases to the pubic symphysis following the intravenous administration of 130 cc of Omnipaque. The patient received water soluble oral contrast (Gastrografin). Coronal and sagittal re-formatted images are provided. DLP: 762.69 mGy-cm COMPARISON: No prior CT. MRI abdomen of ___ FINDINGS: Small bilateral pleural effusions, left slightly greater than right, are low-density. There is adjacent bibasilar atelectasis. Mitral annular calcifications are noted. Imaged portions of heart and pericardium appear otherwise unremarkable. There is a large quantity of free intraperitoneal air layering throughout the abdomen within a background of moderate ascites. Patient is status post umbilical hernia repair with a hyperdense linear focus consistent with mesh at the repair site. Superficial to the mesh repair is a fluid collection within the anterior abdominal wall, centered in the subcutaneous fat, that measures 2.6 x 10.7 cm and also contains bubbles of gas. This extends to the skin incision. The bowel is opacified with water-soluble oral contrast to the level of the mid sigmoid colon. There is no evidence of extravasation of oral contrast to suggest a site of enteric leak. No bowel obstruction. Liver: The liver is diffusely nodular in contour consistent with cirrhosis with a TIPS shunt in place in first showing wall to wall internal enhancement consistent with patency. This technique is not optimized to assess for liver lesions although no discrete masses are identified in the liver. The right anterior portal vein is not well visualized and possibly contains a filling defect (02:14). Left portal vein is similarly difficult to visualize although may simply be diminutive. It is noted that the right anterior portal vein was patent on the recent Doppler ultrasound of ___. Bile ducts and gallbladder: Gallbladder is moderately distended with wall thickening at the fundus which may relate to third spacing. All there is no intra or extrahepatic biliary ductal dilation. Pancreas: Pancreas divisum is incidentally noted. Pancreas appears otherwise unremarkable. Spleen and adrenal glands: The adrenal glands and spleen appear unremarkable except note that the spleen is top-normal in size. Kidneys: Kidneys enhance and excrete contrast symmetrically without evidence of hydronephrosis or concerning focal renal lesions. Aorta is normal in caliber with atherosclerotic calcification. The celiac trunk, superior mesenteric artery, and renal arteries are grossly patent. Main portal vein and superior mesenteric veins are patent. CT of the pelvis with intravenous contrast: There is moderate to large ascites in the pelvis. A small amount of air is seen in the bladder which would be compatible with recent Foley catheter presence. Trace enhancement of the peritoneal lining is seen in the cul-de-sac. Rectum and sigmoid colon are fluid filled and appear otherwise unremarkable. No pathologically enlarged pelvic or inguinal lymph nodes. Bone windows: No suspicious lytic or sclerotic osseous lesions are identified. IMPRESSION: 1. Moderate ascites throughout the abdomen with pneumoperitoneum. While this raises suspicion for enteric leak, there is no extravasation of oral contrast, which has passed to the level of the sigmoid colon, and the finding could be postoperative in nature. Prior umbilical hernia repair with ascites fluid and pneumoperitoneum tracking into the anterior abdominal wall just deep to the surgical incision. 2. Small bilateral pleural effusions and bibasilar atelectasis. 3. Hepatic cirrhosis with patent TIPS. The right anterior portal vein is not well visualized by CT and thrombosis cannot be excluded. However, it is noted that the vein was patent on ultrasound of ___ and could simply be diminutive. 4. Pancreas divisum. Radiology Report INDICATION: ___ year old man with EtOH cirrhosis ascites s/p umbilical hernia repair w/ mesh ___, presented with altered mental status. // Please perform ultrasound-guided paracentesis ___. Please send fluid for cell count and cultures. Dr. ___. TECHNIQUE: Ultrasound guided diagnostic and therapeutic paracentesis COMPARISON: ___ FINDINGS: Limited grayscale ultrasound imaging of the abdomen demonstrated a large amount of ascites. A suitable target in the deepest pocket in the right lower quadrant was selected for paracentesis. PROCEDURE: The procedure, risks, benefits and alternatives were discussed with the patient and written informed consent was obtained. A preprocedure time-out was performed discussing the planned procedure, confirming the patient's identity with 3 identifiers, and reviewing a checklist per ___ protocol. Under ultrasound guidance, an entrance site was selected and the skin was prepped and draped in the usual sterile fashion. 1% lidocaine was instilled for local anesthesia. A 5 ___ catheter was advanced into the largest fluid pocket in the right lower quadrant and 1.5 L of clear orange fluid was removed. A sample was sent to the lab and microbiology as requested. The patient tolerated the procedure well without immediate complication. Estimated blood loss was minimal. Dr. ___ supervised the trainee during the key components of the procedure and reviewed and agrees with the trainee's findings. IMPRESSION: Successful ultrasound-guided diagnostic and therapeutic paracentesis yielding 1.5 L of clear orange fluid. A sample was sent to the lab and microbiology as requested. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man with cirrhosis, recent umbilical hernia repair // assess change in free air COMPARISON: Chest radiograph ___ FINDINGS: PA and lateral views of the chest provided. Lungs are grossly clear. The volume of air in the large, persistent hydropneumoperitoneum has decreased. No pneumothorax. Small, bilateral pleural effusions are unchanged. There is no pneumothorax. Hilar and cardiomediastinal contours are normal. IMPRESSION: 1. Large hydro pneumoperitoneum has been present since ___. The volume of gas has decreased since ___. 2. Small, bilateral pleural increased from ___ to ___, subsequently stable. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 4:20 ___, 1 minutes after discovery of the findings. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Altered mental status Diagnosed with HEPATIC ENCEPHALOPATHY, ALCOHOL CIRRHOSIS LIVER temperature: 98.6 heartrate: 98.0 resprate: 18.0 o2sat: 99.0 sbp: 104.0 dbp: 61.0 level of pain: 13 level of acuity: 2.0

This is a ___ male with EtOH cirrhosis (Child Class C MELD 23 on admission) complicated by refractory ascites s/p TIPS ___, recent umbilical hernia repair (___) who presents with hepatic encephalopathy in 4 days post umbilical hernia repair likely secondary to medication non-compliance and bacterial peritonitis. #Hepatic encephalopathy Grade Patient's encephalopathy thought to likely be secondary to medication non-compliance and bacterial peritonitis in setting of recent surgery. Patient was made NPO, NG tube placement, and received lactulose 30 ml Q2 hours until improvement of mental of status and was then transitioned to 30 ml TID. Encephalopathy was noted to be at least grade III on admission. Infectious work up showed peritonitis for which IV ceftriaxone and IV flagyl were initated (see below.) Further infectious owrk up was negative. Rifaxamin 550 mg BID was also continued. #Secondary Bacterial Peritonitis in setting of recent Umbilical Hernia repair Patient with recent umbilical hernia repair on ___ (4 days prior to admission) and was found to have 956 WBC, ___ RBC on admission and was started on treatment for bacterial peritonitis with IV ceftriaxone and flagyl for 3 days and then transitioned to PO cipro and flagyl for total 10 day course to be completed on ___. 100 grams of albumin were given on day one two and three of hospital course. Free air was noted on CXR in the post-operative period. Serial CXR showed worsening free air so transplant surgery recommended CT abdomen with contrast completed on ___ that showed persistent pneumoperitoneum felt to be consistent with post-operative changes. US guided paracentesis was completed on ___ with removal of 1.5 L and cultures did not show evidence of growth. Patient will follow up with Dr. ___ of transplant surgery in clinic 1 week from discharge with plan for labs on ___. # Alcoholic Cirrhosis (Child's class C, MELD 23 on admission) complicated by diuretic refractory ascites s/p TIPS ___ and encephalopathy. Patient had history of varices with last EGD in ___ with evidence of 2 cords of grade I varices s/p TIPS in ___. Abd. US showed patent TIPS though noted it was high velocity with need for repeat US in 2 months. Daily MELD labs were trended and diruetics were held initially in setting of ___. Spironolactone was restarted at 50 mg daily. Lasix continued to be held given hypokalemia and need for repletion and should be considered to be re-started at time of follow up. #Acute kidney injury (baseline cr 1.0) Patient presented with acute kidney injury with creatine of 1.6 on admission, and BUN/Cr > 20 and FeNa 0.48% all supportive of pre-renal etiology. Creatinine improved after IVF rescussitation to 1.2 on day ___ grams of albumin were given for 3 days total during hospital course. Diuretics were held in setting of ___. Creatinine was monitored in the 48 hours after CT with contrast on ___ given risk of post-contrast nephropathy but stayed stable. #Anion Gap acidosis ___ to Elevated Lactate Patient presented with anion gap of 16 (corrected for albumin) with elevated lactate most likely in the setting of poor PO intake, relative hypotension, and decreased lactate metabolism in the setting of cirrhosis. Patient's lacate improved with IV fluids prior to discharge. #Anemia Patient with chronic known anemia. Hg/Hct stayed stable and patient did not require any transfusions. #Prolonged QTc (440) Patient with QTc at upper limit of normal. QTc prolonging medications were avoided. #HTN Patient not on antihypertensives and remained normotensive throughout hospital course.

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, Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ gentleman with PMHx of HTN, OSA, afib on coumadin who presented to the ED with chest pain and dyspnea. He works as a ___ and was using his forklift in ___ last night when he became short of breath and started having chest pain. He had previously been experiencing a runny-nose, cough, and feeling somewhat fatigued the day prior. His son had been sick with similar symptoms for weeks prior to this. He went home afterwards and was feeling progressively worse with difficulty breathing so he was brought in by ambulance to the emergency room. The patient reports that he has never had previous symptoms like this before. No history of heart attacks or heart failure. He reported feeling sweaty during the episode. At presentation, the patient denied any abdominal pain, nausea, vomiting, paresthesias, dysuria. He sleeps flat on his side at home and does not usually get short of breath with activity or have chest pain with activity. In the ED, initial VS were: 97.9, 60, 124/70, 18, 95% RA Exam notable for: Audible wheezing Labs showed: CBC 8.8/13.3/40.2/224, Cr 2.3, BNP 1281, Trp <0.01 x2, Lactate 1.6 Imaging showed: CTA Chest 1. No evidence of pulmonary embolism or aortic abnormality. 2. Subsegmental atelectasis in the right lower lobe. 3. Mild bronchial wall thickening which is nonspecific and could be seen in small airways disease. 4. 4 mm nodule in the right middle lobe. If patient has elevated risk factors for lung cancer, chest CT in 12 months can be considered. If not, no additional imaging follow-up is recommended. This is per ___ guidelines on incidentally found pulmonary nodules. 5. Dilated main pulmonary artery measuring 3.6 cm across maximal diameter can be secondary to primary pulmonary hypertension. Received: ___ 01:41 IH Albuterol 0.083% Neb Soln 1 NEB ___ ___ 01:41 IH Ipratropium Bromide Neb 1 NEB ___ ___ 02:12 PO Aspirin 243 mg ___ ___ 02:20 IVF NS ___ Started ___ 02:53 IV Atropine Sulfate .5 mg ___ ___ 03:00 IVF NS 500 mL ___ Stopped (___) ___ 04:55 IV MethylPREDNISolone Sodium Succ 125 mg ___ ___ 05:15 IH Albuterol 0.083% Neb Soln 1 NEB ___ ___ 05:15 IH Ipratropium Bromide Neb 1 NEB ___ He was seen by Cardiology in the ED who felt that his chest pain was atypical and unlikely to be ischemic but did recommend stress testing on a non-urgent basis. He was also having episodes of bradycardia in the ED that were felt to be related to untreated OSA and vagal tone causing sinus arrest. Transfer VS were: 98.2, 56, 123/58, 12, 94% RA On arrival to the floor, patient confirms the story as above. He states that he does not have any kidney problems that he knows of but did have a problem ___ years ago when he got very dehydrated in the setting of colonoscopy prep. Supposedly this normalized afterwards. He does not currently have any chest pain and feels his breathing has improved. He continues to have a cough. REVIEW OF SYSTEMS: (+)per HPI 10-point review of systems otherwise negative. Past Medical History: Hypertension Atrial fibrillation on coumadin Obstructive sleep apnea (untreated, non-adherent with CPAP) Social History: ___ Family History: Sister and mother with diabetes. Son with asthma. Physical Exam: ADMISSION PHYSICAL EXAM ======================= VS: 97.9 127/73 49 20 90% Ra GENERAL: Obese gentleman in no apparent distress, laying in bed. HEENT: AT/NC, EOMI, PERRL, anicteric sclera, mucous membranes somewhat dry NECK: obese HEART: Irregularly irregular, bradycardic, distant heart sounds but normal S1, S2, no appreciable m/r/g LUNGS: CTAB, no wheezes, rales, rhonchi, occasional coughing ABDOMEN: obese, nontender in all quadrants, no rebound/guarding EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no significant lesions on visualized skin DISCHARGE PHYSICAL EXAM ======================= Vitals: 97.9 174/75 75 18 91% Ra General: Well-appearing man, breathing slightly uncomfortable with significant audible wheezing. HEENT: No conjunctival injection or scleral icterus. Neck: No cervical lymphadenopathy. No JVD. Lungs: Faint diffuse expiratory wheezing bilaterally, significantly improved from yesterday. No crackles or rhonchi. CV: Regular rate and rhythm. Normal S1 and S2. Abdomen: Soft, nontender, obese. Ext: Warm and well-perfused. No cyanosis or edema. Neuro: Alert and oriented x3. Moving all extremities spontaneously. Pertinent Results: ADMISSION LABS ============== ___ 01:19AM BLOOD WBC-8.8 RBC-4.49* Hgb-13.3* Hct-40.2 MCV-90 MCH-29.6 MCHC-33.1 RDW-12.5 RDWSD-41.1 Plt ___ ___ 01:19AM BLOOD Neuts-70.1 Lymphs-15.7* Monos-11.4 Eos-1.8 Baso-0.3 Im ___ AbsNeut-6.18* AbsLymp-1.39 AbsMono-1.01* AbsEos-0.16 AbsBaso-0.03 ___ 01:19AM BLOOD ___ PTT-26.3 ___ ___ 01:19AM BLOOD Glucose-113* UreaN-30* Creat-2.3* Na-135 K-4.5 Cl-97 HCO3-24 AnGap-19 ___ 03:54AM BLOOD CK(CPK)-78 ___ 01:19AM BLOOD proBNP-1281* ___ 01:19AM BLOOD cTropnT-<0.01 ___ 03:54AM BLOOD cTropnT-<0.01 ___ 03:54AM BLOOD CK-MB-2 ___ 09:32AM BLOOD cTropnT-<0.01 ___ 01:19AM BLOOD Calcium-9.2 Phos-4.6* Mg-2.4 ___ 01:19AM BLOOD Lactate-1.6 PERTINENT IMAGING ================= CTA CHEST ___: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Subsegmental atelectasis in the right lower lobe. 3. Mild bronchial wall thickening which is nonspecific and could be seen in small airways disease. 4. Multiple pulmonary nodules measuring up to 5 mm in the left lower lobe (3:169). If patient has elevated risk factors for lung cancer, chest CT in 12 months can be considered. If not, no additional imaging follow-up is recommended. This is per ___ ___ guidelines on incidentally found pulmonary nodules. 5. Dilated main pulmonary artery measuring 3.6 cm across maximal diameter can be secondary to primary pulmonary hypertension. DISCHARGE LABS ============== ___ 05:00AM BLOOD WBC-9.1 RBC-4.66 Hgb-13.9 Hct-42.2 MCV-91 MCH-29.8 MCHC-32.9 RDW-12.6 RDWSD-41.5 Plt ___ ___ 05:00AM BLOOD ___ PTT-25.9 ___ ___ 05:00AM BLOOD Glucose-98 UreaN-26* Creat-0.8 Na-140 K-4.1 Cl-101 HCO3-29 AnGap-14 ___ 05:00AM BLOOD Calcium-9.4 Phos-4.6* Mg-2.1 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Warfarin 7.5 mg PO DAILY16 2. Hydrochlorothiazide 50 mg PO DAILY 3. Metoprolol Succinate XL 50 mg PO DAILY 4. Doxazosin 1 mg PO HS 5. Lisinopril 40 mg PO DAILY 6. amLODIPine 10 mg PO DAILY 7. CloNIDine 0.2 mg PO TID 8. Famotidine 20 mg PO BID Discharge Medications: 1. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath RX *albuterol sulfate [ProAir HFA] 90 mcg 1 puff IH Q6H:PRN Disp #*1 Inhaler Refills:*0 2. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Benzonatate 100 mg PO TID RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day Disp #*45 Capsule Refills:*0 4. PredniSONE 40 mg PO DAILY Duration: 4 Days RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*4 Tablet Refills:*0 5. Tamsulosin 0.4 mg PO DAILY RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30 Capsule Refills:*0 6. amLODIPine 10 mg PO DAILY RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 7. Famotidine 20 mg PO BID 8. Lisinopril 40 mg PO DAILY RX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: ================= Acute Bronchitis Sinus bradycardia Hypertension Acute Kidney Injury Secondary Diagnoses: ==================== Benign Prostatic Hyperplasia Obstructive Sleep Apnea Atrial Fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: Chest radiograph INDICATION: History: ___ with chest pain// eval for pulm edema TECHNIQUE: AP chest COMPARISON: None available FINDINGS: There is no consolidation, pleural effusion, pneumothorax. Excessive mediastinal fat is noted. Heart is at the upper limits of normal in size with probable mild elevation of pulmonary venous pressure.. There is right basilar atelectasis. IMPRESSION: 1. Linear opacity overlying the right lower lobe likely represents subsegmental atelectasis. 2. No evidence of consolidation Probable mild elevation of pulmonary venous pressure. Radiology Report EXAMINATION: CTA Chest INDICATION: History: ___ with chest pain// eval for aortic 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 4.0 s, 0.5 cm; CTDIvol = 19.3 mGy (Body) DLP = 9.6 mGy-cm. 2) Spiral Acquisition 4.2 s, 32.8 cm; CTDIvol = 23.4 mGy (Body) DLP = 766.3 mGy-cm. Total DLP (Body) = 776 mGy-cm. COMPARISON: None 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. There is moderate to severe coronary arterial calcifications. The pulmonary arteries are well opacified to the subsegmental level, with no evidence of filling defect within the main, right, left, lobar, segmental or subsegmental pulmonary arteries. The main pulmonary artery is dilated, measuring 3.6 cm across maximal diameter (3:93) There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy. The thyroid gland appears unremarkable. There is no evidence of pericardial effusion. There is no pleural effusion. There is an ill-defined linear opacity in the right lower lobe likely representing subsegmental atelectasis. There is a 4 mm nodule in the right middle lobe (3:137). There is a 4 mm nodule in the right upper lobe (series 3:81) there is a 5 mm nodule in the left lower lobe (3:169). There is mild bronchial wall thickening, most prominent bilateral lower lobes. There is no consolidation. Limited images of the upper abdomen are unremarkable. No lytic or blastic osseous lesion suspicious for malignancy is identified. IMPRESSION: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Subsegmental atelectasis in the right lower lobe. 3. Mild bronchial wall thickening which is nonspecific and could be seen in small airways disease. 4. Multiple pulmonary nodules measuring up to 5 mm in the left lower lobe (3:169). If patient has elevated risk factors for lung cancer, chest CT in 12 months can be considered. If not, no additional imaging follow-up is recommended. This is per ___ society guidelines on incidentally found pulmonary nodules. 5. Dilated main pulmonary artery measuring 3.6 cm across maximal diameter can be secondary to primary pulmonary hypertension. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Chest pain Diagnosed with Other chest pain temperature: 97.9 heartrate: 60.0 resprate: 18.0 o2sat: 95.0 sbp: 124.0 dbp: 70.0 level of pain: 8 level of acuity: 2.0

Mr. ___ is a ___ gentleman with a history of HTN, OSA, Afib on Coumadin who presented to the ED with sudden onset chest pain and dyspnea found to have likely acute bronchitis with reactive airways. He was started on treatment with inhalers and prednisone burst. He was significantly improving prior to discharge. No evidence of acute coronary syndrome or heart failure during this hospitalization. He had episodes of asymptomatic bradycardia overnight in setting of severe OSA so metoprolol and clonidine were discontinued with improvement in heart rates. He was able to ambulate without desaturation and had appropriate HR compensation with activity. As he was stable and respiratory status was continuing to improve he was medically cleared for discharge. He will follow up with primary ___ and has established ___ with Dr. ___ as his cardiologist. #Acute Bronchitis: Patient presented with dyspnea, wheezing, chest pain in the setting of recent viral URI. Negative cardiac workup while inpatient. He was treated with prednisone and nebulized inhalers, and his respiratory status was significantly improved prior to discharge. He will continue prednisone course for total five days: Prednisone 40mg PO daily (___). He was prescribed Albuterol inhaler and given a spacer. Patient can continue Benzonatate 100mg PO TID for cough. #Sinus Bradycardia: Patient was having asymptomatic sinus bradycardia of ___ bpm overnight, most likely secondary to severe OSA as well as effects from Metoprolol and Clonidine. When these medications were discontinued, his HR mostly stabilized with rare bouts of sinus brady. Can consider holter monitor for further evaluation as an outpatient. #Atrial Fibrillation: Patient has not been adherent with Coumadin; his INR was 1.2 on admission. He was on telemetry and off Metoprolol without any A fib. Given his CHADs VASc score of 1, we discussed with Dr. ___ agreed to discontinue Coumadin and start Aspirin 81mg upon discharge. #Hypertension: Patient has been on aggressive antihypertensive regimen of up to 5 medications in the past, but he has had poor adherence to this regimen. During his hospitalization, we discontinued Metoprolol and Clonidine given bradycardia and he was having rebound hypertension up to SBP 190s. He was discharged on Lisinopril and Amlodipine. He will follow up with primary ___ and Dr. ___ further adjustments to antihypertensive regimen. #Obstructive sleep apnea: Patient has tried CPAP in the past but states that he could not tolerate the discomfort. While hospitalized, his overnight O2 sats dropped to ___, requiring temporary 2L O2. He will need follow-up sleep study and mask re-fitting to find suitable CPAP vs. BiPAP. #Elevated BNP: BNP 1281 on admission, but patient had no clinical or radiologic evidence of volume overload. Furthermore, inpatient cardiac workup was negative for acute ischemia. Patient will get TTE as outpatient with Dr. ___. #Acute Kidney Injury: Patient presented with Cr 2.3 likely pre-renal from hypovolemia as it readily resolved after fluid administration. Discharge Cr 0.8. #Nocturia: This is a chronic issue for the patient, likely secondary to BPH. He was treated with Tamsulosin 0.4mg PO daily. TRANSITIONAL ISSUES =================== #CODE: Full, limited trial #CONTACT: ___ (wife): ___ [ ] Prednisone course: Prednisone 40mg PO daily (___) [ ] Incidental finding of multiple pulmonary nodules measuring up to 5 mm in the left lower lobe (3:169). If patient has elevated risk factors for lung cancer, chest CT in 12 months can be considered. If not, no additional imaging follow-up is recommended. This is per ___ guidelines on incidentally found pulmonary nodules. [ ] Pleasure ensure follow up with sleep medicine for repeat sleep study and mask fit given severe untreated OSA [ ] Patient will receive TTE as an outpatient with Dr. ___ to evaluate for systolic or diastolic dysfunction [ ] Continue to monitor blood pressures, has history of non-adherence, simplified regimen and discontinued unnecessary medications, was hypertensive as inpatient following discontinuation of clonidine; can consider adding HCTZ as clinically indicated if still hypertensive [ ] Did not tolerate metoprolol due to bradycardia overnight, would continue to monitor heart rates given prior paroxysmal atrial fibrillation and consider rate control as clinically indicated [ ] Consider holter monitor as outpatient given episodes of asymptomatic bradycardia while asleep in setting of severe OSA [ ] Anticoagulation discontinued given CHADsVASC of 1, consider restarting DOAC vs. Coumadin as clinically indicated; of note patient has poor adherence

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Penicillins Attending: ___ Chief Complaint: headache, poor coordination, and bumping into things on the right. Major Surgical or Invasive Procedure: N/A History of Present Illness: ___ is a ___ female with a PMHx of epilepsy on Dilantin (last seizure ___ and OSA who presents with headache, poor coordination, and bumping into things on the right. 3 weeks ago, a student accidentally ran into her, causing her to hit the back of her head against a glass door. She remembers the impact well and did notlose consciousness. She did not have any confusion or dizziness afterward, but she has been getting headaches ___ times per week since that incident. She has also had a humming sound in her ears bilaterally since the fall. She has not had any subsequent traumas. On ___ between 1pm and 2pm, she again got a left temporo-parietal headache. Shortly thereafter, she noticed that she was hitting the wrong buttons on her ipad. She is not sure why this is but she denies a problem with her vision; she thinks she might have been less coordinated than usual with her right hand. She also notes that attempted to reach for the faucet but missed. She began bumping into things on her right side. She also noticed that, although she was able to visualize the entire clock, she had trouble interpreting it to tell time. She presented to ___ in ___ on ___, and a head CT demonstrated 1.8 cm left occipital hemorrhage with vasogenic edema but no hydrocephalus. She was transferred to ___ and evaluated by neurosurgery in the ED; they recommended neurology evaluation, repeat imaging the next day at 0500, MRI brain with and without contrast, and SBP<160. Of note, she has a history of epilepsy which began in infancy after a fall down the stairs. Her seizure semiology is seeing familiar people conversing but she is unable to discern any details of teh conversation. She describes these episodes as quite pleasant though sh ___ are unreal. There is however a dream like quality to them. Her last seizure was in ___. She is treated on Dilantin and followed by Dr. ___ in ___. On neuro ROS, the pt denies loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus, and hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, and parasthesiae. No bowel or bladder incontinence or retention. Positive: often feels hot/cold although denies frank fevers or chills; recent diarrhea. 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: Epilepsy GERD OSA Surgical History (Last Verified - None on file): Cholecystectomy Hysterectomy Social History: ___ Family History: Father--stroke, ___, mother--AD Physical ___: Admission exam: PHYSICAL EXAMINATION Vitals: HR: 69 BP: 158/72 RR: 14 SaO2: 97RA General: NAD HEENT: NCAT, no oropharyngeal lesions, neck supple ___: RRR, no M/R/G Pulmonary: CTAB, no crackles or wheezes Abdomen: Soft, NT, ND, +BS, no guarding Extremities: Warm, no edema Neurologic Examination: - Mental status: Awake, alert, oriented x ___ (oriented to hospital but did not know ___. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Speech is fluent with full sentences, intact repetition, and intact verbal comprehension. Naming intact. No paraphasias. No dysarthria. Normal prosody. Able to register 3 objects and recall ___ at 5 minutes. No apraxia. No evidence of hemineglect. No left-right confusion. Able to follow both midline and appendicular commands. - Cranial Nerves: PERRL 3->2 brisk. VF shows a right inferior quadrantanopsia. EOMI, no nystagmus. Hypometric saccades. V1-V3 with decreased sensation on right to LT and temp (90% of normal in V1, 95% of normal in V2, V3 normal). No facial movement asymmetry. Hearing intact to finger rubbilaterally. Palate elevation symmetric. SCM/Trapezius strength ___ bilaterally. Tongue midline. - Motor: Normal bulk and tone. No drift. No tremor or asterixis. [___] L 5 5 5 5 ___ 5 5 5 5 5 R 5 5 5 5 ___ 5 5 5 5 5 - Reflexes: [Bic] [Tri] [___] [Quad] [Gastroc] L 2+ 2+ 2+ 2+ 1 R 2+ 2+ 2+ 2+ 1 Brisk at the knees Plantar response flexor bilaterally - Sensory: Decreased sensation to LT, PP, and temperature in RUE and RLE (RUE/RLE 90% of normal to LT, 80% of normal to temp and PP). Proprioception ok. - Coordination: R>>L dysmetria on FNF. Overshoot with mirror testing. Irregular finger tap and rapid alternating movements. - Gait: Normal initiation. Narrow base. Normal stride length and arm swing. Stable without sway. Negative Romberg. Trouble with tandem (did not fall one to one particular side). Discharge exam: Vitals: HR: 60 BP: 110-140/80 RR: 14 SaO2: 97RA General: NAD HEENT: NCAT, no oropharyngeal lesions, neck supple ___: RRR, no M/R/G Pulmonary: CTAB, no crackles or wheezes Abdomen: Soft, NT, ND, +BS, no guarding Extremities: Warm, no edema Neurologic Examination: - Mental status: Awake, alert, attentive. Provides a clear and detailed hx. Speech is fluent with full sentences, intact repetition, and intact verbal comprehension. No apraxia. No evidence of hemineglect. No left-right confusion. Able to follow both midline and appendicular commands. - Cranial Nerves: PERRL 3->2 brisk. Right lower temporal quadrantanopsia. EOMI, no nystagmus. Normal saccades. Facial sensation intact. No facial movement asymmetry. Hearing intact to finger rub bilaterally. Palate elevation symmetric. SCM/Trapezius strength ___ bilaterally. Tongue midline. - Motor: Normal bulk and tone. No drift. Full strength in uppers and lowers - Reflexes: [Bic] [Tri] [___] [Quad] [Gastroc] L 2+ 2+ 2+ 2+ 1 R 2+ 2+ 2+ 2+ 1 Toes downgoing - Sensory: Intact to LT and cold. - Coordination: There is a mild, b/l, L>R appendicular ataxia with mild and inconsistent overshoot. RAM are mildly clumsy in the uppers. HKS intact. Pertinent Results: ___ 09:30AM GLUCOSE-124* UREA N-11 CREAT-0.7 SODIUM-140 POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-24 ANION GAP-15 ___ 09:30AM ALT(SGPT)-21 AST(SGOT)-24 LD(LDH)-281* CK(CPK)-62 ALK PHOS-72 TOT BILI-0.5 ___ 09:30AM GGT-91* ___ 09:30AM CK-MB-2 cTropnT-<0.01 ___ 09:30AM TOT PROT-7.0 ALBUMIN-4.1 GLOBULIN-2.9 CHOLEST-171 ___ 09:30AM %HbA1c-5.5 eAG-111 ___ 09:30AM TRIGLYCER-68 HDL CHOL-73 CHOL/HDL-2.3 LDL(CALC)-84 ___ 09:30AM TSH-2.0 ___ 09:30AM WBC-5.6 RBC-4.36 HGB-13.8 HCT-39.2 MCV-90 MCH-31.7 MCHC-35.2 RDW-12.8 RDWSD-42.3 ___ 09:30AM NEUTS-60.6 ___ MONOS-7.3 EOS-1.6 BASOS-0.7 IM ___ AbsNeut-3.38 AbsLymp-1.64 AbsMono-0.41 AbsEos-0.09 AbsBaso-0.04 ___ 09:30AM PLT COUNT-176 ___ 09:30AM ___ PTT-28.3 ___ ___ 12:05AM URINE HOURS-RANDOM ___ 12:05AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG ___ 12:05AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 12:05AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD ___ 12:05AM URINE RBC-1 WBC-7* BACTERIA-NONE YEAST-NONE EPI-3 ___ 12:05AM URINE MUCOUS-RARE ___ 08:48PM ___ PTT-27.0 ___ ___ 08:20PM GLUCOSE-125* UREA N-13 CREAT-0.8 SODIUM-140 POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-24 ANION GAP-17 ___ 08:20PM estGFR-Using this ___ 08:20PM ALT(SGPT)-21 AST(SGOT)-19 ALK PHOS-76 TOT BILI-0.3 ___ 08:20PM cTropnT-<0.01 ___ 08:20PM ALBUMIN-4.4 CALCIUM-9.5 PHOSPHATE-3.7 MAGNESIUM-2.1 ___ 08:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 08:20PM WBC-8.9 RBC-4.40 HGB-13.9 HCT-39.3 MCV-89 MCH-31.6 MCHC-35.4 RDW-12.8 RDWSD-41.3 ___ 08:20PM NEUTS-66.2 ___ MONOS-6.7 EOS-1.0 BASOS-0.6 IM ___ AbsNeut-5.92 AbsLymp-2.25 AbsMono-0.60 AbsEos-0.09 AbsBaso-0.05 ___ 08:20PM PLT COUNT-200 CTA head and neck IMPRESSION: 1. Stable hemorrhagic focus within the left occipital lobe, possibly representing lobar hematoma. Possibility of hemorrhagic neoplasm is not excluded. 2. No evidence of vascular malformation or aneurysm. 3. Atherosclerotic disease at the right carotid bifurcation with less than 25% right internal carotid artery stenosis by NASCET criteria. RECOMMENDATION(S): Correlation with MRI of the brain is recommended for further characterization of a left occipital hemorrhagic focus. Additionally long-term followup until complete resolution of the hematoma is recommended to rule out underlying abnormalities in the region. CT head IMPRESSION: 1. Interval stability of left occipital intraparenchymal hemorrhage with associated vasogenic edema. MRI head IMPRESSION: 1. Unchanged 18 x 14 mm left occipital intraparenchymal hemorrhage without definite underlying lesion. Continued surveillance imaging to resolution of hemorrhage is recommended in order to exclude an underlying lesion which could be obscured by hemorrhage. 2. No infarct, new hemorrhage, or enhancing mass. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Phenytoin Sodium Extended 200 mg PO QAM 2. Phenytoin Sodium Extended 300 mg PO QPM 3. Omeprazole 20 mg PO DAILY 4. Celecoxib 100 mg oral PRN 5. Vitamin D 4000 UNIT PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Omeprazole 20 mg PO DAILY 3. Phenytoin Sodium Extended 200 mg PO QAM 4. Phenytoin Sodium Extended 300 mg PO QPM 5. Vitamin D 4000 UNIT PO DAILY 6.Outpatient Occupational Therapy ___ F w right visual field cut. Discharge Disposition: Home Discharge Diagnosis: intraparenchymal hemorrhage 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: Intraparenchymal hemorrhage. Evaluate for underlying lesion. TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of 11 mL of Gadavist intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: Noncontrast head CT ___. CTA head neck ___. FINDINGS: Re-identified is an approximately 18 x 14 mm left occipital intraparenchymal hemorrhage with mild surrounding vasogenic edema and mass effect, grossly unchanged compared to prior CT examination given difference of modality. There is associated susceptibility artifact and intrinsic T1 hyperintensity corresponding to blood product, without definite underlying enhancement. There is no evidence of new hemorrhage, enhancing mass, midline shift or infarction. The ventricles and sulci are normal in caliber and configuration. There is a few punctate foci of left frontal subcortical white matter T2/FLAIR hyperintensity, nonspecific. There is no abnormal enhancement after contrast administration. There is no abnormal focus of slowed diffusion. The principal intracranial vascular flow voids are preserved. No areas microhemorrhage are seen. There is trace mucosal wall thickening in the bilateral anterior ethmoid air cells. The remainder of the visualized paranasal sinuses are otherwise clear. The mastoid air cells are clear. The orbits are grossly unremarkable. IMPRESSION: 1. Unchanged 18 x 14 mm left occipital intraparenchymal hemorrhage without definite underlying lesion. Continued surveillance imaging to resolution of hemorrhage is recommended in order to exclude an underlying lesion which could be obscured by hemorrhage. 2. No infarct, new hemorrhage, or enhancing mass. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman with occipital IPH// Evaluate for interval changes scan to be done at 5am on ___ 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 = 48.1 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: CT head from ___ FINDINGS: There is unchanged appearance of the left occipital intraparenchymal hemorrhage with associated vasogenic edema. There is no shift of midline structures, new areas of hemorrhage or territorial infarct. The ventricles and sulci are unchanged in size and configuration. There is no evidence of acute fracture. There is mild mucosal thickening of the ethmoid air cells. Otherwise, the remainder of the visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. Interval stability of left occipital intraparenchymal hemorrhage with associated vasogenic edema. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: ICH, Transfer Diagnosed with Unsp focal TBI w/o loss of consciousness, init, Fall on same level, unspecified, initial encounter temperature: nan heartrate: 69.0 resprate: 14.0 o2sat: 97.0 sbp: 158.0 dbp: 72.0 level of pain: 0 level of acuity: 2.0

___ right handed woman with a pmhx of epilepsy on longstanding Dilantin and OSA who presents with clumsiness and bumping into things, found to have small left occipital IPH of unclear etiology. The CTA does not show any obvious vascular malformation. MRI with contrast Brain redemonstrates the left occipital hemorrhage with some peripheral enhancement with contrast but no intralesional enhancement to suggest a tumor. The plan is to repeat MRI in ~1 month to assess for underlying lesion. She will then follow up with neurology and neurosurgery for possible angiography. She as evaluated by ___ who recommended home with outpatient ___. She was advised against driving. She was advised to stop taking her home celecoxib for the time being. She was discharged in stable condition.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: s/p MVC Major Surgical or Invasive Procedure: ___: PROCEDURE: 1. Left ultrasound guided renal collecting system access. 2. Left nephrostogram. 3. Left nephrostomy tube placement. ___: 1. Irrigation and debridement of open right talar body fracture, skin to bone. 2. Closed reduction, right open ankle fracture dislocation. 3. Closed reduction of right talar body fracture with manipulation under anesthesia. 4. Irrigation and debridement. Repair of traumatic laceration, left knee, skin and subcutaneous tissue, dermis and muscle 8 cm x 3 cm. 5. Irrigation and debridement. Repair of traumatic laceration, right knee skin, dermis to muscle, 3 cm x 1 cm. ___: NAME OF OPERATION: ___, clot evacuation, left ureteroscopy and right double-J ureteral stent placement. DRAINS PLACED: A 6 x 24 right double-J ureteral stent, a ___ three-way Foley catheter. ___: Left upper extremity: -Roughly 5 cm laceration just distal to the ulnar styloid extending distally over the fourth and fifth metacarpals, through dermis w/ subcutaneous tissue exposed, no apparent tendon injury, no exposed bone s/p suture closure and dressed in xeroform/coban. ___: Through-and-through lip lacerations x3 were repaired in the OR under general anesthesia using layered closure. ___: CT-guided aspiration of left perinephric fluid collection. History of Present Illness: ___ woman in MVA car vs pole, +ETOH. extricated at scene. Found to have injuries including ruptured bladder, bilateral ureteral injuries, open skin defect left infrapatellar space, displaced right ulnar styloid fracture. Taken to OR intubated, ortho reduced subtaler fracture and loosely closed, bilateral knees loosely closed, wrist lacs washed and closed. Plastics closed upper lip laceration. Urology stented right ureter, unable to stent complete disruption/avulsion of left UPJ. Past Medical History: none Social History: ___ Family History: non-contributory Physical Exam: Discharge Physical Exam: VS: T: 98.5F, BP: 121 / 73 mmHg, HR: 74 x min, RR: 17 x min, SaO2: 95 % RA General: pleasant, conversant at first though slowly grows more somnolent, in NAD HEENT: EOMI, laceration closed without surrounding erythema/bleeding CV: skin warm and well perfused Pulm: Breathing comfortably on RA GU: Foley in place with gross blood present in collecting bag. Skin: lacerations closed as above, forearms wrapped in gauze Psych: engaged, appropriate responses initially MSK: right ankle in cast, left ___ in air cast boot. Neuro: sensation intact to light touch to superficial and deep peroneal nerve distributions b/l and C5-T1 b/l. ___ Orientation and Amnesia Test (GOAT) scoring 77/100. Able to respond consistently to 1 step commands and has insight to look at calendar when asked date. Pertinent Results: DISCHARGE LABS: =============== ___ 09:47AM BLOOD ___ PTT-30.9 ___ ___ 04:40AM BLOOD Glucose-95 UreaN-11 Creat-0.5 Na-136 K-4.2 Cl-97 HCO3-26 AnGap-13 ___ 04:40AM BLOOD Calcium-9.7 Phos-4.0 Mg-2.1 ___ 04:40AM BLOOD WBC-12.7* RBC-3.53* Hgb-10.1* Hct-31.7* MCV-90 MCH-28.6 MCHC-31.9* RDW-13.0 RDWSD-42.3 Plt ___ ADMISSION LABS: =============== ___ 06:56AM BLOOD WBC-22.1* RBC-3.90 Hgb-11.2 Hct-35.2 MCV-90 MCH-28.7 MCHC-31.8* RDW-12.6 RDWSD-41.1 Plt ___ ___ 06:56AM BLOOD Neuts-73.1* Lymphs-17.5* Monos-7.0 Eos-0.7* Baso-0.2 Im ___ AbsNeut-16.12* AbsLymp-3.85* AbsMono-1.55* AbsEos-0.16 AbsBaso-0.05 ___ 06:56AM BLOOD ___ PTT-22.1* ___ ___ 06:56AM BLOOD Lipase-209* ___ 04:28PM BLOOD Calcium-8.2* Phos-4.4 Mg-1.4* ___ 06:56AM BLOOD ASA-NEG ___ Acetmnp-NEG Tricycl-NEG ___ 07:05AM BLOOD Type-ART pO2-125* pCO2-33* pH-7.34* calTCO2-19* Base XS--6 ___ 07:05AM BLOOD Glucose-171* Lactate-3.9* Creat-1.07 Na-136 K-2.9* Cl-106 calHCO3-17* ___ 04:35PM BLOOD freeCa-1.12 ___ 06:56AM BLOOD ASA-NEG ___ Acetmnp-NEG Tricycl-NEG IMAGING: ======== ___ CT Head: negative. ___ CT Cspine: negative. ___ CT Chest: bladder apex rupture with extension into proximal urethra; L proximal uretheral injury, no renal vascular injury. Small ground glass opacity and tree in ___ opacities in inferior RUL likely infarct vs. inflammation. ___ CT LEs: small R infrapatellar lac and ecchymosis; large L infrapatellar lac and ecchymosis. No fx/dislocation B knees. ___ R Ankle XR: diplaced comminuted fx posteromedial talus. ___ L ankle XR: no fracture or dislocation. ___ L Forearm: no fracture. ___ R foot: +mid and hind foot fractures. ___ R hand: minimally displaced R ulnar styloid fracture. ___ ___ CT: Right ankle/foot: Comminuted fracture of the posterior and medial aspect of the talus, with lateral dislocation of the talonavicular joint and anterior and lateral subluxation of the subtalar joint. Intra-articular minimally displaced fracture of the anterior cuboid. Nondisplaced fracture of the anterior calcaneal process. Bone fragment is seen at the distal tip of the fibula, likely representing avulsion fracture. Left ankle/foot: Mildly displaced fracture of the posterior base of the second metatarsal. Bone fragments seen at the lateral posterior aspect of the medial cuneiform. Bone fragment is seen at the medial aspect of the cuboid. Tiny bone fragments seen in the tibiotalar joint and at the lateral aspect of the fibula, likely avulsion fractures. Bone fragment seen at the anteromedial aspect of the navicular. ___ CT Abd/Pelvis: Extraperitoneal bladder rupture, with persistent defect of the base of the bladder and probable extension to the proximal urethra. Large intraluminal bladder hematoma extrudes through the defect. Right ureter is opacified to the level of the very distal ureter, however the UVJ remains unopacified, therefore injury to the UVJ is unable to be excluded. Left proximal ureteral injury with large amount of extravasated contrast within the left perinephric space. The mid to distal ureter remains unopacified. Cannot exclude complete left ureteral disruption (of note, the entire course of the left ureter was seen on the earlier CT). Small volume high-density fluid in the perihepatic space and gallbladder fossa. ___ Cystogram: Images show placement of right double-J stent. A catheter and wire could not be passed into the left renal pelvis (the patient has known injury to the proximal left ureter). ___ Perc Nephrostomy: Successful placement of 8 ___ nephrostomy on the left. ___ CT Sinus: Nondisplaced fractures involving the bilateral nasal bones. Moderate associated facial swelling overlying the soft tissues of the anterior facial midline. ___ CT Pelvis Cystogram: No evidence of intraperitoneal bladder rupture. Contrast extravasation from the base of the bladder in at least two areas with possible involvement of the proximal urethra, consistent with extraperitoneal rupture. Interval decrease in size of the intraluminal bladder hematoma. ___ Bladder US: The bladder is collapsed around a Foley catheter. There is a small residual hematoma adjacent to the Foley catheter. Small volume free fluid. ___ CT ___: 1. Interval reduction of the talus, now in anatomic alignment. 2. Multiple fractures in the right foot, as detailed above. ___ CT Torso: 1. New 3.3 x 2.8 x 3.7 cm rim enhancing fluid collection in the expected location of the proximal left ureter, abutting the lateral aspect of the left psoas muscle, likely a urinoma given the known proximal left ureteral rupture. Superimposed infection cannot be excluded. The collection contains foci of air, but these may be related to the left percutaneous nephrostomy. 2. 5.5 x 3.9 cm rim enhancing cystic structure in the prior location of a 2.3 cm left ovarian cyst, likely interim enlargement of a left ovarian cyst. A second site of urinoma is less likely. However, this may be better assessed by pelvic ultrasound, if clinically warranted. 3. Right nephroureteral stent and left percutaneous nephrostomy stent both appear well positioned. No hydronephrosis. 4. Air in the bladder is likely secondary to the Foley catheter. Previously noted extraperitoneal bladder rupture is not adequately reassessed on this exam, as there is no radiopaque contrast in the bladder at this time. 5. Compared to ___, large volume of ascites/intra-abdominal hematoma has resolved. Medications on Admission: omeprazole 20 mg delayed release' Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever RX *acetaminophen [Acetaminophen Pain Relief] 500 mg 2 tablet(s) by mouth four times a day Disp #*32 Tablet Refills:*0 2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth every six (6) hours Disp #*10 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: -Right ankle open fracture/dislocation, open right talar fracture -Nondisplaced fracture of the right anterior process of the calcaneus -Nasal fracture -Lip lacerations: Full thickness lip laceration of both upper and lower lip. Upper lip vertical laceration starting at piriform aperture and extending 3cm inferiorly. Lower lip laceration about 2.5 cm transverse just to the left of midline of the cutaneous lip. -Complete avulsion of the left proximal ureter and partial disruption of the bladder neck at the vesicourethral junction, right ureter intact, no bladder perforation. -Small right infrapatellar laceration and ecchymosis. -Larger left infrapatellar laceration and ecchymosis. -Right ulnar styloid fracture -Left hand with roughly 5 cm laceration just distal to the ulnar styloid extending over the fifth and fourth metacarpals, deep to dermis without obvious tendon injury. Right hand with roughly 4 cm abrasion, involving a portion of the dermis, over the ulnar dorsal hand. -Right avulsion fracture of fibula -Bilateral cuboid fracture -Mildly displaced fracture of the posterior base of the second metatarsal -Avulsion fractures left tibiotalar joint and at the lateral aspect of the fibula -Acute blood loss anemia 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: ich, hemorrhage ___ with polytrauma// ich, hemorrhage. TECHNIQUE: Portable supine frontal view of the chest abdomen and pelvis. COMPARISON: None. FINDINGS: The lungs are clear without a focal consolidation. The cardiomediastinal silhouette is unremarkable. There is no pleural effusion or pneumothorax. Endotracheal tube tip overlies the proximal right mainstem bronchus but is repositioned to the level of the carina on the subsequent chest CT. The bowel gas pattern is unremarkable. No free air is seen. There are no concerning intra-abdominal calcifications. The imaged osseous structures appear intact. IMPRESSION: 1. The lungs are clear. No evidence of pneumothorax. 2. No free air in the abdomen. 3. No acute fractures. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST. INDICATION: History: ___ with polytrauma// ich, hemorrhage. 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 16.0 s, 17.0 cm; CTDIvol = 47.1 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: None available. FINDINGS: There is no intra-axial or extra-axial hemorrhage, edema, shift of normally midline structures, or evidence of acute major vascular territorial infarction. Ventricles and sulci are normal in overall size and configuration. The imaged paranasal sinuses are clear. Mastoid air cells and middle ear cavities are well aerated. The bony calvarium is intact. IMPRESSION: No evidence of acute intracranial process or hemorrhage. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST Q311. INDICATION: History: ___ with polytrauma// ich, hemorrhage. Rule out cervical spine injury. 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 5.5 s, 21.8 cm; CTDIvol = 23.0 mGy (Body) DLP = 499.9 mGy-cm. Total DLP (Body) = 500 mGy-cm. COMPARISON: None. FINDINGS: There is loss of the normal cervical lordosis.No acute cervical spine fractures are identified.There is no evidence of spinal canal or neural foraminal stenosis. There is no prevertebral soft tissue swelling. There is no evidence of infection or neoplasm. The lung apices are clear, the thyroid gland is unremarkable, endotracheal tube is partially evaluated in this exam. IMPRESSION: 1. No acute fracture or traumatic malalignment. Radiology Report EXAMINATION: CT of the torso INDICATION: History: ___ with polytrauma// ich, hemorrhage 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 8.2 s, 64.3 cm; CTDIvol = 20.0 mGy (Body) DLP = 1,284.5 mGy-cm. Total DLP (Body) = 1,285 mGy-cm. COMPARISON: None. FINDINGS: CHEST: HEART AND VASCULATURE: The thoracic aorta is normal in caliber without evidence of acute injury. The heart, pericardium, and great vessels are within normal limits. No pericardial effusion is seen. AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar lymphadenopathy is present. No mediastinal mass or hematoma. PLEURAL SPACES: No pleural effusion or pneumothorax. LUNGS/AIRWAYS: Small ground-glass opacity and ___ nodules in the inferior right upper lobe (02:46) likely infectious or inflammatory nature. The airways are patent to the level of the segmental bronchi bilaterally. An endotracheal tube terminates just above the carina. BASE OF NECK: Visualized portions of the base of the neck show no abnormality. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. A 2.6 x 1.6 cm ill-defined hypodensity along the falciform ligament (2:104) favors focal fat deposition. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesion or laceration. 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 evidence of renal parenchymal laceration. The left proximal ureter is ill-defined with surrounding blush of excreted contrast, compatible with ureteral injury, likely partially given that contrast opacifies the mid and distal ureter. There is simple fluid within the left perinephric region and retroperitoneum. The right ureter is unremarkable. Renal vasculature appears intact. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. There is no evidence of mesenteric injury. There is mild-to-moderate retroperitoneal free fluid around the left kidney, tracking along the bilateral paracolic gutters, and in the pelvis. There is no free air in the abdomen. PELVIS: There is rupture of the apex of the bladder, with extension to the proximal urethra. The bladder contains hyperdense which could be excreted contrast and/or hematoma. Excreted contrast from the right ureteral jet is seen extending outside of the bladder. There is perivesical fluid, as well as fluid within the extraperitoneal spaces of the pelvis. There is also a small amount of fluid extending into the left inguinal canal. REPRODUCTIVE ORGANS: The uterus is unremarkable. The left ovary contains a 2.3 cm physiologic cyst. 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. Mild atherosclerotic disease is noted. BONES: There is no acute fracture. No focal suspicious osseous abnormality. Mild degenerative changes of bilateral hips is noted. There is symmetric widening of the bilateral sacroiliac joints. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Rupture of the apex of the bladder, with extension to the proximal urethra. The bladder contains hyperdense which could be excreted contrast and/or hematoma. Excreted contrast from the right ureteral jet is seen extending outside of the bladder. 2. Left proximal ureteral injury, likely partial given that contrast opacifies the mid and distal ureter. Simple fluid within the left perinephric region and retroperitoneum. No evidence of renal vascular injury. No renal parenchymal laceration. 3. Small ground-glass opacity and ___ nodules in the inferior right upper lobe is likely infectious or inflammatory nature. 4. No acute fracture of visualized osseous structures in the chest, abdomen or pelvis. 5. Endotracheal tube terminates just above the carina. Radiology Report EXAMINATION: KNEE (2 VIEWS) BILATERAL INDICATION: ___ year old woman with MVC// fractures TECHNIQUE: Frontal lateral views of radiographs of bilateral knees. COMPARISON: None. FINDINGS: An overlying cast obscures evaluation of the right proximal tibia and fibula. Soft tissue edema is seen in the infrapatellar space bilaterally. There is an open skin defect along the left infrapatellar space. No fracture or dislocation is 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: 1. Soft tissue edema in the infrapatellar space, left greater than right, as well as an open skin defect along the left infrapatellar space. 2. No acute fracture or dislocation. Radiology Report EXAMINATION: CT LOW EXT W/O C BILATERAL Q61B INDICATION: ___ year old woman with MVC// Fractures TECHNIQUE: MDCT axial images of the bilateral knees were obtained and displayed in soft tissue and bone algorithms. Coronal and sagittal reformations were performed. DOSE: Acquisition sequence: 1) Spiral Acquisition 15.1 s, 32.0 cm; CTDIvol = 20.6 mGy (Body) DLP = 657.7 mGy-cm. Total DLP (Body) = 658 mGy-cm. COMPARISON: None FINDINGS: A cast overlies the proximal right tibia and fibula. No acute fracture or dislocation of the bilateral knees. There is no suprapatellar effusion bilaterally. There is a small open skin defect overlying the right infrapatellar region with a few foci of air and mild subcutaneous stranding compatible with a laceration/ecchymosis. There is a larger open skin defect measuring approximately 4.8 cm overlying the left infrapatellar region with multiple foci of air and subcutaneous stranding compatible with a laceration/ecchymosis. IMPRESSION: 1. Small right infrapatellar laceration and ecchymosis. 2. Larger left infrapatellar laceration and ecchymosis. 3. No acute fracture or dislocation of the bilateral knees. Radiology Report EXAMINATION: DX TIB/FIB AND ANKLE INDICATION: ___ year old woman with MVC// fractures TECHNIQUE: Frontal and lateral views of the left tibia and fibula. Frontal, lateral, and internal rotation views of the left ankle. COMPARISON: None. FINDINGS: There is soft tissue about the patella as well as a open skin defect along the infrapatellar space. No fracture or dislocations are seen. There are no significant degenerative changes. The mortise is congruent. The tibial talar joint space is preserved and no talar dome osteochondral lesion is identified. No suspicious lytic or sclerotic lesion is identified. No soft tissue calcification or radiopaque foreign body is identified. IMPRESSION: Open skin defect and soft tissue edema about the patella. No fracture dislocation. Radiology Report EXAMINATION: DX TIB/FIB AND ANKLE INDICATION: ___ year old woman with MVC// fractures fractures TECHNIQUE: Multiple views of the right tibia, fibula, and ankle. COMPARISON: Bilateral lower extremity CT ___ at 07:33 FINDINGS: Patient is status post casting which markedly limits evaluation of bony detail. There is a displaced comminuted fracture of the posteromedial talus. An ossific density distal to the lateral malleolus could represent mildly displaced avulsion fracture or a fracture fragment from elsewhere within the ankle. There is partial anterior subluxation of the talus relative to the tibia. The calcaneal cuboid joint is widened. No definite tibial or fibular fracture is identified. IMPRESSION: Markedly limited evaluation due to casting which limits evaluation of bony detail. 1. Displaced comminuted fracture of the posteromedial talus. 2. Ossific density distal to the lateral malleolus could represent mildly displaced avulsion fracture or fracture fragment from elsewhere within the ankle. 3. Partial anterior subluxation of the talus relative to the tibia. Radiology Report EXAMINATION: FOOT 2 VIEWS BILATERAL INDICATION: ___ year old woman with MVC// fractures TECHNIQUE: Multiple views of the bilateral feet COMPARISON: Bilateral lower extremity CT ___ at 09:03 FINDINGS: Left foot: No acute fractures or dislocation are seen. There are no significant degenerative changes. Mineralization is normal. There are no erosions. Right foot: Evaluation of the mid and hindfoot is markedly limited due to overlying cast. Known mid and hindfoot fractures, including comminuted fracture of the posteromedial talus, are better assessed on the same day CT. IMPRESSION: Markedly limited radiographic evaluation of the mid and hindfoot of the right foot due to overlying cast. Known right mid and hindfoot fractures, including comminuted fracture of the posteromedial talus, are better assessed on the same day CT. Radiology Report EXAMINATION: DX FOREARM AND WRIST INDICATION: ___ year old woman with MVC// fractures TECHNIQUE: Frontal, oblique, and lateral view radiographs of left forearm and wrist COMPARISON: None FINDINGS: Evaluation of the tips of the index and middle fingers is limited due to support devices. No acute fractures or dislocation are seen. There are no significant degenerative changes. Carpal bones are well aligned. Mineralization is normal. There are no erosions. A triangular calcific density in the distal upper arm adjacent to the distal humerus is without apparent donor site and may represent heterotopic ossification. IMPRESSION: No definite acute fracture or dislocation. Triangular calcific density in the posterior soft tissues adjacent to the distal humerus is without apparent donor site and may represent heterotopic calcification. Radiology Report EXAMINATION: DX HAND AND WRIST INDICATION: ___ female who presents following motor vehicle collision TECHNIQUE: Frontal, oblique, and lateral view radiographs of the right hand and wrist. COMPARISON: None FINDINGS: There is a tiny corticated density adjacent to the distal tip of the ulnar styloid. This likely represents and accessory ossicle or sequela of old trauma. Please correlate with pain at this location as an acute injury is felt to be less likely. IMPRESSION: As above. Radiology Report EXAMINATION: ELBOW (AP, LAT AND OBLIQUE) LEFT INDICATION: ___ female who presents following motor vehicle collision fx TECHNIQUE: Lateral and frontal oblique views of the left elbow COMPARISON: None FINDINGS: No definite acute fractures or dislocations are seen. Joint spaces are preserved without significant degenerative changes. There is suggestion of anterior elbow effusion. No soft tissue calcifications or radiopaque foreign bodies are detected. IMPRESSION: Although no acute fracture or dislocation is seen, occult fracture cannot be excluded given suggestion of anterior elbow effusion. Radiology Report EXAMINATION: Bilateral ankles- fractures Foot fractures INDICATION: ___ year old woman with MVC// Bilateral ankles- fractures TECHNIQUE: MDCT axial images were acquired through the lower extremities bilaterally without intravenous contrast administration. Coronal and sagittal reformations were performed and reviewed on PACS. COMPARISON: Right ankle radiograph from ___ FINDINGS: Left ankle/foot: The left toes are partially excluded in the field-of-view. A mildly displaced fracture of the posterior base of the second metatarsal is seen, series 2, image 148. Bone fragments are seen at the lateral posterior aspect of the medial cuneiform. A bone fragment is seen at the medial aspect of the cuboid, series 2, image 138. Tiny bone fragments are seen in the tibiotalar joint and at the lateral aspect of the fibula, series 104, image 74, likely avulsion fractures. A bone fragment is seen at the anteromedial aspect of the navicular, series 2, image 130. Right ankle/foot: Comminuted fracture of the posterior and medial aspect of the talus. There is lateral dislocation of the talonavicular joint, with associated large hemarthrosis. There is also anterior and lateral subluxation of the subtalar joint. There is associated subcutaneous emphysema. Minimally displaced fracture of the anterior cuboid. Nondisplaced fracture of the anterior calcaneus. A bone fragment is seen at the distal tip of the fibula, likely representing avulsion fracture. IMPRESSION: Right ankle/foot: 1. Comminuted fracture of the posterior and medial aspect of the talus, with lateral dislocation of the talonavicular joint and anterior and lateral subluxation of the subtalar joint. 2. Intra-articular minimally displaced fracture of the anterior cuboid. 3. Nondisplaced fracture of the anterior calcaneal process. 4. Bone fragment is seen at the distal tip of the fibula, likely representing avulsion fracture. Left ankle/foot: 1. Mildly displaced fracture of the posterior base of the second metatarsal. 2. Bone fragments seen at the lateral posterior aspect of the medial cuneiform. 3. Bone fragment is seen at the medial aspect of the cuboid. 4. Tiny bone fragments seen in the tibiotalar joint and at the lateral aspect of the fibula, likely avulsion fractures. 5. Bone fragment seen at the anteromedial aspect of the navicular. Radiology Report EXAMINATION: CT ABD AND PELVIS W/O CONTRAST INDICATION: NO_PO contrast; History: ___ with GU injury sp blunt traumaNO_PO contrast*** WARNING *** Multiple patients with same last name!// eval urinary system 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 6.3 s, 49.6 cm; CTDIvol = 13.3 mGy (Body) DLP = 660.6 mGy-cm. Total DLP (Body) = 661 mGy-cm. COMPARISON: CT abdomen and pelvis ___ at 07:24 FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: An ill-defined 1.9 x 1.7 cm hypodensity along the falciform ligament is better seen on the earlier CT. There is a small amount of high-density perihepatic fluid ___ 104). The liver otherwise demonstrates homogeneous attenuation throughout. There is no evidence of intrahepatic or extrahepatic biliary dilatation. Trace high-density fluid is seen in the gallbladder fossa. The gallbladder is otherwise within normal limits. PANCREAS: The pancreas is normal in bulk and homogeneous in attenuation. There is no main ductal dilatation. SPLEEN: The spleen is normal in size and homogeneous in attenuation. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size. There is excreted contrast in both collecting systems. There is a large amount of extravasated contrast within the left perinephric space, secondary to left proximal ureteral injury. The mid to distal left ureter is not opacified. The right ureter is opacified to the level of the very distal ureter, however the UVJ remains unopacified. There is no right hydronephrosis. There is no nephrolithiasis. GASTROINTESTINAL: Small and large bowel loops are normal in caliber. There is no bowel obstruction. PELVIS: There is a persistent defect at the base of the bladder with large intraluminal hematoma extruding through the defect. There is also probable extension to the proximal urethra (602:37). Hyperdense fluid is again seen in the perivesical and extraperitoneal spaces. REPRODUCTIVE ORGANS: The uterus is unremarkable. A 2.3 cm left ovarian cyst was better seen on the earlier CT. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: The abdominal aorta and IVC are normal in course and caliber. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Extraperitoneal bladder rupture, with persistent defect of the base of the bladder and probable extension to the proximal urethra. Large intraluminal bladder hematoma extrudes through the defect. 2. Right ureter is opacified to the level of the very distal ureter, however the UVJ remains unopacified, therefore injury to the UVJ is unable to be excluded. 3. Left proximal ureteral injury with large amount of extravasated contrast within the left perinephric space. The mid to distal ureter remains unopacified. Cannot exclude complete left ureteral disruption (of note, the entire course of the left ureter was seen on the earlier CT). 4. Small volume high-density fluid in the perihepatic space and gallbladder fossa. NOTIFICATION: Findings discussed with ___ from urology by ___, MD via telephone at 11:05 am on ___, 5 minutes after discovery. Radiology Report EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT IN O.R. INDICATION: ORIF right ankle fracture. COMPARISON: Plain radiograph of the right ankle performed earlier on the same day at 07:56, CT at 09:03. FINDINGS: 15 intraoperative images were acquired without a radiologist present. Images show steps related to reduction of the possibly open subtalar fracture dislocation. IMPRESSION: Please refer to the operative note for details of the procedure. Radiology Report EXAMINATION: RETROGRADE UROGRAPHY (FILMS ONLY) IN CYSTO IN O.R. INDICATION: Bilateral ureteral stents, sister, and bilateral urethrograms TECHNIQUE: 32 intraoperative AP images were acquired without a radiologist present. COMPARISON: CT abdomen and pelvis from 11 ___ FINDINGS: 32 intraoperative images were acquired without a radiologist present. Images show placement of right double-J stent. A catheter and wire could not be passed into the left renal pelvis (the patient has known injury to the proximal left ureter). Extravasated contrast is seen in the left hemiabdomen. IMPRESSION: Images show placement of right double-J stent. A catheter and wire could not be passed into the left renal pelvis (the patient has known injury to the proximal left ureter). Please refer to the operative note for details of the procedure. Radiology Report INDICATION: ___ year old woman s/p MVC ureteral injury// proximal left ureteral injury COMPARISON: CT abdomen pelvis dated ___ 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: General anesthesia provided by Anesthesia Team. MEDICATIONS: 1 g of Ancef CONTRAST: 20 ml of Optiray contrast FLUOROSCOPY TIME AND DOSE: 10 minutes, 109 mGy PROCEDURE: 1. Left ultrasound guided renal collecting system access. 2. Left nephrostogram. 3. Left nephrostomy tube placement. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The right flank was prepped and draped in the usual sterile fashion. After the injection of 5 cc of 1% lidocaine in the subcutaneous soft tissues, the left renal collecting system was accessed through a posterior lower calyx under ultrasound guidance using a 21 gauge Cook needle. Prompt return of urine confirmed appropriate positioning. Injection of a small amount of contrast outlined a dilated renal collecting system. Under fluoroscopic guidance, a Nitinol wire was advanced into the renal collecting system. After a skin ___, the needle was exchanged for an Accustick sheath. Once the tip of the sheath was in the collecting system; the sheath was advanced over the wire, inner dilator and metallic stiffener. The wire and inner dilator were then removed and diluted contrast was injected into the collecting system to confirm position. A ___ wire was advanced through the sheath and coiled in the collecting system. The sheath was then removed and a 8 ___ nephrostomy tube was advanced into the renal collecting system. The wire was then removed and the pigtail was formed. Contrast injection confirmed appropriate positioning. The catheter was then flushed, 0 silk stay sutures applied and the catheter was secured with a Stat Lock device and sterile dressings. The catheter was attached to a bag. FINDINGS: 1. Left nephrostogram demonstrated transected proximal ureter with urine extravasation. Ureteropelvic junction appears to be intact. 2. Focused ultrasound showed fluid interdigitating in fascial planes without discrete collection amenable to drainage. IMPRESSION: Successful placement of 8 ___ nephrostomy on the left. Radiology Report EXAMINATION: CT SINUS/MANDIBLE/MAXILLO FACIAL W/O CONTRAST Q116 CT HEAD SINUS. INDICATION: ___ year old woman with midline facial lac, broken teeth, c/f facial fx. Evaluation for facial fractures. TECHNIQUE: Helically-acquired multidetector CT axial images were obtained through the maxillofacial bones and mandible. Intravenous contrast was not administered. Axial images reconstructed with soft tissue and bone algorithm to display images with 1.25 mm slice. Coronal and sagittal reformations were also constructed. All produced images were evaluated in production of this report. DOSE: Acquisition sequence: 1) Spiral Acquisition 2.7 s, 20.9 cm; CTDIvol = 25.8 mGy (Head) DLP = 539.6 mGy-cm. Total DLP (Head) = 540 mGy-cm. COMPARISON: Comparison to noncontrast head CT from ___. FINDINGS: Nondisplaced fractures of the bilateral nasal bones. Linear lucencies in the anterior malar regions are consistent with zygomamatico facial canals (series 2, image 40). Moderate facial swelling overlying the soft tissues of the anterior facial midline. Moderate mucosal thickening involving the bilateral ethmoid air cells and bilateral maxillary sinuses. There is no evidence of abnormal fluid collections. Bilateral mastoids appear normal. The globes, extraocular muscles, optic nerves, and retrobulbar fat appear normal. The visualized upper aerodigestive tract appears normal. The patient is intubated with moderate associated secretions. The mandible and temporomandibular joints appear normal. IMPRESSION: 1. Nondisplaced fractures involving the bilateral nasal bones. 2. Moderate associated facial swelling overlying the soft tissues of the anterior facial midline. 3. Moderate paranasal sinus disease, as described above. Radiology Report EXAMINATION: FOOT AP,LAT AND OBL RIGHT INDICATION: ___ year old woman with known R ankle fracture// interval changes after surgery interval changes after surgery COMPARISON: CT lower extremity ___ FINDINGS: AP, lateral and oblique views of the right foot are obtained through cast which obscures bone detail. Limited visualization of posterior talar fracture. Radiology Report EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT PORT INDICATION: ___ year old woman with known R ankle fracture// eval for post-surgical changes eval for post-surgical changes COMPARISON: CT lower extremity ___ FINDINGS: AP lateral and oblique views of the right ankle or taken through cast which limits bone detail. There is limited visualization of the previously described talar fracture Radiology Report EXAMINATION: CT CYSTOGRAM (PEL) W/CONTRAST INDICATION: ___ year old woman with known bladder rupture// eval for intra-peritoneal bladder rupture TECHNIQUE: CT cystogram. 200 cc of contrast was injected into the bladder through the Foley catheter. DOSE: Acquisition sequence: 1) Spiral Acquisition 2.3 s, 30.1 cm; CTDIvol = 8.1 mGy (Body) DLP = 244.1 mGy-cm. 2) Spiral Acquisition 2.5 s, 33.2 cm; CTDIvol = 12.8 mGy (Body) DLP = 424.7 mGy-cm. Total DLP (Body) = 669 mGy-cm. COMPARISON: CT abdomen pelvis from ___. FINDINGS: PELVIS: The partially visualized small and large bowel are unremarkable. A right double-J stent is partially visualized, with the distal tip in the bladder. There is contrast extravasation from the base of the bladder in at least 2 areas, series 604, image 38 and image 42, with possible involvement of the proximal urethra. This is consistent with extraperitoneal rupture. No evidence of intraperitoneal bladder rupture. A 2.5 cm x 4.0 cm hyperdense structure is seen in the inferior and anterior aspect of the bladder, consistent with hematoma, measuring previously 4.1 cm x 5.7 cm. A small amount of free fluid is seen. REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable. LYMPH NODES: There is no pelvic or inguinal lymphadenopathy. VASCULAR: No atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. No evidence of intraperitoneal bladder rupture. 2. Contrast extravasation from the base of the bladder in at least two areas with possible involvement of the proximal urethra, consistent with extraperitoneal rupture. 3. Interval decrease in size of the intraluminal bladder hematoma. Radiology Report EXAMINATION: BLADDER US INDICATION: ___ year old woman s/p MVA// evaluate for clot TECHNIQUE: Grey scale and color Doppler ultrasound images of the bladder were obtained. COMPARISON: CT cystogram dated ___. FINDINGS: The bladder is compressed rounded Foley catheter. There is a small, hypoechoic soft tissue mass adjacent to the Foley catheter, which likely represents mild residual bladder hematoma. A hypoechoic collection medial to the bladder may represent a small amount of free fluid. Incidentally noted is a hypoechoic cystic structure posterior to the bladder, which may represent an ovarian cyst IMPRESSION: 1. The bladder is collapsed around a Foley catheter. There is a small residual hematoma adjacent to the Foley balloon. 2. Small volume pelvic free fluid. Radiology Report EXAMINATION: CT LOW EXT W/O C RIGHT Q61R INDICATION: ___ who is now s/pI D/CLOSED REDUCTION OPEN RIGHT ANKLE FRACTURE/DISLOCATION// assess for dislocation and bony fragments TECHNIQUE: MDCT axial images were acquired through the right lower extremity without intravenous contrast administration. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 13.7 s, 31.6 cm; CTDIvol = 20.8 mGy (Body) DLP = 637.1 mGy-cm. Total DLP (Body) = 647 mGy-cm. COMPARISON: CT bilateral lower extremities from ___. FINDINGS: There has been interval reduction of the talus, now in anatomic alignment. Comminuted mildly displaced fracture of the posterior and medial aspects of the talus, with multiple small fragments seen. Minimally displaced fracture of the anterior cuboid. Probable avulsion fractures of the posterior aspect of the cuboid also seen (series 3, image 185). Nondisplaced fracture through the dorsal and posterior aspect of the cuboid (series 606, image 45). Nondisplaced fracture of the anterior process of the calcaneus again seen. A few tiny bone fragments are seen in close proximity (series 604, image 22), which could represent avulsion fractures. A bone fragment is seen at the distal tip of the fibula, likely representing avulsion fracture. Subcutaneous edema is seen in the right foot. Small amount of subcutaneous emphysema is seen, improved compared to previously. IMPRESSION: 1. Interval reduction of the talus, now in anatomic alignment. 2. Multiple fractures in the right foot, as detailed above. Radiology Report INDICATION: ___ year old woman with perc nephrostomy and minimal output// assess location of perc nephrostomy TECHNIQUE: Portable supine abdominal radiograph. COMPARISON: CT abdomen and pelvis ___. IMPRESSION: There is a right ureteral stent in place. A left percutaneous nephrostomy tube projects over the left mid abdomen in the expected location of the left kidney. There are no abnormally dilated loops of large or small bowel. There is no free intraperitoneal air, although evaluation is limited by supine technique. Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ year old woman s/p MVC with left ureteral disruption, now s/p left percutaneous nephrostomy tube, right ureter stent placement. Evaluate for infected urinoma. 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 3.6 s, 47.7 cm; CTDIvol = 8.0 mGy (Body) DLP = 381.7 mGy-cm. 2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7 mGy-cm. 3) Stationary Acquisition 5.4 s, 0.5 cm; CTDIvol = 30.0 mGy (Body) DLP = 15.0 mGy-cm. Total DLP (Body) = 398 mGy-cm. COMPARISON: CT cystogram dated ___ including the pelvis only. CT cystogram dated ___ including the abdomen pelvis. CT torso with intravenous contrast dated ___. FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is decompressed. PANCREAS: The pancreas demonstrates normal bulk without dilatation of the main duct. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: There is no hydronephrosis. There is a double-J right nephroureteral stent. There is a left percutaneous nephrostomy catheter. In the expected location of the proximal left ureter, abutting the lateral aspect of the left psoas muscle at the level of L3, there is a new rim enhancing fluid collection measuring 3.3 x 2.8 x 3.7 cm, likely a urinoma given the known proximal left ureteral rupture (02:31). Superimposed infection cannot be excluded particularly given the presence of rim enhancement. The collection contains foci of air, but these may be related to the percutaneous nephrostomy tube. Previously seen large volume of intraperitoneal fluid/hematoma has resolved. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is not seen. PELVIS: There is a Foley catheter in the bladder. Air in the bladder lumen is likely secondary to the Foley catheter. The previously demonstrated extraperitoneal bladder rupture is not adequately reassessed on this exam as there is no radiopaque contrast in the bladder at this time. REPRODUCTIVE ORGANS: The uterus and right ovary appear unremarkable. In the prior location of the left ovary however, there is a 5.5 x 3.9 cm fluid-filled structure with a thin rim of contrast enhancement. The initial contrast enhanced torso CT from ___ demonstrated at 2.3 cm left ovarian cyst in the same location. Presently, the left ovary is not definitively seen separate from this structure, and a thin rim of ovarian parenchyma appears present around this structure. This most likely represents interim enlargement of a left ovarian cyst in a ___ woman. A second site of urinoma is less likely. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. BONES: There is no evidence of worrisome osseous lesions or acute fracture. IMPRESSION: 1. New 3.3 x 2.8 x 3.7 cm rim enhancing fluid collection in the expected location of the proximal left ureter, abutting the lateral aspect of the left psoas muscle, likely a urinoma given the known proximal left ureteral rupture. Superimposed infection cannot be excluded. The collection contains foci of air, but these may be related to the left percutaneous nephrostomy. 2. 5.5 x 3.9 cm rim enhancing cystic structure in the prior location of a 2.3 cm left ovarian cyst, likely interim enlargement of a left ovarian cyst. A second site of urinoma is less likely. However, this may be better assessed by pelvic ultrasound, if clinically warranted. 3. Right nephroureteral stent and left percutaneous nephrostomy stent both appear well positioned. No hydronephrosis. 4. Air in the bladder is likely secondary to the Foley catheter. Previously noted extraperitoneal bladder rupture is not adequately reassessed on this exam, as there is no radiopaque contrast in the bladder at this time. 5. Compared to ___, large volume of ascites/intra-abdominal hematoma has resolved. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 5:36 pm, 30 minutes after discovery of the findings. Radiology Report EXAMINATION: CT INTERVENTIONAL PROCEDURE INDICATION: ___ year old woman with ___ s/p MVC with several fractures and L ureteral disruption now s/p L perc neph tube, R ureter stent placement. Elevated WBC and abdominal discomfort. CT abd-pelvis shows ring enhancing collection, concern for infected urinoma. Drainage of ___ collection. ?Urinoma? COMPARISON: CT dated ___ PROCEDURE: CT-guided aspiration of left perinephric fluid collection. OPERATORS: Dr. ___, ___ fellow and Dr. ___, attending radiologist, performed the entire procedure. 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 CT scan of the intended biopsy area was performed. Based on the CT findings, an appropriate position for the left perinephric fluid collection 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 coaxial needle was introduced into the fluid collection. The inner stylet was removed and 3 cc of serosanguineous fluid were aspirated. The sample was sent for microbiology and culture. The needle was removed and sterile dressing was applied. The procedure was tolerated well and there were no immediate post-procedural complications. DOSE: Acquisition sequence: 1) Spiral Acquisition 9.9 s, 30.2 cm; CTDIvol = 9.0 mGy (Body) DLP = 261.5 mGy-cm. 2) Stationary Acquisition 6.1 s, 1.4 cm; CTDIvol = 64.0 mGy (Body) DLP = 92.1 mGy-cm. Total DLP (Body) = 364 mGy-cm. SEDATION: Moderate sedation was provided by administering divided doses of 2 mg Versed and 100 mcg fentanyl throughout the total intra-service time of 10 minutes minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. FINDINGS: 1. Preprocedural images demonstrate a 3 cm fluid collection in the left perinephric region just anterior to the psoas muscle. 2. CT fluoroscopic images demonstrate sequential advancement of hyper dense needle tip within the targeted collection. 3. Postprocedure images demonstrate no evidence of large hematomas. IMPRESSION: Successful CT-guided aspiration of left perinephric fluid collection. Gender: F Race: UNKNOWN Arrive by UNKNOWN Chief complaint: MVC Diagnosed with Unspecified injury of bladder, initial encounter, Car driver injured in clsn with statnry object in traf, init temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: UTA level of acuity: 1.0

Patient summary: ================ ___ y/o F presenting to ___ ___ s/p MVC vs. pole with airbag deployment and prolonged extrication. Pt with an open R ankle/foot fracture which was splinted at the scene, GCS 8 in the trauma bay, subsequently intubated. Trauma work up in ED (+) R diplaced comminuted fx posteromedial talus, R mid and hind foot fractures, minimally displaced R ulnar styloid fracture, bil lacerations over the knees, small laceration of the anterior L tibia, laceration over the ulnar left hand, and Extraperitoneal bladder rupture. ___ MD with difficulty obtaining ___ signals DP or ___ signals in the right lower extremity. R ankle reduced and splinted, and subsequently able to obtain ___ DP and ___ signals. Pt s/p I+D and ORIF of R dislocated ankle fracture, I+D and closure of bil knee and L hand lacerations on ___. Pt s/p cystoscopy, clot evacuation, left ureteroscopy and right double-J ureteral stent placement on ___. Plastics was also consulted for repair of through-and-through lip lacerations on ___, and nondisplaced fx of bilateral nasal bones and frontal processes of b/l zygomatic bones . ___ also consulted and placed a L PCN on ___. Labs notable for a drifting Hct down to 19, which responded to one unit of blood. ___ pt was weaned off of vasopressor support and CBI, now with foley catheter draining punch colored urine. She was extubated and in stable condition. She was called out from the ICU to the floor on ___. On the floor, monitored clinical care for 5 more days. Performed additional drainage of ___ collection on ___. No complications registered. Discharged to rehab facility on ___ to continue care as an outpatient.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Ambien Attending: ___. Chief Complaint: Fall Major Surgical or Invasive Procedure: None History of Present Illness: History obtained from daughter, as the patient speaks limited ___. Pt is ___ with a PMHx notable for PD w/ psychotic features, CAD, afib on coumadin, and CHF who was reportedly in his baseline state of health until earlier today at which time the patient's daughter reports that she heard a thump from the other room and saw that the patient had fallen. Per her report, he struck his face face first, mostly on the left side. He had no loss of consciousness, vision changes, slurred speech, or complaints of headache. The patient's daughter denies he has experienced recent fatigue, nausea/vomiting, anorexia. He has had no recent change in weight (daughter weighs him every morning) or peripheral edema. He has not reported recent angina or palpitations. Past Medical History: - CHF - CAD s/p CABG x 4 - Atrial fibrillation on warfarin - Hypothyroidism - Hyponatremia - R lung nodule ___, monitored with serial CT, has not grown - Anxiety, depression, paranoia - Iron deficiency anemia - Bladder tumor s/p resection Social History: ___ Family History: Both parents with diabetes Physical Exam: ADMISSION PHYSICAL EXAM 100.0 93 132/87 22 95% on 2LNC GEN: Well developed, well nourished, showing increased work of tachypnea. HEENT: Normocephalic, 3cm swelling on forehead, minor scratches on back of neck and scalp, no tenderness along cervical, thoracic, or lumbar spine CV: Regular rate, regular rhythm. +S1S2 with early systolic III/VI murmur PULM: Clear to auscultation bilaterally BACK: no vertebral tenderness ABD: soft, non tender, non distended EXT: warm, well perfused, no edema NEURO: A&Ox3 DISCHARGE PHYSICAL EXAM Gen: WD/WN, comfortable, NAD. L forehead abrasion and hematoma HEENT: PERRL 3mm-2mm, EOM's intact Neck: No CSpine tenderness, full ROM - cleared at OSH Extrem: warm and well perfused Neuro: Pt is primarily ___ speaking, understands basic ___ and can respond to orientation questions in ___. Daughter at bedside to help interpret with complex assessment. Mental Status: Awake, alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech is fluent with good comprehension. Pertinent Results: ___ CT head: subcentimeter intra-axial cortical acute hemorrhage medical right parietal lobe. tiny mid left parafalcine subdural hemorrhage. no calvarial hemorrhage. ___ CT spine: no cervical spinal fracture. multilevel bridging osteophytes are noted. no soft tissue enhancement or swelling. ___ CT head: 1. Small amount of subarachnoid hemorrhage in the medial posterior right frontal sulci. 2. Probable minimal left parafalcine subdural hematoma. 3. Left frontal subgaleal soft tissue swelling extending over the left frontal sinus. No evidence for a displaced fracture. ___ 05:43AM BLOOD WBC-4.6 RBC-4.19* Hgb-12.1* Hct-36.9* MCV-88 MCH-28.9 MCHC-32.8 RDW-15.4 RDWSD-49.0* Plt ___ ___ 05:50AM BLOOD WBC-4.3 RBC-4.33* Hgb-12.2* Hct-37.6* MCV-87 MCH-28.2 MCHC-32.4 RDW-15.3 RDWSD-48.9* Plt ___ ___ 05:43AM BLOOD Plt ___ ___ 05:50AM BLOOD Plt ___ ___ 05:50AM BLOOD ___ PTT-29.6 ___ ___ 12:45PM BLOOD ___ PTT-30.1 ___ ___ 11:38PM BLOOD Plt ___ ___ 11:38PM BLOOD ___ PTT-30.2 ___ ___ 05:43AM BLOOD Glucose-104* UreaN-35* Creat-1.0 Na-139 K-3.7 Cl-97 HCO3-27 AnGap-15 ___ 05:50AM BLOOD Glucose-110* UreaN-39* Creat-1.2 Na-144 K-3.4* Cl-101 HCO3-29 AnGap-14 ___ 12:45PM BLOOD K-3.4* ___ 11:38PM BLOOD Glucose-151* UreaN-68* Creat-1.4* Na-134* K-4.1 Cl-94* HCO3-21* AnGap-19* ___ 07:22PM BLOOD CK(CPK)-3488* ___ 12:45PM BLOOD CK(CPK)-2895* ___ 04:33AM BLOOD CK(CPK)-1275* ___ 11:38PM BLOOD ALT-87* AST-56* CK(CPK)-559* AlkPhos-71 TotBili-0.5 Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Rosuvastatin Calcium 10 mg PO QPM 2. Furosemide 40 mg PO BID 3. Levothyroxine Sodium 100 mcg PO DAILY 4. Polyethylene Glycol 17 g PO DAILY 5. Potassium Chloride 20 mEq PO DAILY 6. QUEtiapine Fumarate 450 mg PO QHS 7. Sertraline 25 mg PO DAILY 8. Spironolactone 25 mg PO DAILY 9. Thiothixene 10 mg PO BID 10. Warfarin 4 mg PO DAILY16 11. Vitamin D ___ UNIT PO DAILY 12. TraZODone 200 mg PO QHS Discharge Medications: 1. Furosemide 40 mg PO BID 2. Levothyroxine Sodium 100 mcg PO DAILY 3. Polyethylene Glycol 17 g PO DAILY 4. Potassium Chloride 20 mEq PO DAILY Hold for K > 5. QUEtiapine Fumarate 450 mg PO QHS 6. Rosuvastatin Calcium 10 mg PO QPM 7. Sertraline 25 mg PO DAILY 8. Spironolactone 25 mg PO DAILY 9. Thiothixene 10 mg PO BID 10. TraZODone 200 mg PO QHS 11. Vitamin D ___ UNIT PO DAILY 12. HELD- Warfarin 4 mg PO DAILY16 This medication was held. Do not restart Warfarin until follow up with ___ clinic Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: Subdural hematoma, subfalcine hemorrhage Atrial fibrillation diabetes type 2 ___ Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old man with small parafalcine subdural hematoma and right parietal hemorrhage, on coumadin. Assess interval change. TECHNIQUE: Noncontrast head CT with sagittal and coronal reformatted images. DLP 749 mGy cm. COMPARISON: ___. FINDINGS: Motion artifact limits evaluation of the posterior fossa. There is a small amount of subarachnoid hemorrhage in the medial posterior right frontal sulci, adjacent to the falx. There is also minimal left parafalcine hyperdensity which may represent minimal subdural hematoma. There is no evidence for parenchymal edema, mass effect, or acute major vascular territorial infarction. There is global parenchymal volume loss with prominent ventricles and sulci. There is left frontal subgaleal soft tissue swelling extending over the left frontal sinus. No displaced fracture is seen. The orbits appear unremarkable. There is minimal mucosal thickening in the ethmoid air cells. There are partially visualized mucous retention cyst and partially visualized mild mucosal thickening in the included portion of the left maxillary sinus. There is partially visualized minimal mucosal thickening in the included portion of the right maxillary sinus. Partially visualized mastoid air cells appear clear. IMPRESSION: 1. Small amount of subarachnoid hemorrhage in the medial posterior right frontal sulci. 2. Probable minimal left parafalcine subdural hematoma. 3. Left frontal subgaleal soft tissue swelling extending over the left frontal sinus. No evidence for a displaced fracture. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Confusion, s/p Fall, Transfer Diagnosed with Unsp focal TBI w/o loss of consciousness, init, Fall same lev from slip/trip w/o strike against object, init temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: 0 level of acuity: 2.0

Mr. ___ was transferred on ___ from an OSH where he had presented after an unwitnessed fall, likely mechanical. His imaging studies done at the OSH revealed a small parafalcine subdural hematoma and Right parietal hemorrhage. On arrival to ___, he had no neurological deficits. he was admitted to the SICU for monitoring. His home warfarin was immediately held. He was given KCentra and VitK, and later given 1unit of FFP. Repeat CT head the next morning showed stable small SDH and parafalcine hemorrhage. He was then transferred to the surgical floor. During admission, his CHF was managed with gentle diuresis with Lasix as needed. Speech and Swallow evaluation performed during this admission recommended pureed diet and nectar thick liquids, medications should also be given with puree. He was started on a diet and given adequate analgesics. After evaluation by the ___, he was discharged home with services on ___ At discharge, he was tolerating a regular pureed diet, his pain was well controlled. His mental status was at baseline. He will follow up at the ___ clinic and also follow up with Dr. ___. These instructions were conveyed to patient who expressed understanding.

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Lactose Attending: ___ ___ Complaint: Pneumonia Major Surgical or Invasive Procedure: None History of Present Illness: ___ with h/o lung CA (adeno Ca involving visceral pleura - T2a) s/p bilateral wedge resections (___) sent in by Dr. ___ SOB x6 days. He states thats for the past 6 days he has been feeling more fatigued with decreased appetite and progressively worsening SOB. Found to have PNA on CXR in the office today. Denies fevers/chills, leg swelling, calf swelling, abdominal pain or chest pain. Patient has been intermittently tachycardic over the past several months, including pre-op. Of note, he had an EKG ___ that showed diffuse PR depressions and ST elevations, at which time he had no chest pain. TTE was performed the same day that showed no pericardial effusion. No h/o clots. Also had CTA in the past week showing no pericardial effusion or PE and no PNA or endobronchial lesions. . In the ED, initial VS were: T 98.7 HR 122 BP 158/78 RR 20 O2 Sat 95% CXR showed RLL PNA. Blood cultures were obtained and he was given Ceftriaxone 1g iv x1 and Azithromycin 500mg po x1. . On the floor, initial VS were: T 97.4 BP 141/90 HR 108 RR 18 O2 sat 90% RA Past Medical History: Hyperlidemia Hypertension Diabetes Psoriatic arthritis on methotrexate lactose intolerance BPH PSH: B/l knee replacement S/P VATS RUL ___ Social History: ___ Family History: Mother- died of ___ age ___ Father- MI age ___, died age ___ Siblings- sister died of lung cancer ___, another sister is leukemia survivor. Physical Exam: Admission Exam: VS - T 98.7 HR 122 BP 158/78 RR 20 O2 Sat 95% GENERAL - Well appeaing man in NAD HEENT - NCAT, MMM, thyroid non-tender, no palpable masses NECK - JVP 5cm above the RA LUNGS - CTAB, no increased WOB, bronchial breathsounds in the mid R lung, mild egophany, no wheezes, rales or rhonchi. HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, NTND, no rigidity, rebound or guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) NEURO - A/Ox3, CN II-XII grossly intact, non focal . Discharge Exam: VS: T ___ BP 115-140/70-80 HR 94-100s (94) RR 18 O2 Sat 99% RA GENERAL - Well appeaing man in NAD HEENT - NCAT, MMM, thyroid non-tender, no palpable masses NECK - JVP 5cm above the RA LUNGS - CTAB, no increased WOB, no wheezes, rales or rhonchi HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, NTND, no rigidity, rebound or guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) NEURO - A/Ox3, CN II-XII grossly intact, non focal Pertinent Results: Admission Labs: ___ 05:14PM BLOOD WBC-9.9 RBC-4.81 Hgb-13.5* Hct-40.8 MCV-85 MCH-28.1 MCHC-33.1 RDW-13.6 Plt ___ ___ 05:14PM BLOOD Neuts-84.6* Lymphs-9.8* Monos-5.0 Eos-0.3 Baso-0.3 ___ 06:00AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ ___ 05:14PM BLOOD Glucose-156* UreaN-17 Creat-0.8 Na-141 K-3.8 Cl-100 HCO3-29 AnGap-16 ___ 05:14PM BLOOD Calcium-10.1 Phos-3.9 Mg-1.7 ___ 06:00AM BLOOD TSH-0.94 ___ 06:00AM BLOOD Free T4-1.3 ___ 05:29PM BLOOD Lactate-1.2 Discharge Labs: ___ 06:50AM BLOOD WBC-9.7 RBC-4.31* Hgb-12.2* Hct-36.5* MCV-85 MCH-28.4 MCHC-33.5 RDW-14.1 Plt ___ ___ 06:50AM BLOOD Neuts-78.0* Lymphs-15.1* Monos-5.3 Eos-1.3 Baso-0.3 ___ 06:50AM BLOOD Glucose-129* UreaN-11 Creat-0.7 Na-143 K-3.9 Cl-105 HCO3-29 AnGap-13 CXR (___): 1. New right lower lobe perihilar opacity consistent with a pneumonia. Recommend follow up CXR in 4 weeks after completion of antibiotic therapy to ensure resolution. 2. Stable post-surgical changes. . EKG (___): Sinus tachycardia. Delayed R wave progression is likely a normal variant. Compared to the previous tracing of ___ no significant difference. Medications on Admission: 1. oxycodone-acetaminophen ___ mg: ___ Tablets PO Q4H prn for pain. 2. metformin 500 mg Tablet Sig: One (1) Tablet PO BID 3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. fenofibrate micronized 200 mg Capsule Sig: One (1) Capsule PO once a day. 5. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 6. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 7. methotrexate sodium 2.5 mg Tablet Sig: One (1) Tablet PO once a week. 8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 9. senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as needed for constipation. 10. glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Lactaid 3,000 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day: before meals with dairy. Discharge Medications: 1. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 8 days. Disp:*8 Tablet(s)* Refills:*0* 2. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 6. methotrexate sodium 2.5 mg Tablet Sig: Eight (8) Tablet PO every ___. 7. fenofibrate micronized 200 mg Capsule Sig: One (1) Capsule PO qday (). 8. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 11. glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day. 12. Lactaid 3,000 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day: before meals. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Community Acquired Pneumonia Secondary Diagnosis: Sinus Tachycardia Lung Cancer s/p bilateral wedge resections DM2 HLD HTN Psoriasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Cough and wheezing. COMPARISONS: Chest radiograph, ___. FINDINGS: There has been interval development of a right lower lobe perihilar consolidation. Given this change from the recent radiograph, this likely represents an acute infection. Again seen are stable post-surgical changes with volume loss on the right after a right upper lobe resection, and left lower lobe changes from a recent wedge resection. There is no pleural effusion or pneumothorax. The cardiac and mediastinal silhouette is normal without cardiomegaly. There are mild degenerative changes with flowing anterior osteophytes of the mid thoracic spine. IMPRESSION: 1. New right lower lobe perihilar opacity consistent with a pneumonia. Recommend follow up CXR in 4 weeks after completion of antibiotic therapy to ensure resolution. 2. Stable post-surgical changes. Results were discussed with Dr. ___ at 3:10 p.m. on ___ via telephone by Dr. ___. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: COUGH Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, TACHYCARDIA NOS, DIABETES UNCOMPL ADULT, HYPERTENSION NOS, HYPERLIPIDEMIA NEC/NOS temperature: 98.7 heartrate: 122.0 resprate: 20.0 o2sat: 95.0 sbp: 158.0 dbp: 78.0 level of pain: 0 level of acuity: 2.0

Priamry Reason for Admission: ___ y/o man with recent b/l wedge resections for Lung Ca presenting with SOB and new consolidation concerning for PNA also with persistent tachycardia of unknown etiology. .

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: s/p fall, back and chest wall pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ sustained fall from approximately 10 feet from attic door today. Fell onto left side, no LOC, immediately complained of L-sided pain and was assisted by friend. Taken to OSH and films identified rib fractures and L2-L4 lumbar transverse process fractures; she was transferred to ___ for further management. On arrival to ___ ED she is complaining of left rib pain but otherwise denies complaints. Her husband accompanies her and states she appears to have normal speech and affect. On ROS she denies headache, visual changes, shortness of breath, weakness or numbness in the extremeties. Past Medical History: scoliosis, HTN, hypothyroidism, right piriformis syndrome (s/p steroid injection to R hip by PCP), IBS Social History: ___ ___ History: nc Physical Exam: O: T: 99 BP: 140/90 HR: 88 R 18 O2Sats 100 2L Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRLA, EOMs intact b/l Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Chest: + chest wall tenderness to left side, + midline tenderness to L spine Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: CN2-12 intact, UEs and LEs ___ strength b/l, sensation equal and intact b/l, proprioception intact, cerebellar intact to finger-nose-finger Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right + + + + + Left + + + + + Propioception intact Toes downgoing bilaterally Pertinent Results: ___ 10:14PM PH-7.40 COMMENTS-GREEN TOP ___ 10:14PM GLUCOSE-122* LACTATE-1.4 NA+-143 K+-3.7 CL--106 TCO2-24 ___ 10:14PM freeCa-1.13 ___ 10:07PM UREA N-24* CREAT-0.7 ___ 10:07PM estGFR-Using this ___ 10:07PM LIPASE-39 ___ 10:07PM ASA-NEG ETHANOL-NEG ACETMNPHN-5* bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 10:07PM WBC-12.2* RBC-4.27 HGB-13.6 HCT-39.1 MCV-92 MCH-31.9 MCHC-34.9 RDW-12.5 ___ 10:07PM PLT COUNT-248 ___ 10:07PM ___ PTT-24.3* ___ ___ 10:07PM ___ CT Torso: 1. Anterolateral left 4, ___ acute rib fractures. 2. Left L2 and L3 transverse process fractures, better delineated on the same day lumbar spine CT scan. 3. 6mm cavitary nodule in the left upper lobe anterior segment with vague surrounding ground-glass opacity. Recommend ___ month followup. 4. Small bleb at the left lung with no evidence of pneumothorax. 5. Bilateral renal hypodensities, some of which are too small to characterize but likely representing renal cysts; the largest in the left interpolar region measures 16 mm. 6. Right kidney angiomyolipoma. Renal cysts. 7. Hepatic hypodensity within the left lobe of the liver is too small to characterize but statistically likely represents a simple cyst or hemangioma. MR C-spine: No evidence of ligamentous disruption seen but mild increased signal in the posterior soft tissues and interspinous ligaments indicate mild traumatic injury. No evidence of spinal cord compression or intrinsic spinal cord signal abnormalities or intraspinal hematoma seen. Mild multilevel degenerative changes noted. Medications on Admission: levoxyl 750mcg PO daily, Toprol XL 25mg PO daily, meloxicam 15mg PO daily, cymbalta 60mg PO daily, prempro 0.45/1.5mg PO daily, HCTZ 12.5mg PO daily Discharge Medications: levoxyl 750mcg PO daily, Toprol XL 25mg PO daily, meloxicam 15mg PO daily, cymbalta 60mg PO daily, prempro 0.45/1.5mg PO daily, HCTZ 12.5mg PO daily 1. oxycodone 5 mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain for 1 weeks. Disp:*40 Tablet(s)* Refills:*0* 2. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 3. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed for pain. Disp:*45 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: L2-4 Left transverse process fractures, ___ and 5th rib fractures Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report CHEST RADIOGRAPH PERFORMED ON ___ COMPARISON: Chest CT from outside hospital. CLINICAL HISTORY: Fall down stairs with report of left rib fractures. FINDINGS: Portable AP upright chest radiograph is obtained. The lungs appear clear bilaterally without focal consolidation, effusion, or pneumothorax. A left fifth rib fracture seen on CT is not evident on this chest radiograph. Cardiomediastinal silhouette appears normal. IMPRESSION: No acute findings. Please refer to CT chest from outside hospital for further details. Radiology Report INDICATION: ___ woman status post fall. COMPARISON: None. TECHNIQUE: CT with contrast was obtained through the chest and upper abdomen. Delayed images were also provided. Coronal and sagittal reformats were provided. These images were obtained from an outside hospital and uploaded for second read review by a radiologist at the ___ ___. CT OF THE CHEST: A small left bleb is noted within the lower lung (series 8, image 16). There is no evidence of pneumothorax, focal consolidation or pleural effusion. The visualized heart and pericardium are unremarkable. The great vessels are within normal limits. Mediastinal, axillary and hilar lymph nodes ___ not meet size criteria for pathologic enlargement. A 6mm cavitary nodule in the left upper lobe anterior segment surrounded by ground glass opacity is noted (4, 45). Calcification of the right thyroid lobe is noted. This study is not optimized for subdiaphragmatic review. Within this limitation, a small hypodensity is noted within the left lobe of the liver (7, 20) which is too small to characterize. The patient is status post cholecystectomy. The spleen, pancreas, and bilateral adrenal glands appear unremarkable. The common bile duct is mildly prominent, likely reflecting post-cholecystectomy state. It measures approximately 8 mm. Both kidneys enhance symmetrically without evidence of hydronephrosis. Hypodensities are noted within bilateral kidneys, some of which are too small to characterize. The largest hypodensity within the interpolar region of the left kidney measures approximately 16 mm. An interpolar fat density lesion in the right kidney measuring 1cm appears consistent with an angiomyolipoma. There is no free air or free fluid within the visualized portions of the upper abdomen. A left anterolateral fifth rib fracture and possible fourth rib fracture is identified. Minimally displaced transverse process fractures of the L2 and L3 vertebral bodies are identified and are better delineated on the same day lumbar CT spine study. There is S-shaped scoliosis with rightward convexity in the upper thoracic portion and leftward convexity in the lower thoracolumbar portion. IMPRESSION: 1. Anterolateral left 4, ___ acute rib fractures. 2. Left L2 and L3 transverse process fractures, better delineated on the same day lumbar spine CT scan. 3. 6mm cavitary nodule in the left upper lobe anterior segment with vague surrounding ground-glass opacity. Recommend ___ month followup. 4. Small bleb at the left lung with no evidence of pneumothorax. 5. Bilateral renal hypodensities, some of which are too small to characterize but likely representing renal cysts; the largest in the left interpolar region measures 16 mm. 6. Right kidney angiomyolipoma. Renal cysts. 7. Hepatic hypodensity within the left lobe of the liver is too small to characterize but statistically likely represents a simple cyst or hemangioma. Findings discussed with Dr. ___ at 10:40 p.m. on ___ in person. Radiology Report INDICATION: ___ female status post fall from 10 feet. COMPARISON: None. TECHNIQUE: Contiguous axial images were obtained through the cervical spine without the administration of IV contrast. Multiplanar reformats were generated and reviewed. FINDINGS: There is no evidence of acute fracture. There is a grade I anterolisthesis of C4 on C5, likely chronic and related to ___ disease as there is no accompanying soft tissue swelling or interspinous widening on CT to suggest an acute hyperflexion injury. Otherwise, alignment is preserved. Mild degenerative disc disease is noted in the C-spine. The atlanto-occipital and atlanto-axial articulations are intact. The prevertebral soft tissues are well maintained. Calcified nodule is noted within the right thyroid lobe. Bilateral mastoid air cells are clear. IMPRESSION: No acute fracture. Grade I anterolisthesis of C4 on C5 is likely chronic though correlation for focal pain is recommended. Radiology Report INDICATION: ___ female status post fall from 10 feet with lumber spine tenderness. COMPARISON: None. TECHNIQUE: Contiguous axial images were obtained through the lumbar spine without the administration of IV contrast. Multiplanar reformats were generated and reviewed. FINDINGS: Displaced left transverse process fractures are noted at L2, L3 and L4 lumbar vertebrae. Otherwise no acute fracture. Degenerative changes including Schmorl's nodes are noted at the inferior endplate of the L2 vertebral body. An interpolar fat density lesion in the right kidney measuring 1 cm appears consistent with an angiomyolipoma. Hypodensities likely representing cysts are noted within the visualized kidneys better delineated on the same day CT of the chest. IMPRESSION: 1. Displaced fractures of the L2, L3, and L4 left transverse processes of the lumbar vertebrae. Findings discussed with Dr. ___ at ___. 2. Right renal 1-cm angiomyolipoma. Renal cysts. Radiology Report EXAM: MRI of the cervical spine. CLINICAL INFORMATION: Patient with trauma, rule out ligamentous injury. TECHNIQUE: T1, T2, and inversion recovery sagittal, gradient echo and T2 axial, and diffusion sagittal images of the cervical spine were acquired. Correlation was made with the cervical spine CT of ___. FINDINGS: From skull base to T2 level, there is no abnormal signal seen within the vertebral bodies to indicate marrow edema. Although mild increased signal is identified in the posterior soft tissues on the sagittal inversion recovery images which extends to the interspinous regions from C2-3 to C4-5 level, there is no evidence of ligamentous disruption identified. There is no evidence of prevertebral hematoma seen. Degenerative changes are identified with disc bulging from C3-4 to C6-7. Mild foraminal narrowing bilaterally is seen at C4-5 and C5-6 levels. There is no extrinsic spinal cord compression seen. There are no intrinsic spinal cord signal abnormalities identified. The vascular flow voids are maintained. The prevertebral soft tissue thickness is maintained. IMPRESSION: No evidence of ligamentous disruption seen but mild increased signal in the posterior soft tissues and interspinous ligaments indicate mild traumatic injury. No evidence of spinal cord compression or intrinsic spinal cord signal abnormalities or intraspinal hematoma seen. Mild multilevel degenerative changes noted. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: FALL Diagnosed with FX LUMBAR VERTEBRA-CLOSE, FRACTURE TWO RIBS-CLOSED, FALL-1 LEVEL TO OTH NEC, DEHYDRATION, HYPERTENSION NOS temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: nan

Pt was admitted to the ACS service for multiple rib fx/transverse process fractures. Her pain was well controlled, and neurosurgery was consulted for spine evaluation. An MRI of her C-spine revealed no evidence of acute pathology. Pt's pain was well controlled in house, and she remained stable, with good breath sounds b/l and O2 sats >95% throughout. Pt is comfortable on day of discharge. She was kept in a c-collar until cleared by neurosurgery on day of discharge. She will follow up with her primary care physician and in ___ clinic for follow-up of rib fractures.