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Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Ace Inhibitors / nifedipine Attending: ___. Chief Complaint: syncope Major Surgical or Invasive Procedure: None History of Present Illness: A ___ woman with history of carotid stenosis, CAD, fibroid uterus, GERD, hyperlipidemia, hypertension, obesity, osteoarthritis, renal artery stenosis, venous insufficiency, impaired fasting glucose, reactive airway disease, atrial flutter and CHF presenting for evaluation of syncope. History obtained from patient with help of family at bedside interpreting. They say that she was in her usual state of health for the day as she was doing normal activities like going to Target. She was folding clothes at home when she developed sudden onset, severe headache over top of the head and occiput, no vision changes but severe lightheadedness lasting over a couple of seconds. Witnesses deny muscle jerks, urinary/bowel incontinence. Pt denies tongue biting. Upon awaking, pt states she continued to have headache and LH. Soon thereafter, she had mild chest pain on the R side of her chest pain, took a SLN with relief. Per patient's son, BP at time of being found down was 192/115, after SLN --> 114/60. In the ED, initial vital signs were: Vital Signs: Temp: 99.4. Pulse: 59. RR: 18. BP: 145/61. MAP: 89.0 mm Hg. O2 sat: 96. O2 flow: Room Air. Pain: 0. - Exam was notable for: Negative by orthostatics - Labs were notable for: WBC, RBC WNL, mild thrombocytopenia 145, INR 3.0, Cr 1.2, AST/ALT 39/24, AP 110. Lactate 2.2 - Imaging: CTH negative for acute intracranial process. C spine negative for fracture or malalignment. Thyroid glan with hypodense nodules up to 4mm, similar appearance to ___. 3 mm left lung apex pulmonary nodule. - The patient was given: Ceftriaxone 1gm - Consults: none Vitals prior to transfer were: Temperature 97.5 °F (36.4 °C).Pulse 57.Respiratory Rate 19. Blood Pressure 127/53.O2 Saturation 98.Pain Level 0. Upon arrival to the floor, patient states that she has pain with urination x 3 days. Also with DOE to ___ block, + PND, +orthopnea, no swelling in her legs. Headaches stopped on arrival. Endorses epigastric pain x 3 days, +++ constipation, no hematochezia or melena. Endores hard pellet stool. Denies ever having nausea/vomiting, diarrhea. Past Medical History: CAROTID STENOSIS s/p R STENT CORONARY ARTERY DISEASE s/p CABG x 4V (___) HX OF TIA HYPERCHOLESTEROLEMIA HYPERTENSION OBESITY GERD OSTEOARTHRITIS RENAL ARTERY STENOSIS s/p STENTING (___) ATRIAL FLUTTER CONGESTIVE HEART FAILURE Social History: ___ Family History: Her father died at age ___ in an accident. Her mother died at age ___ of liver cancer. She has one brother, two sisters, three sons and five daughters. Most of her siblings and children have hypertension and she has a sister with hyperlipidemia and a son who may have sustained a stroke. There is no family history notable for diabetes, early coronary artery disease or sudden cardiac death. Physical Exam: on admission: VITALS - 98.0 139/53 48 18 96%RA ___ 00:00, Vital Signs: Temp: supine, Pulse: 62, BP: 127/48, MAP: 74.3 mm Hg. ___ 00:02, Vital Signs: Temp: sitting, Pulse: 60, BP: 138/49, MAP: 78.7 mm Hg. ___ 00:04, Vital Signs: Temp: standing, Pulse: 62, BP: 143/51, MAP: 81.7 mm Hg. GENERAL - pleasant, well-appearing, in no apparent distress, NAD HEENT - normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear NECK - supple, no LAD, no thyromegaly, JVP at tragus CARDIAC - regular rate with ectopy, bradycardidc, no murmur appreciated on my exam. Does not appear orthopneic when lying flat PULMONARY - bibasilar crackles ABDOMEN - normal bowel sounds, soft, non-tender, non-distended, no organomegaly EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or edema SKIN - without rash BACK: +CVAT on L NEUROLOGIC - A&Ox3, CN II-XII full tested and intact except R strabismus that has been longstanding. Normal sensation, with strength ___ ___ in LUE (weak d/t prior fracture on that side). ___ hip flexion/extension, ___ ankle dorsiflexion/plantar flexion. Negative Kernig's and Brudzinki however +neck pain with flexion of neck and hip flexion. Gait assessment deferred. Finger to nose intact. PSYCHIATRIC - listen & responds to questions appropriately, pleasant On discharge: VITALS - 97.7 142/66 (range SBP 189-104) 61 18 95%RA GENERAL - pleasant, well-appearing, NAD HEENT - normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear CARDIAC - regular rate with irregular rhythm, no mrg PULMONARY - Minimal bibasilar crackles, CTAB ABDOMEN - normal bowel sounds, soft, non-tender, non-distended, no organomegaly EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or edema NEUROLOGIC - A&Ox3, CN II-XII full tested and intact except R strabismus that has been longstanding. Moves all extremities purposefully Pertinent Results: On admission: ___ 12:20AM BLOOD WBC-6.7 RBC-4.61 Hgb-11.2 Hct-37.0 MCV-80* MCH-24.3* MCHC-30.3* RDW-18.7* RDWSD-53.5* Plt ___ ___ 12:20AM BLOOD Neuts-64.4 ___ Monos-10.3 Eos-1.9 Baso-0.6 Im ___ AbsNeut-4.33 AbsLymp-1.51 AbsMono-0.69 AbsEos-0.13 AbsBaso-0.04 ___ 12:20AM BLOOD ___ PTT-45.3* ___ ___ 12:20AM BLOOD Glucose-110* UreaN-27* Creat-1.2* Na-143 K-4.0 Cl-103 HCO3-27 AnGap-17 ___ 12:20AM BLOOD ALT-34 AST-39 AlkPhos-110* TotBili-0.5 ___ 12:20AM BLOOD Lipase-39 GGT-146* ___ 12:20AM BLOOD proBNP-2770* ___ 12:20AM BLOOD cTropnT-<0.01 ___ 07:05AM BLOOD cTropnT-<0.01 ___ 12:20AM BLOOD Albumin-4.2 Calcium-9.5 Phos-3.8 Mg-2.0 ___ 07:05AM BLOOD Ferritn-24 ___ 07:05AM BLOOD TSH-1.2 Micro: ___ 12:10 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Reports: ECG Study Date of ___ 12:24:46 AM Sinus rhythm with frequent premature atrial contractions. RSR' pattern in lead V1, probable normal variant. Extensive non-specific ST-T wave changes. Borderline prolonged Q-T interval. Compared to tracing #1 the Q-T interval is more easily measured and appears prolonged. CT HEAD W/O CONTRAST Study Date of ___ 12:17 AM IMPRESSION: 1. No acute intracranial process. No hemorrhage or other sequelae of trauma identified. 2. Age-appropriate global cerebral atrophy. CT C-SPINE W/O CONTRAST Study Date of ___ 12:18 AM IMPRESSION: 1. No fracture or malalignment. 2. Mild multilevel cervical spine degenerative change. 3. Heterogeneous thyroid gland with hypodense nodules measure up to 5 mm, similar appearance to ___. 4. 3 mm left lung apex pulmonary nodule. Consider follow-up if indicated based on risk factors. RECOMMENDATION(S): The ___ pulmonary nodule recommendations are intended as guidelines for follow-up and management of newly incidentally detected pulmonary nodules smaller than 8 mm, in patients ___ years of age or older. Low risk patients have minimal or absent history of smoking or other known risk factors for primary lung neoplasm. High risk patients have a history of smoking or other known risk factors for primary lung neoplasm. In the case of nodule size <= 4 mm: No follow-up needed in low-risk patients. For high risk patients, recommend follow-up at 12 months and if no change, no further imaging needed. CTA HEAD W&W/O C & RECONS Study Date of ___ 12:29 ___ IMPRESSION: 1. No acute intracranial process without territorial infarct, hemorrhage, or mass effect. 2. Chronic occlusion of left V3 V4 segment vertebral artery which is unchanged comparison to ___. 3. Otherwise patent anterior and posterior circulations without new occlusion, dissection, or vascular malformation. 4. Unchanged 2 mm aneurysm at the left vertebral basilar junction. 5. Unchanged 3 mm aneurysm at the origin of the right posterior communicating artery. 6. Unchanged 4 mm aneurysm at the left communicating segment internal carotid artery, likely at the origin of the posterior communicating artery. 7. Unchanged 2 mm aneurysm the left M1/M2 middle cerebral artery junction. 8. Right maxillary and anterior ethmoid sinus disease, as described. TTE (Complete) Done ___ at 10:23:15 AM FINAL Conclusions The left atrial volume index is severely increased. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is at least 15 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is normal (>=2.5L/min/m2). Doppler parameters are indeterminate for left ventricular diastolic function. The right ventricular cavity is mildly dilated with normal free wall contractility. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal biventricular wall thickness, cavity size and regional/global systolic function. Mild right ventricular cavity dilatation with preserved systolic function. Severe pulmonary hypertension. Mild mitral and aortic regurgitatin. Compared with the prior study (images reviewed) of ___, the severity of pulmonary hypertension has progressed. There are now signs of RV pressure and volume overload. Labs on discharge: ___ 06:46AM BLOOD ___ ___ 06:46AM BLOOD Glucose-110* UreaN-25* Creat-1.1 Na-138 K-3.9 Cl-99 HCO3-28 AnGap-15 ___ 06:46AM BLOOD Calcium-9.4 Mg-1.9 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 100 mg PO DAILY 2. Carvedilol 25 mg PO BID 3. Docusate Sodium 100 mg PO BID 4. Warfarin 5 mg PO 4X/WEEK (___) 5. Warfarin 2.5 mg PO 3X/WEEK (___) 6. HydrALAzine 100 mg PO TID 7. Simvastatin 40 mg PO QPM 8. Furosemide 40 mg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 11. Omeprazole 20 mg PO DAILY 12. Aspirin 81 mg PO DAILY 13. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN shortness of breath Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Docusate Sodium 100 mg PO BID 3. Losartan Potassium 150 mg PO DAILY RX *losartan 50 mg 3 tablet(s) by mouth once a day Disp #*90 Tablet Refills:*0 4. Furosemide 40 mg PO DAILY 5. HydrALAzine 100 mg PO TID 6. Multivitamins 1 TAB PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Simvastatin 40 mg PO QPM 9. Warfarin 3 mg PO DAILY16 RX *warfarin 3 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 10. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN shortness of breath 11. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 12. Prescription Please provide patient with Cane Dx: Osteoarthritis ICD-9 175 ICD-10 M15.9 Prognosis: Good Length: 13 mo 13. Outpatient Lab Work I48.0 Paroxysmal atrial fibrillation Please draw INR on ___ Please fax results to ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Vasovagal syncope Acute on chronic diastolic heart failure Hypertensive emergency Complicated urinary tract infection Constipation Atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ woman with syncope, head strike, loss of consciousness, evaluate for fracture or bleed. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 14.0 s, 14.9 cm; CTDIvol = 47.1 mGy (Head) DLP = 702.4 mGy-cm. Total DLP (Head) = 702 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. Dural falx calcifications are noted. There is no evidence of fracture. There is ethmoid air cell and right maxillary sinus mucosal thickening. The right ostiomeatal unit is occluded due to mucosal thickening. The remaining imaged paranasal sinuses are clear. The visualized portion of the mastoid air cells and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. No acute intracranial process. No hemorrhage or other sequelae of trauma identified. 2. Age-appropriate global cerebral atrophy. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE INDICATION: ___ woman with syncope resulting in head strike, evaluate for fracture. TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue and bone algorithm images were generated. Coronal and sagittal reformations were then constructed. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.8 s, 18.6 cm; CTDIvol = 36.7 mGy (Body) DLP = 681.9 mGy-cm. Total DLP (Body) = 682 mGy-cm. COMPARISON: CTA head and neck ___. FINDINGS: There is no fracture or malalignment. There is no prevertebral fluid or soft tissue swelling. There is mild multilevel cervical spine degenerative change. There is no significant spinal canal or neural foraminal narrowing. There is no cervical lymphadenopathy. A heterogeneously enhancing thyroid gland with hypodense thyroid nodules measuring up to 5 mm is noted (series 3, image 46), similar in appearance to prior CTA neck from ___. A right carotid stent is noted. A 3 mm pulmonary nodules noted at the medial left lung apex (series 3, image 55). IMPRESSION: 1. No fracture or malalignment. 2. Mild multilevel cervical spine degenerative change. 3. Heterogeneous thyroid gland with hypodense nodules measure up to 5 mm, similar appearance to ___. 4. 3 mm left lung apex pulmonary nodule. Consider follow-up if indicated based on risk factors. RECOMMENDATION(S): The ___ pulmonary nodule recommendations are intended as guidelines for follow-up and management of newly incidentally detected pulmonary nodules smaller than 8 mm, in patients ___ years of age or older. Low risk patients have minimal or absent history of smoking or other known risk factors for primary lung neoplasm. High risk patients have a history of smoking or other known risk factors for primary lung neoplasm. In the case of nodule size <= 4 mm: No follow-up needed in low-risk patients. For high risk patients, recommend follow-up at 12 months and if no change, no further imaging needed. Radiology Report EXAMINATION: CTA HEAD WANDW/O C AND RECONS Q1213 CT HEAD INDICATION: ___ female wing with right parietal occipital headache associated with a syncopal event. Evaluate for intracranial hemorrhage. TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Next, rapid axial imaging was performed through the brain during the uneventful infusion of 70 mL of Omnipaque intravenous contrast material. Three-dimensional angiographic volume rendered and segmented images were then generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 5.4 s, 18.0 cm; CTDIvol = 53.0 mGy (Head) DLP = 954.0 mGy-cm. 2) Stationary Acquisition 11.4 s, 0.5 cm; CTDIvol = 173.3 mGy (Head) DLP = 86.7 mGy-cm. 3) Spiral Acquisition 6.6 s, 21.2 cm; CTDIvol = 30.7 mGy (Head) DLP = 651.9 mGy-cm. Total DLP (Head) = 1,693 mGy-cm. COMPARISON: ___ noncontrast head CT. ___ head and neck CTA. FINDINGS: CT head: The gray-white matter differentiation is intact without acute territorial infarct, hemorrhage, or mass effect. There is nonspecific periventricular deep white are hypodensity, likely reflecting sequela of chronic microangiopathy. The ventricles cortical sulci are normal caliber configuration. The extra-axial spaces are unremarkable. The orbits, soft tissues, and calvarium are unremarkable. There is marked mucosal thickening of the right maxillary sinus and partial opacification of the anterior right ethmoid sinus. The mastoid air cells and middle ears are clear. CTA head: There is a tortuous course of the right cervical segment internal carotid artery with partial visualization of atherosclerosis at the proximal external and internal carotid arteries. There is partially visualized atherosclerosis at the left carotid bifurcation bulb. The bilateral posterior communicating arteries are visualized. The anterior communicating artery is not definitively seen. There is a right fetal origin posterior cerebral artery. There is a right dominant vertebral artery. There is absent time of the left V3 and V4 segment vertebral artery with diminished filling of the V2 segment which is unchanged comparison ___, consistent with chronic occlusion. There is a 2 mm outpouching at the left vertebrobasilar junction, likely representing an aneurysm. There is a 3 mm posterior and inferiorly projecting aneurysm at the origin of the right posterior communicating artery (602bO:20). There is a 4 mm posterior and inferiorly projecting aneurysm at the left communicating segment internal carotid artery which may be at the origin of the posterior communicating artery (6:87; 602bO:29). There is a 2 mm superiorly projecting aneurysm at the left M1/M2 middle cerebral artery junction (6:96; 6 02:36). The anterior and posterior circulations are patent without occlusion, dissection, or significant stenosis. There is no evidence of vascular malformation. IMPRESSION: 1. No acute intracranial process without territorial infarct, hemorrhage, or mass effect. 2. Chronic occlusion of left V3 V4 segment vertebral artery which is unchanged comparison to ___. 3. Otherwise patent anterior and posterior circulations without new occlusion, dissection, or vascular malformation. 4. Unchanged 2 mm aneurysm at the left vertebral basilar junction. 5. Unchanged 3 mm aneurysm at the origin of the right posterior communicating artery. 6. Unchanged 4 mm aneurysm at the left communicating segment internal carotid artery, likely at the origin of the posterior communicating artery. 7. Unchanged 2 mm aneurysm the left M1/M2 middle cerebral artery junction. 8. Right maxillary and anterior ethmoid sinus disease, as described. Gender: F Race: HISPANIC/LATINO - GUATEMALAN Arrive by WALK IN Chief complaint: s/p Fall, Head injury Diagnosed with Syncope and collapse temperature: 99.4 heartrate: 59.0 resprate: 18.0 o2sat: 96.0 sbp: 145.0 dbp: 61.0 level of pain: 0 level of acuity: 1.0

Ms. ___ is a ___ woman with CAD s/p CABG, diastolic heart failure with 1+ AI and 1+ MR, poorly controlled hypertension, dyslipidemia, atrial fibrillation, atrial flutter/palpitations, peripheral vascular disease, borderline diabetes, renal artery stenosis, venous insufficiency, degenerative joint disease, TIA and morbid obesity who presents with episode of syncope at home. # Syncope: She syncopized while she was folding towels at home. The patient noted a HA prior to the event, and some CP following. She was noted to be hypertensive during the event as well. Her HTN and CP resolved with SLNTG. She had a NCHCT as well as a CTA of her head which were negative for ICH/ SAH. She was monitored on telemetry and had no evidence of VT or rapid ventricular response with hypotension to explain her event. She underwent TTE which showed no AS or other valvular abnormalities which would explain her syncope. She did have evidence of PAH and RV dysfunction, as well as ___ c/w her known AF. With no identifiable cause identified, this likely represents vasovagal syncope. If she has a recurrence of syncope, it would be reasonable to consider holter monitoring given her extensive cardiac history. # Hypertensive emergency: Pt was noted to be hypertensive with her initial headache preceding the event, which improved with x1 dose of SLNTG. She was managed on her home hydralazine and losartan while in house. She intermittently required IV hydralazine for SBP in the 190's, though she was asymptomatic and at rest during these periods. She should likely have uptitration of her antihypertensive regimen on an outpatient basis. # Acute on chronic diastolic heart failure (1+AI, 1+MR): Ms ___ was noted to be volume overloaded on exam with bibasilar crackles upon admission. She received PO and IV furosemide during her stay, which improved her exam until she was euvolemic. She was then transitioned back to her home 40mg PO Lasix daily and this should be followed and titrated over time. Her weight on discharge was 71.7 kg. # Complicated UTI: UA positive on admission with minimal CVAT on exam. She was treated with 5d of IV ceftriaxone. # Chronic constipation: the patient has known constipation and was complaining of upper abd pain c/w her prior constipation. She was given lactulose which helped her have multiple BM's, which improved her pain. She was continued on her home bowel regimen upon discharge. # Atrial fibrillation (status post surgical PVI with resection ___ in ___. c/b TIA: The patient's coumadin was adjusted for ease of home dosing to 3mg QD. Additionally, her carvedilol was held while in house given her persistent bradycardia to the 50's at rest. She was able to augment her HR with exercise. Thus her carvedilol was held upon discharge pending follow-up with her PCP and cardiology. CHRONIC ISSUES # Coronary artery disease (status post four-vessel CABG, LIMA to LAD, SVG to D1, SVG to OM1, SVG to ramus, NSTEMI ___: home aspirin, losartan, simvastatin were continued. The patient's home carvedilol was held given her bradycardia. # Dyslipidemia: Continued simvastatin 40 mg qd Transitional issues #Incidentally, on CT C-spine a 3 mm left lung apex pulmonary nodule was identified, she will need repeat chest imaging in the future and follow-up of this nodule if indicated based on risk factors and smoking history #She finished a course of ceftriaxone for complicated UTI while in house #Pt will have neurology f/u for multiple aneurysms seen on CTA which was never followed up previously #Pt will be set up with cardiology and pulmonology follow-up for markedly elevated PASP, ___ and changes seen on TTE #If the patient has recurrent syncope, consider Holter monitor in the future #Standing weight on discharge: 71.7 kg #Sent out on this Lasix dose: 40mg PO QD #Pt should have electrolytes checked at next PCP ___ #Patient's home carvedilol was held during this admission given her bradycardia during her stay #The patient's warfarin was changed to 3mg daily to ease administration #patient should have her INR checked on ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: ___ Attending: ___. Chief Complaint: Red eye Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old woman with ESRD on dialysis presents with red and painful right eye. Ocular symptoms started at 3AM on ___ while she was sleeping. Denies trauma or foreign body sensation. She had right eye pain with motion that has since improved. Vision is worse with reading. No photophobia. Denies crusting/exudate. No associated headache, fever or chills. Does not wear contacts. No history of red/painful eye in the past. No sick contacts. She had one episode of vomiting in the ED that she reported to be brown, but ED staff reported as coffee grounds, no gastroccult testing avaiable. Mild residual nausea. No abdominal pain or recent bloody stools. No recent vomitting, but she has a history of hospitalization at ___ ___ for GERD/PUD. In the ED, initial VS were: Exam notable for irregular shaped R pupil, pain w/ eye movement, no perilimbic spraring, ocular pressure 12 OD, visual acuity ___ OD/OS, no corneal abrasions, no cell or flare. Labs notable for AST 49, AP 184, HCT 52, Cr 5.5, K 6.4 (hemolyzed), glucose 406. She had an episode of hematemesis while in the ED. GI was consulted. She received PPI 40mg IV. Rectal exam guaiac negative. VS prior to transfer were: On arrival to the floor, she is comfortable with mild right eye pain and some nausea. REVIEW OF SYSTEMS: Denies nasal congestion, sore throat, cough, chest pain, dysuria, hematuria. Past Medical History: - ESRD on dialysis - on HD ___ - diabetes mellitus - proliferative retinopathy - GERD - PUD ___ - meningioma, s/p resection ___ with resultant seizures - Whipple ___ for pancreatic lesion Social History: ___ Family History: Mother HTN/CVA Sister HTN/CVA Daughter DM2 Father stomach CA Physical Exam: ADMISSION EXAM: VITALS: 98.4 126/84 84 16 93%RA GENERAL: NAD, pleasant HEENT: PERRL, EOMI without pain, right eye with conjuctival erythema, no exudate, MMM NECK: no carotid bruits, no LAD, no JVD LUNGS: CTAB, no W/R/R HEART: RRR, normal S1 S2, no MRG ABDOMEN: Soft, NT, NABS, no organomegaly EXTREMITIES: No c/c/e NEUROLOGIC: A+OX3 DISCHARGE EXAM: VITALS: 97.4/98.2; 94-104/46-56; 57-64; 16; 100RA HEENT: PERRL, EOMI without pain, b/l eyes with conjuctival erythema R>L, no exudate Exam otherwise unchanged since admission Pertinent Results: ADMISSION LABS: ___ 10:30PM BLOOD WBC-8.9 RBC-5.80*# Hgb-16.2*# Hct-52.1*# MCV-90 MCH-27.9 MCHC-31.0 RDW-16.1* Plt ___ ___ 10:30PM BLOOD Glucose-406* UreaN-29* Creat-5.5* Na-136 K-6.4* Cl-91* HCO3-23 AnGap-28* ___ 10:30PM BLOOD ALT-22 AST-49* AlkPhos-184* TotBili-0.4 ___ 07:15PM BLOOD CK(CPK)-34 ___ 07:50AM BLOOD Calcium-9.5 Phos-5.3* Mg-2.5 ___ 10:30PM BLOOD Albumin-4.4 ___ 05:45AM BLOOD ASA-NEG Acetmnp-NEG ___ 08:34PM BLOOD Lactate-1.3 ___ 05:45AM BLOOD Osmolal-308 CARDIAC ENZYMES: ___ 10:45AM BLOOD CK-MB-2 cTropnT-0.03* ___ 07:15PM BLOOD CK-MB-2 cTropnT-0.03* DISCHARGE LABS: ___ 05:45AM BLOOD WBC-9.1 RBC-5.36 Hgb-15.2 Hct-48.6* MCV-91 MCH-28.3 MCHC-31.2 RDW-15.9* Plt ___ ___ 05:45AM BLOOD ___ PTT-32.8 ___ ___ 05:45AM BLOOD Glucose-302* UreaN-52* Creat-8.1* Na-132* K-5.3* Cl-90* HCO3-18* AnGap-29* ___ 05:45AM BLOOD Calcium-9.3 Phos-5.5* Mg-2.6 MICROBIOLOGY: H. pylori: negative IMAGING: REASON FOR EXAMINATION: Eye abnormality and suspected hilar lymphadenopathy due to sarcoidosis. The heart size is normal. Within the limitations of this portable radiograph, no evidence of mediastinal lymphadenopathy is present. The lungs are well inflated. Left basal opacity is noted, potentially representing atelectasis, but infectious process cannot be excluded. Line projecting over the left hemithorax most likely represents VP shunt, please correlate clinically. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Calcium Acetate 667 mg PO TID W/MEALS 2. esomeprazole magnesium *NF* 40 mg Oral BID 3. Glargine 12 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 4. LeVETiracetam 1000 mg PO BID 5. Simvastatin 40 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. sevelamer CARBONATE 800 mg PO TID W/MEALS 8. Metoclopramide 5 mg PO TID 9. Cinacalcet 90 mg PO DAILY 10. Vitamin D 1000 UNIT PO DAILY 11. Nephrocaps 1 CAP PO DAILY 12. Lactulose 30 mL PO BID:PRN constipation 13. Metoprolol Succinate XL 12.5 mg PO DAILY 14. Diltiazem Extended-Release 180 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Calcium Acetate 667 mg PO TID W/MEALS 3. Cinacalcet 90 mg PO DAILY 4. Glargine 12 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 5. LeVETiracetam 1000 mg PO BID 6. Metoclopramide 5 mg PO TID 7. Nephrocaps 1 CAP PO DAILY 8. sevelamer CARBONATE 800 mg PO TID W/MEALS 9. Simvastatin 40 mg PO DAILY 10. Vitamin D 1000 UNIT PO DAILY 11. Diltiazem Extended-Release 180 mg PO DAILY 12. Esomeprazole Magnesium *NF* 40 mg ORAL BID 13. Lactulose 30 mL PO BID:PRN constipation 14. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID last day ___ RX *erythromycin 5 mg/gram (0.5 %) 0.5 (One half) inch(s) eye four times a day Disp #*1 Tube Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY: Conjunctivitis Atrial fibrillation with rapid ventricular rate Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report REASON FOR EXAMINATION: Eye abnormality and suspected hilar lymphadenopathy due to sarcoidosis. AP radiograph of the chest was reviewed with no prior studies available for comparison. The heart size is normal. Within the limitations of this portable radiograph, no evidence of mediastinal lymphadenopathy is present. The lungs are well inflated. Left basal opacity is noted, potentially representing atelectasis, but infectious process cannot be excluded. Line projecting over the left hemithorax most likely represents VP shunt, please correlate clinically. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: RIGHT EYE REDNESS/PAIN Diagnosed with PAIN IN OR AROUND EYE, REDNESS/DISCHARGE OF EYE, HEMATEMESIS, DIAB RENAL MANIF IDDM, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE, END STAGE RENAL DISEASE, LONG-TERM (CURRENT) USE OF INSULIN temperature: 97.2 heartrate: 78.0 resprate: 18.0 o2sat: 96.0 sbp: 117.0 dbp: 53.0 level of pain: 4 level of acuity: 3.0

___ year old woman with ESRD on dialysis presents with red and painful right eye. # Conjunctivitis: Patient initially presented with red and painful red eye, no discharge, no blurry vision, but does endorse more pain with movement of the eye. DDx included conjunctivitis or iritis. No evidence of acute angle glaucoma given lack of headache and normal ocular pressures in the ED. No corneal abraisons were seen on slit lamp exam. Patient started on erythromycin gel for treatment of conjunctivitis. Ophthalmology saw the patient and agreed with treatment as there was low concern for uveitis. During the hospital course, redness also spread to the left eye, so erythromycin gel applied bilaterally. Given improvement with topical antibiotics, steroids were not considered. Plan total 7 day course (last day ___. Asked patient to follow up with her outpatient ophthalmologist if symptoms do not resolve in ___ days. # Paroxysmal afib: Patient with paroxysmal afib on dilt and metoprolol for rate control/rhythm maintenance. EKG with NSR in ___ on presentation to ED. However, on admission to the floor, patient with afib with rates in 130-140s. This was likely due to missing medication (patient does not take AM meds on HD days, then did not have meds in the ED and arrived on the floor in the early AM with RVR). Patient afebrile with no evidence of infection. ___ with cardiac enzymes negative x2 (has stably elevated troponin at 0.02 with CKD, but normal CKMB). Rapid ventricular rate controlled with IV metop 7.5mg, followed by home meds (dilt XR 180mg daily and metop XL 12.5mg daily.) Patient spontaneously converted to NSR with rates in high ___, so metop was discontinued. CHADS=2. Not on anticoagulation. Per patient, she has been diagnosed with afib on multiple prior ED visits, but her PCP is not aware. Plan to continue dilt XR 180mg daily, but not to initiate anticoagulation till PCP follow up. # Vomiting with possible UGIB: Reported coffee ground emesis in the ED, although patient states vomit looked brown. Her HCT is 52 and stool guaiac negative. She has a history of GERD and PUD and is at risk for recurrence although she is taking a PPI at home. Differential also includes ___ tear. BID hct stable high ___. No additional episodes of vomiting since admission to the floor. Patient continued on PPI and plan to follow up with outpatient gastroenterologist for resolution of PUD. # ESRD on HD: Last HD on ___ prior to presentation to ED. Electrolytes stable (K 5.3 at discharge, day prior to next HD session). No urgent indications for HD during this hospitalization ___ to ___. Plan to resume regular outpt HD MWF on discharge. # DM2: Continued home lantus and SSI. # GERD: Continued PPI and reglan. # HLD: Continued simvastatin. # H/o seizures: Continued keppra. # Transitional issues: - code status: full - pending labs: none - medication changes: stopped metoprolol - follow up: with PCP, follow up issues include paroxysmal afib - follow up: with hemodialysis and nephrology - follow up: ophthalmology

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: lisinopril Attending: ___. Chief Complaint: lower extremity edema Major Surgical or Invasive Procedure: None History of Present Illness: This is an ___ with CKD, HTN, RV failure and severe PAH from suspected connective tissue disease/limited SSc, diagnosed by RHC ___ (mPAP 48, PVR 12.5), with CI 1.6 and RAP 23. She is being referred by Dr. ___ volume overload, diuresis. She has been gaining fluid weight over the past several weeks. Despite taking total 60mg torsemide daily patient has been retaining fluid. She has had low energy, been incontinent of urine, and has not been doing well at home. Dr. ___ ___ patient with daughter ___, recommended inpatient management of volume overload given patient has been refusing higher doses of diuretics at home secondary to intermittent incontinence and would require frequent laboratory draws. ___ has brought her macitentan with her. Most recently seen in ___ clinic ___ where she weighed 157 lbs, noted to have difficulty walking room to room but not overly limiting, severe difficulty with stairs. She was using oxygen more frequently, often 24 hours/day. Her O2 sat in clinic was 91% 2L. Usually she uses it with sleep and activity. It was recommended that she f/u with ___ rheumatology as it is easier for her to get to. Recent hospitalization in ___ notable for severe volume overload/ p-HTN, HFpEF exacerbation. She was started on sildenafil and macitentan for pHTN. Was very volume overloaded on admission and treated with lasix drip and metolazone for several days. She had difficult access requiring a CVL, hand arthritis that was responsive to steroids, and an E.coli UTI. In the ED intial vitals were: 97.3 70 115/56 20 96% on 2L. Labs with trop 0.09, CXR w/ pulmonary edema, lactate 2.6. A R-EJ was placed. Patient was given: percocet for leg pain. Vitals on transfer: 97.5 74 121/60 17 99% RA On the floor patient complaining of severe back pain from base of neck to mid back. States pain began 2 weeks ago when she was sitting down into chair and sat down faster than intended hitting chair hard. She did not hear any cracks, pops. She has not noted any lower extremity weakness, paresthesias. She has had difficulty walking and attributes this to her legs feeling heavy, not weak. She has had urinary incontinence since increasing torsemide, stands up to go to the bathroom and urine comes out beyond her control. No incontinence of stool. Has been taking percocet with good effect. She has not had chest pain, palpitations. She denies shortness of breath, cough, wheezing. She wears O2 at all times at home, on 2L NC. She sleeps flat in bed on 1 pillow, no orthopnea or PND. ROS: On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. Past Medical History: - PAH, suspected secondary to CTD/limited SSc. Diagnosed by RHC ___ (mPAP 48, PVR 12.5), with reduced CI and RAP 23 at diagnosis. Required hospitalization for diuresis and sildenafil initiation just afterwards - Positive ___, high titer with anti centromere positivity, and ?Raynaud's (cold fingers, very difficult to pick up oximetry x years), with PAH concerning for limited scleroderma - Hypertension - Chronic renal insufficiency, unclear cause. - Hyperlipidemia - Osteoarthritis. Involving back, knees. History of spinal stenosis and s/p laminectomy in the past. - Obesity - Gout Social History: ___ Family History: Mother died of heart disease, Son and brother with CAD. No family hx of pulmonary hypertension or VTE Physical Exam: =========================== PHYSICAL EXAM ON ADMISSION: =========================== VS: T=97.6 129/71 103 18 92% on 2L GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. Poor dentition. NECK: Supple with JVP of 12-13cm. CARDIAC: PMI located in ___ intercostal space, midclavicular line. tachycardic, S1, S2 with systolic murmur best appreciated at LUSB. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Crackles at bilateral bases, no wheezes or rhonchi ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. +BS EXTREMITIES: 4+ pitting edema in bilateral lower extremities to knees. Bilateral well healed knee scars. Right foot with plantar surface 1cm ulceration without erythema, purulent drainage. Thoracic spine with tenderness to palpation, no ecchymosis or swelling. SKIN: No stasis dermatitis or xanthomas. Scars on bilateral knees as above; R plantar surface ulceration as above. NEURO: axox3, cnII-XII grossly intact, bilateral lower extremity strenth and sensation to light touch intact, no saddle anesthesia, rectal tone intact ============================ PHYSICAL EXAM ON DISCHARGE: ============================ Vital Signs: 97.8/98.6 94/53 (___) 59 (50-60) 20 95% on RA Wt:62.1kg (136lbs) <- 63.6kg (140.2lbs) <-65.7 (144.8lbs)<-66.5kg <- <-70.2kg <-71.9 kg Telemetry: NSR, no significant alarms HR ___ General: older woman lying in bed, comfortable appearing, speaking in full sentences, breathing comfortably on RA, no acute distress HEENT: PERRL, MMM, oropharynx without erythema or exudate, poor dentition Lungs: CTAB no wheezes or rhonchi CV: regular rate and rhythm, II/VI holosystolic murmur best appreciated at LLSB, JVP at 9-10cm Abdomen: obese, soft, non distended, non tender to deep palpation, normoactive bowel sounds Ext: no tenderness to palpation of thoracic spine, no paraspinal muscle tenderness. Improved bilateral lower extremity swelling, trace edema bilaterally; Left third digit with improved PIP and MCP erythema, warmth, swelling; tenderness to palpation of bilateral lower extremities Pertinent Results: =============== ADMISSION LABS: =============== ___ 03:20PM WBC-9.6 RBC-4.07* HGB-13.2 HCT-40.3 MCV-99* MCH-32.4* MCHC-32.7 RDW-17.4* ___ 03:20PM GLUCOSE-135* UREA N-37* CREAT-2.1* SODIUM-139 POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-27 ANION GAP-17 ___ 03:20PM PHOSPHATE-3.1 MAGNESIUM-2.0 ___ 03:20PM cTropnT-0.09* ___ ___ 03:53PM LACTATE-2.6* ___ 03:20PM BLOOD cTropnT-0.09* ___ =============== PERTINENT LABS: =============== ___ 03:20PM BLOOD cTropnT-0.09* ___ ___ 12:50AM BLOOD CK-MB-4 cTropnT-0.07* ___ 10:31PM BLOOD UricAcd-11.8* SCL-70 ANTIBODY <1.0 NEG <1.0 NEG AI RNA POLYMERASE III AB <20 <20 Units ================== LABS ON DISCHARGE: ================== ___ 05:15AM BLOOD Glucose-80 UreaN-66* Creat-2.0* Na-139 K-4.6 Cl-95* HCO3-30 AnGap-19 ___ 05:15AM BLOOD Calcium-10.1 Phos-4.0 Mg-2.4 EKG: Sinus rhythm. Compared to the previous tracing the heart rate is reduced. Otherwise, multiple abnormalities as previously described persist without major change. Intervals Axes Rate PR QRS QT/QTc P QRS T 95 186 82 ___ -11 ============= MICROBIOLOGY: ============= URINE CULTURE (Final ___: Culture workup discontinued. Further incubation showed contamination with mixed skin/genital flora. Clinical significance of isolate(s) uncertain. Interpret with caution. ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- =>64 R CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R ========= STUDIES: ========= CXR ___: FINDINGS: The heart is mildly enlarged with a left ventricular configuration. The cardiac, mediastinal and hilar contours appear stable. There is no pleural effusion or pneumothorax. Diffuse opacification is most suggestive of moderate pulmonary edema. IMPRESSION: Findings consistent with pulmonary edema T Spine xray ___: FINDINGS: The thoracic spine is unable to be adequately evaluated on this radiograph, due to severe osteopenia and overlapping lung parenchymal pathology. IMPRESSION: Thoracic spine is not adequately evaluated on this radiograph due to severe osteopenia and overlapping lung parenchymal pathology. A CT of the thoracic spine is therefore recommended for further evaluation. TTE ___: The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of the basal inferoseptal segment. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular cavity is dilated with depressed free wall contractility. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. Trivial mitral regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Dilated, hypokinetic right ventricle with abnormal septal motion and severe pulmonary artery systolic hypertension consistent with primary pulmonary process (e.g. pulmonary embolus, COPD, etc.) Mildly depressed left ventricular systolic function with regional wall motion abnormalities, as described above. Increased left ventricular filling pressure. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PredniSONE 5 mg PO DAILY 2. Metoprolol Tartrate 50 mg PO BID 3. Potassium Chloride 10 mEq PO DAILY 4. Docusate Sodium 100 mg PO TID 5. Sildenafil 20 mg PO TID 6. Atorvastatin 10 mg PO HS 7. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral QD 8. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain 9. Torsemide 20 mg PO BID 10. Opsumit (macitentan) 10 mg oral QD 11. Senna 8.6 mg PO BID:PRN constipation 12. Ipratropium-Albuterol Neb 1 NEB NEB Q4H wheeze, dyspnea Discharge Medications: 1. Atorvastatin 10 mg PO HS 2. Docusate Sodium 100 mg PO TID 3. Ipratropium-Albuterol Neb 1 NEB NEB Q4H wheeze, dyspnea 4. Opsumit (macitentan) 10 mg oral QD 5. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain 6. PredniSONE 5 mg PO DAILY 7. Senna 8.6 mg PO BID:PRN constipation 8. Sildenafil 20 mg PO TID 9. Torsemide 20 mg PO BID 10. Bisacodyl ___AILY:PRN constipation 11. Colchicine 0.3 mg PO DAILY 12. Lactulose 30 mL PO BID:PRN constipation 13. Metoprolol Succinate XL 50 mg PO DAILY 14. Polyethylene Glycol 17 g PO DAILY 15. Potassium Chloride 10 mEq PO DAILY 16. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral QD Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis: Acute on Chronic Diastolic Heart Failure Exacerbation Secondary Diagnosis: Pulmonary Artery Hypertension Acute Gout Flare 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 INDICATION: Increased edema. TECHNIQUE: Chest, AP and lateral. COMPARISON: ___. FINDINGS: The heart is mildly enlarged with a left ventricular configuration. The cardiac, mediastinal and hilar contours appear stable. There is no pleural effusion or pneumothorax. Diffuse opacification is most suggestive of moderate pulmonary edema. IMPRESSION: Findings consistent with pulmonary edema. Radiology Report EXAMINATION: T-SPINE INDICATION: ___ year old woman s/p fall into chair complaining of severe back pain in thoracic spine. +urinary incontinence. No lower extremity weakness or paresthesias. TECHNIQUE: Thoracic spine, two views. COMPARISON: PA lateral chest x-ray from ___ and ___. FINDINGS: The thoracic spine is unable to be adequately evaluated on this radiograph, due to severe osteopenia and overlapping lung parenchymal pathology. IMPRESSION: Thoracic spine is not adequately evaluated on this radiograph due to severe osteopenia and overlapping lung parenchymal pathology. A CT of the thoracic spine is therefore recommended for further evaluation. Radiology Report EXAMINATION: UNILAT LOWER EXT VEINS INDICATION: ___ year old woman with RV failure, bilateral lower extremity L>R with tenderness to palpation // LLE DVT? TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the left lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, flow and augmentation of the left common femoral, femoral, and popliteal veins. Normal color flow is demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: No evidence of deep venous thrombosis in the left lower extremity veins. Radiology Report INDICATION: ___ female with new PICC. COMPARISON: Chest radiograph dated ___. FINDINGS: Single portable AP chest radiograph demonstrates interval placement of a right PICC which appears to terminate at the junction of the right subclavian and superior vena cava. For placement within the mid superior vena cava, recommend advancement 3cm. Heart size is stably enlarged. Descending aorta appears tortuous. There is no large pleural effusion or pneumothorax. No focal opacity convincing for pneumonia is identified. IMPRESSION: Right PICC terminating at the junction of the right subclavian and superior vena cava. For more appropriate position, recommend advancement 3 cm. Heart size stably enlarged. NOTIFICATION: These findings were communicated to the IV nurse ___ ___ by Dr. ___ telephone at 16:21 on ___ at the time study was reviewed. Radiology Report INDICATION: Right PICC line. TECHNIQUE: Single portable frontal radiograph of the chest. COMPARISON: Chest radiograph from ___ FINDINGS: A right upper extremity PICC line terminates in the proximal right atrium. No focal consolidation is identified. The heart size is mildly enlarged. There is no pleural effusion or pneumothorax. IMPRESSION: Right upper extremity PICC line terminates in the proximal right atrium. If positioning at the cavoatrial junction is desired, the PICC line may be pulled back by 2 cm. NOTIFICATION: Findings were paged to IV team by ___ at 12:15pm on ___. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old woman with right heart failure PAH s/p PICC placement // PICC in place? Contact name: ___: ___ TECHNIQUE: Portable AP radiograph of the chest from ___. COMPARISON: ___. FINDINGS: The right-sided PICC line has been withdrawn, and now terminates in the lower SVC. There is no pneumothorax. There is no focal consolidation or pleural effusion. Mild cardiomegaly is unchanged. The mediastinal contours are stable. IMPRESSION: Right PICC line has been repositioned and now terminates in the low SVC. Otherwise no significant interval change from the study of 2 days prior. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Hand swelling, Leg swelling Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC temperature: 97.3 heartrate: 70.0 resprate: 20.0 o2sat: 96.0 sbp: 115.0 dbp: 56.0 level of pain: 10 level of acuity: 3.0

___ year old woman with RV failure and severe PAH from suspected connective tissue disease/limited SSc, diagnosed by RHC ___ (mPAP 48, PVR 12.5), with CI 1.6 and RAP 23, CKD, HTN, presenting with worsening lower extremity swelling, increased O2 requirement, found to have significant volume overload on exam, elevated BNP, CXR with pulmonary edema consistent with acute heart right failure exacerbation. Course complicated by apparent gout flare. Patient diuresed well with lasix gtt at 15mg/hr->20mg/hr, transitioned to PO toresmide on discharge at dry weight 136lbs. =====================

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: cephalosporins Attending: ___. Chief Complaint: Cellulitis Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo male with pMHx significant for peripheral neuropathy, hemochromatosis, HTN, HLD presenting with L foot pain, erythema and edema x4 days. Patient has a history of a L distal fibula fracture since ___. He has been ambulatory, walking 10 miles per day 4 days ago. However, for the past few days he has noted the pain, erythema and edema and has not been able to ambulate on the leg. He presented to an urgent care yesterday and was given Augmentin 500mg PO BID (took three doses) and represented to urgent care today and was referred to ___ for IV antibiotics. He states that he believes from yesterday into today the redness spread but the pain improved. In the ED initial vitals were: 97.8 58 168/86 16 100% RA Labs were all unnotable and xray was significant only for soft tissue swelling. He was given IV Vanc and Zosyn as well as 1L LR. On the floor, all vitals were stable and he had minimal LLE pain. Past Medical History: Non-diabetic peripheral neuropathy Hemochromatosis Prostate cancer s/p surgery Hyperlipidemia Hypertension Gout Depression Asthma Social History: ___ Family History: Father with MI and likely hemochromatosis Physical Exam: PHYSICAL EXAM ON ADMISSION: Vitals: 97.8 58 168/86 16 100% RA GENERAL: NAD HEENT: AT/NC CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose LLE- erythema outlined and includes most of foot but does not extend much beyond the ankle, edema, large 2cm popped blister with skin still covering and exudate noted PHYSICAL EXAM ON DISCHARGE: Vitals: T 97.9 HR 52 BP 142/75 RR 18 General: Alert, oriented, no acute distress HEENT: Sclera anicteric, moist mucous membranes, oropharynx clear Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, significant hammer toes bilaterally with onchyomycosis and several calluses, Over the lateral aspect of the left foot there is a callus and ulcer from a lysed blister. There is erythema and warmth over the dorsum of the foot which is decreased from line drawn around erythema in ED. Decreased sensation from ankles to toes bilaterally. Wound was explored and is very superficial Pertinent Results: LABS ON ADMISSION: ___ 09:58PM BLOOD WBC-8.3 RBC-4.17* Hgb-13.8* Hct-39.7* MCV-95 MCH-33.1* MCHC-34.7 RDW-13.5 Plt ___ ___ 09:58PM BLOOD Neuts-63.5 ___ Monos-6.4 Eos-3.3 Baso-0.3 ___ 09:58PM BLOOD ___ PTT-28.8 ___ ___ 09:58PM BLOOD Glucose-99 UreaN-13 Creat-0.7 Na-138 K-4.5 Cl-102 HCO3-27 AnGap-14 ___ 09:58PM BLOOD Calcium-9.5 Phos-3.6 Mg-2.1 ___ 09:30PM BLOOD Lactate-1.9 . LABS ON DISCHARGE ___ 07:45AM BLOOD WBC-5.9 RBC-3.93* Hgb-13.1* Hct-37.8* MCV-96 MCH-33.4* MCHC-34.8 RDW-13.5 Plt ___ ___ 07:45AM BLOOD Neuts-62.7 ___ Monos-6.2 Eos-5.1* Baso-0.4 ___ 07:45AM BLOOD ___ PTT-29.1 ___ ___ 07:45AM BLOOD Glucose-88 UreaN-12 Creat-0.7 Na-143 K-4.0 Cl-105 HCO3-26 AnGap-16 ___ 07:45AM BLOOD Calcium-9.3 Phos-4.4 Mg-2.1 ___ 07:45AM BLOOD VitB12-442 ___ 07:45AM BLOOD CRP-34.8* ___ 08:37AM BLOOD %HbA1c-PND ___ 07:45AM BLOOD SED RATE-PND . IMAGING: TIB/FIB (AP & LAT) LEFT Xray: AP and lateral views of the left tibia and fibula were provided. There is a deformity of the left distal fibula with subtle fracture lucency and callus formation noted indicative of a healing fracture. Mild overlying soft tissue swelling is noted. Ankle mortise appears grossly symmetric. Mild spurring is seen at the distal tibia on the lateral projection. . No soft tissue gas or radiopaque foreign body. Minimal vascular calcification noted. Limited views of the left knee are unremarkable. IMPRESSION: Healing fracture of the left distal fibula. Mild overlying soft tissue swelling. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 40 mg PO DAILY 2. Simvastatin 20 mg PO DAILY 3. Allopurinol ___ mg PO DAILY 4. Citalopram 20 mg PO DAILY 5. Sildenafil 100 mg PO DAILY:PRN sexual encounter 6. Aspirin 81 mg PO DAILY 7. Fish Oil (Omega 3) 1000 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Advil ___ (ibuprofen-diphenhydramine cit) 200-38 mg oral prn insomnia Discharge Medications: 1. Allopurinol ___ mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Citalopram 20 mg PO DAILY 4. Fish Oil (Omega 3) 1000 mg PO DAILY 5. Lisinopril 40 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Simvastatin 20 mg PO DAILY 8. Acetaminophen 650 mg PO Q6H:PRN pain 9. Advil ___ (ibuprofen-diphenhydramine cit) 200-38 mg oral prn insomnia 10. Sildenafil 100 mg PO DAILY:PRN sexual encounter 11. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 7 Days RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 12. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days Discharge Disposition: Home Discharge Diagnosis: Cellulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with cellulitis nonhealing fx // eval non-healing fibula fx COMPARISON: None. FINDINGS: AP and lateral views of the left tibia and fibula were provided. There is a deformity of the left distal fibula with subtle fracture lucency and callus formation noted indicative of a healing fracture. Mild overlying soft tissue swelling is noted. Ankle mortise appears grossly symmetric. Mild spurring is seen at the distal tibia on the lateral projection. . No soft tissue gas or radiopaque foreign body. Minimal vascular calcification noted. Limited views of the left knee are unremarkable. IMPRESSION: Healing fracture of the left distal fibula. Mild overlying soft tissue swelling. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: L Foot pain, Cellulitis Diagnosed with CELLULITIS OF FOOT, HYPERTENSION NOS temperature: 97.8 heartrate: 58.0 resprate: 16.0 o2sat: 100.0 sbp: 168.0 dbp: 86.0 level of pain: 3 level of acuity: 3.0

___ year old male with history of peripheral neuropathy, hemochromatosis, HTN, HLD and healing L fibula fracture presented with cellulitis. . #Cellulitis - the patient had a callous on the lateral side of his right foot and then developed erythema, edema, and warmth over the area consistent with cellulitis 4 days prior to admission. He has a lesion from a blister which was probed and is superficial. His Xray showed a healing left fibula fracture and only soft tissue swelling with no evidence of osteomyelitis. He was initially given vancomycin and zosyn in the ED. On day 2 of admission, the cellulitis was diminished. He had minimal pain. Osteomyelitis is unlikely given the superficial nature of the lesion, rapid improvement, and lack of pain over the bone. The patient was discharged on Bactrim DS BID for 7 days in addition to the augmentin prescription he was prescribed at urgent care. He was told to follow up with his PCP and podiatry next week. He should have ongoing care with podiatry given his neuropathy and structural problems with his feet. . # Hypertension - continued home dose lisinopril . # Hyperlipidemia - continued home dose simvastatin . # Depression - continued home dose citalopram . # Gout - continued home dose allopurinol

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Aspirin Attending: ___ Chief Complaint: tachycardia, cough Major Surgical or Invasive Procedure: None this hospitalization History of Present Illness: ___ yo male with h/o schizophrenia, ___ disease, hx of abdominal lymphoma, HTN, HLD, t2DM p/w Afib RVR. . Pt was recently admitted from ___ with SBO, discharged with ___. He was initially doing well but starting on ___, ___ noted that HR was increasing to 110-130s. He was seen in clinic on ___ for his tachycardia. Per documentation, pt was in sinus rhythm with rate of 129, though EKG not currently uploaded so unable to confirm. Given that he was HD stable and asymptomatic, pt was discharged with instructions to continue his metoprolol at previous dose of 200 mg. He returned to his PCP's office today for ongoing monitoring, was noted still to be tachycardic, EKG consistent with afib with RVR so he was referred to the ED. He continues to deny any symptoms, no sensation of palpitations, chest pain, shortness of breath, lightheadedness or dizziness. He does report that he has had a new cough, productive of green sputum over the past 2 days, no fevers or chills, no hemoptysis. He denies any constipation, diarrhea, abdominal pain. He does have chronic headaches. He states he is compliant with his medications and he has a nurse that gives him his meds BID. . In the ED initial VS were 98.3 128 139/98 16 98% HR ranged from 125-130 in ED, received metoprolol IV 5 mg x 3 with brief improvement in his heart rate to ___. CTA chest done for concern for PE given d-dimer 1162, no PE but did show multifocal PNA. Pt received azithro and ceftriaxone and admitted for management of PNA and afib. . On the floor, pt has no complaints. He states he is feeling fine, but overall poor historian. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies sinus tenderness, rhinorrhea or congestion. Denied shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: -H/O LYMPHOMA: large cell probably T cell in jejunum s/p 6 mo ?chemo rx, CT abd WNLs in ___ -SMALL BOWEL OBSTRUCTION: thought to be secondary to lymphoma -BACK PAIN: s/p 3 back operations last being in ___ -PSYCHOSIS: refuses to acknowledge, brief psych hospitalization for manic episode ___ -HYPERTENSION -GASTROESOPHAGEAL REFLUX -HEADACHES -URINARY FREQUENCY -CATARACTS s/p surgical resection -Fatty liver disease first noted in ___ with mild transaminitis -Type 2 DIABETES MELLITUS -EXERTIONAL DYSPNEA -ACTINIC KERATOSIS -Likely drug induced PARKINSONISM -MYOCARDIAL INFARCTION: documented in ___ at ___ with presenting symptoms of N/V with EKG significant for an NSTEMI and positive cardiac enzymes, subsequent ECHO WNLs, EF=60% Social History: ___ Family History: No cardiovascular disease other than HTN. Physical Exam: ADMISSION EXAM: . Vitals: T: 98.5 BP: 136/101 P: 77 R: 18 O2: 98% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, poor dentition Neck: supple, JVP not elevated, no LAD Lungs: crackles at right mid lung field, left lung ronchorous with decreased breath sounds at base, no wheezes, rales CV: irregularly irregular, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . DISCHARGE EXAM: . VITALS: 98.3 97.9 140/92 66-116 (104) 20 96% RA I/Os: 910 | 740 FSG: 121 GENERAL: Appears in no acute distress. Alert and interactive. Well nourished appearing. HEENT: Normocephalic, atraumatic. EOMI. PERRL. Mucous membranes dry without plaques or exudate. NECK: supple. ___: Irregularly irregular rate and rhythm, without murmurs, rubs or gallops. S1 and S2 normal. RESP: Decreased breath sounds at bases bilaterally with faint inspiratory dry crackles at bases. No wheezing, rhonchi. ABD: well-healed midline scar. Soft, non-tender, non-distended, with normoactive bowel sounds. EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses NEURO: Evidence of cognitive impairment. Alert and oriented x 3. Pertinent Results: ADMISSION LABS: . ___ 12:33PM BLOOD WBC-7.1 RBC-4.36* Hgb-12.0* Hct-35.8* MCV-82 MCH-27.6 MCHC-33.6 RDW-14.6 Plt ___ ___ 12:33PM BLOOD Neuts-76.1* Lymphs-15.1* Monos-5.9 Eos-2.6 Baso-0.4 ___ 12:33PM BLOOD ___ PTT-31.2 ___ ___ 12:33PM BLOOD Glucose-174* UreaN-17 Creat-0.9 Na-139 K-4.0 Cl-103 HCO3-25 AnGap-15 ___ 12:33PM BLOOD cTropnT-0.02* ___ 12:33PM BLOOD Calcium-7.9* Phos-2.7 Mg-1.3* ___ 02:25PM BLOOD D-Dimer-1162* ___ 12:33PM BLOOD TSH-2.4 ___ 06:34PM BLOOD Lactate-1.6 . DISCHARGE LABS: . ___ 07:55AM BLOOD WBC-7.6 RBC-4.48* Hgb-12.0* Hct-37.5* MCV-84 MCH-26.8* MCHC-32.0 RDW-14.8 Plt ___ ___ 07:55AM BLOOD ___ PTT-51.0* ___ ___ 07:55AM BLOOD Glucose-110* UreaN-17 Creat-1.1 Na-135 K-4.5 Cl-101 HCO3-20* AnGap-19 ___ 07:55AM BLOOD Calcium-8.9 Phos-3.1 Mg-1.6 . URINALYSIS: clear, negative for ___, negative for Nitr, no protein . MICROBIOLOGY DATA: ___ Blood cultures (x 2) - pending ___ Sputum culture - test cancelled, poor sample . IMAGING: ___ CHEST (PA & LAT) - Frontal and lateral views of the chest were obtained. There are low lung volumes. Bibasilar opacities are seen, which could be due to atelectasis, infection, or aspiration. The cardiac and mediastinal silhouettes are unremarkable. The hila are similar in appearance as compared to ___. . ___ CTA CHEST W&W/O C&RECON - Nodular ground-glass opacities in the right lung and left lower lobe with mild mediastinal lymphadenopathy, consistent with multifocal pneumonia. Follow up imaging is recommended after treatment to ensure resolution. No pulmonary embolism. Mild pulmonary edema. 1.2 cm hypodense nodule in the left lobe of the thyroid, which may be evaluated further with thyroid ultrasound if clinically indicated. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 2.5 mg PO DAILY 2. Atorvastatin 80 mg PO DAILY 3. Carbidopa-Levodopa (___) 1 TAB PO TID 4. GlipiZIDE 5 mg PO DAILY 5. HydrALAzine 25 mg PO BID 6. Lisinopril 40 mg PO DAILY 7. Metoprolol Succinate XL 200 mg PO DAILY 8. Omeprazole 20 mg PO DAILY 9. Potassium Chloride 40 mEq PO DAILY 10. ammonium lactate *NF* 12 % Topical daily to dry areas of legs 11. celecoxib *NF* 200 mg Oral daily:PRN pain 12. Mirtazapine 7.5 mg PO DAILY Discharge Medications: 1. Amlodipine 2.5 mg PO DAILY 2. Atorvastatin 80 mg PO DAILY 3. Carbidopa-Levodopa (___) 1 TAB PO TID 4. HydrALAzine 25 mg PO BID 5. Lisinopril 40 mg PO DAILY 6. Omeprazole 20 mg PO DAILY 7. Potassium Chloride 40 mEq PO DAILY Hold for K > 5 8. ammonium lactate *NF* 12 % Topical daily 9. GlipiZIDE 5 mg PO DAILY 10. Metoprolol Succinate XL 200 mg PO DAILY 11. Mirtazapine 7.5 mg PO DAILY 12. Diltiazem Extended-Release 240 mg PO DAILY RX *diltiazem HCl 240 mg 1 capsule, extended release(s) by mouth DAILY Disp #*30 Capsule Refills:*0 13. Warfarin 5 mg PO DAILY16 RX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet Refills:*0 14. Enoxaparin Sodium 70 mg SC Q12H RX *enoxaparin 60 mg/0.6 mL 60 mg SC EVERY 12 HOURS Disp #*14 Syringe Refills:*0 15. Levofloxacin 750 mg PO DAILY Duration: 6 Days started ___, ending ___ RX *levofloxacin 750 mg 1 tablet(s) by mouth DAILY Disp #*6 Tablet Refills:*0 16. Outpatient Lab Work Please check ___ in 2-days. Have results faxed to: ___. MD at ___. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES: 1. Paroxysmal atrial fibrillation, with rapid ventricular response 2. Healthcare-associated pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAM: AP and lateral views of the chest. CLINICAL INFORMATION: ___, recent hospitalization, tachycardia. ___. FINDINGS: Frontal and lateral views of the chest were obtained. There are low lung volumes. Bibasilar opacities are seen, which could be due to atelectasis, infection, or aspiration. The cardiac and mediastinal silhouettes are unremarkable. The hila are similar in appearance as compared to ___. IMPRESSION: Low lung volumes. Bibasilar opacities could be due to infection, aspiration and/or atelectasis. Radiology Report INDICATION: Palpitations and tachycardia. COMPARISON: CT torso, ___, CT abdomen and pelvis, ___, chest x-ray ___. TECHNIQUE: Contiguous axial MDCT images were taken through the chest in arterial phase after administration of 100 cc of Omnipaque intravenous contrast material. Coronal and sagittal reformats as well as maximum intensity projection oblique images were also examined. FINDINGS: There is a 1.2 cm hypodensity in the left lobe of the thyroid. There are ___ nodules in the right upper, right middle and right lower lobes with hazy consolidation. There is also hazy consolidation at the left lower lobe and left perifissural area. Mild, likely reactive, mediastinal lymphadenopathy is present. These findings are consistent with a multifocal pneumonia. There is mild septal thickening, concerning for mild pulmonary edema. The central airways are patent. CTA: The aorta and pulmonary vasculature are well opacified. The aorta maintains a normal contour without any evidence of acute aortic syndrome. The heart is normal in size without pericardial effusion. There is no pulmonary embolism in main, right, left, lobar or subsegmental pulmonary arteries. The imaged portions of the upper abdomen are unremarkable. There is no suspicious lesion in the visualized osseous structures. IMPRESSION: 1. Nodular ground-glass opacities in the right lung and left lower lobe with mild mediastinal lymphadenopathy, consistent with multifocal pneumonia. Follow up CXR is recommended after treatment to ensure resolution. 2. No pulmonary embolism. 3. Mild pulmonary edema. 4. 1.2 cm hypodense nodule in the left lobe of the thyroid, which may be evaluated further with thyroid ultrasound if clinically indicated. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Tachycardia Diagnosed with HEART FAILURE NOS, ATRIAL FLUTTER temperature: 98.3 heartrate: 128.0 resprate: 16.0 o2sat: 98.0 sbp: 139.0 dbp: 98.0 level of pain: 0 level of acuity: 2.0

IMPRESSION: ___ with PMH significant for history of large T-cell jejunal lymphoma (completed chemotherapy, complicated by SBO), chronic paranoid schizophrenia, ___ disease, HTN, HLD, GERD, non-insulin dependent diabetes mellitus, CAD (history of NSTEMI) who presents with presumed new-onset atrial fibrillation and concern for multifocal pulmonary infection. . # Paroxysmal atrial fibrillation vs. atrial flutter: Evidence of increasing heart rate noted by ___ on ___ (118-130 bpm) with PCP visit on ___ with HR that appeared NSR in the 120s. ECG from ___ appears sinus. No prior history of A.fib reported. Suspect atypical rhythm has been present greater than 48-hours prior to admission. Patient denies lightheadedness, dizziness or palpitations. No history of thyroid disease and normal TSH. Admitted with A.fib with RVR to the 130 bpm range. No prior anticoagulation (or ASA given prior GI bleeding concerns). Etiology unclear, but patient has history of CAD, HTN which are risk factors. Unlikely a rhythm of ischemia (cardiac biomarker reassuring on admission, ECG without ischemia). He was monitored on telemetry and he was maintained on oral Diltiazem and oral metoprolol with adequate rate control. We deferred rhythm control at this point; unlikely to benefit from cardioversion given duration. As an outpatient, one could consider TEE/cardioverion vs. attempt at chemical cardioversion. Given evidence of intermittent regularity and possible ___ benefit from ablation in the future? We opted initiate anticoagultaion given his CHADS2 score of 3 after discussion with his home nursing staff. He was started on Lovenox 70 mg SC Q12 hours with Coumadin 5 mg daily for bridging. At discharge, his INR was 3.1 and thus we held his dose for ___. He was provided with a lab slip to have his INR redrawn in 2-days and his PCP ___ further determine ongoing Coumadin dosing. A TTE was performed and demonstrated LVEF 40% and some rate-related cardiomyopathy changes. . # Multifocal pneumonia: Reports 2-days of minimally productive cough with yellow-whitish phlegm on admission. Denies dyspnea or fevers. CT imaging of the chest revealed area of right greater than left patchy opacification concerning for healthcare-associated PNA vs. aspiration vs. atelectasis. He did not require supplemental oxygen. He was initially covered with Vancomycin, Cefepime and Metronidazole given concern for HCAP vs. aspiration (started ___ but he was then transitioned to oral Levofloxacin with good effect. Speech and swallow evaluated him and felt there were no concerns for frank aspiration. A sputum culture was attempted, but was difficult to obtain. . # Hypertension, essential: Home regimen includes CCB, hydralazine, ACEI and beta-blocker. BP controlled at recent PCP ___. Continued home regimen. . # Coronary artery disease: History of NSTEMI in ___ (seen at ___). Treated conservatively with medical management, no report of cardiac catheterization. No active chest pain. EKG without ischemic. No ASA. Anticoagulated, as above. Continued statin. . # History of small bowel lymphoma: Recent admission for partial high-grade SBO that improved with conservative management, occurred at the anastomotic suture of his prior resection for small bowel lymphoma. Also had received post-op radiation treatment. On admission, passing flatus and having BMs. Tolerating diet and without N/V. Benign abdominal exam. Will need outpatient oncology ___. . # DMII: Glipizide held and patient started on HISS for now. . # HLD: Continue atorvastatin. # Chronic paranoid schizophrenia: At baseline and well controlled. Patient does not endorse any HI/SI or paranoid thoughts. Not currently requiring anti-psychotics. . # ___ disease: continue home sinemet dosing. . # Incidental thyroid nodule: Noted incidentally on CT scan. TSH 2.4 this admission. Benign exam. Outpatient thyroid ultrasound. .

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: headaches Major Surgical or Invasive Procedure: ___ brain biopsy and EVD placement, Dr. ___ ___ VP shunt placement, Dr ___ ___ of Present Illness: Patient presents to ED with 2 wks of headaches with nausea and vomiting. Also unsteady gait and persistent double vision. Companion states that she has also been forgetful and not herself. Past Medical History: depression Social History: ___ Family History: noncontributory Physical Exam: ON ADMISSION: : T:98.1 BP:130/87 HR:82 R:18 O2Sats: 100% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 3mm and minimally reactive EOMs: intact b/l Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place and year, but not month. Cranial Nerves: I: Not tested II: Pupils equally round and minimally reactive to light. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Coordination: finger-nose-finger revealed some delay bilaterally, rapid alternating movements normal ON DISCHARGE: Gen: NAD HEENT: no OP lesions, R frontal/parietal incision, with dried blood otherwise well healed sutures intact w/ drainage, partially shaved head. EOMI PULM: CTAB CV: rrr no m/r/g Abd: Soft, nontender, nondistended. ___: no asterixis, no ___ edema or rash Neuro: Oriented, drowsy but arouses to voice, EOMI, ___, bilat horiz 2 beat nystagmus, face symmetric, no tongue deviation, strength ___, sensation intact to light touch, visual fields full to confrontation, FTN remains delayed but no dysmetria, gait slow but steady w/ walker Pertinent Results: ___ CTA HEAD ___ C & RECONS: 1. Interval placement of right frontal approach ventriculostomy catheter with minimal interval decrease in the size of the ventricles. Stable transependymal flow of CSF. 2. Ill-defined heterogeneous pineal gland mass. Possible differential diagnosis includes germinoma versus pineoblastoma. 3. Prominent venous structures are identified from the mass extending to adjacent venous sinuses. No enlarged arterial structures are seen. ___ CT STEREOTAXIS W/ CONTRAST: 1. Unchanged positioning of the ventriculostomy catheter, with interval decrease in the size of the lateral and third ventricles. 2. Large irregularly enhancing mass within the region of pineal gland, causing effacement of the quadrigeminal plate cistern. ___ CT HEAD W/O CONTRAST: 1. Marked decreased size of the lateral ventricles as well as decreased effacement of the quadrigeminal plate cistern compared to the prior examination. Transependymal flow of CSF has also greatly improved. 2. New small hyperdensity in third ventricle suggestive of small intraventricular hemorrhage. 3. No evidence of acute infarction. 4. Ill-defined heterogeneous pineal gland mass is stable in size. ___ MR ___ W/O CONTRAST; MR ___ &W/O CONTRAST; MR ___ & W/O CONTRAST: 1. Heterogeneous high signal on axial T1 postcontrast imaging within the cervical and thoracic spine with more focal nodular high signal at the C2-C3 and T8 levels, as described. These areas of high signal are not seen on the sagittal T1 post-contrast sequence or precontrast sequences. Given history of pineal mass, these findings could represent subarachnoid seeding. Recommend correlation with CSF analysis. 2. Mild degenerative changes of the cervical spine. Radiology Report CHEST (PORTABLE AP) Study Date of ___ 4:17 ___ IMPRESSION: No previous images. Cardiac silhouette is within normal limits and there is no vascular congestion, pleural effusion, or acute focal pneumonia. ___ CXR No previous images. Cardiac silhouette is within normal limits and there is no vascular congestion, pleural effusion, or acute focal pneumonia. ___ CT HEAD W/O CONTRAST 1. Hypodensity in the region of previously seen tumor as well as in the midline involving the genu and anterior portion of corpus callosum could be related to ischemic changes . Further evaluation with MRI of the brain is recommended. 2. The ventricular size is decreased compared to the prior study. 3. There is redistribution of blood products in the third ventricle but no definite new hemorrhage seen. ___ MRI BRAIN IMPRESSION: 1. The ventricles appear slit-like, similar to the most recent CT from ___, but decreased compared to ___. VP shunt catheter position is stable. 2. The large peripherally enhancing midline mass centered in the pineal region demonstrates marked enlargement of its central nonenhancing portion compared to the preoperative MRI from ___. The mass is now overall larger, extending further anteriorly. The expanded central nonenhancing portion appears heterogeneous, with complex fluid and small amount of blood. The enlargement is most likely secondary to decreased intracranial pressure and associated fluid shifts after relief of hydrocephalus. 3. Unchanged mild contrast enhancement along the right superior cerebellar folia compared to the preoperative MRI, suggesting tumor infiltration. 4. Linear blood products and contrast enhancement along the biopsy track through the right parietal and occipital parenchyma. The contrast enhancement is presumably reactive, but should be reassessed on follow up. 5. No evidence for an acute infarction. Medications on Admission: prozac Discharge Medications: 1. Rolling Walker Please dispense one rolling walker Diagnosis: Gait unsteadiness secondary to brain mass Prognosis: Poor ___: ___ weeks 2. Acetaminophen 650 mg PO Q6H:PRN pain 3. Dexamethasone 8 mg PO Q12H take at 8am and again at 2 or 4pm RX *dexamethasone 4 mg 2 tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*1 4. Famotidine 20 mg PO Q12H RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 5. Docusate Sodium 100 mg PO BID take first RX *docusate sodium 100 mg 1 tablet(s) by mouth BID prn Disp #*30 Tablet Refills:*1 6. Senna 17.2 mg PO BID:PRN constipation take second 7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours as needed Disp #*20 Tablet Refills:*1 Discharge Disposition: Home Discharge Diagnosis: Glioblastoma Hydrocephalus Diplopia Cerebral edema Discharge Condition: Mental Status: Confused sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CTA HEAD WANDW/O C AND RECONS Q1213 CT HEAD INDICATION: ___ year old woman with new pineal mass // Interval changes TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Next, rapid axial imaging was performed through the brain during the uneventful infusion of 70 mL of Omnipaque intravenous contrast material. Three-dimensional angiographic volume rendered and segmented images were then generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 6.0 s, 20.0 cm; CTDIvol = 53.0 mGy (Head) DLP = 1,060.0 mGy-cm. 2) Stationary Acquisition 4.2 s, 0.5 cm; CTDIvol = 63.9 mGy (Head) DLP = 31.9 mGy-cm. 3) Spiral Acquisition 6.9 s, 22.3 cm; CTDIvol = 30.7 mGy (Head) DLP = 686.4 mGy-cm. Total DLP (Head) = 1,778 mGy-cm. COMPARISON: Outside head MRI from ___ FINDINGS: CT HEAD WITHOUT CONTRAST: There is interval placement of right frontal approach ventriculoperitoneal shunt catheter with its tip near the septum pellucidum in the frontal horn of right lateral ventricle. There is associated new right frontal convexity pneumocephalus. There is minimal interval decrease in the size of the ventricles now measuring 3.6 cm, previously 3.8 cm. There is stable hypodensities in the periventricular white matter in keeping with transependymal flow of CSF. There is an ill-defined hypo enhancing lesion in the region of the pineal gland measuring approximately 2.9 x 4.1 cm causing effacement of the quadrigeminal plate cistern corresponding to the previously seen heterogeneously enhancing pineal mass. There is no evidence of infarction or hemorrhage. No midline shift is seen. The visualized portion of the paranasal sinuses,mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. CTA HEAD: The vessels of the circle of ___ and their principal intracranial branches appear normal with no evidence of stenosis,occlusion or aneurysm. The dural venous sinuses are patent. There are several prominent vascular structures likely veins (601 B: 16) extending from the mass to the adjacent venous sinuses. IMPRESSION: 1. Interval placement of right frontal approach ventriculostomy catheter with minimal interval decrease in the size of the ventricles. Stable transependymal flow of CSF. 2. Ill-defined heterogeneous pineal gland mass. Possible differential diagnosis includes germinoma versus pineoblastoma. 3. Prominent venous structures are identified from the mass extending to adjacent venous sinuses. No enlarged arterial structures are seen. Radiology Report EXAMINATION: CT STEREOTAXIS W/ CONTRAST INDICATION: ___ year old woman with pineal tumor, pre-biopsy // CT stereotaxis w/ frame on prior to OR TECHNIQUE: Contiguous axial images of the brain were obtained after the uneventful administration of Omnipaque intravenous contrast. Thin bone-algorithm reconstructed images and coronal and sagittal reformatted images were then produced. DOSE: Found no primary dose record and no dose record stored with the sibling of a split exam. COMPARISON: CTA Head within without contrast dated ___. MRI from outside hospital dated ___. FINDINGS: Examination was performed with a stereotactic halo in place. There is a right transfrontal approach ventriculostomy catheter, which is unchanged in positioning and terminates in the frontal horn of the right lateral ventricle. The lateral and third ventricles appear smaller, now measuring approximately 2.8 cm compared to 3.6 cm on the prior exam. Decreased transependymal flow of CSF is noted. There is stable postoperative pneumocephalus within the right frontal convexity. Again visualized is the large irregularly enhancing mass within the region of the pineal gland measuring approximately 2.9 x 4.1 cm causing effacement of the quadrigeminal plate cistern. There is no evidence of fracture, infarction, or hemorrhage. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. Unchanged positioning of the ventriculostomy catheter, with interval decrease in the size of the lateral and third ventricles. 2. Large irregularly enhancing mass within the region of pineal gland, causing effacement of the quadrigeminal plate cistern. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman with brain tumor status post stereotactic brain biopsy. Evaluate postop changes. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 10.0 s, 17.0 cm; CTDIvol = 48.8 mGy (Head) DLP = 829.0 mGy-cm. Total DLP (Head) = 843 mGy-cm. COMPARISON: ___ head CTA. ___ outside contrast brain MRI. FINDINGS: Right frontal approach ventriculostomy shunt catheter is unchanged in position. Minimal pneumocephalus along the right frontal convexity is decreased from ___. The ventricles are decreased in size from ___. Periventricular hypodensities are less apparent on the current examination consistent with significantly decreased transependymal flow of CSF. New small hyperdensity is noted within the third ventricle (see 03:14). As before in ill-defined hypoenhancing lesion in the region of the pineal gland is unchanged in size in shows persistent effacement of the quadrigeminal plate cistern, however the degree of effacement has decreased from the prior examination. There is no evidence of acute hemorrhage or infarction. No midline shift is identified. The visualized portion of the paranasal sinuses, mastoid air cells and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: 1. Marked decreased size of the lateral ventricles as well as decreased effacement of the quadrigeminal plate cistern compared to the prior examination. Transependymal flow of CSF has also greatly improved. 2. New small hyperdensity in third ventricle suggestive of small intraventricular hemorrhage. 3. No evidence of acute infarction. 4. Ill-defined heterogeneous pineal gland mass is stable in size. NOTIFICATION: The findings were discussed by Dr. ___ With Dr. ___ on the telephoneon ___ at 10:09 ___, 10 minutes after discovery of the findings. Radiology Report EXAMINATION: MRI of the cervical thoracic and lumbar spine with without contrast. MR ___ WAND W/O CONTRAST ___ MR ___ SPINE INDICATION: ___ female with 2 weeks of headache, nausea, vomiting and unsteadiness with recent brain MRI demonstrating pineal mass. Evaluate for spinal lesions. 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 9 mL of Gadavist contrast agent, additional axial and sagittal T1 images were obtained. COMPARISON: None. FINDINGS: Study is moderately degraded by motion. Within these confines: CERVICAL SPINE: There is normal cervical alignment. The vertebral body heights are preserved. The marrow signal is unremarkable. The intervertebral discs demonstrate normal signal and height. There small central disc protrusions at C4-C5, C5-C6, and C6-C7 causing mild spinal canal narrowing without significant neural foraminal stenosis. There is a right C7-T1 foraminal perineural cyst (11:33). The cervical cord demonstrates normal signal morphology. The paravertebral soft tissues are unremarkable. On axial T1 postcontrast imaging there is heterogeneous T1 hyperintensity within the subarachnoid space, some which appears more focal such is in the right ventral thecal sac at the C2-C3 level (21:13), with focal enhancement measuring 3 mm. These areas of high signal are not seen on sagittal T1 postcontrast or precontrast imaging. THORACIC SPINE: There is normal thoracic alignment. The vertebral body heights are preserved. The marrow signal is unremarkable. There intervertebral discs demonstrate normal signal height. There is no significant neural foramina or spinal canal stenosis. The thoracic cord demonstrates normal signal morphology. There is no abnormal postcontrast enhancement. The paravertebral soft tissues are unremarkable. On axial T1 postcontrast imaging there is heterogeneous T1 hyperintensity within the subarachnoid space, some of which appears more focal such as at the dorsal left lateral aspect of the thoracic cord at the T8 level (08:34) where there is nodular high signal measuring 4 mm. This is not seen on the sagittal T1 postcontrast ward noncontrast sequences. LUMBAR SPINE: There is normal lumbar alignment. The vertebral body heights are preserved. The marrow signal is unremarkable. The intervertebral disc spaces demonstrate normal signal height. There is no significant neural foraminal or spinal canal stenosis. The conus terminates appropriately at the mid L1 level. The cauda equina nerve roots demonstrate normal signal morphology. There is no abnormal postcontrast enhancement. Paravertebral soft tissues are unremarkable. IMPRESSION: 1. Study is moderately degraded by motion. 2. Heterogeneous high signal on axial postcontrast imaging within the cervical and thoracic spine with more focal nodular high signal at the C2-C3 and T8 levels, as described with now all corresponding findings on sagittal postcontrast imaging. While findings may be artifactual in nature, subarachnoid tumor seeding is not excluded on the basis of this examination. Consider correlation with CSF analysis and attention on followup imaging. 3. Mild degenerative changes of the cervical spine. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with ___ with 2 wks of HA, nausea, vomiting and unsteadiness. MRI revealed pineal mass. // pre op pre op IMPRESSION: No previous images. Cardiac silhouette is within normal limits and there is no vascular congestion, pleural effusion, or acute focal pneumonia. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman with new VPS. postop scans. Please do at 2200. // ___ year old woman with new VPS. postop scans. Please do at 2200. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 4.8 s, 16.0 cm; CTDIvol = 53.0 mGy (Head) DLP = 848.0 mGy-cm. Total DLP (Head) = 848 mGy-cm. COMPARISON: CT head without contrast dated ___, MR head dated ___ FINDINGS: A right frontal approach ventriculoperitoneal shunt catheter is again noted, with the tip terminating in unchanged position at the level of the foramen of ___. Expected postprocedural pneumocephalus is noted. Previously seen hyperdensity within the third ventricle is less prominent on the current examination, likely reflective resolving blood products. Again noted is an ill-defined, hypodense lesion in the region of the pineal gland, demonstrating persistent effacement of the quadrigeminal plate cistern. Small hyperdensity within the right and left lateral ventricles appears to have been present on prior examination as well (03:18). There is no evidence of fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. Status post right ventriculoperitoneal shunt placement. 2. Evolving blood products within the third ventricle. Small persistent hyperdensity within the right lateral ventricle. 3. The region of the pineal tumor the slightly hypodense on the current study. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman with ___ with 2 wks of HA, nausea, vomiting and unsteadiness. MRI revealed pineal mass // interval change TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 4.8 s, 16.0 cm; CTDIvol = 53.0 mGy (Head) DLP = 848.0 mGy-cm. Total DLP (Head) = 848 mGy-cm. COMPARISON: CT ___, MR head ___ FINDINGS: A VP shunt terminates in the region of the foramen of ___. An ill-defined hypodense lesion in midline at the site of previously seen pineal mass. The hypodensity within the lesion is new since the earlier CT of ___ but unchanged from ___ and could be due to tumor necrosis or infarction. There is also a hypodensity seen within the region of the corpus callosum series 3, image 16 which although unchanged from the earlier examination of ___ is better visualized on the current study and extends superiorly in the midline. The ventricles are smaller than seen on the previous study. A small amount of blood products are seen inferiorly in the third ventricle which due to redistribution of previously seen blood products . There is no definite new hemorrhage identified. IMPRESSION: 1. Hypodensity in the region of previously seen tumor as well as in the midline involving the genu and anterior portion of corpus callosum could be related to ischemic changes . Further evaluation with MRI of the brain is recommended. 2. The ventricular size is decreased compared to the prior study. 3. There is redistribution of blood products in the third ventricle but no definite new hemorrhage seen. RECOMMENDATION(S): MRI with gadolinium. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ ___ on the telephoneon ___ at 4:45 ___, 3 minutes after discovery of the findings. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD INDICATION: ___ year old woman with pineal mass status post stereotactic biopsy on ___ and VP shunt placement on ___. Further investigation is requested of new hypodensity in the region of the tumor and in the ___ and anterior corpus callosum, seen on the ___ head CT and concerning for ischemia. TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of 9 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: Postsurgical head CTs from ___. Presurgical MRI of the head from ___ and CTA of the head ___. FINDINGS: The midline mass centered in the pineal region demonstrates thick, irregular, and nodular peripheral enhancement, as seen previously. The central nonenhancing portion of the mass has markedly expanded compared to the preoperative MRI from ___. This causes interval enlargement of the mass with increased anterior extension. The mass now measures 5.8 cm AP, 3.7 cm craniocaudad, and 4.8 cm transverse, images 9:125 and 10:13, compared to 4.0 x 3.5 x 3.5 cm when measured in the same planes on ___. The central nonenhancing portion of the mass is heterogeneous with predominantly high signal on T2 weighted images. Its signal on precontrast T1 weighted images is lobe was higher than that of CSF. It demonstrates only small foci of low signal intensity on gradient echo images, consistent with small amount of blood products. The enhancing rim of the mass demonstrates low signal on gradient echo images, consistent with blood products. There is mild contrast enhancement along the right superior cerebellar folia, similar to the preoperative MRI from ___, suggesting tumor infiltration. There is linear T1 hyperintensity, low signal on gradient echo images, and contrast enhancement extending from the right posterior aspect of the pineal region mass to the right parietal burr hole, consistent with blood and probably reactive enhancement along the surgical biopsy track. A right frontal approach ventriculostomy catheter is again seen in place with its tip in the frontal horn of right lateral ventricle. The ventricles are slit-like, unchanged compared to the most recent CT from ___, but decreased compared to the ___ head CT obtained immediately following VP shunt placement. There is persistent slight asymmetry in the size of frontal horns of the lateral ventricles, right smaller than left. There is no evidence for acute infarction on diffusion-weighted images. Major flow voids of the circle of ___ appear grossly preserved. ___ cisterna magna is again noted, a normal variant. There is mild mucosal thickening in left greater than right maxillary sinuses and ethmoid air cells. IMPRESSION: 1. The ventricles appear slit-like, similar to the most recent CT from ___, but decreased compared to ___. VP shunt catheter position is stable. 2. The large peripherally enhancing midline mass centered in the pineal region demonstrates marked enlargement of its central nonenhancing portion compared to the preoperative MRI from ___. The mass is now overall larger, extending further anteriorly. The expanded central nonenhancing portion appears heterogeneous, with complex fluid and small amount of blood. The enlargement is most likely secondary to decreased intracranial pressure and associated fluid shifts after relief of hydrocephalus. 3. Unchanged mild contrast enhancement along the right superior cerebellar folia compared to the preoperative MRI, suggesting tumor infiltration. 4. Linear blood products and contrast enhancement along the biopsy track through the right parietal and occipital parenchyma. The contrast enhancement is presumably reactive, but should be reassessed on follow up. 5. No evidence for an acute infarction. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Transfer, Headache, Ataxia, Abnormal CT Diagnosed with Other hydrocephalus, Other specified endocrine disorders temperature: 98.1 heartrate: 82.0 resprate: 18.0 o2sat: 100.0 sbp: 130.0 dbp: 87.0 level of pain: 0 level of acuity: 2.0

___ is a ___ yr old female who presented to ___ with complaints of headache and vision changes accompanied by nausea/vomiting and unsteady gait and intermittent confusion. MRI revealed pineal mass with significant hydrocephalus. Patient was brought to the OR for EVD placement and post-operative admitted to the ICU for close neuro monitoring. Post-operative, patient remained neurologically intact with intermittent double vision. #Glioblastoma - pineal mass found on brain MRI on admission as above. Brain biopsy ___ consistent with glioblastoma. mass was unresectable, she initiated brain XRT, ___ of ___ started ___, she will return on ___ to resume treatments in ___ clinic. Sutures will be removed in ___ clinic this week. She will also f/u with Dr ___ in ___ clinic w/ plan to initiate avastin and temodar. Port will be placed as outpatient in anticipation of ongoing chemotherapy in near future. Ongoing neurologic deficits include intermittent diplopia due to compression of tectum and word finding difficulty. She is ambulatory with a walker. She declined home ___ and will start outpatient ___. #Cerebral edema - ___ above, was started on dexamethasone, will cont 8mg BID on discharge to be adjusted by rad onc or neuro-onc. Also to be determined need for PCP ___ by ___ providers, if able to wean steroids quickly will not start Bactrim. #Hydrocephalus - Noted on admission head CT and brain MRI. Patient underwent placement of EVD at time of brain biopsy by Dr ___ on ___, converted to VP shunt on ___ after decision made that primary mass was not resectable. Delta Valve 1.5 placed the procedure was well tolerated. She is no longer having headaches. Follow-up with Dr ___ is being arranged. # Hyponatremia - new finding on ___. Was started on salt tabs per neurosurgery but had also been receiving IVF. she was also started on Bactrim and steroids which can cause hyponatremia. No acute changes in neuro symptoms, no headaches. salt tabs stopped and Na remained stable, likely med related vs SIADH. Na remains 130 at time of discharge no further intervention indicated. # Proteus UTI - received 3 days CTX. Also then initiated Bactrim ___ after pt reported urgency however UA normal at that time and repeat Cx negative. Bactrim stopped. # Leukocytosis - likely due to steroids pt afebrile and no signs systemic infxn

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Penicillins / Iodine-Iodine Containing / Aspirin / Epinephrine / Clindamycin / Oxcarbazepine / Dilaudid / Lumigan / Alphagan P Attending: ___. Chief Complaint: breakthrough seizures Major Surgical or Invasive Procedure: none History of Present Illness: ___ is a ___ LH F with h/o complex migraines and migrainous aura without headache vs. partial complex seizure disorder (on gabapentin monotherapy w bitemporal discharges on EEG), breast cancer s/p resection and glaucoma who presents with multiple events in the past 24 hrs concerning for breakthrough seizures. Last night, on 2 occasions patient awoke suddenly from sleep and sat bolt upright (felt like she was being "pulled up" into sitting position), with a sudden extreme fear sensation and screaming. Also smelled something "unpleasant" at this time which has difficulty describing, not a burning smell. The episodes lasted ~10 seconds each, and were followed by feeling of extreme fatigue. No frank LOC during events, although has difficulty fully remembering them afterward. In the morning, she had 2 more of the same spells while downstairs in her home. No palpitations, nausea or rising sensation. No headache except for occasional bifrontal pressure headache which she attributes to sinuses. Has history of anxiety but felt very different from this, no increased stressors at home. She called Dr. ___ recommended she come to the ED for neurology evaluation and possible admission. In the ED waiting room, she had another spell. Has also had an episode of olfactory aura alone (no fear) since arriving in her room, none witnessed by me. She now feels she is back to baseline but her husband states she is "not herself" (he has difficulty describing exactly what he means by this, but does think she seems a little "slower" than usual). In terms of factors lowering seizure threshold, 2 weeks ago was recently treated for a sinus infection (presenting with facial pain, nasal congestion and purulent discharge) two weeks ago but has been having ear "fullness" and conjunctival injection since then. She has recently started antibiotic ear drops for this and is scheduled to see ENT this week. Denies fever, chills, rhinorrhea, dysuria, nausea, diarrhea, cough, sputum. She has been having "interrupted" sleep for past few nights but otherwise sleeping well. Has not missed any doses of her gabapentin. Patient she first developed the above spells (sudden fear sensation, screaming, olfactory aura) in ___ and was admitted to the EMU for 5 days to capture events. Gabapentin was weaned off during the admission. EEG showed occasional bitemporal (L>R) slowing and L temporal sharps but no epileptiform discharges or seizures. During hospitalization she had an MRI brain which was unremarkable, and an LP with paraneoplastic antibody panel and cytology which was all normal. She was discharged home on increased Gabapentin dose, and has remained seizure-free since then (until today). She was also admitted to EMU in ___ for separate events concerning for CPSz vs. migraine aura without headache. She has a history of migraine headaches in her ___ with complex auras (zig-zag lines, headache and confusion). In ___ she developed new events: sense of something about to happen, flashing lights, cloudy vision, visual field cut and face/lips/arm numbness. She was started on Keppra (stopped ___ due to side effect of feeling sick and tired), subsequently added clonazepam and gabapentin. Then added Oxcarbazepine which gave her a rash. Was admitted to EMU from ___ where all AEDs were stopped to capture events. EEG showed bitemporal sharp and spike epileptiform discharges, but no seizures. She was discharged on gabapentin monotherapy. Ultimate etiology of these events was thought to be migraine aura without headache. EPILEPSY RISK FACTORS: She was hit in the head with a baseball ___ years ago, no LOC. Has a cousin with seizures, no other FHx of epilepsy or neurologic problems. No history of meningitis or encephalitis. Highest level of education was college. PRIOR AED TRIALS: Keppra (felt sick and tired), Oxcarbazepine (rash), Clonazepam Neuro ROS: pt denies headache but her husband says she has daily migraines; neither of them can exactly describe the headache quality. Denies any recent migraine auras. +chronic tinnitus and vertigo. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. General ROS: +daytime fatigue for at least 6 months. Denies recent fever or chills (though chronically "chilly"). No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: 1. Neurologic - Migraines with aura, Seizures (partial complex, likely temporal lobe), Vertigo (prior head injury ~ ___ years prior to admission when hit by baseball w/o LOC, lasts seconds to one minute, episodic) 2. Oncologic - Breast cancer (dx ~ ___ 3. Endocrine - Osteopenia 4. Gastrointestinal - h/o indigestion and "gassy" symptoms 5. Cardiovasculasr - Mitral valve regurgitation 6. Psychiatric - Anxiety (intermittent) 7. Ophthalmologic - Glaucoma (bilateral), Cataract (s/p R surgery, ___ Social History: ___ Family History: Seizures (cousin). ___ cancer (family). Physical Exam: GENERAL EXAM: - Vitals: 97.3 72 123/60 18 100% RA - General: Awake, cooperative, NAD. - HEENT: NC/AT. +conjunctival injection. Unable to complete HEENT eval (pt in hall), no acute abnormalities per ED. - Neck: Supple, no carotid bruits appreciated. No nuchal rigidity - Pulmonary: CTABL - Cardiac: RRR, no murmurs - Abdomen: soft, nontender, nondistended - Extremities: no edema, pulses palpated - Skin: no rashes or lesions noted. NEURO EXAM: - Mental Status: Awake and alert, oriented to person and place but states date is ___ or ___. Able to relate history without difficulty but has difficulty with details of today's events and timeline of her prior episodes. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Able to register 3 objects and recall ___ at 5 minutes ___ with categorical prompting, ___ with choices) which is stable from prior evals. Good knowledge of current events. No evidence of apraxia or neglect. - Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to finger counting. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. - Motor: Normal bulk except mild wasting of EDBs bilaterally. Normal tone throughout. No pronator drift. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 5 - Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. - DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 0 R 2 2 2 2 0 Plantar response was flexor bilaterally. - Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. - Gait: not tested Pertinent Results: ADMISSION LABS ___ 04:45PM GLUCOSE-92 UREA N-8 CREAT-0.6 SODIUM-134 POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-26 ANION GAP-11 ___ 04:45PM estGFR-Using this ___ 04:45PM CALCIUM-9.0 PHOSPHATE-3.0# MAGNESIUM-1.7 ___ 04:45PM WBC-5.6 RBC-4.01* HGB-12.5 HCT-36.4 MCV-91 MCH-31.1 MCHC-34.2 RDW-12.5 ___ 04:45PM NEUTS-75.9* LYMPHS-17.1* MONOS-3.7 EOS-3.0 BASOS-0.3 ___ 04:45PM PLT COUNT-153 ___ 03:03PM LACTATE-1.3 ___ 03:00PM ALT(SGPT)-17 AST(SGOT)-44* ALK PHOS-59 TOT BILI-0.5 ___ 03:00PM ALBUMIN-4.2 ___ 03:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG CXR ___ No acute cardiopulmonary process. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 500 mg PO Q7:00 AM 2. Gabapentin 500 mg PO Q3:00 ___ 3. Gabapentin 600 mg PO HS 4. Timolol Maleate 0.25% 1 DROP BOTH EYES DAILY 5. travoprost 0.004 % ophthalmic daily 6. Atenolol 12.5 mg PO DAILY:PRN palpitations 7. Neomycin-Polymyxin-HC Otic Susp 4 DROP BOTH EARS TID Discharge Medications: 1. Gabapentin 500 mg PO QAM 2. travoprost 0.004 % OPHTHALMIC DAILY 3. Timolol Maleate 0.25% 1 DROP BOTH EYES DAILY 4. Neomycin-Polymyxin-HC Otic Susp 4 DROP BOTH EARS TID 5. Gabapentin 500 mg PO Q3:00 ___ 6. Atenolol 12.5 mg PO DAILY:PRN palpitations 7. Gabapentin 600 mg PO HS Discharge Disposition: Home Discharge Diagnosis: partial complex seizures Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Neuro: no focal abnormalities Followup Instructions: ___ Radiology Report HISTORY: ___ female with seizure. Evaluation for pneumonia. COMPARISON: Comparison is made to radiographs of the chest from ___. FINDINGS: PA and lateral views of the chest demonstrates the lungs are well expanded and clear. The cardiomediastinal silhouette is unremarkable. Surgical clips are again seen in the right breast. There is no pleural effusion, pulmonary edema, pneumothorax or focal consolidation concerning for pneumonia. IMPRESSION: No acute cardiopulmonary process. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: SEIZURE Diagnosed with EPILEPSY, NOS WITHOUT INTRACTABLE EPILEPSY, ALTERED MENTAL STATUS temperature: 97.3 heartrate: 72.0 resprate: 18.0 o2sat: 100.0 sbp: 123.0 dbp: 60.0 level of pain: 0 level of acuity: 2.0

___ is a ___ LH F with h/o complex migraines and migrainous aura without headache vs. partial complex seizure disorder (on gabapentin monotherapy w bitemporal discharges on EEG), breast cancer s/p resection and glaucoma who presents with multiple events in the past 24 hrs concerning for breakthrough seizures. Describes these as sudden sensation of being "pulled forward", extreme fear and screaming, and unpleasant smell that last 10 seconds and are followed by fatigue. Has had total of 5 spells since last night and one olfactory aura in ED. Of note, recently had sinusitis and has ongoing ear fullness and conjunctival injection, which could be a risk factor for increased seizure frequency. She was admitted to the EMU for EEG LTM with hopes of capturing an event. However, she had no further events upon admission, so rather than waiting to have telemetry started, the patient asked to leave with plans for elective admission in the future. She was counseled that she remained at risk of having futher seizure events at home, and she should continue to practice seizure precautions, and return to the ED if she felt unsafe. Gabapentin continued at home dose TRANSITIONAL ISSUES - F/U with neurology

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Aspirin / Nitrate Analogues Attending: ___. Chief Complaint: Hypoglycemia, encephalopathy Major Surgical or Invasive Procedure: Dobhoff placement and removal x 2 History of Present Illness: Note: History obtained from patient's husband through an interpreter, the ___ medical record, and records from her rehabilitation center-- ___ Health and Rehab] Ms. ___ is a ___ ___ speaking woman presenting from rehab on ___ with confusion and restlessness overnight, found at rehab to be hypoglycemic, hypotensive, and possible PNA. On the morning of ___ around 6am Ms. ___ was found to be unable to take her scheduled medications. She had been noted to be goaining and restless in bed overnight. FSBG at that time was 48 and hypotensive to 76/40. She was given glucagon with improvement in BS to 112 and BP to 129/67. Transferred to ___ ER for further evaluation. She had a recent hospitalization (___) for influenza A, COPD, acute-on-chronic ___ exacerbation, UTI, hypernatremia, acute-on-chronic CKD, and NSTEMI type 2. In the ED, initial vitals were: 95.7 61 157/86 14 99% at triage, her HR remained between ___ and her blood pressure downtrended into SBP's of 100's. She was noted to have a ___ as low as 40. Her O2 sat was initially 98-100% on RA, but downtrended to 90% and she required 2L NC. She was given a total of 4L of IVF (NS, D5NS, and LR) as well as dextrose x 2 for hypoglycemia. She was given cefepime and vanc for PNA seen on CXR. She was noted to have low urine output prior to admission and bolused 500 cc. On the floor, she remains lethargic and is unable to participate in the exam to endorse or deny symptoms. Past Medical History: Primary Biliary Cirrhosis Chronic itching iron deficiency anemia Diabetes mellitus, type 2, poorly controlled, last HbA1c 9.0 ___ Atrial fibrillation, on coumadin Coronary artery disease s/p stent to the RCA ___. systolic heart failure (LVEF 60-65%, no comment on diastolic function on ___ Hypertension. Hypercholesterolemia. Seizures ___ disease Hx. PUD and gastritis Hx. abnormal pap smears Status post bilateral total knee replacement. Low back pain Chronic kidney disease with baseline creatinine 1.3-1.9 Social History: ___ Family History: Brother with DM. No CAD or COPD. Physical Exam: Admission physical =================================== Vitals: 98.5, 146/69, 74, 18, 100% on 2L NC General: Lethargic, lying in bed in NAD HEENT: Sclera anicteric, MM mildly dry, oropharynx clear, PERRL Neck: Supple, JVP difficult to assess to due neck size CV: irregilarly irregular rhythm, normal rate, normal S1 + S2, no murmurs, rubs, gallops Lungs: Diffuse moderate wheezing throughout all lung fields. No rales or rhonchi Abdomen: Distended, obese, Soft, non-tender, bowel sounds present, unable to appreciate organomegaly, no rebound or guarding GU: foley in place draining yellow urine Ext: Warm, well perfused, 2+ DP pulses. Clubbing noted in upper and lower extremities. Neuro: Somnolent, opens eyes and weakly squeezes hands when verbally asked. Does not vocalize in response to questions, easily falls asleep again. Can briefly sit up with assistance. Discharge physical ==================================== DISCHARGE WEIGHT (STANDING, MID-DAY) = 79.9kg Vitals: 98.4 82 134/51 20 95% on 1L ___ pain I/O: -- AM 8 hr: 0/large inc -- yest 24 hr: 770/7505 + inc General: Lying in bed, awake and alert. Oriented to person and "Hospital, ___, not date or year. HEENT: conjunctiva with trace resolving hemorrhages, minor left erythema. MM very dry, oropharynx clear, PERRL, EOMI Neck: Supple, JVP WNL CV: irregularly irregular rhythm, normal rate, normal S1 + S2, no murmurs, rubs, gallops. Lungs: CTAB no W/R/R Abdomen: Distended, obese, Soft, non-tender to palpation in all quadrants, bowel sounds present GU: seen prior to second baldder scan and foley placement, at that time no foley in place Ext: Warm, well perfused. Clubbing noted in upper and lower nailbeds. No peripheral edema in lower extremities, hips/dependent portions. Knees notable for bilateral knee replacement scars. Neuro: A&O x 2, can state name, hospital, and ___. Not year or name of hospital. EOMI, tongue midline. Moves all four extremities purposefully and follows commands. Pertinent Results: Admission labs: ___ 10:09AM BLOOD WBC-9.9 RBC-4.58 Hgb-10.3* Hct-38.2 MCV-83 MCH-22.5* MCHC-26.9* RDW-25.2* Plt ___ ___ 10:09AM BLOOD ___ PTT-38.7* ___ ___ 10:09AM BLOOD Glucose-38* UreaN-35* Creat-1.7* Na-143 K-5.1 Cl-104 HCO3-30 AnGap-14 ___ 10:09AM BLOOD ALT-7 AST-51* AlkPhos-113* TotBili-0.4 ___ 07:40AM BLOOD ___ ___ 10:09AM BLOOD Albumin-3.2* Calcium-9.2 Phos-5.1*# Mg-2.3 Important labs: ___ 08:05AM BLOOD ___ 08:05AM BLOOD Ret Man-1.4 ___ 06:50AM BLOOD cTropnT-0.02* ___ 02:55PM BLOOD cTropnT-0.02* ___ 08:05AM BLOOD calTIBC-333 VitB12-1233* Folate-14.6 ___ Ferritn-50 TRF-256 ___ 05:55AM BLOOD TSH-12* ___ 08:15AM BLOOD T4-6.2 T3-95 Discharge Labs: ___ 07:50AM BLOOD WBC-6.2 RBC-4.03* Hgb-9.4* Hct-33.7* MCV-84 MCH-23.4* MCHC-27.9* RDW-23.7* Plt Ct-72* ___ 07:50AM BLOOD ___ PTT-39.7* ___ ___ 07:50AM BLOOD Glucose-93 UreaN-27* Creat-1.3* Na-143 K-3.4 Cl-96 HCO3-39* AnGap-11 ___ 08:05AM BLOOD ALT-7 AST-25 LD(LDH)-381* AlkPhos-86 TotBili-0.5 ___ 07:50AM BLOOD Calcium-8.8 Phos-3.2 Mg-1.8 ___ 08:05AM BLOOD TotProt-6.5 Calcium-9.0 Phos-3.8 Mg-1.8 Iron-22* ___ 08:05AM BLOOD calTIBC-333 VitB12-1233* Folate-14.6 ___ Ferritn-50 TRF-256 ___ 08:15AM BLOOD T4-6.2 T3-95: Micro: ___ 11:43 am URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: YEAST. 10,000-100,000 ORGANISMS/ML.. ___ Blood cx negative ___ 10:37 am STOOL CONSISTENCY: SOFT Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). Imaging: ___ EKG Slight baseline artifact. Diminished limb lead QRS amplitude. Atrial fibrillation with a well-controlled ventricular rate. Non-specific ST segment flattening in lead I with T wave inversion in lead aVL. Suggestion of Q waves in leads III and aVF consistent with prior inferior myocardial infarction. Poor anterior R wave progression consistent with prior anterior myocardial infarction. Left axis deviation with left anterior fascicular block. Compared to the previous tracing of ___ the overall ventricular rate is slightly faster. T waves are more inverted in lead aVL. Left precordial electrode placement is clearly different. An ongoing lateral ischemic process cannot be excluded. Clinical correlation is suggested. ___ CXR IMPRESSION: In comparison with the study of ___, there is substantial enlargement of the cardiac silhouette with moderate pulmonary edema and bilateral effusions with compressive atelectasis at the bases. ___ PORTABLE CXR AP FINDINGS: AP portable upright view of the chest. Increased opacities in the lower lungs raise concern for early pneumonia. There is a small left pleural effusion. No overt evidence for an edema. No pneumothorax. Patient is rotated to the left. Prominent cardiomediastinal silhouette is stable. No acute bony abnormalities. IMPRESSION: Increased opacities in the lower lungs raise concern for pneumonia. Small left effusion. ___ NONCONTRAST HEAD CT FINDINGS: There is no evidence of hemorrhage, infarction, mass, edema, or shift of normally midline structures. Mild prominence of the ventricles and sulci likely relate to age related involutional changes, unchanged from prior. There is minimal left maxillary sinus mucosal thickening. Otherwise, the visualized paranasal sinuses and mastoid air cells are clear. The patient is status post bilateral lens removal. There is mild swelling of the soft tissues along the left periorbital region. There is no evidence of fracture. IMPRESSION: No evidence of acute intracranial process. Mild edema of the left periorbital soft tissues. No evidence of fracture. EKG: A fib, HR 86. Q waves in V1-V3, III, aVF and poor R wave progression unchanged from prior from ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 2. Carbidopa-Levodopa (___) 1 TAB PO TID 3. Docusate Sodium 100 mg PO DAILY 4. Ferrous Sulfate 325 mg PO DAILY 5. Lactulose 30 mL PO BID 6. LeVETiracetam 500 mg PO BID 7. Metoprolol Succinate XL 200 mg PO DAILY 8. Omeprazole 40 mg PO BID 9. Psyllium 1 PKT PO DAILY 10. Senna 8.6 mg PO QHS 11. Simvastatin 40 mg PO QPM 12. Tiotropium Bromide 1 CAP IH DAILY 13. Torsemide 60 mg PO DAILY 14. TraZODone 50 mg PO QHS 15. Ursodiol 600 mg PO BID 16. Zolpidem Tartrate 5 mg PO QHS 17. Acetaminophen 650 mg PO Q4H:PRN pain 18. Mylanta 30 ml oral QID PRN heartburn 19. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 20. Bisacodyl 10 mg PR QHS:PRN constipation 21. DiphenhydrAMINE 25 mg PO QHS:PRN severe itching 22. Fleet Enema ___AILY:PRN constipation 23. Milk of Magnesia 30 mL PO DAILY:PRN constipation 24. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation q6hr:PRN SOB, dyspnea 25. TraMADOL (Ultram) 50 mg PO BID:PRN pain 26. TraZODone 25 mg PO QHS:PRN sleep, agitation 27. NovoLIN 70/30 (insulin NPH and regular human) 20 units subcutaneous BID 28. 70/30 20 Units Breakfast 70/30 20 Units Dinner Insulin SC Sliding Scale using HUM Insulin 29. Warfarin Dose is Unknown PO DAILY16 30. loperamide 2 mg oral q2hr:PRN loose stool Discharge Medications: 1. Acetaminophen 650 mg PO Q8H pain 2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 3. Bisacodyl 10 mg PR QHS:PRN constipation 4. Carbidopa-Levodopa (___) 1 TAB PO TID 5. Docusate Sodium 100 mg PO DAILY 6. Ferrous Sulfate 325 mg PO DAILY 7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 8. Glargine 10 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 9. LeVETiracetam 500 mg PO BID 10. Metoprolol Succinate XL 150 mg PO DAILY 11. Psyllium 1 PKT PO DAILY 12. Senna 8.6 mg PO QHS 13. Simvastatin 40 mg PO QPM 14. Tiotropium Bromide 1 CAP IH DAILY 15. Ursodiol 600 mg PO BID 16. Omeprazole 40 mg PO BID 17. QUEtiapine Fumarate 12.5 mg PO QHS 18. QUEtiapine Fumarate 12.5 mg PO DAILY:PRN agitation 19. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation q6hr:PRN SOB, dyspnea 20. TraMADOL (Ultram) 50 mg PO BID:PRN pain 21. Fleet Enema ___AILY:PRN constipation 22. Lactulose 30 mL PO BID 23. loperamide 2 mg oral q2hr:PRN loose stool 24. Milk of Magnesia 30 mL PO DAILY:PRN constipation 25. Mylanta 30 ml oral QID PRN heartburn 26. Warfarin 2 mg PO DAILY16 27. Erythromycin 0.5% Ophth Oint 0.5 in LEFT EYE QID Duration: 5 Days Discharge Disposition: Extended ___ Facility: ___ Discharge Diagnosis: Primary: # ___ Associated Pneumonia # decompensated diastolic HF # suspicion for Hypothyroidism # Encephalopathy # Hypernatremia # Hypoglycemia/Type 2 Diabetes # thrombocytopenia # AF/anticoagulation # Acute on Chronic Kidney Injury # poor po intake Secondary: # Primary Biliary Cirrhosis # chronic iron deficiency anemia # COPD/asthma # ___ Disease/Dementia # Hypertension # History of seizures # ___ disease # HLD Discharge Condition: Mental Status: Confused - most times (A&O x ___. 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: ___ year old woman with COPD, CHF, persistent O2 requirement // interval change of effusion, other acute process interval change of effusion, other acute process IMPRESSION: In comparison with the study of ___, there is substantial enlargement of the cardiac silhouette with moderate pulmonary edema and bilateral effusions with compressive atelectasis at the bases. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with staged dobhoff placement // ___ dobhoff placement XR ___ dobhoff placement XR IMPRESSION: In comparison with the earlier study of this date, there has been placement of a Dobbhoff tube with its tip in the mid to upper stomach. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman s/p dobhoff placement // dobhoff placement dobhoff placement COMPARISON: Chest radiographs ___ through ___. IMPRESSION: 3 images are submitted, showing sequential progression of the esophageal feeding tube with the wire stylet in place from the upper midline on image labeled #1. , to the mid esophagus on #2, to the distal esophagus on # 3. . Moderate to severe cardiomegaly is chronic. Mild pulmonary edema has changed in distribution but not in overall severity since ___ accompanied by stable come moderate bilateral pleural effusion right greater than left. There is no pneumothorax. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: DOBHOFF PLACEMENT IMPRESSION: In comparison with the earlier study of this date, the Dobbhoff tube now extends well into the stomach. Gender: F Race: HISPANIC/LATINO - PUERTO RICAN Arrive by AMBULANCE Chief complaint: Altered mental status Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, DIAB W MANIF NEC ADULT temperature: 95.7 heartrate: 61.0 resprate: 14.0 o2sat: 99.0 sbp: 157.0 dbp: 86.0 level of pain: 13 level of acuity: 2.0

___ ___ presents from SNF with confusion and restlessness overnight, found to be hypoglycemic and hypotensive, with possible HCAP s/p treatment, course complicated by decompensated heart failure, severe delirium, poor PO, and thrombocytopenia. ISSUES ACTIVE AT DISCHARGE # thrombocytopenia: Gradually downtrending since admission, nadired at 52 on ___, currently 72 at discharge. No clinical evidence of bleeding and no H&H drop, so consumptive thrombocytopenia unlikely. Liver and spleen appeared normal on CT in ___ and LFTs were WNL. Etiology was not entirely clear. She was seen by the hematology consult service, and an initial work up was done. Could be due to iron deficiency, medication effect (on cefepime ___, or other etiology. Very low likelihood of HIT. Will need hematology follow up with Dr. ___. # Suspicion for Hypothyroidism: TSH of 12, however in the setting of a hospitalized patient with recent serious medical illness this admission, utility of this TSH is less certain. Her encephalopathy recovered prior to supplementation, so repeat TSH in ___ week recommended to confirm diagnosis. She was not started on supplementation. # Encephalopathy: Initially was quite delerious with mental status ranging from somnolent (responsive to pain) to agitated (pulling IVs and dobhoffs) to baseline (A&O x ___ and pleasantly chatty). For the ___ days prior to discharge, she was at baseline and meaninfully involved in her ___, without any need for chemical or medical restraints. Was possibly related to her pneumonia, heart failure, dysynchronous day/night cycle, and dobhoff. Keppra level was 34.4 (unclear whether peak/trough), which was above the expected range for a 500mg BID dosing schedule (trough RR is 3.1-10.0 mcg/mL and peak RR is 10.0-25.0 mcg/mL). However her mental status improved, so the dosing was not changed. She is very easily oversedated by trazodone, which we discontinued using during this hospitalization. Her Zolpidem was also discontinued. Scheduled 12.5mg seroquel at night to aid with establishing day/night routine. # Hypoglycemia/Type 2 Diabetes: Her initial hypoglycemia prior to presentation was likely related to HCAP, poor PO intake, and insulin regimen. She was changed from 20 units of 70/30 BID with ISS to 10 glargine qHS with sliding scale with no lows and relative control ___ day prior to discharge was 99-215). HgbA1c 9.5 in ___. # AF/anticoagulation: Prior to admission was rate-controlled at home on metoprolol sucinate 200mg daily, she was rate controlled here with 150mg daily. CHADS2 score is 4, has never had CVA. On warfarin, which was initially supratherapeutic on admission (likely decreased PO intake). When she was on tube feeding, she was subtherapeutic and on lovenox. She was therapeutic for 2 days prior to discharge. Warfarin dosing will need to be closely followed while her PO intake is fluctuating. # Nutrition/Concern about swallow: Mainly effected by mental status, requiring dobhoff for medication and tubefeeds for approximately 4 days. She was evaluated by nutrition when she was at her baseline mental status prior to discharge and was recommended for Aspiration precautions, nectar thick and puree, small bites, and 1:1 observation for meals. # Family meeting, Goals of ___: Had a family meeting with her ___, granddaughter, and ___. Reviewed her condition and likely progressive course of her dementia. Discussed that at times during this stay she required physical restraints to prevent her from removing her dobhoff tube multiple times. At this time, they had no changes to what they believe she would want, but will continue to discuss what interventions are within her goals of ___ with her PCP.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: amlodipine Attending: ___ Chief Complaint: diarrhea Major Surgical or Invasive Procedure: none History of Present Illness: Mrs. ___ is a ___ yo woman with PMH of pulmonary HTN and right-sided HF, HTN, HLD, AF, PFO, valvular heart disease p/w diarrhea. Her symptoms began around ___ after taking macrobid for UTI. At that time she noted profuse watery diarrhea. She was admitted ___ and diagnosed with c diff. During that admission her WBC was elevated to 22. She was discharged on high dose oral vancomycin 500 mg q6hrs to complete a 14 day course. She finished the course ___ and shortly after again had increased diarrhea. She returned to the ED ___ for evaluation. During this visit stool samples were sent and she was given a week more of oral vancomycin. Notably after discharge her c diff came back negative. At home she continued to have diarrhea and increasing weakness. She called her PCP and said she was too weak to be seen. Her PCP gave her ___ 4 week course of oral vancomycin. She began to feel too weak to get out of bed and her son was worried she was slightly confused. She also endorses poor PO intake. She denies any fevers, chills, sick contacts. Denies any abdominal pain. 14 point ROS negative except per HPI In the ED vitals on arrival were T 98.7, HR 80, BP 99/58, RR18, O2Sat 95% RA. She was given 1L NS. Labs were checked which were remarkable for Cr 1.7, Hgb 8.9, WBC 9.8, UA with only 2 wbc, INR 2.9. She was not given any medications. Her vitals on transfer were T 97.5, HR 58, BP 108/55, RR16, O2Sat 93% 2L Upon arrival to the floor, the patient feels tired and frustrated she has ongoing symptoms. Endorses the story above. No new complaints. Past Medical History: ===================== 1. Complex pulmonary hypertension: Diagnosed in ___ during hospitalization, right heart catheterization revealing RA 17, PCWP 19, mean PAP 33, 3.6 Woods units. 2. Right ventricular failure. 3. Paroxysmal atrial fibrillation. 4. Heart failure with preserved ejection fraction. 5. Prediabetes (hemoglobin A1c 6.3%). 6. Hypertension. 7. Obstructive sleep apnea, on CPAP. 8. PFO. 9. GERD. 10. Obesity. 11. Former tobacco use. Social History: ___ Family History: Family History: Father died at ___ of heart disease. Mother died at ___ of heart disease, had a CABG and valve replacement prior. 7 siblings, 4 of whom passed away at older age. 4 children who are healthy. No family history of hypertension, diabetes mellitus, or SCD. Physical Exam: ADMISSION EXAM: General Appearance: pleasant, very pale, comfortable, no acute distress Eyes: PERLL, EOMI, no conjuctival injection, anicteric ENT: no sinus tenderness, MMM, oropharynx without exudate Respiratory: CTA b/l with good air movement throughout Cardiovascular: irregular, S1 and S2 wnl, soft systolic murmur Gastrointestinal: obese, nd, +b/s, soft, nt, no masses or HSM Extremities: no cyanosis, right ankle with slight effusion, bilateral varicose veins Skin: warm, no rashes/no jaundice/no skin ulcerations noted Neurological: Alert, oriented to self, time, date, reason for hospitalization. Psychiatric: pleasant, appropriate affect GU: no catheter in place DISCHARGE EXAM: Gen: sitting up in bed, comfortable appearing Eyes: no scleral icterus, EOMI ENT: OP clear, MMM Heart: RRR no mrg, elevated JVD Lungs: mild crackles at bases, otherwise CTA bilaterally Abd: soft nontender, normal bowel sounds Ext: trace pitting edema b/l ___, wwp Neuro: AOx3, moving all extremities Psych: pleasant, appropriate mood and affect Pertinent Results: ADMISSION LABS: ___ 04:00PM BLOOD WBC-9.6 RBC-2.97* Hgb-8.9* Hct-27.6* MCV-93 MCH-30.0 MCHC-32.2 RDW-16.1* RDWSD-54.7* Plt ___ ___ 04:00PM BLOOD ___ PTT-71.4* ___ ___ 04:00PM BLOOD ___ PTT-71.4* ___ ___ 04:00PM BLOOD Glucose-117* UreaN-34* Creat-1.7* Na-138 K-5.0 Cl-98 HCO3-18* AnGap-22* DISCHARGE LABS: ___ 04:00PM URINE MUCOUS-RARE* ___ 09:15AM BLOOD WBC-12.3* RBC-3.11* Hgb-8.8* Hct-28.7* MCV-92 MCH-28.3 MCHC-30.7* RDW-16.1* RDWSD-54.7* Plt ___ ___ 09:15AM BLOOD Glucose-143* UreaN-25* Creat-1.0 Na-142 K-3.8 Cl-100 HCO3-28 AnGap-14 ___ 09:15AM BLOOD Calcium-8.7 Mg-2.1 CXR No definite radiographic evidence for pneumonia. Mild pulmonary vascular congestion with bibasilar atelectasis. CT Abd/Pelvis 1. No evidence of acute colitis or other acute abdominopelvic abnormality. 2. Diverticulosis without evidence of diverticulitis 3. Cholelithiasis 4. Small bilateral pleural effusions with overlying atelectasis. Superimposed pneumonia would be hard to exclude in the proper clinical context. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. AcetaZOLamide 125 mg PO Q24H 2. Amiodarone 200 mg PO DAILY 3. Dabigatran Etexilate 150 mg PO BID 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. Lisinopril 10 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Phenelzine Sulfate 15 mg PO TID 8. Torsemide 20 mg PO EVERY OTHER DAY 9. Torsemide 10 mg PO EVERY OTHER DAY 10. Vitamin D 1000 UNIT PO DAILY 11. Metoprolol Succinate XL 50 mg PO DAILY 12. Vancomycin Oral Liquid ___ mg PO Q6H 13. biotin 1 mg oral DAILY 14. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic (eye) BID 15. Pantoprazole 20 mg PO Q24H Discharge Medications: 1. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 2 Days RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1 tablet(s) by mouth twice a day Disp #*4 Tablet Refills:*0 2. Torsemide 20 mg PO DAILY RX *torsemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. AcetaZOLamide 125 mg PO Q24H 4. Amiodarone 200 mg PO DAILY 5. biotin 1 mg oral DAILY 6. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic (eye) BID 7. Dabigatran Etexilate 150 mg PO BID 8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 9. Lisinopril 10 mg PO DAILY 10. Metoprolol Succinate XL 50 mg PO DAILY 11. Multivitamins 1 TAB PO DAILY 12. Pantoprazole 20 mg PO Q24H 13. Phenelzine Sulfate 15 mg PO TID 14. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Non-infectious diarrhea Acute heart failure exacerbation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with weakness//pneumonia? TECHNIQUE: Upright AP view of the chest COMPARISON: Chest radiograph ___ FINDINGS: Evaluation is slightly limited by patient rotation. Moderate to severe cardiac enlargement is re-demonstrated, grossly unchanged. The aorta is tortuous with mild atherosclerotic calcifications noted at the aortic arch. Central mediastinal venous congestion is present. Mild pulmonary vascular congestion is demonstrated with patchy atelectasis noted in the lung bases. Lungs are hyperinflated with mild emphysematous changes re-demonstrated. No focal consolidation, pleural effusion, or pneumothorax is detected. No acute osseous abnormality is visualized. IMPRESSION: No definite radiographic evidence for pneumonia. Mild pulmonary vascular congestion with bibasilar atelectasis. Radiology Report EXAMINATION: CT ABD AND PELVIS W/O CONTRAST TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired without intravenous contrast. Non-contrast scan has several limitations in detecting vascular and parenchymal organ abnormalities, including tumor detection. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 7.1 s, 46.4 cm; CTDIvol = 20.1 mGy (Body) DLP = 919.1 mGy-cm. Total DLP (Body) = 919 mGy-cm. COMPARISON: ___ FINDINGS: LOWER CHEST: There are small bilateral pleural effusions, right greater than left with subjacent opacities which likely reflect atelectasis however superimposed pneumonia would be hard to exclude. The visualized airways are patent. There is a large hiatal hernia. Calcification of the mitral valve is present. No pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout. There is no evidence of focal lesions within the limitations of an unenhanced scan. The previously seen enhancing lesion in the left hepatic lobe is not visualized on this nonenhanced study. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder contains gallstones without wall thickening or evidence of inflammation. 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. There is a 1.3 cm calcified splenic artery aneurysm, unchanged. 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: There is a large hiatal hernia. Otherwise the stomach is unremarkable. Small bowel loops demonstrate normal caliber and wall thickness throughout. There is extensive diverticulosis of the sigmoid and descending colon without evidence of acute diverticulitis. No abnormal bowel wall thickening or pericolonic inflammation to suggest active colitis. The appendix is normal. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Moderate to severe 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 acute colitis or other acute abdominopelvic abnormality. 2. Diverticulosis without evidence of diverticulitis 3. Cholelithiasis 4. Small bilateral pleural effusions with overlying atelectasis. Superimposed pneumonia would be hard to exclude in the proper clinical context. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Diarrhea Diagnosed with Diarrhea, unspecified temperature: 98.7 heartrate: 80.0 resprate: 18.0 o2sat: 95.0 sbp: 99.0 dbp: 58.0 level of pain: 0 level of acuity: 3.0

This is a ___ year old female with past medical history of complex pulmonary hypertension, paroxysmal atrial fibrillation, diastolic CHF, OSA on CPAP, obesity, with recent admission ___ for Cdiff colitis admitted with persistent loose stool and dyspnea on exertion, found to be volume overloaded # Diarrhea Patient presented with multiple bowel movements at home in setting of prior hospital stay for Cdiff colitis. She had been seen in ED with a negative Cdiff PCR but had been continued on PO vancomycin anyways. On this admission, repeat Cdiff PCR was negative. CT abd/pelvis did not show signs of colitis or other acute GI abnormality. Diarrhea spontaneously resolved following admission and returned to normal frequency. It is possible that she had a viral enteritis that resolved around time of presentation. # Acute hypoxic respiratory failure # Acute on Chronic Diastolic CHF # ___ secondary to cardiorenal syndrome Patient admitted with hypoxia, Cr 1.7 from baseline 1.0, as well as weight of 190lbs from prevously recorded 180lbs during prior admission. Patient was felt to have cardiorenal syndrome secondary to acute dCHF. She was started on IV diuresis with improvement in her weight and oxygenation. She was discharged at her dry weight of 179-180lb and resumed on home torsemide (dose increased from 20mg/10mg QOD to 20mg daily). She will have ___ come for routine weight and BMP checks. # Anemia Patient admitted with Hgb 8.6 from 10.7 during recent prior admission. Labs notable for absence of signs of hemolysis or nutritional deficiency. She was guaiac negative without signs of active bleeding. She did have a large bruise on her posterior L shoulder and concern that her pradaxa may have acheived supratherapeutic levels in setting of her ___ as below. Her Hgb subsequently remained stable without worsening anemia. It was felt that she may have had a missed bleed in the setting of above pradaxa issues with possible bone suppression in setting of her recent illnesses. Would consider outpatient workup if anemia persists or worsens. # UTI: pt found to have positive urine culture for pansesnitive e.coli on admission. However, her UA was initially negative. D/t worsening leukocytosis UA was rechecked and found to be dirty on repeat. She was treated with 3 days of Bactrim for uncomplicated cystitis. # Paroxysmal Afib As above, in setting of renal failure, Pradaxa was held initially. It was then restarted once ___ resolved. #HTN Held lisinopril in setting of acute illness above. Restarted on discharge. #OSA Continued acetazolamide # Depression Continued Phenelzine # GERD Continued PPI

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: naproxen / Zoloft Attending: ___ Chief Complaint: Acute on chronic chest pain Major Surgical or Invasive Procedure: ___ LP (___) History of Present Illness: HPI: ___ with hx of paranoid schizophrenia, NIDDM, recently diagnosed stage IV lung cancer not yet undergoing treatment presenting with acute on chronic chest pain. Pt was admitted to ___ ___ after presenting with chest pain, dyspnea, confusion, and 40 lb weight loss. He was known at that time to have a RUL spiculated mass with hilar lymphadenopathy as well as mass effect on vessels/airways; EBUS on ___ had demonstrated NSCLC at CHA. CT chest with contrast at that time also raised concern for metastatic disease to LNs, bone, and adrenals. On ___, he presented to ___ with ongoing chest pain and DOE, which had progressed. He also endorsed new headache, and was subsequently found to have intracranial metastatic disease. During that hospitalization, MRI head and spine were deferred given known shrapnel in RUE (per notes, cleared by radiology for MRI but pt reluctant). CT chest was negative for PE, and demonstrated known RUL mass/R mediastinal lesion with postobstructive consolidation (atelectasis more likely than pneumonia given absence of cough or fever). Pt had previously been scheduled for bronchoscopy with CHA pulmonologist Dr. ___ persistent plugging of RML/RLL; plan at that time was to pursue bronchoscopy as outpatient. Plan was also made to follow up with ___ oncology at pt and pt's mother's request; thoracic oncology team planned to obtain pathology from CHA for further testing. Intracranial metastases prompted neurosurgical consultation; recommended outpatient f/u for further treatment planning. Since discharge, pt states that he thinks he has been mixing up his medications. At present, he organizes his own medications, but states that his mother is planning to start helping with his medications. Pt describes ___ substernal chest pain, worse with inspiration, which has interfered with his ability to fall asleep intermittently over the past ___ nights. He states that the pain moves from his back to his front (not front to back, and not two separate pains). Quality of pain is "like something pushing through me," fluctuates in intensity, but persists throughout the night. Pain has been present for about 1 month. He takes Tylenol pm and oxycontin, tizanidine for pain, with good effect. Pain is worse with movement. He initially denies cough, although subsequently recalls a productive cough, nonbloody, the details of which he cannot recall, but believes that it occurred while using the incentive spirometer. Denies F/C, endorses some posttussive emesis, nonbloody. Denies abdominal pain, diarrhea, constipation, dysuria, but he has noted darker urine. He describes weight loss: 185 lbs 3 weeks prior, now ___ lbs. Weight loss is unintentional. He endorses R frontal headaches, wrapping around to L temporal area and occiput, similar compared to prior. Denies ___ edema. He endorses constipation for approx. 1 week, denies bowel/bladder incontinence or urinary retention, denies saddle anesthesia. In the ___ ED: VS 96.6, 121->85->100, 120/74, 100% RA Exam notable for: Resp: Reduced lung sounds on right side compared to left, no wheezes or rhonchi, normal work of breathing Cardiovascular: Regular rate and rhythm, normal ___ and ___ heart sounds Labs notable for: WBC 18.7, Hb 9.4, Plt 621 BUN 14, Cr 0.8 TnT<0.01 x2 BNP 106 ALT 22, AST 40 Alk phos 264 Tbili 0.3, Albumin 3.3 Serum tox negative Imaging: CTA chest: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Essentially unchanged evaluation from ___ ___ with a right upper lobe pulmonary mass in addition to mediastinal and right hilar lymphadenopathy with resultant attenuation of the right middle lobe bronchi and subsequent findings suggestive of postobstructive pneumonia. 3. Innumerable lytic metastases of the ribs and thoracic spine, notable for a T5 destructive vertebral mass with intra canal extension, also unchanged from prior study. 4. 2.2 cm indeterminate right adrenal nodule may represent metastatic disease and is also unchanged. Received: Tylenol Morphine sulfate 4 mg IV Piperacillin-tazobactam 4.5 g IV x1 On arrival to the floor, pt provides above history. ROS: 10 point review of system reviewed and negative except as otherwise described in HPI Past Medical History: per prior notes, confirmed with pt: Schizophrenia Anxiety Asthma GERD HLD Chronic LBP and LLE pain Stage IV lung cancer as per HPI Social History: ___ Family History: Aunt with history of lung cancer Physical Exam: ADMISSION PHYSICAL EXAM VS: ___ 2352 Temp: 97.6 PO BP: 115/77 L Sitting HR: 100 RR: 18 O2 sat: 94% O2 delivery: Ra GEN: alert and interactive, comfortable, no acute distress, sitting at edge of bed HEENT: PERRL, anicteric, conjunctiva pink, oropharynx without lesion or exudate, moist mucus membranes, ears without lesions or apparent trauma LYMPH: no anterior/posterior cervical, supraclavicular adenopathy CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs, or gallops, S1/S2 are not diminished; pulsus <4 LUNGS: Decreased breath sounds at R base, otherwise CTAB without wheeze or rhonchi GI: soft, nontender, without rebounding or guarding, nondistended with normal active bowel sounds, no hepatomegaly EXTREMITIES: no clubbing, cyanosis, or edema GU: no foley SKIN: no rashes, petechia, lesions, or echymoses; warm to palpation NEURO: A&Ox3, cranial nerves II-XII intact, strength in bilateral LEs is ___ including hip flexors, knee extension and flexion; sensation to light touch intact in bilateral LEs. Gait slow, cautious, with slightly wide gait. Pt declines UE strength testing on admission ___ fatigue. PSYCH: blunted affect, appropriate DISCHARGE PHYSICAL EXAM Pertinent Results: ADMISSION LABS: ___ 02:30PM BLOOD WBC: 18.7* RBC: 3.76* Hgb: 9.4* Hct: 29.4* MCV: 78* MCH: 25.0* MCHC: 32.0 RDW: 15.8* RDWSD: 43.___* ___ 02:30PM BLOOD Neuts: 61.8 Lymphs: ___ Monos: 13.0 Eos: 0.1* Baso: 0.3 Im ___: 0.6 AbsNeut: 11.55* AbsLymp: 4.53* AbsMono: 2.44* AbsEos: 0.02* AbsBaso: 0.06 ___ 02:30PM BLOOD Glucose: 99 UreaN: 14 Creat: 0.8 Na: 142 K: 4.2 Cl: 95* HCO3: 27 AnGap: 20* ___ 05:36PM BLOOD ALT: 22 AST: 40 AlkPhos: 264* TotBili: 0.3 ___ 05:36PM BLOOD proBNP: 106 ___ 05:36PM BLOOD cTropnT: <0.01 ___ 02:30PM BLOOD cTropnT: <0.01 ___ 05:36PM BLOOD Albumin: 3.3* ___ 05:36PM BLOOD ASA: NEG Ethanol: NEG Acetmnp: NEG Tricycl: NEG DISCHARGE LABS ============= ___ 06:55AM BLOOD WBC-17.4* RBC-3.33* Hgb-8.7* Hct-26.8* MCV-81* MCH-26.1 MCHC-32.5 RDW-21.3* RDWSD-59.7* Plt ___ IMAGING ======= EKG: Sinus tachycardia at 108 bpm, normal axis, normal intervals (QTc 487), TW flattening in all limb leads, and in V5-V6, TWIs in V5, no ST segment changes, no pathologic Q waves. Compared to prior, tachycardia and TWI flattening is new. # CT A/P with contrast (___): 1. Re-demonstration of a 2.6 cm right adrenal nodule, which could reflect metastasis. Mild thickening of the left adrenal gland is indeterminate. 2. Extensive predominantly lytic osseous metastases throughout the imaged lumbar spine and pelvis. No pathologic fractures are seen. The L5 lesion does have a soft tissue component that encroaches slightly on the canal. If clinically appropriate based on neurologic examination, a lumbar spine MRI could be performed to evaluate for tumor invasion into the spinal canal. 3. Re-demonstration of right basilar atelectasis. # CT Head w/ contrast (___) 1. Re-identified a 1.4 cm mass anterior to the right temporal lobe with associated osseous destruction and possible periosteal reaction of the greater wing of the right sphenoid bone, with possible underlying lytic changes in the left frontal bone, concerning for possible metastasis, and extra-axial mass lesion such as a meningioma can't be completely rule out, correlation with MRI is recommended.2. Unchanged 3 mm crescentic, enhancing rim along the right frontal convexity which may represent dural thickening, metastatic disease or subdural hemorrhage.3. Relatively unchanged sinus disease. # Chest CTA (___): 1. No evidence of pulmonary embolism or aortic abnormality. 2. Essentially unchanged evaluation from CTA ___ with a right upper lobe pulmonary mass in addition to mediastinal and right hilar lymphadenopathy with resultant attenuation of the right middle lobe bronchi and subsequent findings suggestive of postobstructive pneumonia throughout the right lung. 3. Innumerable lytic metastases of the ribs and thoracic spine, notable for a T5 destructive vertebral mass with intra canal extension, also unchanged from prior study. 4. 2.2 cm indeterminate right adrenal nodule may represent metastatic disease and is also unchanged. #CXR ___ The right pleural effusion has significantly increased in volume since the prior study. The mediastinal adenopathy and right hilar adenopathy is unchanged. The right upper lobe mass is also unchanged. Cardiomediastinal silhouette is stable. Radiopaque densities projecting over the Left chest are unchanged. #CT HEAD ___. Re-demonstrated are multiple extra-axial soft tissue masses with associated bony destruction in the right temporal and bilateral frontal lobes, which remain concerning for possible metastasis. As before, extra-axial mass lesions such as a meningioma cannot be excluded. 2. Interval decrease in density in a 3 mm extra-axial collection along the right frontal convexity likely represents subdural hemorrhage. 3. No evidence of new hemorrhage or infarction. #CT L SPINE ___ Destructive bone lesions along the lumbar spine, although without evidence for substantial lumbar spinal stenosis based on this. #CT CHEST ___. Moderate narrowing of the superior vena cava as it enters the atrium. 2. Marked increase in atelectasis of the right middle and lower lobes with the concern for superimposed infection. Correlation with clinical circumstances is recommended. 3. No definite short-term change in metastatic lung cancer including destructive spinal lesions with some encroachment into the spinal canal at T5. ___ US ___. No evidence of deep vein thrombosis in the right upper extremity. 2. Superficial thrombophlebitis of a branch of the right cephalic vein near the antecubital fossa. #CTA NECK ___. Patent appearance of the carotid and vertebral arteries in the neck without evidence of stenosis, occlusion or dissection. 2. No evidence of filling defects noted within the internal jugular and subclavian veins. 3. There is a 2 cm irregular nodule noted along the pleura of the right upper lobe in the setting of bilateral pleural effusions in the setting of known lung cancer. 4. There is asymmetric soft tissue edema and fat stranding noted about the right face including the preseptal right orbital region with diffuse lymphadenopathy throughout the neck and mediastinum. No evidence of abscesses. 5. Re-identified enhancing metastatic lesion with surrounding bony erosion of the sphenoid involving the frontotemporal region. There is also suspicion for calvarial lytic lesions, permeative changes of the right frontal calvarium and known diffuse osseous metastases including lytic lesions within the thoracic spine. #CXR ___ Heart size and mediastinum are stable. Right pleural effusion is more moderate associated also with atelectasis and elevation of right hemidiaphragm. Right upper lobe pulmonary nodules better appreciated on the chest CT from ___. Left lung is overall clear. There is no interval development of left pleural effusion. There is no appreciable pneumothorax. No pulmonary edema. #CTA CHEST ___. Limited evaluation of the subsegmental pulmonary arteries, however no evidence of central pulmonary embolism through the segmental pulmonary arteries. No acute aortic abnormality. No evidence of pulmonary embolism or aortic abnormality. 2. Minimal change in extensive right lower lobe and, to a lesser extent, right middle lobe atelectasis. Relative hypoattenuating opacities in the right middle lobe could represent pneumonia, or alternatively infiltrative extension of right hilar lymphadenopathy, and clinical correlation is recommended. 3. No short-term interval change in metastatic lung cancer, again with a destructive bony lesion at the T5 vertebral body with encroachment into the vertebral canal. 4. Small right pleural effusion. #CT HEAD WO CONTRAST ___. Moderately motion limited exam. Given the limitation, multiple extra-axial soft tissue masses with associated bone destruction in the right temporal and bilateral frontal lobes are grossly unchanged. 2. Known right frontal convexity 3 mm extra-axial collection is also unchanged. No new intracranial hemorrhage. #CXR ___ The right hemidiaphragm is elevated with atelectasis in the right lung base. A small right pleural effusion is unchanged. No focal consolidation or pneumothorax is identified. The cardiomediastinal silhouette is stable in appearance. The opacities in the right middle lobe and right hilar lymphadenopathy are better appreciated on prior CT. No acute osseous abnormalities are identified. Metallic densities projecting over the left hemithorax are noted. #EEG ___ HOUR IMPRESSION: This was an abnormal continuous video-EEG monitoring study due to diffuse background indicative of a mild encephalopathy, which is nonspecific as to etiology. Common causes include medication effects, toxic- metabolic disturbances and/or infection. Intermittent frontally predominant rhythmic delta slowing (FIRDA) is a nonspecific finding and can be seen with toxic-metabolic disturbances and deep midline lesions. There are no electrographic seizures. MICRO ====== # ___ LP (___): TNC 6, RBC 1, TP 140, Gluc 37, LDH 40 Medications on Admission: The Preadmission Medication list may be inaccurate and requires further investigation. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN Wheezing 2. Amitriptyline 50 mg PO QHS 3. Benztropine Mesylate 0.5 mg PO BID 4. BuPROPion 100 mg PO BID 5. Divalproex (DELayed Release) 500 mg PO BID 6. Fluticasone Propionate 110mcg 1 PUFF IH BID 7. Gabapentin 800 mg PO TID 8. Prazosin 1 mg PO QHS:PRN nightmares 9. RisperiDONE 4 mg PO QHS 10. RisperiDONE 1 mg PO DAILY:PRN Agitation 11. Simvastatin 40 mg PO QPM 12. Venlafaxine XR 225 mg PO DAILY 13. Vitamin D 1000 UNIT PO DAILY 14. HydrOXYzine 25 mg PO Q8H:PRN Itching 15. Tizanidine 2 mg PO TID 16. varenicline 1 mg oral BID 17. MetFORMIN (Glucophage) 500 mg PO DAILY 18. Percocet (oxyCODONE-acetaminophen) 10 mg oral Q4H:PRN Pain Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary dx Metastatic lung cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ with chest pain and hx cancer// ? effusion/ PNA COMPARISON: Prior CT of the chest from ___ FINDINGS: PA and lateral views of the chest provided. Multiple metallic BBs are seen projecting over the chest likely representing retained foreign bodies. There is persistent right basal opacity which likely represents a combination of residual consolidation and trace effusion. The overall appearance is not significantly changed from prior CT allowing for differences in technique. Known right hilar and right upper lobe masses are not well visualized. Cardiomediastinal silhouette appears stable. Bony structures appear grossly unchanged. IMPRESSION: Persistent right basal opacity remains concerning for residual consolidation and possible tiny associated effusion. Known right hilar and right upper lobe mass is better assessed on prior CT. Radiology Report EXAMINATION: CTA CHEST WITH CONTRAST INDICATION: ___ with pleuritic chest pain and shortness of breath.// 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: Total DLP (Body) = 473 mGy-cm. COMPARISON: CTA chest from ___ FINDINGS: HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the subsegmental level without filling defect to indicate a pulmonary embolus. The thoracic aorta is normal in caliber without evidence of dissection or intramural hematoma. The heart, pericardium, and great vessels are within normal limits. No pericardial effusion is seen. AXILLA, HILA, AND MEDIASTINUM: There is a re-demonstrated right hilar lymphadenopathy with a conglomerate encasing and attenuating the right pulmonary artery measuring approximately 4.6 x 2.5 cm, unchanged from prior study. Additional enlarged mediastinal lymph nodes are demonstrated in the subcarinal region and are also unchanged no axillary or left hilar lymphadenopathy is present. PLEURAL SPACES: No pleural effusion or pneumothorax. LUNGS/AIRWAYS: Again seen in the anterior right upper lobe is a 3.0 x 2.1 cm pulmonary mass, unchanged from prior. The above described right hilar nodal mass encases the right middle lobe bronchi with resultant hypodense consolidation in the right upper, middle, and lower lobes concerning for postobstructive pneumonia, and is also unchanged. Atelectasis is demonstrated at the right lung base. Moderate centrilobular emphysema is demonstrated throughout bilaterally, otherwise the left lung is clear. The airways are patent to the level of the segmental bronchi bilaterally. BASE OF NECK: An enlarged right thyroid lobe without discrete nodularity is again demonstrated. ABDOMEN: Included portion of the upper abdomen is notable for a 2.2 cm right adrenal nodule, also unchanged. BONES: There is re-demonstration of multiple osseous lytic lesions throughout the ribs and vertebral bodies highly concerning for metastatic disease, all of which are grossly unchanged, and most notable for the T5 vertebral body destructive lytic mass with soft tissue extension into the anterior spinal canal, similar in appearance to prior. IMPRESSION: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Essentially unchanged evaluation from CTA ___ with a right upper lobe pulmonary mass in addition to mediastinal and right hilar lymphadenopathy with resultant attenuation of the right middle lobe bronchi and subsequent findings suggestive of postobstructive pneumonia throughout the right lung. 3. Innumerable lytic metastases of the ribs and thoracic spine, notable for a T5 destructive vertebral mass with intra canal extension, also unchanged from prior study. 4. 2.2 cm indeterminate right adrenal nodule may represent metastatic disease and is also unchanged. Radiology Report EXAMINATION: LUMBAR PUNCTURE (W/ FLUORO) N8 RF SPINE INDICATION: ___ with hx of paranoid schizophrenia, NIDDM, recently diagnosed stage IV lung cancer not yet undergoing treatment presenting with acute on chronic chest pain in thesetting of widely metastatic disease. Has mets to brain, complains of headache. Prior attempt of LP as inpt was unsuccessful. Had outpt ___ LP scheduled for ___, but now needing expedited care.// obtain LP for cytology TECHNIQUE: After informed consent was obtained from the patient and mother explaining the risks, benefits, and alternatives to the procedure, the patient was laid in prone position on the fluoroscopic table. A pre-procedure time-out was performed confirming the patient's identity, relevant history, procedure to be performed and labs. Puncture was performed at L4-5. Approximately 5 cc of 1% lidocaine was administered for local anesthesia. Under fluoroscopic guidance, a 20 gauge, 3.5 inch spinal needle was inserted into the thecal sac. There was good return of clear CSF. 16 mls of CSF were collected in 4 tubes and sent for requested analysis. Additional 4 mL CSF was collected in a single cytology tube. COMPARISON: None. FINDINGS: Successful lumbar puncture was performed at L4-5. 16 mls of CSF were collected in 4 tubes and 4 mL of CSF was collected in a single cytology tube. IMPRESSION: 1. Lumbar puncture at L4-L5 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: CHEST (PORTABLE AP) INDICATION: ___ year old man with widely metastatic lung cancer// New hypoxia after chest radiation TECHNIQUE: Chest AP COMPARISON: ___ IMPRESSION: The right pleural effusion has significantly increased in volume since the prior study. The mediastinal adenopathy and right hilar adenopathy is unchanged. The right upper lobe mass is also unchanged. Cardiomediastinal silhouette is stable. Radiopaque densities projecting over the Left chest are unchanged. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with known metastatic lung cancer, mets to brain// Acute onset lethargy this AM TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Stationary Acquisition 4.0 s, 15.1 cm; CTDIvol = 49.8 mGy (Head) DLP = 752.0 mGy-cm. 2) Stationary Acquisition 2.0 s, 7.7 cm; CTDIvol = 48.8 mGy (Head) DLP = 376.0 mGy-cm. Total DLP (Head) = 1,128 mGy-cm. COMPARISON: Head CT dated ___. FINDINGS: Re-demonstrated is a thin, 3 mm subdural collection along the right frontal convexity. While the more posterior aspect remains hyperdense, most of the collection appears more hypodense. The 1.4 x 1.3 cm extra-axial soft tissue density anterior to the right temporal lobe (5:9) is unchanged, and may represent a metastatic lesion or meningioma. There is unchanged periosteal reaction with surrounding osseous destruction of the greater wing of the sphenoid bone. A 0.7 x 0.6 cm possible lytic lesion in the left frontal bone (05:12) is unchanged. There is unchanged soft tissue thickening overlying the right frontal bone. There is no evidence of fracture, infarction,hemorrhage, or edema. There is prominence of the ventricles and sulci suggestive of involutional changes. Mild periventricular and subcortical white matter hypodensities are nonspecific, but likely represent sequela of chronic ischemic microvascular disease. There is increasing opacification of the right frontal sinus, and mild mucosal thickening in the left frontal sinus, bilateral ethmoid air cells and bilateral maxillary sinuses. Otherwise, the visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are normal. IMPRESSION: 1. Re-demonstrated are multiple extra-axial soft tissue masses with associated bony destruction in the right temporal and bilateral frontal lobes, which remain concerning for possible metastasis. As before, extra-axial mass lesions such as a meningioma cannot be excluded. 2. Interval decrease in density in a 3 mm extra-axial collection along the right frontal convexity likely represents subdural hemorrhage. 3. No evidence of new hemorrhage or infarction. Radiology Report EXAMINATION: CT CHEST W/CONTRAST Q412 INDICATION: ___ year old man with known metastatic lung cancer, now with increased facial swelling. // CT VenogramPost contrast CT venogram to evaluate for SVC syndrome TECHNIQUE: Multidetector CT images of the chest were obtained without intravenous contrast. This was followed by delayed contrast-enhanced imaging of the chest. Sagittal and coronal reformations of the contrast-enhanced series are included in the study. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.6 s, 29.9 cm; CTDIvol = 3.8 mGy (Body) DLP = 112.4 mGy-cm. 2) Spiral Acquisition 4.6 s, 29.7 cm; CTDIvol = 11.0 mGy (Body) DLP = 319.1 mGy-cm. Total DLP (Body) = 432 mGy-cm. COMPARISON: ___. FINDINGS: The superior vena cava is patent. The cavoatrial junction is somewhat narrowed. Minimum caliber is about 8 mm in diameter compared to background diameter of 20 mm. The heart is borderline in size. There is a small right-sided pleural effusion and a trace left-sided pleural effusion, both new. Invasive right hilar and subcarinal lymphadenopathy appears unchanged. A number of other mildly prominent mediastinal lymph nodes also show no definite short-term change. A large medial right upper lobe nodule is unchanged. Emphysema is mild. The right lower lobe shows much more extensive opacification with air bronchograms, and the right middle lobe is now collapsed with a relatively hypoattenuating appearance raising concern for pneumonia. Limited views of the upper abdomen show right adrenal masses suggesting metastatic disease and more equivocal thickening of the left adrenal but probably also involved with metastatic disease. Dysmorphic spleen, as before. Widespread predominantly blastic skeletal metastases demonstrate no short definite short-term change. Moderately extensive lytic lesions are most striking in T1, T3 and T5, as before. T5 is again partly collapsed with a soft tissue mass mildly encroaching into the spinal canal as before. IMPRESSION: 1. Moderate narrowing of the superior vena cava as it enters the atrium. 2. Marked increase in atelectasis of the right middle and lower lobes with the concern for superimposed infection. Correlation with clinical circumstances is recommended. 3. No definite short-term change in metastatic lung cancer including destructive spinal lesions with some encroachment into the spinal canal at T5. Radiology Report EXAMINATION: CT L-SPINE W/ CONTRAST Q332 INDICATION: ___ year old man with metastatic lung cancer and ___ weakness // Eval for large lumbar mets TECHNIQUE: Multidetector CT images of the lumbar spine were obtained after delayed contrast administration. Sagittal and coronal reformations were also performed. DOSE: Acquisition sequence: 1) Spiral Acquisition 6.7 s, 36.1 cm; CTDIvol = 22.4 mGy (Body) DLP = 794.6 mGy-cm. Total DLP (Body) = 795 mGy-cm. COMPARISON: CT of the abdomen and pelvis is available from ___. FINDINGS: There is extensive mixed lytic and blastic disease. This demonstrates no short-term change. Moderately large lytic lesion is noted along the anterior L2 vertebral body in addition other lesions. An L5 lesion involves the left posterior part of the spinal canal including soft tissue mass partly growing posteriorly into the spinal canal, yielding mild spinal stenosis only, and narrowing of the left L5-S1 neural foramen. There is an extensive metastasis involving the right ilium and destructive lesion and at unchanged along the anterior column of the right acetabulum, partly imaged. Additional lesions include medium-sized lytic lesion in the left ilium. Two suspicious right adrenal masses suggest metastatic disease without short-term change. The left adrenal is thickened, possibly involved with metastatic disease. Trace free fluid is found in the pelvic cul de sac. Atherosclerotic calcification is moderate. IMPRESSION: Destructive bone lesions along the lumbar spine, although without evidence for substantial lumbar spinal stenosis based on this. Radiology Report EXAMINATION: CTA NECK WANDW/OC AND RECONS Q25 CT NECK INDICATION: ___ year old man with metastatic lung cancer // Venous phase pleaseUnilateral swelling of right face TECHNIQUE: Rapid axial imaging was performed from the aortic arch through the skull base during infusion of Omnipaque intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 14.6 mGy (Head) DLP = 2.9 mGy-cm. 2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 14.6 mGy (Head) DLP = 2.9 mGy-cm. 3) Stationary Acquisition 7.1 s, 0.2 cm; CTDIvol = 113.4 mGy (Head) DLP = 22.7 mGy-cm. 4) Spiral Acquisition 4.1 s, 26.7 cm; CTDIvol = 32.7 mGy (Head) DLP = 851.3 mGy-cm. 5) Spiral Acquisition 4.1 s, 26.7 cm; CTDIvol = 32.7 mGy (Head) DLP = 851.3 mGy-cm. Total DLP (Head) = 1,731 mGy-cm. COMPARISON: None. FINDINGS: CTA neck: The left vertebral artery originates directly from the aortic arch. This is an anatomic variant. There is minimal calcification of the aortic arch and carotid bifurcations bilaterally. Right dominant vertebral artery. No stenosis of the internal carotid arteries bilaterally by NASCET criteria. CT angiography of the neck shows patent appearance of the carotid and vertebral arteries without stenosis or occlusion or dissection. CTV neck: No evidence of filling defects within the internal jugular and partially imaged subclavian veins. Other: There is a 2 cm irregular nodule appreciated along the pleura of the right upper lobe (4:1). Bilateral pleural effusions, right greater than left. Emphysematous changes noted in the right apex. Multiple metallic fragments are noted within the soft tissues of the left hemithorax, possibly bullet fragments. The thyroid gland appears grossly unremarkable. Asymmetric soft tissue edema and fat stranding noted throughout the right face, including the preseptal right orbital region. No evidence of abnormal fluid collections. There are enlarged lymph nodes in the supraclavicular region bilaterally measuring 1.4 cm on the right (06:59) and 1 cm on the left (6:70). Another 1 cm lymph node noted in level 2B on the left (6:146). Prominent lymph nodes also noted within the mediastinum measuring upwards of 1 cm (6:19). Re-identified enhancing metastatic lesion with bony erosion of the sphenoid (4:191). Calvarial lesions of with adjacent soft tissue are also suspicious for lytic lesions (04: 192, 204). The right frontal calvarium involves permeative changes (04:201). Partially visualized subdural hemorrhage is re-identified along the right convexity (04:202). Mild mucosal thickening seen in the bilateral maxillary sinuses and ethmoid air cells (4:153). Near complete opacification of the right frontal sinus (4:182). Patient with known diffuse skeletal metastases including a 1 cm lytic lesion within the T1 vertebral body (6:79). Mild multilevel degenerate changes of visualized spine with prominent anterior osteophyte at C5. No high-grade spinal canal stenosis. IMPRESSION: 1. Patent appearance of the carotid and vertebral arteries in the neck without evidence of stenosis, occlusion or dissection. 2. No evidence of filling defects noted within the internal jugular and subclavian veins. 3. There is a 2 cm irregular nodule noted along the pleura of the right upper lobe in the setting of bilateral pleural effusions in the setting of known lung cancer. 4. There is asymmetric soft tissue edema and fat stranding noted about the right face including the preseptal right orbital region with diffuse lymphadenopathy throughout the neck and mediastinum. No evidence of abscesses. 5. Re-identified enhancing metastatic lesion with surrounding bony erosion of the sphenoid involving the frontotemporal region. There is also suspicion for calvarial lytic lesions, permeative changes of the right frontal calvarium and known diffuse osseous metastases including lytic lesions within the thoracic spine. Radiology Report EXAMINATION: UNILAT UP EXT VEINS US INDICATION: ___ year old man with metastatic lung cancer and RUE swelling // RUE doppler to eval for DVT TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper extremity veins. Right upper extremity duplex ultrasound COMPARISON: No priors are available for comparison FINDINGS: There is normal flow with respiratory variation in the bilateral subclavian veins. The right internal jugular, axillary, and brachial veins are patent, show normal color flow, spectral doppler, and compressibility. The basilic vein is patent, compressible and show normal color flow. There is thrombus in a branch of the right cephalic vein near the antecubital fossa, consistent with superficial thrombophlebitis. IMPRESSION: 1. No evidence of deep vein thrombosis in the right upper extremity. 2. Superficial thrombophlebitis of a branch of the right cephalic vein near the antecubital fossa. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with metastatic lung cancer and post obstructive pneumonia, now with tachycardia and hypoxia // Evaluate for pulmonary edema, pneumonia. Evaluate for pulmonary edema, pneumonia. IMPRESSION: Heart size and mediastinum are stable. Right pleural effusion is more moderate associated also with atelectasis and elevation of right hemidiaphragm. Right upper lobe pulmonary nodules better appreciated on the chest CT from ___. Left lung is overall clear. There is no interval development of left pleural effusion. There is no appreciable pneumothorax. No pulmonary edema. Radiology Report EXAMINATION: CTA CHEST WITH CONTRAST INDICATION: ___ year old man with metastatic lung cancer, tachycardia, mild new hypoxia // assess for PE TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of intravenous contrast. Reformatted coronal, sagittal, thin slice axial images, and oblique maximal intensity projection images were submitted to PACS and reviewed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.2 mGy (Body) DLP = 1.8 mGy-cm. 2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.2 mGy (Body) DLP = 1.8 mGy-cm. 3) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.2 mGy (Body) DLP = 1.8 mGy-cm. 4) Stationary Acquisition 4.6 s, 0.2 cm; CTDIvol = 77.0 mGy (Body) DLP = 15.4 mGy-cm. 5) Spiral Acquisition 5.4 s, 35.1 cm; CTDIvol = 10.0 mGy (Body) DLP = 344.5 mGy-cm. Total DLP (Body) = 365 mGy-cm. COMPARISON: CT chest from ___ and ___ FINDINGS: HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the segmental level without filling defect to indicate a pulmonary embolus. Limited evaluation of the subsegmental pulmonary arteries due to motion artifact. The thoracic aorta is normal in caliber without evidence of dissection or intramural hematoma. The main pulmonary artery is top normal in caliber. The heart, pericardium, and great vessels are unchanged. The superior vena cava remains patent. Narrowing of the superior vena cava near the cavoatrial junction to 9 mm is similar to prior study from ___. No pericardial effusion is seen. AXILLA, HILA, AND MEDIASTINUM: Extensive, infiltrative right hilar and mediastinal lymphadenopathy is grossly unchanged compared to the prior study from ___. PLEURAL SPACES: Trace right pleural effusion is unchanged. No pneumothorax. LUNGS/AIRWAYS: A paramediastinal right upper lobe mass measuring 3.1 cm is unchanged (series 6:110). There is extensive atelectasis and volume loss in the right lower lobe, and to a lesser extent the right middle lobe, similar to the immediate prior study. Relative hypoattenuating opacities in the right middle lobe could represent pneumonia/infection, or extension of extensive right hilar lymphadenopathy. BASE OF NECK: Visualized portions of the base of the neck show no abnormality. ABDOMEN: Included portion of the upper abdomen is notable for a 2.8 cm right adrenal mass, concerning for metastatic disease. Thickening of the left adrenal gland is similar to the previous study, also suspicious for metastatic involvement. Dysmorphic splenic appearance is unchanged. BONES: Redemonstration of widespread skeletal metastases including lytic lesions in the T1, T3, T5, and T12 vertebral bodies. Compression deformity of T5 is unchanged, with soft tissue density material extending into the vertebral canal, unchanged. IMPRESSION: 1. Limited evaluation of the subsegmental pulmonary arteries, however no evidence of central pulmonary embolism through the segmental pulmonary arteries. No acute aortic abnormality. No evidence of pulmonary embolism or aortic abnormality. 2. Minimal change in extensive right lower lobe and, to a lesser extent, right middle lobe atelectasis. Relative hypoattenuating opacities in the right middle lobe could represent pneumonia, or alternatively infiltrative extension of right hilar lymphadenopathy, and clinical correlation is recommended. 3. No short-term interval change in metastatic lung cancer, again with a destructive bony lesion at the T5 vertebral body with encroachment into the vertebral canal. 4. Small right pleural effusion. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with metastatic lung cancer with brain mets and worsening confusion. // Evaluate for brain mets, bleed. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 45.5 mGy (Head) DLP = 855.5 mGy-cm. 2) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 45.5 mGy (Head) DLP = 855.5 mGy-cm. Total DLP (Head) = 1,711 mGy-cm. COMPARISON: CT head dated ___ and ___. FINDINGS: Study is moderately limited by motion. Given the limitation, the known right frontal convexity iso to hypodense subdural collection with hyperdense component posteriorly is likely not significantly changed. The known extra-axial soft tissue density anterior to the right temporal lobe is suboptimally visualized on today's exam but grossly similar. Osseous destruction of the greater wing of the sphenoid bone adjacent to this lesion is again noted. Bilateral frontal bone lytic lesion along the inner table are unchanged. Right frontal scalp soft tissue thickening is unchanged. No new intracranial hemorrhage. There is no evidence of large territory infarction, edema,or mass. The ventricles and sulci are normal in size and configuration. No fracture. Opacification of the right frontal, ethmoid air cells, and right sphenoid sinus are unchanged. Mucosal thickening of the bilateral maxillary sinuses is also unchanged. The mastoid air cells and middle ear cavities are clear. The visualized portion of the orbits are normal. IMPRESSION: 1. Moderately motion limited exam. Given the limitation, multiple extra-axial soft tissue masses with associated bone destruction in the right temporal and bilateral frontal lobes are grossly unchanged. 2. Known right frontal convexity 3 mm extra-axial collection is also unchanged. No new intracranial hemorrhage. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with tachypnea, tachycardia, AMS // evaluate effusion, infection TECHNIQUE: AP radiograph of the chest. COMPARISON: Chest radiograph ___. CTA chest ___. IMPRESSION: The right hemidiaphragm is elevated with atelectasis in the right lung base. A small right pleural effusion is unchanged. No focal consolidation or pneumothorax is identified. The cardiomediastinal silhouette is stable in appearance. The opacities in the right middle lobe and right hilar lymphadenopathy are better appreciated on prior CT. No acute osseous abnormalities are identified. Metallic densities projecting over the left hemithorax are noted. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Chest pain, Dyspnea Diagnosed with Chest pain, unspecified temperature: 96.6 heartrate: 121.0 resprate: 18.0 o2sat: 100.0 sbp: 120.0 dbp: 74.0 level of pain: 8 level of acuity: 3.0

PATIENT SUMMARY ============= Mr. ___ is a ___ year old man with history of newly diagnosed stage IV NSCLC and paranoid schizophrenia who was initially admitted to the HMED and then OMED services for expedited work up of his metastatic cancer, then transferred to the FICU for AMS likely ___ Leptomeningeal carcinomatosis which responded to high dose dexamethasone then back to OMED for continued management, radiation, and steroids ,with plan for radiation through ___ and discharge to rehab. # Metastatic NSCLC # Right ptosis and right sided facial swelling Mets to brain (R frontal), ribs, thoracic spine, lumbar spine, R adrenals. Pt s/p fluoroscopic guided LP, CSF cytology negative though protein is elevated to 140 c/f leptomeningeal spread. S/p XRT to chest area ___ with improvement in chest pain (sternal bone XRT only--did not treat intrathoracic tumor). Plan remains to complete palliative RT here in the hospital until ___ and then to pursue all further cancer care as an outpatient after d/c from rehab with Dr. ___. Awaiting final genetic studies, tumor molecular profiling and f/u path from CHA slides (received ___ to determine potential chemo/immunotherapy options - as outpatient. Palliative care involved. # AMS - Resolved Acute onset lethargy on ___ possibly due to infection, which resolved spontaneously, worsened again on ___ on the floor and triggered x 2 for somnolence. Mental status has waxed and waned in ICU. EEG with diffuse slowing, no seizure. Suspect related to leptomeningeal involvement of NSCLC which improved with steroids. Infectious studies negative - Bcx, ucx. MRI not obtained d/t chest shrapnel. Held sedating agents. Pt on dexamethasone while inpatient 4mg IV q12 hours, He will continue dexamethasone 4mg PO BID until follow-up with Dr. ___ neurooncologist on ___. While he is on dexamethasone he should continue Bactrim DS and PPI. Received Keppra load ___ and then on maintenance 500mg. # Post-obstructive pneumonia - Resolved # Leukocytosis # Moderate right pleural effusion # Tachypnea Pt lethargic ___ and ___ with WBC uptrending, afebrile but with lethargy. CT chest showed possible post-obstructive PNA. Initially on broad spectrum abx, then narrowed to CTX and azithro when MRSA negative. However, given c/f worsening AMS, broadened to Zosyn; WBC downtrended, abx completed on ___. BCx NGTD. # Anemia: Past studies with low iron, low TIBC and elevated ferritin suggestive of anemia of chronic disease, as well as low transferrin sat, elevated RDW-SD c/f iron deficiency anemia as well. Hb trending down iso continuous IVF. Pt currently not complaining of chest pain or dizziness. s/p 1uPRBCs on ___, stable. # Hypercalcemia PTH-rp negative during last admission, Corrected Ca ___. Low PTH on ___, PTH-rp low on ___. s/p pamidronate ___, will need repeat and followup (see transitional issues). # Transient ___ weakness (resolved) # Lytic bone lesions with T5 vertebral body with concern for soft tissue extension into the spinal canal He had transient bilateral ___ weakness on ___. CT lumbar spine showed destructive bone lesions along the lumbar spine, though without obvious spinal stenosis (would be better evaluated by MRI). Unable to obtain MRI during prior hospitalization given known shrapnel. ___ strength returned to normal, no urinary/fecal incontinence/retention, no ___, no saddle anesthesia. # Acute on chronic chest pain # Acute on chronic dyspnea Pain localized to R-side coinciding with the location of R ant lung mass invading into the rib. CT with R lesion and R pleural effusion. CTA chest negative for PE. No signs of tamponade. Has had persistent leukocytosis without fevers, and endorses some cough, but no PNA on CXR. S/p XRT to chest ___ with improvement in sx. On exam with consistently decreased breath sounds on right lung. #___ Palliative care has been following for assistance with pain management and GOC discussions. Mom, HCP was starting to think about hospice care. However, is interested in pursuing more diagnostic evaluation. Pt with 9 biological children from young age up to in their ___, and is close with some but not all of them. Some have been visiting hospital but it is unclear how much family knows of his critical illness. Further chemotherapy and treatment options to be discussed with outpatient oncologist. CHRONIC ISSUES ============================= # Schizophrenia: He has a history of schizophrenia with paranoia that is well controlled. Is an active member of his community. - home buproprion SR 150mg PO BID, Risperidone 4mg PO QHS, Prazosin 1mg PO QHS PRN, depakote 500mg PO BID, benztropine 0.5mg PO BID Initially risperidone and tizanidine held d/t sedation/AMS but restarted home Risperidone 1mg PO daily PRN ___, restarted tizanidine ___ # Diabetes: Held home metformin and ISS given pt not hyperglycemic. # Asthma: Home albuterol, fluticasone. CORE MEASURES # CODE: Full # CONTACT: Mom, ___: ___ TRANSITIONAL ISSUES =================== [] PAML is inaccurate; per pt's mother meds are what is in our computer however med rec with pharmacy is different. Needs further reconciliation and titration with PCP. Stabilized on current regimen while in hospital thus discharged on this regimen. [] Initiation of zoledronic acid IV every 12 weeks for prevention of skeletal-related events is recommended on an outpatient basis. ___ has received a dose of IV pamidronate ___. [] Dexamethasone taper: Continue 4mg BID until follow up with Dr. ___ on ___ Must be on DS Bactrim and PPI while on Dexamethasone

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Abacavir / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Palpitations Major Surgical or Invasive Procedure: Cardioversion In ED History of Present Illness: HPI attained by MERIT in ED and corroborated with patient on arrival to floor. ___ with HIV on HAART (CD4 281 on ___, on dolutegravir, darunavir, and lamuvidine), a fib on metoprolol, amiodarone apixaban, rheumatic heart disease s/p bioprosthetic AV/MV (biopresthetic valve AVR ___, ___ ___, CAD s/p CABG x 2 with multiple PCRs, CKD, HFpEF >55% ___, and bladder cancer c/b urethral stricture who presents with palpitations, found to be in afib. Palpitations have been present for ___ days. He had been instructed to take extra doses of metoprolol if he experienced palpitations, so he had been doing so without much effect. He reported no chest pain. He has had dyspnea but could be chronic since recent hospital stay. His afib history is as follows: S/p 5 DCCV s/p PVI ___, s/p AT ablation ___, s/p PCM on ___ for tachy-brady, had a presentation for afib in ___ during which he was started on metop (previously only on amio and apixaban, previously on coreg but this had been discontinued on a prior presentation BEFORE ___. Had recent prolonged hospitalization for dyspnea, admitted ___ with discharge to home on ___. During that admission, dyspnea had thorough workup including EBUS and BAL without evidence of malignancy or infection; diagnosis of exclusion was ILD. The etiology of his breathing problem is unclear but it did occur after his building was being reconstructed with replacement of asbestos pipes. Of note he also became anemic and was found to have esophagitis on EGD. He was treated for UTI with E.coli at his prior hospital stay, received 5 days (end ___ of antibiotics (ceftriaxone, zosyn). He also has a history of klebsiella UTI in ___ to ___. Note he is DNR/DNI but ok for transfer to hospital. He has been taking prednisone 40mg/day for interstitial lung disease at his last hospital stay. He was initiated on atovaquone because of PCP prophylaxis while on steroids. Regarding his HIV: He was seen by Dr. ___ on ___. Plan to recheck HIV viral load at next office visit in one month. Regarding his breathing: He was seen at ___ clinic on ___ for follow-up of pulmonary infiltrates and mediastinal lymphadenopathy. He reported during that clinic visit that he had no improvement with his steroids and that he is still using his oxygen. Regarding his urinary retention: He was seen at ___ clinic on ___ and passed voiding trial with no PVR. He was able to self cath easily. He was to discuss with PCP about moving urology care permanently to ___. Past Medical History: 1. Rheumatic heart disease with AS/MS, S/P bioprosthetic AVR and MVR in ___, and repeat bioprosthetic AVR in ___ 2. Severe bioprosthetic mitral regurgitation, S/P 26 ___ ___ in ___, complicated by HCAP with ESBL 3. CAD S/P CABG in ___ (SVG-PDA, SVG-OM1), uUnsuccessful PCI of occluded OM1 branch and successful PCI of the distal LCx with a 2.5x18mm Endeavor DES in ___, and redo CABG in ___ (LIMA-LAD, SVG-PDA, SVG-D1) 4. Atrial fibrillation, S/P DCCV ___ and ___, PVI catheter ablation ___, DCCV ___ and ablation ___, currently on amiodarone and apixiban 5. Tachy-brady syndrome, S/P PPM ___ 6. HFpEF (EF 62% ___ 6. Hypertension 7. Hyperlipidemia 8. Pulmonary hypertension 9. HIV ___ CD4 count 340, VL 1.5) 10. Low grade bladder neoplasm S/P resection ___. Recurrent UTI 12. BPH Social History: ___ Family History: Father had a history of throat cancer. Otherwise no history of sudden cardiac death, cardiac arrhythmias, myocardial infarction or stroke. Physical Exam: VITALS: Temp: 97.7 (Tm 97.7), BP: 102/69, HR: 113, RR: 18, O2 sat: 97%, O2 delivery: 2L GENERAL: Elderly male sitting comfortably, Alert and interactive. No acute distress. HEENT: NCAT. Sclera anicteric and without injection NECK: mildly elevated JVD CARDIAC: irregularly irregular tachycardia. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Bilateral crackles (R>L). No wheezes, rhonchi or rales. No accessory muscle use ABDOMEN: Normal bowels sounds, non distended, no guarding, no rebound EXTREMITIES: No edema. SKIN: Warm. No visible rash. NEUROLOGIC: Purposeful limb movement against gravity, fluent speech, alert and oriented. Discharge Exam: VS: ___ 0743 Temp: 97.6 PO BP: 117/68 HR: 90 RR: 18 O2 sat: 96% O2 delivery: RA GENERAL: NAD HEENT: AT/NC, anicteric sclera, MMM NECK: supple CV: irregularly irregular rhythm, no murmurs/rubs/gallops PULM: crackles at left lung base GI: abdomen soft, nondistended, nontender in all quadrants, no rebound/guarding, no masses EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ irregular radial pulses bilaterally NEURO: Alert, moving all 4 extremities with purpose, face symmetric, able to transfer from chair to bed independently DERM: Warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: Admission Lab Results ___ 10:50AM BLOOD WBC-18.0* RBC-4.77 Hgb-13.7 Hct-42.3 MCV-89 MCH-28.7 MCHC-32.4 RDW-20.7* RDWSD-67.2* Plt ___ ___ 10:50AM BLOOD Neuts-93.4* Lymphs-3.2* Monos-1.9* Eos-0.3* Baso-0.2 Im ___ AbsNeut-16.84* AbsLymp-0.58* AbsMono-0.34 AbsEos-0.06 AbsBaso-0.03 ___ 10:50AM BLOOD ___ PTT-30.0 ___ ___ 10:50AM BLOOD Glucose-187* UreaN-24* Creat-1.1 Na-130* K-4.7 Cl-93* HCO3-24 AnGap-13 ___ 10:50AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 10:50AM BLOOD Calcium-9.1 Phos-2.7 Mg-2.0 Pertinent Interval Labs: ___ 07:16AM BLOOD WBC-18.3* RBC-4.42* Hgb-12.6* Hct-38.9* MCV-88 MCH-28.5 MCHC-32.4 RDW-19.9* RDWSD-63.5* Plt ___ ___ 07:16AM BLOOD Neuts-77.4* Lymphs-14.3* Monos-5.7 Eos-1.4 Baso-0.2 Im ___ AbsNeut-14.41* AbsLymp-2.66 AbsMono-1.07* AbsEos-0.26 AbsBaso-0.03 ___ 06:50AM BLOOD ___ PTT-78.4* ___ ___ 07:16AM BLOOD Glucose-94 UreaN-19 Creat-1.0 Na-136 K-4.3 Cl-96 HCO3-27 AnGap-13 ___ 07:16AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.4 Sigmoidoscopy results: Moderate diverticulosis Dried blood present up to 30cm no fresh blood notified. Imaging Results: CXR: ___ IMPRESSION: No substantial short-term change. CXR: ___ FINDINGS: In comparison with the prior study from ___, pulmonary opacities are again seen, more diffuse on the right, with slight interval improvement since ___, slight interval improvement in aeration of the right lung. Again, difficult to separate the contribution made by interstitial lung disease, possible superimposed pneumonia/aspiration, and possible asymmetric pulmonary edema. No large pleural effusion is seen. No evidence of pneumothorax. Patient is status post median sternotomy and aortic valve repair. Left-sided dual lead pacemaker is stable in position. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 2. Amiodarone 200 mg PO DAILY 3. Apixaban 2.5 mg PO BID 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 20 mg PO QPM 6. Baclofen 10 mg PO TID:PRN Muscle Spasms 7. Docusate Sodium 100 mg PO BID 8. Dolutegravir 50 mg PO DAILY 9. LaMIVudine 150 mg PO DAILY 10. Metoprolol Succinate XL 25 mg PO DAILY 11. Oxazepam 10 mg PO QHS:PRN insomnia 12. Omeprazole 20 mg PO BID 13. Senna 8.6 mg PO BID:PRN Constipation - First Line 14. Atovaquone Suspension 1500 mg PO DAILY PCP ___ 15. Mirtazapine 15 mg PO QHS 16. PredniSONE 40 mg PO DAILY 17. Darunavir 800 mg PO BID 18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 19. Prochlorperazine 5 mg PO BID:PRN nausea 20. Centrum (multivit-iron-min-folic acid;<br>multivit-mins-ferrous gluconat;<br>multivitamin-iron-folic acid) 1 pill oral DAILY 21. Metoprolol Tartrate 25 mg PO PRN Palpitations with elevated heart rates Discharge Medications: 1. Bisacodyl 10 mg PO DAILY RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 2. Diltiazem Extended-Release 240 mg PO DAILY RX *diltiazem HCl 240 mg 1 capsule(s) by mouth Daily Disp #*30 Capsule Refills:*0 3. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second Line RX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth daily Refills:*0 4. Metoprolol Succinate XL 100 mg PO DAILY RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Omeprazole 20 mg PO BID 6. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 7. Apixaban 2.5 mg PO BID 8. Aspirin 81 mg PO DAILY 9. Atorvastatin 20 mg PO QPM 10. Atovaquone Suspension 1500 mg PO DAILY PCP ___ 11. Baclofen 10 mg PO TID:PRN Muscle Spasms 12. Centrum (multivit-iron-min-folic acid;<br>multivit-mins-ferrous gluconat;<br>multivitamin-iron-folic acid) 1 pill oral DAILY 13. Darunavir 800 mg PO BID 14. Docusate Sodium 100 mg PO BID 15. Dolutegravir 50 mg PO DAILY 16. LaMIVudine 150 mg PO DAILY 17. Mirtazapine 15 mg PO QHS 18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 19. Oxazepam 10 mg PO QHS:PRN insomnia 20. PredniSONE 40 mg PO DAILY 21. Prochlorperazine 5 mg PO BID:PRN nausea 22. Senna 8.6 mg PO BID:PRN Constipation - First Line Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Atrial Fibrillation with rapid ventricular response Lower GI bleed: undifferentiated. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with dyspnea, palpitations// evaluate for pna, pulm edema TECHNIQUE: Single frontal view of the chest COMPARISON: ___ FINDINGS: In comparison with the prior study from ___, pulmonary opacities are again seen, more diffuse on the right, with slight interval improvement since ___, slight interval improvement in aeration of the right lung. Again, difficult to separate the contribution made by interstitial lung disease, possible superimposed pneumonia/aspiration, and possible asymmetric pulmonary edema. No large pleural effusion is seen. No evidence of pneumothorax. Patient is status post median sternotomy and aortic valve repair. Left-sided dual lead pacemaker is stable in position. Radiology Report EXAMINATION: Chest radiograph, portable AP upright. INDICATION: Increasing leukocytosis and worsening atrial fibrillation. History of interstitial lung disease. COMPARISON: ___. FINDINGS: Patient is status post endovascular aortic valve repair. Patient is also status post coronary artery bypass graft surgery. Pacemaker/ICD device appears unchanged. Cardiac, mediastinal and hilar contours appear stable including mild cardiomegaly. There are small pleural effusions, probably unchanged. There is no pneumothorax. Heterogeneous opacification of each lung, right greater than left, suggests pneumonia, which is most striking in the right upper lobe. There is probably a pattern of waxing and waning pulmonary edema that coincides. There is little if any significant change since the recent prior examination. IMPRESSION: No substantial short-term change. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Palpitations Diagnosed with Palpitations temperature: 98.0 heartrate: 129.0 resprate: 20.0 o2sat: 99.0 sbp: 92.0 dbp: 72.0 level of pain: 0 level of acuity: 2.0

PATIENT SUMMARY STATEMENT FOR ADMISSION Mr. ___ is a ___ gentleman with HIV on HAART, paroxysmal a fib on apixaban, rheumatic heart disease s/p bioprosthetic AV/MV, CAD s/p CABG, CKD, HFpEF and bladder cancer who presented with palpitations s/p cardioversion and CXR initially c/f pneumonia but with reassuring exam. Now hemodynamically stable off antibiotics and awaiting further workup of recurrent afib.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: ___: ERCP/ sphincterotomy ___ laparoscopic cholecystectomy History of Present Illness: ___ year old female who presented to the hospital with upper abdominal pain x3 days found to have gallstone pancreatitis and probable ___ transferred from OSH for ERCP, which is planned for tomorrow (now this) AM. Reports N/V x1 at time of onset of pain, none since. Pain described as across upper abdomen, nonradiating, has not moved since onset. Laying on R side aggravates pain, laying flat supine alleviates pain. Reports chills at home and temp of ___ F at OSH. Last ate 1.5 days ago (___). Last BM unknown, not "today" (yesterday), which she considers constipated for her. Denies diarrhea or blood in stool. Denies HA, dizziness, CP, SOB, dysuria, hematuria, sick contacts. Past Medical History: GERD -avascular necrosis b/l shoulders -arthritis -??? asthma Social History: ___ Family History: Mother died of pancreatic CA at ___ -Father died of lung CA at ___ (smoker) -Pt thinks her sister had/has gallstones Physical Exam: Physical Exam: upon admission: ___: Vitals: 98.3, 77, 132/72, 16, 98% RA, 70 GEN: A&O, NAD, well appearing HEENT: mucus membranes moist, mild scleral icterus CV: RRR PULM: Breathing comfortably on room air laying supine ABD: Soft, distended, epigastric tenderness w guarding, no rebound, very mild RUQ tenderness, no masses or hernias appreciated Ext: No ___ edema, ___ warm and well perfused Pertinent Results: ___ 06:25AM BLOOD WBC-9.9 RBC-3.13* Hgb-10.2* Hct-30.8* MCV-98 MCH-32.6* MCHC-33.1 RDW-16.4* RDWSD-59.1* Plt ___ ___ 07:55AM BLOOD WBC-10.0 RBC-3.14* Hgb-10.2* Hct-30.0* MCV-96 MCH-32.5* MCHC-34.0 RDW-16.0* RDWSD-55.9* Plt ___ ___ 08:39PM BLOOD WBC-14.3* RBC-3.63* Hgb-11.8 Hct-35.4 MCV-98 MCH-32.5* MCHC-33.3 RDW-15.1 RDWSD-54.2* Plt ___ ___ 08:39PM BLOOD Neuts-90.2* Lymphs-1.1* Monos-7.5 Eos-0.0* Baso-0.2 Im ___ AbsNeut-12.93* AbsLymp-0.16* AbsMono-1.07* AbsEos-0.00* AbsBaso-0.03 ___ 06:25AM BLOOD Plt ___ ___ 06:25AM BLOOD Glucose-109* UreaN-23* Creat-0.8 Na-141 K-4.0 Cl-105 HCO3-25 AnGap-11 ___ 07:55AM BLOOD Glucose-102* UreaN-15 Creat-0.7 Na-143 K-3.8 Cl-106 HCO3-25 AnGap-12 ___ 08:39PM BLOOD Glucose-54* UreaN-13 Creat-0.9 Na-138 K-4.0 Cl-102 HCO3-19* AnGap-17 ___ 06:25AM BLOOD ALT-109* AST-64* AlkPhos-391* TotBili-1.5 ___ 07:55AM BLOOD ALT-121* AST-64* AlkPhos-398* TotBili-3.4* ___ 06:25AM BLOOD Lipase-294* ___ 08:39PM BLOOD Lipase-1251* ___ 06:25AM BLOOD Calcium-7.9* Phos-2.3* Mg-2.2 ___ 07:55AM BLOOD Albumin-2.6* Calcium-8.0* Mg-2.1 ___: CXR: No acute cardiopulmonary abnormality. ___: ERCP: Successful ERCP with extraction of stone Medications on Admission: The Preadmission Medication list is accurate and complete. 1. HYDROcodone-acetaminophen 7.5-325 mg oral Q4H:PRN 2. Flovent HFA (fluticasone) 220 mcg/actuation inhalation BID 3. PredniSONE 10 mg PO DAILY:PRN shortness of breath 4. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 5. Omeprazole Dose is Unknown PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*14 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID 4. 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 four (4) hours Disp #*12 Tablet Refills:*0 5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line 6. Senna 8.6 mg PO BID:PRN Constipation - Second Line 7. Omeprazole 40 mg PO DAILY 8. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 9. Flovent HFA (fluticasone) 220 mcg/actuation inhalation BID Discharge Disposition: Home Discharge Diagnosis: gallstone pancreatitis choledocholithiasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PRE-OP AP ONLY) INDICATION: History: ___ with cholangitis*** WARNING *** Multiple patients with same last name!// pre-op TECHNIQUE: Upright AP view of the chest COMPARISON: None. FINDINGS: Heart size is normal. Aortic knob is mildly calcified. Mediastinal and hilar contours are normal. Lungs are hyperinflated with emphysematous changes noted in the upper lobes. No focal consolidation, pleural effusion, or pneumothorax is seen. Severe degenerative changes of the right glenohumeral joint are noted. Narrowed acromial humeral intervals bilaterally suggest rotator cuff disease. No acute osseous abnormality. IMPRESSION: No acute cardiopulmonary abnormality. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Abd pain, Transfer Diagnosed with Unspecified jaundice, Right upper quadrant pain temperature: 98.9 heartrate: 100.0 resprate: 16.0 o2sat: 95.0 sbp: 122.0 dbp: 80.0 level of pain: 7 level of acuity: 3.0

___ year old female admitted from an outside hospital with upper abdominal pain. On review of imaging, she was found to have gallstone pancreatitis and probable choledocholithiasis. She was transferred here for ERCP which was done on HD #2. A biliary sphincterotomy was done with the removal of pus, stones and sludge. The patients liver function tests were monitored and after they trended down, the patient was taken to the operating room where she underwent a laparoscopic cholecystectomy. The operative course was stable. The patient was extubated after the procedure and monitored in the recovery room. The patient resumed a regular diet and was voiding without difficulty. Her incisional pain was controlled with oral analgesia. The patient was discharged on a course of ciprofloxacin. Discharge instructions were reviewd and questions answered. A follow-up appointment was made in the acute care clinic.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: CARDIOTHORACIC Allergies: Bactrim / Fragmin / Iodinated Contrast Media Attending: ___ Chief Complaint: palpitations Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old female well known to service that recently underwent coronary artery bypass graft surgery x2 on ___ and was discharged home after uneventful post op course. on ___ to home. She noted yesterday that after changing from sitting to standing position that she had palpitations and heart rate on finger sat monitor that rate 120's, she laid down and heart rate slowed to 106 and lightheadness resolved. She did okay over night but again this after with position change noted that heart rate up to 130's with lightheadedness and palpitations. She was directed to take 6.25 mg Lopressor at home around 4pm and presented to the hospital for evaluation. Currently denies palpitations. Additionally notes having dyspnea with activity but denies CP, Nausea, vomiting, syncope. Past Medical History: Coronary artery disease s/p PCI Deep Vein Thrombosis, ___ Iron Deficiency Anemia Transient Ischemic Attack, ___ Myocardial Infarction ___ Prediabetes Pulmonary nodule - Ultrasound negative Social History: ___ Family History: Grandmother CAD Physical ___: 98.1- 114/76-107-18 100% Room air General: Skin: Dry intact Neck: Supple Full ROM Chest: Lungs clear bilaterally except decreased left base Heart: RRR no murmur or rub Abdomen: Soft non-distended non-tender bowel sounds + BM ___ Extremities: Warm well-perfused Edema none Neuro: generalized weakness no focal deficits a/o x3 Pulses: DP Right: P Left: P ___ Right: P Left: P Radial Right: P Left: P Pertinent Results: ___ ___ ___ ___ Radiology Report CHEST (PORTABLE AP) Study Date of ___ 8:28 ___ ___ CSURG FA8 ___ 8:28 ___ CHEST (PORTABLE AP) Clip # ___ Reason: eval etiology of SOB UNDERLYING MEDICAL CONDITION: ___ year old woman with SOB REASON FOR THIS EXAMINATION: eval etiology of SOB Final Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with SOB // eval etiology of SOB TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: There is minimal left basilar atelectasis and unchanged elevation of the left hemidiaphragm. No focal consolidation, pleural effusion or pneumothorax. The median sternotomy wires are intact. The size of the cardiac silhouette is within normal limits. IMPRESSION: Unchanged elevation of the left hemidiaphragm with subjacent atelectasis. 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. Famotidine 20 mg PO BID 4. Isosorbide Dinitrate 5 mg PO TID 5. TiCAGRELOR 90 mg PO BID 6. Metoprolol Tartrate 6.25 mg PO BID Discharge Medications: 1. Metoprolol Succinate XL 25 mg PO DAILY RX *metoprolol succinate 25 mg one tablet(s) by mouth once a day Disp #*30 Tablet Refills:*2 2. Famotidine 20 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Isosorbide Dinitrate 5 mg PO TID 5. Rosuvastatin Calcium 20 mg PO QPM 6. TiCAGRELOR 90 mg PO BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: palpitations Discharge Condition: Alert and oriented x3, non-focal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage No Edema Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with SOB // eval etiology of SOB TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: There is minimal left basilar atelectasis and unchanged elevation of the left hemidiaphragm. No focal consolidation, pleural effusion or pneumothorax. The median sternotomy wires are intact. The size of the cardiac silhouette is within normal limits. IMPRESSION: Unchanged elevation of the left hemidiaphragm with subjacent atelectasis. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Tachycardia Diagnosed with Tachycardia, unspecified temperature: 98.1 heartrate: 107.0 resprate: 18.0 o2sat: 100.0 sbp: 114.0 dbp: 76.0 level of pain: 0 level of acuity: 2.0

Ms. ___ was admitted for dyspnea on exertion and palpitations. During her admission her Lopressor was increased but she remained in sinus rhythm throughout. Her chest radiograph did not reveal significant effusions and she remained on room air with excellent oxygen saturation. Orthostatics were negative. On hospital day two she was discharged to home.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: amlodipine / latex / Penicillins / ciprofloxacin Attending: ___ Chief Complaint: Chest tightness Major Surgical or Invasive Procedure: ___ - podiatry clipped a blister History of Present Illness: ___ PMH ESRD on HD (missed last two appts), Linear Grade B Esophagitis, CAD on Plavix/ASA, CHF, T2DM, HTN, HLD, ESRD on HD (___), PVD with chronic non-healing left calcaneal ulcer s/p left ___ bypass c/b recurrent distal bypass graft stenosis requiring yearly graft PTA p/w chest tightness which is exacerbated/caused by persistent, productive cough and that is occasionally accompanied by hemoptysis. Prior to this admission, patient felt so unwell that he was unable to make his two most recent hemodialysis appointments. Endorses hiccups and epigastric/substernal CP that improves with belching. The chest pain is pleuritic, non-radiating and non-exertional. He also endorses dyspnea, DOE, nausea but no vomiting. Denies fevers/chills, congestion, rhinorrhea, abdominal pain, diarrhea and constipation. No known sick contacts. No recent travel, or prison time. Notably, patient recently admitted ___, presenting with cough, chest pain, and coffee ground emesis. This was felt to represent food mixed with vomit i/s/o stable H/H. Felt most likely recurrent esophagitis ___ gastroparesis or medication non-compliance. He was treated with Reglan, PO PPI and patient's nausea/vomiting improved. In the ED: Initial vital signs were notable for: 98.1 100 143/88 20 98% RA Labs were notable for: - Trop 0.17 -> 0.17 - MB 2 - Flu negative - Lactate 2.3 Studies performed include: CXR IMPRESSION: No acute intrathoracic process. CTA: 1. No evidence of pulmonary embolism or acute aortic abnormality. 2. Diffuse esophageal wall thickening and adjacent fat stranding suggestive of esophagitis. Per discussion with Dr. ___ patient recently had an endoscopy which demonstrated grade B esophagitis. 3. Trace right pleural effusion. 4. Mild cardiomegaly with left ventricular hypertrophy and moderate coronary artery calcifications. EKG: Sinus rhythm at 102 with frequent PVCs, normal axis, normal intervals, peaked T waves, no ST/T wave changes Patient was given: ___ 15:00 IV Calcium Gluconate ___ 15:00 IV Insulin Regular 10 units ___ 15:00 IV Dextrose 50% 25 gm ___ 16:06 IV Calcium Gluconate 1 gm ___ 16:18 IVF NS Started 250 mL/hr ___ 17:43 IV CefTRIAXone 1 gm ___ 17:47 IV Azithromycin (500 mg ordered) Consults: Renal, "Noted. Will assess in AM and plan for HD on ___ unless other acute issues arise." Vitals on transfer: 98.5 102 162/78 18 99% RA Upon arrival to the floor, patient corroborates above information. Continued to have off and on chest pain that is worse with deep breaths and improves with belching. REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise negative. Past Medical History: - Linear Grade B Esophagitis - ESRD TTS ___ - DMII complicated by severe nonproliferative diabetic retinopathy and chronic left heel ulcer - Hypertension - Hyperlipidemia - Peripheral Vascular Disease s/p RLE angiogram with SFA stent by Dr. ___ in ___, left femoral to posterior tibial artery bypass with vein graft by Dr. ___ in ___ with balloon angioplasty of vein graft stenosis in ___ - Chronic left heel ulceration complicated by wet gangrene in ___ requiring multiple debridements - Chronic non-healing right heel s/p debridement of right heel ulcer and removal of foreign body by Podiatry in ___ - Psoriatic Arthritis - Osteoarthritis Social History: ___ Family History: Per prior discharge summary. Mother with diabetes, asthma, and hypertension. Father with prostate cancer. Grandmother with ovarian cancer. Physical Exam: ADMISSION PHYSICAL EXAM ============================== VITALS: 98.3 | 170/85 | 91 | 19 | 95%Ra General: ill appearing middle-aged male, actively coughing without production HEENT: NC, AT. Nares patent. Chest: Decreased aeration throughout, no appreciable rales, rhonchi or wheezes. CV: RRR, ___ systolic murmur appreciated Abdomen: Soft, non-tender, no HSM. Ext: fistula with palpable thrill to left arm. Left heal ulcer with various stages of healing, but no obvious signs of infection; not warm to touch. Legs warm without edema. Neuro: Gross non-focal, AOx3 DISCHARGE PHYSICAL EXAM ============================== General: laying in bed, nontoxic, NAD. HEENT: NC, AT. Moist mucous membranes. Chest: Poor air movement but overall clear to auscultation. CV: RRR, systolic murmur likely d/t fistula Abdomen: Soft, non-tender, nondistended. GU: No foley. Ext: fistula with palpable thrill to left arm. Neuro: Grossly non-focal. Moving all limbs ith purpose against gravity. Derm: B heel ulcers denuded but starting to heal Pertinent Results: ADMISSION LABS =============================== ___ 02:44PM BLOOD WBC-12.4* RBC-5.52 Hgb-13.9 Hct-44.7 MCV-81* MCH-25.2* MCHC-31.1* RDW-18.3* RDWSD-50.8* Plt ___ ___ 02:44PM BLOOD Neuts-83.9* Lymphs-10.4* Monos-4.9* Eos-0.3* Baso-0.2 Im ___ AbsNeut-10.35* AbsLymp-1.29 AbsMono-0.61 AbsEos-0.04 AbsBaso-0.03 ___ 02:44PM BLOOD Glucose-263* UreaN-64* Creat-12.4*# Na-134* K-5.4 Cl-86* HCO3-20* AnGap-28* ___ 02:44PM BLOOD CK-MB-2 cTropnT-0.17* ___ 06:47PM BLOOD cTropnT-0.16* ___ 02:44PM BLOOD Calcium-9.1 Phos-7.9* Mg-2.7* ___ 02:58PM BLOOD Lactate-2.3* K-5.1 MICRO LABS ================================ ___ 2:20 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 2:20 pm BLOOD CULTURE 2 OF 2. 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 ___: Reported to and read back by ___. ___ ON ___ AT 0030. GRAM POSITIVE COCCI IN CLUSTERS. ___ 02:53PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE IMAGING & STUDIES ================================= ___ CXR FINDINGS: AP upright and lateral views of the chest provided. There is no focal consolidation, effusion, or pneumothorax. The cardiomediastinal silhouette is normal. Atherosclerotic calcifications in the aortic knob are again noted. No displaced fractures are seen. IMPRESSION: No acute intrathoracic process. ___ CTA IMPRESSION: 1. No evidence of pulmonary embolism or acute aortic abnormality. 2. Diffuse esophageal wall thickening and adjacent fat stranding suggestive of esophagitis. Per discussion with Dr. ___ patient recently had an endoscopy which demonstrated grade B esophagitis. 3. Trace right pleural effusion. 4. Mild cardiomegaly with left ventricular hypertrophy and moderate coronary artery calcifications. DISCHARGE LABS ================================== ___ 11:10AM BLOOD WBC-6.8 RBC-4.35* Hgb-10.9* Hct-35.7* MCV-82 MCH-25.1* MCHC-30.5* RDW-16.5* RDWSD-49.5* Plt ___ ___ 07:50AM BLOOD Calcium-8.4 Phos-3.5 Mg-2.0 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 80 mg PO QPM 2. Clopidogrel 75 mg PO DAILY 3. Gabapentin 100 mg PO DAILY 4. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 5. Lisinopril 20 mg PO DAILY 6. Doxazosin 6 mg PO 4X/WEEK (___) 7. CloNIDine 0.2 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 2. Calcium Carbonate 500 mg PO QID:PRN heartburn RX *calcium carbonate [Tums] 200 mg calcium (500 mg) 1 tablet(s) by mouth 4 per day Disp #*120 Tablet Refills:*0 3. CARVedilol 25 mg PO BID hold in AM on dialysis days RX *carvedilol 25 mg 1 tablet(s) by mouth at bedtime Disp #*90 Tablet Refills:*0 RX *carvedilol 25 mg 1 tablet(s) by mouth 4x/week ___ Disp #*48 Tablet Refills:*0 4. Glargine 12 Units Bedtime RX *insulin glargine [Lantus Solostar U-100 Insulin] 100 unit/mL (3 mL) AS DIR 12 Units before BED; Disp #*1 Syringe Refills:*0 5. Nephrocaps 1 CAP PO DAILY RX *B complex with C#20-folic acid [Nephrocaps] 1 mg 1 capsule(s) by mouth qPM Disp #*90 Capsule Refills:*0 6. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp #*180 Tablet Refills:*0 7. Sucralfate 1 gm PO QID RX *sucralfate 1 gram/10 mL 10 mL by mouth 4 a day Disp #*1 Package Refills:*1 8. Lisinopril 40 mg PO DAILY RX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 9. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 10. Gabapentin 100 mg PO DAILY RX *gabapentin 100 mg 1 capsule(s) by mouth daily Disp #*90 Capsule Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: #ESOPHAGITIS #ESRD on HD #HYPERTENSION Discharge Condition: Mental Status: Clear and coherent, but with baseline learning disability and distrust of "orientation" questions. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. (Supposed to use a walker given foot wounds) Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ with cough x 4 days in an HD patient.// PNA? COMPARISON: Multiple prior chest radiographs dating back to ___. FINDINGS: AP upright and lateral views of the chest provided. There is no focal consolidation, effusion, or pneumothorax. The cardiomediastinal silhouette is normal. Atherosclerotic calcifications in the aortic knob are again noted. No displaced fractures are seen. IMPRESSION: No acute intrathoracic process. Radiology Report EXAMINATION: CTA CHEST WITH CONTRAST INDICATION: History: ___ with cough and hemoptysis for 4 days.// 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 1.5 s, 0.5 cm; CTDIvol = 9.1 mGy (Body) DLP = 4.6 mGy-cm. 2) Spiral Acquisition 4.4 s, 34.6 cm; CTDIvol = 15.3 mGy (Body) DLP = 530.2 mGy-cm. Total DLP (Body) = 535 mGy-cm. COMPARISON: CTA torso dated ___. FINDINGS: HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the subsegmental level without filling defect to indicate a pulmonary embolus. The thoracic aorta is normal in caliber without evidence of dissection or intramural hematoma. Moderate atherosclerotic calcifications in the aortic arch, coronary arteries and origins of the great vessels are noted. Heart is mildly enlarged and there is mild left ventricular hypertrophy. Pericardium and great vessels are otherwise unremarkable. No pericardial effusion is seen. AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar lymphadenopathy is present. No mediastinal mass. The esophagus demonstrates moderate diffuse circumferential thickening and edema with mild fat stranding. PLEURAL SPACES: There is a tiny right pleural effusion. There is no pneumothorax. LUNGS/AIRWAYS: There is minimal compressive atelectasis in the right lower lobe. Otherwise, the lungs are clear without masses or areas of parenchymal opacification. 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 aside from a small hiatal hernia. BONES: No suspicious osseous abnormality is seen.? There is no acute fracture. SOFT TISSUES: Re-demonstrated is mild bilateral gynecomastia. IMPRESSION: 1. No evidence of pulmonary embolism or acute aortic abnormality. 2. Diffuse esophageal wall thickening and adjacent fat stranding suggestive of esophagitis. Per discussion with Dr. ___ patient recently had an endoscopy which demonstrated grade B esophagitis. 3. Trace right pleural effusion. 4. Mild cardiomegaly with left ventricular hypertrophy and moderate coronary artery calcifications. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 9:44 pm, 5 minutes after discovery of the findings. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Chest pain, Cough Diagnosed with Cough, Shortness of breath, Chest pain, unspecified temperature: 98.1 heartrate: 100.0 resprate: 20.0 o2sat: 98.0 sbp: 143.0 dbp: 88.0 level of pain: 8 level of acuity: 3.0

Mr. ___ is a ___ PMH ESRD on HD (missed last two appts), Linear Grade B Esophagitis, CAD on Plavix/ASA, CHF, T2DM, HTN, HLD, ESRD on HD (___), PVD with chronic non-healing left calcaneal ulcer s/p left ___ bypass c/b recurrent distal bypass graft stenosis requiring yearly graft PTA who presented pleuritic chest pain and productive cough of reddish sputum, with negative CTA, negative cardiac workup, and ongoing pain attributable to esophagitis

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a ___ year old female with history of GERD who presents with diarrhea. The patient was in her usual state of health until ___ around midnight when she developed diarrhea associated with bloating and nausea. She reports persistent symptoms since then. Stool is described as mucousy with ocassional red clots of BRB. She reports fevers and chills but denies vomiting or dysuria. Also denies chest pain, shortness of breath, rashes, sick contacts or recent travel. Of note, she had been taking bactrim on ___ & ___ (4 doses) for possible infected cut on right arm. She reports eating fried clams for lunch on ___ and felt unwell towards the end of her meal. She had normal colonoscopy in ___. In the ED, initial VS: T- 100.5, HR- 94, BP- 129/50, RR- 18, SaO2- 100% on RA. CT abd/pelvis consistent with colitis. She received IV hydration, cipro, flagyl, zofran, morphine and tylenol in the ED with good response. She is being admitted for further evaluation. On transfer, vital signs were T- 97, HR- 100, RR- 18, BP- 137/67, SaO2- 100% on RA. On arrival to the floor, vital signs were Temp 98.7F, BP 110/52, HR 90, R 20, O2-sat 97% RA. Patient currently afebrile and comfortable. Past Medical History: 1. GERD 2. OSA 3. Seasonal allergies Social History: ___ Family History: No family history of inflammatory bowel disease or autoimmune disorders. Physical Exam: ADMISSION PHYSICAL EXAM VS - Temp 98.7F, BP 110/52, HR 90, R 20, O2-sat 97% RA GENERAL - Alert, interactive, well-appearing in NAD HEENT - EOMI, sclerae anicteric, dry mucuous membranes, OP clear NECK - Supple, no JVD, HEART - RRR, nl S1-S2, no MRG LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use ABDOMEN - Mild tenderness in lower abdomen, positive bowel sounds, soft, non-distended. EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses SKIN - no rashes or lesions LYMPH - no cervical LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, no focal deficits, steady gait. DISCHARGE PHYSICAL EXAM VS: TEMP 98.1, BP 100/72, HR 73, RR 18, O2 sat 9% on RA GENERAL: A & OX3, NAD HEENT: PERRL, MMM, OP Clear NECK: supple, JVD flat HEART: RRR, nl S1, S2, no MRG LUNGS: CTAB, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use ABDOMEN: Tenderness to palpation in lower abdomen, positive bowel sounds, soft, non-distended, no hepatosplenomegaly EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses LYMPH: no cervical LAD Pertinent Results: ADMISSION LABS ___ 07:30PM BLOOD WBC-17.1*# RBC-4.90 Hgb-14.4 Hct-41.5 MCV-85 MCH-29.4 MCHC-34.8 RDW-13.0 Plt ___ ___ 07:30PM BLOOD Neuts-88.2* Lymphs-8.0* Monos-3.0 Eos-0.4 Baso-0.4 ___ 07:30PM BLOOD Glucose-125* UreaN-11 Creat-1.0 Na-133 K-4.4 Cl-97 HCO3-20* AnGap-20 ___ 07:30PM BLOOD Albumin-4.6 Calcium-8.9 Phos-2.2* Mg-2.0 ___ 07:30PM BLOOD ALT-13 AST-32 AlkPhos-109* TotBili-0.4 DISCHARGE LABS ___ 06:25AM BLOOD WBC-8.6 RBC-3.80* Hgb-11.4* Hct-32.7* MCV-86 MCH-29.9 MCHC-34.7 RDW-13.0 Plt ___ ___ 06:25AM BLOOD Glucose-111* UreaN-6 Creat-0.8 Na-142 K-3.8 Cl-107 HCO3-26 AnGap-13 PERTINENT LABS ___ 07:38PM BLOOD Lactate-2.2* ___ 07:09AM BLOOD Lactate-0.8 MICROBIOLOGY FECAL CULTURE (Final ___: NO ENTERIC GRAM NEGATIVE RODS FOUND. NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Preliminary): Pending FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: NO E.COLI 0157:H7 FOUND. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ___: FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. Blood Cx ___ X2: NGTD Urine Cx: no growth RADIOLOGY: CT ABD/PELVIS (___) IMPRESSION: Diffuse wall thickening and fat stranding surrounding the distal transverse colon and proximal descending colon, findings consistent with colitis. No evidence of adjacent diverticula. No perforation or abscess formation. Medications on Admission: 1. Omeprazole 40mg daily 2. Sertaline 100mg daily Discharge Medications: 1. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 2. sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day. 3. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 12 days. Disp:*36 Tablet(s)* Refills:*0* 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever or pain. 5. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. Disp:*10 Tablet, Rapid Dissolve(s)* Refills:*0* 6. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal DAILY (Daily) as needed for hemorrhoidal pain. Disp:*1 tubes* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: C.diff colitis Secondary diagnosis: GERD OSA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: ___ female with abdominal pain, worse in the left lower quadrant and bloody diarrhea. COMPARISON: CT abdomen and pelvis from ___. TECHNIQUE: ___ MDCT-acquired axial images from the lung bases to the pubic symphysis were displayed with 5-mm slice thickness. Intravenous contrast was administered. Coronal and sagittal reformations were prepared. FINDINGS: Lung bases are clear. There is no focal nodule, mass, or effusion. The imaged cardiac apex is within normal limits. The liver demonstrates homogeneous parenchymal enhancement without suspicious focal lesion. The hepatic veins and portal venous system are grossly patent. No intra- or extra-hepatic biliary ductal dilatation is identified. The gallbladder, spleen, pancreas and adrenal glands are normal. There is symmetric enhancement and excretion of the kidneys without suspicious focal lesion or hydronephrosis. The abdominal aorta and its branch vessels are non-aneurysmal and grossly patent. Surgical clips are seen at the level of the ___ takeoff (2:46). Retroperitoneal surgical clips are also seen. GI: The stomach and small bowel loops are normal in caliber and configuration without evidence of obstruction or inflammation. The appendix is not clearly visualized; however, there are no secondary signs of acute appendicitis. There is diffuse wall thickening and stranding around the distal transverse colon and proximal descending colon, findings consistent with colitis. No free air is identified to suggest microperforation. There is no free fluid. No diverticula are identified to suggest that this is related to acute diverticulitis. No clear obstructing mass lesion is visualized within the colon. CT PELVIS WITH INTRAVENOUS CONTRAST: The uterus is not clearly visualized, likely secondary to prior surgical resection. No adnexal mass lesion is identified. The bladder is mildly distended and appears within normal limits. There is no pelvic free fluid. No pathologically enlarged pelvic or inguinal lymph nodes are identified. Multiple surgical clips are also seen within the midline pelvis. OSSEOUS STRUCTURES: No bone destructive lesion or acute fracture is identified. Grade one anterolisthesis of L4 on L5 is stable. IMPRESSION: Diffuse wall thickening and fat stranding surrounding the distal transverse colon and proximal descending colon, findings consistent with colitis. No evidence of adjacent diverticula. No perforation or abscess formation. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: DIARRHEA Diagnosed with ABDOMINAL PAIN LLQ, DIARRHEA, MELENA temperature: 100.5 heartrate: 94.0 resprate: 18.0 o2sat: 100.0 sbp: 129.0 dbp: 50.0 level of pain: 6 level of acuity: 3.0

___ female with GERD presented with diarrhea and abdominal cramping, and was found to have C.diff colitis. ACTIVE ISSUES # C.diff colitis: Pt's C.diff developed in the setting of chronic PPI use, recent ABx (Clindamycin & bactrim) in past three weeks. She underwent CT abd/pelvis since admission, and was found to have diffuse wall thickening surrounding distal transverse colon and proximal descending colon. Her C.diff toxin screening was positive. Pt was treated with metronidazole initially iv, later switched to po, given her lack of comorbidities and first presentation. Her diarrhea started to abate on HD #3. Pt tolerated po diet well prior to discharge from the hospital. Plan is to complete 14 days of metronidazole from discontinuation of ciprofloxacin. # Rash: pt developed tiny bustules along hair follicles along the waistband of her underwear area and anterior abdomen on HD#3. The rash was stable in the next ___ hours while she was in the hospital. We felt the rash was most likely secondary to folliculitis and not consistent with drug rash so did not change antibiotic regimen. CHRONIC ISSUES # GERD: We continued her home omeprazole at 40 mg qd. However, PPI use is associated with increased risk of C.diff colitis, and would recommend re-evaluate for the indication for current regimen. # OSA: We continued her home CPAP. TRANSITIONAL ISSUES # CODE STATUS: Full (confirmed) # PENDING STUDIES ON DISCHARGE: - Stool O&P on ___ - blood culture on ___ # MEDICATION CHANGES - Flagyl 500 mg q8 hour for 2 weeks # FOLLOW UP PLAN - Appt with PCP ___ ___ - Pt may need switch of antibiotics if rash worsens

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Ciprofloxacin / Penicillins Attending: ___. Chief Complaint: Fall Major Surgical or Invasive Procedure: None History of Present Illness: ___ with PMHx significant for extensive atherosclerosis disease including CAD s/p CABG x2, stent, ___ CEA, HTN, T2DM, and Alzheimers dementia presenting status post fall. Patient is a poor historian at baseline and lives alone at assisted living facility. Per patient report, he fell 1x yesterday and then again today. Today he was trying to maneuver between the sink and the toilet in the bathroom when he fell. "I just lost my balance." He reports some lightheadedness and dizziness but denies any aura, no LOC, no urinary or fecal incontinance. He can't remember how long it took him to hoist himself up off the ground but thinks it was probably a while. He lives alone, in independent living and the fall was unwitnessed. He otherwise denies any chest pain, shortness of breath. No fevers or chills. Per ED, "patient is pleasant but unclear how reliable he is for a history." Of note, patient had an admission for fall in ___ where he sustained right ___ rib fractures. In the ED, initial VS were: 99.6, 105, 149/86, 16, 93% RA Exam notable for: Mental Status: a&ox2, disoriented to date and place, confused at times, calm, cooperative and pleasant Ecchymosis on arms and legs however non-tender. Unremarkable exam. Labs showed: - CBC: 10.5/11.9/39.7/190 - Chem7: K 4.5, Cr 1.1 - CK 492 - Trp T: 0.31 Imaging showed: - CT C-spine: No fracture or malalignment, multilevel multifactorial degenerative changes - CT Head: No acute process - CXR: Left base retrocardiac opacity raises concern for pneumonia or aspiration. Bilateral pleural effusions. Re-demonstrated fracture of the anterolateral right seventh rib. Received: ___ 17:16 IVF NS ___ 18:01 IV Heparin bolus & gtt ___ 18:06 PO Aspirin 243 mg ___ 21:28 PO/NG Clopidogrel 75 mg ___ 21:29 PO Metoprolol Succinate XL 50 mg ___ 21:29 PO/NG Furosemide 20 mg On arrival to the floor, patient is resting. he gives the history as above. Endorses a cough, only coughing up phlegm. No fever, chills, no chest pain. Past Medical History: CAD s/p CABG ___ ___ in ___) s/p cardiac stents ___ s/p CABG ___ ___ in ___.) DMII HTN Carotidendarterectomy in ___ (R) and ___ (L) Mild CRI (Cr 1.5-1.8) Anemia Eczema BPH Social History: ___ Family History: Mother - MI at age of ___ Father - brain tumor Brother - ___ MI at age ___ Brother - kidney failure Physical Exam: ADMISSION EXAM: ============= VS: 97.6, 157/85, 93 20 94 RA 64.5kg GENERAL: NAD, AOx2 (to name and place, not year) HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, prominent carotid pulsation, JVP to mid neck at 30 degrees HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: Coarse crackles diffusely with decreased breath sounds at Left base. ABDOMEN: nondistended, nontender in all quadrants, +BS, no rebound/guarding EXTREMITIES: cool to mid shin, 2+ pitting edema bilaterally. PULSES: 2+ DP pulses bilaterally NEURO: A&Ox2, strength ___ throughout non focal. SKIN: scattered ecchymosis and superficial skin ulcerations on back buttocks and extremities, 2x sacral ulcerations. DISCHARGE EXAM: ============== Vitals: 97.6 157 / 66 77 19 94 RA 62.4kg General: elderly man, in NAD, resting supine comfortably; oriented to self, year is ___, ___ HEENT: Sclerae anicteric, OP clear, hematoma on scalp Neck: JVP not significantly elevated Lungs: Normal WOB, lungs with basilar crackles CV: RRR, S1/S2, no m/r/g Abdomen: soft, NT/ND Ext: warm, well perfused, no edema SKIN: scattered ecchymosis and superficial skin ulcerations on back buttocks and extremities, 2x sacral ulcerations. Pertinent Results: ADMISSION LABS: ============= ___ 04:08PM BLOOD WBC-10.5*# RBC-4.72 Hgb-11.9* Hct-39.7* MCV-84 MCH-25.2* MCHC-30.0* RDW-16.2* RDWSD-49.8* Plt ___ ___ 03:26AM BLOOD ___ PTT-40.0* ___ ___ 04:08PM BLOOD Glucose-131* UreaN-30* Creat-1.1 Na-141 K-4.5 Cl-101 HCO3-23 AnGap-17* ___ 04:08PM BLOOD ___ ___ 04:08PM BLOOD cTropnT-0.31* ___ 11:27PM BLOOD CK-MB-11* cTropnT-0.39* ___ 03:26AM BLOOD ALT-15 AST-32 AlkPhos-100 TotBili-1.0 ___ 03:26AM BLOOD Calcium-9.5 Phos-2.6* Mg-1.8 INTERVAL LABS: ============ ___ 03:26AM BLOOD CK-MB-10 cTropnT-0.39* ___ 10:18AM BLOOD CK-MB-7 cTropnT-0.32* DISCHARGE LABS: ============= ___ 06:25AM BLOOD WBC-7.8 RBC-4.41* Hgb-11.0* Hct-36.8* MCV-83 MCH-24.9* MCHC-29.9* RDW-16.4* RDWSD-49.7* Plt ___ ___ 06:25AM BLOOD Glucose-118* UreaN-33* Creat-1.0 Na-143 K-4.5 Cl-104 HCO3-25 AnGap-14 ___ 06:25AM BLOOD Calcium-9.1 Phos-2.5* Mg-2.1 REPORTS: ======= CXR ___ Left base retrocardiac opacity raises concern for pneumonia or aspiration. Bilateral pleural effusions. Re-demonstrated fracture of the anterolateral right seventh rib. CT HEAD ___. Small posterior scalp hematoma without underlying fracture. 2. No acute intracranial abnormality on noncontrast head CT. Specifically no large territory infarct or intracranial hemorrhage. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Tamsulosin 0.4 mg PO QHS 2. Metoprolol Succinate XL 50 mg PO DAILY 3. Furosemide 20 mg PO DAILY 4. Clopidogrel 75 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 7. Finasteride 5 mg PO DAILY 8. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 9. Sertraline 25 mg PO DAILY 10. Pravastatin 40 mg PO QPM Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Aspirin 81 mg PO DAILY 3. Finasteride 5 mg PO DAILY 4. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 5. Sertraline 25 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Community Acquired Pneumonia Type II NSTEMI Dementia 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: Frontal and lateral views INDICATION: History: ___ with cough and s/p fall// ?pneumonia TECHNIQUE: Chest: Frontal and Lateral COMPARISON: ___ FINDINGS: Patient is status post median sternotomy and CABG. The cardiac and mediastinal silhouettes are stable with the cardiac silhouette mild to moderately enlarged. There is persistent blunting of the bilateral posterior costophrenic angles suggesting small pleural effusions. In addition, there is retrocardiac left base opacity raising concern for pneumonia or aspiration. Fracture of the lateral right ninth rib is re-demonstrated. No definite additional rib fracture is seen, but bones are osteopenic and chest radiography has low sensitivity for the detection of such. IMPRESSION: Left base retrocardiac opacity raises concern for pneumonia or aspiration. Bilateral pleural effusions. Re-demonstrated fracture of the anterolateral right seventh rib. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: History: ___ with s/p fall unwitnessed and on plavix// ?bleed TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Total DLP (Head) = 1,304 mGy-cm. COMPARISON: CT head dated ___. FINDINGS: There is no evidence of acute territorial infarction,hemorrhage,edema, or mass. Subcortical, deep, and periventricular white matter hypodensities are nonspecific, but likely represent the sequela of chronic microvascular ischemic disease. There is prominence of the ventricles and sulci suggestive of involutional changes. Dense atherosclerotic calcifications are noted within the cavernous carotid arteries. There is no evidence of fracture. Mucous retention cyst within the right maxillary sinus. Mild mucosal thickening within the left maxillary sinus and bilateral ethmoid air cells. Soft tissue within the bilateral ear canals likely represents cerumen. The mastoid air cells and middle ear cavities are clear. Patient is status post bilateral lens resections. Otherwise, the visualized portion of the orbits are unremarkable. IMPRESSION: 1. No evidence of fracture or intracranial hemorrhage. 2. Mild paranasal sinus disease. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: History: ___ with s/p fall// ?fracture TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue and bone algorithm images were generated. Coronal and sagittal reformations were then constructed. DOSE: Total DLP (Body) = 506 mGy-cm. COMPARISON: CT C-spine dated ___. FINDINGS: Posterior offset of C1 on C2 on the right is unchanged compared to ___, likely degenerative in nature (series 602, image 24). Mild anterolisthesis of C3 on C4 is also unchanged and likely degenerative. Otherwise, alignment is normal. No fractures are identified.There is no prevertebral soft tissue swelling. There is no evidence of infection or neoplasm. Multilevel degenerative disc disease throughout the the cervical spine, most severe at C5-6 and C6-7. Posterior intervertebral osteophytes cause mild-to-moderate narrowing of the spinal canal, most severe at C5-6 (series 2, image 43). There is also multilevel neural foraminal stenosis due to a combination of uncovertebral and facet osteophytes, also most severe at C5-6. The lung apices are clear. No cervical lymphadenopathy. No large thyroid nodules. IMPRESSION: 1. No evidence of fracture or traumatic malalignment. Posterior offset of C1 on C2 on the right is unchanged compared to ___, likely degenerative in nature. Mild anterolisthesis of C3 on C4 is also unchanged and likely degenerative. 2. Multilevel multifactorial degenerative changes, most severe at C5-6 with moderate spinal canal stenosis and severe bilateral neural foraminal stenosis. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old man with NSTEMI on heparin gtt, found to have fallen out of bed by RN staff, with large hematoma on posterior head. AOx2 at prior baseline, non focal neurologic examination// Evaluation for IC hemorrhage TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained without intravenous contrast. Coronal and sagittal reformations and bone algorithms reconstructions were also performed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 18.0 s, 18.5 cm; CTDIvol = 48.8 mGy (Head) DLP = 903.1 mGy-cm. 2) Sequenced Acquisition 5.0 s, 10.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 501.7 mGy-cm. Total DLP (Head) = 1,405 mGy-cm. COMPARISON: CT head from ___. FINDINGS: There is no evidence of acute large territory infarct, hemorrhage, edema, or mass. The ventricles and sulci are prominent compatible with age related involutional changes. Periventricular and subcortical white matter hypodensities are nonspecific, but likely reflect sequelae of chronic small vessel ischemic disease. There is a small posterior scalp hematoma without underlying fracture. A mucous retention cyst is visualized in the right maxillary sinus. There is mild mucosal thickening left maxillary sinus and ethmoid air cells. Otherwise the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: 1. Small posterior scalp hematoma without underlying fracture. 2. No acute intracranial abnormality on noncontrast head CT. Specifically no large territory infarct or intracranial hemorrhage. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: s/p Fall, Weakness Diagnosed with Non-ST elevation (NSTEMI) myocardial infarction, Fall on same level, unspecified, initial encounter temperature: 99.6 heartrate: 105.0 resprate: 16.0 o2sat: 93.0 sbp: 149.0 dbp: 86.0 level of pain: 5 level of acuity: 2.0

___ with Alzheimer's disease, CAD, HFpEF, who presented with a fall, found to have a Type II NSTEMI and Pneumonia. # Community Acquired PNA: Presented with mild leukocytosis and respiratory symptoms, with convincing imaging evidence of PNA. Therapy complicated by allergy to both quinolone and penicillins. Initially started on Azithromycin ___ and Aztreonam given allergies. Ultimately received 5 day course of therapy with Azithromycin, last day ___. # ___ on CKD: Peak Cr of 1.5, from 1.1 on admission after receiving IV diuretics for suspected volume overload. Diuretics subsequently held, he remained euvolemic, and his Cr returned to baseline ~1. # Falls: Second fall in the last year. No obvious cardiac etiology, though PNA could certainly have triggered a fall. Patient is severely frail. Discontinued metoprolol, flomax, and plavix. Discharged to rehab following ___ evaluation. # Sacral Ulcer: Will need continued close wound care and nutritional optimization. # Swallowing: S+S team recommended nectar prethickened liquids and video swallow study. After discussion with family, decided to forgo plans for video swallow as family would like to optimize PO nutrition for patient. Family is aware of aspiration risk. Discharged on thin liquid and dysphagia diet. # Type II NSTEMI # History of CAD: Likely demand ischemia in setting of fall and PNA. No complaint of chest pain or concerning EKG changes. Briefly on heparin drip, but was discontinued. Not a candidate for cath per Cardiology evaluation. Medical management was advised but Plavix and metoprolol were discontinued given risk from falls. Statin was also discontinued. Continue aspirin. # HFpEF: Admitted with elevated BNP, with some JVD elevation on admission exam. Received IV diuretics early on in admission, but Cr increased quickly peaked to 1.5 with this. Maintained euvolemia without diuretics for days prior to discharge so lasix was discontinued. # BPH: Continued on finasteride. Discontinued flomax. # Mood: Continued on sertralin. TRANSITIONAL ISSUES ====================== - Antibiotics course: finished ___ Azithromcyin for CA-PNA. - Wound care assessment: -- Coccyx/sacral deep tissue pressure injury 2x0.5cm -- Left glut full thickness stage 3 pressure injury 1x~0.2cm -- Right elbow, partial thickness traumatic ulcer 1 x 0.5cm -- Left elbow traumatic full tissue flap, skin tear 2 x 2.5 cm -- Right knee traumatic ulcer ~ 2 x 1 cm Apply commercial wound cleanser or normal saline to cleanse wounds. Pat the tissue dry with dry gauze. Apply moisture barrier ointment to the periwound tissue with each dressing change. Apply xeroform to elbows, cover with ABD pad, secure with kling wrap. To right knee, cover with Adaptic gauze and secure with Kling change daily. Continue Mepilex Sacral Border dressing to coccyx and change q 3 days. To left glut continue Mepilex 4 x 4 and change q 3 days. Please offload heels as he is at risk for developing pressure injury. - Discharge diet: thin liquids, soft dysphagia diet #CODE: DNR/DNI confirmed #CONTACT: ___ ___ SON , ___ (daughter) ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Jaw pain s/p fall Major Surgical or Invasive Procedure: Open Reduction Internal Fixation of compound symphysis fracture and closed reduction with maxillomandibular fixation of right condylar fracture of mandible History of Present Illness: ___ presenting after 15 foot fall while climbing down a water tower. Patient reports that he slipped from the ladder and landed on his feet then onto his chin. Denies LOC. Presented to OSH and was transferred to ___ after Dx of mandibular fracture and receiving Unasyn. Upon arrival, patient reported jaw pain and malocclusion. No chest pain or SOB. No fevers or chills. No nausea or vomiting. No weakness, numbness or tingling. Past Medical History: None Social History: ___ Family History: Non-contributory Physical Exam: DISCHARGE PHYSICAL EXAM: Gen: Comfortable, AAOx3 HEENT: Normocephalic, atraumatic, PERRL, EOMI. No midface tenderness. 4 cm chin laceration with good approximation, oozing, sutures have been removed. Patient in maxillomandibular fixation. CV: RRR S1 and S2 without murmurs rubs or gallops Abd: Soft, Nontender, Nondistended Extr/Back: No cyanosis, clubbing or edema. Posterior tibial pulses 2+ bilaterally Neuro: Speech fluent. CN II-XII intact bilaterally. Strength and sensation intact bilaterally Pertinent Results: ___ 05:10AM BLOOD WBC-6.8 RBC-4.87 Hgb-14.2 Hct-42.9 MCV-88 MCH-29.2 MCHC-33.1 RDW-13.6 Plt ___ ___ 05:10AM BLOOD Glucose-99 UreaN-12 Creat-0.9 Na-141 K-4.4 Cl-101 HCO3-29 AnGap-15 Medications on Admission: None Discharge Medications: 1. Bacitracin Ointment 1 Appl TP QID RX *bacitracin zinc 500 unit/gram apply to chin laceration four times per day Refills:*0 2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID RX *chlorhexidine gluconate 0.12 % swish in mouth twice per day Refills:*0 3. Ibuprofen Suspension 600 mg PO Q8H:PRN pain Duration: 2 Weeks RX *ibuprofen 100 mg/5 mL 30 mL by mouth every six (6) hours Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Mandibular Fractures Discharge Condition: Mental Status: Clear and coherent. Followup Instructions: ___ Radiology Report INDICATION: History: ___ with fall with mandible fracture // eval for surgical planning TECHNIQUE: 2 PANOREX VIEWS COMPARISON: Reference made to CT maxillofacial from outside institution performed on ___ at 23:50. FINDINGS: Some patient motion makes examination suboptimal. The comminuted, displaced superior right mandibular fracture is not included on the image. The parasymphyseal mandibular fracture was better assessed on preceding CT. The fracture appears to extend between the 2 central incisors. Better seen on CT, the right lateral incisor appears decreased in height as compared to the adjacent right central incisor and adjacent left right canine. The left lateral incisor appears somewhat angulated. Fracture of a right-sided mandibular molar was better seen on CT. Radiology Report HISTORY: Jaw fracture, status post ORIF and CRIF, evaluate alignment. PANOREX, ONE VIEW. MANDIBLE, FOUR VIEWS The patient's mouth appears to have been wired shut. Two screws extend across the parasymphyseal portion of the mandible. No displaced fracture is detected on these views. A known sagittal midline fracture through the midline mental portion of the mandible is not well appreciated radiographically, likely due to close apposition of the fracture fragments as well as technical limitations. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: MANDIBULAR FX Diagnosed with MULT FX MANDIBLE-CLOSED, TOOTH (BROKEN) (FRACTURED) (DUE TO TRAUMA), WITHOUT MENTION OF COMPLICATION, OPEN WOUND OF JAW, FALL-1 LEVEL TO OTH NEC temperature: 99.0 heartrate: 78.0 resprate: 16.0 o2sat: 98.0 sbp: 125.0 dbp: 59.0 level of pain: 4 level of acuity: 3.0

Patient was admitted to the Acute Care Surgery service for pain control, IV antibiotics and with plan for operative management of mandibular fractures. Patient did well after admission; his pain was controlled and vitals and lab tests remained stable. A tertiary survey did not demonstrate any other injuries. Patient was taken to the Operating Room on HD 2 by ___ where he received Open reduction internal fixation of symphysis fracture a closed reduction of right condylar fracture and maxillomandibular fixation. He tolerated the procedure well and was stable postoperatively. IV antibiotics were continued until discharge.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: nausea/vomiting and watery diarrhea Major Surgical or Invasive Procedure: NONE History of Present Illness: History of Present Illness: ___ YO gentleman presenting with one day of nausea and vommiting. History is obtained from patient and supplemented by ED records as patient is not too verbose this evening. He apparently ate some chicken this afternoon and had episodes of nausea vommiting and diarrhea. He is unable to quantify how frequently he is having bowel movements but he had 2 bowel movements over the course of one hour while admitting him. These stools are watery and of moderate volume. No frank blood by nursing report. He denies fevers and also denies seeing blood. Unclear if there are sick contacts. . On the floor, he is lying in the fetal postions and answering questiosn appropriatly but very brief one to three word answers. He refuses to lay on his back for the exam. Endorses thirst and is activly stooling. No vommiting since being in the ED. . Review of systems: (+) Per HPI Past Medical History: 1. ___ years 2. Diabetes ___ years 3. TIAs 4. Renal insufficiency- Most recent BUN/CRE= 39/1.5 5. Anemia- 6. Pulmonary nodules 7. Hyperuricemia 8. Cerebrovascular disease 9. Diverticulitis 10. Prostatectomy 11. Glaucoma Social History: ___ Family History: His son has a cardiomyopathy. His sister died of lung cancer Physical Exam: Admission Physical Exam: Vitals: 98.6 156/67 108 20 99 3L Physical exam is compromised by patient lying on side and actively stooling during entire duration of exam. General: Alert, oriented, answers questions appropriately HEENT: dry MM Neck: unable to assess Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, diffusely TTP throughout Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Discharge Physical Exam: Vitals: 97.8 121/71 82 22 97RA General: alert, oriented x3, NAD HEENT: NCAT, EOMI, PERRL, dry MM NECK: no palpable lymphadenopathy, JVP to 9cm ___: RRR, normal s1,s2, no murmurs rubs gallops Lungs: Patient breathing comfortably room air at rest. Right basilar inspiratory crackles. Otherwise clear to auscultation, no wheezing. Abdomen: Obese, soft, non distended, non tender, +BS Ext: wwp, 2+ pulses, no LLE Skin: no rashes Pertinent Results: ADMISSION LaBS: ___ 08:45PM BLOOD WBC-9.7 RBC-4.67 Hgb-14.5 Hct-43.8 MCV-94 MCH-31.2 MCHC-33.2 RDW-15.7* Plt ___ ___ 08:45PM BLOOD Neuts-87.6* Lymphs-4.9* Monos-4.6 Eos-2.7 Baso-0.2 ___ 08:45PM BLOOD Glucose-199* UreaN-48* Creat-1.8* Na-145 K-4.0 Cl-106 HCO3-23 AnGap-20 ___ 08:45PM BLOOD ALT-28 AST-37 AlkPhos-102 TotBili-0.4 ___ 08:45PM BLOOD Albumin-4.6 DISCHARGE LABS: ___ 07:05AM BLOOD WBC-6.5 RBC-4.07* Hgb-12.7* Hct-37.8* MCV-93 MCH-31.1 MCHC-33.5 RDW-16.2* Plt ___ ___ 10:15AM BLOOD Neuts-72.9* Lymphs-15.8* Monos-8.1 Eos-2.9 Baso-0.3 ___ 07:05AM BLOOD Glucose-136* UreaN-28* Creat-1.3* Na-145 K-3.5 Cl-109* HCO3-26 AnGap-14 ___ 07:05AM BLOOD Calcium-8.3* Phos-1.9* Mg-1.9 Iron-59 ___ 07:05AM BLOOD calTIBC-265 VitB12-663 Folate-GREATER TH Ferritn-176 TRF-204 ___ 10:15AM BLOOD LEGIONELLA PNEUMOPHILA ANTIBODY-PND ECG ___ 10:33:38 ___ Baseline artifact makes interpretation difficult. Repeat tracing is suggested. Probable sinus rhythm with ventricular premature beats. Compared to the previous tracing of ___ artifact is new, ventricular rate is faster. IntervalsAxes ___ ___ CXR ___: IMPRESSION: Bibasilar atelectasis and low lung volumes. While ther is no overt evidence of pneumonia, a retrocardiac opacity in the appropriate clinical setting may be an early infectious process. CXR ___: FINDINGS: As compared to the previous radiograph, there is no relevant change. Unchanged low lung volumes with areas of atelectasis at both lung bases. No interval appearance of pneumonia. No pleural effusions. Unchanged left pectoral pacemaker, unchanged borderline size of the cardiac silhouette, without pulmonary edema. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob/wheezing 2. Allopurinol ___ mg PO DAILY 3. Bumetanide 4 mg PO DAILY hold for SBP<100 4. FoLIC Acid 1 mg PO DAILY 5. GlipiZIDE 10 mg PO BID 6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES Frequency is Unknown 8. Levothyroxine Sodium 88 mcg PO DAILY 9. Metoprolol Succinate XL 25 mg PO DAILY hold for sbp<100 or hr<50 10. Pregabalin 200 mg PO DAILY 11. Simvastatin 40 mg PO DAILY 12. Timolol Maleate 0.25% 1 DROP RIGHT EYE BID 13. Valsartan 80 mg PO DAILY hold for sbp<100 14. Ambien CR *NF* (zolpidem) 10 mg Oral QHS 15. Aspirin 325 mg PO DAILY 16. coenzyme Q10 *NF* 100 mg Oral unknown 17. Pyridoxine 25 mg PO DAILY Discharge Medications: 1. GlipiZIDE 10 mg PO BID 2. Metoprolol Succinate XL 25 mg PO DAILY hold for sbp<100 or hr<50 3. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob/wheezing 4. Allopurinol ___ mg PO DAILY 5. Aspirin 325 mg PO DAILY 6. Bumetanide 4 mg PO DAILY hold for SBP<100 7. FoLIC Acid 1 mg PO DAILY 8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 9. Levothyroxine Sodium 88 mcg PO DAILY 10. Pregabalin 200 mg PO DAILY 11. Pyridoxine 25 mg PO DAILY 12. Simvastatin 40 mg PO DAILY 13. Timolol Maleate 0.25% 1 DROP RIGHT EYE BID 14. Valsartan 80 mg PO DAILY hold for sbp<100 15. coenzyme Q10 *NF* 100 mg Oral unknown 16. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 17. Ambien CR *NF* (zolpidem) 10 mg Oral QHS Discharge Disposition: Home Discharge Diagnosis: Viral gastroenteritis. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: ___ man with increased respiratory failure. Question pneumonia. COMPARISON: ___. TECHNIQUE: PA and lateral views of the chest. FINDINGS: There are low lung volumes which accentuates bibasilar atelectasis. Cardiomediastinal silhouette and hilar contours are unremarkable. A battery pack with pacemaker leads terminating in the right atrium and right ventricle are in unchanged position. A slight increase in the retrocardiac density may be due to low lung volumes versus early infectious process. IMPRESSION: Bibasilar atelectasis and low lung volumes. While ther is no overt evidence of pneumonia, a retrocardiac opacity in the appropriate clinical setting may be an early infectious process. Radiology Report CHEST RADIOGRAPH INDICATION: Dyspnea on exertion, evaluation for pneumonia. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, there is no relevant change. Unchanged low lung volumes with areas of atelectasis at both lung bases. No interval appearance of pneumonia. No pleural effusions. Unchanged left pectoral pacemaker, unchanged borderline size of the cardiac silhouette, without pulmonary edema. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: VOMITING AND/OR NAUSEA Diagnosed with NONINF GASTROENTERIT NEC temperature: 97.9 heartrate: 94.0 resprate: 26.0 o2sat: 95.0 sbp: 149.0 dbp: 54.0 level of pain: 0 level of acuity: 3.0

___ w/ PMH significant for anemia, CHF with preserved EF who presented with nausea/vomiting and watery diarrhea for 24 hours.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: UROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: RLQ pain, N/V, chills and dysuria found to have 3mm stone and hydronephrosis on CT. Major Surgical or Invasive Procedure: PROCEDURE: Cystoscopy, right retrograde pyelogram, right ureteral stent placement. History of Present Illness: ___ presenting for the third time with RLQ pain, N/V, chills and dysuria found to have 3mm stone and hydronephrosis on CT. Past Medical History: Nephrolithiasis ___, Right Retrograde Pyelogram, Right Ureteral Stent PlacementCarrasquillo ___ REDUCTION PERCUTANEOUS PINNING RIGHT ___ METACARPALRozental Social History: ___ Family History: Daughter with nephrolithiasis Physical Exam: WdWn male, NAD, AVSS Interactive, cooperative Abdomen soft, Nt/Nd IUC has been removed. He is voiding. Lower extremities w/out edema or pitting and no report of calf pain Pertinent Results: ___ 06:50AM BLOOD WBC-8.0 RBC-4.12* Hgb-12.2* Hct-35.8* MCV-87 MCH-29.6 MCHC-34.1 RDW-12.4 RDWSD-39.9 Plt ___ ___ 03:08PM BLOOD WBC-11.7* RBC-4.42* Hgb-12.9* Hct-38.3* MCV-87 MCH-29.2 MCHC-33.7 RDW-12.4 RDWSD-39.6 Plt ___ ___ 03:08PM BLOOD Neuts-82.4* Lymphs-7.8* Monos-9.0 Eos-0.1* Baso-0.3 Im ___ AbsNeut-9.67* AbsLymp-0.92* AbsMono-1.05* AbsEos-0.01* AbsBaso-0.03 ___ 06:50AM BLOOD Glucose-83 UreaN-11 Creat-1.3* Na-141 K-4.1 Cl-102 HCO3-28 AnGap-11 ___ 03:08PM BLOOD Glucose-88 UreaN-11 Creat-1.5* Na-137 K-4.4 Cl-100 HCO3-24 AnGap-13 ___ 10:04 pm URINE Site: CYSTOSCOPY RIGHT RENAL URINE. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 4:13 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: < 10,000 CFU/mL. Medications on Admission: NONE Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild Reason for PRN duplicate override: Patient is NPO or unable to tolerate PO 2. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg ONE capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 3. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild NOT relieved by Acetaminophen RX *ibuprofen 600 mg ONE tablet(s) by mouth Q6hrs Disp #*25 Tablet Refills:*0 4. Phenazopyridine 100 mg PO TID:PRN burning with urination Duration: 3 Days RX *phenazopyridine [Pyridium] 100 mg ONE tablet(s) by mouth q8hrs Disp #*9 Tablet Refills:*0 5. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 7 Days RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg ONE tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 6. Tamsulosin 0.4 mg PO QHS RX *tamsulosin [Flomax] 0.4 mg ONE capsule(s) by mouth Daily Disp #*21 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: nephrolithiasis; Right ureteral stone with obstruction Acute kidney injury urinary tract infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT ABD AND PELVIS W AND W/O CONTRAST, ADDL SECTIONS INDICATION: +PO contrast; History: ___ hx nephrolithiasis with 5d RLQ pain and fever+PO contrast// ?appendicitis vs renal calculus or urinary tract obstruction 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 6.6 s, 51.6 cm; CTDIvol = 9.5 mGy (Body) DLP = 491.6 mGy-cm. Total DLP (Body) = 500 mGy-cm. COMPARISON: None. FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is 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: Right kidney is enlarged with delayed nephrogram and there is moderate right hydroureteronephrosis secondary to an obstructing right distal ureteral calculus, just proximal to the ureterovesical junction measuring 3 mm. Additionally, perinephric and periureteral fluid and stranding suggest possible forniceal rupture. The left kidney enhances normally with subcentimeter hypodensity in the upper pole, too small to fully characterize, but likely a cyst. There is no left-sided hydronephrosis in the left ureter appears unremarkable. 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: There is moderate right hydroureteronephrosis with periureteral stranding due to an obstructing 3 mm right distal ureteral calculus, just proximal to the ureterovesical junction. The urinary bladder and distal left ureter are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The prostate and seminal vesicles are grossly unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease is noted. BONES: Curvilinear area of subchondral sclerosis in the left femoral head suggest avascular necrosis without evidence for femoral head collapse. There is no evidence of worrisome osseous lesions or additional fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Obstructing 3 mm right distal ureteral calculus, just proximal to the ureterovesical junction, resulting in upstream moderate right hydroureteronephrosis. Right-side perinephric and periureteral fluid and stranding suggest possible forniceal rupture. Please note that infection of the right collecting system is also not excluded, and correlation with urinalysis is needed. 2. Left femoral head avascular necrosis without evidence for femoral head collapse. 3. Normal appendix. Radiology Report EXAMINATION: ABDOMEN (SUPINE ONLY) IN O.R. INDICATION: Intraoperative abdominal radiographs TECHNIQUE: Intraoperative abdominal radiographs were obtained. Total fluoro time is 17.9 seconds. Cumulative Dose: 4.11 mGy. COMPARISON: CT abdomen pelvis from ___ FINDINGS: Intraoperative images were acquired without a radiologist present. Please see operative note for further details of the procedures. Images show intra-abdominal contrast injection through a right ureteral stent. IMPRESSION: Intraoperative images were obtained. Please refer to the operative note for details of the procedure. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: RLQ abdominal pain Diagnosed with Calculus of ureter, Urinary tract infection, site not specified, Right lower quadrant pain temperature: 101.1 heartrate: 83.0 resprate: 16.0 o2sat: 100.0 sbp: 160.0 dbp: 91.0 level of pain: 8 level of acuity: 3.0

Mr. ___ presents with right ureteral stone and obstruction so he was admitted to urology for nephrolithiasis management. He was taken urgently to the operative theatre where he underwent cystoscopy, right retrograde pyelogram, right ureteral stent placement. He tolerated the procedure well and recovered in the PACU before transfer to the general surgical floor. See the dictated operative note for full details. Overnight, the patient was hydrated with intravenous fluids and received appropriate perioperative prophylactic antibiotics. On POD1, catheter was removed. Intravenous fluids and Flomax were given to help facilitate passage of stones. At discharge on POD1, patient’s pain was controlled with oral pain medications, tolerating regular diet, ambulating without assistance, and voiding without difficulty. Patient was explicitly advised to follow up as directed as the indwelling ureteral stent must be removed and or exchanged and definitive stone management addressed.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: sob Major Surgical or Invasive Procedure: none History of Present Illness: This is a ___ year old lady with a history of htn, family hx of cad, and anxiety who presents with a 1 week history of worsening dyspnea on exertion prompting diagnosis of bilateral PEs in the ___ ED. She reports a the gradual onset of SOB 1 week prior associated w/ progressive DOE, fatigue. For the past three days she had several days of RUQ pain that radiated to the back was unrelieved by position, food or rest. Prior to onset of sx she reports a sedentary holiday break where she spent the majority of the time on the couch, which is not atypical from usual except that it was not interrupted by periods of work as ___ ___ ___. She denies CP, palpitations, diaphoresis. No family or personal history of blood clot or miscarriages. She is not taking any estrogen containing medications. She has not smoked tobacco since ___. She is not up to date on her routine cancer screening, last mammogram > ___ years ago, PAP negative in ___ and no colonscopy. Her abdominal pain has resolved since yesterday. In the ED, initial VS were: 97.9 98 129/68 20 91% ra. Chem 7 notable for Ca ___. ALT/AST 51/62, AP 110, Lipase 22. D dimer was 5240 and BNP was 105. White count was 11.1. CTA chest demonstrated bilat lobar and segmental PE with equivocal CT signs of rt heart strain and no infarct. RUQ US showed fatty liver as well as cholelithiasis without cholecystitis. CXR showed no acute cardiopulmonary process. EKG was negative for RHS pattern but showed lateral ST depressions. Trop was negative. Cardiology was consulted and performed a bedside TTE which showed right ventricular mid-free wall akinesia with normal apical motion. She was given aspirin and started on a heparin gtt. Admission to the medical ICU was requested given evidence of right heart strain. On arrival to the MICU, her VS were: 109 140/74 92% on 3L NC. She was comfortable and in NAD. Past Medical History: 1. Obesity 2. Tobacco use 3. Positive PPD in ___, received ___ year ING 4. Esophageal Reflux 5. Anxiety 6. Hypertension 7. Irritable Bowel Syndrome Social History: ___ Family History: No family hx of DVT or PE Physical Exam: Admission: Vitals: 109 140/74 92% on 3L NC. General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated but compromised exam somewhat by obesity CV: Regular rate and rhythm, tachycardic without murmur Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, obese nontender GU: no foley Ext: warm, well perfused, calves are symmetric w/out erythema or swelling or tenderness to exam, no cords palpated Discharge: AVSS, on RA Not otherwise changed Pertinent Results: ___ 03:30PM BLOOD WBC-11.1* RBC-5.08 Hgb-15.5 Hct-45.2 MCV-89 MCH-30.5 MCHC-34.3 RDW-12.7 Plt ___ ___ 06:25AM BLOOD WBC-9.0 RBC-4.44 Hgb-13.7 Hct-40.7 MCV-92 MCH-31.0 MCHC-33.7 RDW-13.0 Plt ___ ___ 06:35AM BLOOD ___ ___ 06:25AM BLOOD Glucose-83 UreaN-12 Creat-0.7 Na-138 K-3.4 Cl-102 HCO3-26 AnGap-13 ___ 03:30PM BLOOD ALT-51* AST-62* AlkPhos-110* TotBili-0.7 ___ 03:30PM BLOOD D-Dimer-5240* TTE: The left ventricle is not well seen. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The right ventricle has akinesis of the mid-free wall and normal motion of the apex ___ sign). The aortic valve is not well seen. The mitral valve leaflets are not well seen. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Right ventricular mid-free wall akinesia with normal apical motion ___ sign) consistent with acute pulmonary embolism. Due to the patient's habitus, this was a suboptimal and technically difficult study. CTA: IMPRESSION: 1. Bilateral lower lobar and segmental pulmonary emboli with equivocal CT evidence for right heart strain. 2. No signs of pulmonary infarction. 3. Fatty liver with cholelithiasis. Medications on Admission: 1. Omeprazole 20mg daily 2. Sertraline 50mg daily 3. Aspirin 81 mg daily 4. Alprazolam 1mg tid 5. Hydrochlorothiazide 25mg daily Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN pain do not take more than 4g per day 2. Aspirin 81 mg PO DAILY 3. Enoxaparin Sodium 130 mg SC Q12H RX *enoxaparin 150 mg/mL 130mg (you will have to waste 20mg from the 150mg syringe) once every 12 hours Disp #*14 Syringe Refills:*0 4. Warfarin 6 mg PO DAILY16 RX *warfarin 2 mg 3 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 5. Simethicone 120 mg PO QID:PRN stomach 6. DiCYCLOmine 20 mg PO TID:PRN stomach pain 7. Sertraline 50 mg PO DAILY 8. Omeprazole 20 mg PO DAILY 9. Outpatient Lab Work diagnosis: acute pulmonary embolism, on anticoagulation date: ___ labs: ___ Send report to ___., Phone: ___, Fax: ___ Discharge Disposition: Home Discharge Diagnosis: acute pulmonary embolism hypokalemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: ___ female with shortness of breath. Question pneumonia. COMPARISON: None. FINDINGS: Frontal and lateral views of the chest. The lungs are clear of consolidation or effusion. Cardiac silhouette is enlarged. Hypertrophic changes are noted in the spine. No acute osseous abnormality detected. IMPRESSION: Enlarged cardiac silhouette without definite superimposed acute cardiopulmonary process. Radiology Report HISTORY: Right upper quadrant pain. COMPARISON: None available. FINDINGS: The liver appears diffusely increased in echogenicity consistent with fatty deposition within the liver. Otherwise, no focal lesions identified within the liver. There is no intra or extrahepatic ductal dilatation with the common bile duct measurinh 5 mm. The main portal vein is patent with hepatopetal flow. The gallbladder contains stone but is without evidence of distention, gallbladder wall edema, or pericholecystic fluid. Sonographic ___ sign was absent. The pancreas is not well visualized due to overlying bowel gas. The visualized outline of the aorta appears normal in caliber. IMPRESSION: 1. The liver is diffusely increased echogenicity consistent with fatty deposition within the liver. More significant hepatic disease including significant hepatic fibrosis/cirrhosis cannot be excluded on the basis of this study. 2. Cholelithiasis without cholecystitis. Radiology Report CHEST CTA PERFORMED ON ___. COMPARISON: Chest radiograph from same day. CLINICAL HISTORY: Short of breath, hypoxic, elevated D-dimer, question PE. TECHNIQUE: Multidetector CT through the chest was performed following IV contrast administration with multiplanar reformations provided. FINDINGS: There are multiple filling defects within these lobar and segmental branches of the bilateral pulmonary arterial tree. There is no saddle embolus seen and the filling defects are only seen within the lobar branches and beyond. There is mild flattening of the intraventricular septum, which could indicate mild right heart strain. The heart is otherwise unremarkable. There is no lymphadenopathy. The thoracic aorta is normal. The airway is centrally patent. There is prominent epicardial fat deposition. Lung windows demonstrate no worrisome nodule, mass, or consolidation. Mild centrilobular apically predominant emphysema is noted. There is no evidence of infarction within the lungs. There is no pleural or pericardial effusion. In the imaged portion of the upper abdomen, fatty liver is noted. There is likely a gallstone within the gallbladder. The adrenal glands are normal. BONES: Unremarkable. IMPRESSION: 1. Bilateral lower lobar and segmental pulmonary emboli with equivocal CT evidence for right heart strain. 2. No signs of pulmonary infarction. 3. Fatty liver with cholelithiasis. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: SHORTNESS OF BREATH Diagnosed with PULM EMBOLISM/INFARCT temperature: 97.9 heartrate: 98.0 resprate: 20.0 o2sat: 91.0 sbp: 129.0 dbp: 68.0 level of pain: 0 level of acuity: 2.0

___ with HTN, obesity presents with DOE and found to have acute pulmonary embolism. She was admitted to the MICU where she had a TTE with right heart stain but no failure. She was started on a heparin drip which was switched to lovenox and warfarin at the time of discharge. # Acute pulmonary embolism: She is obese with a sedentary lifestyle. She does not appear to have other risk factors. She was treated with heparin drip which was switched to lovenox. She will start warfarin and follow up with her PCP and ___ clinic for further titration. Her INR goal is ___ and she should be treated for at least 6 months. At the time of discharge she was able to ambulate on room air without oxygen desaturation. Her dyspnea was not fully resolved but improved on discharge. # Hypokalemia: She was treated with potassium supplementation. # Anxiety: - continue home sertraline 50mg daily - continue home alprazolam 1mg tid prn anxiety # GERD: - continue home omeprazole 20mg daily

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Morphine / opiates Attending: ___. Chief Complaint: fever Major Surgical or Invasive Procedure: none History of Present Illness: ___ with a complicated past medical history of longstanding type 2 diabetes on insulin, hypertension, and laryngeal stenosis with vocal cord paralysis with hx of sudden apneas requiring ongoing tracheostomy now presents with fevers, generalized weakness, and malaise. He has a 10-month history of having intermittent episodes of symptoms including the above along with HA, stiff neck, shivering cold, and nausea. At the onset of these symptoms, he generally also has a putrid smell and taste in his mouth. Due to this and prior purulence from his trach, he has been intermittently treated with courses of levofloxacin for presumed tracheitis which always resolve his symptoms and makes him feel completely well, though the symptoms always recur. Initially they would recur after a few months, but the period of time inbetween episodes has progressively shortened. He finished his most recent levofloxacin course a few weeks ago and started to feel ill again after a few days. Over the past ___ days, he has had significant low-grade fevers 99.8-101 associated with similar symptoms including generalized weakness, malaise, HA, stiff neck, nausea, and also left eye discomfort with lacrimation. He also has had subjective confusion recently as well. He saw his ENT doctor today who preformed a tracheoscopy which did not reveal evidence of tracheitis. He was therefore sent to the ED for further evaluation. On further review of systems, he reports mild burning at the end of urination, chronic loose stools without any recent change (non-bloody, non-melenic), and + left eye pressure with subjective blurriness. Outside of this, he denies any unintentional weight loss, cough, sputum production, SOB, chest discomfort, sore throat, abdominal discomfort, vomiting, change in loose stools, hematuria, penile discharge, flank pain, recent arthralgias or arthritis, skin rash, oral/genital ulcerations, or any other complaints. Of note, he has been worked up extensively by GI for intermittent diarrhea which has included negative stool studies, bacterial overgrowth breath testing, colonoscopy, and upper endoscopy with biopsies (negative for celiac and Whipple's). It was recommended that he increase his Creon and try immodium for relief. His symptoms were attributed to possible diabetic enteropathic diarrhea given the negative work-up. Finally, he says in the past even prior to these recent 10 months he has had intermittent similar symptoms to a less severe degree. The possibility of Reactive Arthritis was apparently raised, though he has not had any treatment for this. In the ED initial vitals were: 98.0 70 133/88 16 99% RA - Labs were significant for normal CBC, normal chem 7 save for creatinine of 1.6 (recent baseline 1.5), negative u/a, and lactate of 2.6. - Patient was given 1L NS. He received acetaminophen and no other medications. Vitals prior to transfer were: 98.3 72 172/88 16 100% RA On the floor, initial VS: 98.0 167/94 63 18 98%RA He was lying comfortably in bed in NAD. Past Medical History: Past Medical History: 1. Type 2 diabetes (seen by Dr. ___ at ___. 2. Hypertension. 3. Obstructive sleep apnea. 4. Obesity. 5. Bilateral vocal cord paralysis. 6. Laryngeal stenosis. 7. Nephrolithiasis. 8. Sialolithasis. 9. Chronic sinus and ear infections. Past Surgical History: 1. Vocal cord implant in ___. 2. C7-T1 spinal fusion in ___, with a repeat fusion in ___. 3. Separated sternum, status post surgical repair in ___. 4. Cholecystectomy in ___. 5. Right shoulder rotator cuff repair ___. 6. Appendectomy. Social History: ___ Family History: Does not know his parents, as he is adopted. He has no known siblings. He has one daughter who is healthy. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals - 98.0 167/94 63 18 98%RA GENERAL: well-developed, well-appearing, obese, adult male lying comfortably in bed in NAD HEENT: AT/NC, EOMI without discomfort with eye movement. PERRL. no scleral injection or icterus. pink conjunctiva, MMM without ulcerations. good dentition, nontender supple neck, no LAD, no JVD CARDIAC: normal rate, regular rhythm. nl S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: moving all extremities well, no cyanosis, clubbing or edema PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes. no ___ lesions or ___ nodes, no splinter hemorrhages. DISCHARGE PHYSICAL EXAM: VS 98.4/98, 149/76, 71, 16, 100% on RA GENERAL: well-developed, well-appearing, obese, adult male lying comfortably in bed in NAD HEENT: AT/NC, EOMI without discomfort with eye movement. PERRL. no scleral injection or icterus. pink conjunctiva, MMM without ulcerations. good dentition, nontender supple neck, no LAD, no JVD CARDIAC: normal rate, regular rhythm. nl S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: soft, obese, NTND, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: moving all extremities well, no cyanosis, clubbing or edema PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, negative Jolt sign, negative ___ and ___ signs SKIN: warm and well perfused, no excoriations or lesions, no rashes. Pertinent Results: ADMISSION LABS ==================================== ___ 01:40PM GLUCOSE-80 UREA N-16 CREAT-1.6* SODIUM-140 POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-25 ANION GAP-15 ___ 01:40PM WBC-9.2 RBC-4.98 HGB-17.1 HCT-47.4 MCV-95 MCH-34.3* MCHC-36.0* RDW-12.4 ___ 01:40PM NEUTS-66.2 ___ MONOS-6.6 EOS-5.8* BASOS-0.9 ___ 01:40PM ALBUMIN-4.4 CALCIUM-9.7 PHOSPHATE-2.3* MAGNESIUM-1.9 ___ 01:40PM ALT(SGPT)-26 AST(SGOT)-22 LD(LDH)-208 ALK PHOS-98 TOT BILI-0.4 ___ 01:40PM LIPASE-59 ___ 04:56PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 04:56PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG ___ 05:04PM LACTATE-2.6* DISCHARGE LABS ===================================== ___ 01:45AM BLOOD ESR-4 ___ 01:45AM BLOOD CRP-3.7 ___ 01:45AM BLOOD HIV Ab-PND STUDIES ===================================== ___ CXR FINDINGS: The patient is status post sternotomy. Discontinuities of sternal wires appear unchanged. There is an apparently closed tracheostomy with a stent and overlying clips, but correlation with current status and any history of instrumentation is recommended. The cardiac, mediastinal and hilar contours appear unchanged including mild cardiomegaly. The lungs appear clear. There are no pleural effusions or pneumothorax. IMPRESSION: No evidence of acute cardiopulmonary disease. MICROBIOLOGY ===================================== ___ Blood cultures x 2 pending ___ 1:45 am SEROLOGY/BLOOD Source: Venipuncture. RAPID PLASMA REAGIN TEST (Pending): Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Furosemide 20 mg PO BID 2. GlipiZIDE 10 mg PO BID 3. Creon 12 2 CAP PO TID W/MEALS 4. Lisinopril 10 mg PO DAILY 5. Metoprolol Tartrate 25 mg PO DAILY 6. Omeprazole 20 mg PO DAILY 7. testosterone 1.62 % (20.25 mg/1.25 gram) transdermal once daily 8. Vitamin D 1000 UNIT PO DAILY 9. Aspirin 81 mg PO DAILY 10. LOPERamide 2 mg PO QID:PRN diarrhea 11. Magnesium Oxide 400 mg PO DAILY 12. Cyanocobalamin 100 mcg PO DAILY 13. Glargine 15 Units Breakfast Humalog 15 Units Breakfast Humalog 15 Units Lunch Humalog 6 Units Dinner Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Creon 12 2 CAP PO TID W/MEALS 3. Furosemide 20 mg PO BID 4. Glargine 15 Units Breakfast Humalog 15 Units Breakfast Humalog 15 Units Lunch Humalog 6 Units Dinner 5. Lisinopril 10 mg PO DAILY 6. LOPERamide 2 mg PO QID:PRN diarrhea 7. Omeprazole 20 mg PO DAILY 8. Cyanocobalamin 100 mcg PO DAILY 9. GlipiZIDE 10 mg PO BID 10. Magnesium Oxide 400 mg PO DAILY 11. Metoprolol Tartrate 25 mg PO DAILY 12. testosterone 1.62 % (20.25 mg/1.25 gram) transdermal once daily 13. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary: Fever Secondary: vocal cord paralysis status-post tracheotomy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report CHEST RADIOGRAPHS HISTORY: Shortness of breath. COMPARISONS: ___. TECHNIQUE: Chest, PA and lateral. FINDINGS: The patient is status post sternotomy. Discontinuities of sternal wires appear unchanged. There is an apparently closed tracheostomy with a stent and overlying clips, but correlation with current status and any history of instrumentation is recommended. The cardiac, mediastinal and hilar contours appear unchanged including mild cardiomegaly. The lungs appear clear. There are no pleural effusions or pneumothorax. IMPRESSION: No evidence of acute cardiopulmonary disease. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Fever Diagnosed with FEVER, UNSPECIFIED, HEADACHE temperature: 98.0 heartrate: 70.0 resprate: 16.0 o2sat: 99.0 sbp: 133.0 dbp: 88.0 level of pain: 3 level of acuity: 3.0

___ with history of IDDM, HTN, obesity, and vocal cord paralysis with tracheostomy admitted for work-up of subacute worsening of fevers and malaise in setting of 10 months of intermittent episodes.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ with history of blindness and prostate cancer presenting with shortness of breath. He reports ___ days of shortness of breath, worse with exertion unable to even walk a few steps without shortness of breath), dizziness, and productive cough. His chest and nose feel congested and he is unable to breathe out of the left nostril. Unable to see color of sputum because he is blind. No chest pain except when coughing. No fever/chills, nausea/vomiting, or diarrhea. Reports LLQ pain with coughing. He smoked 1 ppd up until four days ago, when he stopped due to shortness of breath. He was evaluated at an OSH two days ago and was sent ___ with pills (unclear if these were an antibiotic) and an inhaler, which did not seem to help. Sister reports failure to thrive at ___ with progressive weight loss for years. Patient's twin brother died of pancreatic cancer last year. In the ED, initial vital signs were: 98.4 120 ___ 90% RA - ED exam was notable for: Congested cough, lungs relatively clear (?coarse BS at bases), scattered wheeze, abdomen tender in LLQ but nondistended/soft, no edema. Smelled of smoke. - Labs were notable for: FluAPCR positive. Lactate 1.2. Electrolyte panel and CBC unremarkable. CXR showed no cardiopulmonary acute process. - The patient was given: ___ 16:06 IH Albuterol 0.083% Neb Soln 1 NEB ___ 16:06 IH Ipratropium Bromide Neb 1 NEB ___ 16:06 IVF 1000 mL NS 1000 mL ___ 19:06 PO Azithromycin 500 mg ___ 19:06 PO PredniSONE 40 mg ___ 22:04 IH Albuterol 0.083% Neb Soln 1 NEB ___ 22:04 IH Ipratropium Bromide Neb 1 NEB He improved substantially after nebulizers. He was observed in the ED, and was noted to have persistent hypoxia on room air. He was admitted to medicine for further management. Upon arrival to the floor, patient endorses improved dyspnea. Endorses abdominal discomfort, but no recent diarrhea, no n/v. REVIEW OF SYSTEMS: [+] per HPI Past Medical History: BLINDNESS ELEVATED BLOOD PRESSURE H/O PROSTATE CANCER S/P ___ RADICAL PROSTATECTOMY H/O GASTROESOPHAGEAL REFLUX Social History: ___ Family History: Significant for hypertension in his mother's side. Twin brother died last year of pancreatic cancer. Physical Exam: ==================== EXAM ON ADMISSION ==================== Vital Signs: 97.4 111/51 94 18 100% RA General: Alert & oriented x 3; 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, II/VI systolic murmur, rubs Lungs: Bibasilar crackles, no wheezing, rhonchi Abdomen: +bowel sounds, ecchymoses throughout, soft, tenderness to palpation diffusely, more so on left lower quadrant. +voluntary guarding. Tenderness over left flank, indurated, erythematous, drain with 200cc of sanguinous pus. GU: No foley Ext: Warm, well perfused, no clubbing, cyanosis. 1+ edema bilaterally Left > Right Neuro: ___ strength upper/lower extremities, grossly normal sensation, gait deferred, +Asterixis. ==================== EXAM ON DISCHARGE ==================== Vital Signs: 99.3, 107, 110/63, 16, 99%RA General: Thin gentleman, Alert, oriented, no acute distress, more interactive than previous Lungs: CTAB CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: thin, soft, nontender Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ======================== LABS ON ADMISSION ======================== ___ 03:40PM BLOOD WBC-4.5 RBC-4.62 Hgb-14.3 Hct-44.8 MCV-97 MCH-31.0 MCHC-31.9* RDW-13.3 RDWSD-48.0* Plt ___ ___ 03:40PM BLOOD Neuts-64.8 Lymphs-18.2* Monos-16.6* Eos-0.0* Baso-0.2 Im ___ AbsNeut-2.89 AbsLymp-0.81* AbsMono-0.74 AbsEos-0.00* AbsBaso-0.01 ___ 03:40PM BLOOD Glucose-103* UreaN-26* Creat-0.8 Na-138 K-4.9 Cl-97 HCO3-28 AnGap-18 ___ 03:40PM BLOOD Calcium-10.2 Phos-4.1 Mg-2.2 ___ 03:45PM BLOOD Lactate-1.2 ======================== LABS ON DISCHARGE ======================== ___ 09:00AM BLOOD WBC-7.2 RBC-4.34* Hgb-13.6* Hct-41.8 MCV-96 MCH-31.3 MCHC-32.5 RDW-14.3 RDWSD-50.5* Plt ___ ___ 09:00AM BLOOD Glucose-130* UreaN-20 Creat-0.6 Na-139 K-3.7 Cl-98 HCO3-33* AnGap-12 ___ 09:00AM BLOOD Calcium-9.7 Phos-4.3 Mg-2.1 ======================== MICROBIOLOGY ======================== ___ Blood culture - no growth to date ___ Urine culture - no growth ======================== IMAGING/STUDIES ======================== ___ CXR - Lungs are hyperinflated without focal consolidation. Cardiac, mediastinal and hilar contours are normal. Pulmonary vasculature is not engorged. No acute osseous abnormalities seen. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Multivitamins 1 TAB PO DAILY 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath Discharge Medications: 1. Multivitamins 1 TAB PO DAILY 2. Nicotine Patch 21 mg TD DAILY 3. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath 4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H Discharge Disposition: Extended ___ Facility: ___ Discharge Diagnosis: Primary: Flu, COPD exacerbation Secondary: weight loss, failure to thrive 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 hypoxia TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph ___ FINDINGS: Lungs are hyperinflated without focal consolidation. Cardiac, mediastinal and hilar contours are normal. Pulmonary vasculature is not engorged. No acute osseous abnormalities seen. IMPRESSION: No acute cardiopulmonary abnormality. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Cough, Dyspnea Diagnosed with Chronic obstructive pulmonary disease w (acute) exacerbation temperature: 98.4 heartrate: 120.0 resprate: 22.0 o2sat: 90.0 sbp: 107.0 dbp: 80.0 level of pain: 0 level of acuity: 2.0

Mr. ___ is a ___ with history of blindness and prostate cancer presenting with shortness of breath and positive flu PCR. # Acute Influenza, COPD: The patient presented with dyspnea and cough, and was found to have a positive influenza PCR. A CXR showed no focal consolidation, but was hyperinflated. Given the patient's 50 pack year smoking history and productive cough with wheeze on exam, there was concern that the patient had additionally triggered a COPD exacerbation, though he had no known diagnosis of COPD. He was treated with oseltamivir for a 5 day course for influenza. In addition, he was treated with a prednisone burst and nebulizers. He was weaned to room air. However, as he continued to desat and become acutely short of breath with exertion, he was discharged to acute rehab to further recover. He will likely benefit for further evaluation of COPD in the outpatient setting. # Failure to thrive/weight loss: A review of the patient's chart and a discussion with his sister showed that he has had significant weight loss. In ___ he weighed around 150lb, in ___ 132lb, and during this hospitalization 110lb (BMI 16.7). He has a history of prostate cancer, s/p radical resection, but was noted to have PSA of 1.3 in ___. A colonoscopy in ___ was normal. There is concern for lung malignancy given long smoking history. Could also be related to living situation, as patient lives alone and is reportedly not consistently able to eat full meals. While working with ___ he was found to be very deconditioned, and was discharged to rehab. Further workup was deferred to the outpatient setting.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ with PMH of HTN, DM, HLD, AS s/p AVR (___), smoldering myeloma, past ETOH abuse presenting with abdominal pain. He was initially taken to ___ by EMS after he developed abdominal pain several days ago. He had imaging done showing diverticulitis and was discharged on ___ on cipro/flagyl. He presented to the ED on ___ because of persistent abdominal pain. He reports that initially the pain seemed to get slightly better after discharge, but then it returned and became progressively worse. His pain is in the lower abdomen bilaterally and is band like without radiation. He denies any nausea or vomiting. He has eaten very little due to the pain, although food does not particularly worsen his symptoms. He has not had any diarrhea or fevers at home. Last BM was day of presentation. His last and only other episode of diverticulitis was ___ years ago. He does report that he has developed constipation over the past 5 months. His stools appear slightly thinner than previously. He has not noticed any blood. He also feels that he is not eating well due to lack of appetite which has persisted for ~2 months. He also notes that he lost around 10 pounds (213 to 203) in 3 weeks-1 month. He thinks this weight loss is unintentional. In the ED, initial vitals were: 98 102 113/90 18 98% RA. Labs notable for WBC 8.7, H/H 11.9/35.9, Plt 256, no bands or left shift, Cr 1.2 (at baseline), BUN 13, lactate 2.7. Imaging notable for uncomplicated sigmoid diverticulitis, and a 7mm new pulmonary nodule in LLL. He was given 2mg IV morphine X 2, Iv cipro/flagyl, and 1L IV NS. Decision was made to admit for IV antibiotics given "failure" of outpatient treatment. On the floor, initial vitals were 97.6 122/74 72 18 97% RA. He reported that his pain had improved with morphine in the ED. Past Medical History: - Severe aortic stenosis ___ cath: valve area 0.7 cm2, mean gradient 42 L/min) - Hypertension - Hyperlipidemia - Type 2 diabetes mellitus, on oral meds (A1c 6.7 in ___ - Depression - Gout - MGUS - Transaminitis and ?___ (CT abdomen from ___ shows hypodense liver, consistent with fatty liver) Social History: ___ Family History: Father had CAD, CABG for angina. Father and brother have diabetes. Mother and brother both have hypertension. Mother with colon cancer. Mother and daughter with breast cancer. Daughter diagnosed with breast cancer at age ___, had a small mass removed. Physical Exam: ON ADMISSION ============ Vital Signs: 97.6 122/74 72 18 97% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-distended, tenderness to palpation in lower abdomen R > L with mild voluntary guarding but rebound or rigidity GU: No foley Ext: Warm, well perfused, no clubbing, cyanosis or edema Neuro: CNII-XII grossly intact, moving all extremities equally ON DISCHARGE ============== Vital Signs: 98.1 123/68 78 18 97% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, obese, tenderness to palpation in lower abdomen R > L with mild voluntary guarding but no rebound or rigidity GU: No foley Ext: Warm, well perfused, no clubbing, cyanosis or edema Neuro: CNII-XII grossly intact, moving all extremities equally Pertinent Results: LABS ON ADMISSION ================= ___ 01:45PM BLOOD WBC-8.7 RBC-3.98* Hgb-11.9* Hct-35.9* MCV-90 MCH-29.9 MCHC-33.1 RDW-12.1 RDWSD-39.3 Plt ___ ___ 01:45PM BLOOD Neuts-62.7 ___ Monos-9.6 Eos-2.5 Baso-0.3 Im ___ AbsNeut-5.43 AbsLymp-2.11 AbsMono-0.83* AbsEos-0.22 AbsBaso-0.03 ___ 01:45PM BLOOD Glucose-157* UreaN-13 Creat-1.2 Na-142 K-4.8 Cl-105 HCO3-23 AnGap-19 ___ 01:45PM BLOOD ALT-31 AST-40 AlkPhos-50 TotBili-0.3 ___ 01:45PM BLOOD cTropnT-<0.01 ___ 01:45PM BLOOD Albumin-4.3 ___ 01:53PM BLOOD Lactate-2.7* LABS ON DISCHARGE ================== ___ 04:45AM BLOOD WBC-8.1 RBC-3.73* Hgb-11.3* Hct-34.1* MCV-91 MCH-30.3 MCHC-33.1 RDW-12.3 RDWSD-40.7 Plt ___ ___ 04:45AM BLOOD Glucose-133* UreaN-13 Creat-1.2 Na-136 K-3.9 Cl-100 HCO3-22 AnGap-18 ___ 04:45AM BLOOD Calcium-8.8 Phos-4.1 Mg-1.1* ___ 11:57PM BLOOD Lactate-1.2 IMAGING ======= CT abd/pelvis IMPRESSION: 1. Uncomplicated sigmoid diverticulitis. 2. Since the CT abdomen and pelvis of ___, there has been interval development of a 7 mm pulmonary nodule in the left lower lobe. RECOMMENDATION(S): 3 month follow-up chest CT of the 7 mm left lower lobe pulmonary nodule is recommended. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetFORMIN (Glucophage) 1000 mg PO BID 2. amLODIPine 5 mg PO DAILY 3. Atorvastatin 20 mg PO QPM 4. Multivitamins 1 TAB PO DAILY 5. Aspirin 81 mg PO DAILY 6. GlipiZIDE 5 mg PO BID 7. FoLIC Acid 1 mg PO DAILY 8. Thiamine 100 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 20 mg PO QPM 3. FoLIC Acid 1 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Thiamine 100 mg PO DAILY 6. Ciprofloxacin HCl 750 mg PO Q12H RX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth q12hr Disp #*15 Tablet Refills:*0 7. MetroNIDAZOLE 500 mg PO Q8H RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth q8hr Disp #*15 Tablet Refills:*0 8. amLODIPine 5 mg PO DAILY 9. GlipiZIDE 5 mg PO BID 10. MetFORMIN (Glucophage) 1000 mg PO BID Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ================= Uncomplicated diverticulitis SECONDARY DIAGNOSIS ===================== Pulmonary nodule Diabetes Mellitus Type II Coronary Artery Disease Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ with recently diagnosed diverticulitis on ___ who presents with worsening lower abdominal pain. Bilateral lower quadrant tenderness to palpation on exam. Evaluate for bowel perforation or worsening diverticulitis. TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 963 mGy-cm. COMPARISON: CT abdomen pelvis of ___. FINDINGS: LOWER CHEST: A 7 mm nodule in the left lower lobe (2:2) is new since ___. No pericardial or pleural effusions. Dense aortic valve calcifications are present. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. 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 symmetric size with normal nephrogram. There is no hydronephrosis. Two subcentimeter hypodensities in the right kidney are too small to characterize by CT, but statistically likely cysts. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. There is sigmoid diverticulosis, with an area of asymmetrically increased adjacent fat stranding, wall thickening, and hyperemia in the mid lower abdomen (2:70, 602b:45), compatible with known diverticulitis. No free intraperitoneal air or drainable fluid collection detected. The appendix is normal. PELVIS: Mild thickening of the bladder wall is likely reactive in the setting of adjacent diverticulitis (602b:45). The distal ureters are unremarkable. There is no free fluid in the pelvis. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic disease involving the abdominal aorta and the origin of the its great vessels and extending into the common iliac arteries is again noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: An umbilical hernia containing fat is noted. IMPRESSION: 1. Uncomplicated sigmoid diverticulitis. 2. Since the CT abdomen and pelvis of ___, there has been interval development of a 7 mm pulmonary nodule in the left lower lobe. RECOMMENDATION(S): 3 month follow-up chest CT of the 7 mm left lower lobe pulmonary nodule is recommended. NOTIFICATION: The above findings and recommendation were communicated via telephone by Dr. ___ to Dr. ___ at 17:00 on ___, 10 min after discovery. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abd pain, Depression Diagnosed with Dvtrcli of lg int w/o perforation or abscess w/o bleeding temperature: 98.0 heartrate: 102.0 resprate: 18.0 o2sat: 98.0 sbp: 113.0 dbp: 90.0 level of pain: 10 level of acuity: 2.0

___ with PMH of HTN, DM, HLD, AS s/p AVR (___), smoldering myeloma, ETOH abuse presenting with abdominal pain due to diverticulitis. # Diverticulitis: Originally diagnosed at ___ and was discharged there on ___. Presented to ___ bc of ongoing pain. On repeat imaging on this admission, remains uncomplicated. Most likely not a failure of PO antibiotics from ___ since symptoms may take some time to resolve. He has fortunately not developed complicated disease. Last colonoscopy in ___, recommend repeat in ___ due to only fair prep. Continued on cipro/flagyl while in house. He was able to tolerate food at discharge. Would recommend follow up colonoscopy after acute diverticulitis resolves to exclude underlying malignancy, particularly given weight loss and change in stool pattern. # Elevated lactate: likely dehydration, and after fluids, resolved. # Pulmonary nodule: new 7mm pulmonary nodule. Reimaging recommended at ___ months. Colonoscopy as above. # History of alcohol abuse: reports no alcohol in the past ___ years. Continued thiamine, multivitamin, folate # DM: Held home metformin and glipizide. ISS continued while hospitalized # CAD s/p CABG: Continued home aspirin and atorvastatin # Hypertension: Held home amlodipine 5mg in the setting of initial poor PO intake. TRANSITIONAL ISSUES =================== []Should finish cipro and flagyl course- take up to and including ___. []3 month follow-up chest CT of the 7 mm left lower lobe pulmonary nodule is recommended.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / hydrochlorothiazide / metformin Attending: ___ Major Surgical or Invasive Procedure: None attach Pertinent Results: ADMISSION LABS ___ 06:45AM BLOOD WBC-7.8 RBC-3.81* Hgb-10.3* Hct-34.4 MCV-90 MCH-27.0 MCHC-29.9* RDW-16.0* RDWSD-52.9* Plt ___ ___ 04:25PM BLOOD Neuts-83.3* Lymphs-11.6* Monos-3.8* Eos-0.5* Baso-0.4 Im ___ AbsNeut-11.22* AbsLymp-1.57 AbsMono-0.51 AbsEos-0.07 AbsBaso-0.06 ___ 04:25PM BLOOD ___ PTT-29.0 ___ ___ 04:25PM BLOOD Glucose-349* UreaN-10 Creat-0.9 Na-139 K-4.6 Cl-99 HCO3-23 AnGap-17 ___ 04:25PM BLOOD ALT-13 AST-11 AlkPhos-105 TotBili-0.6 ___ 04:25PM BLOOD Albumin-3.8 Calcium-7.8* Phos-2.9 Mg-1.3* Cholest-194 ___ 04:25PM BLOOD %HbA1c-11.3* eAG-278* ___ 04:25PM BLOOD Triglyc-132 HDL-63 CHOL/HD-3.1 LDLcalc-105 ___ 07:07AM BLOOD TSH-1.8 ___ 07:07AM BLOOD Free T4-1.4 ___ 05:05PM BLOOD ___ pO2-49* pCO2-42 pH-7.41 calTCO2-28 Base XS-1 ___ 05:05PM BLOOD O2 Sat-81 DISCHARGE LABS ___ 06:45AM BLOOD WBC-7.8 RBC-3.81* Hgb-10.3* Hct-34.4 MCV-90 MCH-27.0 MCHC-29.9* RDW-16.0* RDWSD-52.9* Plt ___ ___ 06:45AM BLOOD Plt ___ ___ 06:45AM BLOOD Glucose-127* UreaN-14 Creat-1.0 Na-140 K-4.2 Cl-101 HCO3-26 AnGap-13 ___ 06:45AM BLOOD Calcium-8.6 Phos-3.9 Mg-2.0 IMAGING CXR ___ IMPRESSION: Hilar adenopathy compatible with patient's history of sarcoidosis as seen previously though likely worse compared to ___. Increased interstitial markings in the lungs. Underlying parenchymal changes in the setting of sarcoidosis would be possible though atypical infection or component of edema are also possible. LOWER EXTREMITY ULTRASOUND FOR DVT ___ IMPRESSION: Technically limited due to body habitus however no evidence of deep venous thrombosis in the right or left lower extremity veins. TRANSTHORACIC ECHO ___ IMPRESSION: Suboptimal image quality. Moderate pulmonary hypertension. Hyperdynamic left ventricle. Compared with the prior TTE (images not available for review) of ___ , pulmonary artery pressure is now measurable Moderate pulmonary hypertension with evidence of right ventricular pressure overload is now present. EF 76%. CTA ___ IMPRESSION: No evidence of pulmonary embolism or aortic abnormality. Diffuse ground-glass opacities associated interlobular septal thickening suggestive of mild pulmonary edema. Redemonstration of enlarged mediastinal and hilar lymph nodes consistent with history of sarcoidosis. DISCHARGE PHYSICAL EXAM VS: 98.3 PO 122 / 78 86 18 98 Ra GENERAL: Alert and interactive. In no acute distress. Obese, seated in chair on oxygen. EYES: NCAT. Conjugate gaze. Sclera anicteric and without injection. ENT: MMM. JVP difficult to assess given habitus, appears to be mid neck CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. RESP: CTAB, no crackles. ABDOMEN: Normal bowel sounds, non distended, non-tender to deep palpation in all four quadrants. MSK: No clubbing, cyanosis. Sock indentations bilaterally with 1+ ankle edema, adioposity around calves, tender b/l. Warm PSYCH: appropriate, good mood and affect Radiology Report INDICATION: ___ with dyspnea // dyspnea. History of sarcoidosis. TECHNIQUE: PA and lateral views the chest. COMPARISON: Chest x-ray from ___. Chest CTs from ___ and ___. FINDINGS: Bilateral hilar adenopathy is most likely due to adenopathy in light of patient's history of sarcoidosis. The degree of hilar enlargement appears slightly worse compared to exam from ___. Increased interstitial markings in the lungs bilaterally. No confluent consolidation. No pleural effusion. IMPRESSION: Hilar adenopathy compatible with patient's history of sarcoidosis as seen previously though likely worse compared to ___. Increased interstitial markings in the lungs. Underlying parenchymal changes in the setting of sarcoidosis would be possible though atypical infection or component of edema are also possible. Radiology Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: Ms. ___ is a ___ with history of pulmonary hypertension, sarcoidosis c/b L optic perineuritis, obesity, COPD, HTN, DMII, presenting for dyspnea. // r/o DVT TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: None. FINDINGS: Note is made the exam is technically limited due to body habitus however there is normal compressibility, color flow, and spectral doppler of the bilateral common femoral, femoral, and popliteal veins. Normal color flow 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: Technically limited due to body habitus however no evidence of deep venous thrombosis in the right or left lower extremity veins. Radiology Report EXAMINATION: CTA CHEST INDICATION: Ms. ___ is a ___ with history of pulmonary hypertension, sarcoidosis c/b L optic perineuritis, obesity, COPD, HTN, DMII, presenting for dyspnea. // r/o 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 2.9 s, 37.9 cm; CTDIvol = 15.2 mGy (Body) DLP = 575.4 mGy-cm. 2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7 mGy-cm. 3) Stationary Acquisition 4.2 s, 0.5 cm; CTDIvol = 23.2 mGy (Body) DLP = 11.6 mGy-cm. Total DLP (Body) = 589 mGy-cm. COMPARISON: Multiple prior chest CTs, most recently from ___. FINDINGS: HEART AND VASCULATURE: No filling defect in the main pulmonary artery throughout its subsegmental branches bilaterally. The pulmonary artery is slightly enlarged measuring 3.4 cm in The heart is normal in size and shape. No pericardial effusion. Mild atherosclerotic calcifications are noted in the LAD, none in the coronary arteries and aorta. The aorta is normal in caliber throughout. NECK, THORACIC INLET, AXILLAE AND CHEST WALL: The thyroid is heterogeneous, unchanged from prior. No enlarged lymph nodes in either axilla or thoracic inlet. No abnormalities on the chest wall. No atherosclerotic calcifications in the head and neck arteries. MEDIASTINUM AND HILA: The esophagus is unremarkable. Several mediastinum and hilum lymph nodes are again noted to be enlarged, unchanged in size from prior study, the largest in the subcarinal station measuring 1.8 cm in short axis diameter (301:80 6%. PLEURA: No pleural effusions. Mild bilateral apical scarring. LUNGS: Respiratory motion artifacts impair optimal parenchymal evaluation. The airways are patent to the subsegmental levels. Mild diffuse bronchial wall thickening, no bronchiectasis or mucus plugging. Several simple cysts are seen scattered throughout the parenchyma, unchanged from prior study, the largest in the anterior aspect of the left upper lobe measuring up to 3.4 cm (301:71). Mild centrilobular pulmonary emphysema is again noted. Mild diffuse ground-glass opacities are noted in both lungs associated with mild interlobular septal thickening. No suspicious lung nodules or masses. CHEST CAGE: No acute fractures. Mild dorsal spondylosis. No suspicious lytic or sclerotic lesions. UPPER ABDOMEN: The limited sections of the upper abdomen show no significant abnormal findings. IMPRESSION: No evidence of pulmonary embolism or aortic abnormality. Diffuse ground-glass opacities associated interlobular septal thickening suggestive of mild pulmonary edema. Redemonstration of enlarged mediastinal and hilar lymph nodes consistent with history of sarcoidosis. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Dyspnea, Hyperglycemia Diagnosed with Dyspnea, unspecified temperature: 98.5 heartrate: 91.0 resprate: 22.0 o2sat: 95.0 sbp: 144.0 dbp: 91.0 level of pain: 0 level of acuity: 2.0

BRIEF HOSPITAL COURSE: ===================== Ms. ___ is a ___ with history of pulmonary hypertension, sarcoidosis c/b L optic perineuritis, obesity, hypertension, type 2 diabetes mellitus, who recently finished high dose prednisone taper, presenting with progressive with dyspnea as well as hyperglycemia. She was started on a Lasix drip with boluses of IV Lasix. However, patient with variable weight and continued lower extremity edema which made establishing her dry weight difficult. Though Ms. ___ felt her dyspnea had improved from presentation, she continued to require oxygen above her baseline needs. It was felt that further diuresis in the hospital would not significantly improve her breathing or decreased her oxygen needs at this time. She desired discharge. On day of discharge she desaturated to 67% when ambulating on stairs without oxygen and 71% briefly when ambulating up stairs with oxygen. Discussed with patient that she would need to wear oxygen at all time to maintain oxygen saturation above 85%. She agreed and understood the risks of not wearing oxygen and having significant desaturations. Her home torsemide was increased to 80mg torsemide daily. During her hospitalization our pulmonary team assessed her and thought that her dyspnea was due to increased volume status and will follow up with her as an outpatient. Additionally, the ___ diabetes team was extensively involved in assisting with medication management given patient's diabetes was not well controlled with A1c of 11.3% on admission and her difficulty affording medications. She was provided with 14-day free supply of NPH/humalog upon discharge and urged to call her insurance to change plans for the upcoming year. She was provided with 30-day free supply of lancets/test strips/syringes upon discharge. She was scheduled for follow-up with pulmonary, her primary care physician, and ___ prior to discharge.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Lipitor / Lisinopril / Bactrim DS Attending: ___. Chief Complaint: facial swelling Major Surgical or Invasive Procedure: I+D of sub-mandibular, parapharyngeal and sub-masseteric abscess from odontogenic infection by ___ on ___ History of Present Illness: Ms. ___ is a ___ female with a past medical history of hypertension who presents with facial edema. Patient recently underwent a tooth extraction. Post procedurally the doctor placed her on a 5-day course of clindamycin. Patient reports after discontinuation of antibiotics she began to have worsening facial edema, pain, difficulty swallowing. She presented to her dentist office today who advised her to come to the emergency department. She denies fevers, chills, breathing. ___ the ED, she was febrile with a temperature of 101.5 T-max. She was given IV morphine for pain normal saline, Tylenol clindamycin and Dilaudid. Laboratories significant for WBC 14.5 and NA 129 CT scan of the face shows a 0.6 x 2.8 cm right subperiosteal abscess with extension into the medial pterygoid muscle and masseter muscle compatible with odontogenic abscess with leftward deviation of the pharynx and pharyngeal fat. She was seen by OMFS and taken to the OR. Patient was seen post-operatively. She reported continued pain ___ the right face however improved. Past Medical History: Bariatric surgery Social History: ___ Family History: notable for Colon cancer, coronary artery disease Physical Exam: ADMISSION: ========== VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert and ___ no apparent distress FACE: R face with significant submandibular edema extending medially, ___ drains ___ place EYES: Anicteric, pupils equally round CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally ___ all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect . . DISCHARGE EXAM: ================ VS: 24 HR Data (last updated ___ @ 1155) Temp: 98.3 (Tm 98.8), BP: 161/95 (146-171/74-95), HR: 76 (60-76), RR: 16 (___), O2 sat: 96% (94-96), O2 delivery: RA GEN: Alert and ___ no apparent distress sitting up ___ bed FACE: R face with significant submandibular edema extending medially but this is improving, ___ drains have been removed, trachea is midline. Trismus improving. EYES: Anicteric, pupils equally round CV: RR, no m/r/g RESP: Lungs clear to auscultation with good air movement b/l GI: soft, not tender to palpation, BS+ SKIN: no jaundice NEURO: awake, alert, conversant with clear speech, facial asymmetry from swelling rather than any apparent CN motor deficits PSYCH: pleasant, appropriate affect . . Pertinent Results: ADMISSION/SIGNIFICANT LABS: ======================== ___ 12:04PM BLOOD WBC-14.5* RBC-4.71 Hgb-12.6 Hct-37.5 MCV-80* MCH-26.8 MCHC-33.6 RDW-14.9 RDWSD-42.8 Plt ___ ___ 12:04PM BLOOD Glucose-125* UreaN-14 Creat-0.9 Na-129* K-5.1 Cl-86* HCO___-27 AnGap-16 MICRO: ====== ___ Blood Cx: NGTD ___ Blood Cx: NGTD ___ 10:57 pm SWAB RIGHT SUBMANDIBULAR SPACE ABSCESS. GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND SINGLY. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. WOUND CULTURE (Final ___: MIXED BACTERIAL FLORA. MODERATE GROWTH MIXED BACTERIAL FLORA ( >=3 COLONY TYPES) CONSISTENT WITH OROPHARYNGEAL FLORA. This culture contains mixed bacterial types (>=3) so an abbreviated workup is performed. Any growth of P.aeruginosa, S.aureus and beta hemolytic streptococci will be reported. IF THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT ___ this culture. ANAEROBIC CULTURE (Preliminary): RESULTS PENDING. 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. . 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. POTASSIUM HYDROXIDE PREPARATION (Final ___: Test cancelled by laboratory. PATIENT CREDITED. Inappropriate specimen collection (swab) for Fungal Smear (___). IMAGING/OTHER STUDIES: =================== CT sinus/mandible/maxilla ___ "FINDINGS: Socket from prior right mandibular molar extraction is seen. Adjacent increased sclerosis of the right mandible is suggestive of chronic inflammation. Along the lingular aspect and under body of the right half of the mandible, there is a multiloculated complex rim enhancing fluid collection with lobulated extension into the medial pterygoid muscle and inferior aspect of the masseter. The subperiosteal portion of the abscess measures 0.6 x 2.8 cm (transverse x AP; series 3, image 107; series 602, image 46). Multiple lobulations are seen with the largest component measuring 1.2 x 1.8 cm (series 3, image 90) ___ the medial pterygoid. Reactive inflammatory changes including surrounding fat stranding and thickening of the right platysma muscle. Subsequently, there is also leftward shift of the oropharynx and parapharyngeal fat. No facial bone or mandibular fracture. Pterygoid plates are intact. The temporomandibular joints are anatomically aligned. The orbits are intact. Incidental note of bilateral optic nerve head drusens. Otherwise, the globes and extraocular muscles are unremarkable. No orbital hematoma. Included paranasal sinuses are clear. Included extracranial soft tissues are unremarkable. IMPRESSION: A 0.6 x 2.8 cm right subperiosteal abscess with extension into the medial pterygoid muscle and masseter muscle, compatible with an odontogenic abscess. Subsequently, there is leftward deviation of the pharynx and parapharyngeal fat. " ___ Panorex "FINDINGS: Lucent area ___ the right mandible situated between ___ 18 and 21 correlates with the CT finding of bone destruction and abscess. Multiple dental fillings. Remaining teeth appear otherwise unremarkable. IMPRESSION: Lytic area ___ the right mandible corresponding to recent CT Findings." LABS ON DISCHARGE: ================ ___ WBC-7.2 RBC-4.37 Hgb-11.7 Hct-35.5 MCV-81* MCH-26.8 MCHC-33.0 RDW-14.7 RDWSD-43.8 Plt ___ DIFF: Neuts-64.3 ___ Monos-7.5 Eos-3.1 Baso-0.4 Im ___ AbsNeut-4.63 AbsLymp-1.76 AbsMono-0.54 AbsEos-0.22 AbsBaso-0.03 Glucose-100 UreaN-8 Creat-0.5 Na-138 K-3.8 Cl-98 HCO3-26 AnGap-14 Albumin-3.4* Calcium-9.0 Phos-3.3 Mg-1.9 . . Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 100 mg PO DAILY 2. Losartan Potassium 100 mg PO DAILY 3. Hydrochlorothiazide 25 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO TID Duration: 7 Days Do not exceed 4000 mg of acetaminophen from all sources ___ any 24-hour period. RX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day Disp #*42 Tablet Refills:*0 2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID Duration: 7 Days RX *chlorhexidine gluconate [Peridex] 0.12 % Rinse mouth with 15 mL twice a day Refills:*0 3. LevoFLOXacin 500 mg PO Q24H last dose will be on ___ RX *levofloxacin 500 mg 1 tablet(s) by mouth once a day Disp #*7 Tablet Refills:*0 4. MetroNIDAZOLE 500 mg PO Q8H last dose will be on ___ RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day Disp #*21 Tablet Refills:*0 5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain taper and stop over next ___ days RX *oxycodone 5 mg 1 tablet(s) by mouth q4h:PRN Disp #*20 Tablet Refills:*0 6. Polyethylene Glycol 17 g PO DAILY Duration: 7 Days Titrate for goal 1 bowel movement per day. RX *polyethylene glycol 3350 [Miralax] 17 gram 1 dose by mouth Daily, as directed Disp #*14 Packet Refills:*1 7. Atenolol 100 mg PO DAILY RX *atenolol 100 mg 1 tablet(s) by mouth once a day Disp #*7 Tablet Refills:*0 8. Hydrochlorothiazide 25 mg PO DAILY RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth once a day Disp #*7 Tablet Refills:*0 9. Losartan Potassium 100 mg PO DAILY RX *losartan 100 mg 1 tablet(s) by mouth daiily Disp #*7 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: # Sepsis # Mandibular/pterygoid/masseter abscess # Essential HTN # Hx of gastric bypass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/ CONTRAST INDICATION: ___ with recent right lower molar extraction p/w face swelling and trismus// eval for abscess over the right mandible TECHNIQUE: Helical axial images were acquired through the facial bones. Bone and soft tissue reconstructed images were generated. Coronal and sagittal reformatted images were also obtained. DOSE: Acquisition sequence: 1) Spiral Acquisition 2.9 s, 22.4 cm; CTDIvol = 25.9 mGy (Head) DLP = 581.3 mGy-cm. Total DLP (Head) = 581 mGy-cm. COMPARISON: None. FINDINGS: Socket from prior right mandibular molar extraction is seen. Adjacent increased sclerosis of the right mandible is suggestive of chronic inflammation. Along the lingular aspect and under body of the right half of the mandible, there is a multiloculated complex rim enhancing fluid collection with lobulated extension into the medial pterygoid muscle and inferior aspect of the masseter. The subperiosteal portion of the abscess measures 0.6 x 2.8 cm (transverse x AP; series 3, image 107; series 602, image 46). Multiple lobulations are seen with the largest component measuring 1.2 x 1.8 cm (series 3, image 90) in the medial pterygoid. Reactive inflammatory changes including surrounding fat stranding and thickening of the right platysma muscle. Subsequently, there is also leftward shift of the oropharynx and parapharyngeal fat. No facial bone or mandibular fracture. Pterygoid plates are intact. The temporomandibular joints are anatomically aligned. The orbits are intact. Incidental note of bilateral optic nerve head drusens. Otherwise, the globes and extraocular muscles are unremarkable. No orbital hematoma. Included paranasal sinuses are clear. Included extracranial soft tissues are unremarkable. IMPRESSION: A 0.6 x 2.8 cm right subperiosteal abscess with extension into the medial pterygoid muscle and masseter muscle, compatible with an odontogenic abscess. Subsequently, there is leftward deviation of the pharynx and parapharyngeal fat. Radiology Report EXAMINATION: Panorex radiograph. INDICATION: Odontogenic infection. COMPARISON: CT is available from the same day. FINDINGS: Lucent area in the right mandible situated between ___ 18 and 21 correlates with the CT finding of bone destruction and abscess. Multiple dental fillings. Remaining teeth appear otherwise unremarkable. IMPRESSION: Lytic area in the right mandible corresponding to recent CT Findings. Gender: F Race: WHITE - OTHER EUROPEAN Arrive by WALK IN Chief complaint: Facial swelling Diagnosed with Localized swelling, mass and lump, head, Essential (primary) hypertension temperature: 98.2 heartrate: 59.0 resprate: 18.0 o2sat: 100.0 sbp: 161.0 dbp: 63.0 level of pain: 8 level of acuity: 3.0

___ w/ HTN, hx of gastric bypass, admitted for urgent I+D of sub-mandibular, parapharyngeal and Sub-masseteric Abscess from odontogenic infection. . .

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: Percutaneous cholecystostomy tube ___ History of Present Illness: HPI: ___ with 6 days of RUQ pain, which started after eating, and has been fairly constant since that time. The pain became acutely worse this morning, and she was seen by her PCP who recommended she present to the ED. She has had some subjective chills, as well as some diarrhea for the past 5 days. She states she had similar, transient pain when she was younger, which she attributed to ulcers, but has not had pain in many years. She has not noted any association with eating, and has not had any nausea or vomiting. She has been able to eat small meals and drink water without nausea or exacerbation of pain Past Medical History: PMH: GERD, ulcer disease, hypertension Social History: ___ Family History: NC Physical Exam: PHYSICAL EXAMINATION upon admission ___ Temp: 99.7 HR: 79 BP: 124/69 Resp: 16 O(2)Sat: 98 Normal Constitutional: Comfortable; well-appearing HEENT: Normocephalic, atraumatic Oropharynx within normal limits Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm Abdominal: Soft, +RUQ TTP, + ___ sign Extr/Back: No cyanosis, clubbing or edema Skin: Warm and dry Neuro: Speech fluent Psych: Normal mood, Normal mentation ___: No petec Pertinent Results: ___ 04:55AM BLOOD WBC-12.9* RBC-3.50* Hgb-10.8* Hct-32.1* MCV-92 MCH-30.9 MCHC-33.7 RDW-11.8 Plt ___ ___ 04:55AM BLOOD WBC-15.8* RBC-3.56* Hgb-11.0* Hct-32.8* MCV-92 MCH-30.8 MCHC-33.5 RDW-11.6 Plt ___ ___ 04:40AM BLOOD WBC-12.0* RBC-3.70* Hgb-11.7* Hct-34.3* MCV-93 MCH-31.7 MCHC-34.2 RDW-11.6 Plt ___ ___ 04:55AM BLOOD Plt ___ ___ 04:55AM BLOOD Plt ___ ___ 04:55AM BLOOD ___ PTT-30.5 ___ ___ 04:55AM BLOOD Glucose-100 UreaN-11 Creat-0.8 Na-134 K-3.5 Cl-98 HCO3-30 AnGap-10 ___ 04:55AM BLOOD Glucose-87 UreaN-12 Creat-0.5 Na-136 K-3.8 Cl-99 HCO3-28 AnGap-13 ___ 04:55AM BLOOD ALT-53* AST-95* AlkPhos-206* Amylase-29 TotBili-0.7 ___ 04:55AM BLOOD ALT-44* AST-37 AlkPhos-154* TotBili-0.5 ___ 06:42PM BLOOD ALT-104* AST-140* AlkPhos-201* TotBili-0.5 ___ 04:55AM BLOOD Lipase-16 ___ 06:42PM BLOOD Lipase-31 ___ 10:49PM BLOOD Lactate-1.1 ___: EKG: Sinus rhythm. Prolonged P-R interval. No previous tracing available for comparison ___: US liver/gallbladder: IMPRESSION: Severe gallbladder wall thickening, with apparent anterior focal wall irregularity which could be artifactual, but discontinuity of the wall is not excluded. No large fluid collections or biliary dilation. CT may be helpful for further evaluation. ___: US of gallbladder: IMPRESSION: Findings consistent with acute cholecystitis, probably with a focal perforation interposed between the gallbladder and liver. Mild luminal distention is noted, and percutaneous cholecystostomy tube placement is scheduled to be attempted. ___: ___: GB drainage: IMPRESSION: Technically successful ultrasound-guided percutaneous cholecystostomy tube placement. Technically difficult study requiring two passes. 40 mL of purulent appearing fluid was drained. Sample sent for microbiological analysis. There were no immediate complications. ___ 10:40 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 ___: Reported to and read back by ___. ___ ON ___ AT 0610. GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. ___ 1:35 pm BILE GRAM STAIN (Final ___: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). FLUID CULTURE (Preliminary): ANAEROBIC CULTURE (Preliminary Medications on Admission: ___: omeprazole 40", tylenol 3 prn, prilosec 20', atenolol 12.5', lisinopril 10', prozac 20', simvastatin ___ every other day, asa 81', calcium +D, multivitamin, folate Discharge Medications: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 5. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 10 days. Disp:*30 Tablet(s)* Refills:*0* 6. hydromorphone 2 mg Tablet Sig: ___ Tablets PO every six (6) hours as needed for pain: may cause increased drowsiness, avoid driving while on this medicaiton. Disp:*30 Tablet(s)* Refills:*0* 7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: hold for loose stool. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: cholecystitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ female with cholelithiasis, right upper quadrant and epigastric pain x several days. No prior examinations for comparison. RIGHT UPPER QUADRANT ULTRASOUND: The gallbladder is partially distended, with internal layering stones and sludge. There is severe circumferential wall edema up to 14 mm, with heterogeneous appearance and increased vascularity. In the region of the gallbladder fundus, there is questionable focal wall interruption (images ___ and 46). However, there are no surrounding large fluid collections. The liver is normal in echotexture. There is normal hepatopetal flow in the portal vein. IVC is also patent. There is no intrahepatic or common biliary ductal dilation, with the latter measuring 3 mm. The pancreas is obscured by overlying bowel gas. There is no pancreatic duct dilation. The right kidney measures 12.4 cm, without stones, masses, or hydronephrosis. IMPRESSION: Severe gallbladder wall thickening, with apparent anterior focal wall irregularity which could be artifactual, but discontinuity of the wall is not excluded. No large fluid collections or biliary dilation. CT may be helpful for further evaluation. Radiology Report CLINICAL INFORMATION: ___ female with right upper quadrant pain, for preoperative evaluation. COMPARISON: None. FINDINGS: Frontal and lateral chest radiographs demonstrate clear lungs without effusion or pneumothorax. Note is made of an azygos fissure. The heart size is normal, and the mediastinal contours are unremarkable. IMPRESSION: Clear lungs without acute chest pathology. Radiology Report INDICATION: Acute cholecystitis for seven days and previous ultrasound showing gallbladder wall thickening. Please evaluate size of the gallbladder lumen to check if amenable to percutaneous cholecystostomy tube placement. COMPARISON: ___. TECHNIQUE: Right upper quadrant ultrasound. FINDINGS: Previous ultrasound of ___ had showed findings consistent with acute cholecystitis, but the gallbladder lumen was largely collapsed without sufficient distention to permit attempt of cholecystostomy tube placement. Repeat examination was performed to reassess gallbladder lumen size. Hepatic echotexture appears within normal limits. Common hepatic duct measures 6 mm. Gallbladder is markedly abnormal, with extensive mural edema and a focal fluid collection interposed between the gallbladder and liver that measures approximately 2.2 x 1.4 cm, an appearance which is suggestive of a perforated cholecystitis with a small subhepatic/pericholecystic collection. The lumen is still not markedly distended; however, in comparison with the examination of ___, the degree of distention has increased slightly. It is felt that percutaneous cholecystostomy tube placement could be attempted, though it is expected to be difficult. Imaged portion of pancreas appear within normal limits with portions of the pancreatic head and tail obscured by overlying bowel gas. IMPRESSION: Findings consistent with acute cholecystitis, probably with a focal perforation interposed between the gallbladder and liver. Mild luminal distention is noted, and percutaneous cholecystostomy tube placement is scheduled to be attempted. Radiology Report ULTRASOUND-GUIDED PERCUTANEOUS CHOLECYSTOSTOMY DATED ___ INDICATION: ___ with acute cholecystitis for six days. Please place percutaneous cholecystostomy tube. COMPARISON: Comparison is made to previous ultrasound dated ___ and ___. PHYSICIANS: Dr. ___ and Dr. ___ performed the procedure. Dr. ___ attending radiologist, was present throughout the procedure. PROCEDURE: Following a detailed discussion of the risks, benefits, and alternatives to the procedure, written informed consent was obtained. The patient was transferred to the ultrasound suite and placed in the supine position. An initial preprocedure ultrasound was performed for purposes of skin point localization prior to cholecystostomy tube placement. This again demonstrated a markedly abnormal gallbladder with massive wall thickening and edema and a small collection located between the gallbladder and liver edge consistent with prior perforation. Preprocedure timeout was performed as per ___ protocol using two unique patient identifiers. The skin overlying the right upper quadrant was prepped and draped in usual sterile fashion. Approximately 8 mL of 1% lidocaine was infiltrated into the skin, subcutaneous tissue, and into the liver capsule under ultrasound guidance. An 8 ___ pigtail catheter was inserted into the liver and gallbladder under ultrasound guidance. The procedure was technically difficult due to marked induration in the region of the severely inflamed gallbladder, and required two passes for placement of the 8 ___ pigtail catheter. Once satisfactorily position was confirmed within the gallbladder, the pigtail tube was advanced over the trocar and pigtail was formed within the gallbladder. 40 mL of yellow and red-tinged purulent fluid was aspirated. A sample was sent for a microbiological analysis as requested. The catheter was attached to a closed drainage system on free drainage. There were no immediate complications. The patient tolerated the procedure well. SEDATION: Moderate sedation was provided by administering divided doses of fentanyl 100 mcg and Versed 2 mg throughout the total intraservice time of 35 minutes, during which the patient's hemodynamic parameters were continuously monitored. The patient was transferred back to the floor in stable condition. POE orders were entered on the online system. IMPRESSION: Technically successful ultrasound-guided percutaneous cholecystostomy tube placement. Technically difficult study requiring two passes. 40 mL of purulent appearing fluid was drained. Sample sent for microbiological analysis. There were no immediate complications. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: ABD PAIN Diagnosed with ACUTE CHOLECYSTITIS, ABDOMINAL PAIN RUQ temperature: 99.7 heartrate: 79.0 resprate: 16.0 o2sat: 98.0 sbp: 124.0 dbp: 69.0 level of pain: 4 level of acuity: 3.0

___ year old female admitted to the acute care sevice with right upper quadrant abdominal pain. Upon admission, she was made NPO, given intravenous fluids, and underwent ultrasound imaging of her abdomen. She was reported to have severe gallbladder wall thickening, with apparent anterior focal wall irregularity. Her blood culture from 1 bottle grew gm + cocci and she was started on vancomycin and unasyn. Because of the severe inflammation if the gallbladder, she went to ___ on HD #4 for placement of a cholecystostomy tube where 40cc of purulent fluid was drained. Her bile was cultured for gm - rods. Her vancomycin and zosyn were discontinued on HD # 7 and she was placed on augmentin to complete her 2 week course of antibiotics. Her vital signs are stable and her abdominal pain has decreased. She is afebrile and her white blood cell count is 13. She is tolerating a regular diet and voiding without difficulty. She is preparing for discharge home with the drain in place and ___ services to provide additional support and instruction. She has been instructed to maintain a record of the drainage and to bring it with her on her follow-up visit. She will follow up with the acute care service in 3 weeks.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Ace Inhibitors / Sulfa (Sulfonamide Antibiotics) / Fish Product Derivatives / Bactrim / lisinopril Attending: ___. Chief Complaint: Syncope Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old female with history of AF on warfarin, HTN/HL, prior caudate CVA, and chronic uvular edema/angioedema, presenting s/p syncopal episode just hours after discharge today from an admission for angioedema with fiberoptic intubation. She was at home, walking with 2 aids when she complained of lightheadedness and had a brief syncopal episode during which she was helped to a seated position by the aids, unresponsive ~30 seconds. She recovered immediately thereafter without any complaints or evidence of seizure/post-ictal state. She continued to have mild nausea without vomiting, so was brought back for evaluation. Upon arrival she was asymptomatic. During her previous admission, no precipitating triggers of her angioedema were identified. She only required a few hours of intubation for airway protection and was continued on an oral regimen of antihistamines and a prednisone taper with resolution of her symptoms. Per her transitional issues, she will followed up with Allergy as an outpatient with Dr. ___. She was also symptomatic with evidence of a UTI on urine culture, discharged with ciprofloxacin to finish today. Family requested a skin biopsy during her admission, which is currently pending. She was also deemed a fall risk, per her evaluation by ___ while in house. In the ED, initial VS were: 97.2 75 161/79 16 95% RA. EKG showed AF at 60bpm, RBBB, QTc 486 (previously 466) with inf/lat ST changes. Labs were notable for creatinine of 1.2, increasing from 1.0 earlier in the day in the ED. CXR showed "worsening CHF" and a right-sided pleural effusion. She also intermittently became bradycardic to the ___, but remained asymptomatic, oxygenating well. Therefore, the decision was made to admit her to medicine for diuresis and arrhythmia monitoring. On arrival to the floor, VS 97.9 142/69 60 18 96% RA. Pt does not recall her syncopal event and denies chest pain, palpitations, mouth swelling, shortness of breath, cough, fevers, chills, lightheadedness. REVIEW OF SYSTEMS: (-) per HPI and for headache, vision changes, abdominal pain, nausea, vomiting, diarrhea Past Medical History: - Left Caudate Head infarct - Angioedema: pruritis and periorbital and lip/tongue edema, previously intubated in MICU (___), etiology thought to be due to lisinospril, which was subsequenlty discontinued. Recurrence in ___ requiring MICU admission, managed with IV steroids and H1/H2 blockers, no intubation required. - Atrial fibrillation on Coumadin - Hypertension - Hyperlipidemia - Osteoporosis - Osteoarthritis - S/p right hip replacement - Eczema - ___ as a child Social History: ___ Family History: - Cousin with peanut allergy developed in his ___. - No family history of asthma or eczema Physical Exam: ADMISSION PHYSICAL EXAM: VS - Temp 97.9 142/69 60 18 96% RA. GENERAL - elderly female sleeping in bed, easily arousable to voice, appears comfortable HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry mucous membranes, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, breath sounds diminished at bases, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, irregularly irregular, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, alert and oriented to person, place and year, CNs II-XII grossly intact, muscle strength ___ throughout, DTRs 2+ and symmetric, gait deferred Pertinent Results: ___ 10:45PM GLUCOSE-183* UREA N-43* CREAT-1.2* SODIUM-138 POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-30 ANION GAP-16 ___ 10:45PM cTropnT-<0.01 ___ 10:45PM WBC-10.4 RBC-4.22 HGB-13.3 HCT-40.8 MCV-97 MCH-31.5 MCHC-32.6 RDW-12.7 ___ 10:45PM NEUTS-86.0* LYMPHS-6.9* MONOS-6.7 EOS-0.3 BASOS-0 ___ 10:45PM PLT COUNT-219 ___ 10:45PM ___ PTT-27.4 ___ ___ 01:00PM ___ PTT-35.4 ___ ___ 06:35AM GLUCOSE-109* UREA N-30* CREAT-1.0 SODIUM-139 POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-27 ANION GAP-16 ___ 06:35AM WBC-9.5 RBC-3.97* HGB-12.5 HCT-37.9 MCV-96 MCH-31.5 MCHC-32.9 RDW-12.4 ___ 06:35AM PLT COUNT-201 ___ 06:15AM GLUCOSE-109* UREA N-30* CREAT-0.8 SODIUM-142 POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-25 ANION GAP-16 ___ 06:15AM CALCIUM-9.3 PHOSPHATE-2.0* MAGNESIUM-1.8 ___ 06:15AM WBC-10.3 RBC-3.93* HGB-12.4 HCT-38.3 MCV-97 MCH-31.6 MCHC-32.4 RDW-12.8 ___ 06:15AM PLT COUNT-190 TTE ___: The left atrium is dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is borderline/mild bileaflet mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. Tricuspid valve prolapse is present. Moderate [2+] tricuspid regurgitation is seen. There is no pericardial effusion. EKG ___: Atrial fibrillation. Right axis deviation. Right bundle-branch block. Non-specific ST-T wave changes. Compared to tracing #2 no diagnostic interval change. QT/QTc: 470/478 CXR ___: Previous pleural effusions have substantially decreased. Lungs are clear. Moderate cardiomegaly stable. Normal pulmonary vasculature. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Famotidine 20 mg PO BID 2. Hydrochlorothiazide 25 mg PO DAILY 3. Metoprolol Tartrate 12.5 mg PO BID 4. PredniSONE 20 mg PO DAILY Duration: 1 Days ___ Tapered dose - DOWN 5. PredniSONE 10 mg PO DAILY Duration: 2 Days ___ 6. PredniSONE 5 mg PO DAILY starting ___ 7. Ciprofloxacin HCl 500 mg PO Q12H 8. Fexofenadine 60 mg PO BID 9. Acetaminophen 1000 mg PO Q8H 10. Alendronate Sodium 70 mg PO QWEEK 11. Calcarb 600 With Vitamin D *NF* (calcium carbonate-vitamin D3) 600 mg(1,500mg) -200 unit Oral BID 12. Lidocaine 5% Patch 1 PTCH TD DAILY 13. Vitamin D 1000 UNIT PO DAILY 14. Warfarin 1 mg PO QPM 15. Simvastatin 20 mg PO DAILY Discharge Medications: 1. Fexofenadine 60 mg PO BID 2. Hydrochlorothiazide 25 mg PO DAILY 3. PredniSONE 5 mg PO DAILY starting ___ 4. Simvastatin 20 mg PO DAILY 5. Vitamin D 1000 UNIT PO DAILY 6. Warfarin 1 mg PO QPM 7. Amlodipine 5 mg PO DAILY 8. Docusate Sodium 200 mg PO BID 9. Polyethylene Glycol 17 g PO DAILY:PRN constipation 10. Senna 2 TAB PO HS 11. Acetaminophen 1000 mg PO Q8H 12. Alendronate Sodium 70 mg PO QWEEK 13. Calcarb 600 With Vitamin D *NF* (calcium carbonate-vitamin D3) 600 mg(1,500mg) -200 unit Oral BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Syncope Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report INDICATION: Syncope. COMPARISON: Chest radiograph from ___ and CT torso from ___. CHEST, AP AND LATERAL: Increased mild pulmonary edema with central venous congestion, , moderate right and small left pleural effusions. Moderate cardiomegaly is chronic. Compression deformities of a mid thoracic vertebra, with near complete loss of height; and lower thoracic vertebra, with 50% loss of anterior height, unchanged for at least five months. Mild left acromioclavicular arthropathy. IMPRESSION: Increasing congestive heart failure. Radiology Report AP CHEST, ___, 9:17 A.M. HISTORY: ___ woman with atrial fibrillation, pleural effusions and now a white count, question pneumonia. IMPRESSION: AP chest compared to ___: Previous pleural effusions have substantially decreased. Lungs are clear. Moderate cardiomegaly stable. Normal pulmonary vasculature. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: SYNCOPE/PRESYNCOPE Diagnosed with SYNCOPE AND COLLAPSE, PULMONARY CONGESTION & HYPOSTASIS, ATRIAL FIBRILLATION, CARDIAC DYSRHYTHMIAS NEC, HYPERTENSION NOS temperature: 97.2 heartrate: 75.0 resprate: 16.0 o2sat: 95.0 sbp: 161.0 dbp: 79.0 level of pain: 0 level of acuity: 2.0

___ F with history of atrial fibrillation on warfarin, hypertension, and chronic idiopathic uvular edema/angioedema discharged ___ after treatment of angioedema and readmitted the same day for witnessed pre-syncopal/syncopal episode at assisted living. # Syncope/Pre-syncope: Per report, pt was lightheaded and was helped to a seated position by aids, unclear if there was true loss of consciousness. Of note, patient was "hyper and giddy" prior to the episode per report of home aid, raising suspicion for medication side effect given recent addition of 2 antihistamines and high dose predisone for angioedema. Differential also included vasovagal, neurologic and cardiac etiologies. Lack of focal neuro deficits and normal neuro exam made CVA/TIA unlikely, seizure also unlikely given lack of post-ictal period. ACS unlikely given lack of acute change on EKG and negative cardiac enzymes x 2. Valvular dysfunction considered given R>L pleural effusions on CXR. TTE ___ showed Moderate (2+) mitral regurgitation, no aortic stenosis or other valvular dysfunction. Bradycardia on telemetry as described below. Pt denied dizziness, lightheadedness this admission and had no further syncopal episodes. # Bradycardia: Per ED report, pt initially had bradycardia to ___, asymptomatic. Currently, pt having frequent episodes of asymptomatic bradycardia in ___ with ___ second pauses. Beta blocker held. Suspect that current antihistamine regimen for recent angioedema contributing. Spoke with pt's allergist Dr. ___ believes that steroids are a more important component of her angioedema treatment than the antihistamines at this point and noted that pt was on fairly low doses of both famotidine and fexofenadine. Cardiology evaluated patient and recommended decreased dose of metoprolol, no indication for pacemaker. # ___: Resolved. Creatinine 1.2 from 1.0 at discharge. Likely pre-renal etiology given response to fluids. # Leukocytosis: WBC 12.2 ___. Pt was afebrile with no localizing infectious symptoms. UA negative, chest x-ray showed improvement in pleural effusions and no focal infiltrate. Recheck was 11.2 on day of discharge. # Chronic angioedema: Pt recently admitted for angioedema which required brief intubation for airway protection. Was discharged on day of presentation with no symptoms of angioedema with plan to continue prednisone taper and follow up with her allergist. Prednisone taper was continued and patient discharged on 5mg daily with plan to continue at that dose until seen for scheduled follow up in allergy clinic. Due to concern that antihistamines may have been contributing to her dizziness/syncope prior to admission as well as her bradycardia on telemetry, famotidine was held and fexofenadine continued. Pt denied any symptoms of angioedema this admission. # Hypertension: Home beta blocker was discontinued due to bradycardia as described above. Subsequently, SBP elevated 160s-170s, patient asymptomatic. Home HCTZ continued and low dose amlodipine added with better control of blood pressure. # Atrial fibrillation: Pt was kept on home warfarin dose 1 mg daily # Hyperlipidemia: continued simvastatin # Osteoporosis: continued calcium and vitamin D

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Ibuprofen / Keflex / Antihistamines / Latex / Bactrim Attending: ___. Chief Complaint: Syncope Major Surgical or Invasive Procedure: None History of Present Illness: ___ y/o female with PMHx of UC (s/p colectomy), DVT (on coumadin) who presents after fall and questionable LOC. Patient was in her kitchen this morning and rose from a chair to get a cup of coffee. She reports "blacking out" without any warning and falling to the ground. She does not think she passed out, and she did not hit her head. She called her daughter who came to her aid. There was no chest pain, shortness of breath, palpitations, lightheadedness.No prior episodes of syncope or seizure. No urinary incontinence. She was noted by EMS to have a large laceration on the dorsal surface of her left hand as well as skin tears on her left shoulder and right elbow. In the ED, initial VS were 98.4 90 183/106 20 98%RA. Initial labs were significant for no leukocytosis, H/H 12.3/39.4, INR 3.9. Chem panel significant for Na 149, K 4.9, Cl 114, HCO3 17, BUN 20, Cr 1.4. AG was 18. Noncontrast CT head was negative for acute process. EKG reportedly NSR NANI, no ST changes. She was given 2mg morphine x2 and tetanus vaccine. Transfer VS were 98.4 103 108/56 19 97% RA. On arrival to the floor, patient reports no pain, no dizziness. Denies headache, blurry vision, focal weakness or numbness. She does report that she has felt weak for the past several weeks generally, with poor PO intake over several months. Denies fevers, chills, cough, abdominal pain, dysuria, hematuria. REVIEW OF SYSTEMS: 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. All other 10-system review negative in detail. Past Medical History: - Refractory colitis s/p subtotal colectomy - Pyoderma gangrenosum - Breast CA s/p left lumpectomy + XRT - GERD - Glaucoma - HTN - Hypothyroidism - Depression - Osteoporosis - Basal cell ca PAST SURGICAL HISTORY: - s/p ex lap, subtotal colectomy and ileostomy - s/p left salpingo-ophrectomy, - s/p multiple parastomal hernia repairs, including one with ileal resection - s/p left breast biopsy - SBO - History of DVT, on warfarin - CKD - Pseudogout - Blepharitis (OD) Social History: ___ Family History: -Father with MI, stroke -Mother with MI Physical Exam: PHYSICAL EXAM ON ADMISSION: ======================================== VS: 98.1 116/60 96 26 99%RA BP lying 118/74 BP standing 72/48 General: Awake, alert, oriented x3. Lying in bed, with left hand in skyhook. HEENT: Right pupil larger than left, right also barely reactive. Right lower eyelid with ectropion. Sclera nonicteric. Somewhat dry mucous membranes, no oral lesions. Neck: Supple. No cervical or supraclavicular LAD. CV: Tachycardic, regular rhythm. No murmur appreciated. Lungs: Lungs clear with some decreased air movement at the bases. Abdomen: BS+. Soft, nondistended. Mild diffuse tenderness. Ostomy on left side, with brown semi-formed stool. GU: Deferred. No foley. Ext: 1+ ___ edema. Hyperpigmentation of the LEs, consistent with chronic venous stasis. Neuro: AOx3. CN2-12 grossly intact. Strength not tested, though moving all four extremities with no focal deficits. Skin: Very thin, fragile, dry. 12cm skin tear over the dorsum of the left wrist. 24x24cm skin tear over left shoulder. PHYSICAL EXAM ON DISCHARGE: ======================================== VS: 97.5 124/61 73 16 96%RA BP lying 130/64 BP sitting 120/60 General: Awake, alert, oriented x3. Sitting up in bed, eating breakfast. HEENT: Right pupil larger than left, right also barely reactive. Right lower eyelid with ectropion. Sclera nonicteric. MMM, no oral lesions. Neck: Supple. No cervical or supraclavicular LAD. CV: RRR. No murmur appreciated. Lungs: Lungs clear with some decreased air movement at the bases. Abdomen: BS+. Soft, nondistended, nontedner. Ostomy on left side, with brown semi-formed stool and some liquid. GU: Deferred. No foley. Ext: Trace ___ edema. Hyperpigmentation of the LEs, consistent with chronic venous stasis. Neuro: AOx3. CN2-12 grossly intact. Strength not tested, though moving all four extremities with no focal deficits. Skin: Very thin, fragile, dry. 12cm skin tear over the dorsum of the left wrist, is also about 1cm wide. 24x24cm superficial skin tear over left shoulder. Pertinent Results: LABS: ===================================== ___ 08:30AM BLOOD WBC-6.9 RBC-4.05* Hgb-12.3 Hct-39.4 MCV-97 MCH-30.3 MCHC-31.1 RDW-13.7 Plt ___ ___ 08:30AM BLOOD Neuts-63.9 ___ Monos-8.3 Eos-3.3 Baso-0.8 ___ 08:30AM BLOOD ___ PTT-46.0* ___ ___ 08:30AM BLOOD Glucose-122* UreaN-20 Creat-1.4* Na-149* K-4.9 Cl-114* HCO3-17* AnGap-23* ___ 08:30AM BLOOD Calcium-8.8 Phos-3.2 Mg-1.8 ___ 08:42AM BLOOD Lactate-1.5 ___ 05:40AM BLOOD WBC-6.7 RBC-3.07* Hgb-9.2* Hct-28.5* MCV-93 MCH-30.1 MCHC-32.4 RDW-14.1 Plt ___ ___ 05:40AM BLOOD Glucose-82 UreaN-13 Creat-1.1 Na-144 K-3.7 Cl-109* HCO3-25 AnGap-14 ___ 05:40AM BLOOD Calcium-8.1* Phos-2.8 Mg-1.6 ___ 05:40AM BLOOD ___ PTT-28.7 ___ ___ 05:40AM BLOOD WBC-7.3 RBC-3.06* Hgb-9.2* Hct-28.2* MCV-92 MCH-30.2 MCHC-32.7 RDW-14.0 Plt ___ ___ 05:40AM BLOOD ___ PTT-31.8 ___ ___ 05:40AM BLOOD Glucose-92 UreaN-14 Creat-1.3* Na-144 K-4.6 Cl-111* HCO3-27 AnGap-11 REPORTS: ===================================== -GLENO-HUMERAL SHOULDER (W/ Y VIEW) LEFTStudy Date of ___: IMPRESSION: No left shoulder acute fracture or dislocation. -HAND (AP, LAT & OBLIQUE) LEFTStudy Date of ___: IMPRESSION: No left hand or wrist fracture or dislocation. -CHEST (PA & LAT)Study Date of ___: MPRESSION: No acute cardiopulmonary process. -CT HEAD W/O CONTRASTStudy Date of ___: IMPRESSION: No acute intracranial process. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 75 mcg PO DAILY 2. Timolol Maleate 0.5% 1 DROP BOTH EYES BID 3. Align (bifidobacterium infantis) 4 mg oral daily 4. Cyanocobalamin 1000 mcg PO DAILY 5. Miconazole 2% Cream 1 Appl TP PRN ostomy change 6. Artificial Tears Preserv. Free 2 DROP BOTH EYES BID 7. Warfarin 2 mg PO 3X/WEEK (___) 8. Warfarin 3 mg PO 4X/WEEK (___) 9. Multivitamins 1 TAB PO DAILY 10. Pataday (olopatadine) 0.2 % ophthalmic 1 drop in both eye daily Discharge Medications: 1. Artificial Tears Preserv. Free 2 DROP BOTH EYES BID 2. Cyanocobalamin 1000 mcg PO DAILY 3. Levothyroxine Sodium 75 mcg PO DAILY 4. Timolol Maleate 0.5% 1 DROP BOTH EYES BID 5. Acetaminophen 1000 mg PO TID This should be given TID for 7-days and then changed to PRN basis. 6. Heparin 5000 UNIT SC BID 7. Mirtazapine 7.5 mg PO HS 8. Align (bifidobacterium infantis) 4 mg oral daily 9. Miconazole 2% Cream 1 Appl TP PRN ostomy change 10. Multivitamins 1 TAB PO DAILY 11. Pataday (olopatadine) 0.2 % ophthalmic 1 drop in both eye daily Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Syncope 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 HISTORY: Weakness. COMPARISON: Multiple prior chest radiographs, most recently ___. FINDINGS: Frontal and lateral views of the chest. High position of the IVC filter is similar to prior. Heart size and cardiomediastinal contours are stable. Aortic knob calcification is unchanged. The lungs are clear without focal consolidation, pleural effusion, or pneumothorax. IMPRESSION: No acute cardiopulmonary process. Radiology Report HISTORY: Status post fall with left hand pain. COMPARISON: None. FINDINGS: 3 views the left hand, 3 views of the left wrist, and dedicated scaphoid view. Evaluation of fine bony detail is mildly limited by overlying cast material. Within this limitation, no fracture or dislocation. Joint narrowing with subchondral sclerosis and marginal osteophytes are noted involving the PIP and DIP joing as well as the ___ CMC and triscaphe joints. No focal lytic or sclerotic lesion. Marked soft tissue swelling with subcutaneous gas is seen overlying the dorsum of the hand and wrist. IMPRESSION: No left hand or wrist fracture or dislocation. Radiology Report HISTORY: Status post fall with pain in left shoulder and hand. COMPARISON: None. FINDINGS: 4 views of the left shoulder. No fracture or dislocation. Acromioclavicular and coracoclavicular intervals are maintained. Moderate acromioclavicular degenerative changes. No focal lytic or sclerotic lesion. IMPRESSION: No left shoulder acute fracture or dislocation. Radiology Report HISTORY: Fall on Coumadin. COMPARISON: Comparison is made with CTA head from ___. TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without administration of IV contrast. Reformatted coronal and sagittal and thin section bone algorithm reconstructed images were acquired. FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or infarction. Prominent ventricles and sulci suggest age related involutional changes or atrophy. Periventricular white matter hypodensities are consistent with chronic small vessel ischemic disease. The basal cisterns appear patent and there is preservation of gray-white matter differentiation. No fracture is identified. Scattered areas of aerosolized secretions are seen in the ethmoid air cells and sphenoid sinuses, suggestive of mild acute sinus disease. Otherwise, the visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The globes are intact. IMPRESSION: No acute intracranial process. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Syncope Diagnosed with SYNCOPE AND COLLAPSE, OPEN WOUND OF WRIST, TETANUS TOXOID INOCULAT, UNSPECIFIED FALL temperature: 98.4 heartrate: 90.0 resprate: 20.0 o2sat: 98.0 sbp: 183.0 dbp: 106.0 level of pain: 4 level of acuity: 2.0

PRIMARY REASON FOR HOSPITALIZATION: ================================================= ___ y/o female with PMHx of UC (s/p colectomy), DVT (on coumadin) who presents after fall at home.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Ketorolac / B blockers / Percocet / Toradol / Dilaudid / levofloxacin / Beta-Blockers (Beta-Adrenergic Blocking Agts) Attending: ___ ___ Complaint: Left sided abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Per Dr. ___ note: "Ms. ___ is a ___ woman with history of DVT/PE on warfarin, HTN, HLD, thoracic radiculitis, endometriosis, irritable bowel syndrome, s/p CCY, s/p appendectomy presenting with abdominal pain. The patient reports that she was in her usual state of health until about two months when she developed left sided abdominal pain. She also reported loose watery stools, as well has dizziness and lightheadedness. She saw her PCP for this on ___, and was thought to have gastroenteritis and advised to continue to adhere to a BRAT diet and continue to drink fluids. She also started taking a probiotic with enzymes. Labs at that time notable for a lipase of 155 (ULN 82), LFTs and BMP wnl. Stool cultures were negative. The patient reports that she tried the BRAT diet for a few more days but did not notice any difference in her pain or other symptoms and became discouraged so she discontinued it. She reports that her pain worsened over the past several days. It is primarily left-sided, upper and lower, and feels "dull like a toothache". The pains is present continuously, associated with nausea and dry heaving. She has had little to eat or drink in the last two days due to pain and nausea. She continues to have loose watery stools, ___ per day, and bloating. She denies any fevers or chills. She reports that the pain is exacerbated by everything: sitting, walking, eating. She does not use NSAIDs and does not drink alcohol. She reports that she has been on the same medications at the same doses for years. No travel or sick contacts. She presented again to her PCP today for evaluation. CT obtained notable for ___ inflammatory change adjacent to the neck of the pancreas suggestive acute pancreatitis so she was referred to the ED for further management. Of additional note, the patient has a history of right-sided abdominal pain thought to be due to thoracic radiculitis for which she is followed by pain clinic. She feels that this current pain is different from that right-sided pain. In the ED, vitals: Tmax 100.0, 89, 131/86 20 100% RA Exam notable for: Abdomen mildly distended, ttp in epigastric and LLQ, normal bowel sounds Labs notable for: WBC 5.9, Hb 9.5, INR 4.6; LFTs wnl, lipase 58; lactate 1.4 Imaging: CXR Patient given: morphine 4 mg IV, Zofran 4 mg IV, 2L LR On arrival to the floor, the patient reports that she continues to have left-sided abdominal discomfort and nausea. She has dry heaves but no emesis. She continues to have several watery loose stools per day. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. " Past Medical History: - DVT/PE on warfarin - HTN - HLD - Mitral valve prolapse - Thoracic radiculitis - GERD - Anemia/thalassemia trait - Asthma - Endometriosis - Irritable bowel syndrome - Generalized anxiety disorder - PTSD - Affective psychosis - S/p CCY - S/p appendectomy Social History: ___ Family History: No known family history of pancreatic or biliary disease. Physical Exam: ADMISSION EXAM: VITALS: 99.3 136/86 70 18 98 RA GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, tender to palpation in left upper quadrant without rebound or guarding. 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 EXAM: VITALS: ___ Temp: 98.3 PO BP: 125/84 HR: 72 RR: 18 O2 sat: 98% O2 delivery: Ra GENERAL: Alert and in no apparent distress, appears comfortable, conversant EYES: Anicteric ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate. Moist mucus membranes. CV: RRR, no murmurs/rubs, no S3, no S4. 2+ radial pulses bilaterally. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored on room air. GI: Abdomen soft, mildly distended, mildly tender to palpation in LUQ. Bowel sounds present but hypoactive. Obese. GU: No GU catheter present MSK: Moves all extremities, no edema or swelling SKIN: No rashes or ulcerations noted NEURO: Alert, oriented x3, face symmetric, speech fluent, moves all limbs PSYCH: Pleasant, flat affect, calm, cooperative Pertinent Results: LABS ON ADMISSION: ___ 03:43PM BLOOD WBC-5.9 RBC-4.57 Hgb-9.5* Hct-30.9* MCV-68* MCH-20.8* MCHC-30.7* RDW-18.5* RDWSD-41.7 Plt ___ ___ 03:43PM BLOOD Neuts-64.2 ___ Monos-10.9 Eos-0.9* Baso-0.5 Im ___ AbsNeut-3.78 AbsLymp-1.35 AbsMono-0.64 AbsEos-0.05 AbsBaso-0.03 ___ 03:43PM BLOOD ___ PTT-40.7* ___ ___ 03:43PM BLOOD Glucose-103* UreaN-7 Creat-0.9 Na-139 K-4.1 Cl-106 HCO3-20* AnGap-13 ___ 03:43PM BLOOD ALT-22 AST-29 AlkPhos-105 TotBili-0.3 ___ 03:43PM BLOOD Lipase-58 ___ 03:43PM BLOOD cTropnT-<0.01 ___ 03:43PM BLOOD Albumin-3.7 Calcium-8.7 Phos-2.0* Mg-2.0 ___ 03:43PM BLOOD Triglyc-84 ___ 05:30AM BLOOD tTG-IgA-8 ___ 03:48PM BLOOD Lactate-1.4 ___ 03:50PM URINE Color-Straw Appear-Clear Sp ___ ___ 03:50PM URINE Blood-SM* Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 03:50PM URINE RBC-6* WBC-0 Bacteri-NONE Yeast-NONE Epi-0 ===================== LABS ON DISCHARGE: ___ 05:50AM BLOOD WBC-4.3 RBC-4.70 Hgb-9.5* Hct-31.5* MCV-67* MCH-20.2* MCHC-30.2* RDW-17.2* RDWSD-40.2 Plt ___ ___ 05:50AM BLOOD ___ ___ 05:50AM BLOOD Glucose-47* UreaN-7 Creat-0.8 Na-144 K-4.1 Cl-108 HCO3-20* AnGap-16 ___ 05:30AM BLOOD ALT-19 AST-18 AlkPhos-99 TotBili-0.4 ___ 05:50AM BLOOD Calcium-8.6 Phos-2.6* Mg-2.0 ===================== MICROBIOLOGY: ___ 3:50 pm URINE URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ 3:25 pm STOOL CONSISTENCY: WATERY Source: Stool. C. difficile PCR (Final ___: NEGATIVE. ___ 3:25 pm STOOL CONSISTENCY: WATERY Source: Stool. FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Pending): OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. FECAL CULTURE - R/O VIBRIO (Pending): FECAL CULTURE - R/O YERSINIA (Pending): FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: No E. coli O157:H7 found. ___ 12:31 pm STOOL CONSISTENCY: SOFT Source: Stool. OVA + PARASITES (Pending): ===================== CT ABDOMEN/PELVIS ___: (ATRIUS) IMPRESSION: Peripancreatic inflammatory change adjacent to the neck of the pancreas, extending towards the porta hepatis, suggesting acute pancreatitis. Status post cholecystectomy and appendectomy. CXR ___: No acute cardiopulmonary abnormality. EKG ___: Normal sinus rhythm. No significant change compared with ___ EKG. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with abdominal pain, vomiting and pancreatitis// ?pulmonary edema, pna TECHNIQUE: AP and lateral chest radiographs were obtained COMPARISON: CT dated ___ FINDINGS: There is no focal consolidation, pleural effusion or pneumothorax identified. There is no evidence of pulmonary edema. The size of the cardiac silhouette is mildly enlarged but unchanged. IMPRESSION: No acute cardiopulmonary abnormality. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Abd pain Diagnosed with Epigastric pain, Left lower quadrant pain, Essential (primary) hypertension temperature: 97.2 heartrate: 89.0 resprate: 20.0 o2sat: 100.0 sbp: 131.0 dbp: 86.0 level of pain: 7 level of acuity: 3.0

Ms. ___ is a ___ woman with history of DVT/PE on warfarin, HTN, HLD, thoracic radiculitis, endometriosis, irritable bowel syndrome, s/p CCY, s/p appendectomy who presented with left sided abdominal pain (since ___, worsened over several days), nausea and vomiting. She was still having some moderate LUQ pain and nausea, that seem to worsen with attempts at eating. She was going to try solid food for dinner, but said she was nauseated. I discussed with her that I wanted to make sure she could keep down adequate liquids and solid food such as dinner tonight and breakfast tomorrow and if so, that she could likely go home tomorrow. She was initially in agreement, but then said she really wanted to go home. She said that she had kept down soda and fluids and said she thought that she would feel better and do better at home. I explained that I would prefer that she make sure that she could eat solid food before going home. She expressed understanding the risks of going home and said that if her pain or nausea significantly worsened, she could return to the ED. She also felt like she could manage her symptoms with the same PRN medications at home as she is getting here. I discussed with her that she needs her INR rechecked to determine when to restart warfarin and to see her PCP within the next 1 week. She agreed and said she would make sure to do these things.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: lithium Attending: ___ Chief Complaint: Pre-syncope Major Surgical or Invasive Procedure: EGD and colonoscopy on ___ History of Present Illness: ___ with PMH of bipolar disorder, gastritis, colonic polyps and GERD with ongoing workup for diarrhea and anemia who presented after a pre-syncopal episode at her PCP's office while waiting in line to drop off a stool sample. She felt lightheaded and fell, but denies LOC, head strike, CP, SOB, nausea, palpitations. After this episode, labs were drawn at her PCP's office which was concerning for Hgb 7.4. She was sent to ___ ED for further workup. She was previously hospitalized at ___ from ___ for hypotension, nonbloody vomiting and diarrhea. At that time she had a BP in the 70's with tachycardia in the 120's. She received a CT abdomen which showed diverticulosis, hepatic steatosis, and sigmoid colitis. There was an initial concern for pancreatitis given her elevated lipase, however, there was no evidence on CT imaging. Her electrolytes were repleted. Stool cultures including bacteria, c diff, norovirus were all negative. She was discharged on a 7 day course of cipro (refused to take flagyl due to nausea). She did not receive any scopes at that time. Since her discharge in ___, her diarrhea and vomiting have not completely resolved. She has had ongoing outpatient workup for diarrhea and anemia. Patient states she has felt ongoing fatigue, anorexia, as well as weight loss over the past few months (unintentional). Denies NSAID use, is not anticoagulated. Patient states she has ___ alcoholic drinks per day, smokes 1 pack cigarettes per day. Occasional marijuana use, otherwise denies any drug use. Past Medical History: Diverticulitis ___ hypertension bipolar disorder Social History: ___ Family History: Father: HTN, diverticulitis (1 episode) Mother: good health FH of colon cancer, cholecystitis Physical Exam: ADMISSION EXAM: VS: ___ Temp: 98.0 PO BP: 123/78 R Lying HR: 89 RR: 18 O2 sat: 99% O2 delivery: Ra Appearance: pale, middle aged woman lying in bed, no acute distress Eyes: no conjuctival injection, anicteric ENT: no sinus tenderness, Respiratory: good air movement throughout, faint expiratory wheezing Cardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops Gastrointestinal: distended, nontender to palpation in all quadrants, no rebound or guarding Extremities: no cyanosis, clubbing or edema Skin: warm, no rashes/no jaundice/no skin ulcerations noted Neurological: alert, able to answer all questions DISCHARGE EXAM: T98.6 PO 103 / 68 103 18 98 Ra Appearance: NAD, alert and oriented x3 Eyes: no conjuctival injection, anicteric Respiratory: CTAB Cardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops Gastrointestinal: distended, nontender to palpation in all quadrants, no rebound or guarding Extremities: no cyanosis, clubbing or edema Skin: warm, no rashes/no jaundice/no skin ulcerations noted Neurological: alert, able to answer all questions Pertinent Results: ADMISSION LABS: ___ 04:18PM BLOOD WBC-11.7*# RBC-2.18* Hgb-7.0* Hct-21.5* MCV-99* MCH-32.1*# MCHC-32.6 RDW-22.0* RDWSD-79.3* Plt ___ ___ 04:18PM BLOOD Neuts-82.3* Lymphs-9.8* Monos-5.9 Eos-0.6* Baso-0.6 NRBC-0.2* Im ___ AbsNeut-9.62*# AbsLymp-1.14* AbsMono-0.69 AbsEos-0.07 AbsBaso-0.07 ___ 04:18PM BLOOD ___ PTT-28.7 ___ ___ 04:18PM BLOOD Glucose-115* UreaN-4* Creat-0.5 Na-140 K-3.4 Cl-96 HCO3-26 AnGap-18 ___ 04:18PM BLOOD ALT-6 AST-50* LD(LDH)-306* AlkPhos-171* TotBili-1.1 DirBili-0.4* IndBili-0.7 ___ 07:00AM BLOOD Calcium-7.8* Phos-3.6 Mg-1.2* Iron-152 PERINANT INTERVAL LABS: ___ 07:00AM BLOOD Ret Aut-1.1 Abs Ret-0.03 ___ 04:18PM BLOOD ___ 07:00AM BLOOD Lipase-66* ___ 07:00AM BLOOD ALT-<5 AST-33 LD(LDH)-227 AlkPhos-140* TotBili-1.2 ___ 07:00AM BLOOD TSH-5.5* ___ 07:20AM BLOOD T4-8.3 ___ 07:00AM BLOOD CRP-8.6* ___ 08:39AM BLOOD Lactate-1.3 DISCHARGE LABS: ___ 07:20AM BLOOD WBC-8.3 RBC-2.64* Hgb-8.3* Hct-25.0* MCV-95 MCH-31.4 MCHC-33.2 RDW-20.9* RDWSD-69.4* Plt ___ ___ 07:20AM BLOOD Glucose-86 UreaN-<3* Creat-0.4 Na-141 K-3.6 Cl-102 HCO3-24 AnGap-15 IMAGING/REPORTS: ___ RUQS: LIVER: The liver is diffusely echogenic. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 4 mm. GALLBLADDER: There is no evidence of stones or gallbladder wall thickening. PANCREAS: The pancreas is not well visualized, largely obscured by overlying bowel gas. SPLEEN: Normal echogenicity, measuring 12.3 cm. KIDNEYS: The right kidney measures 11.0 cm. She left kidney measures 11.1 cm. No hydronephrosis or suspicious renal mass. 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. EGD ___: Impression: (biopsy) Abnormal mucosa in the stomach (biopsy) Otherwise normal EGD to third part of the duodenum Recommendations: - Follow up with biopsy results - Proceed with colonoscopy Colonoscopy ___: Impression: Internal hemorrhoids Diverticulosis of the colon (biopsy) Otherwise normal colonoscopy to cecum Recommendations: - Follow up on biopsy results - Refer to GI consult team for further recommendations - Given suboptimal prep and purpose of colonoscopy, procedure was inadequate for colorectal screening and the patient should continue her current schedule of screenings. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. RisperiDONE 1 mg PO QHS 2. Omeprazole 40 mg PO BID 3. Sucralfate 1 gm PO TID Discharge Medications: 1. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. LOPERamide 2 mg PO QID:PRN diarrhea/loose stool Hold if No BM, discuss increasing with your PCP if not sufficient RX *loperamide 2 mg 1 tab by mouth QIDPRN Disp #*120 Capsule 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 5. Omeprazole 40 mg PO BID 6. RisperiDONE 1 mg PO QHS 7. Sucralfate 1 gm PO TID Discharge Disposition: Home Discharge Diagnosis: Primary: Pre-syncope Anemia Secondary: Etoh use disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with hypotension, tachycardic, pre-syncope, likely slow GIB, smokes ppd// any evidence of acute cardio/pulm process? TECHNIQUE: Single frontal view of the chest COMPARISON: Chest radiograph on ___ FINDINGS: Cardiac size is normal. The lungs are clear. There is no pneumothorax or pleural effusion. IMPRESSION: No acute cardiopulmonary abnormality Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year old woman with h/o EtOH abuse, chronic diarrhea, possible GIB, syncope// Please evaluate hepatic parenchyma and biliary tree for possible etiology of diarrhea and/or any other acute process in patient with long history of alcohol use TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: None. FINDINGS: LIVER: The liver is diffusely echogenic. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 4 mm. GALLBLADDER: There is no evidence of stones or gallbladder wall thickening. PANCREAS: The pancreas is not well visualized, largely obscured by overlying bowel gas. SPLEEN: Normal echogenicity, measuring 12.3 cm. KIDNEYS: The right kidney measures 11.0 cm. She left kidney measures 11.1 cm. No hydronephrosis or suspicious renal mass. 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. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Fatigue, Presyncope Diagnosed with Acute posthemorrhagic anemia temperature: 98.9 heartrate: 107.0 resprate: 22.0 o2sat: 100.0 sbp: 90.0 dbp: 66.0 level of pain: 0 level of acuity: 2.0

___ with PMH bipolar disorder, gastritis, colonic polyps and GERD with ongoing workup for diarrhea and anemia who presented after a pre-syncopal episode, admitted for further workup of possible GI bleed.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Prochlorperazine / Lisinopril / Cefaclor / Baclofen / doxycycline Attending: ___. Chief Complaint: Chest and back pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with h/o HTN, HLD, T2DM c/b neuropathy and gastroparesis, chronic pancreatitis, prior DVT no longer on anticoagulation, and history of epidural abscess s/p T2-T5 laminectomies presents to the ED with c/o chest and back pain. She notes that two days ago she developed pain in her left arm that radiates down the entire arm, is described as "numb and heavy." She states that her hand feels "like it is a mitten." There was no preceding trauma or injuries. She does note that that she has had similar pain in the past when she had an epidural abscess. She notes that she then developed shortness of breath and is now having pain with deep inspiration. She then developed a sense of back pain radiating through to her chest which she calls "chest pain." She describes the pain as "squeezing, tight and heavy." The pain is constant with no clear exacerbating or alleviating factors. She notes associated nausea. She denies any fever, abdominal pain, vomiting, diarrhea, BRBPR, urinary retention, bladder or bowel incontinence, or saddle anesthesia. A code cord was called on arrival. In the ED, vitals were: T97.8 HR 99 BP 157/74 RR 18 O2 99 on RA Exam: Notable for : Tearful, ___ LUE strength, pain with moving right leg. Labs: Notable for WBC 5.3, CRP 3.2, D-Dimer 311, Lactate 2.4->2.9, Trop <0.01 x2 Studies: -MRI w/o contrast (patient refused contrast): No definitive epidural abscess, though limited by w/o contrast. Right dorsal lateral epidural T2 signal extends from T4-T9 is similar from prior study (___) and ventrally displaces thecal sac w/o definitive cord compression or cord signal abnormalities. Could represent epidural lipomatosis, however unusual configuration. Cord compression at C5-C6 level of degenerative spinal cord narrowing, at T3-T9 due to described epidural abnormality. -CXR IMPRESSION: No acute intrathoracic process. They were given: ___ 01:24IVMorphine Sulfate 4 mg ___ 01:50IVHYDROmorphone (Dilaudid) .5 mg ___ 02:25IVHYDROmorphone (Dilaudid) .5 mg ___ 02:46IVLORazepam 1 ___ ___ 04:25IVHYDROmorphone (Dilaudid) .5 mg ___ 08:18IVHYDROmorphone (Dilaudid) .5 mg ___ 08:57SCInsulin 4 ___ ___ 09:27PO/NGGabapentin 900 mg ___ 09:27POFenofibrate 145 mg ___ 09:27PO/NGAspirin 81 ___ ___ 09:27POMetFORMIN XR (Glucophage XR) 1000 mg ___ 09:27PO/NGDocusate Sodium 100 mg ___ 09:27PO/NGSenna 8.6 ___ ___ 11:29IVHYDROmorphone (Dilaudid) .5 mg ___ 13:20SCInsulin 8 ___ ___ 15:33IVHYDROmorphone (Dilaudid) .5 mg On arrival to the floor, patient is tearful and notes that she is having chest tightness, pointing to her epigastrium. She notes that this all started two days ago. She notes that the pain is reproducible by pushing down on her upper abdomen. When discussing her back pain, she tells me that it is worse than usual, but at baseline has been pretty bad after her surgery. She is also having decreased sensation of her left arm and discomfort of her right leg and feels as if it is very weak. The numbness of her left arm is described as if covered by a blanket. She notes that her left arm is heavy and she feels that she cannot lift it as well. She states that these symptoms also started >24 hours ago and are more noticeable now than they were at onset. She states that these are the exact symptoms from her epidural abscess. Currently she says that she feels lousy and somewhat nauseous, but has not vomited. Endorses constipation. Past Medical History: UC Pancreatitis Gastritis DM (retinopathy and neuropathy) Mechanical fall resulting in lumbar spine trauma w/compression fractures PE diagnosed in ___, not on anticoagulation Appendectomy Cholecystectomy Increased triglycerides Obesity Depression Endometrial carcinoma s/p hysterectomy Social History: ___ Family History: Father - coronary artery disease, diabetes. Mother - NFS, gadolinium, renal failure, died related to NFS. Siblings - none. Daughter is adopted. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: Reviewed in poe GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. BACK: Point tenderness below surgical incision site, with R-flank tenderness, and significant tenderness to CVA maneuver. ABDOMEN: Tender to deep palpation in epigastrium and RUQ. No guarding. No rebound. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rash. DISCHARGE PHYSICAL EXAM ======================== VITALS: 24 HR Data (last updated ___ @ 048) Temp: 98.5 (Tm 98.7), BP: 114/71 (108-148/57-79), HR: 97 (92-103), RR: 16 (___), O2 sat: 97% (95-97), O2 delivery: RA GENERAL: Lying in bed, NAD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: CTAB ABD: soft, normoactive BS, mild epigastric tenderness, RUQ tenderness. No rebound or guarding. BACK: Tenderness in upper and mid thoracic spine NEURO: AAOx3, strength ___ RUE, 4+/5 LUE, ___ LLE, ___ RLE Pertinent Results: ADMISSION LABS ============== ___ 09:37PM BLOOD WBC-5.3 RBC-4.58 Hgb-12.7 Hct-39.0 MCV-85 MCH-27.7 MCHC-32.6 RDW-12.3 RDWSD-37.5 Plt ___ ___ 09:37PM BLOOD Neuts-41.9 ___ Monos-8.9 Eos-3.4 Baso-0.9 Im ___ AbsNeut-2.22 AbsLymp-2.33 AbsMono-0.47 AbsEos-0.18 AbsBaso-0.05 ___ 09:37PM BLOOD Glucose-392* UreaN-22* Creat-0.7 Na-139 K-4.3 Cl-103 HCO3-22 AnGap-14 ___ 09:37PM BLOOD cTropnT-<0.01 ___ 06:06AM BLOOD D-Dimer-311 ___ 01:10AM BLOOD ALT-24 AST-20 AlkPhos-54 TotBili-0.3 ___ 09:37PM BLOOD cTropnT-<0.01 ___ 01:10AM BLOOD Lipase-45 ___ 01:10AM BLOOD Albumin-4.1 ___ 05:02AM BLOOD VitB12-326 ___ 01:10AM BLOOD CRP-3.2 ___ 01:18AM BLOOD Lactate-2.4* DISCHARGE LABS ============== ___ 05:47AM BLOOD WBC-3.6* RBC-3.79* Hgb-10.6* Hct-33.1* MCV-87 MCH-28.0 MCHC-32.0 RDW-12.4 RDWSD-39.5 Plt ___ ___ 05:47AM BLOOD Glucose-244* UreaN-19 Creat-0.8 Na-139 K-4.7 Cl-105 HCO3-25 AnGap-9* ___ 06:00AM BLOOD ALT-30 AST-29 AlkPhos-43 TotBili-<0.2 ___ 04:00PM BLOOD cTropnT-<0.01 ___ 05:47AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.0 INTERVAL LABS/MICROBIOLOGY/REPORTS ================================== MR CERVICAL SPINE W/O CONTRAST Study Date of ___ 1. Limited evaluation of epidural abscess in the absence of intravenous contrast and motion. 2. Postsurgical changes related to patient's known T2 through T5 neck knees and epidural abscess effect aeration. 3. Within limits of study, no definite evidence of patient's previously noted epidural abscess. 4. Subcentimeter nonspecific cervical lymph nodes as described, which may be reactive. 5. Grossly stable multilevel cervical, thoracic, and lumbar spine spondylosis compared to ___ prior full spine MRI evidence of moderate or severe vertebral canal or neural foraminal narrowing. 6. Grossly stable probable epidural lipomatosis as described. 7. Grossly stable chronic L3 anterior compression fracture, as described. 8. Incompletely characterized left renal punctate at least partially cystic structure, as described. CTA CHEST Study Date of ___ 1. No evidence of acute aortic abnormality. 2. Evaluation for pulmonary emboli limited by extensive respiratory motion artifact. Within this limitation, no pulmonary embolism to segmental levels. CT HEAD W/O CONTRAST Study Date of ___ 1. No acute intracranial abnormality on noncontrast CT head. Specifically no acute large territory infarct or intracranial hemorrhage. 2. Mild age advanced global atrophy. MRI ___ IMPRESSION: 1. Motion limited exam. 2. S/p laminectomies from T2 through T5. No evidence for recurrent epidural collection in the cervical, thoracic, or lumbar spine. No evidence for diskitis or osteomyelitis. 3. Unchanged multilevel degenerative disease in the cervical, thoracic, and lumbar spine, as well as thoracic dorsal epidural lipomatosis, as detailed above. 4. Splenomegaly is again partially imaged. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Docusate Sodium 100 mg PO BID 3. Fenofibrate 160 mg PO DAILY 4. Polyethylene Glycol 17 g PO DAILY 5. Senna 8.6 mg PO BID 6. Gabapentin 1800 mg PO QHS 7. basaglar 45 Units Breakfast basaglar 45 Units Bedtime 8. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral DAILY 9. NovoLOG U-100 Insulin aspart (insulin aspart U-100) 100 unit/mL subcutaneous per sliding scale 10. MetFORMIN XR (Glucophage XR) 1000 mg PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H RX *acetaminophen [Acetaminophen Extra Strength] 500 mg ___ tablet(s) by mouth every eight (8) hours Disp #*30 Tablet Refills:*0 2. Lidocaine 5% Patch 1 PTCH TD QAM RX *lidocaine [Lidocaine Pain Relief] 4 % Place 1 Patch once a day Disp #*30 Patch Refills:*0 3. Naproxen 500 mg PO Q12H:PRN Pain - Moderate RX *naproxen 250 mg ___ tablet(s) by mouth twice daily as needed Disp #*30 Tablet Refills:*0 4. Nortriptyline 25 mg PO QHS RX *nortriptyline 25 mg 1 capsule(s) by mouth every night Disp #*30 Capsule Refills:*0 5. Gabapentin 1200 mg PO BID RX *gabapentin 600 mg 2 tablet(s) by mouth twice a day Disp #*120 Tablet Refills:*0 6. Glargine 60 Units Breakfast Glargine 60 Units Bedtime Insulin SC Sliding Scale using Novolog Insulin RX *insulin glargine [Basaglar KwikPen U-100 Insulin] 100 unit/mL (3 mL) ___efore breakfast and before bed Disp #*3 Syringe Refills:*0 7. Aspirin 81 mg PO DAILY 8. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral DAILY 9. Docusate Sodium 100 mg PO BID 10. Fenofibrate 160 mg PO DAILY 11. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 12. NovoLOG U-100 Insulin aspart (insulin aspart U-100) 100 unit/mL subcutaneous per sliding scale 13. Polyethylene Glycol 17 g PO DAILY 14. Senna 8.6 mg PO BID Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES ================== Acute on chronic back pain Chronic Pancreatitis SECONDARY DIAGNOSES ===================== Type II Diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: MR CODE CORD COMPRESSION PT27 MR SPINE INDICATION: ___ with h/o type 2 diabetes, chronic pancreatitis, GBS bacteremia and epidural abscess status post T2 through T5 laminectomy on ___, here with back pain and left arm/ right leg defiicts TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique. Axial T2 imaging was performed. Axial GRE images of the cervical spine were performed. COMPARISON: MRI cervical, thoracic, lumbar spine without contrast dated ___. ___ cervical and thoracic spine x-ray. ___ torso CT. FINDINGS: Study is limited due to patient refusal of administration of intravenous contrast and motion. CERVICAL: Vertebral body alignment is preserved.Vertebral body heights are preserved. There is no definite focal marrow signal abnormality.The visualized portion of the spinal cord is grossly preserved in signal and caliber. There is loss of intervertebral disc signal throughout the cervical spine. Intervertebral disc heights are grossly preserved. At C4-5 there is disc bulge, facet joint hypertrophy, ligamentum flavum thickening, with mild vertebral canal and mild bilateral neural foraminal narrowing. At C5-6 there is disc bulge, ligamentum flavum thickening, with mild vertebral canal and no neural foraminal narrowing. At C6-7 there is disc bulge, ligamentum flavum thickening, with mild vertebral canal and no neural foraminal narrowing. Otherwise, there is no definite evidence of moderate or severe vertebral canal or neural foraminal narrowing of cervical spine. THORACIC: Vertebral body alignment is grossly preserved. Vertebral body heights are preserved. T5 vertebral body probable hemangioma is noted. With Schmorl's nodes are seen throughout the thoracic spine. Postsurgical changes related to interval T2 through T5 laminectomies are noted. The visualized portion of the spinal cord is grossly preserved in signal and caliber. Intervertebral discheightsandsignalare grossly preserved. There is redemonstration of a dorsal lateral T1 and T2 hyperintense STIR hypointense epidural collection extending from T5-T9, causing mild spinal canal narrowing without definite evidence of cord compression, again suggestive epidural fat. The previously seen collection at the T2-T5 level is not seen on the current exam. Otherwise, there is no definite evidence of moderate or severe thoracic spine or vertebral canal narrowing. LUMBAR: There is minimal dextroscoliosis of the lumbar spine. Grossly stable chronic L3 approximately 15% anterior compression deformities again seen. Schmorl's nodes are again seen at multiple levels throughout the lumbar spine. L2 and L5 probable hemangiomas are noted. Probable transitional anatomy with partial sacralization of L5 is again noted. At T12-L1 there is disc bulge, epidural fat, facet joint hypertrophy, vertebral canal and no neural foraminal narrowing. L1-2 there is disc bulge, epidural fat, ligamentum flavum thickening, with mild vertebral canal and no neural foraminal narrowing. At L2-3 there is disc bulge, epidural fat, ligamentum flavum thickening, facet joint hypertrophy, with mild vertebral canal and no neural foraminal narrowing. At L3-4 there is loss, facet joint hypertrophy, ligamentum flavum thickening, epidural fat, vertebral canal and mild right neural foraminal narrowing. At L4-5 there is ligamentum flavum thickening, epidural fat, facet joint hypertrophy, no canal and no neural foraminal narrowing. At L5-S1 there is disc bulge, facet joint hypertrophy, ligamentum flavum thickening, with mild vertebral canal and mild bilateral neural foraminal narrowing. OTHER: Within the limits of this noncontrast study there is no paravertebral or paraspinal mass identified. Nonspecific approximately 9 mm right level 2A probable lymph node is seen (see 11:7). Additional nonspecific bilateral level 5 subcentimeter lymph nodes are seen (see 11: ___. Limited imaging of the abdomen again suggests probable in the left upper quadrant (see 12:23 on ___ prior MRI and 13:23 on current study and 05:55 on ___ torso CT). Limited imaging kidneys again suggests left renal probable parapelvic cyst (see 14:8 on current study and 5:67 on ___ prior torso CT). Additional punctate left renal approximately 1 mm T2 hyperintense lesion is seen, incompletely characterized, and may correspond to punctate left renal hypodensity seen on prior torso CT (see 14:11 on current study and 5:70 on ___ prior torso CT). Nonspecific probable dependent edema is noted in the dorsal lumbar soft tissues. IMPRESSION: 1. Limited evaluation of epidural abscess in the absence of intravenous contrast and motion. 2. Postsurgical changes related to patient's known T2 through T5 neck knees and epidural abscess effect aeration. 3. Within limits of study, no definite evidence of patient's previously noted epidural abscess. 4. Subcentimeter nonspecific cervical lymph nodes as described, which may be reactive. 5. Grossly stable multilevel cervical, thoracic, and lumbar spine spondylosis compared to ___ prior full spine MRI evidence of moderate or severe vertebral canal or neural foraminal narrowing. 6. Grossly stable probable epidural lipomatosis as described. 7. Grossly stable chronic L3 anterior compression fracture, as described. 8. Incompletely characterized left renal punctate at least partially cystic structure, as described. NOTIFICATION: Findings discussed with ___, MD by ___, MD via telephone at 04:03 on ___. Radiology Report EXAMINATION: CTA CHEST WITH CONTRAST INDICATION: ___ year old woman with strange constellation of symptoms: 2 days of severe chest pain radiating into the back, L arm numbness and R hip flexor weakness.// Rule out dissection or other cause of chest pain 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, 31.7 cm; CTDIvol = 14.8 mGy (Body) DLP = 467.2 mGy-cm. 2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7 mGy-cm. 3) Stationary Acquisition 1.2 s, 0.5 cm; CTDIvol = 6.6 mGy (Body) DLP = 3.3 mGy-cm. Total DLP (Body) = 472 mGy-cm. COMPARISON: Chest CT ___ FINDINGS: HEART AND VASCULATURE: Exam is moderately limited by extensive respiratory motion artifact. Within this limitation, no pulmonary embolism to segmental levels. 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. No mediastinal mass. PLEURAL SPACES: No pleural effusion or pneumothorax. LUNGS/AIRWAYS: Lungs are clear without masses or areas of parenchymal opacification. The airways are patent to the level of the segmental bronchi bilaterally. 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 acute aortic abnormality. 2. Evaluation for pulmonary emboli limited by extensive respiratory motion artifact. Within this limitation, no pulmonary embolism to segmental levels. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman with strange constellation of symptoms: 2 days of severe chest pain radiating into the back, L arm numbness and R hip flexor weakness.// Rule out stroke TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 747.3 mGy-cm. Total DLP (Head) = 747 mGy-cm. COMPARISON: None. FINDINGS: There is no evidence of acute large territory infarction,hemorrhage,edema, or mass. There is mild age advanced global atrophy. There is no evidence of fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. Chronic fatty replacement of the parotid glands. IMPRESSION: 1. No acute intracranial abnormality on noncontrast CT head. Specifically no acute large territory infarct or intracranial hemorrhage. 2. Mild age advanced global atrophy. Radiology Report INDICATION: ___ with h/o T2DM c/b neuropathy and gastroparesis, chronic pancreatitis, remote cholecystectomy, w RUQ and chest pain getting opioids and no BM x4days, reports no gas x 3 d.// Eval for obstruction TECHNIQUE: Supine and upright abdominal radiographs were obtained. COMPARISON: CT abdomen pelvis ___ FINDINGS: There are no abnormally dilated loops of large or small bowel. A mild-to-moderate amount of stool is seen, predominantly in the right and transverse colon. There is no free intraperitoneal air. Osseous structures are unremarkable. Cholecystectomy clips overlie the right upper quadrant. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: Nonobstructive bowel gas pattern with mild to moderate colonic fecal load. Radiology Report EXAMINATION: MRI CERVICAL, THORACIC, AND LUMBAR PT22 MR SPINE INDICATION: ___ year old woman with right leg weakness and arm numbness. Evaluate for epidural abscess. Review of the ___ medical record reveals that the patient history of epidural abscess status post T2-T5 laminectomies in ___, admitted for back pain, chest pain, left arm numbness, right leg weakness. The symptoms are reportedly similar to her prior symptoms in the setting of prior epidural abscess. 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 7 cc Gadavist contrast agent, additional axial and sagittal T1 images were obtained. COMPARISON: Cervical, thoracic, and lumbar spine MRI without contrast from ___. Cervical, thoracic, and lumbar spine MRI without contrast from ___. FINDINGS: Motion artifact slightly limits evaluation. The localizer sequence again demonstrates 7 cervical, 12 rib-bearing, and 5 lumbar-type vertebrae, as well as a partially lumbarized S1, as seen previously. CERVICAL: No evidence for diskitis, osteomyelitis, epidural collection, or paravertebral collection. No evidence for pathologic intrathecal contrast enhancement. No spinal cord signal abnormalities are identified on sagittal T2 weighted allowing for mild motion artifacts; evaluation on axial T2 weighted images is much more limited by motion. The cerebellar tonsils are normally positioned. Visualized posterior fossa appears unremarkable. C2-C3: No significant spinal canal narrowing. Mild left neural foraminal narrowing by facet osteophytes. C3-C4: No significant spinal canal narrowing. Neural foraminal narrowing by left uncovertebral and facet osteophytes appears mild on motion limited evaluation. C4-C5: No significant spinal canal narrowing. Neural foraminal narrowing by uncovertebral and facet osteophytes appears at least mild on the right and at least moderate on the left on motion limited evaluation. C5-C6: No evidence for significant spinal canal narrowing. Neural foraminal narrowing by uncovertebral and facet osteophytes appears at least mild bilaterally on motion limited evaluation. C6-C7: No evidence for significant spinal canal narrowing. Left neural foraminal narrowing by uncovertebral and facet osteophytes appears mild on motion limited evaluation. C7-T1: No evidence for spinal canal or neural foraminal narrowing. THORACIC: S/p laminectomies at T2 through T5. No evidence for recurrent epidural collection. No thecal sac narrowing at the surgical levels. No evidence for rim enhancing collection in the overlying soft tissues. No evidence for pathologic intrathecal contrast enhancement. No evidence for spinal cord signal abnormalities allowing for motion artifact. No evidence for diskitis or osteomyelitis. No prevertebral collection. Unchanged vertebral body heights. Specifically, mild T12 superior endplate deformity with mild loss of height are again noted. Mild anterior wedging of T6 and T7 vertebral bodies are also again noted. A small hemangioma is again seen within the T5 vertebral body. Dorsal epidural lipomatosis is again seen from T5 through T9. At T5-T6, there is a small right paracentral disc protrusion which minimally indents the ventral thecal sac. The ventral surface of the cord is mildly remodeled, but the cord is surrounded by plentiful CSF laterally and posteriorly. These findings are unchanged compared to ___. At T7-T8, there is a right paracentral disc herniation covered by endplate osteophytes, indenting the ventral thecal sac and approaching the right ventral spinal cord without cord compression. There is overall mild narrowing of the thecal sac by the osteophytes and dorsal epidural lipomatosis. No change compared to ___. At T8-T9, there is a right paracentral disc protrusion covered by endplate osteophytes, which in combination with dorsal epidural lipomatosis causes mild narrowing of the thecal sac without mass effect on the spinal cord. No change since the ___ MRI. Mild disc bulges facet arthropathy are again seen at T10-T11, T11-T12, and T12-L1, without significant spinal canal narrowing. LUMBAR: Mild L1 vertebral body loss of height, as well as moderate L3 vertebral body loss of height minimal retropulsion, are unchanged. Multiple hemangiomas are again seen, largest within the L5 vertebral body. No evidence for diskitis, osteomyelitis, epidural collection, or paravertebral collection. No pathologic intrathecal contrast enhancement. The conus medullaris appears unremarkable, terminating at L1, as seen previously. L1-L2: Mild disc bulge and facet arthropathy without significant spinal canal or neural foraminal narrowing. L2-L3: Minimal L3 superior corner retropulsion, mild disc bulge, and mild-to-moderate facet arthropathy. No significant mass effect on the intrathecal nerve roots. Mild narrowing of the subarticular zones without frank compression of the traversing L3 nerve roots. Minimal neural foraminal narrowing without exiting L2 nerve root impingement. L3-L4: Mild disc bulge, larger on the right than left, and moderate facet arthropathy. Mild narrowing of the subarticular zones without frank compression of the traversing L4 nerve roots. No mass effect on the intrathecal nerve roots. Minimal bilateral neural foraminal narrowing without mass effect on the exiting L3 nerve roots. L4-L5: Minimal disc bulge, infolding of the ligamentum flavum, and moderate facet arthropathy. Mild narrowing of the left subarticular zone with contact of the traversing left L5 nerve root, without evidence for frank compression. No mass effect on the intrathecal nerve roots. No significant neural foraminal narrowing. L5-S1: Mild disc bulge with endplate osteophytes and moderate facet arthropathy. Mild right and moderate left neural foraminal narrowing. No significant spinal canal narrowing. The above described degenerative changes are not significantly changed compared to ___. Degenerative changes of the partially imaged sacroiliac joints are again noted. OTHER: Nonenlarged bilateral cervical lymph nodes, and multiple bilateral supraclavicular lymph nodes measuring up to 12 mm on the right (14:20) and 9 mm on the left (14:23) are similar to the cervical spine MRI from ___, nonspecific in etiology. There is a fluid level in the distal thoracic esophagus. Linear opacities in the visualized portions of the lower lobes of the lungs are nonspecific but statistically likely related to atelectasis or scarring. On the localizer sequence image 4:6, the spleen measures 14 cm craniocaudad, compared to 15 cm on the abdominal/pelvic CT from ___. IMPRESSION: 1. Motion limited exam. 2. S/p laminectomies from T2 through T5. No evidence for recurrent epidural collection in the cervical, thoracic, or lumbar spine. No evidence for diskitis or osteomyelitis. 3. Unchanged multilevel degenerative disease in the cervical, thoracic, and lumbar spine, as well as thoracic dorsal epidural lipomatosis, as detailed above. 4. Splenomegaly is again partially imaged. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Chest pain Diagnosed with Chest pain, unspecified, Other dorsalgia, Weakness temperature: 97.8 heartrate: 99.0 resprate: 18.0 o2sat: 99.0 sbp: 157.0 dbp: 74.0 level of pain: 10 level of acuity: 3.0

___ w/ past medical history of T2DM, HTN, HLD, chronic pancreatitis, prior GBS bacteremia c/b T2-T6 epidural abscess s/p decomp/laminectomy in ___ who presented with back pain and symptoms of RLE weakness and LUE numbness. Patient underwent extensive work up and evaluation by neurology and ortho spine teams. MRI did not show any evidence of recurrent epidural abscess. Etiology of her chronic back and abdominal pain are unclear, but likely musculoskeletal pain. TRANSITIONAL ISSUES ==================== [] Patient continues to have chest pain/back pain and would benefit from outpatient pain clinic. Initial appointment has been set up. [] Patient would benefit from social work as outpatient as patient has had multiple stressors. [] Patient continues to have uncontrolled blood sugars. Please refer patient to ___. Insulin was increased to 60 units of glargine BID.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: ___ - ___ Catheter placement ___ - Cardioversion History of Present Illness: ___ year old male with a PMH of HFrEF (Last LVEF 23% ___, LV thrombus, VFib arrest s/p AICD placement (___ ___, AFib/Aflutter s/p cardioversion and ablation (___ ___ who was admitted with shortness of breath and insomnia. Pt had an episode of syncope in ___, presumed from ventricular arrhythmias; he was started on amiodarone for this. Over the past few months, however, he has had progressive development of nausea, insomnia, and paresthesias. These were thought to be secondary to amiodarone, which was discontinued. One week ago, he was seen by the clinic where they found weight gain of 2 lb, an increase in Cr 1.4 (increased from 1.2) and persistent insomnia (told to decrease torsemide from 20 to 10mg daily). He presented in ___ 2 days ago refering worsening in his SOB especially when coughing and insomnia. On the floor, Pt was initially managed for CHF exacerbation with IV furosemide, hydralazine, and a nitroglycerin drip. As he continued to be cold and clammy, with a rise in lactate (to a peak of 5) and persistent fatigue, he underwent a RHC which showed CI 1.7, wedge pressure in the 30___, and a RAP of 20. Given his persistent evidence of volume overload, Pt was transferred to the CCU for initiation of nitroprusside gtt and continued tailored therapy with furosemide gtt. Vitals on transfer: T 99.9F BP 114/84 HR 90 RR 17 O2 98% on RA On arrival to the CCU, Pt states that he is persistently fatigued. He has pain at his ___ catheter insertion site. He notes persistent lightheadedness and nausea with hiccupping. He denies fevers, chills, CP, SOB, orthopnea, abdominal pain, and vomiting. Past Medical History: 1. CARDIAC RISK FACTORS - Cocaine abuse, in remission - Alcohol abuse, in remission 2. CARDIAC HISTORY - Coronaries: No recent cath on file - Pump: HFrEF (last LVEF 23%) with a previous LV thrombus - Rhythm: Aflutter s/p ablation (___ ___ 3. OTHER PAST MEDICAL HISTORY - Depression - Asthma Social History: ___ Family History: Parents passed away of unknown reasons. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: ON ADMISSION: VS: T 99.9F BP 114/84 HR 90 RR 17 O2 98% on RA GENERAL: Heavyset ___ male, sitting up in bed with R Swan catheter in place. Alert and oriented x3. Speaking somewhat slowly but fluently. HEENT: Sclerae anicteric. MMM. NECK: Difficult to assess JVP due to habitus. CARDIAC: Tachycardic with irregular rhythm, normal S1/S2. No M/R/G. LUNGS: Lungs CTAB. ABDOMEN: Hypoactive bowel sounds. Abdomen is soft, somewhat distended, non-tender to palpation throughout. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant skin lesions or rashes. PULSES: Radial pulses palpable and symmetric. ON DISCHARGE: Afebrile, 98.5 79-114/50-71 ___ 18 97-98% I/O: ___ telemetry: no events NSR Weight: 96.3 admit --> 87.6--> 85.5 -> 87.7 -> 88.1 -> 87.8 GEN: ___ male, lying in bed. Alert and oriented x3. NECK: JVP no seen at 45 degrees CARDIAC: Regular rhythm, normal S1/S2. No M/R/G. LUNGS: Lungs CTAB. ABDOMEN: Abdomen is soft, somewhat distended, non-tender to palpation throughout. EXTREMITIES: Warm, well perfused proximally. No clubbing, cyanosis, or peripheral edema. Pertinent Results: ADMISSION LABS ================= ___ 02:15PM GLUCOSE-106* UREA N-18 CREAT-1.4* SODIUM-131* POTASSIUM-3.9 CHLORIDE-94* TOTAL CO2-23 ANION GAP-18 ___ 02:15PM ALT(SGPT)-142* AST(SGOT)-102* ALK PHOS-141* TOT BILI-3.0* DIR BILI-0.9* INDIR BIL-2.1 ___ 02:15PM cTropnT-<0.01 ___ 02:15PM proBNP-8655* ___ 02:15PM ALBUMIN-3.6 CALCIUM-8.8 PHOSPHATE-4.2 MAGNESIUM-2.1 ___ 02:15PM WBC-5.2 RBC-3.66* HGB-11.2* HCT-34.2* MCV-93 MCH-30.6 MCHC-32.7 RDW-15.0 RDWSD-51.7* ___ 02:15PM NEUTS-65.2 ___ MONOS-12.3 EOS-0.6* BASOS-0.2 IM ___ AbsNeut-3.41 AbsLymp-1.12* AbsMono-0.64 AbsEos-0.03* AbsBaso-0.01 ___ 02:15PM PLT COUNT-167 ___ 02:10PM URINE HOURS-RANDOM ___ 02:10PM URINE UHOLD-HOLD ___ 02:10PM URINE COLOR-Yellow APPEAR-Hazy* SP ___ ___ 02:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-6.0 LEUK-NEG ___ 02:10PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-0 ___ 02:10PM URINE HYALINE-54* ___ 02:10PM URINE MUCOUS-RARE* Cardiac Cath ___ Elevated biventricular filling pressures with cardiogenic shock CXR ___ Cardiomegaly without superimposed acute cardiopulmonary process. RUQUS ___. The liver is mildly echogenic diffusely, likely steatosis. 2. Distension of the IVC and hepatic veins likely due to cardiac disease. 3. Multiple hepatic cysts, the largest measuring 2.2 cm in the right hepatic lobe. Radiology Report INDICATION: ___ with a fib and chest pain// Chest pain TECHNIQUE: Single portable view of the chest. COMPARISON: Chest x-ray from ___. FINDINGS: Heart is moderately enlarged. Left chest wall single lead pacing device is noted. Nodular opacity projecting over left lung base described on prior is not as well seen on today's exam. Bibasilar atelectasis is noted. No acute osseous abnormalities. IMPRESSION: Cardiomegaly without superimposed acute cardiopulmonary process. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with swan// swan placement and pulm edema TECHNIQUE: Chest, single AP portable view. COMPARISON: Chest x-rays from 6 ___, ___, and ___. FINDINGS: A right IJ ___-___ catheter is present. The tip overlies the proximal right pulmonary artery. No pneumothorax detected. Left-sided pacemaker is present, with lead tip overlying the right ventricle. There is moderate to moderately severe cardiomegaly,, unchanged. There is upper zone redistribution, without other evidence of CHF. Hazy increased retrocardiac density likely reflects atelectasis. Minimal subsegmental atelectasis is also seen in the right mid and lower zones. No gross effusion. No pneumothorax detected. Again seen is a nodular density lying lateral to the left heart border. On some views, the appearance is suggestive of a nipple shadow. IMPRESSION: Moderate cardiomegaly and bibasilar atelectasis. Pacemaker lead overlying the right ventricle. ___ catheter tip overlying proximal right pulmonary artery. Upper zone redistribution. Doubt other evidence of CHF. Nodular density in left lower lung laterally again noted, possibly a nipple shadow, as questioned on the previous film. However, repeat frontal, lateral and shallow oblique chest x-ray views with nipple markers is recommended for confirmation. This can be obtained as a non urgent study. RECOMMENDATION(S): Frontal, lateral, and shallow oblique chest x-ray views with nipple markers is recommended for more complete characterization of the nodular density in the left lower lung laterally. This can be obtained as a non urgent study, when the patient is stable. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with CHF exacerbation, Swan in place// Interval change in pulm edema, effusions. Swan placement TECHNIQUE: Chest, single AP portable view COMPARISON: Chest x-ray from ___, and ___. FINDINGS: The cardiomediastinal silhouette is unchanged. Again seen is moderately severe to severe chronic cardiomegaly. A left-sided single lead pacemaker is present, with tip over right ventricle, similar to prior. A right IJ Swan-Ganz catheter tip overlies the pulmonary outflow tract near the main pulmonary artery. No pneumothorax is detected. There is mild upper zone redistribution and engorgement of hilar vessels, but doubt other evidence of CHF. Vascular engorgement is similar, possibly minimally improved compared with ___. Probable mild atelectasis in the retrocardiac region, unchanged. Otherwise, no focal infiltrate/consolidation no effusion. Again seen is a nodular density in the left lung laterally, adjacent to the left heart border. Please see report of ___ chest x-ray for recommendations for additional assessment. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year old man with transaminitis// Patient with swan and drips cannot go off of the floor. LFT's trending in different direction compared to CHF. TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: Abdominal ultrasound from ___ FINDINGS: LIVER: The liver is diffusely echogenic. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. There are multiple anechoic cysts seen throughout the liver, the largest measuring up to 2.2 cm in the right hepatic lobe. There is enlargement of the IVC and hepatic veins. 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 8.0 cm. KIDNEYS: Limited views of the right kidney show no hydronephrosis. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. The liver is mildly echogenic diffusely, likely steatosis. 2. Distension of the IVC and hepatic veins likely due to cardiac disease. 3. Multiple hepatic cysts, the largest measuring 2.2 cm in the right hepatic lobe. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Cough, Weakness Diagnosed with Heart failure, unspecified temperature: 97.3 heartrate: 63.0 resprate: 18.0 o2sat: 96.0 sbp: 101.0 dbp: 74.0 level of pain: 0 level of acuity: 3.0

Mr. ___ is a ___ year old male with a PMH of HFrEF (Last LVEF 23% ___, LV thrombus, VFib arrest s/p AICD placement (___ ___, AFib/Aflutter s/p cardioversion and ablation (___ ___ was admitted for insomnia as a potential side effect of amiodarone use. On admission he was noted to be wet and cold. RHC showed cardiac index of 1.7 and his lactate was elevated to 5. He was transferred to the CCU for Swan directed diuresis and IV afterload reducing agents. In the CCU, he underwent successful DCCV of his atrial fibrillation to sinus rhythm. He was started on digoxin and torsemide 40 twice daily. The patient was started on Spironolactone, imdur and hydralazine. He was kept on his apixaban and lisinopril. After stabilization in the ICCU the patient was transferred to the ward where he was further diuresed with P.O. diuretics. Diuretics were eventually held as the patient was dry and had some episodes of hypotension. The patient was started on low-dose of metoprolol to be uptitrated as an outpatient. We re-emphasized that because the patient had an electrical shock from your ICD in ___, he should avoid driving and/or operating heavy machinery for a period up to 6 months due to increase risk of harm to yourself and/or others. On the day of discharge the patient was in sinus rhythm was dry and warm with no signs of congestion. # Discharge weight: 87.9 kg.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / clindamycin / doxycycline Attending: ___. Chief Complaint: syncope Major Surgical or Invasive Procedure: None History of Present Illness: ___ with a background history of type II DM, HTN, hyperparathyroidism status post exploration and parathyroidectomy, breast cancer status post surgical, radiotherapy and hormonal treatment, and osteoporosis, presenting as a transfer from ___ following an episode of syncope at home, and two further witnessed episodes, one in the ambulance on route to ___, and one while in ___. Patient was in her normal state of health when she awoke this morning. When stepping out of shower, had a sudden loss of consciousness, with no warning symptoms, except for some mild light-headedness. Denied chest pain, shortness of breath, nausea/vomiting, visual changes, and headache. Fell to the ground, landing on her right hip and arm. Denied tongue biting and incontinence, but unable to comment on limb jerking as no one witnessed episode. Unclear duration of loss of consciousness. Feels she may have struck her head as awoke on the ground, and did report low back and right hip pain upon waking. Reported "fogginess" and headache post event, with difficulty recalling events. Spoke with daughter (RN) and PCP, who recommended presenting to ED. On route to ___, had a second syncopal episode while seated in the car, during a sudden turn. Again, denies warning symptoms, except for some "wooziness" prior to syncopal episode. Husband reports episode lasted ___ secs, with eyes open and staring up and to the left throughout. ___ have had some twitching of left sided extremities, but no definitive jerking. At ___, patient had a third syncopal episode as she was being transferred from the stretcher to the CT scanner. Unclear duration of event. At ___, she underwent a complete trauma work-up, including imaging of the hip, head and C-spine, all of which were negative for traumatic injury. The patient was transferred to ___ for further syncope workup, given concern for arrhythmia as a likely cause for these events. Past Medical History: 1. Type II DM 2. HTN 3. Previous TIA vs. migraine 4. Anxiety 5. Osteoporosis 6. Hyperparathyroidism status post neck exploration and parathyroidectomy 7. Herpes gingivostomatitis 8. GERD 9. Breast cancer status post lumpectomy and left axillary lymphadenectomy (___), radiotherapy (___) and now on hormonal treatment Social History: ___ Family History: Father with MI at ___ years old. Mother and maternal aunt with a history of breast cancer. Maternal grandmother with a history of ovarian cancer. Physical Exam: ADMISSION EXAM ============================ VS: Temp 98.3 BP 143/84 HR 63 RR 18 SaO2 96% RA GENERAL: sitting comfortably in bed, no apparent distress HEENT: AT/NC, EOMI, PERRLA, no conjucntival pallor, anicteric sclera, MMM NECK: supple, non-tender, no LAD, no JVD CV: RRR, S1 and S2 normal, no murmurs/rubs/gallops RESP: CTAB, no wheeze/crackles, breathing comfortably without use of accessory muscles of respiration ___: soft, non-tender, no distention, BS normoactive EXTREMITIES: moving all four extremities with purpose, no lower extremity edema or cyanosis SKIN: no rashes/lesions NEURO: A/O x3, CN II-XII intact, strength ___ in all extremities, sensation intact DISCHARGE EXAM ============================ Vitals: Temp: 98.0 PO HR: 59 BP: 130/79 RR: 18 O2 sat: 98% O2 delivery: Ra General: Well appearing woman in no acute distress. Comfortable. AAOx3. Neuro: CNII-XII grossly intact. Speech normal. Strength ___ and equal in upper and lower extremities bilaterally. Sensation grossly intact. HEENT: Normocephalic, atraumatic. EOMI. MMM. Cardiac: Regular rate & rhythm. Normal S1/S2. No murmurs, rubs, or gallops. Pulmonary: Clear to auscultation bilaterally. Breathing comfortably on room air. Abdomen: Soft, non-tender, non-distended. Extremities: Warm, well perfused, non-edematous. Pertinent Results: ADMISSION LABS ========================== ___ 06:45AM BLOOD WBC-5.2 RBC-3.96 Hgb-11.8 Hct-36.1 MCV-91 MCH-29.8 MCHC-32.7 RDW-12.9 RDWSD-42.3 Plt ___ ___ 06:45AM BLOOD Plt ___ ___ 06:45AM BLOOD Glucose-125* UreaN-10 Creat-0.5 Na-142 K-4.4 Cl-104 HCO3-24 AnGap-14 ___ 02:40PM BLOOD K-4.4 ___ 02:40PM BLOOD cTropnT-<0.01 ___ 02:40PM BLOOD Calcium-8.4 Phos-3.3 Mg-1.5* DISCHARGE LABS ========================== ___ 06:35AM BLOOD WBC-4.9 RBC-3.96 Hgb-11.8 Hct-36.3 MCV-92 MCH-29.8 MCHC-32.5 RDW-12.7 RDWSD-42.7 Plt ___ ___ 06:35AM BLOOD Plt ___ ___ 06:35AM BLOOD Glucose-125* UreaN-10 Creat-0.5 Na-143 K-4.6 Cl-105 HCO3-22 AnGap-16 ___ 06:35AM BLOOD Calcium-8.6 Phos-2.5* Mg-2.3 PERTINENT STUDIES ========================= X-RAY HAND/WRIST (___) No acute fracture or dislocation. TTE (___) IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved regional/global systolic function. Mild mitral regurgitation. MRI HEAD (___) 1. No evidence for acute intracranial hemorrhage or infarction. No abnormal enhancement to suggest intracranial metastatic disease. 2. Evidence of chronic small vessel ischemic disease. CTA HEAD/NECK (___) 1. No acute intracranial abnormality on noncontrast head CT. Specifically no large territory infarct or intracranial hemorrhage. 2. Mild narrowing of the distal segment of the right vertebral artery. Otherwise, the carotid and vertebral arteries, and their principal intracranial branches are unremarkable, without evidence of high-grade stenosis or occlusion. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Anastrozole 1 mg PO DAILY 2. Citalopram 20 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Vitamin D ___ UNIT PO DAILY 5. Lisinopril 10 mg PO DAILY 6. MetFORMIN (Glucophage) 500 mg PO QPM 7. Multivitamins 1 TAB PO DAILY 8. Omeprazole 20 mg PO EVERY OTHER DAY 9. Montelukast 10 mg PO DAILY 10. Calcium Carbonate 500 mg PO DAILY Discharge Medications: 1. Anastrozole 1 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Calcium Carbonate 500 mg PO DAILY 4. Citalopram 20 mg PO DAILY 5. MetFORMIN (Glucophage) 500 mg PO QPM 6. Montelukast 10 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Omeprazole 20 mg PO EVERY OTHER DAY 9. Vitamin D ___ UNIT PO DAILY 10. HELD- Lisinopril 10 mg PO DAILY This medication was held. Do not restart Lisinopril until your primary care physician tells you to start it again. Discharge Disposition: Home Discharge Diagnosis: Primary: ============ Syncope Secondary: ============ Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with pain and swelling after fall//r/o fracture COMPARISON: None FINDINGS: AP, lateral, oblique views of the right hand, right wrist and a dedicated navicular view provided. The distal radius and ulna are intact. The carpals align anatomically. The scaphoid appears intact. The bones of the right hand appear intact. No significant DJD. Soft tissues appear grossly unremarkable. IMPRESSION: No acute fracture or dislocation. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST INDICATION: ___ with hx breast cancer with multiple syncopal episodes concerning for seizure// mass or other cause for possibly new onset seizures? TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of Gadavist intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: CT head ___ FINDINGS: There is no evidence of acute infarction. No intracranial hemorrhage. No mass, mass effect, edema or midline shift. There is no abnormal enhancement. The dural venous sinuses appear patent. The ventricles and sulci are normal, without evidence of hydrocephalus. Periventricular and subcortical white matter FLAIR hyperintensities are noted, a nonspecific finding that most likely represents the sequelae of chronic small vessel ischemic disease. There is gross preservation of the principal intracranial vascular flow voids. Mild mucosal thickening is seen in scattered ethmoid air cells. The remainder of the visualized paranasal sinuses, middle ear cavities, and mastoid air cells are well aerated and clear. The orbits are within normal limits bilaterally. IMPRESSION: 1. No evidence for acute intracranial hemorrhage or infarction. No abnormal enhancement to suggest intracranial metastatic disease. 2. Evidence of chronic small vessel ischemic disease. Radiology Report EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK INDICATION: ___ woman with unclear cause for new syncope. Please evaluate for vascular abnormalities to explain 3 syncopal episodes. 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 75 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 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 747.5 mGy-cm. 2) Spiral Acquisition 4.5 s, 35.8 cm; CTDIvol = 13.3 mGy (Body) DLP = 474.8 mGy-cm. 3) Stationary Acquisition 4.6 s, 0.5 cm; CTDIvol = 27.1 mGy (Body) DLP = 13.5 mGy-cm. Total DLP (Body) = 488 mGy-cm. Total DLP (Head) = 748 mGy-cm. COMPARISON: CT of the head and neck from ___. Head MR from ___. FINDINGS: CT HEAD WITHOUT CONTRAST: There is no evidence of acute large territory infarction, intracranial hemorrhage, edema, or mass effect. Very minimal nonspecific white matter hypodensities probably represent sequela of chronic small vessel disease. There is prominence of the ventricles and sulci, probably related involutional changes. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. CTA HEAD: The vessels of the circle of ___ and their principal intracranial branches appear normal without stenosis, occlusion, or aneurysm formation. The dural venous sinuses are patent. CTA NECK: Suboptimal visualization at the level of C2 due to artifact from dental fillings. Within this limitation, the distal segment of the right vertebral artery appears slightly narrowed. Otherwise, the carotid and vertebral arteries and their major branches appear unremarkable. There is no evidence of internal carotid artery stenosis by NASCET criteria. OTHER: The visualized portion of the lungs demonstrate bilateral atelectasis. The thyroid gland is slightly inhomogeneous and several small nodules are noted, not meeting ACR guidelines for follow-up. There is no lymphadenopathy by CT size criteria. Multilevel degenerative changes in the cervical spine. IMPRESSION: 1. No acute intracranial abnormality on noncontrast head CT. Specifically no large territory infarct or intracranial hemorrhage. 2. Mild narrowing of the distal segment of the right vertebral artery. Otherwise, the carotid and vertebral arteries, and their principal intracranial branches are unremarkable, without evidence of high-grade stenosis or occlusion. Gender: F Race: WHITE - OTHER EUROPEAN Arrive by AMBULANCE Chief complaint: Syncope Diagnosed with Syncope and collapse temperature: 98.4 heartrate: 66.0 resprate: 18.0 o2sat: 96.0 sbp: 139.0 dbp: 76.0 level of pain: 2 level of acuity: 2.0

___ woman with PMHx notable for type II diabetes, hypertension, hyperparathyroidism s/p exploration and parathyroidectomy, breast cancer s/p surgical, radiotherapy, and hormonal treatment, and osteoporosis presented for syncope x3 episodes over course of 1 day. Primarily concerning for arrhythmia event, however symptoms did not recur and no findings captured on continuous telemetry. Patient underwent additional extensive neurological workup as detailed below. Given resolution of symptoms and unremarkable workup, was discharged home with plan for long term cardiac monitor and EP follow up. Patient advised to not drive for at least 6 months. # SYNCOPE / FALL Referred from ___ following three episodes of syncope that occurred over course of a single day. First with associated fall and head strike without significant injury. Reported onset of unusual feeling coming over her body, then sudden loss of consciousness lasting on order of seconds to minute. Initially un-witnessed, later seen by her husband and hospital staff (in CT scanner during third episode) to have loss of tone but without any significant tonic-clonic motions. No tongue biting or incontinence. Overall clinical presentation most concerning for arrhythmia, however no episodes captured on cardiac monitoring. Episodes did not recur while at ___. Workup notable for EKG with T-wave inversions in V1 and V3 and 1mm ST-depressions in anterior leads, though not necessarily related and unclear if new. No chest pain and negative troponins. Initial CT head and C-spine without acute process. MRI brain only with chronic small vessel changes, no mass lesions. CTA head and neck prelim read without vascular cause identified. Continuous EEG monitoring x24h without epileptiform findings. Carotid sinus massage produced mild "woozy" feeling though did not re-produce episodes or have associated telemetry findings. TTE with mild concentric LVH though otherwise reassuring. Lyme titer sent at outside hospital was negative. Of note, patient was normotensive off of home antihypertensive (lisinopril), so concern for possible hypotensive episodes. Given that no definitive cause was identified patient was discharged with plan for long term cardiac event monitor which will be mailed to her home. Also scheduled to follow up with outpatient cardiology for further management. # DIABETES - held metformin during hospitalization only, used insulin sliding scale # ANXIETY - continued citalopram # HTN - HELD lisinopril as patient remained normotensive throughout hospitalization # OSTEOPOROSIS - continue calcium and vitamin D # GERD - continue omeprazole every other day TRANSITIONAL ISSUES ================================= [ ] Cardiac monitoring to be completed as outpatient. Per cardiology event monitor will be mailed to her home. [ ] HELD lisinopril at time of discharge, given normotensive throughout hospital stay, and possible contribution. Please re-check BP and assess need for re-treatment. [ ] Patient was directed to not drive for at least 6 months. Please re-affirm this at time of follow up. #CONTACT: ___ (husband: ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Erythromycin Base / Nsaids / lisinopril / Lipitor / carvedilol / tramadol / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year-old woman with CAD s/p PCI, HFrEF, AF on Coumadin, ESRD on HD, Depression, HTN, HLD, Lupus who presented with dizziness and hypotension, being admitted to the ___ for low-dose pressor requirement. 2 weeks ago, she feel while at a relative's home and was found to have a L shoulder fracture and R shoulder dislocation for which she was given oxycodone. Since starting the oxycodone, she has had constant lightheadedness and dizziness with nausea and subsequent very poor oral intake. She went to HD today and prior to the session was noted to have SBP in the ___ and was noted to be febrile (temperature unclear). She was given 600c IV and referred to the ED without getting her HD session. In the ED, - Initial Vitals: T 99.7, HR 118, BP 90/46, RR 22, O2 96%2L - Exam: Comfortable, normal level of alertness, JVP flat. Rectal exam with guaiac negative brown stool. ___ warm, well-perfused. - Labs: Notable for WBC 10.6, INR 3.4, Flu neg. - Imaging: CXR unremarkable, bedside US with moderately decreased EF and nl RV - Consults: None - Interventions: Vancomycin 1g, Cefepime 1g, Hydrocortisone 100mg, NS 1L, Levophed 0.1 mcg/kg/min On arrival to the ___, she reports that she feels a bit better from earlier. She is no longer dizzy. Denies any difficulty breathing. She denies any recent cough, difficulty breathing, chest pain, abdominal pain, vomiting, congestion, headache. She had 2 days of unformed stools ___, but after stopping bowel regimen has had normal BMs. She does not make any urine. No sick contacts. ROS: Positives as per HPI; otherwise negative. Past Medical History: - SLE c/b lupus nephritis (s/p renal transplant ___ c/b failure now on HD - HFrEF ___ ischemic cardiomyopathy - CAD s/p NSTEMI with pLAD occlusion, s/p BMS ___, DES to pRCA ___ - HTN - Pericarditis with pericardial effusion - Atrial Flutter - TIA ___ - Rheumatic Fever as a child - Gout - Sleep apnea, on CPAP - Depression - Osteoporosis Social History: ___ Family History: - Former ___, lives with husband & ___ year-old daughter. Not working but prior to her fall was able to do all her ADLs (laundry, cooking, cleaning). Had 1 glass of wine when on the ___ but very infrequent EtOH intake. Physical Exam: ADMISSION PHYSICAL EXAM VS: T 99.3, HR 92, BP 102/33, RR 16, O2 95%2L GEN: Well-appearing but weak, lying in bed, AOx3. EYES: PERRL HENNT: NC/AT. MMM. No pharyngeal edema or erythema. CV: NR, RR. Nl S1, S2. No m/r/g. RESP: CTAB. GI: Soft, nontender, nondistended. MSK: No ___ edema. Warm, well-perfused. SKIN: No rashes, macules, skin breaks. NEURO: AOx3. DISCHARGE PHYSICAL EXAM VS: 24 HR Data (last updated ___ @ 334) Temp: 97.9 (Tm 98.9), BP: 102/68 (102-119/68-73), HR: 83 (83-116), RR: 18, O2 sat: 99% (93-99), O2 delivery: CPAP Weight 87.54kg Gen - sitting up in bed, comfortable appearing Eyes - EOMI ENT - OP clear, MMM Heart - RRR no mrg Lungs - CTA bilaterally Abd - soft nontender, normal bowel sounds Ext - L arm in sling, point pain over shoulder joint; Skin - no rashes Vasc - 2+ DP pulses; L fistula c/d/i Neuro - AOx3, moving all extremities; RUE decreased strength of finger and wrist flexion consistent with known ulnar nerve palsy, stable from day prior Psych - appropriate Pertinent Results: ADMISSION ___ 11:35AM BLOOD WBC-10.6* RBC-2.55* Hgb-8.8* Hct-27.9* MCV-109* MCH-34.5* MCHC-31.5* RDW-15.4 RDWSD-61.5* Plt ___ ___ 11:35AM BLOOD ___ PTT-34.7 ___ ___ 11:35AM BLOOD Glucose-103* UreaN-11 Creat-2.5*# Na-135 K-4.2 Cl-93* HCO3-29 AnGap-13 ___ 11:15PM BLOOD ALT-64* AST-98* LD(LDH)-246 AlkPhos-121* TotBili-0.3 DISCHARGE ___ 06:41AM BLOOD WBC-4.6 RBC-2.33* Hgb-8.0* Hct-26.8* MCV-115* MCH-34.3* MCHC-29.9* RDW-15.4 RDWSD-64.9* Plt ___ ___ 06:41AM BLOOD Glucose-84 UreaN-13 Creat-4.0*# Na-143 K-4.5 Cl-102 HCO3-30 AnGap-11 ___ 06:41AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.4 IMAGING: ========== ___ CXR Limited, negative. ___ HUMERUS (AP & LAT) LEFT Comminuted fracture at the level of the left humeral surgical neck with displacement of the greater tuberosity. ___ SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA BILAT Comminuted fracture involving the surgical neck of the left humerus with displacement of the greater tuberosity. The right shoulder is unremarkable. ___ Mild regional left ventricular systolic dysfunction, c/w CAD. Moderate aortic stenosis. Mild aortic and mitral regurgitation. The visually estimated left ventricular ejection fraction is 50%. Compared with the prior TTE (images not available for review) of ___, LV systolic function has improved. ___ CT UP EXT W/O C RIGHT Comminuted fracture of the left proximal humerus with fracture displacement at the surgical neck and greater tuberosity. Findings are compatible with a Neer three part fracture. ___ CT UP EXT W/O C LEFT 1. Regularity superolateral humeral head consistent with ___ deformity likely related to prior anterior shoulder dislocation. There is no current glenohumeral joint dislocation. 2. High-grade tear of the supraspinatus tendon tendon retraction and calcification within the free edge of the tendon likely representing avulsion injury. 3. Mild irregularity of the anterolateral aspect of the humeral head next the bicipital groove, suspicious for subacute fracture. ___ LIVER OR GALLBLADDER US 1. No specific evidence of cirrhosis or portal hypertension. No focal liver lesions or ascites. 2. Biliary sludge within the gallbladder without evidence of cholecystitis. ___ CHEST (PORTABLE AP) In comparison with the study of ___, there is little interval change. Again there are low lung volumes that accentuate the prominence of the cardiac silhouette. No vascular congestion or acute focal pneumonia. The implanted rhythm monitor is again noted within the lower left chest wall. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. acitretin 10 mg oral DAILY 2. Allopurinol ___ mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Calcitriol 0.5 mcg PO 3X/WEEK (___) 5. Calcium Acetate ___ mg PO TID W/MEALS 6. Mirtazapine 15 mg PO QHS 7. PredniSONE 3 mg PO DAILY 8. Prochlorperazine 5 mg PO Q8H:PRN nausea 9. rOPINIRole 2 mg PO QPM 10. Rosuvastatin Calcium 40 mg PO QPM 11. Tacrolimus 0.5 mg PO Q12H 12. Warfarin 3.75-5 mg PO DAILY16 13. Zolpidem Tartrate 5 mg PO QHS 14. Losartan Potassium 12.5 mg PO 4X/WEEK (___) 15. Metoprolol Succinate XL 12.5 mg PO 3X/WEEK (___) 16. B Complex w-Vit C (vit B1 mn-B2-B3-B5-B6-B12-C-FA) ___ mg oral DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Gabapentin 100 mg PO BID 3. Lidocaine 5% Patch 1 PTCH TD QAM 4. Midodrine 5 mg PO TID 5. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every six (6) hours Disp #*6 Tablet Refills:*0 6. Polyethylene Glycol 17 g PO BID 7. Senna 17.2 mg PO BID 8. Warfarin 3 mg PO DAILY16 9. acitretin 10 mg oral DAILY 10. Allopurinol ___ mg PO DAILY 11. Aspirin 81 mg PO DAILY 12. B Complex w-Vit C (vit B1 mn-B2-B3-B5-B6-B12-C-FA) ___ mg oral DAILY 13. Calcitriol 0.5 mcg PO 3X/WEEK (___) 14. Calcium Acetate ___ mg PO TID W/MEALS 15. Mirtazapine 15 mg PO QHS 16. PredniSONE 3 mg PO DAILY 17. Prochlorperazine 5 mg PO Q8H:PRN nausea 18. rOPINIRole 2 mg PO QPM 19. Rosuvastatin Calcium 40 mg PO QPM 20. Tacrolimus 0.5 mg PO Q12H Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: # Adrenal insufficiency # Hypotension # L shoulder fracture # ESRD on HD # Paroxysmal Atrial Flutter # OSA # Depression # Chronic systolic CHF # CAD # Gout # Restless leg syndrome 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: ___ with hypotension, fever// PNA? signs of vol overload? TECHNIQUE: Chest PA and lateral COMPARISON: Multiple prior comparisons, most recent from ___ FINDINGS: Exam is mildly limited due to patient rotation. Implanted rhythm monitor is again noted within the lower left chest wall. Lung volumes are low. Bronchovascular markings are prominent the lower lungs likely due to crowding. No convincing evidence for pneumonia or edema. No large effusion or pneumothorax. Overall cardiomediastinal silhouette is stable allowing for rotation. IMPRESSION: Limited, negative. Radiology Report EXAMINATION: SHOULDER (AP, NEUTRAL AND AXILLARY) TRAUMA BILATERAL INDICATION: ___ year old woman with reported R shoulder dislocation and L humerus fracture// fracture? dislocation? TECHNIQUE: Three views of each shoulder were obtained COMPARISON: ___ FINDINGS: The right shoulder is unremarkable with no acute fracture or significant degenerative change. The left shoulder demonstrates a comminuted fracture involving the surgical neck and displacement of the greater tuberosity. There is no significant impaction or angulation. There is no dislocation. IMPRESSION: Comminuted fracture involving the surgical neck of the left humerus with displacement of the greater tuberosity. The right shoulder is unremarkable. Radiology Report EXAMINATION: HUMERUS (AP AND LAT) LEFT INDICATION: ___ year old woman with reported R shoulder dislocation and L humerus fracture// fracture? TECHNIQUE: Three views of the left humerus were obtained COMPARISON: Radiograph of the left shoulder from earlier today FINDINGS: Re-demonstrated is a comminuted fracture of the left humeral surgical neck with a displaced greater tuberosity. No significant impaction or angulation. No additional fractures are identified. IMPRESSION: Comminuted fracture at the level of the left humeral surgical neck with displacement of the greater tuberosity. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with hypotension// interval change IMPRESSION: In comparison with the study of ___, the cardiomediastinal silhouette is stable a and there is no evidence of vascular congestion, pleural effusion, or acute focal pneumonia. The implanted rhythm monitor is again noted within the lower left chest wall. Radiology Report EXAMINATION: Q51R INDICATION: ___ year old woman ESRD with R shoulder dislocation s/p reduction comminuted L proximal humeral fracture.// Eval shoulders for ortho consideration of surgery TECHNIQUE: Multiple contiguous 2 mm axial images were obtained through the left shoulder without the administration of intravenous contrast. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.3 s, 22.9 cm; CTDIvol = 30.6 mGy (Body) DLP = 679.0 mGy-cm. Total DLP (Body) = 679 mGy-cm. COMPARISON: Compared to radiographs from ___. FINDINGS: There is a comminuted fracture of the left proximal humerus. Fracture lines are seen at the surgical neck with some impaction. There is also displaced fracture at the greater tuberosity. The lesser tuberosity appears intact. Findings are consistent with a Neer three part fracture. The rest of the bony structures are intact. There is no glenohumeral joint dislocation. The supraspinatus remains attached to the greater tuberosity fracture fragment which is displaced medially. AC joint is within normal limits. Visualized lung apex is grossly clear. IMPRESSION: Comminuted fracture of the left proximal humerus with fracture displacement at the surgical neck and greater tuberosity. Findings are compatible with a Neer three part fracture. Radiology Report EXAMINATION: Q51L INDICATION: ___ year old woman s/p fall ___ days ago w/ R shoulder anterior dislocation s/p reduction; L shoulder comminuted humeral fracture.// Eval for fracture. TECHNIQUE: Multiple contiguous 2 mm axial images were obtained through the right shoulder without the administration intravenous contrast. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.8 s, 24.9 cm; CTDIvol = 30.6 mGy (Body) DLP = 740.2 mGy-cm. Total DLP (Body) = 740 mGy-cm. COMPARISON: Compared to the right shoulder radiographs from ___ FINDINGS: There is no glenohumeral joint dislocation. There is a ___ deformity of the superolateral humeral head consistent with prior anterior shoulder dislocation. There is slight irregularity along the lateral aspect of the bicipital groove, best seen on series 4, image 27, suspicious for a subacute fracture. There is mild irregularity of the AC joint. The subacromial interval is narrowed and there is likely a high-grade tear of the supraspinatus tendon. There is a 6 mm calcification within the distal tendon suspicious for an avulsion injury. This is best seen on series 7, image 39. Visualized right lung apex is grossly clear. IMPRESSION: 1. Regularity superolateral humeral head consistent with ___ deformity likely related to prior anterior shoulder dislocation. There is no current glenohumeral joint dislocation. 2. High-grade tear of the supraspinatus tendon tendon retraction and calcification within the free edge of the tendon likely representing avulsion injury. 3. Mild irregularity of the anterolateral aspect of the humeral head next the bicipital groove, suspicious for subacute fracture. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year-old woman with CAD s/p PCI, HFrEF, AF on Coumadin, ESRD on HD, Depression, HTN, HLD, Lupus who presented with dizziness and hypotension, being admitted to the FICU for low-dose pressor requirement. Low albumin and LFTs abnormal so questionable cirrhosis causing vasoplegia contribution?// cirrhotic liver? TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: Correlation is made to CT chest ___. FINDINGS: LIVER: The hepatic parenchyma appears coarsened. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 6 mm GALLBLADDER: Gallbladder sludge without gallbladder wall thickening. PANCREAS: The imaged portion of the pancreas appears within normal limits, without masses or pancreatic ductal dilation, with portions of the pancreatic tail obscured by overlying bowel gas. SPLEEN: Normal echogenicity. Spleen length: 10.3 cm KIDNEYS: The kidneys were not well visualized. Patient is status post renal transplant. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. No specific evidence of cirrhosis or portal hypertension. No focal liver lesions or ascites. 2. Biliary sludge within the gallbladder without evidence of cholecystitis. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman p/w hypotension, now newly septic looking for source.// sepsis, ?PNA IMPRESSION: In comparison with the study of ___, there is little interval change. Again there are low lung volumes that accentuate the prominence of the cardiac silhouette. No vascular congestion or acute focal pneumonia. The implanted rhythm monitor is again noted within the lower left chest wall. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Hypotension Diagnosed with Hypotension, unspecified temperature: 99.7 heartrate: 118.0 resprate: 22.0 o2sat: 96.0 sbp: 90.0 dbp: 46.0 level of pain: 4 level of acuity: 2.0

This is a ___ year old female with past medical history of CAD, systolic CHF, OSA on CPAP, paroxysmal atrial flutter with prior stroke, SLE complicated by lupus nephritis, on HD, prior chronic hypotension requiring outpatient midodrine, titrated off of this medication within the last ___ year, with a recent fall with resulting R shoulder dislocation and L shoulder fracture, subsequently admitted ___ with worsening dizziness and hypotension, with extended hospital course notable for negative infectious workup, persistent hypotension requiring midodrine, subsequent clinical improvement # Hypotension # Adrenal insufficiency Patient admitted to ICU after presenting with hypotension. Patient IV fluid resuscitated and initiated on intravenous vasopressors. Workup yielded no signs of clear infectious etiology. Outside of fractures, dislocations (mentioned below), exam and review of systems was without localizing findings. TTE showed partially recovered EF to 50% without any changes. Given concern for adrenal insufficiency, she received several days of stress dose steroids with Hydrocort 50mg Q6H. Given patient's history of borderline-low blood pressures requiring previous midodrine (which had been discontinued over recent ___ year), she was restarted on midodrine. Subsequent and cosyntropin test was felt to demonstrate adequate adrenal reserve at that time. Based on endocrine service evaluation and clinical picture, perhaps hypotension related to brief adrenal insufficiency (the result of ___ years of sub-physiological prednisone dosing suppressing ACTH) in setting of stress of her fall, fractures and dislocation, which resolved with her stress dose steroids and resolving stress of her acute illness. Patient was returned to her chronic prednisone dose, and midodrine was weaned from 15mg TID to 5mg TID by time of discharge. Anticipate this may be able to be weaned further and discontinued over next ___ months (this is of importance given that it impacts her transplant listing). Had multidisciplinary discussion between endocrine, nephrology, and cardiology who felt risk/benefit would not favor trial of fludrocortisone. # s/p Fall with R shoulder dislocation, L shoulder fracture 2 weeks prior to admission, she fell while at a relative's home and was found to have a L shoulder fracture and R shoulder dislocation. On admission here, orthopedics was consulted, recommended repeat imaging which confirmed a comminuted left proximal humerus with fracture displacement at the surgical neck and greater tuberosity compatible with a Neer three part fracture. She had a high-grade tear of the R supraspinatus tendon tendon with retraction and calcification within the free edge of the tendon likely representing avulsion injury and concern for subacute fracture of the humeral head. Of note, the CTs were labeled incorrectly, radiologist who read the studies was contacted regarding this. She was treated with standing Tylenol, Gabapentin, prn oxycodone (kept on low doses because her blood pressure was sensitive to this). Orthopedic recommendations: - NWB LUE in sling, OK for pendulums, OK for passive range of motion to the level of the shoulder with ___ - WBAT RUE, sling for comfort, range of motion as tolerated Discharged with follow-up with Dr. ___ ___. # ESRD on HD Continued on tacrolimus, Calcitriol. Continued HD MWF. Given hypotension (above), goal weight was increased to 86kg. Discharge weight = 86.5kg. # A flutter # Supratherapeutic INR Had variable INR this admission requiring adjustment of Coumadin dosing. At discharge patient was on warfarin 3mg daily, INR 2.2. Would recheck INR on ___ at rehab, adjust dosing for goal INR ___. # OSA Continued CPAP QHS # Depression Continued Mirtazapine # Chronic systolic CHF # CAD Continued statin, ASA. Given hypotension, held metoprolol and losartan. Volume management with HD. Goal standing weight = 86kg # Gout Continued Allopurinol # Restless leg syndrome Continued rOPINIRole # Constipation While on oxycodone, was started on bowel regimen with miralax and senna # History of skin cancer Held acitretin during admission, restarted at discharge

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abd pain Major Surgical or Invasive Procedure: ___ attempted ___ drainage of pericolonic fluid collection, aborted History of Present Illness: ___ with longstanding h/o recurrent prostatitis presented initially with sx c/w prostatitis starting last ___. Reports having difficulty urinating, fevers/chills. He went to his PCP on ___ for persistent symptoms and was prescribed Bactrim, but returned on ___ with persistent symptoms despite the antibiotics. He was prescribed Cipro at this point, which still did not improve his symptoms, so he had a non-con CTAP done showing possible diverticulitis, so he was referred to ___ ___ where he underwent another CT, this time with contrast, which demonstrated diverticulitis and concern for abscess and possible vesicular fistula. He was started on antibiotics at ___ prior to being transferred to ___ for surgical evaluation. Has had 2 colonoscopies in the past, most recently in ___, with diverticulosis but otherwise unremarkable. Past Medical History: Past Medical History: CLL (never treated, in remission), h/o proctitis (reports initial attacks beginning ___ ago, treated several times with prolonged courses of antibiotics, last episode ___ ago), h/o kidney stones Past Surgical History: Tonsillectomy Social History: ___ Family History: Father with diverticulitis Physical Exam: Vitals: 98 60 112/72 18 99RA Gen: AAOx3 NAD comfortable CV: NRRR Chest: CLAB Abd: Soft, mildly ttp in lower quadrants but significantly improving from previous. No guarding or organomegaly. No hernias or masses. Extrem: Without deformity or edema Pertinent Results: ___ 07:08AM BLOOD WBC-21.7* RBC-4.03* Hgb-12.3* Hct-36.7* MCV-91 MCH-30.5 MCHC-33.5 RDW-12.4 RDWSD-41.2 Plt ___ ___ 05:45AM BLOOD WBC-24.6* RBC-3.60* Hgb-11.2* Hct-33.4* MCV-93 MCH-31.1 MCHC-33.5 RDW-12.5 RDWSD-42.4 Plt ___ ___ 05:20AM BLOOD WBC-26.7* RBC-3.60* Hgb-11.3* Hct-33.3* MCV-93 MCH-31.4 MCHC-33.9 RDW-12.5 RDWSD-42.6 Plt ___ ___ 12:45AM BLOOD WBC-31.0* RBC-3.76* Hgb-11.7* Hct-34.5* MCV-92 MCH-31.1 MCHC-33.9 RDW-12.5 RDWSD-42.3 Plt ___ ___ 12:45AM BLOOD Neuts-27* Bands-1 Lymphs-66* Monos-3* Eos-0 Baso-0 Atyps-3* ___ Myelos-0 AbsNeut-8.68* AbsLymp-21.39* AbsMono-0.93* AbsEos-0.00* AbsBaso-0.00* ___ 07:08AM BLOOD Plt ___ ___ 05:45AM BLOOD Plt ___ ___ 05:20AM BLOOD Plt ___ ___ 12:34PM BLOOD ___ ___ 12:45AM BLOOD Plt Smr-NORMAL Plt ___ ___ 07:08AM BLOOD Glucose-PND UreaN-PND Creat-PND Na-PND K-PND Cl-PND HCO3-PND ___ 05:45AM BLOOD Glucose-108* UreaN-17 Creat-0.7 Na-138 K-3.8 Cl-105 HCO3-24 AnGap-13 ___:20AM BLOOD Glucose-88 UreaN-22* Creat-0.7 Na-141 K-3.7 Cl-105 HCO3-24 AnGap-16 ___ 12:45AM BLOOD Glucose-129* UreaN-14 Creat-0.9 Na-138 K-4.2 Cl-100 HCO3-25 AnGap-17 ___ 07:08AM BLOOD Calcium-PND Phos-PND Mg-PND ___ 05:45AM BLOOD Calcium-8.6 Phos-2.8 Mg-2.0 ___ 05:20AM BLOOD Calcium-8.8 Phos-2.9 Mg-2.1 Medications on Admission: None Discharge Medications: 1. Acetaminophen ___ mg PO Q8H:PRN pain/headache RX *acetaminophen 500 mg ___ tablet(s) by mouth every 8 hours Disp #*30 Tablet Refills:*0 2. Ciprofloxacin HCl 750 mg PO Q12H RX *ciprofloxacin HCl 250 mg 3 tablet(s) by mouth twice daily Disp #*84 Tablet Refills:*0 3. MetroNIDAZOLE 500 mg PO TID RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three times daily Disp #*42 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Diverticulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ y/o M p/w 6 days abd pain, +F/C, microscopic hematuria, CT w/diverticulitis +abscess abutting bladder // eval and drainage of abscess COMPARISON: Outside CT ___. PROCEDURE: Ultrasound-guided drainage of a diverticular phlegmon/fluid collection. OPERATORS: Dr. ___ fellow and Dr. ___ radiologist. Dr. ___ supervised the trainee during the key components of the procedure and reviewed and agree with the trainee's findings. TECHNIQUE: The risks, benefits, and alternatives of the procedure were explained to the patient. After a detailed discussion, informed written consent was obtained. A pre-procedure timeout using three patient identifiers was performed per ___ protocol. The patient was placed in a supine position on the US scan table. Limited preprocedure ultrasound was performed to localize the collection. Based on the ultrasound findings an appropriate skin entry site for the drain placement was chosen. The site was marked. Local anesthesia was administered with 1% Lidocaine solution. Using continuous sonographic guidance, an 8 ___ Exodus catheter was attempted to be placed within the collection, however it could not be deployed within the small fluid collection. Therefore, an 18G ___ needle was inserted into the collection. 0.038 ___ wire was placed through the needle and needle was removed. This was followed by placement of a dilator folowed by ___ Exodus catheter into the collection. The plastic stiffener and the wire were removed, however no fluid, nor air, could be aspirated from the catheter. The Pigtail was deployed, however the position of the pigtail could not be confirmed via ultrasound due to the presence of adjacent inflammatory echogenic fat. Given this finding, the patient subsequently had a a noncontrast CT scan of the pelvis to better localize the position of the catheter. The catheter was secured by a StatLock. The catheter was attached to bag. Sterile dressing was applied. The procedure was tolerated well, and there were no immediate post-procedural complications. SEDATION: Moderate sedation was provided by administering divided doses of 2 mg Versed and 125 mcg fentanyl throughout the total intra-service time of 27 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. FINDINGS: Small amount of fluid is seen within the pelvis, to the left and above the bladder, correlating to the site of the small fluid collection seen on recently performed CT scan. Extensive adjacent inflammatory fat. Following the procedure, the location of the pigtail could not be determined under ultrasound, and the patient's subsequently had a CT scan of the pelvis which demonstrated little to no fluid at the site of previously seen collection, and the pigtail catheter was positioned within the pelvis, adjacent to where the collection was previously seen. Given these findings, the pigtail catheter was subsequently removed. IMPRESSION: Attempted US-guided placement of ___ pigtail catheter into the pelvic collection. No fluid was aspirated at the time of drain placement, and subsequent CT scan of the pelvis demonstrated resolution of the previously seen small collection and therefore the pigtail catheter was removed. The patient remained stable throughout the procedure and subsequent CT scan of the pelvis. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 4:45 ___, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: CT pelvis without contrast INDICATION: Diverticular abscess. Evaluate position of pigtail catheter. TECHNIQUE: Multidetector CT images of the pelvis were acquired without intravenous contrast. Non-contrast scan has several limitations in detecting vascular and parenchymal organ abnormalities, including tumor detection. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: 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: Outside hospital CT torso ___. Ultrasound-guided drainage ___. FINDINGS: Again noted is prominent thickening of the distal sigmoid colon in an area of prominent diverticula with surrounding fat stranding compatible with acute diverticulosis. A pigtail catheter is noted within the vicinity of a previously noted diverticular abscess, the confines of which are difficult to evaluate given lack of intravenous contrast, however the abscess appears to be nearly completely resolve compared to the prior outside CT examination. It is difficult to discern whether catheter extends into the bowel lumen. Retained barium contrast is noted within the visualized portion of the large bowel. The imaged portion of the abdominal aorta is normal in caliber. There is no mesenteric, retroperitoneal, or inguinal lymphadenopathy. A few mildly prominent left pelvic sidewall lymph nodes are noted, likely reactive. There is no free pelvic fluid or air. Bladder, prostate and lower rectum are grossly unremarkable. There is no suspicious focal bone lesion. IMPRESSION: Left lower quadrant percutaneous pigtail catheter within a diverticular abscess, which appears nearly completely resolved compared to the preprocedure CT examination. The catheter is very close to the sigmoid colon and it is uncertain whether it extends into he lumen. This can be further evaluated with contrast injection with fluoroscopy. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abd pain, Transfer Diagnosed with Unspecified abdominal pain temperature: 98.5 heartrate: 74.0 resprate: 16.0 o2sat: 98.0 sbp: 124.0 dbp: 80.0 level of pain: 4 level of acuity: 2.0

Ms. ___ was admitted to ___ on ___ following presentation in the ED with abdominal pain which on CT done in the ED appeared to be due to active diverticulitis with a very small pericolonic fluid collection. He was started on IV Cipro and IV flagyl and bowel rest with fluid resuscitation. An attempt was made by the interventional radiology team to percutaneously drain the abscess however this was aborted. It was ultimately felt that the fluid collection was likely too small and resolving sufficiently such that it does not require additional drainage. Mr. ___ diet was gradually advanced over the following 24 hours to regular, which he tolerated. His abdominal pain continued to improve and was nearly completed resolved at the time of discharge. Mr. ___ at the time of discharge was ambulating, eating, tolerating oral medications, and toileting himself. He was discharged on 2 weeks of oral cipro and flagyl with scheduled follow up.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: Pericardiocentesis (___) Right heart catheterization (___) Thoracic Harware removal (___) History of Present Illness: HISTORY OF PRESENTING ILLNESS: ___ with h/o rheumatic heart disease (mild MS, Moderate AS), MSSA bacteremia ___ T4-5 epidural abscess and discitis in ___ s/p multiple courses of antibiotic therapy, recent NSTEMI w/ normal stress, HCV, CKD stage 3, remote IVDU, mild cognitive impairment, presents with fevers, worsened shortness of breath and found to have new large pericardial effusion. Approxiamtely 1 month ago, patient was admitted to OSH after acute onset AMS and shortness of breath. Found there to have a troponin elevation that was worked up with stress test, which was negative for ischemia. She was then admitted to ___ ___ with AMS, fevers, soft tissue mass on her thoracic spine concerning for phlegmon. She was treated with broad spectrum antibiotics, phlegmon was aspiration and culture did not reveal any micro-organism. She was discharged on her chronic suppressive doxycycline after feeling somewhat better. She was somewhat better but over the past 3 days prior to this presentation she was having shortness of breath, fevers, and increased back pain. Also developed new sternal pleuritic chest pain, which she has not had before. She initially presented to an ___ where she was found to febrile and have a large pericardial effusion with concern for possible tamponade so she was transferred to ___ ED for further management. In the ED, - Initial vitals were: 99.1 ___ 18 93% 4L NC - Exam notable for: Negative pulsus paradoxus - Labs notable for: WBC 10.8, hgb 8.5, lactate 0.8, BNP 1752, albumin 2.9 - Studies notable for: - Unilateral ___ w/ no DVT - TTE with large pericardial effusion, no e/o tamponade. - EKG with Sinus tachycardia to 102, low volatage, no e/o ischemia although or pericarditis although limited by significant aritifact. - Patient was given: 1 L NS and 2 g cefepime (received vancomycin at OSH) - Cardiology was consulted: Recommended admission to CCU for anticipation of pericardiocentesis On arrival to the CCU, she described history c/w the above. She noted years of intermittent joint pains and swelling, new intermittent rashes breaking out on arms. She noted that her mother was diagnosed with lupus. ROS: Positive per HPI. Remaining 10 point ROS reviewed and negative. Past Medical History: -MSSA Bacteremia ___ complicated by persistent T5 epidural abscess and discitis s/p T5-T6 corpectomy, T3-T8 posterior fusion (___) for persistent infection/vertebral body destruction -Remote IVDU - ___ years ago on methadone -HCV (unclear if treated in past) -Mild cognitive Impairment -Opiate dependence on methadone -CKD III (baseline Cr 0.7-1) -History of recurrent UTI's on macrobid suppressive therapy -Depression/Anxiety -Decubitus ulcers -Mitral stenosis (per echo at ___ ___ Social History: ___ Family History: No FH of cardiac disease per patient. Mother with h/o hemochromatosis and SLE. Physical Exam: ADMISSION PHYSICAL EXAM: VS: Reviewed in Metavision GENERAL: Chronically ill appearing. HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. NECK: Supple. JVP up at 90 degrees. CARDIAC: regular rate tachy, ___ SEM at base. No rub. LUNGS: Crackles at bases. No respiratory distress ABDOMEN: Soft, non-tender, non-distended. No palpable hepatomegaly or splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. Back: Warm paraspinal soft tissue mass in thoracic region SKIN: excoriations, but no clear rashes PULSES: Distal pulses palpable and symmetric. NEURO: AOx3. No focal lesions DISCHARGE PHYSICAL EXAM: GENERAL: NAD HEENT: AT/NC, anicteric sclera, MMM NECK: supple, no LAD CV: ___ midsystolic murmur auscultated in RUSB PULM: CTAB GI: abdomen soft, nondistended, nontender in all quadrants EXTREMITIES: no cyanosis, clubbing, or edema BACK: dressing clean and dry, drain removed NEURO: Strength ___ in bilateral upper and lower extremities. Sensation intact to light touch bilaterally. Pertinent Results: ADMISSION LABS ============== ___ 06:17PM BLOOD WBC-10.7* RBC-2.89* Hgb-8.5* Hct-26.9* MCV-93 MCH-29.4 MCHC-31.6* RDW-14.3 RDWSD-48.2* Plt ___ ___ 06:17PM BLOOD Neuts-71.9* Lymphs-14.1* Monos-10.5 Eos-2.1 Baso-0.5 Im ___ AbsNeut-7.66* AbsLymp-1.50 AbsMono-1.12* AbsEos-0.22 AbsBaso-0.05 ___ 05:20AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-2+* Macrocy-NORMAL Microcy-NORMAL Polychr-1+* Ovalocy-1+* Tear Dr-OCCASIONAL ___ 06:17PM BLOOD ___ PTT-28.2 ___ ___ 05:20AM BLOOD Ret Aut-2.5* Abs Ret-0.08 ___ 06:17PM BLOOD Glucose-105* UreaN-15 Creat-1.2* Na-137 K-3.9 Cl-103 HCO3-23 AnGap-11 ___ 06:17PM BLOOD ALT-11 AST-15 AlkPhos-78 TotBili-0.4 ___ 05:20AM BLOOD ALT-13 AST-20 LD(LDH)-303* CK(CPK)-51 AlkPhos-88 TotBili-0.5 DirBili-<0.2 IndBili-0.5 ___ 06:17PM BLOOD proBNP-1752* ___ 06:17PM BLOOD Albumin-2.9* ___ 05:20AM BLOOD Albumin-3.1* Calcium-8.0* Phos-3.1 Mg-1.8 Iron-16* ___ 05:20AM BLOOD calTIBC-198* Hapto-348* Ferritn-203* TRF-152* ___ 05:20AM BLOOD RheuFac-16* ___ Titer-1:80* CRP-161.1* ___ 05:20AM BLOOD TSH-1.3 ___ 05:20AM BLOOD C3-135 C4-16 ___ 06:20PM BLOOD Lactate-0.8 DISCHARGE LABS ============== ___ 08:40AM BLOOD WBC-8.8 RBC-3.00* Hgb-8.8* Hct-27.4* MCV-91 MCH-29.3 MCHC-32.1 RDW-15.4 RDWSD-49.4* Plt ___ ___ 08:40AM BLOOD ___ PTT-31.2 ___ ___ 08:40AM BLOOD Plt ___ ___ 08:40AM BLOOD Glucose-111* UreaN-10 Creat-1.0 Na-148* K-3.3* Cl-109* HCO3-24 AnGap-15 ___ 08:40AM BLOOD Calcium-8.4 Phos-3.6 Mg-1.8 MICRO ===== ___ BCx - final no growth ___ UCx - final no growth ___ BCx - final no growth ___ pericardial fluid - gram stain negative, acid fast smear negative. preliminary fluid culture, anaerobic culture, acid fast culture, viral culture with no growth *** ___ pericardial fluid in blood culture bottles - no growth ___ pericardial fluid cytology - negative for malignant cells. Rare mesothelial cells, numerous neutrophils, lymphocytes, histiocytes, and many red blood cells. IMAGING AND STUDIES =================== TTE ___: Conclusions: Overall left ventricular systolic function is normal. The right ventricle has normal free wall motion. There is a small (up to 0.6 cm inferolateral to the left ventricle) to moderate (up to 1.4 cm anterior to the right ventricle) circumferential pericardial effusion. The effusion is echo dense, c/w blood, inflammation or other cellular elements. There are no 2D or Doppler echocardiographic evidence of tamponade. IMPRESSION: Small to moderate circumferential, echodense pericardial effusion without echocardiographic evidence for increased pericardial pressure/tamponade physiology. Compared with the prior TTE ___ , respiratory variation of the mitral inflow pattern is no longer appreciated. PET ___: 1. Increased radiotracer uptake within the subcutaneous tissues and paraspinal musculature extending along the pedicle screws and interconnecting rod on the right at T7 and T8, suspicious for infection. No increased radiotracer uptake to suggest discitis or an epidural abscess. 2. Small pericardial effusion with mild peripheral FDG uptake; the FDG may be due pharmacokinetics of the effusion, but could possibly reflect infection. 3. Focus of FDG avidity along the right pericardium without a definite CT correlate, likely a reactive epicardial lymph node. There also nonenlarged axillary lymph nodes with low level FDG uptake, also likely reactive in nature. 4. Multiple foci of radiotracer uptake throughout the large bowel, which appear to correlate with stool and are likely physiologic. 5. Smooth septal thickening at the lung bases bilaterally, compatible with mild fluid overload. Small bilateral pleural effusions with loculated components in the major fissures. CXR ___: In comparison with the study of ___, the pericardial drain has been removed. There may be a small residual component of air in the pericardium. There is decreasing opacification at the right base consistent with mild decrease in pleural effusion, though residual atelectasis is again seen. Left hemidiaphragm is obscured consistent with substantial volume loss in the left lower lobe and possible small effusion. TTE ___: CONCLUSION: The left atrium is not well seen. The estimated right atrial pressure is ___ mmHg. There is normal regional and global left ventricular systolic function. The visually estimated left ventricular ejection fraction is >=55%. Normal right ventricular cavity size with mild global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is trivial mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. The pulmonary artery systolic pressure could not be estimated. There is a moderate circumferential pericardial effusion. There is increased respiratory variation in transmitral/transtricuspid inflow but no right atrial/right ventricular diastolic collapse. IMPRESSION: Focused study. Moderate circumferential pericardial effusion with evidence of increased pericardial pressures but without frank echocardiographic evidence of pericardial tamponade. Grossly biventricular systolic function. Mild tricuspid regurgitation. Compared with the prior TTE ___, the findings are similar. TTE ___: CONCLUSION: The estimated right atrial pressure is ___ mmHg. There is normal regional left ventricular systolic function. Overall left ventricular systolic function is normal. The visually estimated left ventricular ejection fraction is 60-65%. Normal right ventricular cavity size with normal free wall motion. The mitral valve leaflets appear structurally normal. The estimated pulmonary artery systolic pressure is borderline elevated. There is a small to moderate circumferential pericardial effusion. There is increased respiratory variation in transmitral/transtricuspid inflow c/w increased pericardial pressure/tamponade physiology. IMPRESSION: 1) Moderately sized serous fibrinous largely circumferential pericardial effusion. The largest extent of the pericardial effusion is anterior to the RV/RA. There is mild respirophasic variation in mitral inflow velocities suggestion low pressure tamponade physiology. RA pressure appears normal. Compared with the prior TTE (images reviewed) of ___, the size of the pericardial effusion has decreased. There now is very mild respirophasic variation in mitral inflow velcities. The cut of is 25% variation and the measurements ranged from ___. The IVC is normal in size suggestion low pressure tamponade physiology. CXR ___: 1. Pericardial drain in place with decreased amount of air in the pericardium. There is no pneumothorax. 2. Decreased bilateral pleural effusions 3. Bibasilar atelectasis TTE ___: CONCLUSION: The left atrial volume index is mildly increased. The estimated right atrial pressure is >15mmHg. There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is normal regional and global left ventricular systolic function. Quantitative 3D volumetric left ventricular ejection fraction is 61 %. Left ventricular cardiac index is high (>4.0 L/min/m2). There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal. The aortic valve leaflets (?#) are mildly thickened. There is mild aortic valve stenosis (valve area 1.5-1.9 cm2). There is no aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is mild [1+] mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. There is mild pulmonary artery systolic hypertension. There is a large circumferential pericardial effusion. There is increased respiratory variation in transmitral/transtricuspid inflow c/w increased pericardial pressure/tamponade physiology. In the presence of pulmonary artery hypertension, typical echocardiographic findings of tamponade physiology may be absent. IMPRESSION: Large circumferential pericardial effusion with signs of tamponade. Normal biventricular systolic function. Mild aortic stenosis. Mild mitral and tricuspid regurgitation. Mild pulmonary hypertension. Compared with the prior TTE ___, the pericardial effusion is now larger. CXR ___: Pericardial drain in place with small quantity of anticipated air in the pericardium. Decreasing pleural effusions and opacities suggesting atelectasis the lung bases. Echo ___: Overall left ventricular systolic function is normal. The right ventricle has low normal free wall motion. The pulmonary artery systolic pressure could not be estimated. There is a large circumferential pericardial effusion predominantly located adjacent to the right ventricle. There is right atrial systolic collapse c/w early tamponade physiology. There is mild TV/MV inflow respiratory variation. The pericardial thickness is normal. IMPRESSION: Large circumferential/anterior pericardial effusion with early signs of echocardiographic tamponade. Compared with the prior TTE (images reviewed) of ___ , the pericardial effusion is larger(was present but small on prior echo) and there are now early signs of tamponade physiology. Unilateral lower extremity veins right ___: No evidence of deep venous thrombosis in the right lower extremity veins. EKG ___: EKG with Sinus tachycardia to 102, low volatage, no e/o ischemia although or pericarditis although limited by significant aritifact. TTE ___: EF 65%, Moderate AS, mild MS from rheumatic heart disease. STRESS TEST: ___: Reportedly negative at CHA. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild 2. Aspirin 81 mg PO DAILY 3. ClonazePAM 1 mg PO QAM Anxiety 4. Doxepin HCl 10 mg PO HS 5. Levothyroxine Sodium 112 mcg PO DAILY 6. DULoxetine 40 mg PO DAILY 7. Methadone 89 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Senna 17.2 mg PO QHS 10. ClonazePAM 1.5 mg PO LUNCH anxiety 11. Ditropan XL (oxybutynin chloride) 10 mg oral BID 12. Docusate Sodium 100 mg PO BID 13. Doxycycline Hyclate 100 mg PO Q12H Discharge Medications: 1. Nafcillin 2 g IV Q4H RX *nafcillin in dextrose iso-osm 2 gram/100 mL 2 grams IV every 4 hours Disp #*180 Intravenous Bag Refills:*0 2. Pantoprazole 40 mg PO Q24H RX *pantoprazole [Protonix] 40 mg 1 tablet(s) by mouth once daily Disp #*30 Tablet Refills:*0 3. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild 4. Aspirin 81 mg PO DAILY 5. ClonazePAM 1 mg PO QAM Anxiety 6. ClonazePAM 1.5 mg PO LUNCH anxiety 7. Ditropan XL (oxybutynin chloride) 10 mg oral BID 8. Doxepin HCl 10 mg PO HS 9. DULoxetine 40 mg PO DAILY 10. Levothyroxine Sodium 112 mcg PO DAILY 11. Methadone 89 mg PO DAILY Consider prescribing naloxone at discharge 12. Multivitamins 1 TAB PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnosis: Pericardial effusion with tamponade Acute Kidney Injury Secondary diagnoses: Normocytic anemia CKD III Hypothyroidism 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 RIGHT INDICATION: ___ woman with leg swelling// ?R DVT TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the right lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, flow, and augmentation of the right common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: No evidence of deep venous thrombosis in the right lower extremity veins. Radiology Report EXAMINATION: Chest radiograph, semi-upright AP portable. INDICATION: Enlarged pericardial effusions status post pericardiocentesis. COMPARISON: Prior day. FINDINGS: New pericardial drain projects to the left of midline. Associated pericardial air is found. Cardiac shadow is somewhat reduced in size, although it is difficult to the separated change in the size of the cardiac shadow from coinciding reduction in atelectasis at the lung bases and in bilateral pleural effusions. There is no pneumo thorax. IMPRESSION: Pericardial drain in place with small quantity of anticipated air in the pericardium. Decreasing pleural effusions and opacities suggesting atelectasis the lung bases. Radiology Report EXAMINATION: Portable AP chest INDICATION: ___ year old woman with large pericardial effusion s/p pericardiocentesis.// r/o pneumothorax TECHNIQUE: Portable AP chest COMPARISON: Portable AP chest from ___ FINDINGS: In comparison the previous film, there is little overall change. There is no evidence of pneumothorax. Pericardial drain is unchanged in position. There is a small amount of air in the pericardium which is decreased in size from the prior film. There continues to be bibasilar atelectasis. There are bilateral pleural effusions that have decreased from the prior exam. Hardware is unchanged. IMPRESSION: 1. Pericardial drain in place with decreased amount of air in the pericardium. There is no pneumothorax. 2. Decreased bilateral pleural effusions 3. Bibasilar atelectasis Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ with h/o rheumatic heart disease (mild MS, Moderate AS), MSSAbacteremia ___ T4-5 epidural abscess and discitis in ___ s/pmultiple courses of antibiotic therapy, recent NSTEMI w/ normalstress, HCV, CKD stage 3, remote IVDU, mild cognitive impairment,presents with fevers, worsened shortness of breath and found tohave new large pericardial effusion, now s/p pericardiocentesis.// cardiopulmonary reason for shortness of breath? reaccumulation of pericardial evidence? IMPRESSION: In comparison with the study of ___, the pericardial drain has been removed. There may be a small residual component of air in the pericardium. There is decreasing opacification at the right base consistent with mild decrease in pleural effusion, though residual atelectasis is again seen. Left hemidiaphragm is obscured consistent with substantial volume loss in the left lower lobe and possible small effusion. Radiology Report EXAMINATION: CT T-SPINE W/O CONTRAST INDICATION: ___ year old woman s/p T5-T6 corpectomy and T3-T8 posterior fusion who presented with pericardial effusion requiring pericardiocentesis. Evidence of spine hardware infection seen on ___ PET scan.// evidence of hardware infection? evidence of hardware infection? TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue and bone algorithm images were generated. Coronal and sagittal reformations were then constructed. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.0 s, 31.9 cm; CTDIvol = 27.2 mGy (Body) DLP = 866.4 mGy-cm. Total DLP (Body) = 866 mGy-cm. COMPARISON: MR ___ dated ___. Prior CT T spine dated ___ FINDINGS: Exaggerated thoracic kyphosis with spondylosis is persistent otherwise alignment is unchanged. There are unchanged multilevel degenerative changes in the lower cervical and upper thoracic spine. The anterior fusion involves T5-T6 level with biomechanical device in place. The posterior fixation rods spanning with by medical device placement at T5-T6. Fusion involves T2-T8. The anterior fusion of T5-T6. At the vertebral body of T5 there is the previously described lucency around the left lateral margin of the intervertebral biomechanical device, (series 2, image 44), is no longer demonstrated. However, there is streak artifact from hardware and evaluation of the spinal canal is limited. Again demonstrated is the right T3 pedicular screw at the lateral margin of the T3 vertebral body with less than a mm of perihardware lucency (series 602 image 34). There is no evidence of periarticular fracture. There is no evidence of spinal canal or neural foraminal stenosis. There is no prevertebral soft tissue swelling. No evidence of drainable fluid collection within the paraspinal musculature or visualized spinal canal. Re-demonstrated are small bilateral pleural effusions, left greater than right. There mild interval improvement of loculated effusion along the right oblique fissure. However there still is layering of pleural fluid along the oblique fissures. There are bibasilar ground-glass opacification likely representative of atelectasis. IMPRESSION: 1. No evidence of hardware complication within the limitations of streak artifact. 2. Bilateral small pleural effusions left greater than right with bibasilar atelectasis. Radiology Report EXAMINATION: THORACIC SINGLE VIEW IN OR INDICATION: POST. RMVL T2-8 HARDWARE TECHNIQUE: Frontal view radiograph of the thoracic spine. COMPARISON: CT Thoracic Spine ___. FINDINGS: There has been interval removal of the posterior spinal fixation hardware in the thoracic spine. The expandable vertebral body cage in the midthoracic spine is still present. The endotracheal tube terminates 3.5 cm above the carina. An tubular structure which projects of the cervical and thoracic spine may represent a surgical drain. There is cardiomegaly. Hazy opacities in the partially visualized lower lungs may represent pleural effusions. IMPRESSION: Interval removal of the posterior thoracic spinal fixation hardware. Radiology Report INDICATION: ___ year old woman with PICC// Pt had a L PICC,44cm ___ ___ Contact name: ___: ___ TECHNIQUE: Chest AP COMPARISON: ___ IMPRESSION: Left-sided PICC line projects to the cavoatrial junction. Lungs are low volume with bibasilar atelectasis. Pulmonary edema is slightly improved. Cardiomediastinal silhouette is stable. Small bilateral effusions are unchanged. No pneumothorax is seen. The spinal hardware has been removed in the interim. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Dyspnea, PERICARDIAL EFFUSION, Transfer Diagnosed with Pericardial effusion (noninflammatory), Dyspnea, unspecified temperature: 99.1 heartrate: 106.0 resprate: 18.0 o2sat: 93.0 sbp: 92.0 dbp: 66.0 level of pain: 3 level of acuity: 2.0

___ with h/o rheumatic heart disease (mild MS, Moderate AS), MSSA bacteremia ___ T4-5 epidural abscess and discitis in ___ s/p multiple courses of antibiotic therapy, recent NSTEMI w/ normal stress, HCV, CKD stage 3, remote IVDU, mild cognitive impairment, presents with fevers, worsened shortness of breath and found to have new large pericardial effusion, now s/p pericardiocentesis. She was then transferred to the medicine service for ongoing management spinal soft tissue infection. Per ID and Ortho recommendations, her spinal hardware was removed for source control and she was started on a 6 week course of Nafcillin. #CORONARIES: Negative stress at CHA #PUMP: EF 65%, Moderate AS, mild MS from rheumatic heart disease. #RHYTHM: Sinus tachycardia ACUTE ISSUES: ============= # Pericardial effusion with tamponade New effusion with symptoms of pleuritic CP. S/p pericardiocentesis ___. Unclear etiology. Concern for ___ syndrome. Differential includes infectious in the setting of chornic spinal infetion, autoimmune in the setting of joint pain/rashes, malignancy all of which are less likely. Cytology was negative for malignancy. Autoimmune studies were remarkable for ___ pos, RF 16 Titer 1:80, CRP 161, normal C3, C4. Rheumatology was consulted and did not suspect a rheumatologic etiology for her pericardial effusion given the data above. Patient also has signs suggestive of pericarditis (ecg changes, pleuritic chest pain on admission). Fluid studies including gram stain and cultures have been negative to date. Patient was begun on Colcichine 0.6 mg BID and naproxen to treat pericarditis. Both drugs were then stopped after patient was clinically stable due to concerns of kidney injury. # Spinal Infection Fevers/leukocytosis on admission likely due to spinal infection given history of chronic spine infection on suppressive doxycycline and recent thoracic soft tissue phlegmon. A PET scan done on ___ showed increased radiotracer uptake within the subcutaneous tissues and paraspinal musculature extending along the pedicle screws and interconnecting rod on the right at T7 and T8, suspicious for infection. A CT scan on ___ showed no evidence of hardware complication within the limitations of streak artifact. ID and orthopedic surgery were consulted and recommended removal of spinal hardware. S/p surgery ___. Discharged on 6 weeks of IV naficillin 2g Q4H. Pt will require weekly LFT and CBC check. After completion of nafcillin, pt will not be restarted on suppressive doxycycline. # ___ on CKD, resolved: Cr to max of 1.5 during admission (baseline 1.0). Likely due to pre-renal hypovolemic etiology with possible contribution from NSAIDs, resolved with IVF. No evidence of ATN/AIN. Colchicine/naproxen stopped prior to discharge as above. Cr 1.0 upon discharge. # Anemia: Acute on chronic normocytic anemia. Anemia of chronic inflammation given increased ferritin, low TIBC, low transferrin. Also iron deficiency present given tsat 8%. Treated with IV iron. # Recent NSTEMI: Occurred in setting of evluation for acute onset dyspnea at ___ ealier in ___ stress per patient at ___. Not on statin due to low ASCVD risk per HCA notes. Continued ASA. # H/o Rheumatic heart disease, moderate AS, Mild MS: Murmur notable on exam. Possible etiology of pulmonary edema. Did not require diuresis following pericardiocentesis. CHRONIC ISSUES: =============== # CKD III: ___ resolved as above. #h/o IVDU: continued methadone 89 mg QD # Overactive bladder: oxybutynin ER not on formulary, oxybutynin 5 mg QID while in hospital. # Pruritus: Pt with a history of pruritus. Continued home doxepin. # Anxiety/Depression: Continued outpt duloxetine 40 mg QD. Continue clonazepam 1 mg qAM and 1.5 mg QPM. # Hypothyroidism: Continue home levothyroxine 112 mcg QD TRANSITIONAL ISSUES: ============== [] New diarrhea on ___. Please follow up to r/o C. Diff. Stool sample was taken on day of discharge. [] Consider iron supplementation as outpatient [] Weekly LFT and CBC due to Naficillin use [] Consider repeat CRP at follow-up to ensure down-trending. [] Continue naficllin 2g Q24 for 6 week course (last day ___ [] Check BMP at next PCP appointment to monitor Na (Na 148 on discharge) and potassium (3.3 on discharge) #CODE: Full #CONTACT/HCP: Proxy name: ___ (husband)

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: Post partum hemorrhage Major Surgical or Invasive Procedure: Uterine artery embolization D&C for retained products of conception History of Present Illness: ___ year old G1P1 POD10 from cesarean section for failure to progress, complicated by post partum hemorrhage, requiring D&C and Bakri Balloon placement x 24 hours and multiple blood products, presents to ED by ambulance after developing heavy vaginal bleeding this evening while breast-feeding. She reports feeling vaginal bleeding soaking through her pants, followed by a large gush. She was reportedly found diaphoretic and hypotensive to the ___ systolic by EMS, and was transferred to ___ ED. She denies loss of consciousness, although she has felt dizzy with sitting up. No chest pain or shortness of breath. Of note, her cesarean section was performed on ___, and notable for manual delivery of the placenta, which was reported to be intact. The uterus was then wiped with a laparotomy pad, with "no placental fragments remaining." The EBL for the case was 600cc. She then subsequently had heavy vaginal bleeding with concern for atony. A dilation and evacuation was performed, followed by sharp curettage with a banjo curette. A Bakri balloon was placed and kept in place x 24 hours. Her total EBL was 2400cc. She received a total of 6u pRBC and 2 units FFP transfusion while at ___, and was discharged home on post-operative day 5. Her hematocrit on discharge was 28. Past Medical History: ___: Denies PSH: Cesarean section, tonsillectomy OBHx: G1P1, LTCS as above on ___ of 8 lb, 15 Oz baby at 41+6 weeks EGA, also complicated by chorioamnionitis and postpartum hemorrhage as above GYNHx: Denies uterine procedures. Hx of infertility with multiple egg transfers. Social History: ___ Family History: noncontributory Physical Exam: On admission: T 98.5 HR 77 BP 117/76 RR 18 O2 sat 97% RA Gen: NAD CV: RRR Abd: soft, non-tender. Fundus palpated at umbilicus, firm. Bedside TAUS: vascularized products vs. clot ~3.8cm in size visualized in lower uterine segment Bimanual exam: cervix dilated ~2-3cm, with removal of a plum sized clot from lower uterine segment. Pertinent Results: ___ pelvic MRI 6.5 cm uterine mass composed of innumerable early vessels with early arterial enhancement and early venous drainage, indicative of an arteriovenous malformation. This is centered within the left lower uterine myometrium, with intramural vascular communication circumferentially, and a large component extending into the endometrial cavity. Arterial supply appears to be predominantly via the left ovarian artery, and venous drainage via the left internal iliac vein and possibly the left gonadal vein. ___ PUS 1. Echogenic material measuring 6.1 cm within the endometrial cavity demonstrating a small amount of venous flow representing retained products of conception. Fluid is also demonstrated within the cavity. 2. Large region of abnormal vascularity in the left lateral myometrium with peak systolic velocity of 117 cm/sec and end-diastolic velocity of 74 cm/sec suggestive of residual AV connection. ___ abd CT IMPRESSION: 1. The ovarian veins appear patent. There is no evidence of thrombophlebitis. 2. Enlarged uterus as detailed above with retained fluid and multiple locules of gas. Gas is presumably from prior instrumentation two days ago, however it is difficult to exclude gas-forming bacteria within blood products, in the setting of fever. 3. No evidence of abscess or other drainable fluid collection. 4. Small foci of nondependent gas within the bladder are likely related to recent Foley catheter; correlate with catheter history. ___ renal US IMPRESSION: Mild left hydronephrosis and mild left proximal hydroureter. The mid and distal ureter are not well seen on this study. No stone or mass identified. Bladder not well evaluated. Consider urological consultation. ___ 10:20 pm BLOOD CULTURE Source: Venipuncture. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 6:31 pm BLOOD CULTURE Source: Venipuncture 2 OF 2. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 7:17 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: YEAST. <10,000 organisms/ml. ___ 07:20AM BLOOD WBC-6.6 RBC-2.98* Hgb-8.9* Hct-26.2* MCV-88 MCH-29.8 MCHC-34.0 RDW-14.6 Plt ___ ___ 04:34AM BLOOD WBC-7.9 RBC-2.77* Hgb-8.1* Hct-24.0* MCV-87 MCH-29.2 MCHC-33.8 RDW-14.4 Plt ___ ___ 01:15PM BLOOD WBC-7.7 RBC-2.58* Hgb-7.5* Hct-22.6* MCV-88 MCH-29.0 MCHC-33.1 RDW-14.6 Plt ___ ___ 07:45AM BLOOD WBC-7.2 RBC-2.43* Hgb-7.2* Hct-21.6* MCV-89 MCH-29.8 MCHC-33.5 RDW-14.7 Plt ___ ___ 07:18AM BLOOD WBC-11.2* RBC-2.61* Hgb-7.6* Hct-23.1* MCV-89 MCH-29.1 MCHC-32.8 RDW-14.6 Plt ___ ___ 07:00AM BLOOD WBC-15.1* RBC-2.76* Hgb-8.2* Hct-24.5* MCV-89 MCH-29.5 MCHC-33.3 RDW-14.8 Plt ___ ___ 11:02AM BLOOD WBC-13.6*# RBC-3.26* Hgb-10.2* Hct-28.9* MCV-89 MCH-31.1 MCHC-35.1* RDW-14.9 Plt ___ ___ 03:00AM BLOOD WBC-7.3 RBC-3.04* Hgb-9.1* Hct-26.8* MCV-88 MCH-29.9 MCHC-34.0 RDW-14.8 Plt ___ ___ 06:56PM BLOOD WBC-11.0# RBC-3.77* Hgb-11.5* Hct-33.8* MCV-90 MCH-30.5 MCHC-34.1 RDW-14.6 Plt ___ ___ 07:45AM BLOOD Neuts-68.0 ___ Monos-5.9 Eos-2.5 Baso-0.7 ___ 07:18AM BLOOD Neuts-76.9* Lymphs-17.0* Monos-4.4 Eos-1.4 Baso-0.3 ___ 06:56PM BLOOD Neuts-77.8* Lymphs-15.9* Monos-4.7 Eos-1.3 Baso-0.3 ___ 07:20AM BLOOD Plt ___ ___ 04:34AM BLOOD Plt ___ ___ 11:02AM BLOOD ___ PTT-26.8 ___ ___ 03:00AM BLOOD Plt ___ ___ 03:00AM BLOOD ___ PTT-25.8 ___ ___ 12:27AM BLOOD Plt ___ ___ 07:08PM BLOOD ___ PTT-23.9* ___ ___ 06:56PM BLOOD Plt ___ ___ 11:02AM BLOOD ___ 03:00AM BLOOD ___ 07:35AM BLOOD Creat-1.8* ___ 07:20AM BLOOD UreaN-8 Creat-1.7* ___ 09:01AM BLOOD Glucose-96 UreaN-9 Creat-1.6* Na-141 K-4.9 Cl-108 HCO3-26 AnGap-12 ___ 04:34AM BLOOD Creat-1.6* ___ 01:15PM BLOOD Creat-1.3* ___ 11:02AM BLOOD Glucose-97 UreaN-6 Creat-0.8 Na-138 K-4.1 Cl-102 HCO3-27 AnGap-13 ___ 03:00AM BLOOD Glucose-89 UreaN-8 Creat-0.7 Na-140 K-3.9 Cl-108 HCO3-24 AnGap-12 ___ 06:56PM BLOOD Glucose-99 UreaN-12 Creat-1.0 Na-138 K-4.7 Cl-104 HCO3-22 AnGap-17 ___ 11:02AM BLOOD Calcium-8.3* Phos-3.9 Mg-1.8 ___ 06:56PM BLOOD Calcium-8.8 Phos-4.1 Mg-1.8 ___ 01:15PM BLOOD ALT-12 AST-16 ___ 11:02AM BLOOD HCG-30 ___ 03:00AM BLOOD HCG-32 ___ 10:02AM URINE Hours-RANDOM Creat-68 Na-161 K-18 Cl-124 ___ 07:17PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR ___ 06:03PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-MOD ___ 08:40PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG ___ 06:03PM URINE RBC-2 WBC-4 Bacteri-NONE Yeast-NONE Epi-0 Radiology Report EXAMINATION: MRI of the pelvis with and without contrast INDICATION: ___ year old woman with delayed secondary postpartum hemorrhage. // Please evaluate for any evidence of an arteriovenous malformation TECHNIQUE: Multiplanar MRI of the pelvis is obtained at 1.5 Tesla both pre and post administration of 15 mL of MultiHance. COMPARISON: None FINDINGS: An enlarged uterus is identified in this recently postpartum patient with the fundus extending to the level of the umbilicus. There is gas and hemorrhagic fluid is seen within the endometrial canal, extending to the endocervical canal in the upper vagina. Thinning of the anterior lower uterine segment is noted with associated susceptibility artifact, edema and enhancement transversely along the lower abdominal wall, consistent with recent cesarean section. There is a masslike lesion composed innumerable serpentine vessels centered within the left lower uterine wall extending into the endometrial cavity. This has approximate total ___ of 5 x 5.5 x 6.5 cm. On pre contrast imaging, there are both areas of T2 hyperintensity, particularly in extending into the endometrial cavity, as well as areas of T2 hypointense flow voids. This area is relatively homogeneously intermediate in signal on T1 weighted sequences and low in signal on diffusion-weighted sequences. After administration of contrast, there is brisk enhancement of innumerable serpiginous vessels thought to represent a combination of arteries and veins given the early, asymmetric contrast opacification of the left internal iliac vein (1251S: 32). Contrast opacification of an asymmetrically enlarged left gonadal vein is also earlier than expected, likely on the basis of early drainage from this the vascular nidus (12:54). While the majority of the vessels are confined to this masslike nidus, there is communication with a myometrial of vessels extending circumferentially around the uterus to the contralateral side (1250:9). There is a trace amount of free pelvic fluid. The ovaries are normal in appearance. Osseous structures are unremarkable. IMPRESSION: 6.5 cm uterine mass composed of innumerable early vessels with early arterial enhancement and early venous drainage, indicative of an arteriovenous malformation. This is centered within the left lower uterine myometrium, with intramural vascular communication circumferentially, and a large component extending into the endometrial cavity. Arterial supply appears to be predominantly via the left ovarian artery, and venous drainage via the left internal iliac vein and possibly the left gonadal vein. NOTIFICATION: Interpretation was discussed with via phone by Dr ___ with Dr ___ at approximately 4:30pm on ___. Plan is for treatment with endovascular embolization. Radiology Report INDICATION: ___ female with major postpartum hemorrhage status post c-section and D&C with uterine AV fistula demonstrated on pelvic MRI. COMPARISON: MRI of the pelvis from ___. TECHNIQUE: OPERATORS: Dr. ___ radiology fellow), Dr. ___ ___ (radiology resident, and Drs. ___ (interventional radiology attendings) performed the procedure. The attendings, Drs. ___ ___ were present and supervising throughout the procedure. Drs. ___, attending radiologists, personally supervised the trainee during the key components of the procedure and reviewed and agreed with the trainee's findings. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 150mcg of fentanyl and 3 mg of midazolam throughout the total intra-service time of 3 hours 10 minutes during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: Fentanyl, midazolam, 200 mcg nitroglycerin, 2 g cefazolin. CONTRAST: 297 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 40 minutes, 1156 mGy PROCEDURE: 1. Right common femoral artery access. 2. Left internal iliac arteriogram with cone beam CT. 3. Left uterine arteriogram. 4. Embolization of the left uterine artery to stasis utilizing cyanoacrylate glue/lipiodol mixture. 5. Right uterine arteriogram. 6. Aortogram extending to the superficial femoral arteries. 7. Selective left ovarian arteriogram. PROCEDURE DETAILS: Following a discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. Right groin was prepped and draped in the usual sterile fashion. Using palpatory and fluoroscopic guidance, the right common femoral artery was punctured using a 21 gauge micropuncture needle at the level of the mid femoral head. A Nitinol wire was advanced into the aorta. A small skin incision was made over the needle and the needle was exchanged for a micropuncture sheath. The inner stiffener and wire were removed and ___ wire was advanced into the aorta. The micropuncture sheath was then exchanged for a 5 ___ sheath which was attached to a continuous heparinized saline side arm flush. An Omni flush catheter was advanced over the wire and the ___ wire was exchanged for a Glidewire. The Glidewire was used to select the left external iliac artery and the Omniflush catheter was exchanged for a pudendal catheter. The pudendal catheter was used to cannulate the left internal iliac artery. A left internal iliac arteriogram 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 ___ (attendings Dr. ___ Dr. ___. These images were used in the interpretation, decision making for intervention and reporting of this procedure. A left uterine arteriogram was performed. Using the arteriogram as a road map a pre-loaded high-flow Renegade catheter and Transcend wire were advanced distally into the uterine artery. Initially, some spasm was noted and 200 mcg of nitroglycerin was administered. Following resolution of spasm, the pudendal catheter was advanced slightly to decrease arterial inflow. Embolization of the arteriovenous fistula was performed with cyanoacrylate/lipiodol mixture to stasis. The microcatheter was retracted and a more proximal injection in the left uterine artery demonstrated recruitment of several additional branches supplying the arteriovenous fistula. Embolization to stasis was then performed at the more proximal left uterine artery. Repeat left internal iliac arteriogram demonstrates cessation of flow into the left uterine artery and no flow towards the arteriovenous fistula. The microcatheter was then removed and the pudendal catheter was used to engage the right uterine artery. A right uterine arteriogram was performed. The Glidewire was then used to unform the pudendal catheter and the pudendal catheter was exchanged for the Omni Flush catheter. An aortogram was performed just below the level of the renal arteries to evaluate the ovarian arteries. The Omni Flush catheter was then exchanged for ___ catheter. The ___ catheter was used to selectively cannulate the ostium of the left ovarian artery. The Renegade Hi Flow microcatheter and microwire were used to advance slightly more distal into the left ovarian artery. A selective left ovarian arteriogram was performed. The catheters and wires were then removed and the sheath was removed. Manual pressure was held until hemostasis was achieved. Sterile dressings were applied. The patient tolerated the procedure well and there were no immediate post-procedure complications. FINDINGS: 1. Left uterine artery supplying a large arteriovenous fistula with drainage into the internal iliac and left gonadal veins. 2. Embolization of the arteriovenous fistula utilizing cyanoacrylate glue/lipiodol mixture with embolization performed to stasis. The pudendal catheter was advanced into the left uterine artery during embolization to decrease arterial inflow and prevent non-target embolization through the fistula. 3. Repeat contrast injection from the proximal left uterine artery following embolization demonstrated recruitment of at least two additional branches supplying the arteriovenous fistula from the more proximal left uterine artery. 4. Embolization of the left uterine artery to stasis back towards its more proximal segment. 5. Repeat left internal iliac arteriogram demonstrates cessation of flow into left uterine artery and arteriovenous fistula. Flow is preserved in the remaining branches of the internal iliac artery. 6. Right uterine arteriogram demonstrates hypervascularity related to postpartum state. No supply to arteriovenous fistula was noted. 7. Aortogram demonstrates hypertrophy of bilateral ovarian arteries, as expected given immediate postpartum state. 8. Selective left ovarian arteriogram demonstrates no supply to the arteriovenous fistula. IMPRESSION: Successful cyanoacrylate/lipiodol embolization of the left uterine artery and arteriovenous fistula to stasis. Radiology Report EXAMINATION: PELVIS, NON-OBSTETRIC INDICATION: ___ year old woman with heavy vaginal bleeding s/p embolization now with more bleeding POD#1 from embolization // eval for any other source of bleeding, rpoc TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with transabdominal approach. The patient declined transvaginal sonography. COMPARISON: MRI dated ___ FINDINGS: The uterus is anteverted and retroflexed and measures 15.3 x 7.0 x 10.0 cm. Echogenic material and fluid is demonstrated within the endometrial cavity. The echogenic material measures 6.1 x 3.7 cm. A small amount of venous flow is demonstrated within the echogenic material. The left lateral myometrium demonstrates a large region with abnormal vascularity. This region appears hypervascular with peak systolic velocity of 117 cm/sec and end-diastolic velocity of 74 cm/sec. The ovaries were not imaged. There is no free fluid. IMPRESSION: 1. Echogenic material measuring 6.1 cm within the endometrial cavity demonstrating a small amount of venous flow representing retained products of conception. Fluid is also demonstrated within the cavity. 2. Large region of abnormal vascularity in the left lateral myometrium with peak systolic velocity of 117 cm/sec and end-diastolic velocity of 74 cm/sec suggestive of residual AV connection. NOTIFICATION: The findings were discussed by ___ with Dr. ___ ___ on the telephone on ___ at 10:11 AM, 5 minutes after discovery of the findings. Radiology Report INDICATION: ___ woman s/p LTCS on ___ c/b hemorrhage, readmitted with vaginal bleeding and imaging c/f AVM s/p embolization ___ and US-guided D C for rPOC ___ now with fever to 101.5 // r/o intra-abdominal infection, pelvic thrombophlebitis TECHNIQUE: Contiguous helical MDCT images were obtained through the abdomen and pelvis first without contrast utilizing low-dose technique and then after administration of Omnipaque IV contrast and scanning in the venous phase. Multiplanar axial, coronal, sagittal and maximal intensity projection coronal images were generated. DOSE: Total body DLP: 424 mGy-cm COMPARISON: MR ___ ___ FINDINGS: LOWER CHEST: The included lung bases are clear. The heart is not enlarged and there is no pericardial effusion. CT ABDOMEN WITH CONTRAST: HEPATOBILIARY: The liver enhances normally without focal lesions. There is no intra or extrahepatic biliary duct dilation. The gallbladder is normal without stones or wall thickening. The portal vein is patent. PANCREAS: The pancreas has normal attenuation without focal lesions, duct dilation or peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation without focal lesions. ADRENALS: Bilateral adrenal glands are normal in size and shape. URINARY: The kidneys excrete contrast promptly and symmetrically and are without hydronephrosis, mass or perinephric abnormality. 3 mm hypodense rounded focus in the interpolar region of the right kidney is too small to characterize but is most likely a simple cyst. GASTROINTESTINAL: The stomach, small and large bowel are normal in caliber without wall thickening or obstruction. RETROPERITONEUM: There is a 1.3 cm left retroperitoneal lymph node (06:42). CT PELVIS WITH CONTRAST: The uterus remains enlarged measuring 13.7 x 7.6 x 10.1 cm. The endometrium is distended to approximately 22 mm containing fluid and multiple locules of gas. A large amount of amorphous hyperdense material along the left inferior aspect of the uterus and cervix is compatible with embolic material (cyanoacrylate/lipiodol). A few loculated gas in the urinary bladder are noted non dependently. There is small amount of free fluid in the pelvis CTV ABDOMEN AND PELVIS: Bilateral gonadal veins appear patent. The abdominal aorta and iliac arteries are normal in caliber. BONES AND SOFT TISSUES: There are no worrisome blastic or lytic lesions. The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. The ovarian veins appear patent. There is no evidence of thrombophlebitis. 2. Enlarged uterus as detailed above with retained fluid and multiple locules of gas. Gas is presumably from prior instrumentation two days ago, however it is difficult to exclude gas-forming bacteria within blood products, in the setting of fever. 3. No evidence of abscess or other drainable fluid collection. 4. Small foci of nondependent gas within the bladder are likely related to recent Foley catheter; correlate with catheter history. NOTIFICATION: The findings were telephoned to Dr. ___ By ___ at 21:55, ___, 5 min after discovery. Radiology Report EXAMINATION: RENAL U.S. INDICATION: ___ year old woman with worsening creatinine and mild left flank pain // please eval for any souurce of infection, worsening creatinine TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: CT abdomen pelvis on ___. FINDINGS: RIGHT: The right kidney measures 10.6 cm. There is no hydronephrosis, stones, or masses. Normal cortical echogenicity and corticomedullary differentiation. LEFT: The left kidney measures 11.1 cm. There is mild left hydronephrosis and mild left proximal hydroureter. The mid and distal ureter are not well seen. No stones or masses bilaterally. Normal cortical echogenicity and corticomedullary differentiation. The bladder is only minimally distended and can not be fully assessed on the current study. IMPRESSION: Mild left hydronephrosis and mild left proximal hydroureter. The mid and distal ureter are not well seen on this study. No stone or mass identified. Bladder not well evaluated. Consider urological consultation. NOTIFICATION: These findings were discussed with Dr. ___ by Dr. ___ at 1223 pm on ___ by phone at time of discovery. Gender: F Race: WHITE - OTHER EUROPEAN Arrive by UNKNOWN Chief complaint: Vaginal bleeding Diagnosed with DELAY P/PART HEM-POSTPAR temperature: 99.8 heartrate: 90.0 resprate: 16.0 o2sat: 99.0 sbp: 107.0 dbp: 63.0 level of pain: 1 level of acuity: 2.0

Ms. ___ is ___ year old s/p LTCS on ___ at ___ ___ with postpartum hemorrhage s/p D&C and Bakri balloon placement who presented with vaginal bleeding at home and concern for secondary postpartum hemorrhage. She was hemodynamically stable on admission with no active bleeding. There was initial concern for abnormal placentation vs. vascular malformation and Maternal Fetal Medicine was consulted. A bedside US revealed a vascularized intrauterine mass and a MRI was done ___ for further characterization. MRI findings were consistent with arterial venouse malformation. Interventional Radiology was consulted and she underwent embolization on ___. Please see procedure note for details. She continued to have bleeding post embolization and an pelvic ultrasound was consistent with retained products of conception. She underwent an US guided D&C on ___. Please see operative note for details. She received uterotonics and had improved bleeding. She was transfused one unit packed RBC ___ for symptomatic anemia with appropriate hematocrit and symptomatic response. She developed a post-procedural fever to 101.8F concerning for endometritis. CT did not show abdominal collections or evidence of thrombophlebitis. Infectious disease was consulted and she was treated initially with IV ampicillin/gentamycin/clindamycin. She was subsequently noted to have ATN possibly secondary to drug toxicity and switched to Unasyn on ___. Her blood cultures were negative and she was treated for yeast in her urine culture. She was afebrile for over 48 hours and was discharged on oral Augmentin. Urology was consulted given ___ with concerns of embolization material in the left ureteral vessels. Renal US showed Mild left hydronephrosis and mild left proximal hydroureter. Her creatinine was trended. Ureteral stenting was deferred pending renal functional testing for obstruction that was scheduled as an outpatient. She was discharged home in stable condition on ___ with antibiotics and close outpatient follow-up scheduled and precautions provided.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Cipro / lisinopril / clavulanic acid / atenolol Attending: ___. Chief Complaint: chills, malodorous urine Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old gentleman with PMHx of paraplegia with neurogenic bladder and frequent UTIs, recently admitted to ___ on ___ for Pseudomonas UTI treated with cefepime, who presenting with concern of UTI for 1 day. He endorses feeling hot, chills, and malodorous urine. Urine was murky in color. He was given 7 days of cefepime, but wonders if he needed 10 days instead. Has some nausea, no vomiting. Unable to feel below T4 at baseline and therefore not aware if burning while peeing. Denies back pain, chest pain, shortness of breath, headache, dizziness, diarrhea. He recently completed 5 days of Cefepime in ___, given through a PICC linem which was subsequently removed. He uses a condom catheter and bag for urination. He lives alone at home without any other assistant. In the ED: - VS were T 99.4 HR 88 BP 144/67 RR 20 SaO2 100% - On exam, he had no CVA tenderness, AKA of right leg, right leg - Labs were notable for WBC 11.1 with PMNs 71.7%, phos 2.5, lactate 1.7, UA with large leuk, neg nitrite, 46 WBC, 1 epi - Blood and urine cultures were taken - He was given 2g cefepime, 5mg oxycodone, 10mg baclofen, 25mg amitryptyline - He was admitted for complicated UTI On the floor, he feels well. Otherwise ROS is negative. Past Medical History: Paraplegia due to fall down shaft in ___ Recurrent UTIs Osteomyelitis s/p left AKA ___ Prostate cancer s/p surgical resection in ___, no chemoradiation Phantom limb pain Corneal dystrophy, anterior s/p cataract surgery on R eye Social History: ___ Family History: Pt unaware of significant family history. Physical Exam: EXAM ON ADMISSION: ====================== Vitals: T 98.1 BP 148/68 HR 84 RR 18 SaO2 94% on RA GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs, + pectus excavatum LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, right leg with msucular atrophy, left leg AKA NEURO: CN II-XII intact, absent sensation below navel, paralysis of ___ ___, ___ strength UEs SKIN: warm and well perfused, no excoriations or lesions, no rashes EXAM ON DISCHARGE: ====================== Vitals: 98.0 (98.7) 136/74 (136-156/64-78) 85 (72-86) 20 (___) 97% RA (97-100% RA) GENERAL: NAD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs, + pectus excavatum LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, right leg with msucular atrophy, left leg AKA NEURO: grossly intact SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: LABS ON ADMISSION: =================== ___ 07:20PM BLOOD WBC-11.1* RBC-4.99 Hgb-14.5 Hct-42.1 MCV-84 MCH-29.1 MCHC-34.5 RDW-14.4 Plt ___ ___ 07:20PM BLOOD Neuts-71.7* ___ Monos-6.4 Eos-1.7 Baso-0.5 ___ 07:20PM BLOOD Glucose-83 UreaN-10 Creat-0.6 Na-134 K-4.3 Cl-97 HCO3-23 AnGap-18 ___ 07:20PM BLOOD Calcium-9.0 Phos-2.5* Mg-2.3 ___ 07:35PM BLOOD Lactate-1.7 ___ 03:40PM URINE Color-Straw Appear-Hazy Sp ___ ___ 03:40PM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG ___ 03:40PM URINE RBC-8* WBC-46* Bacteri-FEW Yeast-NONE Epi-1 ___ 03:40PM URINE AmorphX-RARE LABS ON DISCHARGE: =================== ___ 07:41AM BLOOD WBC-9.7 RBC-5.02 Hgb-14.5 Hct-43.1 MCV-86 MCH-28.8 MCHC-33.6 RDW-14.5 Plt ___ ___ 07:41AM BLOOD Glucose-67* UreaN-11 Creat-0.5 Na-137 K-4.0 Cl-100 HCO3-20* AnGap-21* ___ 07:41AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.0 MICROBIOLOGY: =================== ___ 3:40 pm URINE URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. ___ 7:20 pm BLOOD CULTURE Blood Culture, Routine (Pending): ___ 8:59 pm BLOOD CULTURE Blood Culture, Routine (Pending): STUDIES: =================== ___ LINE REPLACEMENTStudy Date of ___ 11:02 AM IMPRESSION: Successful placement of a 47 cm left arm approach single lumen PICC with tip in the lower SVC. The line is ready to use. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amitriptyline 25 mg PO QHS 2. Amlodipine 10 mg PO DAILY 3. Baclofen 10 mg PO QID 4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain 5. Valsartan 80 mg PO DAILY Discharge Medications: 1. Amitriptyline 25 mg PO QHS 2. Baclofen 10 mg PO QID 3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain 4. CefePIME 1 g IV Q12H RX *cefepime [Maxipime] 1 gram 1 gram intravenously every 12 hours Disp #*18 Vial Refills:*0 5. Amlodipine 10 mg PO DAILY 6. Valsartan 80 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: - Urinary Tract Infection Secondary: - Neurogenic Bladder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report INDICATION: ___ year old man with inability to advance PICC by IV team at bedside. // ___ repo COMPARISON: None. TECHNIQUE: OPERATORS: Dr. ___ resident 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. CONTRAST: None. FLUOROSCOPY TIME AND DOSE: 2.8 min, 2 mGy PROCEDURE: Replacement of left PICC. PROCEDURE DETAILS: Using sterile technique and local anesthesia, the existing PICC was aspirated and flushed and a Nitinol guidewire was introduced into the superior vena cava (SVC). The exisiting PICC was removed. A peel-away sheath was then placed over the guidewire. The guidewire was then advanced into the superior vena cava. A single lumen PICC measuring 47 cm in length was then placed through the peel-away sheath with its tip positioned in the lower 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: Existing left arm approach PICC with tip in the left axilla was replaced with a new single lumen PICC with tip in the lower SVC. IMPRESSION: Successful placement of a 47 cm left arm approach single lumen PICC with tip in the lower SVC. The line is ready to use. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: UTI SX Diagnosed with URIN TRACT INFECTION NOS, DEHYDRATION temperature: 99.4 heartrate: 88.0 resprate: 20.0 o2sat: 100.0 sbp: 144.0 dbp: 67.0 level of pain: 4 level of acuity: 3.0

BRIEF HOSPITAL COURSE: ============================ ___ with PMHx of paraplegia with neurogenic bladder and frequent UTIs admitted for complicated UTI (46 WBCs on UA, few bacteria). Started on IV cefepime. Urine cx revealed mixed bacterial flora, consistent with fecal contamination. Treated with 10-day course of IV cefepime given history of recurrent UTIs. Urine culture showed mixed bacterial flora, consistent with fecal contaminants. Repeat urine culture was not ordered since patient had already received several doses of IV cefepime. By time of discharge, (treatment day #2), patient's symptoms had resolved entirely.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old ___ man with PMH of schizophrenia, dementia, right frontoparietal craniotomy presents from ___ ___ assisted living after a witnessed fall. Per ED discussion with family, he appeared at his baseline mental status and orientation. He was complaining of right shoulder/elbow pain, otherwise no complaints. Per discussion with RN at ___, he has had ___ weeks of altered behavior. He has been more violent toward the other residents, whereas usually he has a very affable demeanor. His baseline mental status is awake, alert and pleasant, but with decreased situational awareness, and unable to advocate for himself or describe symptoms. His nurse reports that he saw his doctor ___ this past week for the increased violent behavior, although she is not sure what was done for him if anything. In the ED, initial vitals were: 98.3, 103, 159/89, 18, 96% RA Exam notable for bloody sputum at corners of mouth, trauma survey unremarkable. He had one episode of emesis/frothy sputum but no other abdominal symptoms or findings. Also noted to have brief hypoxia and wheezing while sleeping which resolved spontaneously. UA revealed large leuks, positive nitrites, many bacteria. Labs notable for Cr 3.4, BUN 38 (no known baseline), Hb 12.1, WBC 8.1, lactate 1.1. Imaging notable for: CT head and C-spine negative; right shoulder/elbow xrays: no fracture or misalignment, CXR: borderline cardiomegaly but rotated, no ptx, no rib fx. Patient was given his home metoprolol and keppra, as well as 1g CTX IV. Decision was made to admit for treatment of UTI. Vitals on transfer: 98.4, 92, 143/84, 20, 97% RA On the floor, pt is somnolent but rouses to voice. Answers that he is in the hospital but not sure which hospital. Further history to be obtained once ___ interpreter is available. Review of systems: 10 point ROS reviewed and negative except as per HPI Past Medical History: -Schizoprhenia -Dementia -?Sz disorder -CKD Social History: ___ Family History: Unknown Physical Exam: ADMISSION PHYSICAL EXAM: ========================== VS: 98.5, 135 / 82, 85, 20, 97% Ra Gen: Sleepy, rouses to voice, NAD HENT: NC/AT. Dry MM. Eyes: No scleral icterus. CV: RRR no r/m/g Pulm: CTAB Abd: Soft, non-tender, non-distended GU: No foley Ext: WWP, no peripheral edema Skin: warm, dry Neuro: Sleepy, rouses to voice. Alert to person, hospital. No gross deficits. Psych: Unable to assess DISCHARGE PHYSICAL EXAM: ========================== Vitals: 98.1, 124 / 73, 78 18 92 Ra Gen: Awake, alert HENT: NC/AT. MMM. Eyes: No scleral icterus. CV: RRR no r/m/g Pulm: CTAB Abd: Soft, non-tender, non-distended GU: No foley Ext: WWP, no peripheral edema. R hip with no obvious ecchymosis, bony abnormality, non-tender to palpation. Apparent pain with external rotation of the hip. Full ROM at the R knee with no bony abnormality and non-tender to palpation. Skin: warm, dry Neuro: Awake, alert to person, hospital. Tardive dyskinesia. Psych: Agreeable affect Pertinent Results: ADMISSION LABS: ___ 09:18PM BLOOD WBC-8.1 RBC-3.86* Hgb-12.1* Hct-37.4* MCV-97 MCH-31.3 MCHC-32.4 RDW-11.6 RDWSD-40.9 Plt ___ ___ 09:18PM BLOOD Glucose-158* UreaN-38* Creat-3.4* Na-137 K-4.3 Cl-99 HCO3-20* AnGap-22* ___ 09:18PM BLOOD ALT-15 AST-24 AlkPhos-96 TotBili-0.8 ___ 09:18PM BLOOD Albumin-4.2 Calcium-9.2 Phos-3.2 Mg-2.3 ___ 11:27PM URINE Blood-TR Nitrite-POS Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-LG ___ 11:27PM URINE RBC-5* WBC-93* Bacteri-MANY Yeast-NONE Epi-0 DISCHARGE LABS: ___ 10:35AM BLOOD WBC-4.5 RBC-3.30* Hgb-10.9* Hct-32.5* MCV-99* MCH-33.0* MCHC-33.5 RDW-11.9 RDWSD-42.8 Plt ___ ___ 10:35AM BLOOD Glucose-242* UreaN-36* Creat-2.9* Na-136 K-4.1 Cl-104 HCO3-18* AnGap-18 ___ 10:35AM BLOOD Calcium-7.8* Phos-3.3 Mg-2.0 MICROBIOLOGY: ___ 11:27 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: PROTEUS MIRABILIS. 10,000-100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROTEUS MIRABILIS | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S IMAGING: CT head: Postsurgical changes are seen following right frontoparietal craniotomy. Otherwise, no acute major intracranial process. CT Cspine: 1. No evidence of acute fracture. There is minimal anterolisthesis of the C3-C4 vertebral level, likely degenerative in etiology. Please correlate clinically for focal pain at this level. 2. Mild-to-moderate degenerative changes in the cervical spine with mild multilevel vertebral canal and neural foraminal stenosis. 3. Mild thickening of the esophagus may reflect esophagitis. Please correlate with clinical exam. Right Shoulder Xray: Mild arthritis, no fracture or dislocation. Right Elbow: No fracture or dislocation Chest Xray: AP portable supine view of the chest. Patient is slightly rotated 2 the right. Widened mediastinum may be technique related. Lungs are clear. Cardiac silhouette appears normal in size. No large effusion or definite signs of pneumothorax on this supine radiograph. Bony structures are intact. Limited, negative. Renal ultrasound: 1. No evidence of hydronephrosis, nephrolithiasis, or perinephric fluid collection bilaterally. 2. There is thickening and irregularity of the posterior aspect of the bladder which likely represents trabeculation. However, a bladder mass cannot be excluded based on this exam. Consider more detailed evaluation if desired with more completely distended bladder Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Calcium Acetate 1334 mg PO BID 2. Benztropine Mesylate 1 mg PO BID 3. Haloperidol 2 mg PO QHS 4. Haloperidol Decanoate (long acting) 100 mg IM Frequency is Unknown 5. LevETIRAcetam 250 mg PO BID 6. Metoprolol Tartrate 50 mg PO BID 7. Senna 17.2 mg PO QHS:PRN constipation Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H last day ___ 2. Benztropine Mesylate 1 mg PO BID 3. Calcium Acetate 1334 mg PO BID 4. Haloperidol Decanoate (long acting) 100 mg IM ONCE Duration: 1 Dose 5. Haloperidol 2 mg PO QHS 6. LevETIRAcetam 250 mg PO BID 7. Metoprolol Tartrate 50 mg PO BID 8. Senna 17.2 mg PO QHS:PRN constipation Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnosis: Urinary tract infection Secondary diagnosis: acute kidney injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: RENAL U.S. INDICATION: ___ year old man with post-void residual of 550, dirty UA // eval for obstruction TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: None. FINDINGS: The right kidney measures 9.2 cm. The left kidney measures 10.4 cm. The kidneys appear atrophic and more echogenic, with decreased corticomedullary differentiation. There is a 1.2 cm cyst in the left upper renal pole. There is no visualized hydronephrosis, stones, or masses bilaterally. The bladder is partially distended. There is irregularity and thickening of the posterior aspect of the bladder which is likely due to trabeculation however, a bladder mass is not excluded. IMPRESSION: 1. No evidence of hydronephrosis, nephrolithiasis, or perinephric fluid collection bilaterally. 2. There is thickening and irregularity of the posterior aspect of the bladder which likely represents trabeculation. However, a bladder mass cannot be excluded based on this exam. Consider more detailed evaluation if desired with more completely distended bladder NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 11:18 pm, 20 minutes after discovery of the findings. Gender: M Race: UNKNOWN Arrive by UNKNOWN Chief complaint: R Elbow pain, s/p Fall Diagnosed with Altered mental status, unspecified, Urinary tract infection, site not specified, Chronic kidney disease, unspecified temperature: 98.3 heartrate: 103.0 resprate: 18.0 o2sat: 96.0 sbp: 159.0 dbp: 89.0 level of pain: 0 level of acuity: 2.0

___ year old ___ man with PMH of schizophrenia, dementia, right frontoparietal craniotomy presents from ___ ___ after a witnessed fall i/s/o ___ weeks of altered behavior, found to have a UTI. Treated with ceftriaxone with improvement in mental status to baseline, and transitioned to ciprofloxacin to complete a 10 day course for complicated UTI.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: codeine / valproic acid / ibuprofen / propofol / chlorhexidine / cefazolin / cefazolin / levofloxacin / dexmedetomidine / bupivacaine / divalproex sodium Attending: ___. Chief Complaint: HD CATH REPLACEMENT Major Surgical or Invasive Procedure: Replacement of tunneled dialysis line History of Present Illness: ___ with history of ESRD (HD TRS), fell down steps yesterday, seen at ___ where he had CT head and chest, but no neck, he was discharged home. Pt believe his catheter may have broke during fall. Today he presents because he rolled over in bed overnight and dialysis port came out. Of note, pt is an extremely poor historian and cannot relay a good sequence of events. Pt has never been seen at ___ before. In the ED, Had C-spine here which was negative. CXR showed mild-moderate pulmonary edema. The patient was evaluated by the interventional fellow regading cath tip replacement with plan to replace tomorrow. In the ED, initial VS were 98.4 84 117/49 12 100% RA. Exam notable for palpable fibrous tract that was surrounding the catheter, as well as forehead scrape. Labs showed macrocytic anemia with hgb 8.7, plt 136, Na 131, K 5.2, Cl 94. Imaging showed CT Head without acute intracranial process, CT C-spine without fracture, and CXR with mild/moderate pulmonary edema. ___ was consulted and will likely replace catheter tomorrow. Vascular surgery was consulted for possibility of retained catheter tip, but they deemed the catheter tip intact. Decision was made to admit to medicine for further management. On arrival to the floor, patient reports a history of falls starting approximately 5 months ago. He does not lose consciousness. Feels unsteady with his gait. ___ was going to see him at his home. Past Medical History: ESRD, on HD ___ Chronic Back Pain L Foot pain PTSD Schizophrenia Anxiety Deprssion LUE fistula Social History: ___ Family History: Mother with diabetes, HTN, HLD Physical Exam: ADMISSION PHYSICAL EXAM: VS - 97.9 129/59 887 18 100%RA GENERAL: NAD, flat affect HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs. Area of tunneled line open, c/d/I. Fibrous tract can be felt. LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose. LUE with fistula and good thrill PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE EXAM VS - 97.9 123/52 85 18 100% GENERAL: NAD, brighter affect HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: nontender supple neck, no LAD, no JVD CHEST : RRR, S1/S2, no murmurs, gallops, or rubs. Tunneled HD catheter in bandage. Site of insertion c/d/I, nontender LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose. LUE with fistula and good thrill PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, decreased proprioception in bilateral great toes. Sensation to light touch intact. Strength ___ ___ SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS ___ 03:00AM BLOOD WBC-6.1 RBC-2.65* Hgb-8.7* Hct-26.9* MCV-102* MCH-32.8* MCHC-32.3 RDW-21.3* RDWSD-78.7* Plt ___ ___ 03:00AM BLOOD Neuts-69.8 Lymphs-15.5* Monos-9.5 Eos-3.4 Baso-1.5* Im ___ AbsNeut-4.26 AbsLymp-0.95* AbsMono-0.58 AbsEos-0.21 AbsBaso-0.09* ___ 02:00PM BLOOD ___ ___ 03:00AM BLOOD Glucose-93 UreaN-26* Creat-3.7* Na-131* K-5.2* Cl-94* HCO3-28 AnGap-14 ___ 03:00AM BLOOD ALT-20 AST-49* AlkPhos-100 TotBili-0.8 ___ 03:00AM BLOOD Albumin-3.5 ___ 07:40AM BLOOD Albumin-3.5 Calcium-9.1 Phos-3.4 Mg-1.9 ___ 06:50AM URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-NEG amphetm-NEG oxycodn-POS mthdone-NEG MICRO: none IMAGING: EKG ___: Sinus rhythm. Q-T interval is borderline prolonged for rate. Leftward axis. Prominent voltage raises the possibility of left ventricular hypertrophy. Non-specific ST-T wave abnormalities may be related to left ventricular hypertrophy. No previous tracing available for comparison. CT Head/ CT C-spine ___: No acute intracranial process. No acute fracture or vertebral malalignment. CXR ___: Mild to moderate pulmonary edema. Cardiomegaly. Tunneled Dialysis Line Placement ___: 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. DISCHARGE LABS: ___ 08:02AM BLOOD WBC-6.6 RBC-2.92* Hgb-9.3* Hct-29.8* MCV-102* MCH-31.8 MCHC-31.2* RDW-20.5* RDWSD-77.3* Plt ___ ___ 08:02AM BLOOD Glucose-94 UreaN-49* Creat-5.5* Na-133 K-5.2* Cl-96 HCO3-25 AnGap-17 ___ 07:40AM BLOOD ALT-16 AST-36 LD(LDH)-418* AlkPhos-99 TotBili-0.9 ___ 08:02AM BLOOD Calcium-8.7 Phos-3.6 Mg-1.8 ___ 07:40AM BLOOD VitB12-811 ___ 09:20AM BLOOD %HbA1c-5.2 eAG-103 ___ 07:40AM BLOOD TSH-12* ___ 08:02AM BLOOD T4-6.5 T3-68* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amphetamine-Dextroamphetamine XR 20 mg PO DAILY 2. Aspirin 325 mg PO DAILY 3. Calcium Carbonate 600 mg PO Frequency is Unknown 4. Vitamin D 1000 UNIT PO DAILY 5. ClonazePAM 1 mg PO Frequency is Unknown 6. Nephrocaps 1 CAP PO DAILY 7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 8. LeVETiracetam 250 mg PO BID 9. Lisinopril 2.5 mg PO DAILY 10. Metoprolol Tartrate 12.5 mg PO DAILY 11. OLANZapine 2.5 mg PO QHS 12. OLANZapine 5 mg PO DAILY 13. Omeprazole 20 mg PO Frequency is Unknown 14. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain 15. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Frequency is Unknown pain 16. Polyethylene Glycol 17 g PO DAILY 17. sevelamer CARBONATE 2400 mg PO TID W/MEALS 18. Simvastatin 20 mg PO QPM 19. TraZODone 50 mg PO QHS Discharge Medications: 1. Amphetamine-Dextroamphetamine XR 20 mg PO DAILY 2. Aspirin 325 mg PO DAILY 3. ClonazePAM 0.5 mg PO Q8H:PRN anxiety do not drink alcohol or drive while on this medication RX *clonazepam 0.5 mg 1 tablet(s) by mouth every eight (8) hours Disp #*21 Tablet Refills:*0 4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 5. LeVETiracetam 250 mg PO BID 6. Lisinopril 2.5 mg PO DAILY 7. Metoprolol Tartrate 12.5 mg PO DAILY 8. Nephrocaps 1 CAP PO DAILY 9. OLANZapine 2.5 mg PO QHS 10. OLANZapine 5 mg PO DAILY 11. Omeprazole 20 mg PO BID 12. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain do not drink alcohol or drive while on this medication 13. Polyethylene Glycol 17 g PO DAILY 14. sevelamer CARBONATE 2400 mg PO TID W/MEALS 15. Simvastatin 20 mg PO QPM 16. TraZODone 50 mg PO QHS 17. Vitamin D 1000 UNIT PO DAILY 18. Acetaminophen 1000 mg PO Q8H:PRN pain do not exceed 3g in a day (3 pills) RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) hours Disp #*75 Tablet Refills:*0 19. Calcium Carbonate 500 mg PO BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: End Stage Renal Disease on Dialysis Recurrent Falls Schizophrenia Chronic Anemia Hyponatremia Discharge Condition: Activity Status: Ambulatory - requires assistance or aid (walker or cane). Level of Consciousness: Alert and interactive. Mental Status: Confused - sometimes. Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: History: ___ with head strike and LOC // R/O acute process TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced Acquisition 16.0 s, 16.4 cm; CTDIvol = 48.9 mGy (Head) DLP = 802.7 mGy-cm. 4) Sequenced Acquisition 4.0 s, 4.1 cm; CTDIvol = 48.9 mGy (Head) DLP = 200.7 mGy-cm. Total DLP (Head) = 1,003 mGy-cm. COMPARISON: None. FINDINGS: The examination is slightly motion degraded. Within these confines: There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles and sulci are normal in size and configuration. There is no evidence of fracture. There are small mucous retention cyst in the right frontal sinus. Otherwise, the visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: No acute intracranial process. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE INDICATION: History: ___ with head strike and LOC // R/O acute process R/O acute process 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) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Spiral Acquisition 6.0 s, 23.3 cm; CTDIvol = 37.3 mGy (Body) DLP = 871.0 mGy-cm. Total DLP (Body) = 871 mGy-cm. COMPARISON: None. FINDINGS: There is no acute fracture or vertebral malalignment. Degenerative changes are noted throughout the C-spine, most prominent at C6-7 with endplate sclerosis and disc space narrowing. 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. IMPRESSION: No acute fracture or vertebral malalignment. Radiology Report EXAMINATION: Chest radiographs INDICATION: History: ___ with fall, dialysis catheter traumatically removed from R-side // evaluate for pneumothorax, acute process TECHNIQUE: Single portable supine AP image of the chest. COMPARISON: None. FINDINGS: The lungs are well expanded. There are perihilar opacities and reticular opacities, consistent with mild to moderate pulmonary edema. There are no pleural effusions or pneumothorax. The cardiomediastinal silhouette demonstrates moderate to severe enlargement IMPRESSION: Mild to moderate pulmonary edema. Cardiomegaly. Radiology Report INDICATION: ___ year old man with ESRD and recently removed tunneled dialysis catheter. Pt was consulted on in ED. // Replacement of tunneled dialysis line COMPARISON: Chest radiograph of ___. 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: 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. FLUOROSCOPY TIME AND DOSE: 1.8 min, 3 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 right upper chest was prepped and draped in the usual sterile fashion. Under continuous ultrasound guidance, the patent right internal jugular vein was partially 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. ___ 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: Partially thrombosed right internal jugular vein. Final fluoroscopic image showing tunneled hemodialysis 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. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Chest pain Diagnosed with Oth complication of vascular prosth dev/grft, init, Exposure to other specified factors, initial encounter, Chronic kidney disease, unspecified temperature: 98.4 heartrate: 84.0 resprate: 12.0 o2sat: 100.0 sbp: 117.0 dbp: 49.0 level of pain: 0 level of acuity: 2.0

Mr. ___ is a ___ yo M with ESRD on T/R/S dialysis, immature LUE fistula, schizophrenia, PTSD, ADHD, depression, and chronic back pain who presented after tunneled dialysis catheter was completely withdrawn s/p fall. Patient had previously been evaluated for fall at ___, noting facial lacerations and left rib fractures. The next day he noticed his catheter fell out and came to ___ for replacement. Given his recent trauma, CT head and CT C-spine were performed, both of which did not reveal acute pathology. Patient's tunneled dialysis line was replaced and he received dialysis in house ___. He tolerated 500cc of his goal 1L ultrafiltration, before becoming anxious. He also reported a 5 month history of instability and recurrent falls. On exam, he had some evidence of bilateral peripheral neuropathy. B12 and A1c were within normal limits, TSH returned elevated at 12; T3, T4 were pending at the time of discharge. He was evaluated by ___ who recommended discharge home with continued ___ services. # Fall: Patient had a recent fall, for which he had a CT head and c-spine which were without acute abnormality. Patient is a poor historian. CXR and UA without signs of localizing infection. Urine toxicology positive for opiates, which patient takes at home. Spoke with patient's wife who reports he has some difficulty mentating at baseline. Has been falling more over the past 5 months. Patient at baseline seems to be AAOx2-3 with difficulty naming months of year backwards. Per ___ record, patient was on Oxycodone 5mg q4h PRN as well as Percocet ___ q8hrs PRN. He was also on clonazepam 1mg tid PRN anxiety, as well as trazodone and olanzapine. In an effort to consolidate sedating medications, his pain regimen was titrated to Oxycodone 5mg q6h PRN pain and his clonazepam titrated to 0.5mg tid PRN anxiety. Patient was planned to have ___ at home, which was reinforced by inpatient ___ assessment. Evaluation for peripheral neuropathy revealed B12, A1C within normal limits. TSH was elevated at 12 with normal T4 and low T3. # End Stage Renal Disease: Hemodialysis ___, s/p left AV fistula. Had been getting HD via right tunneled line which fell out after fall. This was replaced in ___ and patient received half session of dialysis, stopped secondary to anxiety. Patient has a LUE that seems close to maturation and was to be evaluated by his vascular surgeon outpatient. While inpatient, he was continued on sevelamer, nephrocaps, and lisinopril. # Schizophrenia: Continued olanzapine, trazodone, and clonazepam. Clonazepam was decreased from 1mg to 0.5mg q8hr PRN anxiety. #ADHD: Continued on Amphetamine-Dextroamphetamine XR 20 mg PO DAILY # Anemia: Admission H/H 8.7/26.9, likely chronic secondary to ESRD. No signs and symptoms of active bleeding. - Continue to monitor # Hyponatremia: Resolved. Likely in the setting of volume overload and missed ESRD session. TRANSITIONAL ISSUES - Patient received half-dialysis session ___ stopped early secondary to patient anxiety. Ultrafiltration of 500cc of goal 1000cc. He should continue his ___ dialysis schedule. - Patient has purse-string stitch on right HD line which should be removed at his next dialysis date, ___. - Per ___ record, patient was on Oxycodone 5mg q4h PRN as well as Percocet ___ q8hrs PRN. He was also on clonazepam 1mg tid PRN anxiety, as well as trazodone and olanzapine. In an effort to consolidate sedating medications, his pain regimen was titrated to Oxycodone 5mg q6h PRN pain and his clonazepam titrated to 0.5mg tid PRN anxiety. Further adjustments to his pain regimen and anxiolysis at the discretion of PCP. - Patient with recurrent falls, including one down a flight of stairs. To continue to work with home ___ but may need further evaluation for gait instability. B12, A1c WNL this admission, TSH elevated to 12. T3 of 68, T4 of 6.5 - Patient was to have appointment with vascular surgeon to assess maturity of LUE fistula while inpatient.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: lisinopril / ACE Inhibitors Attending: ___. Chief Complaint: Lower extremity weakness Major Surgical or Invasive Procedure: None History of Present Illness: ___ with history of hypertension, atrial fibrillation, complete heart block s/p PPM, presenting with inability to ambulate starting the morning of presentation. Patient has been having months of myalgias. For the past few months, the patient has had multifocal myalgias and arthralgias (shoulder, back, feet), and sensation of lower extremity heaviness. For the past month, he has been able to ambulate at home for about ___, then becomes fatigued and complains of L hernia bulge. Over the past month his relative has been assisting him with getting dressed in the morning and perform daily activities. On morning of admission, he again had bilateral lower extremity heaviness with inability to bear weight independently, for which was brought to ___ ED. Patient states it is been having diarrhea in the past as well as possibly urinary incontinence when he has the diarrhea. No recent travel. No numbness or tingling. He has noticed word-finding difficulties, but no change in speech or comprehension. Chronic mild headaches. Occasional posterior neck and lower back pain. No vomiting, diarrhea, seizures, change in vision, coordination. Urinary frequency with post-micturitional dribbling, no constipation. Subjective fever last night. Nighttime dry mouth without dysphagia. He was seen for similar complaints by PCP ___ ___, with serologic evaluation unremarkable (ESR 9, ___ negative, CCP <16, CRP 0.9, RF <10) and considered referral to Ortho v. Rheum. In the ED, initial VS were: 98.2 84 159/81 100% RA Code Cord was called due to ___ weakness and lack of reflexes. CT spine was done (MRI not obtained due to Pacemaker). Labs showed: Mg 1.5, Phos 2.3, Lactate 2.7. Otherwise unremarkable. Imaging showed: CT T/L Spine ___ 1. No evidence of a mass lesion causing high-grade spinal canal stenosis in the thoracic and vertebral spine. 2. No evidence of fracture or traumatic malalignment in the thoracic or lumbar spine. 3. Mild to moderate thoracic and lumbar spondylosis. 4. Common bile duct is enlarged, measuring up to 1.0 cm, but tapers normally at the level of the ampulla. Please correlate with LFTs if there is concern for biliary obstruction. 5. Cholelithiasis, incompletely imaged. CT Head ___ No acute intracranial process Neurology was consulted and involved in the above w/u imaging discussion but given largely unremarkable results, felt that no further neurologic evaluation was needed. Decision was made to admit to medicine for further management of weakness. On arrival to the floor, patient interviewed with ___ translator on the phone for 30 minutes. Unfortunately, the patient is argumentative and continues to state that he is here for weakness that has been going on for a while, however acutely worsened this AM leading to inability to stand (notably, the patient stood and ambulated to the scale on admission). He denies any recent fevers, chills, weight loss, N/V or other infectious symptoms. He reports diarrhea 4 months ago that is completely resolved. He struggles to understand orientation questions but limited ___ phone interpreter. Past Medical History: HTN HERNIA GYNECOMASTIA PROSTATE NODULE ATRIAL FIBRILLATION COMPLETE HEART BLOCK ___ s/p PPM NISSEN FUNDIPLOCATION in ___ ___ H/O MACROCYTOSIS nl b12, folate Social History: ___ Family History: Unable to give a meaningful family history due to mental status Physical Exam: ADMISSION EXAM: VS - 98.0; 172 / 82; 77; 18 96 RA GENERAL: NAD, lying in bed, well appearing HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva, MMM, poor dentition NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose. Notable strength ___ in bilateral extremities - patient raises both legs and keeps off bed to active resistence. PULSES: 2+ DP pulses bilaterally NEURO: Oriented to name, hospital, limited by translation on phone. CN2-12 testing limited because there is no interpreter available SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE EXAM: VS: 98.2, 151/77, HR 7, RR 18, 96% RA GENERAL: NAD, lying in bed, well appearing HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva, MMM, poor dentition NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB ABDOMEN: nondistended, +BS, nontender, no organomegaly PULSES: 2+ DP pulses bilaterally NEURO: a&ox3, normal speech, ___ strength in UE and ___, sensation in tact to light touch, able to walk with wide-based gait SKIN: warm and well perfused, no rashes Pertinent Results: Admission labs: ___ 12:50PM BLOOD WBC-6.9 RBC-4.24* Hgb-14.0 Hct-41.5 MCV-98 MCH-33.0* MCHC-33.7 RDW-13.6 RDWSD-49.0* Plt ___ ___ 12:50PM BLOOD Neuts-66.1 ___ Monos-7.4 Eos-1.0 Baso-0.4 Im ___ AbsNeut-4.56 AbsLymp-1.71 AbsMono-0.51 AbsEos-0.07 AbsBaso-0.03 ___ 12:50PM BLOOD Glucose-121* UreaN-16 Creat-0.9 Na-142 K-3.4 Cl-99 HCO3-29 AnGap-17 ___ 12:50PM BLOOD Calcium-8.7 Phos-2.3* Mg-1.5* ___ 01:30PM BLOOD Lactate-2.7* Discharge labs: ___ 05:55AM BLOOD WBC-6.5 RBC-3.92* Hgb-12.8* Hct-37.9* MCV-97 MCH-32.7* MCHC-33.8 RDW-14.0 RDWSD-49.6* Plt ___ ___ 05:55AM BLOOD Neuts-58.4 ___ Monos-11.1 Eos-2.5 Baso-0.5 Im ___ AbsNeut-3.78 AbsLymp-1.75 AbsMono-0.72 AbsEos-0.16 AbsBaso-0.03 ___ 05:55AM BLOOD Glucose-99 UreaN-16 Creat-1.0 Na-145 K-2.6* Cl-101 HCO3-30 AnGap-17 ___ 05:55AM BLOOD ALT-23 AST-31 LD(LDH)-214 AlkPhos-115 TotBili-0.7 ___ 05:55AM BLOOD Albumin-3.7 Calcium-8.0* Phos-3.4 Mg-2.1 Imaging: CT T/L Spine ___ 1. No evidence of a mass lesion causing high-grade spinal canal stenosis in the thoracic and vertebral spine. 2. No evidence of fracture or traumatic malalignment in the thoracic or lumbar spine. 3. Mild to moderate thoracic and lumbar spondylosis. 4. Common bile duct is enlarged, measuring up to 1.0 cm, but tapers normally at the level of the ampulla. Please correlate with LFTs if there is concern for biliary obstruction. 5. Cholelithiasis, incompletely imaged. CT Head ___ No acute intracranial process Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. amLODIPine 10 mg PO DAILY 2. Losartan Potassium 100 mg PO DAILY 3. Metoprolol Succinate XL 50 mg PO DAILY 4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild Discharge Medications: 1. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN indigestion RX *alum-mag hydroxide-simeth [Antacid] 200 mg-200 mg-20 mg/5 mL ___ ml by mouth QID:prn Refills:*0 2. Carvedilol 25 mg PO BID RX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 3. HydrALAZINE 50 mg PO QID RX *hydralazine 50 mg 1 tablet(s) by mouth four times a day Disp #*120 Tablet Refills:*1 4. Potassium Chloride 20 mEq PO DAILY Hold for K > 5 RX *potassium chloride [K-Tab] 20 mEq 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*1 5. Ranitidine 75 mg PO DAILY:PRN indigestion RX *ranitidine HCl [Acid Reducer (ranitidine)] 75 mg 1 tablet(s) by mouth daily: prn Disp #*30 Tablet Refills:*1 6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 7. amLODIPine 10 mg PO DAILY 8. Losartan Potassium 100 mg PO DAILY 9.Rolling walker Diagnosis: Hypokalemia Prognosis: Good Length of need: 13 months 10.Outpatient Occupational Therapy Treat and evaluate: 12 weeks, 3 sessions/week ICD-10: ___ Generalized muscle weakness 11.Outpatient Physical Therapy Treat and evaluate: 12 sessions, 3 sessions/week ICD 10: ___ Generalized muscle weakness Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnosis: Hypokalemia Hypomagnesemia Hypertension Secondary diagnosis: Atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: History: ___ with lower extremity paralysis bilaterally // ?mass TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain, intermediate and bone windows. Coronal and sagittal reformats were also performed. DOSE: DLP: Acquisition sequence: 1) Sequenced Acquisition 18.0 s, 19.1 cm; CTDIvol = 47.3 mGy (Head) DLP = 903.1 mGy-cm. Total DLP (Head) = 903 mGy-cm. COMPARISON: None. FINDINGS: There is no intra-axial or extra-axial hemorrhage, edema, shift of normally midline structures, or evidence of acute major vascular territorial infarction. Prominence of ventricles and sulci are compatible with age related involutional changes. Ill-defined periventricular and subcortical white matter hypodensities are nonspecific but likely due to sequela of small-vessel ischemic disease. Sclerosis of the right sphenoid sinus suggest prior chronic inflammation. Mild mucosal thickening is seen involving the sphenoid and posterior ethmoid air cells. The imaged paranasal sinuses are otherwise clear. Mastoid air cells and middle ear cavities are well aerated. The bony calvarium is intact. IMPRESSION: No acute intracranial process. Radiology Report EXAMINATION: CT T-SPINE W/ CONTRAST INDICATION: ___ year old man with pacemaker unable to get MRI with acute ___ weakness // ?cord compression TECHNIQUE: Contrast-enhanced helical multidetector CT was performed. 100 cc of Omnipaque 350 intravenous contrast was administered. Soft tissue and bone algorithm images were generated. Coronal and sagittal reformations were then constructed. DOSE: Acquisition sequence: 1) Spiral Acquisition 13.9 s, 54.3 cm; CTDIvol = 32.9 mGy (Body) DLP = 1,785.3 mGy-cm. Total DLP (Body) = 1,785 mGy-cm. COMPARISON: None. FINDINGS: THORACIC SPINE: Alignment is normal. No fractures are identified. Mild to moderate multilevel degenerative changes are noted with bridging anterior osteophytes. There is mild narrowing of the left posterior aspect of the spinal canal at the T2-T3 vertebral level due to left uncovertebral hypertrophy as well as ligamentum flavum thickening and calcification. There is no evidence of high-grade central canal or neural foraminal stenosis. There is no prevertebral soft tissue swelling. There is no evidence of infection or neoplasm. No abnormal enhancement is seen. LUMBAR SPINE: Alignment is normal. No fractures are identified. Mild multilevel degenerative changes are seen with mild anterior osteophytes. Small disc bulges are noted at L4-5 and L5-S1 with slight flattening of the ventral aspect of the thecal sac. Mild neural foraminal narrowing is noted bilaterally at L3-4, L4-5 and L5-S1 with facet arthropathy. There is no evidence of high-grade spinal canal stenosis. There is no prevertebral soft tissue swelling. There is no evidence of infection or neoplasm. No abnormal enhancement is seen. Limited views of the chest are remarkable for mild atelectasis. Pacemaker wires are partially visualized. Limited views of the abdomen are remarkable for bilateral renal simple cysts, with the largest measuring up to 3.8 cm in the interpolar region of the left kidney. Atherosclerotic calcifications are seen throughout the thoracic and abdominal aorta. The common bile duct is enlarged measuring up to 1.0 cm but tapers normally to the level of the ampulla (series 3: Image 131). Cholelithiasis is incidentally seen. IMPRESSION: 1. No evidence of a mass lesion causing high-grade spinal canal stenosis in the thoracic and vertebral spine. 2. No evidence of fracture or traumatic malalignment in the thoracic or lumbar spine. 3. Mild to moderate thoracic and lumbar spondylosis. 4. Common bile duct is enlarged, measuring up to 1.0 cm, but tapers normally at the level of the ampulla. Please correlate with LFTs if there is concern for biliary obstruction. 5. Cholelithiasis, incompletely imaged. Gender: M Race: BLACK/CAPE VERDEAN Arrive by AMBULANCE Chief complaint: Weakness, Body pain Diagnosed with Weakness temperature: 98.2 heartrate: 84.0 resprate: nan o2sat: 100.0 sbp: 159.0 dbp: 81.0 level of pain: unable level of acuity: 2.0

___ with history of hypertension, atrial fibrillation, complete heart block s/p PPM, presenting with acute lower extremity weakness found to be hypokalemic # Lower extremity weakness: Endorses weakness for several months but acutely worse on day of admission. Differential is broad, but most likely cause is hypokalemia, given his K 2.6 on admission. Other causes include PVD, neuropathy, other electrolyte abnormalities, deconditioning. Neuro imaging in ED was unremarkable, and neuro saw the patient and suggested that his symptoms are unlikely to be from an acute neurologic process. We repleted his K and his condition greatly improved. We started KCl 20 mEq PO daily for him to continue as an outpatient. # Hypokalemia: K of 2.6 on admission. EKG was unchanged from ___, and patient does not endorse chest pain or palpitations. Likely cause is GI losses from his prolonged diarrhea (reported history of 6 months of diarrhea). We started potassium supplementation with KCl tablets 20 mEq daily. He may also have hyperaldosteronism as is renin level was low, aldosterone level was pending at the time of discharge. He will follow-up in ___ clinic on ___. -- At the time this discharge summary was signed, the aldosterone level had resulted, and was also low. I have reached out to Dr. ___ endocrinologist who will be seeing him in follow-up to see if there is any further testing I can help facilitate prior to his appointment. This could be explained by congenital adrenal hyperplasia, ___ syndrome, etc. # Diarrhea: Endorses 6 months of diarrhea. Unknown cause. Stool culture and o&p were negative. He may also have lactose intolerance, as only certain foods exacerbate his diarrhea. We started him on Maalox and zantac prn for abdominal discomfort and indigestion. He may need an EGD as an outpatient to evaluate his anatomy, as he may have a component of malabsorption from past ___ fundoplication. # Hypertensive urgency: Continued home Amlodipine 10mg qD, Losartan 100mg qD. Started hydralazine 50 mg PO QID for hypertension. Started carvedilol 25 mg PO BID in place of metoprolol. Renin level is low. Aldosterone level, pending at discharge, is also low, which may be consistent with a mineralocorticoid excess syndrome. As above, he will follow-up with endocrine as an outpatient. # Metabolic encephalopathy / Delirium: Had significant hospital acquired delirium. His mental status improved with reorientation and family at bedside, and he was back to his baseline prior to discharge. # A-Fib: V-paced. Not on anticoagulation, and PCP reasoned that his risks may outweigh benefits, and he may not reliably take warfarin. Dc'ed his home metoprolol and started carvedilol 25 mg PO BID for better BP control.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Lactose Attending: ___. Chief Complaint: nausea, vomiting, diarrhea Major Surgical or Invasive Procedure: none History of Present Illness: ___ with history of triple negative metastatic breast cancer treated with palliative chemo (eribulin C1D8 as of ___, DM1 c/b gastroparesis presenting with acute onset abdominal pain, subjective fevers, chills, vomiting >20x, diarrhea ___. These symptoms started one day after receiving chemotherapy on ___. She has not noted any blood in vomit or stool. Her pain is ___, periumbilical, without any alleviating factors. She had some nausea after her first round of chemo, but did not have symptoms like this. No sick contacts, new foods, or travel. She denies any h/o DKA or requiring hospitalization for her type I diabetes. She denies any CP, SOB, leg swelling, urinary symptoms, or weakness. ED course: O: 97.9 110 169/99 20 99% meds 23:14 Lovenox 60 mg SC 20:20 Morphine Sulfate 5 mg IV 19:00 Ondansetron 4 mg IV 19:00 Morphine Sulfate 5 mg IV rads 20:36 CT ABD & PELVIS WITH CONTRAST iv 20:20 40 mEq Potassium Chloride / 1000 mL NS Continuous at 250 ml/hr for 1000 ml Review of Systems: As per HPI. All other systems negative. Past Medical History: ONCOLOGIC HISTORY: Left breast cancer stage IIA (pT1c pN1 M0), grade 3 IDC, triple-negative on palliative chemo (eribulin C1D8 as of ___ -please see OMR for full onc history details PMH: - T1DM (hemoglobin A1c ___ was 10.2%) complicated by gastroparesis - LUE DVT on lovenox - Left lymphedema - HTN - Asthma - Anemia - Depression and anxiety - Insomnia - Chlamydia, syphilis Social History: ___ Family History: Diabetes and hypertension, both run in the family, but there is no known family history of breast cancer. Physical Exam: ON ADMISSION: 98.9, 164/92, 102, 16, 95%RA GEN: NAD, reclined in bed HEENT: PERRL, EOMI, slightly dry mucosal membranes, oropharynx clear, no cervical ___: CTAB, no wheezes, rales or rhonchi. CV: RRR with II/VI SEM, nl S1 S2. JVP<7cm Chest: R sided port without surrounding erythema, swelling, TTP ABD: normal bowel sounds, soft, not distended. +mild TTP in epigastric area. EXTR: Warm, well perfused. left UE lymphedema. 2+ radial and DP pulses. NEURO: alert and orientedx3, motor grossly intact ON DISCHARGE: Still with Left upper extremity edema, improving per patient. Pertinent Results: ___ 08:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-150 KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 08:50PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE EPI-<1 ___ 07:05PM LACTATE-1.5 ___ 06:52PM GLUCOSE-256* UREA N-11 CREAT-0.6 SODIUM-140 POTASSIUM-3.2* CHLORIDE-97 TOTAL CO2-29 ANION GAP-17 ___ 06:52PM ALT(SGPT)-14 AST(SGOT)-21 ALK PHOS-91 TOT BILI-0.2 ___ 06:52PM LIPASE-24 ___ 06:52PM ALBUMIN-3.9 ___ 06:52PM WBC-9.2# RBC-3.46* HGB-10.2* HCT-32.3*# MCV-93 MCH-29.6 MCHC-31.7 RDW-13.0 ___ 06:52PM PLT COUNT-448* ON DISCHARGE: ___ 09:43AM BLOOD Neuts-50.8 Lymphs-44.5* Monos-4.2 Eos-0.4 Baso-0.1 ___ 09:43AM BLOOD Glucose-186* UreaN-11 Creat-0.6 Na-140 K-4.1 Cl-100 HCO3-33* AnGap-11 MICRO: ___ BLOOD CULTURE Blood Culture, Routine-FINAL neg EMERGENCY WARD ___ BLOOD CULTURE Blood Culture, Routine-FINAL negEMERGENCY WARD ___ URINE URINE CULTURE-FINAL negEMERGENCY WARD CT ABD/PELVIS ___ The visualized lung bases again demonstrate innumerable pulmonary nodules as well as necrotic left breast mass. The patient is status post right mastectomy. The liver, gallbladder, spleen, bilateral adrenal glands, pancreas, stomach, and visualized loops of small large bowel are within normal limits. Bilateral kidneys are normal with no evidence of hydronephrosis or stones. The appendix is not clearly visualized but there are no secondary signs of appendicitis. There is no free fluid or free air. There is no mesenteric or retroperitoneal lymphadenopathy. Abdominal aorta is normal in caliber. There is no free air or free fluid. CT PELVIS WITH IV CONTRAST: The uterus appears within normal limits with an IUD in place. The rectum, sigmoid colon, and bladder appear unremarkable. There is a small amount of free fluid, likely physiologic. OSSEOUS STRUCTURES: There are no lytic or sclerotic osseous lesions suspicious for malignancy. Mild diffuse body anasarca is again noted. Subcutaneous gas is noted in the anterior subcutaneous tissues, likely from injections. IMPRESSION: 1. No acute abdominal or pelvic process. 2. Visualized lung bases again demonstrate innumerable pulmonary nodules as well as a necrotic left breast mass. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Enoxaparin Sodium 60 mg SC Q12H 2. Citalopram 20 mg PO DAILY 3. Ibuprofen 600 mg PO Q6H:PRN pain 4. TraMADOL (Ultram) 50 mg PO HS pain 5. Glargine 16 Units Breakfast Insulin SC Sliding Scale using novalog Insulin 6. Gabapentin 300 mg PO TID 7. Omeprazole 20 mg PO DAILY 8. Ondansetron 4 mg PO Q8H:PRN nausea 9. Acetaminophen 1000 mg PO Q8H 10. Hydrocortisone Oint 2.5% 1 Appl TP BID 11. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 12. Prochlorperazine 5 mg PO Q6H:PRN nausea 13. Morphine SR (MS ___ 15 mg PO Q12H 14. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID pruritis 15. Senna 2 TAB PO BID 16. Docusate Sodium 100 mg PO BID 17. NovoLOG (insulin aspart) 100 unit/mL subcutaneous QAC Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Citalopram 20 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Enoxaparin Sodium 60 mg SC Q12H 5. Gabapentin 300 mg PO TID 6. Hydrocortisone Oint 2.5% 1 Appl TP BID 7. Ibuprofen 600 mg PO Q6H:PRN pain 8. Glargine 16 Units Breakfast Insulin SC Sliding Scale using novalog Insulin 9. Morphine SR (MS ___ 15 mg PO Q12H 10. Omeprazole 20 mg PO DAILY 11. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 12. Prochlorperazine 5 mg PO Q6H:PRN nausea 13. Senna 2 TAB PO BID 14. TraMADOL (Ultram) 50 mg PO HS pain 15. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID pruritis 16. Polyethylene Glycol 17 g PO Q12H constipation RX *polyethylene glycol 3350 17 gram/dose 17 grams by mouth once to twice daily Disp #*600 Gram Refills:*3 17. NovoLOG (insulin aspart) 100 unit/mL subcutaneous QAC 18. Ondansetron 4 mg PO Q8H:PRN nausea Discharge Disposition: Home Discharge Diagnosis: chemotherapy-induced vomiting Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Metastatic breast cancer on chemotherapy with abdominal pain, nausea, vomiting. COMPARISON: CT abdomen and pelvis and CT Chest from ___. TECHNIQUE: MDCT-acquired axial images were obtained from the lung bases through the abdomen and pelvis after the administration of IV contrast. Multiplanar reformatted images were prepared and reviewed. FINDINGS: CT ABDOMEN WITH IV CONTRAST: The visualized lung bases again demonstrate innumerable pulmonary nodules as well as necrotic left breast mass. The patient is status post right mastectomy. The liver, gallbladder, spleen, bilateral adrenal glands, pancreas, stomach, and visualized loops of small large bowel are within normal limits. Bilateral kidneys are normal with no evidence of hydronephrosis or stones. The appendix is not clearly visualized but there are no secondary signs of appendicitis. There is no free fluid or free air. There is no mesenteric or retroperitoneal lymphadenopathy. Abdominal aorta is normal in caliber. There is no free air or free fluid. CT PELVIS WITH IV CONTRAST: The uterus appears within normal limits with an IUD in place. The rectum, sigmoid colon, and bladder appear unremarkable. There is a small amount of free fluid, likely physiologic. OSSEOUS STRUCTURES: There are no lytic or sclerotic osseous lesions suspicious for malignancy. Mild diffuse body anasarca is again noted. Subcutaneous gas is noted in the anterior subcutaneous tissues, likely from injections. IMPRESSION: 1. No acute abdominal or pelvic process. 2. Visualized lung bases again demonstrate innumerable pulmonary nodules as well as a necrotic left breast mass. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Vomiting, Fever Diagnosed with NAUSEA WITH VOMITING, DIARRHEA temperature: 97.9 heartrate: 110.0 resprate: 20.0 o2sat: 99.0 sbp: 169.0 dbp: 99.0 level of pain: 7 level of acuity: 3.0

___ with history of triple negative metastatic breast cancer treated with palliative chemo (eribulin C1D8 as of ___, DM1 c/b gastroparesis presenting with acute onset abdominal pain, subjective fevers/ chills, vomiting and diarrhea. Abd CT scan was unremarkable for acute intraabdominal process. She did initially have hypokalemia which improved with supplementation. She was also given intravenous fluids and her glucosuria and ketonuria also resolved. Her symptoms of nausea, vomiting and diarrhea as well as abdominal pain had resolved as of the morning after her adssion. She was able to tolerate a diet and felt improved however, she was unable to have a bowel movement. As a result, her bowel regimen was advanced and she responded to miralax which she was given at time of discharge. Otherwise, she was continued on her home medication regimen including her insulin, enoxaparin. She was confirmed full code at admission.

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, cough Major Surgical or Invasive Procedure: None. History of Present Illness: Mr. ___ is a ___ year-old man with PMH HCV cirrhosis and HCC s/p DDLT ___ who presented to the ED with ~3 weeks of progressive worsening DOE and cough. He was seen in the ED ___ with negative TTE and CXR. Subsequently followed up in transplant clinic ___ and prescribed a course of augmentin for possible URI. He describes significant dyspnea with mild exertion such as walking to the bathroom, generally not at rest. He mostly notices the cough at night, while laying completely flat, and reports lower R sided chest/abdominal pain when he coughs. States codeine prescribed outpatient did not help, but oxycodone helps him to get some sleep. Denies fever/chills, chest pain, palpitations, congestion, rhinorrhea, orthopnea, PND, lower extremity edema, or prior history of blood clots. ED Course: O2 sat 93-100% on RA, flu negative, CXR without acute process. Evaluated by GI fellow who recommended empiric treatment for PE given creatinine 2.4. Started on heparin gtt and admitted with plan for V/Q scan. REVIEW OF SYSTEMS: A 10-point ROS was taken and is negative except otherwise stated in the HPI. Past Medical History: - HCV (genotype 1 and 2), now s/p SVR with sofosbuvir, simeprevir and ribavirin in ___ - Cirrhosis ___ class B) [+] HE [+] EV ___, 3 cords of small EVs not amenable to banding s/p scarring from prior banding) [+] Refractory ascites, now s/p TIPS (___) - Portal hypertension (with pancytopenia, splenomegaly), s/p TIPS (___) - Depression - Reflux esophagitis - Squamous cell carcinoma of the penis - History of compartment syndrome R arm - History of multiple orthopedic surgeries Social History: ___ Family History: No family history of liver disease. Physical Exam: ======================== ADMISSION PHYSICAL EXAM ======================== VITALS: ___ 0017 Temp: 98.0 PO BP: 138/77 HR: 82 RR: 18 O2 sat: 96% O2 delivery: RA Dyspnea: 6 RASS: 0 Pain Score: ___ General: Alert, oriented, semi-frequent coughing HEENT: Sclerae anicteric, MMM, oropharynx clear CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Well healing surgical scar from liver txplant. Soft, non-tender, non-distended, bowel sounds present, no organomegaly. Umbilical hernia Ext: Warm, well perfused, no ___ edema Skin: Warm, dry, seborrheic keratosis on back Neuro: Alert and oriented, face symmetric, moves all extremities purposefully ACCESS: R chest POC ======================== DISCHARGE PHYSICAL EXAM ======================== Pertinent Results: ========================= ADMISSION LAB RESULTS ========================= ___ 07:30AM BLOOD WBC-5.0 RBC-3.38* Hgb-10.2* Hct-30.5* MCV-90 MCH-30.2 MCHC-33.4 RDW-17.0* RDWSD-56.0* Plt ___ ___ 07:30AM BLOOD Neuts-72.2* Lymphs-6.4* Monos-9.6 Eos-10.6* Baso-0.4 Im ___ AbsNeut-3.63 AbsLymp-0.32* AbsMono-0.48 AbsEos-0.53 AbsBaso-0.02 ___ 07:30AM BLOOD Plt ___ ___ 07:30AM BLOOD UreaN-30* Creat-2.4* Na-141 K-4.3 Cl-105 HCO3-20* AnGap-16 ___ 07:30AM BLOOD ALT-15 AST-8 AlkPhos-256* TotBili-0.8 ___ 08:15PM BLOOD proBNP-752* ___ 08:15PM BLOOD cTropnT-0.01 ___ 07:30AM BLOOD Albumin-4.2 Calcium-9.2 Phos-2.8 Mg-1.1* ___ 07:30AM BLOOD tacroFK-13.1 ___ 08:31PM BLOOD Lactate-0.4* ====================== DISCHARGE LAB RESULTS ====================== ___ 05:30AM BLOOD WBC-4.3 RBC-3.01* Hgb-9.1* Hct-27.5* MCV-91 MCH-30.2 MCHC-33.1 RDW-16.8* RDWSD-56.2* Plt ___ ___ 05:30AM BLOOD ___ ___ 05:30AM BLOOD Glucose-104* UreaN-24* Creat-2.3* Na-136 K-4.5 Cl-104 HCO3-23 AnGap-9* ___ 05:30AM BLOOD ALT-14 AST-9 LD(LDH)-153 AlkPhos-394* TotBili-0.7 ___ 05:30AM BLOOD Albumin-3.9 Calcium-9.3 Phos-3.8 Mg-1.8 ___ 05:30AM BLOOD tacroFK-12.8 IMAGING AND REPORTS ====================== CHEST X-RAY ___ IMPRESSION: No acute cardiopulmonary process. LUNG VQ SCAN ___ IMPRESSION: Low likelihood ratio for recent pulmonary thromboembolic disease. RUQ ULTRASOUND ___ IMPRESSION: 1. Patent hepatic vasculature. The right hepatic artery is not well assessed. Waveform for the main hepatic artery appears slightly more blunted compared to prior. Main portal vein demonstrates mild turbulent flow with velocity of 90.8 centimeter/second, previously 61.4 centimeter/second. 2. There is an echogenic linear structure in the IVC which likely represents anastomosis but clot cannot be completelyt excluded. A CTA multiphasic liver can be considered. 3. Splenomegaly. CHEST CT WITHOUT CONTRAST ___ IMPRESSION: 1. No acute pulmonary parenchymal findings. 2. 1.3 cm right adrenal nodule, new compared to MRI of the liver from ___, possibly representing focal hemorrhage given short interval appearance. Attention on follow-up imaging is recommended. RUQUS ___ IMPRESSION: 1. Patent transplant hepatic vasculature. 2. Splenomegaly. TTE ___: (with bubble study) No e/o right to left shunt. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with dyspnea// pna? pnx? TECHNIQUE: Single frontal view of the chest COMPARISON: ___ FINDINGS: Right-sided Port-A-Cath terminates at the cavoatrial junction, without evidence of pneumothorax. No focal consolidation, pleural effusion, or evidence of pneumothorax is seen. Cardiac and mediastinal silhouettes are stable. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: DUPLEX DOPP ABD/PEL INDICATION: ___ year old man with liver transplant, persistent dyspnea// Eval liver transplant TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the abdomen were obtained. COMPARISON: None. FINDINGS: Liver echotexture is normal. There is no evidence of focal liver lesions or biliary dilatation. CHD: 6 mm There is no ascites, right pleural effusion, or sub- or ___ fluid collections/hematomas. There are prominent periportal lymph nodes measuring up to 1.8 x 0.9 x 1.0 cm. The spleen has normal echotexture. Spleen length: 16.3 cm DOPPLER: The main hepatic arterial waveform is within normal limits, with prompt systolic upstrokes and continuous antegrade diastolic flow. Peak systolic velocity in the main hepatic artery is 46.5 cm/s, which appears slightly more blunted compared to prior when it measured 97.6 cm/s. The right hepatic artery is not well assessed. Appropriate arterial waveforms are seen in the the left hepatic artery with resistive indices of 0.72, respectively. The main portal vein demonstrates slight turbulent flow with velocity of 90.8 centimeter/second, previously 61.4 centimeter/second. And the right and left portal veins are patent with hepatopetal flow and normal waveform. Appropriate flow is seen in the hepatic veins and the IVC. IMPRESSION: 1. Patent hepatic vasculature. The right hepatic artery is not well assessed. Waveform for the main hepatic artery appears slightly more blunted compared to prior. Main portal vein demonstrates mild turbulent flow with velocity of 90.8 centimeter/second, previously 61.4 centimeter/second. 2. There is an echogenic linear structure in the IVC which likely represents anastomosis but clot cannot be completelyt excluded. A CTA multiphasic liver can be considered. 3. Splenomegaly. NOTIFICATION: The findings were discussed with ___. ___. by ___, M.D. on the telephone on ___ at 9:39 am, 10 minutes after discovery of the findings. Radiology Report EXAMINATION: CT CHEST W/O CONTRAST INDICATION: ___ year-old man with PMH HCV cirrhosis and HCC s/p DDLT ___ who presented to the ED with 3 weeks of progressive worsening DOE and cough of unclear etiology. Infectious workup negative, VQ scan low likelihood for PE. Other possibility would be tacrolimus pneumonitis// pneumonitis? edema? TECHNIQUE: MDCT axial images of the chest were obtained without administration of intravenous contrast. Coronal and sagittal reformations were performed. DOSE: Acquisition sequence: 1) Spiral Acquisition 2.5 s, 39.7 cm; CTDIvol = 16.0 mGy (Body) DLP = 636.0 mGy-cm. Total DLP (Body) = 636 mGy-cm. COMPARISON: CT of the chest from ___. FINDINGS: NECK, THORACIC INLET, AXILLAE, CHEST WALL: The visualized inferior thyroid gland is unremarkable. There is no supraclavicular or axillary lymphadenopathy. UPPER ABDOMEN: This study is not tailored for subdiaphragmatic evaluation. The patient is status post liver transplant. An Amplatzer plug is seen at the level of the pancreatic neck. The spleen is enlarged, measuring 15 cm in AP dimension. There is a 1.3 cm right adrenal nodule, new compared to MRI of the liver from ___, possibly representing focal hemorrhage given short interval appearance. There is a 3 mm nonobstructing stone in the upper pole of the left kidney. There upper abdominal varices. MEDIASTINUM: There is no mediastinal lymphadenopathy. HILA: There is no hilar lymphadenopathy within limitations of a noncontrast study. Small calcified left hilar lymph nodes suggest sequelae of prior granulomatous disease. HEART and PERICARDIUM: Heart size is normal. There is no pericardial effusion. PLEURA: There is no pleural effusion. LUNG: 1. PARENCHYMA: There is mild linear subsegmental atelectasis and peripheral reticulation in the right lower lobe. Lungs are otherwise clear, without parenchymal opacities. There is no pulmonary mass or suspicious nodules. 2. AIRWAYS: Central airways are patent. 3. VESSELS: The thoracic aorta and main pulmonary artery are normal in caliber. There is a port in the right chest wall with catheter terminating at the cavoatrial junction. CHEST CAGE: There is no suspicious osseous lesion or acute fracture. There are mild degenerative changes of the thoracic spine. IMPRESSION: 1. No acute pulmonary parenchymal findings. 2. 1.3 cm right adrenal nodule, new compared to MRI of the liver from ___, possibly representing focal hemorrhage given short interval appearance. Attention on follow-up imaging is recommended. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year old man with recent liver transplant// Eval liver transplant TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: Doppler ultrasound ___ FINDINGS: LIVER: The transplant hepatic parenchyma is within normal limits. The contour of the liver is smooth. There is no focal liver mass. Trace perihepatic fluid is again noted. A small periportal lymph node is again incidentally noted measuring 1.4 cm. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 6 mm GALLBLADDER: The patient is status post cholecystectomy. PANCREAS: The pancreas is not well visualized, largely obscured by overlying bowel gas. SPLEEN: Normal echogenicity. Spleen length: 16.2 cm DOPPLER EXAMINATION: The main, right and left portal veins are patent with hepatopetal flow. The hepatic veins and IVC are patent. Arterial waveforms with sharp upstrokes are seen in the main, right and left hepatic arteries. Resistive indices of the arteries measure 0.62, 0.51 and 0.63 in the main, right and left hepatic arteries respectively. Peak systolic flow in the main hepatic artery measures 89 cm/sec. IMPRESSION: 1. Patent transplant hepatic vasculature. 2. Splenomegaly. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Cough, Dyspnea Diagnosed with Dyspnea, unspecified temperature: 98.1 heartrate: 74.0 resprate: 17.0 o2sat: 100.0 sbp: 122.0 dbp: 72.0 level of pain: 4 level of acuity: 2.0

Mr. ___ is a ___ yo man with PMH of HCV cirrhosis and hepatocellular carcinoma s/p DDLT ___ who presented to the emergency room with 3 weeks of progressive dyspnea on exertion and cough. Infectious work-up, V/Q scan, chest CT, and TTE with bubble study were all unremarkable. We suspected dyspnea was due to deconditioning from recent liver transplant, as well as potentially with a component of post-viral subacute cough. # Subacute Dyspnea, Cough Patient underwent liver transplant approximately one month prior to this admission. One week post-transplant, he developed worsening dyspnea and cough. He presented to the ED in early ___ (prior to this admission), where TTE and CXR were negative. He was seen on clinic and started on Augmentin. He continued to be dyspneic with minimal activity, and presented again to the ED. Due to concern for PE, he was started on empiric heparin and admitted for further workup. A subsequent VQ scan was done (given Cr 2.4) but showed low probability of PE, so heparin was discontinued. He then underwent chest CT, but this was unremarkable. TTE with bubble study was normal. Infectious workup was negative, including respiratory viral panel (Ab negative, Cx still pending). Amb SpO2 were 98% on RA. Overall, his dyspnea was thought to be due to deconditioning from his recent liver transplant, with potentially a component of post-viral vs. post-nasal drip subacute cough. He was prescribed anti-tussive medications and intranasal fluticasone. If his cough persists, could consider Pulmonology follow up as an outpatient. # Chronic kidney disease The patient's postoperative course following transplant was complicated by ___ requiring CRRT. At that time he was discharged with a creatinine of 2.1 (from pre-operation baseline of about 1). On this admission, his creatinine was 2.4. He was given 1 liter of IV fluids with subsequent improvement. His Cr at discharge was 2.2-2.4 which is likely reflective of his new baseline. # HCV/___ s/p DDLT ___ # Deconditioning Patient was discharged home after complicated ___ hospital course. Per patient's wife, she felt that he should have gone to a rehab facility but did not qualify per ___. The patient's major concerns post-transplant were dyspnea and feeling deconditioned and unable to perform many activities at home. ___ was consulted this admission and recommended home with outpatient ___. Otherwise, a RUQUS on admission revealed elevated resistive indices post-transplant. A repeat ultrasound was performed a few days later and showed peak systolic flow 89cm/sec, with overall patent transplant hepatic vasculature. He was maintained on his immunosuppression regimen of MMF, prednisone and tacrolimus. His tacro level at discharge was 12.8, with an decreased Tacrolimus dose of 1.5mg BID. Prophylaxis of fluconazole, bactrim and valganciclovir were continued. He should continue to have close follow up with Transplant Hepatology. # Hypomagnesemia Patient had outpatient magnesium level of 1.1. He was given Magnesium Oxide 400 mg PO/NG BID and discharge Mg was 1.8.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: In brief, Mr. ___ is a ___ with history of decompensated HCV cirrhosis (Childs ___ Class B), complicated by encephalopathy, portal hypertension with esophageal varices and gastropathy, GAVE, being worked up for transplant who presents with abdominal pain. ___ has a recent admission ___ for lightheadedness, found to have hgb 6.5, no overt bleeding but underwent EGD, GAVE treated with APC, started on iron supplementation. ___ underwent repeat EGD on ___ which showed medium sized varices without high risk features, esophageal candidiasis, and angioectasias treated with thermal therapy. ___ has not started fluconazole because his instructions were to decrease nightly seroquel to 50 (from 400mg) while on fluconazole and ___ did not have any 50mg tablets. On ___ ___ started to have some lower abdominal discomfort rated ___ that ___ attributed to constipation, took some extra lactulose and stooled (not black or bloody) and passed a lot of gas which relieved the pain. The following day ___ developed ___ RUQ pain only noticeable when ___ presses on the RUQ, coughs, or moves around. No changes in bowel movements, no fevers, nausea, vomiting, or changes in color of stools or urine. Wife called the liver clinic and ___ was referred to the ED for admission. Of note, ___ had an abdominal MRI ___ which showed 4 lesions that meet criteria for diagnosis of HCC (the largest is 2x2cm), and one smaller lesion that does not (8mm). These findings have not yet been discussed with the patient. In the ED initial vitals were: 99.6 72 131/68 18 100% RA - Labs were significant for Hgb 10.2 (10.4 2d prior), plt 35 (below baseline, INR 1.3, Cr 2.4 (about baseline), tbil 2.4, (from 1.3 2 days ago), UA negative for infection. US showed patent vasculature, no fluid to tap. - Patient was given no medications. Vitals prior to transfer were:98.5 64 118/73 16 100% RA On the floor, patient has ___ RUQ pain only with palpation of his upper abdomen. ___ is otherwise comfortable. Review of Systems: (+) per HPI (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: - HCV cirrhosis diagnosed in ___, complicated by hepatic encephalopathy, portal hypertension, varices, portal hypertensive gastropathy, hypernatremia - history of melena in setting of multiple esophageal varices (grades I to 3) and possible duodenal varix, as well as portal hypertensive gastropathy and GAVE - HCV genotype 1b s/p relapse after interferon/Ribavirin x8-9 months years ago - Exophytic liver mass found during ___ admission, due for 3 month f/u ___ - Neutropenia attributed to splenic sequestration - Bipolar Disorder - Chronic Kidney Disease secondary to lithium - Hypertension Social History: ___ Family History: No family history of malignancy Physical Exam: Admission physical exam: VS - Tc 97.7 HR 67 BP 113/75 RR 20 99% 02 sat on RA GENERAL: well appearing middle aged gentleman, well-groomed, in no distress HEENT: AT/NC, EOMI, icteric sclera, pink conjunctiva, patent nares, MMM NECK: nontender supple neck, no LAD, no JVD CARDIAC: regular rate, rhythm, S1/S2, ___ systolic murmur, no gallops, or rubs LUNG: clear to auscultation bilaterally, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, tenderness to palpation in RUQ. Pain localizes to liver edge on inspiration as palpate. No rebound/guarding, +splenomegaly. EXTREMITIES: no cyanosis, clubbing or edema PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, no asterixis SKIN: warm without rashes, has scattered spider angiomata and palmar erythema Discharge physical exam: VS - Tc 97.7 HR 67 BP 113/75 RR 20 99% 02 sat on RA GENERAL: well appearing middle aged gentleman, well-groomed, in no distress HEENT: AT/NC, EOMI, icteric sclera, pink conjunctiva, patent nares, MMM NECK: nontender supple neck, no LAD, no JVD CARDIAC: regular rate, rhythm, S1/S2, ___ systolic murmur, no gallops, or rubs LUNG: clear to auscultation bilaterally, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, tenderness to palpation in RUQ. Pain localizes to liver edge on inspiration as palpate. No rebound/guarding, +splenomegaly. EXTREMITIES: no cyanosis, clubbing or edema PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, no asterixis SKIN: warm without rashes, has scattered spider angiomata and palmar erythema Pertinent Results: Admission labs: ___ 07:41PM BLOOD WBC-4.4# RBC-3.28* Hgb-10.2* Hct-32.5* MCV-99* MCH-31.1 MCHC-31.3 RDW-20.5* Plt Ct-35* ___ 07:41PM BLOOD Neuts-68.1 ___ Monos-9.3 Eos-2.1 Baso-0.5 ___ 08:01PM BLOOD ___ PTT-31.8 ___ ___ 07:41PM BLOOD Glucose-93 UreaN-30* Creat-2.4* Na-138 K-4.7 Cl-110* HCO3-23 AnGap-10 ___ 07:41PM BLOOD ALT-42* AST-68* AlkPhos-215* TotBili-2.4* ___ 07:41PM BLOOD Albumin-3.2* ___ 07:49PM BLOOD Lactate-2.2* Discharge labs: ___ 08:28AM BLOOD WBC-3.2* RBC-3.18* Hgb-9.4* Hct-31.2* MCV-98 MCH-29.7 MCHC-30.2* RDW-20.5* Plt Ct-36* ___ 08:28AM BLOOD Plt Ct-36* ___ 08:28AM BLOOD Glucose-146* UreaN-29* Creat-2.3* Na-138 K-4.1 Cl-109* HCO3-22 AnGap-11 ___ 08:28AM BLOOD ALT-40 AST-61* AlkPhos-185* TotBili-2.1* ___ 08:28AM BLOOD Calcium-8.6 Phos-3.7 ___ EGD Medium sized varices without high risk features at the distal esophagus Esophageal candidiasis Angioectasias in the antrum (thermal therapy) Otherwise normal EGD to third part of the duodenum ___ Liver US wet read RUQ US: nothing acute (vasculature patent, gallbladder decompressed, tumors not seen due to coarse echotexture, no fluid to tap, some gallbladder thickening explained by cirrhosis) ___ CT chest 1. Assessment of the chest demonstrated no definitive evidence of metastatic disease. Mild emphysema and centrilobular nodules are most likely consistent with respiratory bronchiolitis, please correlate clinically. 2. Several mediastinal lymph nodes, some of them borderline that should be reassessed in three months for documentation of stability. 3. Potential anemia. 4. Paracardiac lymph nodes, borderline as well and should be reassessed at the same time. 5. Stigmata of cirrhosis, partially imaged, will be assessed in details as part of the MRI of the abdomen and the corresponding report will be issued. ___ MRI abdomen IMPRESSION: 1. Three OPTN-5a lesions within segments II and VI, and one OPTN-5b lesion within segment IVb. 2. 8 mm arterially enhancing lesion within segment VII, not meeting OPTN-5 criteria. 3. Hepatic cirrhosis with multiple regenerative nodules. 4. Massive splenomegaly with perisplenic and perigastric varices reflecting chronic portal hypertension. 5. Small amount of perihepatic and perisplenic ascites. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Furosemide 20 mg PO EVERY OTHER DAY 2. Lactulose 30 mL PO TID 3. Nadolol 20 mg PO DAILY 4. Pantoprazole 40 mg PO Q12H 5. QUEtiapine Fumarate 400 mg PO QHS 6. Rifaximin 550 mg PO BID 7. Spironolactone 50 mg PO DAILY 8. Sucralfate 1 gm PO QID 9. Ferrous Sulfate 325 mg PO BID 10. Fluconazole 200 mg PO Q24H Discharge Medications: 1. Ferrous Sulfate 325 mg PO BID 2. Furosemide 20 mg PO EVERY OTHER DAY 3. Lactulose 30 mL PO TID 4. Nadolol 20 mg PO DAILY 5. Pantoprazole 40 mg PO Q12H 6. QUEtiapine Fumarate 400 mg PO QHS 7. Rifaximin 550 mg PO BID 8. Spironolactone 50 mg PO DAILY 9. Sucralfate 1 gm PO QID 10. Nystatin Oral Suspension 5 mL PO QID Duration: 10 Days RX *nystatin 100,000 unit/mL 5 ml by mouth four times a day Disp #*1 Bottle Refills:*0 Discharge Disposition: Home Discharge Diagnosis: HCV cirrhosis 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: ___ w/HCV cirrhosis c/b ___ presents w/1 day of RUQ pain. Tenderness to palpation in RUQ. // Evaluate for cholecystitis, portal vein thrombosis, tumor necrosis/bleed. Please also evaluate for fluid pocket amenable to paracentesis (did not see any on bedside US) TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: MRI abdomen dated ___ FINDINGS: LIVER: The liver is nodular with coarsened echotexture consistent with history of cirrhosis. The liver lesions detected on the MRI are not as well visualized on the ultrasound related to the coarsened echotexture. Main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 4 mm. GALLBLADDER: The gallbladder is decompressed without evidence of stones. There is gallbladder wall thickening related to chronic cirrhosis. Sonographic ___ sign was negative. 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, measuring 23.9 cm. Note is again made of perisplenic varices IMPRESSION: 1. Cirrhotic liver. Liver lesions were better evaluated on MR of ___. 2. Patent hepatic vasculature. No ascites 3. Splenomegaly and varices consistent with sequela of portal hypertension 4. No evidence of cholecystitis. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abd pain Diagnosed with SPRAIN OF KNEE & LEG NOS, OVEREXERTION FROM SUDDEN STRENUOUS MOVEMENT temperature: 99.6 heartrate: 72.0 resprate: 18.0 o2sat: 100.0 sbp: 131.0 dbp: 68.0 level of pain: 6 level of acuity: 3.0

___ with history of decompensated HCV cirrhosis (___ Class B), complicated by encephalopathy, portal hypertension with esophageal varices and gastropathy, GAVE, being worked up for transplant who presents with abdominal pain. His abdominal resolved quickly on the floor and ___ was anxious for same day discharge home. # Abdominal pain: Patient appears to have a tender liver edge, which may have bene related to a more inferior liver lesion. ___ had no signs or symptoms of cholecystitis, no rebound tenderness or peritoneal signs. Not constipated. US was negative for clot. Discussed with liver team, did serial abdominal exams, trended MELD labs, and followe up blood and urine cultures. # Esophageal candidiasis: Was prescribed fluconazole previously but never started course because ___ was concerned about decreasing his seroquel dosing and risk of a manic episode. ___ was switched to nystatin swish and swallow for 10 day course, with GI followup. # liver lesions: New MRI findings (liver lesions) discussed with patient. Did not yet discuss with him whether this will impact his transplant. Tumor board meets ___. After this will be discussed with patient, wife, and hepatology. # HCV cirrhosis: undergoing transplant work up, patient of Dr. ___ is Childs B, with diuretic-controlled ascites, varices, and history of encephalopathy. TrendED MELD labs daily, continueD furosemide and spironolactone for ascites. Continue lactulose and rifaxamin for h/o encephalopathy. # GAVE/Varices: No signs of active bleeding. Continued sucralfate, nadolol and PPI, and iron supplementation. # Thrombocytopenia: Worse than baseline possibly related to massive splenomegaly (sequestration) and decreased thrombopoetin production. Trended daily. Held heparin, used pneumoboots while platelets <50K . # Bipolar disorder: Continued seroquel.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Iodinated Contrast Media - Oral and IV Dye Attending: ___. Chief Complaint: Chest pain/discomfort Major Surgical or Invasive Procedure: No major surgical or invasive procedures were performed during this hospitalization. History of Present Illness: ___ male past medical history of CAD s/p CABG and 5x stents, hyperlipidemia, hypertension, stroke, atrial fibrillation (not on A/C), tissue aortic valve replacement resenting complaining of chest discomfort. Patient states that his pain began 2 days ago and felt like gas pain. He states the pain was constant and associated with nausea. He also endorses a feeling as though his heart was racing as well as lightheadedness. Patient was found to be tachycardic at his primary care physician's office today and was referred to ___. Patient found to be in atrial flutter with rates in 130s. Given concomitant chest pain and elevated troponin I to 0.36, he was given 50mg IV diltiazem with subsequent improvement in rates to 60-70s. He was also given morphine and nitroglycerin SL with resolution of his chest pain. He was given a full dose aspirin and started on heparin gtt, then transferred here for further evaluation and consideration for LHC. In the ED, initial vitals were: T 97.5, HR 79, BP 142/71, RR 15, O2Sat 100%RA - Exam notable for: CTAB, RRR, abdomen benign - Labs notable for: TropT 0.03, Cr 1.5, Hgb 10.9, WBC 7.2 - While in the ED, the patient's heart rate increased again to 126bpm sustained so he was given an additional 20mg IV diltiazem and 30mg PO. - Vitals prior to transfer: HR 63, 114/59, RR 13, O2Sat 94%RA On arrival to the floor, the patient denies any ongoing chest pain. Also denies fevers, chills, cough, shortness of breath, leg swelling or tenderness or any recent travel. REVIEW OF SYSTEMS: (+) Per HPI (-) 10 point ROS reviewed and negative unless stated above in HPI Past Medical History: - CAD s/p CABG and 5x stents - Hyperlipidemia - Hypertension - H/o stroke - H/o atrial fibrillation (not on anticoagulation) - S/p aortic valve replacement (tissue) - PAD - GERD Social History: ___ Family History: -Father died at ___ -Mother died at ___ is unaware of her medical history -Brothers with coronary artery disease Physical Exam: ADMISSION PHYSICAL EXAM: ======================== Vital Signs: 98.5, 98/64 (98-125/64-59), 102 (82-102), 16, 97% RA Weight: 94.9 kg General: Alert, oriented, no acute distress, walking around HEENT: Sclerae anicteric, MMM, oropharynx clear Neck: Supple. JVP flat (visible only with hepatic pressure). CV: Regular rate and rhythm. Normal S1+S2, soft systolic murmur. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended GU: No foley Ext: Warm, well perfused, trace to no edema DISCHARGE PHYSICAL EXAM: ======================== VITALS: afebrile, BP ___, HR ___, RR ___, O2 100% RA GENERAL: Alert, oriented, no acute distress, walking around HEENT: Sclerae anicteric, MMM, oropharynx clear NECK: Supple. JVP flat (visible only with hepatic pressure). HEART: Irregularly irregular. Normal S1+S2, soft systolic murmur. LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi ABDOMEN: Soft, non-tender, non-distended EXT: Warm, well perfused, trace to no edema Pertinent Results: ADMISSION LABS: =============== ___ 11:15PM BLOOD WBC-7.2 RBC-3.64* Hgb-10.9* Hct-33.7* MCV-93 MCH-29.9 MCHC-32.3 RDW-14.4 RDWSD-48.5* Plt ___ ___ 11:15PM BLOOD Neuts-56.3 ___ Monos-9.8 Eos-3.3 Baso-1.4* Im ___ AbsNeut-4.07 AbsLymp-2.07 AbsMono-0.71 AbsEos-0.24 AbsBaso-0.10* ___ 11:15PM BLOOD ___ PTT-67.6* ___ ___ 11:15PM BLOOD Glucose-85 UreaN-19 Creat-1.5* Na-141 K-4.3 Cl-107 HCO3-22 AnGap-16 ___ 06:15AM BLOOD CK(CPK)-51 ___ 11:15PM BLOOD CK-MB-3 ___ 11:15PM BLOOD cTropnT-0.03* ___ 06:15AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.2 Cholest-158 ___ 06:15AM BLOOD Triglyc-182* HDL-26 CHOL/HD-6.1 LDLcalc-96 LDLmeas-108 MICROBIOLOGY: ============= NONE IMAGING: ======== CXR (___): FINDINGS: There is dense retrocardiac opacification and mild chronic lung disease. The remainder of the lungs are clear. No pleural effusion or pneumothorax. Heart size is normal. Median sternotomy wires are midline and intact. Surgical clips project over the mediastinum. A presumed aortic valve replacement is noted. IMPRESSION: 1.Dense retrocardiac opacity likely reflecting atelectasis in the absence of infectious symptoms. 2. Mild chronic lung disease. LABS ON DISCHARGE: ================== ___ 04:50AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.4 ___ 04:50AM BLOOD ALT-12 AST-16 LD(LDH)-222 AlkPhos-82 TotBili-0.4 ___ 04:50AM BLOOD Glucose-87 UreaN-23* Creat-1.7* Na-141 K-4.2 Cl-106 HCO3-25 AnGap-14 ___ 04:50AM BLOOD ___ PTT-50.8* ___ ___ 04:50AM BLOOD WBC-7.2 RBC-3.59* Hgb-10.7* Hct-33.5* MCV-93 MCH-29.8 MCHC-31.9* RDW-14.3 RDWSD-48.9* Plt ___ Radiology Report EXAMINATION: Chest radiographs INDICATION: ___ year old man with Afib/Aflutter// baseline CXR prior to initiation of amiodarone TECHNIQUE: Frontal lateral views of the chest COMPARISON: None. FINDINGS: There is dense retrocardiac opacification and mild chronic lung disease. The remainder of the lungs are clear. No pleural effusion or pneumothorax. Heart size is normal. Median sternotomy wires are midline and intact. Surgical clips project over the mediastinum. A presumed aortic valve replacement is noted. IMPRESSION: 1. Dense retrocardiac opacity likely reflecting atelectasis in the absence of infectious symptoms. 2. Mild chronic lung disease. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Chest pain, Transfer Diagnosed with Non-ST elevation (NSTEMI) myocardial infarction temperature: 97.5 heartrate: 79.0 resprate: 15.0 o2sat: 100.0 sbp: 142.0 dbp: 71.0 level of pain: 0 level of acuity: 2.0

Mr. ___ is an ___ year old man with CAD s/p CABG, cardiac stents, HLD, HTN, CVA, and history of A fib who presented with chest pressure/epigastric pain secondary to Afib/flutter with RVR. At first there was concern for ACS but his trops trended down quickly and he had recent normal pharm nuc stress test in ___ at ___. He had on-going chest pain with afib RVR/aflutter with better response to diltiazem than metoprolol. Because of this he was switched from metoprolol to diltiazem. The patient spontaneously converted to normal sinus rhythm in AM of ___ prior to TEE cardioversion, and patient was discharged on amiodarone. #HISTORY OF ATRIAL FIBRILLATION WITH NEW ATRIAL FLUTTER, RVR: patient presented with rapid rates in ED. Initially controlled with IV metop and dilt, followed by increased dose of PO metop (home dose 50XL, given 75mg XL). Broke through with episodes of RVR, so switched to PO diltiazem with rates decreasing to ___. Of note, the patient is not on anticoagulation prior to admission because AFib improved after valve replacement and because of a GI bleed requiring ICU about ___ years ago (while on warfarin) and smaller amounts of blood in stool since. Patient's home clopidogrel for ___ PAD/stents was held on admission, and he was started on a heparin drip which was continued until apixiban started. Given the patient's persistent Afib/Aflutter, he was scheduled to undergo a TEE cardioversion in AM of ___. The patient spontaneously converted to sinus rhythm in AM of ___, and TEE cardioversion was canceled. Patient was started on amiodarone 200 mg 3 times daily for 1 week, then twice daily for 1 week, then once daily ongoing. Baseline CXR on ___ demonstrated dense retrocardiac opacity, likely reflecting atelectasis in the absence of infectious symptoms, and mild chronic lung disease. Baseline LFTs on ___: ALT 12, AST 16. TSH pending at time of discharge. He was discharged on long-acting diltiazem 120 mg PO daily, in addition to apixaban 2.5 mg PO BID for anticoagulation. #NSTEMI/DEMAND ISCHEMIA: patient has a known history of CAD s/p CABG and multiple stents. Mild troponin elevation in the setting of sustained tachycardia (0.03 to 0.02) in setting of CKD (creatinine 1.4 in ___ in ___ records). Pharm stress test canceled as patient recently received one in ___. He was continued on home ASA, home Imdur. CHRONIC/STABLE ISSUES: ====================== #CKD: Baseline Cr appears to be 1.3-1.7 from ___ records from ___ and the ___. Cr remained at baseline during hospitalization. #PVD s/p bilateral lower extremity stents: significant PAD, symptomatic. Per patient's wife, patient has lower extremity stents placed many years ago. He was continued on home pentoxyifylline, and clopidogrel was held at discharge in favor of continuing ASA and apixaban as above. #HYPERTENSION: Continued imdur, metop and lisinopril. #HYPERLIPIDEMIA: Patient has a reported allergy to statins. He was continued on ezetimibe. #GERD: Continued home Protonix.

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 and falls Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is an ___ year old man with CAD s/p CABG (at age ___, hypertension, hyperlipidemia, vascular dementia, chronic orthostatic hypotension who presented to the ED on ___t home and increasing weakness. ___ patient was in the bathroom and had one unwitness fall against the wall. His wife was nearby and noted that he did not lose consiousness, but there was a question of head trauma. He was propped against the door so it was difficult for his wife to get him out of the bathroom and she had to call her son to help. Later the same day, he had another fall that appears to be mechanical in nature, which he sustained while he was trying to sit in a chair and missed the seat. There was no loss of consciousness or head trauma associated with that fall. Given his advanced dementia, he is unable to clarify if there were any prodromal symptoms leading up to either fall. The following day ___, he was at an ophthalmology appointment and was noted to be very weak in the lower extremities and was unable to stand, requiring a wheelchair. He was seen promptly by his PCP ___. ___ suggested he go to the ED for evaluation. In the ED, initial vitals were 98.6 79 119/77 18 96% on RA. Exam was notable for baseline alertness and orientation to self only. There was also concern for possible nasolabial fold flattening. Labs were unremarkable with the exception of a grossly positive urinalysis. Given this finding and his new weakenss, a neurology consult was obtained, and they felt his exam was unremarkable for focal findings to suggest stroke and instead suggested that a urinary tract infection may explain his new weakness. A non contrast head CT and chest x-ray were both unremarkable. He was started on ceftriaxone (day 1 = ___ and sent to the floor for further management. Overnight, patient felt well and had no specific complaints. He denied any pain, or weakness that he could appreciate, though his history is limited by his severe dementia. In discussion with Dr. ___ morning, he noted that the patient may have had increased urinary frequency recently that would fit with the diagnosis of UTI. On review of systems, he denies nausea, vomiting, abdominal pain, back pain, headache, chest pain, or shortness of breath. Past Medical History: - CAD s/p CABG (___) - Hypertension - Hyperlipidemia - Vascular dementia - AAA s/p repair - Postural hypotension - Osteoarthritis s/p bilateral total hip replacement - Age related macular degeneration - Hypothyroidism - Gout - History of bladder stone - BPH Social History: ___ Family History: MI (maternal uncle at age ___. No known stroke or neurologic disease. Father was healthy, died of old age at ___. Mother died when he was age ___, unknown cause. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 97.3 178/86 72 16 98% on RA GENERAL: well appearing elderly male in NAD laying flat HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM NECK: supple, no LAD, JVD LUNGS: bibasilar crackles HEART: RRR, no MRG, nl S1-S2 ABDOMEN: normal bowel sounds, soft, non-tender, non-distended, no rebound or guarding, no masses EXTREMITIES: no edema, 2+ pulses radial and dp NEURO: awake, A&Ox1, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, please see neuro note for complete exam DISCHARGE PHYSICAL EXAM: VS: 97.3/98.4 146/83 71 18 97%RA GENERAL: well appearing elderly male comfortably eating breakfast HEENT: NC/AT, left pupil asymmetric, poor vision bilaterally, EOMI, sclerae anicteric, MMM NECK: supple, no LAD, JVD LUNGS: bibasilar crackles HEART: RRR, no MRG, nl S1-S2 ABDOMEN: normal bowel sounds, soft, non-tender, non-distended, no rebound or guarding, no masses EXTREMITIES: no edema, 2+ pulses radial and dp NEURO: awake, A&Ox1, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, please see neuro note for complete exam Pertinent Results: Admission labs: ___ 04:50PM BLOOD WBC-10.3 RBC-4.08* Hgb-13.0* Hct-39.7* MCV-97 MCH-31.7 MCHC-32.7 RDW-16.2* Plt ___ ___ 04:50PM BLOOD Neuts-77.9* Lymphs-14.2* Monos-6.3 Eos-1.1 Baso-0.5 ___ 04:50PM BLOOD ___ PTT-36.6* ___ ___ 04:50PM BLOOD Glucose-128* UreaN-34* Creat-1.1 Na-142 K-4.3 Cl-106 HCO3-26 AnGap-14 Discharge Labs: ___ 09:15AM BLOOD WBC-8.8 RBC-3.85* Hgb-11.6* Hct-37.2* MCV-97 MCH-30.1 MCHC-31.2 RDW-15.6* Plt ___ ___ 08:26AM BLOOD Glucose-109* UreaN-23* Creat-1.0 Na-144 K-3.8 Cl-107 HCO3-28 AnGap-13 ___ 08:26AM BLOOD Calcium-9.3 Phos-2.9 Mg-2.2 Micro: ___ urine culture pending: Enterococcus 10k-100k AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 1 S Studies: ___ CT head without contrast: No intracranial hemorrhage or acute territorial infarction. ___ Chest x-ray (portable): Mild bibasilar atelectasis and probable trace left pleural effusion. Unchanged moderate size hiatal hernia. EKG: NSR at 70, NA, NI, RBBB, TWI in 3, avF, V1-V3 without any change from prior. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Simvastatin 40 mg PO EVERY OTHER DAY 2. Omeprazole 20 mg PO BID 3. Allopurinol ___ mg PO DAILY 4. Levothyroxine Sodium 200 mcg PO DAYS (___) 5. Finasteride 5 mg PO DAILY 6. Metoprolol Tartrate 25 mg PO QPM 7. Quetiapine Fumarate 50 mg PO Q8H PRN agitation 8. Terazosin 1 mg PO HS 9. Dipyridamole-Aspirin 1 CAP PO DAILY 10. Docusate Sodium 100 mg PO BID 11. Senna 1 TAB PO BID:PRN constipation 12. Metoprolol Tartrate 50 mg PO QAM Discharge Medications: 1. Allopurinol ___ mg PO DAILY 2. Dipyridamole-Aspirin 1 CAP PO DAILY 3. Finasteride 5 mg PO DAILY 4. Levothyroxine Sodium 200 mcg PO DAYS (___) 5. Metoprolol Tartrate 25 mg PO QPM 6. Metoprolol Tartrate 50 mg PO QAM 7. Omeprazole 20 mg PO BID 8. Quetiapine Fumarate 50 mg PO Q8H PRN agitation 9. Simvastatin 40 mg PO EVERY OTHER DAY 10. Terazosin 1 mg PO HS 11. Ampicillin 500 mg PO Q6H Duration: 7 Days Continue through ___ RX *ampicillin 500 mg 1 capsule(s) by mouth four times a day Disp #*24 Capsule Refills:*0 12. Docusate Sodium 100 mg PO BID 13. Senna 1 TAB PO BID:PRN constipation Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Primary diagnoses: - Urinary tract infection - Mechanical fall Secondary diagnoses: - CAD s/p CABG (___) - Hypertension - Hyperlipidemia - Vascular dementia - AAA s/p repair - Postural hypotension - Osteoarthritis s/p bilateral total hip replacement - Age related macular degeneration - Hypothyroidism - Gout - History of bladder stone - BPH Discharge Condition: Mental Status: Confused - always. Oriented to self only. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report HISTORY: Coronary artery disease, vascular dementia with mechanical fall. TECHNIQUE: Upright AP view of the chest. COMPARISON: ___. FINDINGS: The patient is status post median sternotomy and CABG. Heart size remains mildly enlarged, unchanged. Moderate size hiatal hernia is re- demonstrated. Aortic knob calcifications are present. The mediastinal and hilar contours are unchanged, and there is no pulmonary vascular congestion. Linear opacities in both lung bases likely reflect subsegmental atelectasis. Minimal blunting of the left costophrenic sulcus suggests a trace left pleural effusion. No pneumothorax is identified. IMPRESSION: Mild bibasilar atelectasis and probable trace left pleural effusion. Unchanged moderate size hiatal hernia. Radiology Report HISTORY: Multiple falls and change in mental status. COMPARISON: None. TECHNIQUE: Contiguous axial MDCT sections were obtained through the brain without administration of IV contrast. Coronal, sagittal, and thin slice bone algorithm reformats were reviewed. FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or large territorial infarction. Prominent ventricles and sulci are compatible with age-related volume loss. Periventricular white matter hypodensities are consistent with chronic small vessel ischemic disease. The basal cisterns appear patent and there is preservation of gray-white matter differentiation. No fracture is identified. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The globes are unremarkable. IMPRESSION: No intracranial hemorrhage or acute territorial infarction. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: ALT MS/S/P FALL Diagnosed with URIN TRACT INFECTION NOS, ALTERED MENTAL STATUS temperature: 98.6 heartrate: 79.0 resprate: 18.0 o2sat: 96.0 sbp: 119.0 dbp: 77.0 level of pain: 0 level of acuity: 2.0

___ yo male with history of CAD s/p CABG, HTN, HL, vascular dementia, BPH, and chronic orthostatic hypotension who presents s/p fall X2 and confusion for the past two weeks found to have a UTI. # Enterococcus UTI: History of possible increased urinary frequency noted by Dr. ___ positive urinalysis, and 10k-100k enterococcus growing in culture. It is very possible that this urinary tract infection could account for his new weakness. He was initially started on ceftriaxone in the ED and transitioned to ampicillin on ___ given susceptibilities. He should continue ampicillin 500 mg PO Q6H through ___. # Vascular dementia: Unlikely to have an acute stroke per neurology assessment but he should continue antiplatelet therapy with dipyridamole-aspirin. Neurology raised the possibility that Multiple System Atrophy (MSA), Shy ___ Type could be a unifying diagnosis. Autonomic consultation as an outpatient might help with management. Nocturnal episodes in MSA are often manifestations of REM sleep behavior disorder rather than sundowning, but history is unclear here. If he has apparent dream enactment (yelling, arm movements as though fighting) at night that diagnosis should be considered as it is treated with medications other than Seroquel, usually clonazepam but high dose melatonin is also useful. # Cervical spondylosis and myelopathy and lumbosacral radiculopathy: Per neurology, there is no need for emergent imaging to assess his cervical or lumbar spines for disc disease, but this could be obtained by his primary care physician. Treatment with a soft cervical collar could be considered. # Gout: Continued allopurinol. # Hypothyroidism: Continued levothyroxine ___ through ___. # BPH: Continued finasteride and tamsulosin. # Hyperlipidemia: Continued simvastatin. # Transitional: - Emergency contact: Wife ___ who is HCP ___ or ___ - Continue ampicillin 500 mg PO Q6H through ___ for enterococcus UTI - Recommend neuro follow up in ___ clinic with Dr. ___ ___ or Dr. ___ for evaluation for possible Multiple System Atrophy (MSA), Shy ___ Type - Consider soft collar for symptomatic management of cervical spondylosis, myelopathy, lumbosacral radiculopathy

Name: ___. Unit ___: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Robitussin A-C / Clindamycin / Lipitor / latex Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: ERCP ___ History of Present Illness: ___ with h/o afib not on warfarin, HTN, TIA who presents with diffuse abdominal pain and weakness and was referred to the ED for rapid afib. Pt reports she was in her usual state of health until ___ (3d ago) when she developed severe diffuse abdominal pain. She reports it is hard to describe the quality, but it was very intense and lasted ___. She believes she had a prior episode of this and sought medical attention but is not sure what it was from. She reports the pain resolved within 2hrs. She had ___ nausea but induced emesis x1 to see if it would help. Then the next day (___), she developed L shoulder and lateral chest pain. She reports this was less intense but lasted in the evening ___ into ___. She reports ___ n/v/diarrhea. ___ fevers. She had brief palpitations on ___ that she did not make much of. ___ dysuria. ___ changes in stool pattern. ___ dizziness or SOB. On ___, she noted malaise and generalized weakness with persistence of L shoulder discomfort. She has been eating and drinking ok. She thus, presented to her PCP ___. She was seen in ___ clinic today where VS: BP: 100/62. Heart Rate: 130, and irregular so referred to ED for rapid afib. In the ED, initial vitals: 98.9 125 144/87 18 - Exam notable for: RLQ tenderness, tachy to 130s in flutter - HR resolved to ___ s/p 1LNS - Labs notable for: WBC 5.8 (72%N), AST/ALT 77/254, T bili 0.9, AP 128, BUN/Cr ___, lactate 2, trop neg x2 - Imaging: CT abd with Filling defect in the distal common bile duct with mild extrahepatic biliary ductal dilatation, concerning for choledocholithiasis - Consultants: ERCP called and reportedly plan for ERCP tomorrow ___ east beds though) - Patient was given: 1L NS, 1g tylenol for pain - Vitals prior to transfer: 98.2 59 147/71 18 98% RA On arrival to the floor, pt reports ___ discomfort in L shoulder and lateral chest area (previously a ___. ___ nausea, palpitations, abdominal pain. Past Medical History: - HTN - Afib, not on anticoagulation - Rheumatic Heart Disease with moderate MR. ___ mitral stenosis seen on echo in ___. - TIA - HLD - Cervical cancer s/p TAH/BSO ___ - S/p cholecystectomy with RUQ pain after - H/o adjustment disorder/depression - Lung nodule - Mild Pulmonary Hypertension - GERD - Left Subclavian Stenosis: Noted to have asymmetric blood pressures (R>L) in ___ when seeing cardiology, also noted to have a carotid bruit. Carotid U/s followed by MRA ___ identified subclavian steal physiology with retrograde left vertebral artery flow. Social History: ___ Family History: ___ liver or gallbladder issues Physical Exam: Admission PE: Vitals: 97.4, 116/89, 59, 98% RA General: well-appearing elderly woman, looks younger than stated age, nontoxic, in NAD HEENT: MMM, ___ scleral icterus appreciated Neck: supple, ___ LAD CV: irregular, normal rate, ___ murmurs appreciated Lungs: CTAB, breathing comfortably Abdomen: soft, ND, RLQ > LLQ TTP, ___ RUQ TTP even with deep palpation, +BS GU: ___ foley Ext: WWP. ___ edema Neuro: grossly intact, attentive and appropriate . Discharge PE: Vitals: afebrile, 120-140s/60-70s, 60s, 97% RA General: well-appearing elderly woman, looks younger than stated age, nontoxic, in NAD Neck: supple CV: RRR, ___ murmurs appreciated Lungs: CTAB, breathing comfortably Abdomen: NT, ND, soft Ext: WWP. ___ edema Neuro: grossly intact, attentive and appropriate Pertinent Results: Admission Labs: ___ 10:34AM BLOOD WBC-5.8 RBC-5.48* Hgb-15.9 Hct-47.4 MCV-87 MCH-29.1 MCHC-33.6 RDW-14.0 Plt ___ ___ 10:34AM BLOOD Neuts-72.8* Lymphs-17.9* Monos-7.7 Eos-0.7 Baso-0.8 ___ 10:34AM BLOOD ___ PTT-25.9 ___ ___ 10:34AM BLOOD Glucose-116* UreaN-19 Creat-1.2* Na-137 K-4.6 Cl-104 HCO3-22 AnGap-16 ___ 10:34AM BLOOD ALT-254* AST-77* AlkPhos-128* TotBili-0.9 ___ 10:34AM BLOOD Lipase-41 ___ 04:35PM BLOOD cTropnT-<0.01 ___ 10:34AM BLOOD cTropnT-<0.01 ___ 10:34AM BLOOD Albumin-4.2 ___ 11:40AM BLOOD Lactate-2.0 . >> IMAGING: CT abd: 1. Filling defect in the distal common bile duct with mild extrahepatic biliary ductal dilatation, concerning for choledocholithiasis. An MRCP may be done for further assessment. 2. Normal appendix. 3. Perivaginal cystic structure possibly representing a Bartholin gland cyst with adjacent fat stranding. Clinical correlation is recommended. . Discharge Labs: ___ 07:01AM BLOOD WBC-6.0 RBC-4.13* Hgb-12.5 Hct-35.8* MCV-87 MCH-30.2 MCHC-34.8 RDW-13.4 Plt ___ ___ 07:10AM BLOOD Glucose-99 UreaN-20 Creat-0.9 Na-140 K-3.9 Cl-107 HCO3-24 AnGap-13 ___ 07:01AM BLOOD ALT-136* AST-38 AlkPhos-115* TotBili-0.9 . >> ERCP ___: Cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. 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. The CBD was 15mm in diameter. A single filling defect consistent with a large 1.5cm stone was identified in the CBD. The left and right hepatic ducts and all intrahepatic branches were normal. A biliary sphincterotomy was made with a sphincterotome. There was ___ post-sphincterotomy bleeding. Given the large size of the stone, a sphincteroplasty was successfully performed using a ___ CRE balloon and dilating up to 13.5mm. There was a moderate self limited bleeding after the sphincteroplasty. Given the risk of further bleeding, lithotripsy of the large stone was deferred. A 10mm X 60mm fully covered WallFlex metal stent (REF ___, ___ was successfully placed for hemostasis. Brisk drainage of bile and contrast was noted endoscopically and fluoroscopically. Otherwise normal ercp to third part of the duodenum Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amiodarone 200 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Lisinopril 20 mg PO DAILY 4. Fish Oil (Omega 3) 1000 mg PO DAILY Discharge Medications: 1. Amiodarone 200 mg PO DAILY 2. Aspirin 81 mg PO DAILY Restart ___. Fish Oil (Omega 3) 1000 mg PO DAILY 4. Lisinopril 20 mg PO DAILY 5. Ciprofloxacin HCl 500 mg PO Q12H Last day ___. RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice daily Disp #*8 Tablet Refills:*0 6. Metoprolol Succinate XL 25 mg PO DAILY RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Choledocholithiasis, rapid atrial fibrillation Secondary diagnosis: hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with rapid afib, weakness. Eval for PNA // eval for PNA TECHNIQUE: PA and lateral views of the chest. COMPARISON: ___. FINDINGS: There is mild cardiomegaly. The lungs are clear without focal consolidation or effusion. There is no pulmonary edema. No acute osseous abnormalities identified. IMPRESSION: Cardiomegaly without acute cardiopulmonary process. Radiology Report INDICATION: ___ with right lower quadrant abdominal pain 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: DLP: 518.09 mGy-cm (abdomen and pelvis). IV Contrast: 130 mL Omnipaque COMPARISON: Abdominal pelvis CT 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 are 2 hypodensities, 1 in segment 4A (series 2, image 9), and the other in segment 6 (series 2, image 27), statistically most likely simple cysts. The common bile duct is dilated at 10 mm with a filling defect within the distal common bile duct. Patient is post cholecystectomy. No intrahepatic biliary ductal dilatation is present. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys have bilateral tiny hypodensities, too small to characterize, statistically most likely simple cysts. No hydronephrosis or hydroureter. GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness and enhancement throughout. Diverticulosis of the sigmoid colon is noted, without evidence of wall thickening or fat stranding. The appendix is normal. RETROPERITONEUM: There is no evidence of retroperitoneal and mesenteric lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. There is minimal calcium burden in the abdominal aorta and great abdominal arteries. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The patient is post hysterectomy. Adjacent to the vagina in the right perineal region, there is possibly a cyst with associated fat stranding, possibly a Bartholin gland cyst. BONES AND SOFT TISSUES: There is no evidence of worrisome lesions. IMPRESSION: 1. Filling defect in the distal common bile duct with mild extrahepatic biliary ductal dilatation, concerning for choledocholithiasis. An MRCP may be done for further assessment. 2. Normal appendix. 3. Perivaginal cystic structure possibly representing a Bartholin gland cyst with adjacent fat stranding. Clinical correlation is recommended. RECOMMENDATION(S): An MRCP may be done for further assessment of biliary tree. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 4:02 ___, 5 minutes after discovery of the findings. Gender: F Race: HISPANIC/LATINO - COLUMBIAN Arrive by AMBULANCE Chief complaint: Atrial fibrillation Diagnosed with ATRIAL FIBRILLATION, ABDOMINAL PAIN RLQ temperature: 98.9 heartrate: 125.0 resprate: 18.0 o2sat: nan sbp: 144.0 dbp: 87.0 level of pain: nan level of acuity: 2.0

___ with h/o afib not on warfarin, HTN, TIA who presents with diffuse abdominal pain and weakness and was referred to the ED for rapid afib. . # Choledocholithiasis: Pt presented after an episode of severe diffuse abdominal pain 3d prior to admission. ___ significant abd pain since with fluctuating abdominal exam - RLQ>LLQ TTP initially and then RUQ on HD2. Given LFTs abnormalities and CT findings concerning for filling defect in CBD, pt went for ERCP ___, which showed a large stone in the CBD. There was self-limited bleeding during sphincterotomy so the gallstone was unable to be removed and a stent was placed. Pt looked clinically well throughout. LFTs downtrended. Pt had ___ evidence of cholangitis throughout. Plan for repeat ERCP for stent removal and lithotripsy in ___. 5d course of Cipro BID per ERCP recs. Diet advanced without difficulty prior to discharge on ___. . # L shoulder/lateral chest pain: mild and somewhat nonspecific. ACS ruled out with serial trops. Unclear if this is related to potential choledocholithiasis though would expect referred pain to be in R shoulder. Could be MSK. Pain resolved during admission. . # Afib: initially rapid in clinic to 130, improved to ___ with IVF and then in the high 50-60s in sinus with PACs. CHADS score is 4 - not on anticoagulation as pt has declined in the past. Pt continued on Amio and ASA. Pt flipped back to rapid afib the morning of ___ (to 110-130) so low dose PO metop started and pt discharged on metop succinate 25mg daily. Discussed anticoagulation with her given high CHADS score and she will discuss further with PCP at ___. . # CKD: baseline Cr around 0.9-1, most recently 1.3 in ___. 1.2 on presentation, now 0.9 IVF . # HTN: restarted lisinopril on discharge. # H/o TIA: cont ASA 81 . >> Transitional issues: # CODE STATUS: confirmed Full # CONTACT: daughter, ___ ___ # 5day course of Cipro 500 BID per ERCP recs until ___ # Holding ASA for 4 days after ERCP to restart ___ # Started metoprolol succinate 25mg daily given pt flipped back into rapid afib during admission. # Discussed anticoagulation with pt and her daughter given high CHADS score. Please continue discussions. # Repeat ERCP in ___ for stent removal and lithotripsy of CBD gallstone

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: R leg cellulitis and R Heel Ulcer Major Surgical or Invasive Procedure: Bedside foot debridement History of Present Illness: ___ with multiple medical problems including COPD, DM, PAD, NHL, and atrial fibrillation (not anticoagulated) presenting with right leg swelling and redness. Per report, the patient cut his leg a few months ago which has been monitored and treated by ___. He began to experience new right heel pain with ambulation on ___. His ___ recommended he presented to the ED when the redness was felt to have started to increase. No report of fevers or chills. In the ED, initial vital signs were 97.0 85 121/61 18 97%. His labs revealed leukocytosis to 15.6 with 88% PMNs and BUN/Cr ___. He was evaluated by the podiatry team who recommended admission for IV antibiotics and possible OR debridement. The wound was reported as deeply probing but not to bone. He was given vancomycin, ciprofloxacin, and flagyl. On the floor, his vital signs were ___, 114/50, 86, 20, 100%RA and the borders of his leg cellulitis was demarked with a marker Review of Systems: (+) Per HPI (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: ABNORMAL LFTS ___ ANEMIA ___ - microcytic, normal iron, tsh, creat PROSTATE CANCER - TURP ___ prostate cancer on bx CHRONIC OBSTRUCTIVE PULMONARY DISEASE - hx tob 60pk yr DIABETES MELLITUS ___ DIVERTICULOSIS ERECTILE DYSFUNCTION - low testosterone GASTROESOPHAGEAL REFLUX HEARING LOSS - 70% B/L, uses aids HYPERCHOLESTEROLEMIA HYPERTENSION HYPONATREMIA ___ - c/w SIADH NON-HODGKIN'S LYMPHOMA ___ - rituxan MAJOR DEPRESSION - complicated bereavement, chronically anxious OSTEOARTHRITIS - knee PERIPHERAL NEUROPATHY ___ - spinal stenosis moderate/severe, and polyradiculopathies mild/moderate EMG SECOND DEGREE ATRIOVENTRICULAR BLOCK - type I SHOULDER PAIN - rotator cuff tear ___ MRI SPINAL STENOSIS - ___, severe L4-5 spinal stenosis SYNCOPE - hx distant with needles, recent with needle pain ___ ULCERATIVE COLITIS URINARY INCONTINENCE ___ - s/p TURP VENOUS STASIS CATARACT ___ - right IOL GLAUCOMA ___ - open angle iridectomy DECUBITUS BUTTOCK UL peripheral arterial disease Atrial fibrillation Social History: ___ Family History: From OMR: Mother died at age ___ of unclear etiology, Father at age ___ of heart disease. Brothers with lung cancer, prostate cancer, and heart disease. Sister with colon cancer. Physical Exam: Admission Physical Exam: Vitals- ___, 114/50, 86, 20, 100%RA General: alert and oriented HEENT: MMM, anicteric sclera, decreased visual acuity secondary to shingles infection. Neck: soft, no JVD CV: irregularly, irregular rythm Lungs: CTA, no wheezes or ronchi Abdomen: soft, non-tender, non-distended, BS+ GU: no CVA tenderness Ext: dressing on the R leg and heel is clean dry and intact. Erythema and edema more pronounce on the lateral aspect of right leg extending from the foot to the knee. Erythematous and warm to touch. Neuro: CNII-XII grossly intact, motor grossly intact, speech fluent Skin: red, warm to touch, flakey, with evidence of purulent drainage Discharge Physical Exam: Vitals: 97.8, 131/82, 18, 97% RA General: Alert and oriented, no acute distress HEENT: orphopharynx clear Neck: soft, no JVD Lungs: clear to ascultation bilaterally, no wheezes or ronchi CV: Irregularly, Irregular Abdomen: soft, non-tender, slightly distended, no suprapubic tenderness or distension Ext: dressing on the R leg and heel is clean dry and intact. Erythema on the lateral aspect of right leg extending from the foot to the knee. Warm to touch. Non ttp. The erythema continues to regress from the border line drawn on ___. Neuro: CNII-XII grossly intact and symmetric, no gross motor deficits, speech is fluent Pertinent Results: Admission Labs: ___ 01:58PM LACTATE-1.1 ___ 01:55PM GLUCOSE-177* UREA N-26* CREAT-0.7 SODIUM-132* POTASSIUM-4.0 CHLORIDE-96 TOTAL CO2-23 ANION GAP-17 ___ 01:55PM estGFR-Using this ___ 01:55PM WBC-15.6*# RBC-3.96* HGB-11.7* HCT-33.6* MCV-85 MCH-29.6 MCHC-34.9 RDW-13.7 ___ 01:55PM NEUTS-88.4* LYMPHS-5.7* MONOS-5.8 EOS-0.1 BASOS-0.1 ___ 01:55PM PLT COUNT-249 Interval Labs: ___ 05:50AM BLOOD Glucose-179* UreaN-22* Creat-0.7 Na-132* K-4.4 Cl-97 HCO3-25 AnGap-14 ___ 05:50AM BLOOD WBC-11.2* RBC-3.75* Hgb-11.0* Hct-32.2* MCV-86 MCH-29.3 MCHC-34.2 RDW-13.7 Plt ___ ___ 06:00AM BLOOD Glucose-137* UreaN-18 Creat-0.6 Na-134 K-3.7 Cl-99 HCO3-25 AnGap-14 ___ 06:00AM BLOOD WBC-8.2 RBC-3.82* Hgb-11.3* Hct-32.5* MCV-85 MCH-29.5 MCHC-34.6 RDW-13.9 Plt ___ Discharge Labs: ___ 05:50AM BLOOD Glucose-149* UreaN-21* Creat-0.7 Na-135 K-3.5 Cl-103 HCO3-23 AnGap-13 ___ 05:50AM BLOOD WBC-8.6 RBC-4.05* Hgb-11.8* Hct-34.8* MCV-86 MCH-29.1 MCHC-34.0 RDW-13.8 Plt ___ Microbiology: ___ Wound Culture: 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 in this culture.. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. OF TWO COLONIAL MORPHOLOGIES. STAPH AUREUS COAG +. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | STAPH AUREUS COAG + | | CEFEPIME-------------- 4 S CEFTAZIDIME----------- 2 S CIPROFLOXACIN---------<=0.25 S CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ 4 S <=0.5 S LEVOFLOXACIN---------- =>8 R MEROPENEM-------------<=0.25 S OXACILLIN------------- <=0.25 S PIPERACILLIN/TAZO----- 8 S TETRACYCLINE---------- <=1 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S ANAEROBIC CULTURE (Preliminary): RESULTS PENDING. Blood Cultures x2 (___): Pending Pathology: None Imaging/Studies: CXR (___): IMPRESSION: Ulceration in the skin overlying the right heel. Multi focal regions of lucency within the bones including the calcaneus which could be due to diffuse osteopenia. Although not particularly suspected, osteomyelitis cannot be excluded. MRI would be more specific. Non-ivasive arterial study of lower extremities (___): IMPRESSION: Bilateral tibial disease, possibly some non-compressive vessels. The tibial disease is new compared to the prior study performed on ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 3. Gabapentin 100 mg PO HS 4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 5. Nephrocaps 1 CAP PO DAILY 6. Omeprazole 20 mg PO BID 7. Tamsulosin 0.8 mg PO HS 8. Sodium Chloride 1 gm PO TID 9. Lorazepam 1 mg PO Q8H:PRN anxiety 10. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO BID:PRN pain 11. Lisinopril 40 mg PO DAILY Hold for SBP<100 12. Ascorbic Acid ___ mg PO DAILY 13. Multivitamins 1 TAB PO DAILY 14. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath 15. Lidocaine 5% Patch 1 PTCH TD DAILY Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath 2. Aspirin 81 mg PO DAILY 3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 4. Gabapentin 100 mg PO HS 5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 6. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain 7. Lisinopril 40 mg PO DAILY 8. Lorazepam 1 mg PO Q8H:PRN anxiety 9. Nephrocaps 1 CAP PO DAILY 10. Sodium Chloride 1 gm PO TID 11. Tamsulosin 0.8 mg PO HS 12. Omeprazole 20 mg PO BID 13. Multivitamins 1 TAB PO DAILY 14. Docusate Sodium 100 mg PO BID 15. Ciprofloxacin HCl 500 mg PO Q12H Through ___, then stop. 16. Clindamycin 450 mg PO Q8H Through ___, then stop. 17. Pilocarpine 1% 1 DROP RIGHT EYE Q8H Glaucoma 18. HYDROcodone-acetaminophen *NF* 7.5-750 mg Oral BID: PRN pain Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Foot ulcer Cellulitis 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: ___ male with right heel ulcer and ascending cellulitis. Question osteomyelitis. COMPARISON: ___. FINDINGS: AP, lateral, and oblique views of the right foot. Multi focal lucencies seen within the bones suggestive of osteopenia. Focal regions of lucency also seen within the right calcaneus, not out of proportion to findings elsewhere and there is no focal region of cortical disruption. There is no definite acute fracture. Joint spaces are grossly preserved. There is soft tissue swelling identified as well skin ulceration within the subcutaneous tissues overlying the calcaneus. There is no radiopaque foreign body or subcutaneous gas. Small vessel atherosclerotic calcifications are noted. IMPRESSION: Ulceration in the skin overlying the right heel. Multi focal regions of lucency within the bones including the calcaneus which could be due to diffuse osteopenia. Although not particularly suspected, osteomyelitis cannot be excluded. MRI would be more specific. Radiology Report HISTORY: Right heel ulcer, diabetes. FINDINGS: The ABI on the right is 1.0 and the ABI on the left is 1.21. Doppler tracings are triphasic through the popliteal levels bilaterally and monophasic at the tibial levels bilaterally. Volume recordings demonstrate some waveform widening at the ankle and metatarsal levels bilaterally. IMPRESSION: Bilateral tibial disease, possibly some non-compressive vessels. The tibial disease is new compared to the prior study performed on ___. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: R LEG SWELLING Diagnosed with CELLULITIS OF FOOT temperature: 97.0 heartrate: 85.0 resprate: 18.0 o2sat: 97.0 sbp: 121.0 dbp: 61.0 level of pain: 10 level of acuity: 3.0

___ with multiple medical problems including COPD, DM, PAD, NHL, and atrial fibrillation (not anticoagulated) presenting with right leg swelling and redness concerning for cellulitis vs osteomyeltis. Active Diagnoses: #. Right foot/heel wound Pt with DM and PVD with chronic wound on right foot. Presenting with worsening swelling, redness and pain. Imaging with regions of luceny which were felt to be osteopenia vs osteomyelitis. He was seen by podiatry in the ED, who were unable to probe to bone, but felt that he required IV antibiotics. He had a non-invasive study on ___ to access his arterial flow in the LEs. The arterial study of the lower extremities showed bilateral tibial disease. Switched Cipro to PO on ___. On ___ had Right heel debridement at bedside. His foot bled during the debridement yesterday meaning that Vascular will follow up with him as an outpatient. Leukocytosis improving. Wound culture grew out psuedomonas (cipro sensitive) and Coag+ staph on ___. He will continue with Cipro and Clindamycin as an outpatient until ___. Of note, after discharge, culture sensitivities revealed clinda-resistant MRSA. Rehab was contacted, and the patient was switched to cipro/bactrim. His renal function should be monitored while he is on bactrim. # BPH: Patient uses diapers. He had 990cc in his bladder on the evening of ___. He received a foley catheter on ___ and his suprapubic pain resolved. Continued tamsulosin. Foley will likely be discontinued in rehab on ___.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Erythromycin Base / Levofloxacin / lisinopril Attending: ___. Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old woman with Child's A alcohol/HCV cirrhosis c/b varices, ETOH abuse, type 2 diabetes, chronic pancreatitis presenting with ETOH intoxication and right hip pain. Transferred from home for slurred speech and altered mental status, and reporting traumatic right hip pain that per patient is a hip fracture that does not require surgery, and otherwise here has been belligerent towards staff. Patient refusing to participate in exam other than attending to kick providers with both legs demonstrating full range of motion and good strength in the right lower extremity. On arrival to the MICU, the patient states that she is still feeling tremulous and anxious. She reports that she has been having pain in her right hip for the past month. She has daily nausea and vomiting, which hasn't changed since admission. She also denies diarrhea, although she is not sure when she finished her course of treatment for C. diff. She thinks her visiting nurse ___ have identified a fever ___ F at home but no chills or sweats. Past Medical History: 1. Diabetes complicated by peripheral neuropathy, h/o DKA 2. Depression 3. Recurrent Alcohol Abuse with multiple admissions for detox, no h/o DT or w/d seizures 4. Alcoholic hepatitis 5. Chronic pancreatitis 6. Cirrhosis/varices by MRI 7. Prior suicidal ideation ___ 8. GERD 9. HTN Social History: ___ Family History: Mother - died of ___ Brother - died of ___ Brother - DM Physical ___: On Admission Physical Exam ========================== VITALS: afebrile, BP 150/80s, HR ___, RR 20, satting 98% RA GENERAL: Alert, oriented, no acute distress but tremulous without asterixis HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, ___, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, no tenderness over the right hip, no effusion SKIN: no rash noted NEURO: moving all extremities spontaneously On Discharge Physical Exam ========================== VITALS: 98.3 BP 118/68 HR 105 RR 18 O2: 93% on RA GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, ___, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, no tenderness over the right hip, no effusion SKIN: no rash noted NEURO: moving all extremities spontaneously, minimal UE tremor, no tongue fasciculations Pertinent Results: In the ED ___ =============== ___ 05:35PM BLOOD ___ ___ Plt ___ ___ 05:35PM BLOOD ___ ___ ___ 05:35PM BLOOD ___ ___ 05:35PM BLOOD ___ ___ 05:35PM BLOOD ___ ___ 05:35PM BLOOD ___ ___ 05:35PM BLOOD ___ ___ 05:35PM BLOOD cTropnT-<0.01 ___ 06:45PM BLOOD ___ ___ Base ___ ___ 08:06PM BLOOD ___ On Arrival to MICU ___ ======================= ___ 07:14AM BLOOD ___ ___ Plt ___ ___ 07:14AM BLOOD ___ ___ ___ 07:14AM BLOOD ___ ___ ___ 07:14AM BLOOD ___ LD(LDH)-225 ___ ___ At Discharge from MICU ___ =========================== ___ 03:50PM BLOOD ___ ___ ___ 04:15PM BLOOD ___ Imaging ======= ___ CT A/P: 1. The pancreas has normal attenuation enhancement throughout without evidence of pancreatic ductal dilatation. No evidence of pancreatic necrosis or peripancreatic fluid collections or stranding. Please note that CT findings of pancreatitis ___ lag clinical findings by up to 48 hours. 2. There is an unchanged 0.5 cm hypodensity in the pancreatic tail, which is nonspecific, but likely represents a side branch IPMN. This is been stable since at least ___, suggestive of benignity. 3. Massive dilatation of the urinary bladder ___ RUQ US: Limited exam. Slightly nodular contour of the liver should be correlated for underlying cirrhosis. No evidence of gallstones or choledocholithiasis. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. BusPIRone 15 mg PO TID 3. Creon 12 1 CAP PO TID W/MEALS 4. DULoxetine 60 mg PO DAILY 5. Gabapentin 800 mg PO TID 6. Multivitamins W/minerals 1 TAB PO DAILY 7. Omeprazole 40 mg PO DAILY 8. Simethicone ___ mg PO QID:PRN gas pain 9. amLODIPine 5 mg PO DAILY 10. Losartan Potassium 50 mg PO DAILY 11. MetFORMIN (Glucophage) 1000 mg PO BID 12. Ondansetron 8 mg PO Q8H:PRN nausea 13. TraZODone 50 mg PO QHS:PRN insomnia 14. 70/30 7 Units Breakfast 70/30 7 Units Lunch 70/30 7 Units Dinner degludec 65 Units Breakfast Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild RX *acetaminophen [8 Hour Pain Reliever] 650 mg 1 tablet(s) by mouth every 8 hours Disp #*30 Tablet Refills:*0 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation RX *bisacodyl [___] 5 mg 1 tablet(s) by mouth every day Disp #*30 Tablet Refills:*0 3. Cefpodoxime Proxetil 200 mg PO Q12H RX *cefpodoxime 200 mg 1 tablet(s) by mouth every 12 hours Disp #*2 Tablet Refills:*0 4. Cyanocobalamin 100 mcg PO DAILY RX *cyanocobalamin (vitamin ___ 1,000 mcg 1 tablet(s) by mouth every day Disp #*30 Tablet Refills:*0 5. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth every day Disp #*30 Tablet Refills:*0 6. Lidocaine 5% Patch 1 PTCH TD QAM RX *lidocaine ___ [MTX] 4 %-1 % 1 patch every day Disp #*30 Patch Refills:*0 7. Multivitamins 1 TAB PO DAILY RX *multivitamin 1 tablet(s) by mouth every day Disp #*30 Tablet Refills:*0 8. Senna 8.6 mg PO BID:PRN Constipation RX *sennosides ___ (sennosides)] 8.6 mg 1 tab by mouth every day Disp #*30 Tablet Refills:*0 9. Thiamine 100 mg PO DAILY RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth every day Disp #*30 Tablet Refills:*0 10. 70/30 7 Units Breakfast 70/30 7 Units Lunch 70/30 7 Units Dinner degludec 65 Units Breakfast Insulin SC Sliding Scale using HUM Insulin RX *insulin NPH and regular human [Humulin 70/30 KwikPen] 100 unit/mL (___) AS DIR 7 SC 7 Units before BKFT; 7 Units before LNCH; 7 Units before DINR; Disp #*90 Syringe Refills:*0 RX *blood sugar diagnostic [Accutrend Glucose] 1 strip TID Three times a day with meals Disp #*100 Strip Refills:*0 RX ___ meter [Advanced Glucose Meter] 1 meter three times a day Disp #*1 Each Refills:*0 RX *lancets [___] 23 gauge one lancet three times a day three times a day Disp #*100 Each Refills:*0 RX *insulin degludec [Tresiba FlexTouch ___ 100 unit/mL (3 mL) AS DIR 65 SC 65 Units before BKFT; Disp #*30 Syringe Refills:*0 11. amLODIPine 5 mg PO DAILY RX *amlodipine 5 mg 1 tablet(s) by mouth every day Disp #*30 Tablet Refills:*0 12. Atorvastatin 40 mg PO QPM RX *atorvastatin 40 mg 1 tablet(s) by mouth every day Disp #*30 Tablet Refills:*0 13. BusPIRone 15 mg PO TID RX *buspirone 15 mg 1 tablet(s) by mouth every 8 hours Disp #*90 Tablet Refills:*0 14. Creon 12 1 CAP PO TID W/MEALS RX ___ [Creon] 12,000 ___ ___ unit 1 capsule(s) by mouth every 8 hours with meals Disp #*90 Capsule Refills:*0 15. DULoxetine 60 mg PO DAILY RX *duloxetine [Cymbalta] 60 mg 1 capsule(s) by mouth every day Disp #*30 Capsule Refills:*0 16. Gabapentin 800 mg PO TID RX *gabapentin 800 mg 1 tablet(s) by mouth every 8 hours Disp #*90 Tablet Refills:*0 17. Losartan Potassium 50 mg PO DAILY RX *losartan [Cozaar] 50 mg 1 tablet(s) by mouth every day Disp #*30 Tablet Refills:*0 18. MetFORMIN (Glucophage) 1000 mg PO BID RX *metformin [Fortamet] 1,000 mg 1 tablet(s) by mouth every 12 hours Disp #*60 Tablet Refills:*0 19. Multivitamins W/minerals 1 TAB PO DAILY 20. Omeprazole 40 mg PO DAILY RX *omeprazole 40 mg 1 capsule(s) by mouth every day Disp #*30 Capsule Refills:*0 21. Simethicone ___ mg PO QID:PRN gas pain RX *simethicone ___ Ultra Strength] 180 mg 1 tab by mouth ___ 6 hours Disp #*120 Capsule Refills:*0 22. TraZODone 50 mg PO QHS:PRN insomnia RX *trazodone 50 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 23.Equipment 1 Rolling Walker No refills Use daily Discharge Disposition: Home Discharge Diagnosis: Alcohol Withdrawal Urinary Tract Infection Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report INDICATION: Right hip pain status post fall. COMPARISON: CTU dated ___. FINDINGS: AP view of the pelvis and AP and lateral views of the right hip were provided. The bony pelvic ring is intact. SI joints are symmetric and normal. Imaged lower lumbar spine is unremarkable. Both hips align anatomically without significant osteoarthritis. The femoral necks appear intact bilaterally. IMPRESSION: No fracture. Radiology Report EXAMINATION: CHEST (P AP a AND LAT) INDICATION: ___ with epigastric pain// ? effusion COMPARISON: Prior exam is dated ___ FINDINGS: AP upright and lateral views of the chest provided. No free air seen below the right hemidiaphragm. Lungs are clear. There is no focal consolidation, effusion, or pneumothorax. The cardiomediastinal silhouette is stable. Imaged osseous structures are intact. Chronic right seventh rib deformity again noted. IMPRESSION: No acute intrathoracic process. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ with pancreatitis, recurrent// ? choledocolithiasis/CBD dilation TECHNIQUE: Right upper quadrant ultrasound, patient refused portions of the exam due to discomfort during scanning. COMPARISON: CT of the abdomen pelvis from ___ FINDINGS: Subtle nodularity along the hepatic contour raises potential concern for cirrhosis. Please note the majority of the right lobe was poorly visualized due to under penetration and poor access. No perihepatic ascites. No intrahepatic biliary ductal dilation. Main portal vein is patent with hepatopetal flow. The gallbladder appears normal without stones or evidence of acute cholecystitis. The common bile duct measures up to 5 mm in diameter. The spleen is within normal limits at 12 cm in length. Pancreas is poorly visualized. IMPRESSION: Limited exam. Slightly nodular contour of the liver should be correlated for underlying cirrhosis. No evidence of gallstones or choledocholithiasis. Radiology Report EXAMINATION: CT abdomen and pelvis with contrast INDICATION: ___ with rising lactate and abdominal pain. Evaluate for necrotizing pancreatitis. TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis prior to and 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 2.9 s, 31.5 cm; CTDIvol = 14.7 mGy (Body) DLP = 463.8 mGy-cm. 2) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 24.1 mGy (Body) DLP = 12.0 mGy-cm. 3) Spiral Acquisition 4.9 s, 53.9 cm; CTDIvol = 14.9 mGy (Body) DLP = 803.9 mGy-cm. Total DLP (Body) = 1,280 mGy-cm. COMPARISON: CT abdomen and pelvis ___ FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates decreased density throughout, consistent with hepatic steatosis. There are a few subcentimeter hypodensities scattered throughout the liver, too small to characterize. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation and enhancement throughout, without evidence of pancreatic ductal dilatation. No evidence of peripancreatic fluid collections. Unchanged 0.5 cm hypodensity in the pancreatic tail (___), which is nonspecific, but likely represents a side branch IPMN. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. Small medial small accessory spleen. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There are bilateral subcentimeter hypodensities, too small to characterize. No hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: Small hiatal hernia. Otherwise, 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 is massively distended. The distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable. LYMPH NODES: There are multiple mesenteric nodes, measuring up to 1.0 cm in short axis (___). There is no retroperitoneal lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: Tiny fat containing umbilical hernia. Otherwise, the abdominal and pelvic wall is within normal limits. IMPRESSION: 1. The pancreas has normal attenuation enhancement throughout without evidence of pancreatic ductal dilatation. No evidence of pancreatic necrosis or peripancreatic fluid collections or stranding. Please note that CT findings of pancreatitis may lag clinical findings by up to 48 hours. 2. There is an unchanged 0.5 cm hypodensity in the pancreatic tail, which is nonspecific, but likely represents a side branch IPMN. This is been stable since at least ___, suggestive of benignity. 3. Massive dilatation of the urinary bladder. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: ETOH, R Hip pain Diagnosed with Acute pancreatitis without necrosis or infection, unsp temperature: 97.8 heartrate: 98.0 resprate: 16.0 o2sat: 95.0 sbp: 169.0 dbp: 88.0 level of pain: 3 level of acuity: 3.0

SUMMARY: Ms. ___ is a ___ lady with a PMH of alcoholic and HCV cirrhosis (Childs A) complicated by varices, alcohol abuse, chronic pancreatitis, and diabetes, who presented to the ___ ED initially with slurred speech, AMS, and right hip pain, found to be intoxicated and now s/p phenobarbital loading for high risk of withdrawal.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: morphine Attending: ___. Major Surgical or Invasive Procedure: ___ Cardiac catheterization, DES x2 RCA attach Pertinent Results: ADMISSION LABS ============== ___ 03:40PM BLOOD WBC-24.7* RBC-4.83 Hgb-11.4* Hct-37.4* MCV-77* MCH-23.6* MCHC-30.5* RDW-15.5 RDWSD-41.6 Plt ___ ___ 03:40PM BLOOD Neuts-88.0* Lymphs-4.3* Monos-6.2 Eos-0.0* Baso-0.2 Im ___ AbsNeut-21.75* AbsLymp-1.05* AbsMono-1.54* AbsEos-0.00* AbsBaso-0.04 ___ 03:40PM BLOOD Glucose-272* UreaN-85* Creat-2.5* Na-136 K-6.9* Cl-103 HCO3-17* AnGap-16 ___ 05:45PM BLOOD Albumin-3.7 Calcium-9.0 Phos-5.7* Mg-2.2 ___ 05:45PM BLOOD ALT-50* AST-186* AlkPhos-83 TotBili-0.3 ___ 05:45PM BLOOD ___ PTT-30.7 ___ PERTINENT LABS ============== ___ 05:45PM BLOOD cTropnT-7.01* ___ 06:46PM BLOOD cTropnT-6.31* ___ DISCHARGE LABS ============== ___ 07:00AM BLOOD WBC-9.5 RBC-4.83 Hgb-11.5* Hct-36.5* MCV-76* MCH-23.8* MCHC-31.5* RDW-14.5 RDWSD-38.2 Plt ___ ___ 07:00AM BLOOD ___ PTT-29.3 ___ ___ 07:00AM BLOOD Glucose-241* UreaN-42* Creat-1.5* Na-132* K-5.1 Cl-98 HCO3-22 AnGap-12 IMAGING/OTHER STUDIES ===================== ___ EKG NSR, ST-Elevations in II, III, aVF ___ CARDIAC CATH LM: The Left Main, arising from the left cusp, is a large caliber vessel. This vessel bifurcates into the Left Anterior Descending and Left Circumflex systems. LAD: The Left Anterior Descending artery, which arises from the LM, is a large caliber vessel. The Diagonal, arising from the proximal segment, is a medium caliber vessel. The Septal Perforator, arising from the proximal segment, is a medium caliber vessel. Cx: The Circumflex artery, which arises from the LM, is a large caliber vessel. The ___ Obtuse Marginal, arising from the proximal segment, is a medium caliber vessel. The ___ Obtuse Marginal, arising from the mid segment, is a medium caliber vessel. RCA: The Right Coronary Artery, arising from the right cusp, is a large caliber vessel. There is a 100% stenosis in the proximal segment. There is a moderate thrombus in the proximal and mid segments. There is a 70% stenosis in the proximal and mid segments. The Right Posterior Descending Artery, arising from the distal segment, is a medium caliber vessel. Collaterals from the distal segment of the SP connect to the proximal segment. The Right Posterolateral Artery, arising from the distal segment, is a medium caliber vessel. • Single vessel coronary artery disease • Maximize medical therapy • DAPT for 12 mo with ASA/Ticagrelor. Routine post-STEMI care • 2 DES to RCA Medications on Admission: The Preadmission Medication list may be inaccurate and requires further investigation. 1. clotrimazole 1 % topical BID 2. Docusate Sodium 200 mg PO DAILY 3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE BID 4. HydrALAZINE 50 mg PO Q8H 5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 6. Metoclopramide 10 mg PO QIDACHS 7. Omeprazole 20 mg PO BID 8. Ondansetron 8 mg PO BID:PRN Nausea/Vomiting - First Line 9. OxyCODONE (Immediate Release) 15 mg PO Q6H:PRN Pain - Severe 10. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE BID 11. Senna 8.6 mg PO BID 12. amLODIPine 10 mg PO DAILY 13. Amphotericin B Ophth Soln 0.1% 1 DROP OD BID 14. Atorvastatin 40 mg PO QPM 15. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE Q12H 16. Moxifloxacin 0.5% Ophth (*NF*) 1 DROP OD Q6H eye infection 17. Polyethylene Glycol 17 g PO DAILY 18. Sarna Lotion 1 Appl TP QID:PRN itching 19. Sodium Bicarbonate 1300 mg PO BID 20. Sodium Chloride 1 gm PO BID 21. Multivitamins W/minerals 1 TAB PO DAILY 22. patiromer calcium sorbitex ___ gram oral DAILY 23. OxyCODONE SR (OxyCONTIN) 10 mg PO Q12H 24. Ferrous Sulfate 325 mg PO EVERY OTHER DAY 25. Glargine 3 Units Dinner Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Aspirin 81 mg PO DAILY RX *aspirin [Adult Aspirin Regimen] 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 2. CARVedilol 6.25 mg PO BID RX *carvedilol 6.25 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 3. Lisinopril 5 mg PO DAILY 4. TiCAGRELOR 90 mg PO BID RX *ticagrelor [Brilinta] 90 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 5. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 6. Glargine 7 Units Dinner Insulin SC Sliding Scale using HUM Insulin 7. Metoclopramide 5 mg PO TIDAC RX *metoclopramide HCl 5 mg 1 tablet by mouth three times a day before meals Disp #*90 Tablet Refills:*0 8. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE Q12H 9. clotrimazole 1 % topical BID 10. Docusate Sodium 200 mg PO DAILY 11. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE BID 12. Ferrous Sulfate 325 mg PO EVERY OTHER DAY 13. Multivitamins W/minerals 1 TAB PO DAILY 14. Omeprazole 20 mg PO BID 15. Ondansetron 8 mg PO BID:PRN Nausea/Vomiting - First Line 16. OxyCODONE (Immediate Release) 15 mg PO Q6H:PRN Pain - Severe RX *oxycodone 5 mg 3 tablet(s) by mouth four times a day Disp #*12 Tablet Refills:*0 17. OxyCODONE SR (OxyCONTIN) 10 mg PO Q12H RX *oxycodone [OxyContin] 10 mg 1 tablet(s) by mouth twice a day Disp #*2 Tablet Refills:*0 18. patiromer calcium sorbitex ___ gram oral DAILY 19. Polyethylene Glycol 17 g PO DAILY 20. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE BID 21. Sarna Lotion 1 Appl TP QID:PRN itching 22. Senna 8.6 mg PO BID 23. Sodium Bicarbonate 1300 mg PO BID 24. Sodium Chloride 1 gm PO BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnoses: RCA STEMI s/p PCI CAP Secondary diagnoses: Hyperkalemia ___ 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: ___ with altered mental status // eval PNA COMPARISON: Prior chest CT from ___ and chest radiograph from ___ FINDINGS: AP portable semi upright view of the chest. A fiducial projecting over the left perihilar region is unchanged in position. There is a subtle ground-glass opacity projecting over the right lower lung which could represent a developing pneumonia in the correct clinical setting. Elsewhere, lungs are clear. Small surgical clips project over the right mediastinal border. Cardiomediastinal silhouette is stable. Bony structures are intact. IMPRESSION: Subtle opacity at the right lung base could represent a developing pneumonia. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by UNKNOWN Chief complaint: Diarrhea, Weakness Diagnosed with Non-ST elevation (NSTEMI) myocardial infarction temperature: 98.3 heartrate: 95.0 resprate: 18.0 o2sat: 94.0 sbp: 117.0 dbp: 67.0 level of pain: 10 level of acuity: 3.0

TRANSITIONAL ISSUES: ===================== [] Medications STARTED: Lisinopril 5, atorvastatin increased from 40 to 80 daily, ASA 81, ticagrelor 90 BID, Coreg 6.25 BID [] Medications STOPPED: amlodipine 10 daily, hydralazine 50 q8h, isosorbide mononitrate 30 daily [] Cardiology: Discharge Cr: 1.5 Discharge Weight: 131.83 - We started him on an ACEi while inpatient. His kidney function was stable prior to discharge. [] Follow up blood pressures as an outpatient and consider restarting amlodipine or hydralazine as indicated (see meds that were held above) [] He was being given 7u Lantus in the evening. We discharged him on this, but he had been prescribed 10u prior to admission and reported taking ___ each evening. Can titrate his Lantus at follow-up. SUMMARY ===================== ___ yr old male with a history of CAD with NSTEMI in ___, CKD, gastroparesis, chronic pancreatitis, NSCLC s/p XRT, diabetes, hypertension, and blindness who presented with weakness and confusion found to have inferior STEMI s/p DES x2 to RCA. His course was complicated by pneumonia, hyperkalemia, and ___ on CKD. #CORONARIES: ___ RCA 100% in proximal segment and 70% stenosis in the proximal and mid segments. #PUMP: Mild symmetric LV hypertrophy with small cavity and normal regional and global LV systolic function. EF 55-60%. Dilated RV cavity with SEVERE global free wall hypokinesis. Abnormal interventricular septal wall mition c/w RV pressure and volume overload. Mild MR, mod/severe TR. #RHYTHM: NSR ACTIVE ISSUES: =============== # Inferior STEMI s/p DES x2 to RCA Patient presented with weakness and confusion, without chest pain, and was found to have inferior STEMI. Taken to cath lab, now s/p DES x2 to RCA. He required a brief stay in the CCU for post-catheterization hypotension, which improved with IVF. TTE showed preserved EF but severely hypokinetic RV. He was started on ASA, ticagrelor, atorvastatin and metoprolol following his catheterization, but was switched from metoprolol to carvedilol prior to discharge and tolerated it well. He was started on Lisinopril 5 on day of discharge. # Community Acquired Pneumonia Patient presented with weakness and confusion and wife noted several weeks of coughing. He denied fevers and remained afebrile while inpatient, but had a WBC count of 26 with neutrophilic predominance and left shift and concern for R basilar opacity on CXR. He was treated with ceftriaxone and azithromycin, which he completed prior to discharge and his WBC trended down. # ___ with hyperkalemia Recent admissions for ___, with baseline Cre around 1.2-1.4. Admitted with Cre of 2.5. ___ thought to be pre-renal in the setting of CAP and poor PO intake for several days prior to admission. K 6.9 on arrival and patient was treated with calcium gluconate and insulin with a bolus of D50. He has a history of hyperkalemia, on daily patiromer and low-K diet, and the hyperkalemia was thought to be related to ___ in the setting of chronic hyperkalemia. His ___ patiromer was not continued while in the hospital due to its being nonformulary. His K normalized while in the hospital. # Delirium: patient with mild confusion on admission to the floor, but rapidly improved to baseline. Felt to be multifactorial in the setting of multiple factors placing him at risk for delirium including infectious process, recent MI and chronic opiates. His mental status returned to baseline prior to discharge, but he remains persistently weak which appears consistent with his baseline. # Epigastric Pain Patient complaining of epigastric abdominal pain. Per patient is similar to his baseline pain from his chronic pancreatitis and gastroparesis. Lipase not elevated to indicate acute pancreatitis. Patient with mild elevation in ALT/AST after going to the cath lab for STEMI, thought to be related to brief hypotension. Downtrended to normal prior to discharge. As patient with history of HCV, viral load was sent but result did not return prior to discharge.Pain is similar to baseline. He was continued on his ___ omeprazole and pain regimen while inpatient. His ___ Zofran was held due to azithromycin therapy and patient did not have need for it. CHRONIC ISSUES: ================ # Type II diabetes History of type 2 DM with last A1c- 8.3. Patient was discharged in ___ with plan for glargine 10u qhs, however his wife reports giving him between ___ units qhs based on his blood sugar. He was continued with glargine ___ qhs and ISS TID while inpatient. # History of Iron deficiency Anemia Patient was continued on his ___ ferrous sulfate qod.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: erythromycin base Attending: ___. Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: ___ THORACENTESIS History of Present Illness: ___ F with a history of atrial fib on ___ with recent fall resulting in ___ in ___ complicated by rib fractures and right sided pleural effusion that required drainage presents with recurrent effusion and SOB. In terms of her pleural effusion, her daughter reports that it was first discovered by the patients cardiologist after Ms. ___ was complaining of shortness of breath. A CXR was done for further evaluation which revealed a pleural effusion. The pleural effusion, however, is noted on prior CXRs from ___ (unavaible in our system, only per reports in radiology reports). She was going to be evaluated by IP but then she suffered a ___ and her pleural effusion was managed as an inpatient (see below). She was last hospitalizated from ___ where she had a ___ and also underwent drainage of the known pleural effusion. She had an uncomplicated removal of 2.5 liters of exudative effusion (Tprot pleural fluid/Tprot serum >0.5). CT chest after drainage showed trapped lung with residual pneumothorax but no effusion. She was going to follow-up with IP as an outpatient for further management of her pleural effusion. The pleural effusion was thought to be secondary to trauma from rib fractures related to her fall. She presents from ___ today for increasing SOB. Her SOB was intermittent after her time post-discharge. She noted that it was worse when it was going to rain. She went her PCP on ___ for a follow-up visit where a CXR showed reaccumulation of right effusion. She became increasingly SOB with exertion the day prior to admission and SOB worse with lying flat so she went for evaluation at ___. She also described wheezing and cough. She was then transferred to ___ for further management. In the ED, initial vitals were: 97.8 85 170/111 18 98% Labs in the ED notable for WBC 4.9, Hg 12.1, Plts 106. Chem 7 with sodium 141, potassium 4.1, Cl 104, BUN 24, BUN 16, Cr 1.0, INR 1.3. On the floor, she reports feeling comfortable in bed in terms of her respiratory status. She does have a headache. Review of systems: (+) Per HPI (-) Denies fever, chills, 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 in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History: - traumatic small right-sided SDH and left parietal SAH - atrial fibrillation (off coumadin since ___ - silent L cerebellar CVA (seen on imaging, patient denies this) - hypertension - hyperlipidemia - osteoarthritis - L knee replacement - R hip replacement Social History: ___ Family History: Mother - CVA in her ___ Father - MI in his ___ Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 97.8 ___ 94%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Decreased breath sounds over the right lung, CTA on the left CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: WWP, no edema Neuro: CN II-XII intact DISCHARGE PHYSICAL EXAM: Vitals: T: 97.9 BP:114/87 P:86 RR:18 O2stat:98%RA General: Alert, oriented, anxious, normal speech. HEENT: No JVD, no LAD Lungs: Right lung with crackles and diminished aeration at base, but much improved from ___. Left lung with crackles at the base. CV: Irregular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: No rashes or lesions Neuro: Alert & oriented, no focal neuro deficit, no facial assymetry, MSK: On hands bilaterally, there is ulnar deviation of the digits. No ulnar deviation at the wrists. ___ nodes; rare Heberdon's nodes. Hallux abducto valgus deformity of the feet bilaterally. Skin: No rash Pertinent Results: ADMISSION LABS: ___ 06:40PM GLUCOSE-106* UREA N-16 CREAT-1.0 SODIUM-141 POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-24 ANION GAP-17 ___ 06:40PM estGFR-Using this ___ 06:40PM NEUTS-56.5 ___ MONOS-7.0 EOS-11.8* BASOS-1.2* IM ___ AbsNeut-2.74 AbsLymp-1.11* AbsMono-0.34 AbsEos-0.57* AbsBaso-0.06 ___ 06:40PM NEUTS-56.5 ___ MONOS-7.0 EOS-11.8* BASOS-1.2* IM ___ AbsNeut-2.74 AbsLymp-1.11* AbsMono-0.34 AbsEos-0.57* AbsBaso-0.06 ___ 06:40PM PLT COUNT-279 ___ 06:40PM ___ PTT-32.3 ___ ___ 04:35PM URINE HOURS-RANDOM ___ 04:35PM URINE HOURS-RANDOM ___ 04:35PM URINE UHOLD-HOLD ___ 04:35PM URINE GR HOLD-HOLD ___ 04:35PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 04:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG PERTINENT RESULTS: PLEURAL FLUID STUDIES ___ 12:40PM PLEURAL WBC-460* RBC-1090* Polys-0 Lymphs-11* Monos-2* Eos-86* NRBC-2* Macro-1* ___ 12:40PM PLEURAL Hct,Fl-UNABLE TO ___ 12:40PM PLEURAL TotProt-3.1 Glucose-122 Creat-0.9 LD(LDH)-132 Amylase-27 Albumin-2.0 Cholest-51 ___ 12:40PM PLEURAL Misc-PRO BNP = DISCHARGE LABS: ___ 07:07AM BLOOD WBC-5.8 RBC-3.53* Hgb-11.9 Hct-37.1 MCV-105* MCH-33.7* MCHC-32.1 RDW-14.0 RDWSD-53.3* Plt ___ ___ 07:07AM BLOOD Plt ___ ___ 07:07AM BLOOD Glucose-98 UreaN-18 Creat-1.1 Na-138 K-3.9 Cl-102 HCO3-24 AnGap-16 IMAGING: ___ CXR FROM ___ HOSP: large right sided pleural effusion ___ CXR In comparison with the study of ___, there is little change in the pleural effusion extending upward to the midportion of the right lung with associated volume loss in the right lower and possibly right middle lobe. The left lung is essentially clear and there is no evidence of vascular congestion. ___ CXR Right pleural effusion is resolved. No pneumothorax Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Carvedilol 25 mg PO BID 2. Apixaban 2.5 mg PO BID 3. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY 4. Vitamin B Complex 1 CAP PO DAILY 5. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Apixaban 2.5 mg PO BID 2. Carvedilol 25 mg PO BID 3. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY 4. Vitamin B Complex 1 CAP PO DAILY 5. Vitamin D 1000 UNIT PO DAILY 6. Atorvastatin 40 mg PO QPM RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 7. LaMOTrigine 50 mg PO QHS RX *lamotrigine 100 mg 0.5 (One half) tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 RX *lamotrigine 100 mg ___ tablet(s) by mouth twice/day Disp #*60 Tablet Refills:*1 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES: 1. Pleural effusion 2. Possible partial temporal lobe seizures. SECONDARY DIAGNOSES: 1. Hypertension 2. Atrial fibrillation 3. Arthritis 4. H/o ___ 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 known effusion // eval for any interval change in pleural effusion eval for any interval change in pleural effusion IMPRESSION: In comparison with the study of ___, there is little change in the pleural effusion extending upward to the midportion of the right lung with associated volume loss in the right lower and possibly right middle lobe. The left lung is essentially clear and there is no evidence of vascular congestion. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with pleural effusion, now with increased SOB, sat's stable at 98 on 2L, please eval for growing effusion // please eval for growing effusion please eval for growing effusion COMPARISON: Prior chest radiographs ___. IMPRESSION: Moderate to large right pleural effusion is unchanged. No pneumothorax. Right lung base is obscured and substantially atelectatic. Apparent increase in cardiac silhouette size is due in part to adjacent pleural effusion. Left lung clear. Heart size normal. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman with ___ year old woman on heparin drip, hx of sdh/sah, nwo with word finding difficulties, concern for tia vs stroke. // any head bleed or evidence of acute stroke? 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 5.6 s, 14.6 cm; CTDIvol = 53.8 mGy (Head) DLP = 785.0 mGy-cm. Total DLP (Head) = 785 mGy-cm. COMPARISON: ___ noncontrast CT head. FINDINGS: There is no evidence of major vascular territory infarction, new intracranial hemorrhage, edema, or mass. The ventricles and sulci are mildly prominent, suggestive of age-related involutional changes. Scattered periventricular white-matter hypodensities are present, consistent with chronic small vessel ischemic disease. There is evidence of mild encephalomalacia in the left posterior occipital, unchanged from prior imaging. No osseous abnormalities are seen. 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. No evidence of new hemorrhage. Radiology Report INDICATION: ___ year old woman with right pleural effusion s/p thoracentesis. // assess for PTX or other complication of thoracentesis EXAMINATION: CHEST (PORTABLE AP) TECHNIQUE: Portable chest radiograph, frontal view COMPARISON: Chest radiograph ___ FINDINGS: Previously seen large right pleural effusion is now resolved. There is no consolidation or pneumothorax. Cardiomediastinal silhouette is normal size. Tortuous aortic contour is stable. IMPRESSION: Right pleural effusion is resolved. No pneumothorax. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Dyspnea on exertion Diagnosed with PLEURAL EFFUSION NOS, ATRIAL FIBRILLATION, LONG TERM USE ANTIGOAGULANT temperature: 97.8 heartrate: 85.0 resprate: 18.0 o2sat: 98.0 sbp: 170.0 dbp: 111.0 level of pain: 0 level of acuity: 2.0

In brief this is a ___ yr old female who has a hx of Afib on Apixaban, hypertension, recent admission for fall w/ traumatic SDH & SAH, recent admission for a ___ complicated by rib fractures and right sided hemorrhagic pleural effusion, now presenting with SOB and found to have recurrent right pleural effusion.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: morphine Attending: ___ ___ Complaint: Nausea/vomiting and abdominal distension Major Surgical or Invasive Procedure: None History of Present Illness: Per OMR: ___ with colon adenocarcinoma presents ___ s/p open left colectomy w/ primary handsewn anastomosis and extensive LOA (prior abdominal surgeries) with intractable nausea and nonbloody, nonbilious emesis x2 days since arriving home following his most recent ED visit. Patient initially had an uneventful post-op course and was discharged home on POD2. He was doing well until POD3 when he began experiencing worsening abdominal pain, nausea, dry heaves, and dysphagia with a foreign body sensation in his throat. Evaluation in our ED on POD 6 with barium swallow demonstrated no abnormalities. He was discharged home following a PO trial. Per Mr. ___ report, following his arrival home from the ED (now approximately 48 hours ago) he began experiencing intractable nausea and nonbloody/nonbilious vomiting and was unable to keep any liquids or solids down. He senses that whatever "obstructed feeling" he had in his throat prior is now totally gone. He was seen earlier today at ___ for this complaint and underwent CT AP as part of his workup prior to transfer. His last episode of vomiting was approximately 12 hours ago at the time of interview. Mr. ___ denies constipation, obstipation, or distension. He does endorse abdominal pain which is worse during wretching and which he is unable to localize. He is passing ___ small liquid/semiformed BM per day and is passing gas. He denies fevers, chills, nightsweats, sick contacts, recent travel, trying new foods. Past Medical History: PMH: HTN, HLD, colon adenocarcinoma PSH: -Diagnostic laparoscopy converted to open laparotomy with extensive LOA and left colectomy w/ primary handsewn anastomosis ___, ___ -Ex-lap with right nephrectomy and colon resection (trauma; fall from approx 30 feet) ----- [previously left nephrectomy and splenectomy were documented however this is contradicted by imaging] -Hernia repair (___) -Cholecystectomy (___) Social History: ___ Family History: No family history of colorectal malignancy Physical Exam: T 97.8, BP 101/64, HR 55, RR 16, 98% RA Gen: AxO3 CV: RRR Pulm: No respiratory distress. Abd: Soft, less distended, minimally tender at midline incision only; less tender in LLQ; midline incision c/d/i with steri-strips over. No drainage. Ext: Warm, no edema. Pertinent Results: ___ 09:50AM BLOOD WBC-9.8 RBC-3.44* Hgb-10.1* Hct-30.3* MCV-88 MCH-29.4 MCHC-33.3 RDW-12.7 RDWSD-41.1 Plt ___ ___ 03:26AM BLOOD WBC-7.3 RBC-3.46* Hgb-10.3* Hct-31.1* MCV-90 MCH-29.8 MCHC-33.1 RDW-12.9 RDWSD-42.2 Plt ___ ___ 09:50AM BLOOD Plt ___ ___ 03:26AM BLOOD Plt ___ ___ 03:26AM BLOOD ___ PTT-25.1 ___ ___ 09:50AM BLOOD Glucose-109* UreaN-16 Creat-1.0 Na-140 K-4.2 Cl-101 HCO3-24 AnGap-15 ___ 05:16PM BLOOD Glucose-99 UreaN-20 Creat-1.1 Na-139 K-4.1 Cl-100 HCO3-27 AnGap-12 ___ 03:26AM BLOOD Glucose-190* UreaN-18 Creat-1.1 Na-136 K-3.8 Cl-96 HCO3-25 AnGap-15 ___ 03:26AM BLOOD ALT-42* AST-34 AlkPhos-86 TotBili-0.5 ___ 09:50AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.8 ___ 05:16PM BLOOD Calcium-9.2 Phos-2.7 Mg-1.8 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 20 mg PO QPM 2. Tamsulosin 0.4 mg PO QHS 3. Acetaminophen 1000 mg PO Q8H 4. TraMADol 50-100 mg PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity 5. amLODIPine 10 mg PO DAILY 6. Chlorthalidone 25 mg PO DAILY 7. Lisinopril 40 mg PO DAILY Discharge Medications: 1. amLODIPine 10 mg PO DAILY 2. Atorvastatin 20 mg PO QPM 3. Chlorthalidone 25 mg PO DAILY 4. Lisinopril 40 mg PO DAILY 5. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: Ileus/GI motility dysfunction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ s/p open segmental left colectomy for adenoCa ___ p/w n/v, unclear etiology// Evaluate for contrast load. TECHNIQUE: Supine and upright abdominal radiographs were obtained. COMPARISON: CT abdomen and pelvis from ___. FINDINGS: There is enteric contrast seen extending through the colon to the rectum. The transverse colon is prominent. There is evidence of diverticulosis of the residual descending and sigmoid colon. There is residual enteric contrast seen in the distal small bowel. There are some prominent small bowel loops without pathological dilation. There is no free intraperitoneal air. Osseous structures are unremarkable. There are surgical clips seen in the right upper quadrant. There are multiple rounded radiopacities within the pelvis that likely represent phleboliths. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. The visualized lung bases appear clear. IMPRESSION: 1. The enteric contrast is seen progressing through the colon to the rectum. There is a significant amount of residual enteric contrast. No evidence of obstruction. 2. Diverticulosis of the remnant left colon and sigmoid. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Abd pain, N/V Diagnosed with Unspecified abdominal pain temperature: 98.6 heartrate: 60.0 resprate: 16.0 o2sat: 97.0 sbp: 135.0 dbp: 74.0 level of pain: 7 level of acuity: 3.0

Mr ___ presented to ___ holding at ___ on ___ for ongoing, nausea/ vomiting and abdominal pain. He was conservatively managed with suppositories for comfort until normalized and bowel function resumed

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: nausea, vomiting, dizziness Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ year old ___ speaking man with a history of HTN, HLD, insulin resistance, lumbar stenosis, peripheral edema, who was diagnosed with posterior circulation strokes 2 months ago in ___, presenting with worsening dizziness, nausea, and vomiting with subacute decline in the last month. The patient was hospitalized 2 months ago in ___ for 20 days for visual loss (he described that the L side of the world looked black, and the R looked blurry), nausea, vomiting, and dizziness. He was found to have posterior circulation strokes with bilateral occipital and cerebellar involvement per report of his son at the bedside. Etiology was felt to be due to a R vertebral artery plaque and he was started on ASA 81, simvastatin 20, metformin, and nifedipine. The son also notes that he was told there is extensive plaque in all of his vessels including one of his carotid arteries as well. One month ago the patient flew to ___ to visit his son and daughter in law who recently had a child in order to help out. However, since then he has been getting gradually progressively worse, although his course has been fluctuating throughout. He continues to feel vertiginous almost continuously, although the feeling will occasionally subside for several minutes. He cannot identify anything that triggers the dizziness such as positional changes, and notes that it can be exacerbated for ___ minutes at a time randomly, when he is lying quietly or when he is walking. He is nauseous and vomits multiple times per day. Since his stroke his vision has been slowly gradually impoving and he has regained some vision on the L side which he had lost, but notes that his entire field remains blurry. Denies double vision. No dysarthria or dysphasia. No aphasia noted by family members. He has not been walking well and is very off balance all of the time. He does endorse a ___ headache which is mild. The patient saw his PCP today who referred him to a vascular surgeon, however, the vascular surgeon called and said he could not handle these symptoms so the patient was sent to the ED. On neurologic review of systems, the patient denies difficulty with producing or comprehending speech. Denies diplopia, dysarthria, or dysphagia. Denies muscle weakness. Denies loss of sensation. Endorses generalized weakness On general review of systems, the patient denies fevers, rigors. Denies chest pain, endorses occasional SOB. Denies nausea, vomiting, diarrhea, constipation, or abdominal pain. Past Medical History: - HTN - HLD - posterior circulation stroke 2 months ago - insulin resistance - peripheral edema - lumbar stenosis: at baseline can only walk for 20 minutes before he needs to rest Social History: ___ Family History: Mother - DM Physical ___: ADMISSION PHYSICAL EXAM: VS 98.6 95 141/70 18 93% General: NAD, lying in bed comfortably. Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions Neck: Supple, no nuchal rigidity, no meningismus Skin: No rashes or lesions Swallow: the patient passed by bedside swallow exam Neurologic Examination: - Mental Status - Exam preformed with assistance of daughter in law translating Awake, alert, oriented x 3. Attention to examiner easily attained and maintained. Concentration maintained when recalling days 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 (although this is limited by poor visual acuity) and no paraphasias. Describes that there is a child and a woman in the stroke picture but is unable to see what they are doing, able to name "hand" but not other stroke card objects since he says he cannot see. Normal prosody. No dysarthria. Verbal registration and recall ___. No evidence of hemineglect. - Cranial Nerves - I. not tested II. Equal and reactive pupil. Visual fields were grossly full to finger wiggling however patient endorses very poor visual acuity, worse on the L. III, IV, VI. smooth and full extraocular movements without diplopia or nystagmus, although the patient endorses double vision when gazing L. V. facial sensation was intact, muscles of mastication with full strength VII. face was symmetric with full strength of facial muscles VIII. hearing was intact to finger rub bilaterally. IX, X. symmetric palate elevation and symmetric tongue protrusion with full movement. XI. SCM and trapezius were of normal strength and volume. - Motor - Muscule bulk and tone were normal. No pronation, no drift. No tremor or asterixis. Delt Bic Tri ECR Fext Fflx IP Quad Ham TA Gas L 5 5 ___ 5 5 5 5 5 5 R 5 5 ___ 5 5 5 5 5 5 - Sensation - To extinction to DSS - DTRs - Bic Tri ___ Quad Gastroc L 1 1 1 0 0 R 1 1 1 1 0 Plantar response flexor bilaterally. - Cerebellar - Mild bilateral dysmetria L>R - Gait - Patient able to stand without assistance although looks wobbly and stands with a cautions, wide based gait and takes several hesitant steps. Not able to close eyes and ___ in place since he almost falls over. ====================================================== DISCHARGE PHYSICAL EXAM: VS 98.0 151/71 60 18 97% RA General: NAD, lying in bed with an icepack on forehead. Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions Neck: Supple, no nuchal rigidity, no meningismus Skin: No rashes or lesions Neurologic Examination: - Mental Status Awake, alert, oriented x 3. Attention to examiner easily. Concentration maintained when recalling days backwards. able to name common and uncommon things. Recalls a coherent history consistently. Normal prosody. No dysarthria. No evidence of hemineglect. - Cranial Nerves - I. not tested II. Pupil equal, round and reactive to light. Visual fields were grossly full to finger number flashing, however patient endorses very poor visual acuity, worse on the L but improving from two months ago. III, IV, VI. smooth and full extraocular movements without diplopia or nystagmus, denies diplopia. V. facial sensation was intact, muscles of mastication with full strength VII. face was symmetric with full strength of facial muscles VIII. hearing was intact to finger rub bilaterally. IX, X. symmetric palate elevation and symmetric tongue protrusion with full movement. XI. SCM and trapezius were of normal strength and volume. - Motor - Muscule bulk and tone were normal. No pronation, no drift. No tremor or asterixis. Delt Bic Tri ECR Fext Fflx IP Quad Ham TA Gas L 5 5 ___ 5 5 5 5 5 5 R 5 5 ___ 5 5 5 5 5 5 - Sensation - intact to light touch, temperature, and pain - DTRs - Bic Tri ___ Quad Gastroc L 1 1 1 0 0 R 1 1 1 1 0 Plantar response flexor bilaterally. - Cerebellar - mild bilateral dysmetria - Gait - not tested Pertinent Results: ADMISSION LABS: ___ 05:33PM NEUTS-71.2* ___ MONOS-6.5 EOS-1.0 BASOS-0.6 ___ 05:33PM WBC-9.5 RBC-4.74 HGB-14.2 HCT-41.8 MCV-88 MCH-29.9 MCHC-33.9 RDW-14.3 ___ 05:33PM cTropnT-<0.01 ___ 05:33PM PLT COUNT-241 ___ 05:33PM GLUCOSE-106* UREA N-19 CREAT-1.1 SODIUM-140 POTASSIUM-4.6 CHLORIDE-103 TOTAL CO2-29 ANION GAP-13 ___ 07:00AM %HbA1c-6.3* eAG-134* ___ 07:00AM ALT(SGPT)-33 AST(SGOT)-24 CK(CPK)-78 ALK PHOS-97 TOT BILI-0.3 ============================================================= DISCHARGE LABS: ___ 07:00AM BLOOD WBC-9.1 RBC-4.63 Hgb-13.8* Hct-40.6 MCV-88 MCH-29.8 MCHC-34.0 RDW-14.2 Plt ___ ___ 07:00AM BLOOD Plt ___ ___ 07:00AM BLOOD ___ PTT-30.3 ___ ___ 07:00AM BLOOD Glucose-107* UreaN-15 Creat-0.9 Na-140 K-4.1 Cl-103 HCO3-29 AnGap-12 ___ 07:00AM BLOOD ALT-33 AST-24 CK(CPK)-78 AlkPhos-97 TotBili-0.3 ___ 07:00AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 07:00AM BLOOD TSH-2.4 ============================================================ IMAGING STUDIES: ___ CT HEAD W/O CONTRAST IMPRESSION: Focal hypodensities in the right occipital, parietoccipital lobes and cerebellum suggest prior infarcts, at least subacute in age, possibly old although not necessarily chronic in all cases. MR would be useful to assess further if needed clinically. ___ CTA HEAD AND NECK IMPRESSION: 1. Approximately 50% narrowing of the origin of the left internal carotid artery secondary to mixed plaque. Atherosclerosis of left internal carotid artery origin and of bilateral carotid siphons, without flow-limiting stenosis. 2. High-grade stenosis of the intracranial portion of the V4 segment of the left vertebral artery proximal to ___, spanning approximately 9 mm. 3. Small caliber and irregularity of the V4 segment of the right vertebral artery distal to ___, with resumption of normal caliber just proximal to confluence with the left vertebral artery, which is likely secondary to a combination of hypoplasia and atherosclerotic disease. 4. Small bilateral posterior cerebral arteries, presumably on the basis of atherosclerotic disease, given the patient's age. ___ MR HEAD AND NECK IMPRESSION: Subacute infarcts in the bilateral occipital lobes and the cerebellar hemispheres. A few small foci in the right cerebellar hemisphere may represent acute infarcts. No surrounding edema or mass effect. Nonspecific cerebral white matter changes and some degree of diffuse parenchymal volume loss. Intracranial arteries are better assessed on the recent CT angiogram study. Medications on Admission: - metformin 1 tab daily, PCP asked the patient to stop this today - simvastatin 20 mg, PCP was planning to increase this to 80 mg today - ASA 81 mg - nifedipine 30 mg daily Discharge Medications: 1. Atorvastatin 80 mg PO HS 2. Clopidogrel 75 mg PO DAILY 3. Meclizine 12.5 mg PO Q6H:PRN Dizziness, room spinning sensation Discharge Disposition: Home Discharge Diagnosis: Chronic Vertigo- Felt to be secondary to prior Posterior circulation Stroke Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CTA HEAD AND CTA NECK INDICATION: History: ___ with posterior circulation strokes. Evaluate for thrombosis, arterial disease, perfusion defects. TECHNIQUE: Rapid axial imaging was performed from the aortic arch through the brain during infusion of intravenous contrast material. Images were processed on a separate workstation with display of curved reformats, 3D volume rendered images, and maximum intensity projection images. DOSE: DLP: 1504.3 mGy-cm; CTDI: 84.46 mGy COMPARISON: CT head ___. FINDINGS: There is scattered atherosclerotic vascular disease throughout the aortic arch including the origins of the great vessels, without flow-limiting stenosis. There is a common origin of the innominate artery and left common carotid artery. There is mixed plaque in the proximal right internal carotid artery with approximately 50% narrowing by NASCET criteria. There is minimal atherosclerotic plaque within the proximal left internal carotid artery without flow-limiting stenosis. The distal left cervical internal carotid artery measures 4.9 mm. There is a tiny focus of calcified plaque within the cervical portion of the right vertebral artery, at the C5 level. The cervical portions of the vertebral arteries are otherwise patent without flow-limiting stenosis. There is no evidence of dissection within the vasculature of the neck. The intracranial portion of the nondominant right vertebral artery at and distal to ___ is small in caliber and irregular, resuming normal caliber just proximal to the confluence with the left vertebral artery. This appearance likely represents combination of hypoplasia and atherosclerotic narrowing. There is high-grade narrowing of the intracranial portion of the dominant left vertebral artery proximal to the ___, spanning approximately 9 mm. Bilateral posterior cerebral arteries are unusually small in caliber, presumably on the basis of atherosclerotic vascular disease, given the patient's age. There is atherosclerotic vascular calcification of the bilateral carotid siphons without flow-limiting stenosis. There is no evidence of hemodynamically significant stenosis within the anterior circulation. There is no evidence of aneurysm within the intracranial vasculature. IMPRESSION: 1. Approximately 50% narrowing of the origin of the left internal carotid artery secondary to mixed plaque. Atherosclerosis of left internal carotid artery origin and of bilateral carotid siphons, without flow-limiting stenosis. 2. High-grade stenosis of the intracranial portion of the V4 segment of the left vertebral artery proximal to ___, spanning approximately 9 mm. 3. Small caliber and irregularity of the V4 segment of the right vertebral artery distal to ___, with resumption of normal caliber just proximal to confluence with the left vertebral artery, which is likely secondary to a combination of hypoplasia and atherosclerotic disease. 4. Small bilateral posterior cerebral arteries, presumably on the basis of atherosclerotic disease, given the patient's age. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man with stroke // eval for pna COMPARISON: No comparison IMPRESSION: The lung volumes are low. Mild cardiomegaly with atelectasis at the right lung basis and in the retrocardiac lung regions. No larger pleural effusions. No pneumonia, no pulmonary edema. Radiology Report INDICATION: ___ year old man with recent posterior circulation strokes 2 months ago, presenting with worsening dizziness // eval for acute or subacute strokes TECHNIQUE: MRI of the brain without IV contrast COMPARISON: CT head, CT angiogram head and neck ___ FINDINGS: There are multiple small foci of slightly slow diffusion in the bilateral cerebellar hemispheres, right more than left and in the occipital lobes, right more than left. Most of these can represent subacute infarcts based on the signal intensity on the DWI and FLAIR sequences and the history. However, a few small foci in the right cerebellar hemisphere, inferomedially demonstrate greater slow diffusion compared to the rest of the lesions and may represent small acute infarcts. Slightly increased FLAIR signal intensity is noted in these foci, along with mild gyriform T1 hyperintense signal, that can relate to laminar necrosis. There are multiple small FLAIR hyperintense foci in the cerebral white matter in the subcortical and periventricular locations, nonspecific in appearance and may relate to small vessel ischemic changes. There is mild dilation of the lateral and the third ventricles along with prominent extra-axial CSF spaces, cerebral sulci and cerebellar folia indicating some degree of diffuse parenchymal volume loss. A few tiny foci of negative susceptibility are noted scattered in the brain parenchyma may relate to mineralization or micro hemorrhages. The major intracranial arterial flow voids are noted. The vessels are better assessed on the recent CT angiogram study. Sella, pineal gland and the craniocervical junction regions are unremarkable. Minimal ethmoidal mucosal thickening on both sides. The mastoid air cells are clear. The included orbits are unremarkable. Bone marrow signal is unremarkable. IMPRESSION: Subacute infarcts in the bilateral occipital lobes and the cerebellar hemispheres. A few small foci in the right cerebellar hemisphere may represent acute infarcts. No surrounding edema or mass effect. Nonspecific cerebral white matter changes and some degree of diffuse parenchymal volume loss. Intracranial arteries are better assessed on the recent CT angiogram study - Please see details on the report. Gender: M Race: ASIAN - CHINESE Arrive by WALK IN Chief complaint: Dizziness, Vomiting Diagnosed with CEREBRAL ART OCCLUS W/INFARCT temperature: 98.6 heartrate: 95.0 resprate: 18.0 o2sat: 93.0 sbp: 141.0 dbp: 70.0 level of pain: 0 level of acuity: 3.0

___ year old ___ speaking man with a history of HTN, HLD, lumbar stenosis, recent posterior circulation strokes with resultant nausea and vertigo and blurry vision, presenting with subacute worsening of symptoms over the past month. #Vision change/Vertigo/Nausea/Vomiting: His symptoms were felt to most likely be due to old bilateral occipital and cerebellar infarcts, which are secondary to atherosclerosis in left ICA and vertebral artery causing ischemic strokes. Patient underwent CT head on ___, which showed no new infarcts. CTA performed on ___ showed narrowing and stenosis of left ICA and left vetebral artery. Patient also underwent MRI head on ___, which showed no new infarct or stroke, but as previous shown documented several subacute infarcts in the PCA territory. These were felt to be most likely secondary to his significant intracranial atherosclerotic disease. The patient was started on plavix (with discontinuation of aspirin) and atorvastatin 80mg (from simvastatin 20mg). He was started on Meclizine 12.5mg q6hr PRN dizziness with reported symptomatic improvement. Echo this admission did not reveal a cardiogenic source of possible embolism. Patient continued to improve during his hospital course and was discharged home to with family after seeing physical therapy with outpatient follow-up. A peripheral (inner ear) source of his vertigo was considered, but not well consistent with exam or patient history. AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (X) Yes [performed and documented by nursing staff] – () No 2. DVT Prophylaxis administered by the end of hospital day 2? (X) Yes - () No 3. Antithrombotic therapy administered by end of hospital day 2? (X) Yes - () No 4. LDL documented (required for all patients)? (X) Yes (LDL = 78) - () No 5. Intensive statin therapy administered? (X) Yes - () No [if LDL >= 100, reason not given: ____ ] (intensive statin therapy = simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL >= 100) 6. Smoking cessation counseling given? () Yes - (X) No [if no, reason: (X) non-smoker - () unable to participate] 7. Stroke education given (written form in the discharge worksheet)? () Yes - (X) No (stroke education = personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) 8. Assessment for rehabilitation or rehab services considered? (X) Yes - () No [if no, reason not assessed: ____ ] 9. Discharged on statin therapy? (X) Yes - () No [if LDL >= 100 or on a statin prior to hospitalization, reason not discharged on statin: ____ ] 10. Discharged on antithrombotic therapy? (X) Yes [Type: X() Antiplatelet - () Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - () No [if no, reason not discharge on anticoagulation: ____ ] - (X) N/A

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Back pain, wrist pain Major Surgical or Invasive Procedure: Bone Marrow Biopsy (___) History of Present Illness: Ms. ___ is a ___ yo F, PMH of HTN and hypothyroidism, recently evaluated by heme/onc for an abnormal SPEP (abnormal IgA spike) and macrocytosis, who presents with a 1.5 wk history of back pain. The back pain started suddenly, and may have been associated with her changing the bed linens. She was evaluated on ___ ___. An X-ray at that time showed degenerative changes but no fracture. The pain has persisted over the last week and a half. Pain is mainly central with some radiation around both sides across her abdomen. Mainly precipitated by activity. She has taken vicodin prescribed by her husband, who is a ___. No radiation past the buttock. No appreciable weakness in the legs. No bowel or bladder changes. She also notes ___ lb weight loss since ___. Denies cp, sob, abdominal pain. Yesterday, while trying to sit on her bed, she missed and sat on the floor. She braced herself with her L wrist, which is also now painful as a result. In the ED, initial vital signs were: 98.5 87 132/44 16 98% Labs were notable for WBC 20 with abnormal diff (atypicals, metas, myelos), Ht 28, Cr 1.3. CT spine showed No acute fracture or vertebral malalignment. Patient was given morphine. On Transfer Vitals were: 98.2 114/43 78 18 100/RA Past Medical History: Hypertension Lumbar stenosis Shingles, VZV keratitis Hypothyroid Macrocytosis MGUS? abnormal M spike(IgA kappa) Social History: ___ Family History: No known FH of hematologic malignancies Physical Exam: On admission: Vitals-98.2 114/43 78 18 100/RA General: Well-appearing, sitting comfortably but stiffly in bed HEENT: Normocephalic, atraumatic Neck: No LAD, no JVD CV: RRR, S1, S2, no m/r/g Lungs: CTAB, no wheezing, ronchi, rales Abdomen: soft, nontender, nondistended GU: no Foley Ext: warm and well perfused, 1+ bilateral edema in ankles, R wrist edematous and tender Spine/Back: No bruises, mild lumbar spine tenderness mainly along spinous processes. Neuro: CN II - XII grossly intact, ___ strength normal On discharge: VITALS - Tmax: 98.7 Tc: 98.3 BP: 114/64 HR: 70, RR: 19, 100% on RA I/Os: -1.2L General: anxious, but otherwise well appearing in NAD HEENT: MMM, anicteric Neck: Supple, non-elevated JVP CV: Normal rate, regular rhythm, no murmurs appreciated Respiratory: Clearto auscultation Back: TTP midline ~L1, with TTP over paraspinal muscles of lumbar back L>R with spasm GI: soft, NT, Ext: 1+ edema Neuro: Oriented x3, answers questions appropriately Pertinent Results: ===================== Labs: ===================== ___ 10:40AM BLOOD WBC-20.1*# RBC-2.80* Hgb-9.1* Hct-28.3* MCV-101* MCH-32.6* MCHC-32.1 RDW-17.8* Plt ___ ___ 10:40AM BLOOD Neuts-28* Bands-5 Lymphs-45* Monos-6 Eos-0 Baso-0 Atyps-3* Metas-9* Myelos-4* NRBC-6* ___ 11:40AM BLOOD ___ PTT-33.9 ___ ___ 10:40AM BLOOD Glucose-113* UreaN-32* Creat-1.3* Na-145 K-4.3 Cl-102 HCO3-25 AnGap-22* ___ 06:52PM BLOOD LD(LDH)-344* ___ 06:52PM BLOOD TotProt-6.6 Albumin-3.5 Globuln-3.1 Calcium-12.9* Phos-5.4* Mg-2.1 ___ 05:15AM BLOOD Ret Aut-1.0* ___ 05:15AM BLOOD calTIBC-169* VitB12-978* Ferritn-402* TRF-130* ___ 11:40AM BLOOD FreeKap-665.9* FreeLam-2.9* Fr K/L-227.46* IgG-545* IgA-1407* IgM-23* ___ 10:40AM BLOOD PTH-6* ___ 06:52PM BLOOD PEP-ABNORMAL T ___ 11:40AM BLOOD WBC-16.3* RBC-2.40* Hgb-7.8* Hct-24.5* MCV-102* MCH-32.5* MCHC-31.9 RDW-17.5* Plt ___ ___ 05:15AM BLOOD WBC-12.1* RBC-2.44* Hgb-8.1* Hct-24.7* MCV-101* MCH-33.2* MCHC-32.8 RDW-18.1* Plt ___ ___ 05:40AM BLOOD WBC-13.5* RBC-2.37* Hgb-7.6* Hct-24.5* MCV-103* MCH-32.0 MCHC-31.0 RDW-18.6* Plt ___ ___ 10:10AM BLOOD WBC-13.5* RBC-2.36* Hgb-7.8* Hct-24.4* MCV-103* MCH-32.8* MCHC-31.8 RDW-19.1* Plt ___ ___ 07:00AM BLOOD WBC-14.1* RBC-2.21* Hgb-7.1* Hct-23.1* MCV-104* MCH-32.3* MCHC-30.9* RDW-18.8* Plt ___ ___ 12:00AM BLOOD WBC-11.3* RBC-2.08* Hgb-7.0* Hct-21.7* MCV-104* MCH-33.4* MCHC-32.1 RDW-19.1* Plt ___ ___ 12:00AM BLOOD WBC-14.1* RBC-2.51* Hgb-8.0* Hct-25.3* MCV-101* MCH-32.1* MCHC-31.9 RDW-20.3* Plt ___ ___ 12:29AM BLOOD WBC-14.7* RBC-2.16* Hgb-6.9* Hct-21.6* MCV-100* MCH-31.9 MCHC-32.0 RDW-20.4* Plt ___ ___ 02:44PM BLOOD WBC-9.3 RBC-2.62* Hgb-8.3* Hct-25.6* MCV-98 MCH-31.6 MCHC-32.3 RDW-20.3* Plt ___ ___ 12:10AM BLOOD WBC-5.9 RBC-4.04*# Hgb-12.9# Hct-39.3# MCV-97 MCH-32.0 MCHC-32.9 RDW-20.8* Plt Ct-82* ___ 01:00PM BLOOD WBC-11.3*# RBC-2.77*# Hgb-8.8*# Hct-26.8*# MCV-97 MCH-31.9 MCHC-32.9 RDW-21.5* Plt ___ ___ 11:40AM BLOOD Neuts-29* Bands-4 ___ Monos-10 Eos-1 Baso-0 Atyps-3* Metas-7* Myelos-4* NRBC-6* ___ 05:15AM BLOOD Neuts-22* Bands-1 Lymphs-61* Monos-5 Eos-1 Baso-0 Atyps-6* Metas-1* Myelos-3* NRBC-14* ___ 05:40AM BLOOD Neuts-17* Bands-7* Lymphs-58* Monos-9 Eos-0 Baso-0 Atyps-1* Metas-2* Myelos-6* NRBC-22* ___ 10:10AM BLOOD Neuts-27* Bands-2 Lymphs-54* Monos-10 Eos-0 Baso-0 ___ Metas-5* Myelos-2* NRBC-13* ___ 07:00AM BLOOD Neuts-39* Bands-9* ___ Monos-9 Eos-1 Baso-0 Atyps-3* Metas-4* Myelos-0 NRBC-13* ___ 12:00AM BLOOD Neuts-41* Bands-12* ___ Monos-4 Eos-0 Baso-0 ___ Metas-2* Myelos-0 NRBC-25* ___ 12:00AM BLOOD Neuts-42* Bands-7* ___ Monos-11 Eos-0 Baso-2 ___ Metas-7* Myelos-0 NRBC-21* ___ 12:29AM BLOOD Neuts-53 Bands-1 ___ Monos-6 Eos-2 Baso-0 ___ Metas-3* Myelos-1* NRBC-8* ___ 01:00PM BLOOD Neuts-46* Bands-0 ___ Monos-10 Eos-0 Baso-0 ___ Metas-2* Myelos-0 NRBC-10* ___ 11:40AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-2+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+ Schisto-OCCASIONAL ___ 05:15AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-1+ Macrocy-3+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+ Tear Dr-1+ Ellipto-1+ ___ 05:40AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ ___ 10:10AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-2+ Macrocy-2+ Microcy-NORMAL Polychr-1+ Ovalocy-2+ Schisto-1+ Pencil-OCCASIONAL ___ 07:00AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+ Macrocy-2+ Microcy-OCCASIONAL Polychr-OCCASIONAL Ovalocy-OCCASIONAL Schisto-1+ Acantho-OCCASIONAL Ellipto-1+ ___ 12:00AM BLOOD Hypochr-1+ Anisocy-3+ Poiklo-1+ Macrocy-3+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+ Tear Dr-1+ ___ 12:00AM BLOOD Hypochr-NORMAL Anisocy-3+ Poiklo-1+ Macrocy-3+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+ Schisto-1+ ___ 01:00PM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+ Macrocy-3+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ ___ 11:40AM BLOOD ___ PTT-33.9 ___ ___ 10:10AM BLOOD ___ PTT-51.6* ___ ___ 07:00AM BLOOD ___ PTT-37.5* ___ ___ 12:00AM BLOOD ___ PTT-52.2* ___ ___ 12:00AM BLOOD ___ PTT-54.2* ___ ___ 12:29AM BLOOD ___ PTT-58.9* ___ ___ 12:10AM BLOOD ___ PTT-44.8* ___ ___ 12:10AM BLOOD ___ PTT-44.8* ___ ___ 07:00AM BLOOD CD5-DONE CD23-DONE CD138-DONE CD45-DONE ___ Kappa-DONE CD10-DONE CD13-DONE CD19-DONE CD20-DONE Lambda-DONE ___ 07:00AM BLOOD CD34-DONE CD3%-DONE ___ 05:15AM BLOOD Ret Aut-1.0* ___ 06:20AM BLOOD Glucose-93 UreaN-34* Creat-1.5* Na-141 K-4.0 Cl-105 HCO3-26 AnGap-14 ___ 11:40AM BLOOD Glucose-96 UreaN-32* Creat-1.4* Na-140 K-3.9 Cl-105 HCO3-25 AnGap-14 ___ 05:15AM BLOOD Glucose-92 UreaN-30* Creat-1.3* Na-140 K-3.4 Cl-108 HCO3-28 AnGap-7* ___ 05:40AM BLOOD Glucose-107* UreaN-25* Creat-1.3* Na-141 K-3.7 Cl-109* HCO3-23 AnGap-13 ___ 10:10AM BLOOD Glucose-84 UreaN-22* Creat-1.2* Na-139 K-3.6 Cl-109* HCO3-23 AnGap-11 ___ 07:00AM BLOOD Glucose-90 UreaN-23* Creat-1.1 Na-141 K-3.7 Cl-110* HCO3-23 AnGap-12 ___ 06:00PM BLOOD UreaN-21* Creat-1.0 Na-140 K-3.3 Cl-109* HCO3-21* AnGap-13 ___ 12:00AM BLOOD Glucose-144* UreaN-21* Creat-1.0 Na-141 K-3.8 Cl-110* HCO3-21* AnGap-14 ___ 12:29AM BLOOD Glucose-95 UreaN-19 Creat-0.9 Na-138 K-3.8 Cl-109* HCO3-21* AnGap-12 ___ 12:10AM BLOOD Glucose-86 UreaN-17 Creat-0.8 Na-140 K-3.5 Cl-109* HCO3-20* AnGap-15 ___ 06:20AM BLOOD AlkPhos-57 ___ 10:10AM BLOOD ALT-11 AST-20 LD(LDH)-203 AlkPhos-56 TotBili-0.3 ___ 07:00AM BLOOD ALT-10 AST-23 LD(LDH)-202 AlkPhos-57 TotBili-0.3 ___ 12:00AM BLOOD ALT-13 AST-26 LD(LDH)-246 AlkPhos-60 TotBili-0.4 ___ 12:10AM BLOOD ALT-13 AST-23 LD(___)-299* AlkPhos-56 TotBili-0.4 ___ 06:20AM BLOOD Calcium-12.1* Phos-4.8* Mg-2.2 ___ 11:40AM BLOOD Calcium-11.1* Phos-4.0 Mg-1.9 ___ 08:44PM BLOOD Calcium-11.4* ___ 05:15AM BLOOD Calcium-10.9* Phos-3.8 Mg-1.9 Iron-59 ___ 05:40AM BLOOD Calcium-10.9* Phos-3.2 Mg-1.7 ___ 10:10AM BLOOD Albumin-2.7* Calcium-10.5* Phos-3.4 Mg-1.9 UricAcd-11.4* ___ 07:00AM BLOOD Albumin-2.7* Calcium-10.3 Phos-3.7 Mg-1.8 UricAcd-11.0* ___ 12:00AM BLOOD Albumin-2.7* Calcium-9.0 Phos-3.5 Mg-2.2 ___ 12:00AM BLOOD Albumin-2.8* Calcium-8.0* Phos-2.5* Mg-1.9 UricAcd-8.7* ___ 12:29AM BLOOD Calcium-7.6* Phos-2.2* Mg-2.3 ___ 12:10AM BLOOD Albumin-2.9* Calcium-7.2* Phos-1.9* Mg-2.1 UricAcd-6.4* ___ 05:15AM BLOOD calTIBC-169* VitB12-978* Ferritn-402* TRF-130* ___ 10:10AM BLOOD Hapto-69 ___ 10:40AM BLOOD PTH-6* ___ 06:52PM BLOOD PEP-ABNORMAL T ___ 11:40AM BLOOD FreeKap-665.9* FreeLam-2.9* Fr K/L-227.46* IgG-545* IgA-1407* IgM-23* ___ 05:15AM BLOOD b2micro-12.8* ___ 12:00AM BLOOD IgA-1185* ___ 01:00PM BLOOD WBC-11.3*# RBC-2.77*# Hgb-8.8*# Hct-26.8*# MCV-97 MCH-31.9 MCHC-32.9 RDW-21.5* Plt ___ ___ 01:00AM BLOOD WBC-7.9 RBC-2.86* Hgb-8.9* Hct-27.7* MCV-97 MCH-31.2 MCHC-32.2 RDW-20.8* Plt ___ ___ 01:00PM BLOOD Neuts-46* Bands-0 ___ Monos-10 Eos-0 Baso-0 ___ Metas-2* Myelos-0 NRBC-10* ___ 01:00AM BLOOD Neuts-43* Bands-2 ___ Monos-7 Eos-1 Baso-0 Atyps-2* Metas-9* Myelos-2* NRBC-36* ___ 01:00AM BLOOD ___ PTT-50.1* ___ ___ 01:00AM BLOOD Glucose-152* UreaN-15 Creat-0.7 Na-138 K-4.1 Cl-108 HCO3-21* AnGap-13 ___ 01:00AM BLOOD ALT-10 AST-21 LD(LDH)-292* AlkPhos-62 TotBili-0.3 ___ 01:00AM BLOOD Albumin-2.8* Calcium-6.7* Phos-2.0* Mg-2.0 ===================== Micro: ===================== Blood cultures from ___ pending ===================== Imaging: ===================== CT L-SPINE W/O CONTRAST Study Date of ___ 11:32 AM IMPRESSION: No acute fracture or vertebral malalignment. WRIST(3 + VIEWS) RIGHT Study Date of ___ 12:08 ___ IMPRESSION: No fracture identified. Mild degenerative changes of the first CMC and interphalangeal joints. US ABD LIMIT, SINGLE ORGAN Study Date of ___ 8:26 AM IMPRESSION: Spleen measures 10 cm which is in the normal range; however, it has increased in size compared to the ultrasound on ___ when it measured 8 cm. SKELETAL SURVEY (INCLUD LONG BONES) Study Date of ___ 1:47 ___ IMPRESSION: Nonspecific generalized demineralization & fracture of L1. These findings are nonspecific and no lytic lesions of classic multiple myeloma. MRI L-spine: IMPRESSION: 1. Compression fracture deformity of L1 vertebral body with nearly 50% height loss at the anterior aspect, without evidence of enhancement or significant edema, raising the possibility of subacute vertebral body compression fracture versus devascularization of the vertebral body or avascular necrosis of this vertebral body segment. No evidence of retropulsion into the spinal canal, cord or conus compression. The appearance is not typical for metastatic disease. 2. Diffuse low T1 signal throughout the lumbar spine, most consistent with diffuse bone marrow hyperplasia or bone marrow infiltration. 3. Moderate multilevel spondylosis, most severe at L4-L5, along with grade 1 anterolisthesis at this level, resulting in moderate spinal canal narrowing which appear grossly stable compared to prior study of ___. There is moderate to severe left and mild right neural foraminal narrowing at this level. PET CT SCAN: IMPRESSION: 1. FDG-avid compression fracture of L1. FDG-avidity may relate to pre-existing disease or may be due to the compression fracture itself. Acute fractures are FDG-avid while there is an inflammatory response to the fracture. 2. No there other sites of abnormal FDG avidity in the body. (Note the entire body from skull vertex to toes was surveyed.) U/S of right upper extremity: IMPRESSION: 1. Right brachial vein DVT. 2. Right basilic vein PICC without basilic, axillary, or subclavian vein thrombus. Standing L-spine X-ray: FINDINGS: There is a similar moderate-to-severe compression fracture of the L1 vertebral body, potentially with minimally increased in height loss since the prior study. There is clear evidence for substantial retropulsion. Associated with the fracture, however, a slight kyphotic angulation corresponding to the T12- L1 level without substantial subluxations. The L4-L5 and T11-T12 interspaces are moderately narrowed. Patchy vascular calcifications are preserved. IMPRESSION: Moderate-to-severe L1 compression deformity, similar to perhaps minimally increased. ___: IMPRESSION: No evidence of deep vein thrombosis in the bilateral lower extremities. ===================== Pathology: ===================== Tissue: BONE MARROW, BIOPSY, CORE Procedure Date of ___: pending PATHOLOGIC DIAGNOSIS: SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY. DIAGNOSIS: HYPERCELLULAR BONE MARROW WITH EXTENSIVE INVOLVEMENT BY IMMUNOSECRETORY NEOPLASM, SEE NOTE. Note: By immunohistochemistry neoplastic cells are immunoreactive for CD20, MUM1, CD138, and are IgA kappa restricted (IgG, IgM and Lambda light chains are negative). In addition cells are immunoreactive for CD79a and PAX5 (BSAP) (dim) and negative for BCL1. CD3 and CD5 highlights scattered small lymphocytes. The proliferation fraction is high, in some places reaching more than 50%. The differential diagnosis is restricted to lymphoplasmacytic lymphoma versus round cell myeloma, the latter of which is often CD20 and BCL1 positive. The morphological features, lack of BCL1 expression, expression of PAX5 and absence of lytic lesions in the setting of extensive bone marrow infiltration, all seem to favor the diagnosis of lymphoplasmacytic lymphoma. Unfortunately, marrow aspirate was unyielding "dry tap" precluding examination of a ___ stained bone marrow smear or obtaining cytogenetic studies, which would have greatly facilitated the evaluation of this neoplasm. Of note, flow cytometry of peripheral blood demonstrated an apparently unrelated clonal population of CD5 positive lambda-restricted B lymphocytes. The presence of nucleated red blood cells and immature neutrophils in the peripheral blood is consistent with a myelophthisis process most likely due to the highly proliferative neoplasm in the marrow, as demonstrated by ___ staining and the presence of numerous mitoses. MICROSCOPIC DESCRIPTION. PERIPHERAL BLOOD SMEAR: The smear is adequate for evaluation. Erythrocytes are decreased, normochromic, and macrocytic and have marked anisopoikilocytosis including macroovalocytes elliptocytes and dacrocytes. The white blood cell count is slightly increased. Plasmacytoid lymphocytes and rare plasma cells are seen. Hypolobated and pseudo Pelger-Huet neutrophils are seen. Rare blasts are seen. Platelet count appears normal. Many large and giant platelets are seen. A 200 cell differential shows 36% neutrophils, 46% lymphocytes, 7% monocytes, 1% basophils, 6% myelocytes, 4% metamyelocytes, and 8 nucleated RBCs per 100 nucleated cells. ASPIRATE SMEAR: Not provided (dry tap). CLOT SECTION and BIOPSY SLIDES: The core biopsy material is adequate for evaluation. It consists of a 1.2 cm core biopsy of trabecular marrow and cortical bone with a cellularity of more than 95%. There is a wall-to-wall infiltrate of mononuclear cells comprising most of the cellularity. Majority of the neoplastic cells have atypical morphology with round nuclei and moderate amounts of cytoplasm. Nuclei are positioned centrally, not eccentricaly. Numerous mitoses are seen. Abundant ___ and ___ bodies are seen in some of the cells. Scant background maturing hematopoietic elements are seen. Rare megakaryocytes are seen. The clot section show similar findings. ADDITIONAL STUDIES: Flow cytometry: See separate report ___ Cytogenetics: not submitted (dry tap) By immunohistochemistry staining the neoplastic cells are positive for CD20, CD138, MUM1 and are IgA Kappa restricted (IgG, IgM, and Lambda are negative). Bcl-1 is negative. focally proliferation fraction by ___-67 staining is >50%. This correlates well with high mitotic rate by morphology. CD3 and CD5 highlight scattered T-cells. Lack of staining in other areas of the biopsy may be artifactual due to decalcification which is known to decrease reactivity to the K1-67 antibody. SPECIMEN(S) SUBMITTED: 1. BONE MARROW, BIOPSY, CORE 2. PERIPHERAL BLOOD Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 5 mg PO DAILY 2. Furosemide 20 mg PO DAILY 3. HYDROcodone-acetaminophen ___ mg oral ___ tabs q4-6h prn p;ain 4. Potassium Chloride 20 mEq PO DAILY 5. Levothyroxine Sodium 175 mcg PO DAILY 6. Cyanocobalamin 1000 mcg IM/SC EVERY MONTH 7. Vitamin D ___ UNIT PO DAILY Discharge Medications: 1. Furosemide 20 mg PO DAILY 2. Levothyroxine Sodium 175 mcg PO DAILY 3. Vitamin D ___ UNIT PO DAILY 4. Acyclovir 400 mg PO Q8H 5. Docusate Sodium 100 mg PO BID 6. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H RX *oxycodone [OxyContin] 10 mg 1 tablet extended release 12 hr(s) by mouth every twelve (12) hours Disp #*60 Tablet Refills:*0 7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 8. Lidocaine 5% Patch 1 PTCH TD QPM 9. Ondansetron ___ mg PO Q8H:PRN nausea 10. Cyanocobalamin 1000 mcg IM/SC EVERY MONTH 11. Enoxaparin Sodium 80 mg SC Q12H Start: ___, First Dose: Next Routine Administration Time 12. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN severe breakthrough pain RX *oxycodone 5 mg 1 capsule(s) by mouth every four (4) hours Disp #*60 Tablet Refills:*0 13. Allopurinol ___ mg PO DAILY 14. Polyethylene Glycol 17 g PO DAILY:PRN constipation 15. Senna 8.6 mg PO BID:PRN constipation 16. Acetaminophen 1000 mg PO Q8H:PRN pain 17. Lorazepam 0.5 mg PO Q6H:PRN anxiety RX *lorazepam 0.5 mg 1 tablet by mouth every six (6) hours Disp #*60 Tablet Refills:*0 18. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line flush Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: lymphoplasmacytic lymphoma Secondary: L1 compression fracture, hypercalcemia, acute kidney injury 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: Wrist injury, status post fall. COMPARISON: None available. FINDINGS: Four views of the right wrist, though the navicular view is suboptimal, excluding majority of the scaphoid. No fracture identified. There is normal alignment. There are mild degenerative changes with joint space narrowing at the first carpometacarpal and first interphalangeal joint. No abnormal soft tissue calcification. Soft tissue swelling is noted about the dorsum of the wrist. IMPRESSION: No fracture identified. Mild degenerative changes of the first CMC and interphalangeal joints. Radiology Report HISTORY: Chronic degenerative disease, now with acute low back pain status post fall last night. COMPARISON: Comparison is made with MR ___ from ___ and ___ radiographs from ___. TECHNIQUE: Helical axial MDCT sections were obtained from the lumbar spine. Reformatted images in sagittal and coronal axes were obtained. FINDINGS: There is no acute fracture or vertebral malalignment. There is generalized bony demineralization. Moderate to severe multilevel degenerative changes are seen throughout the ___, most prominent at the L4-5 disc space with posterior disc bulge, vertebral disc space height loss, endplate sclerosis, and vacuum disc phenomenon. Mild anterolisthesis of L4 over L5 is again seen. Compression deformity of L1 is again seen, similar to ___ radiographs from 4 days prior but new since MR from ___. CT is not able to provide intrathecal detail comparable to MRI, but the visualized outline of the thecal sac appears unremarkable. Atherosclerotic disease in is seen in the abdominal aorta. Otherwise, the visualized intra-abdominal organs are unremarkable. IMPRESSION: No acute fracture or vertebral malalignment. Radiology Report INDICATION: Back pain and hematologic abnormalities, possible MDS, MPD; assess for splenomegaly. COMPARISON: Abdominal ultrasound on ___. FINDINGS: The spleen is normal in echotexture and measures 10 cm. On prior ultrasound of ___ it measured 8 cm. No focal lesions are seen within the spleen. There is a trace left pleural effusion. IMPRESSION: Spleen measures 10 cm which is in the normal range; however, it has increased in size compared to the ultrasound on ___ when it measured 8 cm. Radiology Report HISTORY: ? multiple myeloma, renal failure and hypercalcemia. This exam consists of 12 radiographs of the calvarium, thoracic and lumbar spine, pelvis, and proximal humeri and femurs. There is generalized demineralization with a biconcave L1 body and probable associated anterior fracture. No other fracture is identified. There is a mottled appearance to the calvarium and to less extent femurs and humeri with no discrete lytic lesion. The hips and SI joints are normal and symmetric. IMPRESSION: Nonspecific generalized demineralization & fracture of L1. These findings are nonspecific and no lytic lesions of classic multiple myeloma. Radiology Report HISTORY: ___ woman with presumed multiple fluid signal intensity is very cm structures throughout the kidneys. Myeloma, with L1 compression fracture. Evaluate for spinal canal narrowing, cord impingement. TECHNIQUE: Multiplanar, multisequence MRI of the lumbar spine was performed before and after intravenous contrast administration. COMPARISON: CT lumbar spine without contrast ___. Skeletal survey ___. MRI lumbar spine ___. FINDINGS: Again seen is a compression deformity of L1 vertebral body, with approximately 50% height loss anteriorly, with a wedge compression appearance. These findings are stable compared to CT lumbar spine from ___. There is no evidence of significant retropulsion into the spinal canal. The compressed portion of the vertebral body, which is the anterior on half of L1, demonstrates T2 and STIR hypointensity with T1 isointensity. Post-contrast imaging demonstrates hypoenhancement of the compressed portion, as wells as minimal edema, raising the possibility of devascularization of the vertebral body or avascular necrosis of this segment. There is grade 1 (3 mm) anterolisthesis of L4 on L5. There is also grade 1 (2 mm) anterolisthesis of T12 on L1. The other vertebral body heights are preserved. There is diffuse low T1 signal throughout the lumbar spine, most consistent with diffuse bone marrow hyperplasia or bone marrow infiltration. There is a focus of T1 and T2 hyperintensity within the posterior aspect of the T11 vertebral body, not seen on fat saturated images, and most consistent with vertebral hemangioma. The a conus medullaris demonstrates normal signal intensity and morphology and terminates at the level of L2. There is no evidence of cord or conus compression. There is no evidence of abnormal enhancement within the spinal canal or other vertebral bodies. There is generalized ligamentum flavum thickening and facet arthropathy. T11-T12, T12-L1, and L1-L2: There is minimal diffuse disc bulge, without spinal canal or neural foraminal narrowing. L2-L3, L3-L4: There is mild diffuse disc bulge, facet arthropathy, ligamentum flavum thickening and fluid within the facet joints, resulting in mild subarticular zone narrowing with crowding of the traversing nerve roots but no significant nerve root compression. There is no spinal canal or neural foraminal narrowing. L4-L5: There is grade 1 anterolisthesis of L4 on L5 with uncovering of the posterior superior aspect of the intervertebral disc, as well as severe facet arthropathy and moderate ligamentum flavum thickening, resulting in moderate spinal canal narrowing and subarticular zone narrowing. Subarticular zone narrowing resulting in crowding of the bilateral traversing L5 nerve roots. There is moderate to severe left and mild right neural foraminal narrowing. Findings appear grossly stable compared to ___. L5-S1: There is mild diffuse disc bulge, facet arthropathy and ligamentum flavum thickening, without significant spinal canal or neural foraminal narrowing. Note is made of a prominent gallbladder, measuring approximately 5.4 x 4.4 cm. There are multiple pericentimeter fluid signal intensity structures within both kidneys. IMPRESSION: 1. Compression fracture deformity of L1 vertebral body with nearly 50% height loss at the anterior aspect, without evidence of enhancement or significant edema, raising the possibility of subacute vertebral body compression fracture versus devascularization of the vertebral body or avascular necrosis of this vertebral body segment. No evidence of retropulsion into the spinal canal, cord or conus compression. The appearance is not typical for metastatic disease. 2. Diffuse low T1 signal throughout the lumbar spine, most consistent with diffuse bone marrow hyperplasia or bone marrow infiltration. 3. Moderate multilevel spondylosis, most severe at L4-L5, along with grade 1 anterolisthesis at this level, resulting in moderate spinal canal narrowing which appear grossly stable compared to prior study of ___. There is moderate to severe left and mild right neural foraminal narrowing at this level. Dr. ___ these findings by phone with Dr. ___ at 03:45 on ___. Radiology Report HISTORY: ___ female with new right-sided PICC placement. COMPARISON: Radiograph of the chest dated ___. FINDINGS: Portable semi-upright radiograph of the chest demonstrates well expanded clear lungs. The cardiomediastinal and hilar contours are unremarkable. There is no pneumothorax or consolidation. Small bilateral pleural effusions are slightly improved from the prior study. The right-sided PICC line courses up into the neck and ends outside the field of view of this radiograph. IMPRESSION: The right-sided PICC line courses up into the neck and ends outside the field of view of this radiograph. COMMENTS: These findings were discussed with ___ (PICC nurse) by Dr. ___ telephone at 5:09pm on ___, 30 minutes after discovery. Radiology Report INDICATION: Malpositioned right PICC. PHYSICIANS: Dr. ___ (fellow) and Dr. ___ (attending). ANESTHESIA: None. CONTRAST: None. PROCEDURE DETAILS: The patient was brought to the angiography suite and placed supine on the imaging table. The preprocedure timeout was performed as per ___ protocol. A scout fluorscopic image demonstrates an indwelling right PICC extending into the internal jugular vein. One of the lumens of the indwelling right dual-lumen PICC was uncapped and cleaned with alcohol. The lumen aspirated easily and 10 cc sterile saline was injected with moderate force under fluoroscopy. The tip migrated from the right internal jugular vein into the distal SVC without difficulty. Final spot fluoroscopic image demonstrates the PICC in good position with the tip in the distal SVC. The patient tolerated the procedure well without complications. IMPRESSION: Successful repositioning of a right PICC. The tip is in the SVC. Radiology Report HISTORY: Status post right arm PICC with increasing swelling. COMPARISON: None. FINDINGS: Grayscale, color, and spectral Doppler evaluation was performed of the right upper extremity veins. There is normal phasicity of the subclavian veins bilaterally. A right upper extremity PICC enters the basilic vein and courses through the right axillary and subclavian veins. One of the paired brachial veins contains echogenic thrombus, is noncompressible, and demonstrates no flow on color or spectral Doppler evaluation. The other brachial vein, basilic vein (which contains the PICC), cephalic vein, axillary vein, subclavian vein, and right internal jugular vein demonstrate normal compression. IMPRESSION: 1. Right brachial vein DVT. 2. Right basilic vein PICC without basilic, axillary, or subclavian vein thrombus. Findings were communicated via phone call by Dr. ___ to Dr. ___ ___ on ___ at 1241 ___. Radiology Report RADIOGRAPHS OF THE LUMBAR SPINE HISTORY: Newly diagnosed multiple myeloma with L1 compression fracture. COMPARISONS: MR from ___ and skeletal survey from ___. TECHNIQUE: Lumbar spine, AP and lateral, standing views with a brace. FINDINGS: There is a similar moderate-to-severe compression fracture of the L1 vertebral body, potentially with minimally increased in height loss since the prior study. There is clear evidence for substantial retropulsion. Associated with the fracture, however, a slight kyphotic angulation corresponding to the T12- L1 level without substantial subluxations. The L4-L5 and T11-T12 interspaces are moderately narrowed. Patchy vascular calcifications are preserved. IMPRESSION: Moderate-to-severe L1 compression deformity, similar to perhaps minimally increased. Radiology Report HISTORY: Bilateral lower extremity swelling. TECHNIQUE: Grayscale, color Doppler and spectral Doppler evaluation was performed of the bilateral lower extremity veins. COMPARISON: Comparison is made to lower extremity Doppler ultrasound dated ___. FINDINGS: There is normal compressibility, flow, and augmentation of the bilateral common femoral, proximal femoral, mid femoral, distal 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. IMPRESSION: No evidence of deep vein thrombosis in the bilateral lower extremities. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Back pain, Dizziness Diagnosed with LUMBAGO, ANEMIA NOS, HYPERTENSION NOS, HYPOTHYROIDISM NOS temperature: 98.5 heartrate: 87.0 resprate: 16.0 o2sat: 98.0 sbp: 132.0 dbp: 44.0 level of pain: 10 level of acuity: 2.0

Mrs. ___ is a ___ yo F with a recent history of hematologic abnormalities including macrocytosis and an IgA M-spike who presents with 1.5 week history of back pain, 4 month history of ___ lb. unintentional weight loss, ___, and hypercalcemia, concerning for hematologic malignancy. #Lymphoplasmacytic lymphoma vs round cell myeloma: Pt with history of MGUS (IgA elevated at 580 in ___ and unintentional weight loss of 25 lbs over past 3 months concerning for malignancy. Definite lymphocytosis with left shift in myeloid lineages. Also with macrocytic anemia. Pt presented with significantly elevated IgA from prior (1407) and elevated free kappa and free kappa/free lambda light chains. There was concern for MM in particular, given hypercalcemia, anemia, and back pain. BM biopsy (performed on ___ was a dry tap that showed 95% cellularity all packed with cells that are atypical for plasma cells because they are more lymphoid looking either lymphoplasmacytic lymphoma or round cell myeloma. Pt was transferred to the Bone Marrow Transplant service. The final bone marrow biopsy result was pending prior to discharge but preliminary findings were most consistent with lymphoplasmacytic lymphoma. Patient was treated with velcade, dexamethasone, and cytoxan (first day = ___ and will continue to receive treatment in the outpatient setting. #Back pain: Imaging showed a subacute compression fracture at L1 but did not show lytic lesions or plasmacytomas typical for MM. There was no cord compression identified on imaging. Pt was treated with tylenol, oxycodone, oxycontin, and lidocaine patch. She was evaluated by orthopedic spine surgery who recommended a brace when out of bed. She had a standing X-ray on ___ that showed kyphosis and ortho spine advised that a kyphoplasty would be indicated to help with her pain and mobility. Patient preferred to hold off on kyphoplasty given her acute illness and start of chemotherapy. She was discharged on oxycontin 10 mg PO BID with oxycodone for breakthrough pain and a lidocaine patch. #Hypercalcemia: Patient initially presented with calcum of 12.9. Likely due to hematologic malignancy. PTH is 6, which supports non-hyperparathyroid etiologies. She has no neurological symptoms. She was treated with IV fluids and received a dose of pamidronate 90 mg IV on ___ and her calcium decreased to within normal limits prior to discharge. ___: Cr 1.3 at presentation, baseline 0.7. FENa of 0.3%. Creatine initially remained elevated despite IV fluids but decreased to her baseline of 0.7 prior to discharge. #Macrocytic anemia. She is receiving Vitamin B12, and has no apparent reasons for having folate or thiamine deficiency, anemia is likely related to underlying hematologic malignancy. Patient was transfused 2 units of pRBCs during her hospitalization which she tolerated well. #Bilateral lower extremity swelling: Patient had bilateral lower extremity swelling. ___ of bilateral lower extremities were negative for DVTs. She received a dose of 10 mg IV lasix on ___ and was continued home lasix 20 mg PO daily thereafter and her swelling improved prior to discharge. #Right upper extremity swelling: Patient had right PICC placed on ___ and had new swelling of RUE on ___. U/S revealed right brachial vein DVT. She was started on lovenox 80 mg SC Q12H. #Wrist pain: ___ to fall. No fractures on xray. Pain improved with conservative therapy.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: left-sided chest pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ with history of metastatic pulmonary sarcoma, HFpEF, HTN/HLD, and essential tremor who initially presented to ___ for acute onset chest pain and was subsequently transferred to ___ after he was found to have a new pneumothorax and pleural effusion. Patient says that after awaking this AM ~6AM, he felt 'terrible' L-sided chest pain, tearing in quality, max ___ in severity. The pain was non-radiating. High intensity pain lasted for ~.5h, then slowly reducing for .5h. Patient denies any associated SOB or palpitations, no lightheadedness or dizziness. Given the severity of his pain, patient was brought to ___ for evaluation. At ___, patient was chest pain free on arrival. He was noted to be dyspneic getting into the ED. ECG similar to prior, trop <.01 x1. CXR showed a small left PTX and pleural effusion. He was transferred to ___ for further management. Past Medical History: Metastatic Pulmonary Sarcoma HFpEF Pulmonary HTN Moderate AR Essential tremor HTN HLD Glaucoma Hypothyroidsm Social History: ___ Family History: Father: colon cancer Physical Exam: Exam on Admission: =============== VS: 97.6 ___ 20 97 2L GENERAL: NAD HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, OP clear with MMM. NECK: Prominent carotid pulse, no JVP elevation. HEART: RRR, S1/S2, ___ SEM heard throughout the precordium, no gallops or rubs. LUNGS: Relative decrease in breath sounds over L lung, otherwise clear to auscultation. ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: Slightly cool. Trace pretibial edema b/l. PULSES: 1+ radial pulses bilaterally. NEURO: A&Ox3, moving all 4 extremities with purpose. Exam on Discharge: =============== VS: T 98 BP 100/59 HR 67 RR 20 SO2 93% on room air GENERAL: NAD HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, OP clear with MMM, non-tender posterior cervical lymphadenopathy on the L NECK: Prominent carotid pulse, no JVP elevation. HEART: RRR, S1/S2, ___ SEM heard throughout the precordium with maximum intensity at ___ R ICS, no gallops or rubs. LUNGS: Vesicular lung sounds bilaterlly. No adventitious lung sounds. ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: Slightly cool. Trace pretibial edema b/l. PULSES: 1+ radial pulses bilaterally. NEURO: A&Ox3, moving all 4 extremities with purpose. Pertinent Results: Labs on Admission: ============== ___ 06:40AM BLOOD WBC-6.3 RBC-3.99* Hgb-12.6* Hct-39.5* MCV-99* MCH-31.6 MCHC-31.9* RDW-14.1 RDWSD-50.9* Plt ___ ___ 06:40AM BLOOD Glucose-85 UreaN-28* Creat-0.8 Na-145 K-3.8 Cl-105 HCO3-27 AnGap-13 ___ 06:40AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.2 Labs on Discharge: ============== ___ 08:05AM BLOOD WBC-5.6 RBC-3.99* Hgb-12.7* Hct-39.6* MCV-99* MCH-31.8 MCHC-32.1 RDW-14.0 RDWSD-50.8* Plt ___ Imaging: ======= ___ CT CHEST W/O CONTRAST: 1. Numerous metastatic lesions throughout the lungs with the largest occurring in the bases bilaterally. The largest lesion in the left face measures up to 10.8 cm and is associated with obstruction of subsegmental left lower lobe bronchi. Central hypodensity of this lesion and a second lesion in the left lower lobe is suggestive of necrosis. 2. Small left pneumothorax and moderate layering left pleural effusion. 3. Borderline aneurysmal dilation of the ascending thoracic aorta measuring up to 5 cm. ___ CHEST (PORTABLE AP): In comparison with the study of ___, there is little change in the extensive multiple lung masses of varying size, consistent with widespread metastatic disease. Little overall change in the degree of small left apical pneumothorax. Remainder the study is unchanged. ___ CHEST (PA & LAT): In comparison with the earlier study of this date, there is little overall change in the diffuse bilateral pulmonary metastases. The degree of pneumothorax is stable on the left. A line mimicking lateral pneumothorax represents merely a skin fold. ___ CHEST (PA & LAT): Since ___, there has been little change multiple pulmonary metastases some quite large. The small left apical pneumothorax is no longer appreciated. Left lower lobe collapse and moderate left pleural effusion are unchanged. The aorta is tortuous with mild calcification, unchanged. The cardiac border is obscured, but ___ of the cardiac silhouette have decreased. Radiology Report EXAMINATION: CT CHEST W/O CONTRAST INDICATION: ___ with PMHx sarcoma, wedge resection now p/w SOB w/ pneumo on xray at ___// Effusion/pneumothorax? TECHNIQUE: MD CT images were obtained through the chest without the administration of IV contrast. Coronal sagittal reformats were provided. DOSE: Total DLP (Body) = 189 mGy-cm. COMPARISON: None FINDINGS: NECK, THORACIC INLET, AXILLAE, CHEST WALL: There are prominent supraclavicular lymph nodes. UPPER ABDOMEN: Partially visualized cystic lesion in the upper abdomen in the expected location of the right kidney likely represents a simple right renal cyst. MEDIASTINUM: There are numerous prominent paratracheal lymph nodes. HILA: There are prominent right-sided hilar lymph nodes. HEART and PERICARDIUM: Heart appears mildly enlarged. There is no pericardial effusion. PLEURA: There is a small left pneumothorax. There is moderately left pleural effusion. LUNG: 1. PARENCHYMA: There are numerous metastatic lesions throughout both lungs. The largest occur in the bases bilaterally. The largest on the right is subpleural in the right lower lobe and measures approximately 5.0 x 5.0 cm. The largest at the left base measures approximately 10.8 x 6.5 cm and appears centrally hypodense, suggesting necrosis. The second largest lesion also in the base of the left lung also appears slightly hypodense. 2. AIRWAYS: Left lower lobe subsegmental bronchi appear obstructed by large left lower lobe mass. 3. VESSELS: There is borderline aneurysmal dilation of the ascending aorta which measures up to 4.9 cm. There is significant atherosclerotic calcification of the aortic arch and descending thoracic aorta CHEST CAGE: No evidence of fractures or aggressive osseous lesions. IMPRESSION: 1. Numerous metastatic lesions throughout the lungs with the largest occurring in the bases bilaterally. The largest lesion in the left face measures up to 10.8 cm and is associated with obstruction of subsegmental left lower lobe bronchi. Central hypodensity of this lesion and a second lesion in the left lower lobe is suggestive of necrosis. 2. Small left pneumothorax and moderate layering left pleural effusion. 3. Borderline aneurysmal dilation of the ascending thoracic aorta measuring up to 5 cm. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with lung sarcoma, HFpEF, pulmHTN, and HTN/HLD who presents with CP, found to have small pneumothorax.// PTX evaluation IMPRESSION: In comparison with the study of ___, there is little change in the extensive multiple lung masses of varying size, consistent with widespread metastatic disease. Little overall change in the degree of small left apical pneumothorax. Remainder the study is unchanged. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man with pneumo// Pneumothorax progression? IMPRESSION: In comparison with the earlier study of this date, there is little overall change in the diffuse bilateral pulmonary metastases. The degree of pneumothorax is stable on the left. A line mimicking lateral pneumothorax represents merely a skin fold. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ YO with metastatic pulmonary sarcoma and new L PTX. // L PTX resolved? COMPARISON: Chest radiographs from ___ through ___ FINDINGS: PA and lateral views of the chest provided. Since ___, there has been little change multiple pulmonary metastases some quite large. The small left apical pneumothorax is no longer appreciated. Left lower lobe collapse and moderate left pleural effusion are unchanged. The aorta is tortuous with mild calcification, unchanged. The cardiac border is obscured, but ___ of the cardiac silhouette have decreased. IMPRESSION: 1. There is no pneumothorax. No other significant change. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Pneumothorax, Transfer Diagnosed with Pneumothorax, unspecified temperature: 97.5 heartrate: 70.0 resprate: 22.0 o2sat: 97.0 sbp: 134.0 dbp: 72.0 level of pain: UA level of acuity: 2.0

___ is a ___ with history of metastatic pulmonary sarcoma, HFpEF, HTN/HLD, and essential tremor who initially presented to ___ for acute onset chest pain and was subsequently transferred to ___ after he was found to have a left pneumothorax. Acute Issues ============ # Pneumothorax Mr. ___ had presented to ___ with left-sided chest pain. The left-sided pneumothorax was the most likely cause of patient's chest pain. Troponins were negative a ___. Thoracic surgery evaluated the patient in ED and there was no emergent indication for chest tube placement. Mr. ___ was treated with high flow oxygen for a day and the pneumothorax as well as the chest pain completely resolved. # metastatic pulmonary sarcoma We touch based with the patient's oncologist Dr. ___ ___. She had last seen the patient ___ years ago. At that point Mr. ___ wished not to come in anymore for follow up but was offered to be seen anytime if he wished so. # Goals of care: Goals of cares were clarified with Mr. ___ alone and later in the presence of his son. Mr. ___ stated that he would not want to receive CPR in the event of cardiac arrest. He also made clear that he would not want endotracheal intubation/invasive mechanical ventilation for himself. Chronic Issues ============== # HFpEF (LVEF >55%) Mr. ___ did not appear volume overloaded on exam. Continued home furosemide 80mg qd (recently increased last week by cardiologist) # Hypertension Continued home nifedipine 60mg qd, valsartan 320mg qd # Hypothyroidism Continued home levothyroxine 25mcg qd # Essential tremor Continued home phenobarbital 60mg qHS # Dyslipidemia Continued home simvastatin 10mg qHS # Glaucoma Continued home eye gtt # Insomnia/anxiety Continued home lorazepam .5mg qHS PRN, consider alternative agent given advanced again TRANSITIONAL ISSUES =================== [] Consider referral back to ___ with Dr. ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Morphine / Penicillins / Ciprofloxacin Hcl / Warfarin / Cozaar / Norvasc / Lisinopril / Rosuvastatin / Flexeril / Uloric Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None. History of Present Illness: ___ h/o HFrEF with EF 20% (___), asthma, CAD s/p PCI to AD & ramus in ___, mild AR and MR, CKD (b/l Cr~1.7-2.0), hypertension, GERD, and OSA who presents with chest pain, cough, and difficulty breathing. Chest pain began yesterday (___) with cough "all night," on left sternal border. He called his PCP ___ prescribed guaifenesin with codeine cough syrup. The medication helped him stop coughing as much, but he had the cough all throughout the night. He notes associated nasal congestion and malaise in the same time period. In the ED, his chest pain was ___, localized to 6 cm lateral to the sternum on the left at the level of the ___ ICS. The pain worsened with breathing or coughing, and if he pressed on the area the pain is recreated. No radiation. Feels that "may have pulled a muscle." Patient has had ___ MIs in the past and said pain feels similar to those episodes. Pt has difficulty breathing. Pt has had cough for 5 days, but denies hemoptysis. Of note, he was recently admitted from ___ to ___ for chest pain found to be negative from a cardiac/pulmonary perspective as EKG, troponins, ___, and VQ scan were negative. CP was thought ___ GERD and he was discharged on ranitidine. His course was complicated by mild fluid overload in the setting of HFrEF, aspiration pneumonia, SVT with HR's in the 150's in the setting of acute infection, and ___. His ___ and ___ diuretic were stopped with improvement in the ___. He was treated with a 7 day course of cefpodoxime and azithromycin for aspiration pneumonia. His home metoprolol was increased and his heart rates improved. Past Medical History: - Asthma/COPD with restrictive features (FEV1 81% predicted, FEV1/FVC 106% ___ PFTs), - Coronary artery disease s/p ___ to LAD and Ramus ___ patent with 40% ramus, 20% OM1 on cath ___ -HFrEF (EF 20% ___, Ischemic/non-ischemic Cardiomyopathy. - Aortic regurgitation - mild ___ echo) - Mitral regurgiattion - mild-moderate ___ echo) - Dilated ascending aorta - mild ___ echo) - Chronic renal failure (creatinine 1.7-1.9mg/dl) - Gout and CPPD on chronic prednisone - GERD - Obstructive sleep apnea - Hernia repair (epigastric ___ inguinal ___ - Cataracts, bilateral - Lower back pain - Osteoarthritis - Hemorrhoidal surgery - Childhood polio - Rhabdomyolysis - rosuvastatin Social History: ___ Family History: Parents are both deceased. He has no biologic children. He had 17 siblings but only a sister (___, dialysis) and brother (___, kidney problems) are still alive. Physical Exam: DISCHARGE PHYSICAL EXAM Vitals: ___ 0753 Temp: 98.3 PO BP: 124/84 HR: 64 RR: 16 O2 sat: 99% O2 Ra I/Os: ___ GENERAL: Alert and oriented, somnolent, but interactive with exam. HEENT:PERRLA, poor dentition, oropharynx non-erythematous. NECK: No lymphadenopathy. Neck veins difficult to assess for JVD. CARDIAC: S1, S2, no m/g/r LUNGS: Breath sounds decreased in bases bilaterally. Mild crackling at bases. Not using accessory muscles while resting in bed. Upper airway noises on inspiration and expiration. ABDOMEN: Tympanic abdomen. Non-tender, non-distended. EXTREMITIES: Minimal edema in bilateral lower extremities. NEURO: Moving all four extremities. No focal deficits. Pertinent Results: ADMISSION LABS ___ 08:50AM CK-MB-10 proBNP-5130* ___ 08:50AM cTropnT-0.08* ___ 08:50AM WBC-8.0 RBC-3.73* HGB-11.6* HCT-37.2* MCV-100* MCH-31.1 MCHC-31.2* RDW-14.3 RDWSD-52.5* ___ 12:17PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-NEG DISCAHRGE LABS ___ 07:20AM BLOOD WBC-6.7 RBC-3.72* Hgb-11.6* Hct-36.9* MCV-99* MCH-31.2 MCHC-31.4* RDW-14.3 RDWSD-52.1* Plt ___ ___ 08:55AM BLOOD Glucose-193* UreaN-48* Creat-2.2* Na-141 K-4.4 Cl-98 HCO3-33* AnGap-10 ___ 08:27AM BLOOD ALT-33 AST-28 LD(LDH)-221 CK(CPK)-758* AlkPhos-56 TotBili-0.6 ___ 11:14PM BLOOD CK-MB-5 cTropnT-0.21* ___ 08:55AM BLOOD Calcium-8.5 Phos-3.1 Mg-2.2 IMAGING/STUDIES: CARDIAC PERFUSION REST ___: 1. Severe, large resting perfusion defect involving the RCA territory. 2. Small, severe resting perfusion defect involving the LAD territory. PA/Lat CXR ___: There are bilateral lower lobe opacities, likely atelectasis; however, pneumonia cannot be completely excluded. There is a stable small right effusion. The heart is enlarged, similar to previous. The aorta is tortuous. The bones are diffusely osteopenic. There is scoliosis and degenerative changes of the spine. Degenerative changes are seen in the shoulder. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO TID 2. Allopurinol ___ mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. Benzonatate 100 mg PO TID:PRN cough 6. Cetirizine 10 mg PO DAILY 7. Clopidogrel 75 mg PO DAILY 8. Docusate Sodium 100 mg PO BID:PRN constipation 9. Fluticasone Propionate NASAL 1 SPRY NU DAILY 10. FoLIC Acid 1 mg PO DAILY 11. Gabapentin 500 mg PO DAILY 12. LORazepam 0.5 mg PO QHS:PRN leg twitching 13. Metoprolol Succinate XL 100 mg PO DAILY 14. Multivitamins 1 TAB PO DAILY 15. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 16. PredniSONE 5 mg PO DAILY 17. Simethicone 80-160 mg PO QID:PRN bloating, gas 18. Spironolactone 25 mg PO 3X/WEEK (___) 19. Vitamin D 1000 UNIT PO DAILY 20. Ranitidine 150 mg PO DAILY 21. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 22. Calcitriol 0.25 mcg PO TWICE A WEEK 23. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic BID 24. codeine-guaifenesin ___ mg/5 mL oral TID:PRN Discharge Medications: 1. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough 2. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 tablet(s) by mouth q24h Disp #*30 Tablet Refills:*0 3. Torsemide 20 mg PO DAILY RX *torsemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Valsartan 40 mg PO DAILY RX *valsartan 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Allopurinol ___ mg PO EVERY OTHER DAY 6. Artificial Tears ___ DROP BOTH EYES PRN Dry eyes 7. Gabapentin 200 mg PO DAILY 8. Acetaminophen 1000 mg PO TID 9. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 10. Aspirin 81 mg PO DAILY 11. Benzonatate 100 mg PO TID:PRN cough 12. Calcitriol 0.25 mcg PO TWICE A WEEK 13. Cetirizine 10 mg PO DAILY 14. Clopidogrel 75 mg PO DAILY 15. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic BID 16. Docusate Sodium 100 mg PO BID:PRN constipation 17. Fluticasone Propionate NASAL 1 SPRY NU DAILY 18. FoLIC Acid 1 mg PO DAILY 19. LORazepam 0.5 mg PO QHS:PRN leg twitching 20. Metoprolol Succinate XL 100 mg PO DAILY 21. Multivitamins 1 TAB PO DAILY 22. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 23. PredniSONE 5 mg PO DAILY 24. Ranitidine 150 mg PO DAILY 25. Simethicone 80-160 mg PO QID:PRN bloating, gas 26. Vitamin D 1000 UNIT PO DAILY 27. HELD- Atorvastatin 80 mg PO QPM This medication was held. Do not restart Atorvastatin until your doctor says to 28. HELD- Spironolactone 25 mg PO 3X/WEEK (___) This medication was held. Do not restart Spironolactone until your doctor says to restart Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Acute on Chronic systolic Heart Failure ___ on CKD Type II NSTEMI Discharge Condition: Mental Status: Clear and coherent. Activity Status: Out of Bed with assistance to chair or wheelchair. Level of Consciousness: Alert and interactive. From a medical perspective, no contra-indication for cataract surgery on ___. Followup Instructions: ___ Radiology Report EXAMINATION: AP chest radiograph INDICATION: History: ___ with cough, dyspnea// pna? COMPARISON: Chest radiograph ___ FINDINGS: PA and lateral views of the chest provided. There is a left lower lobe opacity in ill-defined linear opacities in the right lower lobe. There is a small right pleural effusion. Mild cardiomegaly is unchanged. Dextroscoliosis of the thoracic spine is noted. IMPRESSION: 1. Left lower lobe opacity could represent aspiration or pneumonia. 2. Ill-defined linear opacities overlying the right lower lobe favor atelectasis versus less likely pneumonia or aspiration. 3. Small right pleural effusion. Radiology Report INDICATION: ___ year old man with SOB, chest pain// eval for fluid overload, pneumonia TECHNIQUE: PA and lateral COMPARISON: Portable chest x-ray ___ FINDINGS: There are bilateral lower lobe opacities, likely atelectasis; however, pneumonia cannot be completely excluded. There is a stable small right effusion. The heart is enlarged, similar to previous. The aorta is tortuous. The bones are diffusely osteopenic. There is scoliosis and degenerative changes of the spine. Degenerative changes are seen in the shoulder. IMPRESSION: Bilateral lower lobe opacities, likely atelectasis however pneumonia cannot be completely excluded. Mild cardiomegaly. Small stable right effusion. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Chest pain Diagnosed with Chest pain, unspecified temperature: 96.9 heartrate: 68.0 resprate: 20.0 o2sat: 99.0 sbp: 138.0 dbp: 79.0 level of pain: 6 level of acuity: 3.0

Mr. ___ is a ___ h/o HFrEF (EF 20% ___, asthma, CAD s/p PCI to AD & ramus in ___, mild AR and MR, CKD (b/l Cr~1.7-2.0), hypertension, GERD, and OSA who presented with chest pain, cough, and difficulty breathing in absence of clear infection or COPD/asthma exacerbation. Breathing improved on diuretics. Chest pain in setting of rising troponins (to 0.22), improved on Nitro SL. Cardiology pursued medical management of possible angina.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Phenergan Plain / Aldactone / Digoxin / amlodipine Attending: ___ Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: ___ F with DM II, ESRD on HD, CAD s/p CABG, CHF, HTN, HLD, prior R CVA in ___, who presented ___ with altered mental status and ultimately found to have L CVA. Per her husband, she had developed cough and mild dyspnea on ___ and was seen by her PCP who diagnosed her with PNA by CXR on ___ and started her on levofloxacin. She seemed to improve from a respiratory standpoint and was otherwise well until the morning of ___ when she was noted to be talking incoherently and was somnolent when seen by someone who was doing her hair. She was saying random but accurate sentences saying "I am going away", "I am going home", "when am I getting off". No noted seizures, fevers, chills, abdominal pain, diarrhea preceding AMS. In the ED, neuro felt that the patient had a toxic-metabolic encephalopathy due to a large dose of Keppra, possibly potentiated by levofloxacin. Cardiology was consulted due to ST depressiosn and elevated troponins, but in the setting of missed HD, they felt ACS treatment was not warranted. On initial assessment on the floor, she was awake, but unable to converse, unable to follow commands, and not oriented to person/place/time. The patient received HD on ___. On ___, the patient was triggered for unresponsiveness and a CT head was ordered out of concern for acute CVA, which revealed a large CVA in the left temparoparietal region. The stroke team recommended no anticoagulation/tPA due to infarct size and the risk for hemorrhagic conversion, but recommended supportive care with permissive hypertension, EEG, and initiating secondary prevention. On transfer, vitals were T 97.7, BP 150/53, HR 84, SaO2 97% on RA. On arrival to the MICU, the patient is unresponsive. Review of systems: Unable to obtain Past Medical History: - R MCA stroke vs. TIA in ___ without residual deficit per husband - ___ disorder - C. Diff Colitis - Ishemic colitis x2: two episodes of ischemic colitis, one in ___ and another in ___, both occuring when she was hypotensive - pnemobilia - DM-II (complicated by Diabetic neuropathy) - ESRD on HD - ___ through R-sided HD catheter. - chronic infrarenal aortic dissection - right common femoral artery aneurysm - CAD: s/p 5V CABG ___ echo ___ cath ___ showed 3V disease. Cath ___ w successful stenting of the LMCA into LAD with Endeavor DES. - Chronic diastolic CHF (last EF 50-55%) - PVD - s/p angioplasty in LLE and s/p bypass in RLE - HTN - Hyperlipidemia - Sensorineural hearing loss - partial loss in Left ear, with hearing aid; complete loss in R ear - COPD: ___ PFT showed reduced FVC with low-normal TLC - Chronic low back pain - s/p cataract surgery - Depression - Left breast cyst at 2 o'clock, 5 cm from the nipple. Patient also has history of a nodular asymmetry in the left medial breast with ___ mammograms showing BiRads 3. Social History: ___ Family History: 2 parents and 6 siblings all died of DM and heart disease. H/o prostate, colon/stomach, and ovarian CA in siblings. Physical Exam: ADMISSION PHYSICAL EXAM T 97.7, BP 150/53, HR 84, SaO2 97% on RA. General- Elderly woman is unresponsive, does not follow commands. HEENT- Conjugate gaze toward the right, with ptosis of right eyelid and R facial droop. Pupils are equal, round, and reactive to light bilaterally. Minimal gag reflex. Neck- No JVD CV- RRR, no m/r/g Lungs- CTAB anteriorly. Abdomen- Soft, nontender. GU- No foley Ext- Trace edema Neuro- Unresponsive. Moving all extremities except LLE, has left-sided hemineglect. Eye exam as above. Patient not able to follow commands. She appears awake and eyes open spontaneously. She localizes to pain. Later during the exam she vocalizes some incomprehensible sounds. DISCHARGE PHYSICAL EXAM: Tmax: 36.8 °C (98.3 °F) Tcurrent: 36.4 °C (97.6 °F) HR: 87 (73 - 94) bpm BP: 153/48(74) {120/35(58) - 164/93(103)} mmHg RR: 16 (14 - 22) insp/min SpO2: 94% Neuro: Mental Status- Awake, not oriented to person, place, or time. Mumbles "okay" repeatedly. Does not follow any directions. CN- PERRL 2mm-->1.5 mm, eye movements are normal, no facial asymmetry, tongue is midline. Motor- normal tone bilaterally, moves all limbs spontaneously and withdraws all limbs from noxious stimulation. Sensory- Withdraws all limbs from noxious stim, says "ouch", does not localize stimulus well. Neck: No JVD Chest: RRR no m/r/g, HD catheter in place Lungs: CTAB anteriorly. Abdomen: Soft, nontender. GU: No foley EXT: Trace edema, Moving all extremities except LLE; did wiggle her toes noxious stimulus Pertinent Results: ___ 01:00PM BLOOD WBC-8.1 RBC-3.10* Hgb-10.3* Hct-31.1* MCV-100* MCH-33.2* MCHC-33.1 RDW-13.1 Plt ___ ___ 06:39AM BLOOD WBC-8.3 RBC-3.26* Hgb-10.5* Hct-32.9* MCV-101* MCH-32.2* MCHC-32.0 RDW-12.6 Plt ___ ___ 04:05AM BLOOD WBC-9.3 RBC-3.35* Hgb-11.1* Hct-33.8* MCV-101* MCH-33.1* MCHC-32.8 RDW-13.4 Plt ___ ___ 01:00PM BLOOD Glucose-315* UreaN-61* Creat-6.6* Na-142 K-6.6* Cl-99 HCO3-29 AnGap-21* ___ 06:39AM BLOOD Glucose-172* UreaN-68* Creat-7.7*# Na-143 K-5.1 Cl-99 HCO3-29 AnGap-20 ___ 04:05AM BLOOD Glucose-118* UreaN-33* Creat-4.6*# Na-138 K-4.2 Cl-96 HCO3-30 AnGap-16 ___ 01:00PM BLOOD ALT-93* AST-71* CK(CPK)-75 AlkPhos-82 TotBili-0.3 ___ 03:58AM BLOOD WBC-9.9 RBC-3.56* Hgb-11.6* Hct-35.7* MCV-100* MCH-32.4* MCHC-32.4 RDW-13.4 Plt ___ ___ 03:58AM BLOOD Glucose-198* UreaN-44* Creat-4.9*# Na-131* K-3.6 Cl-92* HCO3-22 AnGap-21* ___ 04:05AM BLOOD Triglyc-159* HDL-26 CHOL/HD-3.2 LDLcalc-25 C. Diff - NEGATIVE (___) ECHO (___) 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 moderately depressed - quantitative (biplane) LVEF = 35% - secondary to hypokinesis of the basal-mid inferior wall and hypokinesis of the entire anterior wall, apex, and anterior septum. Right ventricular chamber size is normal. with mild global free wall hypokinesis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of ___, there are new left ventricular wall motion abnormalities with worse biventricular global systolic function. Mitral regurgitation has progressed from mild to moderate. No evidence of intracardiac shunt. EEG (___) FINDINGS: EEG is recorded from 7 AM on ___ until 7 AM on ___. Left hemisphere electrodes are disconnected from 1 ___ until 4 ___, and there is continuous 60 Hz artifact over the right hemisphere at the same times. There is continuous O2 artifact after 2 AM, and eye leads are disconnected throughout most of the study. CONTINUOUS EEG: The background activity consists predominantly of polymorphic theta and delta activity. There is no definite posterior dominant rhythm. There is continuous focal slowing, more prominent polymorphic delta activity, and mild attenuation of faster frequencies in the left temporal region. There are no epileptiform discharges or electrographic seizures. SLEEP: No normal sleep architecture is present. There are some segments with decreased muscle activity and overall slowing of the background, but no sleep transients are seen. PUSHBUTTON ACTIVATIONS: There are 5 pushbutton activations, at 10:27, 11:29, 11:30, and 2 at 12:00. During these pushbuttons, only the patient's head is visible on video. Reportedly, the pushbuttons are for some erratic movements of her legs. There are no EEG changes during these pushbuttons. SPIKE DETECTION PROGRAMS: There are frequent automated spike detections, predominantly for electrode and movement artifact. There are no epileptiform discharges. SEIZURE DETECTION PROGRAMS: Seizure detection programs did not detect any electrographic seizures. QUANTITATIVE EEG: Trend analysis is performed with Persyst Magic Marker software. Panels include 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 show diffuse background slowing with more prominent left temporal slowing. CARDIAC MONITOR: Shows a generally regular rhythm with no apparent P waves and a wide QRS complex at an average rate of 60-70 bpm. IMPRESSION: This is an abnormal continuous ICU monitoring study because of continuous focal slowing and attenuation of faster frequencies in the left temporal region. These findings are indicative of a focal structural lesion in the left temporal region, consistent with the patient's known history of stroke. Background activity is otherwise slow and disorganized, indicative of moderate diffuse cerebral dysfunction, which is etiologically nonspecific. No electrographic seizures or epileptiform discharges are present. Five pushbutton activations for movements of her legs had no ictal EEG correlate. The type of leg movements could not be determined because only her head was visible on video at this time. Compared to the prior day's recording, there are no epileptiform discharges, but background activity is otherwise unchanged. CT HEAD ___ Again seen is an evolving left MCA distribution infarct, involving the temporal and parietal lobes with continued edema, similar to the prior study. Linear areas of hyperdensitywithin (2a:19) may represent retained contrast due to slow flow as suggested on prior studies or possible hemorrhagic conversion. The superior right frontal lobe hypodense area consistent with an evolving infarction is stable from the prior study. A linear focus seen within this region (2a: 18) is new since the prior exam. A large area of encephalomalacia in the right temporoparietal area stable. There is no shift of the midline structures and the basilar cisterns are patent. The ventricles and sulci are unchanged in size and configuration, with continued effacement of the occipital horn of the left lateral ventricle. The visualized paranasal sinuses and the middle ear cavities are clear. The mastoid air cells are underpneumatized. IMPRESSION: 1. Similar appearance of evolving left MCA infarction with similar appearing linear foci of hyperdensity which may represent retained contrast, however involving blood products is also possible. 2. Evolving right frontal infarction in the superior right MCA territory stable from the prior study. Linear hyperdense focus within this region which may also represent retained contrast or evolving blood products. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Gabapentin 100 mg PO HS 3. Atorvastatin 40 mg PO DAILY 4. Calcium Acetate 1334 mg PO TID W/MEALS 5. Carvedilol 25 mg PO BID 6. NPH 14 Units Breakfast 7. LeVETiracetam 1000 mg PO BID 8. Losartan Potassium 100 mg PO DAILY 9. NIFEdipine CR 30 mg PO QHS 10. ___ Caps *NF* (B complex-vitamin C-folic acid) 1 mg Oral daily 11. vancomycin *NF* 125 mg ORAL DAILY 12. Nitroglycerin SL 0.4 mg SL PRN cp 13. Probiotic *NF* (B.breve-L.acid-L.rham-S.thermo;<br>L.acidophilus-Bif. animalis;<br>L.rhamn ___ acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus combination no.4;<br>lactobacillus combo no.11) 10 billion cell Oral daily 14. Levofloxacin 500 mg PO Q48H Please start ___, next dose ___, then end Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 40 mg PO DAILY 3. Carvedilol 6.25 mg PO BID 4. NPH 14 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 5. LeVETiracetam 500 mg PO BID 6. LeVETiracetam 500 mg PO POST HD 7. Losartan Potassium 25 mg PO DAILY 8. Vancomycin Oral Liquid ___ mg PO Q6H 9. Calcium Carbonate 1000 mg PO TID 10. Lorazepam 0.5-1 mg IV X1:PRN seizure 11. Phenytoin Infatab 150 mg PO Q8H 12. Calcium Acetate 1334 mg PO TID W/MEALS 13. Probiotic *NF* (B.breve-L.acid-L.rham-S.thermo;<br>L.acidophilus-Bif. animalis;<br>L.rhamn ___ acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus combination no.4;<br>lactobacillus combo no.11) 10 billion cell Oral daily 14. ___ Caps *NF* (B complex-vitamin C-folic acid) 1 mg Oral daily Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Stroke, Ischemic Seizures Secondary: DM Mellitus, type II, well controlled CHF, systolic w/ EF ___ Coronary Artery Disease ESRD on HD Hypertension Hyperlipidemia COPD w/o exacerbation 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 INDICATION: Altered mental status. COMPARISON: Non-contrast head CT from ___. TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without administration of IV contrast. Coronal and sagittal reformatted images were generated. FINDINGS: There is no hemorrhage, edema, mass effect, or vascular territorial infarction. Right temporoparietal encephalomalacia is unchanged compared to the prior examination. Prominent ventricles and sulci reflect age-related atrophy. Periventricular white matter hypodensities likely reflect sequelae of chronic small vessel ischemic disease. Basal cisterns are patent and there is preservation of gray-white matter differentiation. No fracture is identified. Paranasal sinuses show mild mucosal thickening within the left maxillary sinus. Remaining paranasal sinuses, mastoid air cells, and middle ear cavities are clear. Orbits are unremarkable. Calcifications are noted in the cavernous carotids. IMPRESSION: No acute intracranial abnormalities. Radiology Report HISTORY: ___ female with altered mental status with recent pneumonia. COMPARISON: ___. FINDINGS: AP and lateral views of the chest. Left sided dual-lumen central venous catheter seen with distal tip in the right atrium, similar to prior. The lungs are hyperinflated. Increased interstitial markings are seen throughout the lungs similar to prior given differences in technique. More confluent consolidation is seen in the left lung, minimally improved since prior. There is now blunting of the posterior costophrenic angles suggestive of small effusions. Cardiomediastinal silhouette is enlarged but stable. No acute osseous abnormality detected. IMPRESSION: Mild interval improvement in the appearance of the left lung consolidation which persists. As mentioned on prior, followup will be necessary after treatment. Trace pleural effusions. No other change. Radiology Report STUDY: CTA of the head and neck with and without contrast. CLINICAL INDICATION: ___ woman with right-sided facial droop, evaluate for acute bleed. COMPARISON: Prior CTA of the head dated ___ and prior MRI of the brain dated ___. TECHNIQUE: NON-CONTRAST HEAD CT: Axial MDCT images were obtained through the brain, no contrast was administered, the images were reviewed using soft tissue and bone window algorithms. CTA OF THE HEAD AND NECK: Axial MDCT images were obtained from the aortic arch through the head convexity with intravenous contrast. Axial, coronal, sagittal, and thick-slab multiplanar reformations were generated. FINDINGS: HEAD CT WITHOUT CONTRAST: Since the most recent head CT dated ___, there is a new large area of low attenuation in the left temporo-occipital and parietal region, vascular territory of the posterior branches of the left MCA with no evidence of hemorrhagic transformation. Again a chronic infarction is identified in the vascular distribution of the right MCA with extensive area of encephalomalacia. CTA OF THE HEAD: There is a filling defect, suggesting occlusion of the left M2 inferior division branch (3:251), again there are calcified plaques in the petrous and cavernous segments of both intracranial internal carotid arteries and intracranial vertebral arteries. The anterior and right middle cerebral arteries are patent as well as the posterior circulation. No aneurysms larger than 3 mm in size are seen. CTA OF THE NECK: Again, common origin of the left common carotid and brachiocephalic artery is redemonstrated. There are atherosclerotic calcifications in the aortic arch and calcified atherosclerotic plaques are redemonstrated in bilateral common carotid arteries with no significant change since the most recent study, punctate calcifications are visualized in the petrous and cavernous segments bilaterally involving the internal carotid arteries. The thyroid gland is notable for heterogeneous hypodense nodules, previously demonstrated, there is persistent and more significant pleural effusion and right upper lobe and consolidation. Multilevel degenerative changes are visualized throughout the cervical spine, more significant at C5/C6 level. The patient is status post CABG. IMPRESSION: Acute left temporo-occipitoparietal lobe infarction, suggesting occlusion of the M2 segment involving the inferior division branch as described in detail above (3:251). Unchanged right temporal extensive encephalomalacia in the vascular territory of the right middle cerebral artery. These findings were discovered and communicated via phone call by ___ to Dr. ___ on ___ at 20:31 p.m. Radiology Report HISTORY: Left-sided CVA. Question hemorrhagic conversion. TECHNIQUE: Noncontrast head CT. COMPARISON: ___. FINDINGS: There is increased swelling of the left MCA distribution infarction. Within this are linear areas of hyperdensity. Although these may reflect hemorrhage into the infarct, there is persistent high density within the left MCA branches. Thus, this high density may be rather pooling and slow clearance of contrast from the recent CTA, rather than hemorrhage. The encephalomalacic area of the right temporal parietal lobe is stable. There is very slightly increasing shift of the midline by approximately 2 mm. The basal cisterns are widely patent. The ventricles and sulci are normal in size and morphology for the patient's age. The mastoid air cells are underdeveloped. Paranasal sinuses are clear. IMPRESSION: Evolution of left MCA infarction. Linear areas of hyperdensity within the left temporal occipital parietal lobe infarction more likely represents persistent contrast within the vessels rather than hemorrhage, given their shape. Radiology Report HISTORY: Large left-sided CVA; prior R MCA CVA. Please evaluate for stroke evolution and signs of hemorrhage. TECHNIQUE: MDCT axial imaging was obtained through the brain without the administration of intravenous contrast material. Coronal and sagittal reformats were completed. DLP: 1025.7 mg/cm. COMPARISON: CT head without contrast from ___. FINDINGS: Again seen is an evolving left MCA distribution infarct involving predominantly the temporal and parietal lobes, with continued edema, similar in extent to the prior study. The linear areas of hyperdensity seen within the infarct on the prior study have resolved, consistent with pooling of contrast from a prior CTA. There is no evidence of hemorrhagic conversion. The area of encephalomalacia in the right temporal and parietal lobes are stable. Deep and periventricular white matter hypodensities are again seen, likely sequela of chronic small vessel ischemic disease. There is no significant shift of the midline structures. Basilar cisterns are patent. The ventricles and sulci are unchanged in size and configuration, with effacement of the atrium and occipital horn of the left lateral ventricle. The mastoids are underpneumatized. The imaged paranasal sinuses, mastoid antra and middle ear cavities are clear. There is calcification of the carotid siphons. IMPRESSION: Similar appearance of the evolving left MCA infarction with no evidence of hemorrhagic conversion. Continued effacement of the left temporoparietal sulci without increasing mass effect. NOTES ON ATTENDING REVIEW: 1. Linear foci of hyperdensity along the evolving left MCA infarction have decreased in density, but not completely resolved; the largest residual focus is best seen on image 2:15. This is compatible with either slow resorption of retained intravascular contrast or evolving blood products. 2. There is also an evolving right frontal infarction in the superior right MCA territory, with loss of gray/white matter differentiation but no significant mass effect, new since ___, without hemorrhagic transformation. Radiology Report HISTORY: For Dobbhoff placement. FINDINGS: In comparison with study of ___, there has been placement of the Dobbhoff tube with the opaque portion straddling the gastroesophageal junction. Diffuse bilateral pulmonary opacifications persist. Radiology Report HISTORY: History of large left-sided CVA. Evaluate for signs of evolution or hemorrhagic conversion. TECHNIQUE: MDCT axial imaging was obtained through the brain without the administration of intravenous contrast material. DLP: 1538 mGy-cm. COMPARISON: Multiple prior studies most recently CT head without contrast from ___. FINDINGS: Again seen is an evolving left MCA distribution infarct, involving the temporal and parietal lobes with continued edema, similar to the prior study. Linear areas of hyperdensitywithin (2a:19) may represent retained contrast due to slow flow as suggested on prior studies or possible hemorrhagic conversion. The superior right frontal lobe hypodense area consistent with an evolving infarction is stable from the prior study. A linear focus seen within this region (2a: 18) is new since the prior exam. A large area of encephalomalacia in the right temporoparietal area stable. There is no shift of the midline structures and the basilar cisterns are patent. The ventricles and sulci are unchanged in size and configuration, with continued effacement of the occipital horn of the left lateral ventricle. The visualized paranasal sinuses and the middle ear cavities are clear. The mastoid air cells are underpneumatized. IMPRESSION: 1. Similar appearance of evolving left MCA infarction with similar appearing linear foci of hyperdensity which may represent retained contrast, however involving blood products is also possible. 2. Evolving right frontal infarction in the superior right MCA territory stable from the prior study. Linear hyperdense focus within this region which may also represent retained contrast or evolving blood products. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: ALTERED MENTAL STATUS Diagnosed with ALTERED MENTAL STATUS temperature: 98.2 heartrate: 86.0 resprate: 20.0 o2sat: 100.0 sbp: 156.0 dbp: 56.0 level of pain: 13 level of acuity: 1.0

The patient is a ___ year old female with a past medical history significant for DMII, ESRD on HD, CAD s/p CABG, CHF, HTN, HLD and seizures who presented with altered mental status found to have new left parietal stroke. #) ACUTE CEREBROVADSCULAR ACCIDENT: Left MCA stroke with previous R MCA stroke recrudescence. In the ED, the patient was able to speak in sentences, but the sentences did not make sense. She was also having difficulty following commands. A neurology consult was obtained and they felt as though this was likely a toxic metabolic encephalopathy due to a large dose of Keppra, possibly exacerbated by the Levofloxacin she was receving for her PNA. An EEG was also obtained in the ED, which did not show non-convulsive seizures or epileptiform discharges. On initial assessment on the floor, she was awake, but unable to converse, unable to follow commands, and not oriented to person/place/time. The patient received HD on ___. On ___, the patient was triggered for unresponsiveness and a CT head was ordered out of concern for acute CVA, which revealed a large CVA in the left temparoparietal region. The stroke team recommended no anticoagulation/tPA due to infarct size and the risk for hemorrhagic conversion, but recommended supportive care with permissive hypertension, EEG, and initiating secondary prevention. She was then transferred to the MICU for closer monitoring. She was started on PR aspirin and her home BP meds were discontinued. Repeat serial CT scans were obtained. There was initially some concer for hemorrhagic conversion, and ASA was briefly held, although images were thought more consistent with late contrast extravasation and ASA was restarted. Due to persistently poor mental status, a dobhoff tube was placed for enteral feedings. Her course was complicated by subclinical seizure activity on EEG. She was started on phenytoin in addition to her home levitiracetam dosing, and she received intermittent lorazepam IV for possible seizure activity with good effect. By discharge, she was having no more seizure activity, and her medications were switched to PO. #) NSTEMI: Likely represent missed NSTEMI. Drawn in ED given ST depression seen on ECG and noted to be markedly elevated to ~6. Serial measurements were generally flat with low MB fraction. Cardiology was consulted due to ST depressions seen on EKG and elevated troponins. In the settings of missed HD, they did not feel that ACS treatment was warrented. ST segment depressions persisted throughout her hospitalization. Following the identification of her stroke, an echocardiogram was obtained which showed new ___ wall motion abnormalities and decreased LVEF. Patient was not clinically in heart failure. Her ASA, carvedilol and losartan was restarted, at lower doses given MAP goals. #) COMMUNITY-ACQUIRED PNEUMONIA: Respiratory status was stable on admission and no further clinical evidence of PNA although infiltrate persisted on CXR. She was switched to ceftriaxone/azithromycin from levofloxacin and completed a 7 day course of abx. #) RECURRENT C. DIFF COLITIS: Patient was being treated with PO vancomycin at home for recurrent C. diff colitis but was switched to metronidazole and admission. This was switched back to po vancomycin after enteral access with dobhoff was established on ___. She had no clinically signficant diarrhea and repeat CDiff PCR was negative. She should continue with PO vancomycin until ___ to complete two weeks of C. diff treatment following antibiotics. CHRONIC PROBLEMS ================ #) CHRONIC KIDNEY DISEASE, STAGE V: Continue HD. Last received dialysis ___. Should continue to receive HD MWF. #) CONGESTIVE HEART FAILURE, COMPENSATED: No evidence of decompensation currently. Held beta blocker and ___ after stroke for permissive hypertension, which were slowly restarted. Restarted Carvedilol and Losaratan. Echo showed worsened wall motion abnormalities and LVEF as above, although clinically patient was stable. #) DIABETES MELLITUS: Continued HISS. Gabapentin was held given somnolence. A1c was measured at 6.9% #) DYSLIPIDEMIA: Repeat lipids to tailor secondary stroke prevention therapy. #) HYPERTENSION: Goal systolic 110 to 140 to help with perfusion since she had a stroke. Restarted Carvedilol and Losartan. =========================== CONTACT / CODE STATUS =========================== # CODE: Full code (confirmed) # CONTACT: ___ (husband) home ___, cell ___ =========================== ### TRANSITIONAL ISSUES ### =========================== - please check phenytoin trough in two days (___) with target = ___. - please check electrolytes on ___ and ___. replete K to 4, phos to 3, and Mg to 2 - please maintain systolic blood pressure above 110 to help with perfusion since she had a stroke, if persistently below 110, please hold antihypertensives until pressures can tolerate these medications - please continue HD MWF - please avoid haloperidol since this decreases the seizure threshould

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Tape ___ Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ___ PROCEDURE: Exploratory laparotomy, lysis of adhesions (Dr. ___ History of Present Illness: Mr. ___ is a ___ male with PMH most notable for ESRD due to polycystic kidney disease s/p deceased donor renal transplant on ___ ___. His early post-transplant course was complicated by acute cellular rejection within 2 months and a humoral rejection response about 8 months later, as well as BK nephropathy. He has been doing quite well in this regard since then, however, with stable renal function and a stable regimen of Prograf, prednisone and azathioprine. His PMH/PSH is also notable for b/l inguinal hernia repairs in ___, with the left side presenting as an incarcerated SBO, not requiring any bowel resection. He presented to the ED ___ complaining of sudden-onset diffuse crampy abdominal pain since the previous evening, which had been waxing and waning,with +nausea and emesis x 1 (non-bloody/non-bilious). He reported no longer passing any flatus since this pain began. His last bowel movement was the morning of ___, reportedly much smaller than his usual, with no blood/mucus. He reports no fevers/chills, no CP/SOB, no dysphagia. An NGT was placed in ED with return of ~400cc of light green fluid, and a small degree of relief reported by the patient thereafter. Past Medical History: Past Medical History: ESRD from polycystic kidney disease s/p renal transplant in ___, BK nephropathy, HTN, gout, BPH, osteoporosis Past Surgical History: lap-assisted PD catheter placement ___ - Dr. ___, removal and replacement of infected PD cathether ___ - Dr. ___, L inguinal hernia repair ___ - Dr. ___, R inguinal hernia repair ___ - Dr. ___, deceased donor renal transplant ___ - Dr. ___, removal of PD catheter ___ - Dr. ___ Social History: ___ Family History: No family history of DVT or PE. No family history of kidney disease. Father died at ___ related to progressive dementia. Mother died at ___, had colon cancer in ___. Two sisters and a brother who are all in good health. Physical Exam: Exam on admission: Vitals: 98.8 56 136/89 18 100%RA GEN: oriented x3, calm,cooperative HEENT: No scleral icterus CV: RRR, No M/G/R PULM: Clear to auscultation b/l ABD: Soft, mildly distended, mildly tender to deep palpation in epigastrium>LUQ>LLQ, no rebound/rigidity/guarding, no palpable masses, small umbilical hernia with ~2-cm palpable defect and protrusion of easily reducible fat contents, well-healed old surgical scars Ext: No ___ edema/cyanosis/clubbing Exam on discharge: VS: 98.3 50 145/98 18 100RA Gen: AAOx3, pleasant and cooperative CV: Regular Pulm: Clear Abd: Soft, nondistended, with appropriate local incisional tenderness. Incision clean and dry with minimal staple erythema, stable over the past two days. Well healed prior surgical scars. Ext: Warm, no edema. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Tacrolimus 3 mg PO Q12H 2. PredniSONE 2.5 mg PO DAILY 3. Azathioprine 50 mg PO DAILY 4. Amlodipine 5 mg PO DAILY 5. Enalapril Maleate 20 mg PO DAILY 6. Furosemide 20 mg PO DAILY:PRN edema 7. Tamsulosin 0.4 mg PO HS 8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 9. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Frequency is Unknown Discharge Medications: 1. Amlodipine 5 mg PO DAILY 2. Azathioprine 50 mg PO DAILY 3. Enalapril Maleate 20 mg PO DAILY 4. PredniSONE 2.5 mg PO DAILY 5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 6. Prograf (tacrolimus) 2 mg oral Q12 7. Tamsulosin 0.4 mg PO HS 8. Acetaminophen 1000 mg PO Q8H:PRN pain do not take more than 3000mg per day 9. Docusate Sodium 100 mg PO BID decrease or stop if frequent stool or diarrhea RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 10. Metoprolol Tartrate 12.5 mg PO BID RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*4 11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 12. Senna 8.6 mg PO BID:PRN constipation RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*60 Tablet Refills:*0 13. Furosemide 20 mg PO DAILY:PRN edema as directed by your nephrologist Discharge Disposition: Home Discharge Diagnosis: Small-bowel obstruction. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: History of small bowel obstruction with multiple hernias presenting with sudden onset abdominal pain and obstipation, rule out obstruction or free air. COMPARISON: CT torso dated ___. FINDINGS: Frontal upright and supine radiographs of the abdomen were obtained. An NG tube is present with the tip in the left upper quadrant. Dilatd loops of small bowel are seen in the left upper quadrant. There are other multiple scattered air-fluid levels seen on the upright exam in this region as well as in the right lower quadrant. Calcifications bilaterally, which are coarse, curvilinear corresponding to calcifications within renal cyst seen on prior CT. Leftward curvature of the lumbar spine is noted. No free intraperitoneal air is identified. A surgical clip projects over the left femoral head. IMPRESSION: 1. Slighty dilated loops of small bowel with air fluid levels in the left upper quadrant raising possibility of obstruction. CT scan had already been ordered at time of interpretation to further assess. 2. Extensive calcifications bilaterally corresponding to calcifications within renal cysts as seen on prior CT. Radiology Report INDICATION: Possible small-bowel obstruction seen on the KUB. Has a history of a renal transplant in the left lower quadrant. COMPARISONS: CT of the torso from ___. TECHNIQUE: Contiguous axial MDCT images were obtained through the abdomen and pelvis after the administration of oral contrast only. Sagittal and coronal reformatted images were obtained and reviewed. TOTAL DLP: 701.96 mGy-cm. FINDINGS: LUNG BASES: There is dependent bibasilar atelectasis, worse on the left than the right. There is no discrete nodule, consolidations, or pleural effusion. The base of the heart is normal in size. Trace pericardial fluid is within the normal physiologic range. ABDOMEN: The liver is normal in size with multiple hypodensities, consistent with cysts. Several of these cysts have calcifications. One of the cysts right lobe of the liver (2, 12) has become more calcified since the prior exam. The remainder of the cysts are grossly stable. There is no intra- or extra-hepatic biliary duct dilation. The gallbladder, spleen, pancreas, and adrenal glands are normal. The native kidneys are enlarged with innumerable small and large cysts, many of which have peripheral calcifications. The largest on the right measures 13.2 cm and is slightly hyperdense, and likely a hemorrhagic or proteinaceous cyst. These are poorly characterized without intravenous contrast. An NG tube is present with the tip in the stomach. The jejunum, and probably proximal loops of the ileum, and mildly dilated measuring up to 3.3 cm. There is oral contrast throughout the proximal loops, which then becomes diluted. In the left mid abdomen, there is evidence of fecalized material, and a gradual change in caliber in the bowel dilation (2, 59 and 601b, 20) with completel distal decompression. This is consistent with a small bowel obstruction. The loops proximal to transition do not demonstrate wall thickening or pneumatosis. The bowel wall enhances homogeneously. There is a small amount of fluid in the mesentery, as well as in the left abdomen. The distal loops are completely collapsed. The colon is also mostly collapsed. The abdominal vasculature is normal in caliber with moderate atherosclerotic calcifications. There is no mesenteric, retroperitoneal, or periportal lymphadenopathy. PELVIS: There is diverticulosis without evidence of diverticulitis. The large bowel is mostly collapsed. The appendix is not definitely visualized, though there are no secondary signs of appendicitis in the right lower quadrant. There is a small amount of fluid and stranding along the left paracolic gutter. Additionally, there is a small amount of free fluid in the pelvis. The bladder and prostate are unremarkable. There is no pelvic or inguinal lymphadenopathy. In the left lower quadrant, there is a transplanted kidney, which is similar in appearance to the prior exam. There is no hydronephrosis or evidence of a renal mass. There is no perinephric fluid collection. Again, there is a left inguinal hernia, which contains fluid. Overall, the amount of fluid in the hernia appears to have decreased since the prior exam in ___. OSSEOUS STRUCTURES: There are no concerning lytic or sclerotic osseous lesions. No fracture is identified. Bilateral L5 spondylolysis is seen. Anterolisthesis of L5 on S1 has progressed since the prior exam. Other moderate multilevel degenerative changes in the spine are unchanged. IMPRESSION: 1. Small bowel obstruction with a gradual transition point in the left mid abdomen. There is complete collapse of the distal small bowel loops. There is no bowel wall thickening, pneumatosis or free air. There is a small amount of nonspecific fluid around the dilated loops of bowel, in the left paracolic gutter, and layering in the pelvis. 2. Polycystic kidney and liver disease, grossly similar to the prior exam. These cysts are incompletely characterized without intravenous contrast. 3. Normal appearance of the transplanted kidney without hydronephrosis. 4. Fluid-containing left inguinal hernia. 5. Diverticulosis without diverticulitis. 6. Interval worsening of the anterolisthesis of L5 on S1. Changes to the wet read were discussed with Dr. ___ at 8:30 ___ on ___ via telephone by Dr. ___. Radiology Report INDICATION: Abdominal pain. Evaluate for cholecystitis. COMPARISONS: CT of the abdomen from ___, obtained immediately prior to this ultrasound. TECHNIQUE: Grayscale and Doppler ultrasound images were acquired through the upper quadrants. FINDINGS: The liver is normal in shape and contour. There are innumerable cysts throughout the liver, compatible with polycystic liver disease. These are better characterized on the CT. The largest is in the right lobe and measures 6.2 cm. The hepatic parenchyma between the cysts demonstrates normal echogenicity. The main portal vein is patent with normal hepatopetal flow. There is no intra- or extra-hepatic biliary duct dilation. The intra-hepatic common bile duct measures 6 mm. In the proximal extra-hepatic region, there is mild prominence of the duct, up to 8 mm, though it tapers smoothly. No filling defect is identified. The gallbladder is not distended. There are two echogenic foci, which are not definitely mobile or shadowing. These likely represent two polyps. There are no definite stones or sludge. There is no gallbladder wall thickening or pericholecystic fluid to suggest cholecystitis. The pancreas is not well evaluated due to overlying bowel gas. The spleen is somewhat distorted by the adjacent polycystic kidneys, so appears elongated, though is likely normal in size. Limited views of the kidneys demonstrate multiple cysts, again better characterized on the CT. The largest is exophytic off the right upper pole and measures 11.1 x 10.6 x 9.9 cm. There are diffuse low-level echoes throughout this cyst, suggesting the cyst is hemorrhagic or proteinaceous. There is no nodularity or internal flow. IMPRESSION: 1. Two sub-5-mm gallbladder polyps. No definite stones. No cholecystitis. 2. Polycystic liver and kidney disease, better characterized on the concurrent CT. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abd pain Diagnosed with INTESTINAL OBSTRUCT NOS temperature: 98.8 heartrate: 56.0 resprate: 18.0 o2sat: 100.0 sbp: 136.0 dbp: 89.0 level of pain: 8 level of acuity: 3.0

Mr. ___ was evaluated by the transplant surgery team in the ED after initially presenting with abdominal pain, nausea, and emesis. In the setting of several prior abdominal operations, his history, exam, and CT were concerning for small bowel obstruction with transition point in the left-mid abdomen. He was admitted to the transplant service for NG decompression, IV hydration, and serial abdominal exams. On ___, Mr. ___ developed acute, severe abdominal pain and was taken to the operating room for exploratory laparotomy and lysis of adhesions. No definitive transition point was identified. Post-operatively, Mr. ___ recovered well. He was ambulatory on ___, and the NG tube was removed on ___. Bowel function returned on ___, and his diet was subsequently advanced, which Mr. ___ tolerated without difficulty. As he was moderately hypertensive, home enalapril and amlodipine were restarted ___ when he was able to take oral medications. When hypertension to SBP 160s persisted, metoprolol 12.5 BID was started on ___ - this was a former home medication - with good effect. Of note, his tacrolimus dose was decreased from his home regimen of ___ to ___ after a trough of 14.5 on ___. He will continue on this lower dose until his next lab draw on ___ and subsequent follow up with Dr. ___. On ___, Mr. ___ was ambulatory, tolerating a regular diet, and with improved blood pressure control on oral medication (as above). His incision was healing well and he was otherwise without complaint. He was deemed stable for discharge to home with follow up both in the transplant surgery clinic post-operatively and with his primary care provider for blood pressure management. He will also follow up with Dr. ___ as scheduled. He was advised to call the clinic or return to the ED with any recurrent obstructive symptoms, fever, or sign of wound infection. Mr. ___ understood these instructions and agreed with the plan. He was discharged to home on ___ in good condition.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: mechanical fall with head strike Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a ___ with history of hepatitis C, CKD, anemia, on anticoagulation for mechanical AVR/MVR who was admitted after mechanical fall with head strike on ___ and finding of small left insular SAH with small IVH component. At that time INR was 3.3. She was admitted to Neurosurgery and coumadin was held without being actively reversed (approved by cardiology consult). Serial NCHCTs were done which were stable until ___ when there was evidence of a small intraparenchymal hemorrhagic contusion along with the SAH. This was felt to be a normal sequelae of her head strike. She was transferred to the medicine service on ___. Her INR that day was 1.8 and she was started on a heparin gtt with 2900unit bolus as a bridge to coumadin given her mechanical valves. Both the heparin with bolus was approved by the neurosurgical team. The night of ___, she had one recorded elevated PTT to 140s, but subsequent PTTs were in the goal range of 60-80. That day she was also transfused 1 unit PRBC for anemia. The following day ___, her heparin gtt was transitioned to lovenox 30mg SQ given the plan to discharge her home. Prior to discharge, she was noted to be lethargic. Around 130pm, she was even more lethargic and with slurred speech. NCHCT was done at 3pm which showed increasing left temporoparietal hemorrhage, SAH, and mass effect on the left lateral ventricle. Stroke neurology saw the patient urgently and found her hypertensive to 190s/100s, lethargic yet responsive with a right facial droop, left gaze preference, right sided weakness (right arm ___, and right leg ___, bilateral upgoing toes. She was urgently treated with Hydralazine and Labetalol IV doses while urgently transfering to the NICU under the Neurology service. BP was controlled (SBP<150) with a nicardipine gtt. No active reversal was needed as INR was 1.1 and PTT was 34. Serial NCHCTs were done to reevaluate her IPH and SAH. All anticoagulants were stopped. Over several days, her exam improved, she became more attentive, with no gaze preference, and improved strength on the right. On ___, she was transferred to the floor. However she desaturated upon lying flat to the ___ and was placed on a non-rebreather. Pulmonology performed an ultrasound which showed atelectasis in the left lung, extensive, as seen on chest x ray in the morning (likely due to mucus plugging). She was transferred to the unit. She was given incentive spirometry and did well, by the end of the day she was saturating well on 3L nasal cannula. By ___, her chest x ray was improved and she saturated well on room air. She was then transferred back to the floor. Past Medical History: Depression Anemia Alcohol abuse Atrophic vaginitis AVR (19mm Regent) and MVR (27mm St ___ on ___ on warfarin Hepatitis C Herpes simplex Hypertension Migraine headaches S/p hysterectomy Tobacco abuse History of postive RPR History of microhemorrhages presenting as CVA ___, managed at ___ Social History: ___ Family History: Mom had breast cancer in her ___. No h/o abdominal/GI diseases. Family h/o DM (brother, uncle, grandmother). Physical Exam: Upon admission: O: T:98.2 BP: 161/88 HR:77 R 18 O2Sats 100% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 4-3mm EOMs intact 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. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4 to 3 mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Intact to light touch ***** Pertinent Results: ADMISSION LABS: ___ 04:30PM BLOOD WBC-4.2 RBC-3.32* Hgb-9.3* Hct-30.1* MCV-91 MCH-28.0 MCHC-31.0 RDW-15.4 Plt ___ ___ 04:30PM BLOOD Neuts-57.2 ___ Monos-7.0 Eos-1.6 Baso-1.3 ___ 10:00AM BLOOD ___ ___ 04:45PM BLOOD Glucose-107* UreaN-52* Creat-2.9* Na-131* K-6.4* Cl-103 HCO3-19* AnGap-15 ___ 11:20PM BLOOD ALT-50* AST-62* LD(LDH)-253* CK(CPK)-44 AlkPhos-54 TotBili-0.2 ___ 11:20PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 09:15PM BLOOD Calcium-8.6 Phos-4.4 Mg-2.4 ___ 04:40AM BLOOD Hapto-<5* ___ 02:15PM BLOOD TSH-6.3* ___ 02:15PM BLOOD T4-6.1 ___ 02:29PM BLOOD Type-ART pO2-122* pCO2-32* pH-7.43 calTCO2-22 Base XS--1 ___ 07:09PM BLOOD K-5.9* DISCHARGE LABS: ___ 06:05AM BLOOD WBC-6.1 RBC-2.40* Hgb-7.1* Hct-22.5* MCV-94 MCH-29.6 MCHC-31.5 RDW-17.4* Plt ___ ___ 06:05AM BLOOD ___ PTT-82.1* ___ ___ 06:05AM BLOOD Glucose-108* UreaN-43* Creat-1.5* Na-137 K-4.9 Cl-113* HCO3-19* AnGap-10 ___ 06:05AM BLOOD Calcium-9.6 Phos-5.1* Mg-2.2 REPORTS: Non-Contrast Head CT (___) ___: IMPRESSION: 1. Small amount of subarachnoid hemorrhage in the left insular region. 2. Small amount of intraventricular hemorrhage in the right lateral ventricle. No hydrocephalus. 3. No mass effect. Stable ventriculomegaly. CT C-spine ___: IMPRESSION: No acute fracture or malalignment of the cervical spine. Repeat NCHCT ___: IMPRESSION: Stable left insular region subarachnoid hemorrhage as well as a small amount of intraventricular hemorrhage in the right lateral ventricle. TTE ___: Conclusions The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. A mechanical aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. [The amount of regurgitation present is normal for this prosthetic aortic valve.] A mechanical mitral valve prosthesis is present. The mitral prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. The degree of mitral regurgitation seen is normal for this prosthesis. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of ___ the estimated pulmonary artery pressure is lower. There is slightly more pulmonic regurgitation. Other findings are similar. ___ ___: IMPRESSION: Interval development of likely focus of parenchymal hemorrhage, subjacent to the sites of subarachnoid hemorrhage along the left sylvian fissure, compatible with hemorrhagic contusions. Associated mild peripheral edema is seen about these foci of hemorrhage but there is no evidence of mass effect. Left Hip US ___: IMPRESSION: Soft tissue swelling overlying the left hip, with no significant hematoma identified. NCHCT ___: IMPRESSION: No significant change since the previous exam in subarachnoid hemorrhage in the left sylvian fissure and two adjacent foci of intraparenchymal hemorrhage. NCHCT ___: IMPRESSION: Significant increase in size of a left temporoparietal intraparenchymal hemorrhage with increase in subarachnoid hemorrhage involving the left frontal sulci compared to the recent prior exam. There is now increasing mass effect on the left lateral ventricle which is compressed. EKG ___: Sinus rhythm. Possible left atrial abnormality. Possible septal infarction of indeterminate age. Prominent precordial voltage. Non-specific ST-T wave abnormalities may represent strain. Cannot rule out ischemia. Suggest clinical correlation. Compared to the previous tracing of ___ ST-T wave abnormalities are more marked, including J point ST segment elevation in leads VI-V2. Suggest clinical correlation and repeat tracing. ___ ___: IMPRESSION: No significant change in left frontotemporoparietal intraparenchymal hemorrhage, centered in the external capsule, with subarachnoid blood layering within the sylvian fissure and adjacent frontal sulci with unchanged degree of mass effect, effacing the left lateral ventricle. Additional punctate focus of hemorrhage in the left anterior frontal cortex measuring 4 mm is unchanged. No new focus of hemorrhage or infarct. NCHCT ___: IMPRESSION: In comparison to ___ exam, there is no interval change in known left intraparenchymal hemorrhage, as described above. There is surrounding vasogenic edema and mass effect on the left lateral ventricle without significant mass effect. Subarachnoid hemorrhage layering in the sylvian fissure and the left sylvian fissure is unchanged. No new focus of intracranial hemorrhage. CXR ___: IMPRESSION: AP chest compared to more ___: Severe opacification in the left hemithorax is new. The abnormality obscures much of the left lower lung. I cannot tell whether it is pulmonary alone or combination of pulmonary and pleural abnormality. This could be a large pneumonia or a left lower lobe collapse as well as substantial left pleural effusion, most likely hemothorax in this patient. I discussed these findings by telephone with Dr. ___ clinical profile suggests acute lobar collapse. Imaging confirmation can be provided by chest CT scanning if appropriate. Mild pulmonary vascular congestion suggests elevated left atrial pressure. Patient has had median sternotomy and two cardiac valve replacements. There is no pulmonary edema. CXR ___: Cardiomediastinal silhouette including the two replaced valves is stable. The assessment of the left lung demonstrates opacification of the mid and lower lung, unchanged since the prior study and concerning for interval development of infectious process given the absence of the findings on ___. Aspiration or non-aspiration pneumonia are both a possibility. Combination of pleural effusion and lobe collapse should be considered, but the normal pattern of the airways would make the collapse less likely. CXR ___: IMPRESSION: AP chest compared to ___: Some volume loss has developed in the very large consolidation in the left lower lobe, probably due to aspiration pneumonia and some airway obstruction due to retained secretions. Right lung clear. Heart size top normal. The patient has had aortic and mitral valve replacements. No pneumothorax. There is some pleural effusion on the left, but not substantial. CT ABD/PELVIS ___: IMPRESSION: 1. Limited assessment due to lack of IV contrast. No definite mass is identified within the abdomen or pelvis. 2. Small amount of free fluid within the abdomen and pelvis. 3. 5mm non-obstructing stones in the lower pole of the left kidney. CT HEAD ___: IMPRESSION: Mild interval decrease in size of large left intraparenchymal hemorrhage in comparison to the most recent prior noncontrast head CT of ___ with unchanged extent of subarachnoid hemorrhage in the left sylvian fissure. Similar minimal left-to-right midline shift. CT CHEST ___: IMPRESSION: The opacity in the left lung with ground-glass and consolidative component likely reflects pneumonia or aspiration. No other lung parenchymal abnormalities. No evidence of chronic airways disease or pleural effusion. Status post CABG and bivalvular replacement. NCHCT ___: IMPRESSION: Interval stability in size and morphology of the left intraparenchymal hematoma involving the left frontal and left temporal parietal regions, compared to ___. Slight increase in surrounding vasogenic edema but unchanged mild rightward midline shift and partial effacement of the left lateral ventricle. No evidence of new intracranial hemorrhage. EKG ___: Sinus rhythm. Left atrial abnormality. Delayed R wave progression in the precordial leads. Cannot exclude prior anteroseptal myocardial infarction. Prominent voltage and prominent T waves in the precordial leads. Cannot exclude myocardial ischemia versus metabolic abnormalities, particularly hyperkalemia. Compared to the previous tracing of ___ prominent T waves are new. Consider evaluation for hyperkalemia. CXR ___: FINDINGS: As compared to the previous radiograph, the pre-existing left lower lobe pneumonia has almost completely cleared. Only a small retrocardiac opacity still persists. The pre-existing elevation of the hemidiaphragm on the left is improved as compared to the previous image. No pleural effusion. Unchanged appearance of the right lung and of the cardiac silhouette. ___ ___: IMPRESSION: Large left intraparenchymal hemorrhage is unchanged in appearance from CT on ___. No no evidence of hemorrhage or infarction. ___ ___: IMPRESSION: Stable appearance of large left intraparenchymal hemorrhage and associated mass effect. Portable Abdominal XRay ___: FINDINGS: No free intra-abdominal air. Several foreign bodies, obviously clothing, project over the mid abdomen. Moderately distended stomach. Stool in the rectal ampulla as well as in the descending colon. Gas filling of the remaining intestinal component, without evidence of distention or air-fluid levels. No evidence of wall thickening. ___ ___: Large left intraparenchymal hemorrhage with associated mass effect is largely unchanged from the prior study. CXR ___: IMPRESSION: Resolution of left lower lobe pneumonia with no evidence of a new infectious process. ___ ___: IMPRESSION: Stable appearance of the evolving hematoma compared with ___. No significant new abnormalities are seen. Microbiology: UCx from ___ - **FINAL REPORT ___ URINE CULTURE (Final ___: ENTEROBACTER AEROGENES. >100,000 ORGANISMS/ML.. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROBACTER AEROGENES | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 10 mg PO DAILY 2. BuPROPion 150 mg PO BID 3. FoLIC Acid 1 mg PO DAILY 4. LOPERamide 2 mg PO QID:PRN diarrhea 5. Metoprolol Tartrate 100 mg PO BID 6. Mirtazapine 45 mg PO HS 7. Omeprazole 20 mg PO DAILY 8. TraZODone 200 mg PO HS 9. Warfarin 7.5 mg PO DAILY16 10. Multivitamins 1 TAB PO DAILY 11. Thiamine 100 mg PO DAILY Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. BuPROPion 150 mg PO BID 3. FoLIC Acid 1 mg PO DAILY 4. Metoprolol Tartrate 100 mg PO BID 5. Mirtazapine 45 mg PO HS 6. Multivitamins 1 TAB PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Thiamine 100 mg PO DAILY 9. TraZODone 100 mg PO HS:PRN insomnia 10. Warfarin 7.5 mg PO DAILY16 11. Lidocaine 5% Patch 1 PTCH TD QAM 12. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB 13. Acetaminophen 325-650 mg PO Q6H:PRN pain 14. Nimodipine 60 mg PO Q4H 15. Heparin IV No Initial Bolus Initial Infusion Rate: 575 units/hr Goal PTT 50-70. STOP heparin once INR is between 2.5-3.5. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: primary diagnosis: traumatic ___ intraventricular hemorrhage 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 COMPUTED TOMOGRAPHY OF THE THORAX INDICATION: Hemorrhagic contusion, evaluation for malignant disease. COMPARISON: No comparison available at the time of dictation. TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration, no administration of intravenous contrast material, multiplanar reconstructions. FINDINGS: No incidental thyroid findings. No supraclavicular, infraclavicular or axillary lymphadenopathy. All visible lymph nodes are normal in size. Status post CABG with massive aortic wall calcifications, borderline diameter of the pulmonary artery and replacement of the aortic valve as well as CABG. The mitral valve is also replaced. No pericardial effusion. Unremarkable posterior mediastinum. No relevant abnormalities in the upper abdomen. The vertebral body show moderate degenerative changes. Status post sternotomy. No evidence of rib lesions. Mild respiratory motion artifacts. Mild centrilobular pulmonary emphysema. Predominating in the left lower lobe and at the posterior aspect of the lingula is a parenchymal opacity with mixed ground-glass and consolidation components. The opacity shows multiple air bronchograms. Similar opacities are found in the right upper lobe. No other parenchymal abnormalities are seen. The airways are patent. No pulmonary nodules. No evidence of pulmonary malignancy. Minimal dorsal atelectasis, but no evidence of pleural effusions. No pathologic pleural thickening. IMPRESSION: The opacity in the left lung with ground-glass and consolidative component likely reflects pneumonia or aspiration. No other lung parenchymal abnormalities. No evidence of chronic airways disease or pleural effusion. Status post CABG and bivalvular replacement. At the time of dictation and observation, 2:33 p.m., on the ___, the referring physician, ___, was contacted by telephone, without success. Therefore, the findings were communicated by E-mail at the same time point. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old woman with hemorrhagic stroke // Assess for interval change in bleed size TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain, intermediate and bone windows. Coronal and sagittal reformats were also performed. DOSE: DLP: 891.93 mGy-cm CTDI: 55.20 mGy COMPARISON: CT head without contrast ___. FINDINGS: Again seen is a large left intraparenchymal hematoma involving the left frontal and left temporoparietal regions. The morphology and extension of hemorrhage is not significantly changed compared to prior study of ___, however there is slightly increased surrounding hypodensity. The degree of vasogenic edema appears slightly more extensive, with unchanged partially effaced of the left lateral ventricle. Trace left sylvian fissure subarachnoid hemorrhage is stable. There is no evidence of new intracranial hemorrhage. Mild 1-2 mm rightward midline shift is stable. Otherwise, examination is unchanged. The sulci and ventricles are unchanged in size and configuration. There is no evidence of uncal or tonsillar herniation. The basal cisterns are adequately patent. The orbits and soft tissues are grossly unremarkable. The paranasal sinuses and mastoid air cells are clear. The bony calvaria appears intact. IMPRESSION: Interval stability in size and morphology of the left intraparenchymal hematoma involving the left frontal and left temporal parietal regions, compared to ___. Slight increase in surrounding vasogenic edema but unchanged mild rightward midline shift and partial effacement of the left lateral ventricle. No evidence of new intracranial hemorrhage. Radiology Report CHEST RADIOGRAPH INDICATION: Fever, hemorrhagic stroke, evaluation for pneumonia. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, the pre-existing left lower lobe pneumonia has almost completely cleared. Only a small retrocardiac opacity still persists. The pre-existing elevation of the hemidiaphragm on the left is improved as compared to the previous image. No pleural effusion. Unchanged appearance of the right lung and of the cardiac silhouette. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old woman with left IPH // evaluate for extension of bleed TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without the administration of IV contrast. Reformatted coronal, sagittal and thin section bone algorithm-reconstructed images were then generated. DOSE: DLP: 780.4 CTDI: 54.32 COMPARISON: PET-CT scan ___ FINDINGS: A left intraparenchymal hemorrhage which involves the frontal and temporoparietal regions is unchanged in size from ___. Trace subarachnoid hemorrhage along the left sylvian fissure is unchanged. There is persistent vasogenic edema and mass effect with effacement of the left lateral ventricle. Minimal left-to-right shift of normally midline structures is not significantly changed from the prior study. There is no new focus of intracranial hemorrhage or vascular territorial infarction. The basal cisterns appear patent. The sulci and ventricles are unchanged in size and configuration. The paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The globes are unremarkable. IMPRESSION: Large left intraparenchymal hemorrhage is unchanged in appearance from CT on ___. No no evidence of hemorrhage or infarction. Radiology Report HISTORY: Left intraparenchymal hemorrhage. COMPARISON: Multiple prior head CTs, most recently of ___. TECHNIQUE: Contiguous axial MDCT sections were obtained through the brain without administration of IV contrast. Coronal and sagittal reformations, and thin slice bone algorithm reconstructions were reviewed. CTDIvol: 54 mGy. DLP: 829 mGy-cm. FINDINGS: Intraparenchymal hemorrhage involving the left frontal and temporoparietal lobes is similar in extent to ___, and may be slightly less dense. The hemorrhagic component involving the left frontal lobe measures 26 x 17 mm, previously 28 x 15 mm. Edema surrounding the intraparenchymal hemorrhage is similar in extent to prior. Small subarachnoid blood products within the left sylvian fissure are similar to prior. Rightward shift of the normally midline structures, and mass effect on the left midbrain and left lateral ventricle, with dilatation of the right lateral ventricle, are unchanged. No evidence of large acute territorial infarction. No focal osseous abnormalities are identified. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. IMPRESSION: Stable appearance of large left intraparenchymal hemorrhage and associated mass effect. Radiology Report ABDOMEN INDICATION: Pain, evaluation for acute process. COMPARISON: No direct comparison available. FINDINGS: No free intra-abdominal air. Several foreign bodies, obviously clothing, project over the mid abdomen. Moderately distended stomach. Stool in the rectal ampulla as well as in the descending colon. Gas filling of the remaining intestinal component, without evidence of distention or air-fluid levels. No evidence of wall thickening. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old woman with iPh // Eval for stability of the bleed TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without the administration of IV contrast. Reformatted coronal, sagittal and thin section bone algorithm-reconstructed images were then generated. DOSE: DLP: 780.44 mGy-cm CTDI: 53.84 COMPARISON: CT of the head on ___ FINDINGS: An intraparenchymal hemorrhage involving the left frontal and temporoparietal lobes is similar in extent to ___. The overall attenuation of the lesion is slightly less, but largely unchanged from the prior study. There is associated vasogenic edema with narrowing of the left lateral ventricle, unchanged in appearance. Calcifications within the left basal ganglia are unchanged. There is no evidence of large acute territorial infarction. The visualized osseous structures are unchanged with no abnormalities identified. The paranasal sinuses, mastoid air cells and middle ear cavities are clear. Atherosclerotic mural calcifications of the internal carotid arteries are noted. IMPRESSION: Large left intraparenchymal hemorrhage with associated mass effect is largely unchanged from the prior study. Radiology Report HISTORY: Intraparenchymal hemorrhage, evaluation for pneumonia. COMPARISON: Chest radiograph from ___. FINDINGS: Previously noted left basilar opacity has continued to improve with minimal left basilar atelectasis persisting. No new consolidations are identified. Cardiac and mediastinal contours appear stable. No acute fractures are identified. IMPRESSION: Resolution of left lower lobe pneumonia with no evidence of a new infectious process. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old woman with left IPH // ASSESS size of bleed (on anticoagulation now) TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain, intermediate and bone windows. Coronal and sagittal reformats were also performed. DOSE: DLP: ___ MGy-cm COMPARISON: ___. FINDINGS: There is no significant interval change. Involving the left cerebral hemispheric hematoma and surrounding edema again seen. Mass effect on the left lateral ventricle and dilatation of the right lateral ventricle again seen. There is no new area of hemorrhage. IMPRESSION: Stable appearance of the evolving hematoma compared with ___. No significant new abnormalities are seen. Radiology Report INDICATION: Fall while on Coumadin. TECHNIQUE: Contiguous axial images were obtained through the brain without IV contrast. Coronal, sagittal, and thin-section bone reconstruction algorithm images were prepared. COMPARISON: NECT of the head, ___ and ___. FINDINGS: There is new subarachnoid hemorrhage in the left insular region extending into the Sylvian fissure (2:15). There is also small amount of hemorrhage in the atria of the right lateral ventricle (2:14). Prominence of the ventricles and sulci are stable from ___ and are most consistent with global atrophy. The basal cisterns are patent and gray-white matter differentiation is preserved. There is no fracture. The globes are intact. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. IMPRESSION: 1. Small amount of subarachnoid hemorrhage in the left insular region. 2. Small amount of intraventricular hemorrhage in the right lateral ventricle. No hydrocephalus. 3. No mass effect. Stable ventriculomegaly. Radiology Report INDICATION: Fall with head trauma and subarachnoid hemorrhage. Evaluation for fracture. TECHNIQUE: MDCT images were obtained from the skull base to the T3 level. Coronal and sagittal reformations were prepared. COMPARISON: None. FINDINGS: There is no fracture or malalignment of the cervical spine. The atlanto-occipital/axial articulations are intact. There are mild multilevel degenerative changes throughout the cervical spine. There is no prevertebral soft tissue edema. There is no cervical lymphadenopathy. The thyroid gland is unremarkable. The visualized lung apices are noteworthy only for centrilobular and paraseptal emphysema. IMPRESSION: No acute fracture or malalignment of the cervical spine. Radiology Report INDICATION: Subarachnoid hemorrhage and intraventricular hemorrhage after a fall, on Coumadin. Followup NECT. TECHNIQUE: Contiguous axial images were obtained through the brain without IV contrast. Contiguous axial images were obtained through the brain without IV contrast. Coronal, sagittal and thin section bone reconstruction algorithm images were prepared. COMPARISON: NECT of the head from 14:48 on ___. FINDINGS: Subarachnoid hemorrhage within the left insular region extends slightly into the sylvian fissure and is stable from NECT of the head from three hours ago. A small amount of intraventricular hemorrhage in the atrium of the right lateral ventricle is also stable. Ventriculomegaly is unchanged and there is no evidence of obstructive hydrocephalus. The ventricles and sulci are prominent, consistent with global atrophy. The basal cisterns are patent and gray-white matter differentiation is preserved. There is no fracture. The visualized paranasal sinuses, mastoid air cells and middle ear cavities are clear. IMPRESSION: Stable left insular region subarachnoid hemorrhage as well as a small amount of intraventricular hemorrhage in the right lateral ventricle. Radiology Report INDICATION: ___ female with subarachnoid hemorrhage, on treatment with Coumadin. Evaluate for progression. COMPARISON: Head CT performed approximately 15 hours prior to this exam as well as admission head CT performed on ___. TECHNIQUE: Contiguous axial MDCT images were obtained through the head without administration of IV contrast. Coronal, sagittal and thin slice bone reformats were generated. DLP: 892 mGy-cm. CTDI: 54.98 mGy. FINDINGS: Compared with prior examination, there has been development of lobulated appearing foci of hemorrhage subjacent to the sulcal subarachnoid blood in the Sylvian fissure compatible with hemorrhagic contusions in the setting of trauma. The two main foci measure 1.5 x 1.0 cm (2:16) and 1.4 x 0.9 cm (2:14) and show minimal peripheral edema, further confirming intraparenchymal location. Otherwise, there is no new area of hemorrhage, edema, mass, mass effect, or large territorial infarction. The ventricles and sulci are prominent, suggesting age-related involutional changes. Calcification of the bilateral basal ganglia is an incidental finding. There is preservation of gray-white matter differentiation and the basal cisterns are patent. No fracture is identified. The paranasal sinuses, mastoid air cells and middle ear cavities are clear. There is minimal atherosclerotic calcification of the carotid siphons. IMPRESSION: Interval development of likely focus of parenchymal hemorrhage, subjacent to the sites of subarachnoid hemorrhage along the left sylvian fissure, compatible with hemorrhagic contusions. Associated mild peripheral edema is seen about these foci of hemorrhage but there is no evidence of mass effect. COMMENT: These findings were communicated to Ms ___ by Dr. ___ on ___ at 9:20 a.m. via telephone, immediately after discovery. Radiology Report HISTORY: Status post fall with subarachnoid hemorrhage. Induration near left hip. COMPARISON: None. FINDINGS: There is soft tissue edema overlying the left hip. No left hip joint effusion is demonstrated. No fluid collection is identified. IMPRESSION: Soft tissue swelling overlying the left hip, with no significant hematoma identified. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old woman with Hep C, mechanical AVR and MVR here s/p fall found tohave SAH, heparin drip restarted ___ // interval change, increase in bleed; please get ___ AM TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain, intermediate and bone windows. Coronal and sagittal reformats were also performed. DOSE: DLP: 780 mGy-cm CTDI: 55.7 mGy COMPARISON: Multiple prior exams, most recently ct head from ___. FINDINGS: Compared to the prior exam, there has been no significant change. Again seen are two foci of intraparenchymal contusions within the left parietal region adjacent to the sylvian fissure measuring 13 x 10 mm (2:13) and 15 x 7 mm (2:10). Subarachnoid hemorrhage in the adjacent sulci are unchanged. There is no new intraparenchymal hemorrhage. Basal ganglia calcifications are noted. Ventricles and sulci remain prominent consistent with atrophy. The basilar cisterns are patent. The visualized paranasal sinuses, mastoid air cells and middle ear cavities are clear. The bones are unremarkable. IMPRESSION: No significant change since the previous exam in subarachnoid hemorrhage in the left sylvian fissure and two adjacent foci of intraparenchymal hemorrhage. Radiology Report INDICATION: ___ female with subarachnoid hemorrhage on mechanical valve, on Lovenox. With increased lethargy. Evaluate for bleed. COMPARISONS: CT head from ___ and ___ and ___. TECHNIQUE: MDCT axial imaging was obtained through the brain without the administration of intravenous contrast material. Coronal and sagittal reformats were completed. DLP: 780.4 mGy-cm. FINDINGS: Compared to the prior exam, there is no large increase in the intraparenchymal hemorrhage involving the left temporoparietal region measuring approximately 4.9 x 3.3 cm in maximal dimension. There is increased subarachnoid hemorrhage within the left frontal sulci (2:10). Edema surrounding the hemorrhage has increased significantly since the previous exam and there is now mass effect upon the left lateral ventricle which is compressed. The basilar cisterns are patent. The visualized paranasal sinuses, mastoid air cells and middle ear cavities are clear. Bones are intact and there is no acute fracture. IMPRESSION: Significant increase in size of a left temporoparietal intraparenchymal hemorrhage with increase in subarachnoid hemorrhage involving the left frontal sulci compared to the recent prior exam. There is now increasing mass effect on the left lateral ventricle which is compressed. These findings were discussed with ___ by Dr. ___ telephone at approximately 4:15 p.m. Radiology Report REASON FOR EXAMINATION: Evaluation of the patient after right subclavian central venous line insertion. Portable AP radiograph of the chest was reviewed in comparison to ___. The right central venous line tip is at the level of cavoatrial junction. The NG tube tip is in the stomach. The heart size and mediastinum as well as the replaced valve are in unchanged position. There is no evidence of pneumothorax or interval development of substantial pleural effusion. Minimal bibasilar atelectasis is noted. Radiology Report HISTORY: Left frontal intraparenchymal hemorrhage. COMPARISON: Non-contrast head CT ___, 3:40 p.m. TECHNIQUE: Contiguous axial MDCT images were obtained of the head without contrast. Multiplanar reformatted images were generated in the coronal and sagittal planes as well as thin section bone reformats. DLP: 780.44 mGy-cm. FINDINGS: CT HEAD WITHOUT CONTRAST: Compared to yesterday's examination, there is re-demonstration of a large left temporoparietal intraparenchymal hemorrhage measuring 4.9 x 3.3 cm appearing centered within the external capsule, overall unchanged in size with re-demonstration of a small amount of subarachnoid hemorrhage within the adjacent sylvian fissure and adjacent frontal sulci. Additional punctate hyperdense focus of hemorrhage in the anterior left frontal cortex (2:14) is unchanged. Associated mass effect with effacement of the left lateral ventricle is unchanged. There is no significant shift of midline structures. There is no new focus of hemorrhage or infarct. The basal cisterns remain patent. No fracture is identified. The visualized paranasal sinuses, mastoid air cells and middle ear cavities are clear. IMPRESSION: No significant change in left frontotemporoparietal intraparenchymal hemorrhage, centered in the external capsule, with subarachnoid blood layering within the sylvian fissure and adjacent frontal sulci with unchanged degree of mass effect, effacing the left lateral ventricle. Additional punctate focus of hemorrhage in the left anterior frontal cortex measuring 4 mm is unchanged. No new focus of hemorrhage or infarct. Radiology Report INDICATION: Patient with history of intraparenchymal subarachnoid hemorrhage. Assess for interval change. COMPARISONS: ___. TECHNIQUE: MDCT-acquired contiguous images through the head were obtained without intravenous contrast at 5 mm slice thickness. Coronally and sagittally reformatted images are provided. FINDINGS: There is a left intraparenchymal hemorrhage which involves frontal, and temporoparietal regions. It measures 5 x 3.1 cm in maximum dimension, unchanged in size. Subarachnoid hemorrhage layering along the sylvian fissures were demonstrated, unchanged. There is surrounding vasogenic edema and persistent mass effect with effacement of the left lateral ventricle. There is no shift of normally midline structures. No new focus of intracranial hemorrhage is detected. There is no vascular territorial infarction. The basal cisterns remain patent. There is no evidence of herniation. The sulci and ventricles are unchanged in size and configuration. Orbits are unremarkable. Imaged paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: In comparison to ___ exam, there is no interval change in known left intraparenchymal hemorrhage, as described above. There is surrounding vasogenic edema and mass effect on the left lateral ventricle without significant mass effect. Subarachnoid hemorrhage layering in the sylvian fissure and the left sylvian fissure is unchanged. No new focus of intracranial hemorrhage. Radiology Report AP CHEST 5:42 A.M. ON ___ HISTORY: ___ woman with hypoxia. IMPRESSION: AP chest compared to more ___: Severe opacification in the left hemithorax is new. The abnormality obscures much of the left lower lung. I cannot tell whether it is pulmonary alone or combination of pulmonary and pleural abnormality. This could be a large pneumonia or a left lower lobe collapse as well as substantial left pleural effusion, most likely hemothorax in this patient. I discussed these findings by telephone with Dr. ___ clinical profile suggests acute lobar collapse. Imaging confirmation can be provided by chest CT scanning if appropriate. Mild pulmonary vascular congestion suggests elevated left atrial pressure. Patient has had median sternotomy and two cardiac valve replacements. There is no pulmonary edema. Radiology Report REASON FOR EXAMINATION: Coarse breathing, suspected pneumonia. AP radiograph of the chest was reviewed in comparison to ___. Cardiomediastinal silhouette including the two replaced valves is stable. The assessment of the left lung demonstrates opacification of the mid and lower lung, unchanged since the prior study and concerning for interval development of infectious process given the absence of the findings on ___. Aspiration or non-aspiration pneumonia are both a possibility. Combination of pleural effusion and lobe collapse should be considered, but the normal pattern of the airways would make the collapse less likely. Radiology Report AP CHEST, 5:49 AM, ___ HISTORY: ___ woman after CVA. Readmitted for respiratory distress. IMPRESSION: AP chest compared to ___: Some volume loss has developed in the very large consolidation in the left lower lobe, probably due to aspiration pneumonia and some airway obstruction due to retained secretions. Right lung clear. Heart size top normal. The patient has had aortic and mitral valve replacements. No pneumothorax. There is some pleural effusion on the left, but not substantial. Radiology Report EXAMINATION: CT HEAD WITHOUT CONTRAST INDICATION: ___ year old woman with intraparenchymal hemorrhage; evaluate for progression // ___ year old woman with intraparenchymal hemorrhage; evaluate for progression TECHNIQUE: Contiguous axial images were obtained through the head without the administration of intravenous contrast. Coronal and sagittal reformatted images as well as thin section images in a bone window algorithm were generated and reviewed. DOSE: DLP: 892 mGy-cm; CTDI: 56 mGy COMPARISON: Non contrast head CT last performed on ___ with multiple prior head CTs dating back to ___. FINDINGS: HEAD CT: The left intraparenchymal hemorrhage which involves the frontal and temporoparietal regions is slightly decreased in size from ___, measuring 58 x 43 mm on sagittal imaging (previously 65 x 40 mm on a similar slice selection). Trace subarachnoid hemorrhage along the left sylvian fissure is unchanged. There is similar extent of surrounding vasogenic edema and persistent mass effect with effacement of the left lateral ventricle. There is minimal left-to-right shift of normally midline structures, which is not significantly changed. No new focus of intracranial hemorrhage is detected. There is no vascular territorial infarction. The basal cisterns remain patent. There is no evidence of herniation. The sulci and ventricles are unchanged in size and configuration. The orbits are unremarkable. The frontal sinuses are aplastic. The imaged paranasal sinuses, middle ear cavities and mastoid air cells are well aerated bilaterally. The bony calvaria appear intact. IMPRESSION: Mild interval decrease in size of large left intraparenchymal hemorrhage in comparison to the most recent prior noncontrast head CT of ___ with unchanged extent of subarachnoid hemorrhage in the left sylvian fissure. Similar minimal left-to-right midline shift. Radiology Report INDICATION: ___ year old woman with hemorrhagic contusion, now expanding; cachectic,malnourished, anemic, renal failure, evaluate for mass or malignancy. TECHNIQUE: Axial helical MDCT scan of the abdomen and pelvis were without the administration of IV contrast. Oral contrast was given. Coronal and axial reformatted images were also generated for review. DOSE: 382 mGy-cm COMPARISON: MRI abdomen from ___. FINDINGS: Assessment of the soft tissue structures and vasculature is somewhat limited without the administration of IV contrast. CT THORAX: Please see separate report from CT chest performed on the same day for discussion of findings within the thorax. LIVER: The liver is grossly unremarkable. There is no intrahepatic biliary duct dilatation. The gallbladder is unremarkable. PANCREAS: The pancreas does not demonstrate focal lesions, peripancreatic stranding or fluid collection. SPLEEN The spleen is homogeneous and normal in size. ADRENALS: The adrenal glands are unremarkable. KIDNEYS: The kidneys are grossly remarkable. A 5mm non-obstructing stone is seen in the lower pole of the left kidney. There is no hydronephrosis or perinephric abnormalities. GI TRACT: The stomach, duodenum, and small bowel are grossly unremarkable, without evidence of wall thickening or obstruction. The colon is non-dilated without obstructive lesions. There is mild thickening of the colonic wall which may be due to third spacing. The appendix is not visualized. Enteric contrast is see throughout the GI tract into the and rectum. VASCULAR: The aorta contains moderate amount of atherosclerotic calcifications extending into the common iliac arteries but is normal in caliber without aneurysmal dilatation. The IVC and major abdominal vessel patency cannot be assessed on a noncontrast enhanced study. RETROPERITONEUM AND ABDOMEN: There is no overt retroperitoneal or mesenteric lymph node enlargement. No free air or abdominal wall hernias is noted. There is a small amount of ascites. PELVIC CT: The urinary bladder and terminal ureters are grossly unremarkable. No definite pelvic wall or inguinal lymph node enlargement is seen. There is a small amount of pelvic free fluid. OSSEOUS STRUCTURES: No blastic or lytic lesions suspicious for malignancy is present. IMPRESSION: 1. Limited assessment due to lack of IV contrast. No definite mass is identified within the abdomen or pelvis. 2. Small amount of free fluid within the abdomen and pelvis. 3. 5mm non-obstructing stones in the lower pole of the left kidney. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: s/p Fall Diagnosed with TRAUMATIC SUBDURAL HEM, UNSPECIFIED FALL temperature: 98.2 heartrate: 77.0 resprate: 18.0 o2sat: 100.0 sbp: 161.0 dbp: 88.0 level of pain: 1 level of acuity: 2.0

The patient is a ___ with history of hepatitis C, CKD, anemia, on anticoagulation for mechanical AVR/MVR who was admitted after mechanical fall with head strike on ___ and finding of small left insular SAH with small IVH component. At that time INR was 3.3. She was admitted to Neurosurgery and coumadin was held without being actively reversed (approved by cardiology consult). Serial NCHCTs were done which were stable until ___ when there was evidence of a small intraparenchymal hemorrhagic contusion along with the SAH. This was felt to be a normal sequelae of her head strike. She was transferred to the medicine service on ___. Her INR that day was 1.8 and she was started on a heparin gtt with 2900unit bolus as a bridge to coumadin given her mechanical valves. Both the heparin with bolus was approved by the neurosurgical team. The night of ___, she had one recorded elevated PTT to 140s, but subsequent PTTs were in the goal range of 60-80. That day she was also transfused 1 unit PRBC for anemia. The following day ___, her heparin gtt was transitioned to lovenox 30mg SQ given the plan to discharge her home. Prior to discharge, she was noted to be lethargic. Around 130pm, she was even more lethargic and with slurred speech. NCHCT was done at 3pm which showed increasing left temporoparietal hemorrhage, SAH, and mass effect on the left lateral ventricle. Stroke neurology saw the patient urgently and found her hypertensive to 190s/100s, lethargic yet responsive with a right facial droop, left gaze preference, right sided weakness (right arm ___, and right leg ___, bilateral upgoing toes. She was urgently treated with Hydralazine and Labetalol IV doses while urgently transfering to the NICU under the Neurology service. BP was controlled (SBP<150) with a nicardipine gtt. No active reversal was needed as INR was 1.1 and PTT was 34. Serial NCHCTs were done to reevaluate her IPH and SAH. All anticoagulants were stopped. Over several days, her exam improved, she became more attentive, with no gaze preference, and improved strength on the right. On ___, she was transferred to the floor. However she desaturated upon lying flat to the ___ and was placed on a non-rebreather. Pulmonology performed an ultrasound which showed atelectasis in the left lung, extensive, as seen on chest x ray in the morning (likely due to mucus plugging). She was transferred to the ICU. She was given incentive spirometry and did well, by the end of the day she was saturating well on 3L nasal cannula. By ___, her chest x ray was improved and she saturated well on room air. She was then transferred back to the floor. On the floor she did well except that she wasn't taking adequate oral intake. She was felt to be cachectic and had lost lots of weight over the previous year. She had anemia persistently throughout the hospital course which was likely in part due to her chronic renal failure and hepatitis C, but otherwise was of unclear etiology. We did a CT abdomen/pelvis to look for malignancy as a possible cause but did not find anything concerning for cancer. We had nutrition come see her and they recommended Ensure shakes, which were not low potasssium. Unfortunately, she became hyperkalemic, likely secondary to the Ensure and her known chronic renal failure, with potassium peaking at 7.0 on ___. She was given kayexalate, calcium gluconate and insulin and her potassium decreased back to normal levels. Her EKG done at the time of the hyperkalemia showed peaked T-waves, which improved when her potassium improved. The Ensure shakes were stopped. She also became slightly more somnolent around this time, but her UCx returned positive on ___, so she was put on a three day course of ceftriaxone. Her mental status improved with treatment of the UTI. Of note, she was started on warfarin on ___ at a low dose of 2.5. After three days, her INR had still not gone above 1.0, so she was also started on a heparin gtt on ___ to ensure appropriate anticogulation given her two mechanical valves. Her coumadin was increased until it was 7.5mg, which on ___ brought her INR to 2.1. Her heparin gtt was continued as her goal INR was 2.5-3.5. She had a NCHCT to ensure no increased bleeding once her INR was above 2.0, which showed a stable appearance of her hemorrhage. She was sent to rehab with a plan to continue her bridge to warfarin with goal INR 2.5-3.5. She will need her INR checked daily until it is in range. She will need her PTT checked at least every 12 hours and adjusted to maintain goal range of 50-70. In addition, her BUN and Cr have fluctuated during this admission. She has known CKD. At discharge her BUN was 43 and creatinine was 1.5. These will need to be monitored at least twice a week to ensure that she is not having worsening renal failure. ==================================================== AHA/ASA Core Measures for Intracerebral Hemorrhage 1. Dysphagia screening before any PO intake? (x) Yes [performed and documented by admitting resident] – () No 2. DVT Prophylaxis administered by the end of hospital day 2? (x) Yes after initial SAH, DVT ppx was restored, but after admission to ICU, ppx was held off until ___ when SQ heparin was restarted. 3. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker - () unable to participate] 4. Stroke education given (written form in the discharge worksheet)? (x) Yes - () No (stroke education = personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) 5. Assessment for rehabilitation or rehab services considered? (x) Yes - () No [if no, reason not assessed: ____ ]

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Quinidine Hcl Attending: ___. Chief Complaint: hemorrhagic shock Major Surgical or Invasive Procedure: EGD ___ History of Present Illness: Mr. ___ is a ___ year old M w/ hx of atrial fibrillation, HFpEF, gout, HLD, and ___ presenting with black stools. He underwent an esophageal RFA procedure on ___. For the past two days, he has been having dark red-black stools and lightheadedness. He saw his cardiologist this week who decreased his nebivolol for lightheadedness. He did take his bnebivolol and verapamil this morning. He last took his Rivaroxiban last night. He is not on aspirin. he denies any CP, SOB, current lightheadedness, abdominal pain, N/V, hematemesis, hemoptysis. In the ED, his vitals were notable for an acute drop in blood pressure to the ___. Exam notable for tachycardia and being unwell appearing. His Hgb 15 -->9. He was given 3 units pRBCs and 500 cc LR. He was started on norepinephrine peripherally and IV pantoprazole BID. GI was consulted who recommended EGD. He was given one dose of 10 mg IV metoclopramide. In the MICU, he was intubated for his EGD. Intubation was uncomplicated. EGD showed bleeding at the site of his ___ procedure. Hemogel was placed and hemostasis was achieved. Past Medical History: HTN A fib ___ esophagus s/p RFA ablation w c/b hemorrhagic shock HFpEF HTN HLD Insomnia Social History: ___ Family History: No coagulopathy Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: T 98 HR 81 BP 93/63 RR 19 SPO2 100% on 100% FiO2 GEN: Middle-aged male sitting up in bed in no acute distress. Alert and interactive HEENT: Dry MM. PERRL. EOMI. No facial droop. NECK: JVP not visible at 90 degrees CV: RRR. Nl s1/s2. No m/r/g RESP: CTAB. no w/r/r GI: Soft. NT. ND. Normoactive BS. MSK: Normal muscle tone and bulk SKIN: Erythematous. Warm. Cap refill brisk. NEURO: AAOx3. Walks on own. CN grossly intact. DISCHARGE PHYSICAL EXAM: ======================== GEN: Middle-aged male sitting up in bed in no acute distress. Alert and interactive HEENT: Dry MM. PERRL. EOMI. No facial droop. NECK: JVP not visible at 90 degrees CV: RRR. Nl s1/s2. No m/r/g RESP: CTAB. no w/r/r GI: Soft. NT. ND. Normoactive BS. MSK: Normal muscle tone and bulk SKIN: Erythematous. Warm. Cap refill brisk. NEURO: AAOx3. Walks on own. CN grossly intact. Pertinent Results: ADMISSION LABS ============== ___ 12:39PM BLOOD WBC-11.8* RBC-2.95* Hgb-9.4* Hct-29.5* MCV-100* MCH-31.9 MCHC-31.9* RDW-14.1 RDWSD-51.8* Plt ___ ___ 12:39PM BLOOD Neuts-70.0 ___ Monos-6.8 Eos-0.3* Baso-0.3 Im ___ AbsNeut-8.26* AbsLymp-2.59 AbsMono-0.80 AbsEos-0.03* AbsBaso-0.04 ___ 12:39PM BLOOD ___ PTT-26.6 ___ ___ 04:45PM BLOOD ___ 12:39PM BLOOD Glucose-108* UreaN-53* Creat-0.9 Na-140 K-4.2 Cl-108 HCO3-19* AnGap-13 ___ 12:39PM BLOOD Glucose-108* UreaN-53* Creat-0.9 Na-140 K-4.2 Cl-108 HCO3-19* AnGap-13 ___ 12:39PM BLOOD cTropnT-<0.01 ___ 12:39PM BLOOD Calcium-8.6 Phos-2.2* Mg-1.8 ___ 01:09PM BLOOD Glucose-106* Lactate-1.7 Creat-1.0 Na-137 K-3.9 Cl-112* calHCO3-20* ___ 01:09PM BLOOD Hgb-10.3* calcHCT-31 DISCHARGE LABS ============== ___ 05:23AM BLOOD WBC-6.9 RBC-3.07* Hgb-9.6* Hct-29.5* MCV-96 MCH-31.3 MCHC-32.5 RDW-14.9 RDWSD-51.8* Plt ___ ___ 05:23AM BLOOD Plt ___ ___ 05:23AM BLOOD Glucose-103* UreaN-19 Creat-0.8 Na-145 K-4.4 Cl-110* HCO3-23 AnGap-12 IMAGING & STUDIES ================ ___ CXR Comparison to ___. Stable low lung volumes. Stable moderate cardiomegaly with mild elongation of the descending aorta. No pleural effusions. No pulmonary edema. No pneumonia. The hilar and mediastinal contours are unremarkable. ___ CXR FINDINGS: An endotracheal tube tip projects 3.0 cm superior to the carina. Low lung volumes result in crowding of the bronchovascular structures and accentuation of heart size. There is mild atelectasis. The lungs are otherwise clear. The costophrenic angles are excluded from the field of view. Heart size is moderately enlarged. There is mild aortic arch calcification. The mediastinal silhouette is otherwise unremarkable. A soft tissue anchor projects over the right humeral head. IMPRESSION: An endotracheal tube tip projects 3.0 cm superior to the carina. ___ EGD -Large semi-circumferential ulcer was seen at the GE junction consistent with post-RFA ulcer. An adherent clot was seen. After irrigation and suction, friable mucosa was identified. There was spontaneous oozing in setting of contact from the scope -Erythema in the antrum compatible with gastritis. -Normal mucosa in the whole examined duodenum. RECOMMENDATIONS: - ___ extubate patient from GI standpoint. - Continue high dose PPI BID. - Once extubated and no bleeding overnight, may advance diet as tolerated. - If safe from cardiovascular standpoint, as per primary team, holding Xarelto for next 5 days will decrease risk of bleeding, duration of holding Xarelto after discussing with primary team/cardiologist. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Testosterone Gel 1% 50 mg TP DAILY 2. Furosemide 20 mg PO DAILY 3. Omeprazole 40 mg PO DAILY 4. AcetaZOLamide 125 mg PO Q24H 5. Rivaroxaban 20 mg PO DAILY 6. Bystolic (nebivolol) 20 mg oral DAILY 7. Allopurinol ___ mg PO DAILY 8. Verapamil SR 120 mg PO Q24H 9. Atorvastatin 80 mg PO QPM 10. Ranitidine 300 mg PO DAILY 11. Fluticasone Propionate 110mcg 2 PUFF IH BID 12. Zolpidem Tartrate 5 mg PO QHS 13. loteprednol etabonate 0.5 % ophthalmic (eye) Q4H:PRN Discharge Medications: 1. Verapamil SR 180 mg PO Q24H RX *verapamil 180 mg 1 tablet(s) by mouth once a day Disp #*90 Tablet Refills:*0 2. AcetaZOLamide 125 mg PO Q24H 3. Allopurinol ___ mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. Bystolic (nebivolol) 20 mg oral DAILY 6. Fluticasone Propionate 110mcg 2 PUFF IH BID 7. Furosemide 20 mg PO DAILY 8. loteprednol etabonate 1 % ophthalmic (eye) BID 9. Omeprazole 40 mg PO BID 10. Testosterone Gel 1% 50 mg TP DAILY 11. Zolpidem Tartrate 5 mg PO QHS 12. HELD- Rivaroxaban 20 mg PO DAILY This medication was held. Do not restart Rivaroxaban until ___ Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: ================== #Upper GI Bleeding Secondary Diagnosis: ==================== #Atrial fibrillation #Hypertension ___ esophagus #Heart failure with preserved ejection fraction #Hyperlipidemia #Insomnia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with chf, GI bleeding, crackles in lungs// chf? chf? IMPRESSION: Comparison to ___. Stable low lung volumes. Stable moderate cardiomegaly with mild elongation of the descending aorta. No pleural effusions. No pulmonary edema. No pneumonia. The hilar and mediastinal contours are unremarkable. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with a fib, HTN, HFpEF p/w GIB, getting emergently scoped// evaluate ETT placement TECHNIQUE: Frontal view of the chest COMPARISON: Chest radiographs between ___ and ___ FINDINGS: An endotracheal tube tip projects 3.0 cm superior to the carina. Low lung volumes result in crowding of the bronchovascular structures and accentuation of heart size. There is mild atelectasis. The lungs are otherwise clear. The costophrenic angles are excluded from the field of view. Heart size is moderately enlarged. There is mild aortic arch calcification. The mediastinal silhouette is otherwise unremarkable. A soft tissue anchor projects over the right humeral head. IMPRESSION: An endotracheal tube tip projects 3.0 cm superior to the carina. Gender: M Race: WHITE Arrive by OTHER Chief complaint: Dizziness, Melena Diagnosed with Gastrointestinal hemorrhage, unspecified, Hypotension, unspecified, Dizziness and giddiness temperature: 96.7 heartrate: 78.0 resprate: 18.0 o2sat: 98.0 sbp: 81.0 dbp: 48.0 level of pain: 0 level of acuity: 1.0

PATIENT SUMMARY =============== Mr. ___ is a ___ man with chronic A fib on rivaroxaban, congestive heart failure, gout, hyperlipidemia, and other issues admitted with GI bleeding after having undergone radiofrequency ablation for ___ esophagus 8 days ago (___). After the procedure, he developed progressive light-headedness, particularly with exertion, over the past two days. He first presented to his Cardiologist yesterday (___) for a routine follow-up appointment, and due to orthostatic symptoms, his nebivolol dose was reduced to 20mg from 30mg q24h. Due to persistent light-headedness, he presented to the Emergency Department (___) for evaluation. He was hypotensive to the ___ systolic in the ED. Laboratory studies demonstrated a white count of 11.8, hemoglobin of 9.4 (down from 15.4 in ___, and platelets of 201. His INR was 1.5. Chemistry studies revealed a bicarbonate of 19, BUN of 53, and creatinine of 0.9. Chest x-ray did not reveal acute cardiopulmonary abnormalities. Gastroenterology was consulted, and plan on performing an EGD after ICU admission. He received 500cc of crystalloid and 2 units of pRBCs, he was ordered for pantoprazole, and was ultimately initiated on norepinephrine through a peripheral IV for persistent hypotension. He was intubated shortly after admission to the ICU to facilitate EGD, which demonstrated a distal esophageal erosion / ulceration at the ___ site which was sprayed with hemogel. He was immediately extubated after EGD without issues. He was transferred to the medicine ward and able to be discharged after stabilization of his heart rates. TRANSITIONAL ISSUES =================== [] Holding home rivaroxaban until ___ [] Recheck CBC at next visit with PCP [] Continue twice daily PPI until follow-up with GI [] Continue soft diet until ___ [] Avoid NSAIDs for the next week, use Tylenol as needed for pain [] Patient to follow-up with Dr. ___ CODE STATUS: Full code ___ (Wife) ___ ACUTE/ACTIVE ISSUES ================== #Acute upper GI bleed #Hemorrhagic shock Hemorrhagic shock ___ bleed demonstrated an esophageal ulcer at the site of the radiofrequency ablation procedure he had undergone on ___, and hemogel was applied. Briefly required pressors in setting of intubation, but responded well to volume resusitation. He has not had evidence of recurrent hemorrhage and we are continuing to follow clinically for evidence of recurrent GI bleeding, as well as following his blood counts intermittently - there has been no evidence of decreasing hemoglobin. Continued pantoprazole, ranitidine (which is a home medication), and we are holding rivaroxaban for ___ days. #Acute respiratory failure He was intubated to facilitate EGD yesterday, and was immediately extubated post-procedure. We are following his work of breathing, oxygenation, and respiratory status to guide the need for further interventions. He is on ambient air. #Leukocytosis Elevated on presentation to 11.8. No systemic or localizing s/sx of infection. Suspect hemoconcentration in setting of hemorrhagic shock. Normalized without interventions, no indication for antibiotics at this time. #Atrial fibrillation with RVR to 150s His home nodal blockade agents were held on admission due to concern for upper GI bleeding. His home regimen was restarted and he was able to tolerate it well prior to discharge. He was not in RVR at discharge. His outpatient cardiology team was notified of the decision to hold rivaroxaban for 5 to 7 days until ___. #HTN #HFpEF Held his anti-hypertensives initially given bleeding, and then while re-introducing beta-blocker as noted above. CHRONIC/STABLE ISSUES ==================== #OSA: Continued home ___ CPAP.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Sulfa (Sulfonamide Antibiotics) Attending: ___ Chief Complaint: Right lower quadrant pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo M otherwise healthy presenting with RLQ abdominal pain that began ___. Patient states that it was first located in the epigastric region and then subsequently localized to the RLQ. He denies any associated fevers, chills, nausea, vomiting, or anorexia. He denies any recent changes in his bowel habits. He denies any history of prior abdominal surgeries or any recent sick contacts. Past Medical History: PMHx: none PSHx: removal of adenoids Social History: ___ Family History: Non-contributory Physical Exam: Admission Physical Exam: Vitals: T 97.1, HR 64, BP 157/98, RR 18 100% RA Gen: well appearing, NAD CV: RRR, palpable peripheral pulses P: nonlabored breathing on room air GI: soft, nontender, nondistended; mild TTP in RLQ; no rebound or guarding; no tap or shake tenderness Ext: WWP, no CCE Discharge Physical Exam: VS: 97.5 PO 114 / 77 68 98% RA Gen: Awake, alert, sitting up in bed. Pleasant and interactive. CV: RRR Pulm: Clear to auscultation bilaterally. Abd: Soft, non-tender, non-distened. Ext: Warm and dry. no edema. 2+ ___ pulses. Neuro: A&Ox3. Follows commands and moves all extremities equal and strong. Speech is clear and fluent. Pertinent Results: ___ 05:04AM BLOOD WBC-10.0 RBC-4.98 Hgb-15.0 Hct-42.5 MCV-85 MCH-30.1 MCHC-35.3 RDW-11.6 RDWSD-35.5 Plt ___ ___ 02:25PM BLOOD WBC-7.7 RBC-5.34 Hgb-16.4 Hct-45.8 MCV-86 MCH-30.7 MCHC-35.8 RDW-11.8 RDWSD-36.5 Plt ___ ___ 05:04AM BLOOD ___ PTT-28.9 ___ ___ 05:04AM BLOOD Glucose-98 UreaN-11 Creat-1.1 Na-138 K-3.8 Cl-101 HCO3-26 AnGap-15 ___ 02:25PM BLOOD Glucose-90 UreaN-15 Creat-1.1 Na-140 K-4.6 Cl-101 HCO3-28 AnGap-16 ___ 05:04AM BLOOD Calcium-8.6 Phos-3.3 Mg-1.9 ___ 06:00PM BLOOD Lactate-1.1 ___ CT A/P: 1. Findings consistent with acute appendicitis ; the distal appendix is dilated to 12 mm, fluid-filled, and with thickened, hyperemic wall. Mild adjacent periappendiceal fat stranding. No drainable fluid collection or extraluminal gas. Medications on Admission: None Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild do not exceed 4 grams/ 24 hours 2. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*18 Tablet Refills:*0 3. MetroNIDAZOLE 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*27 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Acute Appendicitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: NO_PO contrast; History: ___ with 3 days of worsening RLQ pain, tender at ____PO contrast // r/o appendicitis 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: 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: 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 collapsed. 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. No bowel obstruction or bowel wall thickening is seen. The distal appendix is dilated to 12 mm, fluid-filled, and with thickened hyperemic wall. There is mild adjacent periappendiceal fat stranding. Findings are consistent with acute appendicitis. No drainable fluid collection or extraluminal gas is seen. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Findings consistent with acute appendicitis ; the distal appendix is dilated to 12 mm, fluid-filled, and with thickened, hyperemic wall. Mild adjacent periappendiceal fat stranding. No drainable fluid collection or extraluminal gas. NOTIFICATION: Findings discussed with Dr. ___ by Dr. ___ at 16:15 on ___ via telephone. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: RLQ abdominal pain, Transfer Diagnosed with Unspecified acute appendicitis temperature: 97.1 heartrate: 64.0 resprate: 18.0 o2sat: 100.0 sbp: 157.0 dbp: 98.0 level of pain: 0 level of acuity: 3.0

Mr. ___ is a ___ yo M admitted to the Acute Care Surgery Service on ___ with right lower quadrant/epigastric pain for 3 days. Denies associated fever, chills, nausea, vomiting, or change in bowels. CT abdomen pelvis was consistent with acute appendicitis. Risks and benefits of operative versus medical management with antibiotics was discussed and the patient opted for medical mangagment. He was made NPO, given IV antibiotics, and admitted to the floor for monitoring. On HD2 he remained afebrile, hemodynamically stable, and abdominal pain improved. White blood cell count was 10.0 from 7.7. His diet was progressively advanced to regular with good tolerability with normal bowel function. He was discharged to home on HD2 to complete a 10 day course of antibiotics. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: ibuprofen / morphine Attending: ___. Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: None History of Present Illness: Patient began having RUQ pain and episodes of emesis on ___. The pain was initially ___ and woke her up from sleep with large amounts of green/yellow vomiting. The pain subsequently decreased to ___ and intermittently increased to ___. The pain was noted to be worse after eating. Patient denied nausea and has been passing flatus. Patient was unsure of her temperature but didn't think she had a fever. Her last bowel movement was ___. Past Medical History: Past Medical History: 1. Hypertension. 2. Migraine headaches. 3. Gastroesophageal reflux. 4. Mild sleep-disordered breathing based on recent sleep study. 5. Vitamin D deficiency. 6. Mild esophagitis with gastritis secondary to hemetemesis. (Last endoscopy was done at ___ on ___, which revealed irregular Z-line at the GE junction, normal mucosa of the stomach, normal mucosa of the duodenum. Biopsies were taken which just revealed some mild active esophagitis.) 7. Weight related knee problems for which she is followed here at ___. Past Surgical History: 1. Endoscopy on ___. 2. D&C in ___. 3. Oral surgery for infection in ___ at ___. Social History: ___ Family History: Her family history is noted for a father living with hypertension, coronary artery disease and stroke; mother living with hypertension, rheumatoid arthritis and obesity (had lap band procedure); brother with possible heart condition and overweight; one son with obesity and another with attention deficit disorder. Physical Exam: VS: 98.3 F oral, 112/76, 60, 18, 99% RA N:A&Ox3, ___ and interactive. NAD. C/V: afebrile. RRR. non murmur/no regurg. Resp: Breath sounds clear to auscultation. No distress. GI/GU: Abdomen soft, non-distended. mild tenderness in upper gastric area with deep palpation. no rebound/gaurding. Skin: Grossly intact. Extremities: warm and dry. no edema. ___ pulses 2+ palpable. Pertinent Results: ___ CT ABD & Pelvis IMPRESSION: No evidence of obstruction, no acute intra-abdominal process. Significant reflux of enteric contrast retrograde into the afferent limb extending to the duodenum. There is also contrast within the excluded stomach, potentially from retrograde opacification although underlying gastrogastric fistula is not excluded. ___ Liver/Gallbladder US Impression: Normal appearance of the gallbladder and pancreas. No intrahepatic biliary dilation. Normal common bile duct. ___ CHXR IMPRESSION: No evidence of obstruction. No free air. Previously ingested oral contrast has move distally into the colon. Contrast within the excluded stomach as seen on prior CT may represent gastro gastric fistula versus reflux of contrast. ___ CT ABD & Pelvis Impression: 1. Status post Roux-en-Y gastric bypass. No evidence of small bowel obstruction or internal hernia. No acute process in the abdomen or pelvis. 2. Large fecal loading throughout the colon and rectum. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Amlodipine 10 mg PO DAILY 2. Multivitamins W/minerals 1 TAB PO DAILY 3. TraMADOL (Ultram) 50 mg PO BID:PRN menstrual pain 4. Albuterol Sulfate (Extended Release) 180 mcg PO Q4H wheeze 5. Sumatriptan Succinate 40 mg PO ONCE MR1 migraine 6. Fluoxetine 10 mg PO DAILY 7. Chlorthalidone 25 mg PO DAILY 8. Cyanocobalamin 1000 mcg IM/SC EVERY 4 WEEKS (MO) 9. Vitamin D 5000 UNIT PO DAILY 10. Clindamycin 1% Solution 1 Appl TP DAILY Discharge Medications: 1. TraMADOL (Ultram) 50 mg PO BID:PRN menstrual pain 2. Acetaminophen (Liquid) 650 mg PO Q6H 3. Polyethylene Glycol 17 g PO DAILY:PRN constipation RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth Daily Disp #*15 Packet Refills:*0 4. Senna 8.6 mg PO BID RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp #*15 Tablet Refills:*0 5. Sucralfate 1 gm PO QID RX *sucralfate 1 gram/10 mL 10 ml by mouth four times a day Refills:*0 6. Albuterol Sulfate (Extended Release) 180 mcg PO Q4H wheeze 7. Amlodipine 10 mg PO DAILY 8. Chlorthalidone 25 mg PO DAILY 9. Clindamycin 1% Solution 1 Appl TP DAILY 10. Cyanocobalamin 1000 mcg IM/SC EVERY 4 WEEKS (MO) 11. Fluoxetine 10 mg PO DAILY 12. Multivitamins W/minerals 1 TAB PO DAILY 13. Sumatriptan Succinate 40 mg PO ONCE MR1 migraine Duration: 1 Dose 14. Vitamin D 5000 UNIT PO DAILY 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 INDICATION: ___ s/p roux-en-y bypass p/w bilious emesis, and RUQ abdominal pain+PO contrast // Eval for possible stricture, obstruction TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis following intravenous contrast administration with split bolus technique.Coronal and sagittal reformations were performed.Oral contrast was administered. DOSE: Total DLP (Body) = 791 mGy-cm. COMPARISON: CT abdomen pelvis from ___. FINDINGS: The lung bases are clear. The liver, spleen, kidneys, adrenal glands, gallbladder and pancreas are unremarkable. Oral contrast is seen within the gastric pouch and in the efferent limb extending to the JJ anastomosis. There is also some contrast in the jejunum distant to this anastomosis. There are no dilated loops to suggest obstruction. There is is significant on reflux of oral contrast into the afferent limb seen to the region of the fourth portion of the duodenum. In addition, there is some oral contrast within the excluded portion of the stomach. Colon is unremarkable. The appendix is not visualized, although clip at the base of the cecum suggest prior appendectomy. Intrauterine device seen within the uterus. Adnexae are unremarkable. There is no free intraperitoneal fluid, free air, or intra-abdominal adenopathy. Abdominal aorta is normal in caliber. No focal suspicious osseous lesions. There is no fracture. IMPRESSION: No evidence of obstruction, no acute intra-abdominal process. Significant reflux of enteric contrast retrograde into the afferent limb extending to the duodenum. There is also contrast within the excluded stomach, potentially from retrograde opacification although underlying gastrogastric fistula is not excluded. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ s/p RNYGB ___ presents with abdominal pain and bilious emesis // r/o gallbladder abnormalities TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: CT abdomen pelvis from 1 day prior FINDINGS: LIVER: The hepatic parenchyma appears slightly coarsened. 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. Limited images of the right kidney are unremarkable. IMPRESSION: Normal appearance of the gallbladder and pancreas. No intrahepatic biliary dilation. Normal common bile duct. Radiology Report INDICATION: ___ s/p RNYGB ___ presents with abdominal pain and bilious emesis // assess for abnormality TECHNIQUE: Upright and supine radiographs COMPARISON: CT abdomen pelvis ___ FINDINGS: There are no abnormally dilated loops of large or small bowel. Oral contrast is seen within large bowel loops. Small amount of contrast is seen in the region of the expected excluded stomach which correlates to findings on prior CT. There is no free intraperitoneal air. Surgical clips and chain sutures are seen within the left upper quadrant. There is an intrauterine device seen overlying the pelvis. No acute osseous abnormality. IMPRESSION: No evidence of obstruction. No free air. Previously ingested oral contrast has move distally into the colon. Contrast within the excluded stomach as seen on prior CT may represent gastro gastric fistula versus reflux of contrast. Radiology Report INDICATION: ___ year old woman RNY bypass, persistent post-prandial pain, rule out internal hernia. 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, 0.5 cm; CTDIvol = 2.4 mGy (Body) DLP = 1.2 mGy-cm. 4) Spiral Acquisition 4.5 s, 48.9 cm; CTDIvol = 15.6 mGy (Body) DLP = 762.4 mGy-cm. Total DLP (Body) = 764 mGy-cm. COMPARISON: CT abdomen and pelvis from ___ FINDINGS: LOWER CHEST: There is mild dependent atelectasis at the lung bases bilaterally. There is no pericardial or pleural 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 and the portal vein is patent. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: Heterogeneous attenuation of the spleen is likely related to phase of scanning. It is normal in size. 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: Patient is status post Roux-en-Y gastric bypass surgery. Enteric contrast is seen within the remnant stomach into the jejunum. There is no contrast refluxing into the biliary limb. There is no distension of stomach or loops of bowel. The jejunojejunostomy in the left upper quadrant is unremarkable. Remaining small bowel loops demonstrate normal caliber, wall thickness, and enhancement. The colon is unremarkable. The appendix is not clearly identified but there are no secondary signs of appendicitis. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: An IUD is seen within the uterus. Bilateral adnexa are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Status post Roux-en-Y gastric bypass surgery without evidence of internal hernia or obstruction. No acute process within the abdomen or pelvis. 2. Large fecal loading through the colon and rectum. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Abd pain, Vomiting Diagnosed with Epigastric pain temperature: 98.1 heartrate: 88.0 resprate: 16.0 o2sat: 100.0 sbp: 136.0 dbp: 90.0 level of pain: 8 level of acuity: 3.0

The patient was admitted to the bariatric service and evaluated for abdominal pain. On ___ - US Liver and GB Impression: Normal appearance of the gallbladder and pancreas. No intrahepatic biliary dilation. Normal common bile duct.On ___ - CT Abdomen & Pelvis Impression: No evidence of obstruction. No free air. Previously ingested oral contrast has move distally into the colon. Contrast within the excluded stomach as seen on prior CT may represent gastro gastric fistula versus reflux of contrast.ENDOSCOPIC STUDIES:EGD:Irregular z-line at the GE junction. (biopsy)Previous Roux-n-Y bypass surgery of the stomach (biopsy)Raised nodule with central umbilication with overlying mucous seen in the fundus. This was concerning for a fistula.Both blind and Roux limbs of the jejunum were examined. Normal mucosa was seen.Otherwise normal EGD to jejunum. Although imaging did not reveal a clear cause for the patients pain, per GI fellow Dr. ___ was started on BID PPI. She was given carafate as well which she reported improved her symptoms. Her diet was advanced as tolerated.She continued to have symptoms of pain after eating and the CT scan was repeated on ___. This scan showed large amound of fecal loading throughout the colon and rectum. Therefore, she was given a more aggressive bowel regimen. Upon discharge, pt is alert and oriented ambulating independently without difficulty. She is cardiovascularly stable. Her breath sounds are clear and her breathing is non-labored. Reports abdominal pain is improved and is tolerating stage V Bariatric diet with minimal discomfort, no nausea, no emesis. Minimal tenderness to palpation in upper gastric area. Biopsy results from EGD pending.

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Lovenox Attending: ___ ___ Complaint: fever, palpitations Major Surgical or Invasive Procedure: none History of Present Illness: ___ with NSCLC with bony mets s/p XRT finished ___ now on taxotere (C2 ___, who presents with palpitations and fever. For the past week, the patient has felt fatigued. For the past several days, he has had a cough productive of clear sputum. On ___ the patient was seen by his cardiologist Dr. ___ noted HR to 160s and sent the patient to the ED, where he was diagnosed with new onset paroxysmal A-fib. He was also noted to be neutropenic but discharged home since not febrile. Overnight, he had multiple episodes of palpitations and this morning he felt warm and sweaty, and found his temp to be 100.7 so he came back to the ED. He has a positive sick contact (his ___ year old daughter has a cough and recently received antibiotics from her pediatrician for presumed pneumonia). No GI or GU symptoms at this time. In the ED the patient's initial vitals signs were: 98.6 116 ___ 98% RA. Labs were significant for WBC 1.7 (46% PMN, ANC 782), H/H 9.9/31.4, plt 243, Na 135, K 4.2, Cl 101, HCO3 22, BUN 17, Cr 0.9, glucose 92, troponin <0.01, and lactate 1.8. UA with no significant abnormalities. CXR w/ possible PNA. The patient was given vancomycin and cefepime. He was transferred to OMED for further management. On the floor, VS: 99.9 124/80 115 16 100% RA. Hemodynamically stable, no respiratory distress, feels generally well except tired and with cough. No palpitations at this point. Review of Systems: (+) Per HPI (-) Denies night sweats, recent weight loss or gain. Denies blurry vision, diplopia, loss of vision, photophobia. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, lower extremity edema. Denies shortness of breath, or wheezes. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, melena, hematemesis, hematochezia. Denies dysuria, stool or urine incontinence. Denies arthralgias or myalgias. Denies rashes or skin breakdown. No numbness/tingling in extremities. All other systems negative. Past Medical History: PAST ONCOLOGIC HISTORY: ___: patient complained of clavicular pain ___: MRI of the clavicle w/ abnormal bone marrow uptake ___: MRI of the clavicle w/ abnormal bone marrow uptake ___: CT chest which showed a spiculated LLL 15x26 mm lesion, as well as a likely liver cyst ___: PET scan showed an FDG avid LL mass, hilar and mediastinal adenopathy as well as uptake in the right clavicle and right sacrum ___: Bx/EBUS, bx showed malignant cells c/w adenocarcinoma ___: ___ MRI negative for metastatic disease ___: radiation to right clavicle ___: mild hemoptysis prior to starting chemo ___: C1 Cis+Alimta with 25% ___ ___ to expected tolerance ___: Radiation to lung started due to hemoptysis, total 14 treatments. ___: C2 Cis+Alimta full dose with Zometa ___: C3 Cis+Alimta full dose ___: B12 ___: C4 Cis+Alimta full dose with Zometa ___: Maintenance Alimta ___: CTA sit diagnosed PE and T4 and T9 bone lesion progression, patient did not tolerate Lovenox, Fragmin and Coumadin due to ___ joint pain, started on Xarelto ___: 10 fractions of XRT to T8-10 at ___ ___: C1 Taxotere, Alimta d/c'd ___: schedule for C2 taxotere PAST MEDICAL HISTORY: ___ c/b bone metastasis (EGFR negative, ALK negative, KRAS positive) COPD/asthma Colonic adenoma Gallstones Diverticulosis BPH (benign prostatic hyperplasia) Acute MI s/p DES in ___ Pulmonary embolism Hyperlipidemia Social History: ___ Family History: Father: CAD/PVD Maternal Grandmother: ___ - Type II Mother: Cancer Physical ___: ADMISSION EXAM: ---------------- VITALS: 99.9 124/80 115 16 100% RA General: Alert, oriented, NAD, looks very well HEENT: Mucous membranes moist, sclera anicteric, EOMI Neck: JVD at clavicle CV: RRR, S1 S2, no MRG Lungs: Bibasilar crackles, otherwise CTAB Abdomen: +BS, soft, nontender, not distended Ext: Warm well-perfused, DP 2+ b/l, no edema, cyanosis, clubbing Neuro: moving all extremities, fluent speech and good historian DISCHARGE EXAM: ---------------- VITALS: 98.3 128/68 100 16 100% RA General: Alert, oriented, NAD, looks very well HEENT: Mucous membranes moist, sclera anicteric, EOMI Neck: JVD at clavicle CV: RRR, S1 S2, no MRG Lungs: Bibasilar crackles, otherwise CTAB Abdomen: +BS, soft, nontender, not distended Ext: Warm well-perfused, DP 2+ b/l, no edema, cyanosis, clubbing Neuro: moving all extremities, fluent speech and good historian Pertinent Results: ADMISSION LABS: --------------- ___ 07:10AM BLOOD WBC-1.7*# RBC-3.40* Hgb-9.9* Hct-31.4* MCV-92 MCH-29.3 MCHC-31.7 RDW-14.2 Plt ___ ___ 07:10AM BLOOD Neuts-46* Bands-0 ___ Monos-10 Eos-6* Baso-0 ___ Metas-2* Myelos-2* Promyel-2* NRBC-2* ___ 07:10AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL ___ 07:10AM BLOOD Glucose-92 UreaN-17 Creat-0.9 Na-135 K-4.2 Cl-101 HCO3-22 AnGap-16 ___ 07:10AM BLOOD ALT-38 AST-37 AlkPhos-105 TotBili-0.5 ___ 07:22AM BLOOD Lactate-1.8 DISCHARGE LABS: --------------- ___ 06:55AM BLOOD WBC-3.0*# RBC-3.09* Hgb-9.6* Hct-28.1* MCV-91 MCH-30.9 MCHC-34.0 RDW-14.7 Plt ___ ___ 06:55AM BLOOD Neuts-52 Bands-10* Lymphs-12* Monos-20* Eos-0 Baso-1 Atyps-2* ___ Myelos-3* ___ 06:55AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL Stipple-OCCASIONAL Tear Dr-OCCASIONAL ___ 06:55AM BLOOD Glucose-82 UreaN-14 Creat-0.9 Na-138 K-4.2 Cl-103 HCO3-27 AnGap-12 ___ 06:55AM BLOOD TSH-0.74 IMAGING: --------------- CXR ___ FINDINGS: There is a left lower lobe retrocardiac opacity, more pronounced from ___, which is concerning for developing pneumonia rather than atelectasis superimposed on a pre-existing lesion as seen on the prior PET-CT. A subtle right apical opacity is again seen and may relate to apical pleural thickening. The lungs continue to be hyperinflated, likely representing chronic obstructive pulmonary disease. There is no pleural effusion or pneumothorax. The heart and mediastinal contours are within normal limits. IMPRESSION: Increased left lower lobe retrocardiac opacity is concerning for developing pneumonia rather than atelectasis superimposed on a pre-existing lesion as seen on the prior PET-CT. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 80 mg PO DAILY 2. Metoprolol Succinate XL 50 mg PO DAILY 3. Rivaroxaban 20 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Multivitamins 1 TAB PO DAILY 7. Nitroglycerin SL 0.3 mg SL 3X,Q5MINUTES:PRN chest pain 8. Clopidogrel 75 mg PO DAILY 9. Senna 1 TAB PO BID:PRN constipation 10. albuterol sulfate 90 mcg/actuation inhalation Q4-6H:PRN sob or wheeze 11. Finasteride 5 mg PO DAILY 12. Omeprazole 40 mg PO DAILY 13. Ondansetron 8 mg PO Q8H:PRN nausea 14. Prochlorperazine 5 mg PO Q6H:PRN nausea 15. Tamsulosin 0.4 mg PO HS Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO DAILY 3. Clopidogrel 75 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Finasteride 5 mg PO DAILY 6. Nitroglycerin SL 0.3 mg SL 3X,Q5MINUTES:PRN chest pain 7. Omeprazole 40 mg PO DAILY 8. Ondansetron 8 mg PO Q8H:PRN nausea 9. Prochlorperazine 5 mg PO Q6H:PRN nausea 10. Rivaroxaban 20 mg PO DAILY 11. Senna 1 TAB PO BID:PRN constipation 12. Tamsulosin 0.4 mg PO HS 13. albuterol sulfate 90 mcg/actuation inhalation Q4-6H:PRN sob or wheeze 14. Metoprolol Succinate XL 50 mg PO DAILY RX *metoprolol succinate 50 mg 1 tablet extended release 24 hr(s) by mouth once daily Disp #*5 Tablet Refills:*0 15. Multivitamins 1 TAB PO DAILY 16. Guaifenesin-Dextromethorphan ___ mL PO Q6H:PRN cough This can be purchased over the counter. 17. Levofloxacin 750 mg PO DAILY Duration: 6 Days RX *levofloxacin 750 mg 1 tablet(s) by mouth once daily Disp #*6 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Fever with borderline neutropenia Pneumonia Atrial fibrillation with rapid ventricular response SECONDARY DIAGNOSIS: Non small cell lung cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Palpitations, fever. Evaluate for cardiopulmonary process. TECHNIQUE: Frontal and lateral chest radiographs were obtained with the patient in the upright position. COMPARISON: Chest radiograph from ___, PET-CT from ___ and CT from ___. FINDINGS: There is a left lower lobe retrocardiac opacity, more pronounced from ___, which is concerning for developing pneumonia rather than atelectasis superimposed on a pre-existing lesion as seen on the prior PET-CT. A subtle right apical opacity is again seen and may relate to apical pleural thickening. The lungs continue to be hyperinflated, likely representing chronic obstructive pulmonary disease. There is no pleural effusion or pneumothorax. The heart and mediastinal contours are within normal limits. IMPRESSION: Increased left lower lobe retrocardiac opacity is concerning for developing pneumonia rather than atelectasis superimposed on a pre-existing lesion as seen on the prior PET-CT. Gender: M Race: WHITE - OTHER EUROPEAN Arrive by AMBULANCE WALK IN Chief complaint: AFIB FEVER,PALPITATIONS Diagnosed with ATRIAL FIBRILLATION, NEUTROPENIA, UNSPECIFIED NEUTROPENIA, UNSPECIFIED , FEVER, UNSPECIFIED, PNEUMONIA,ORGANISM UNSPECIFIED temperature: 97.5 98.6 heartrate: 126.0 116.0 resprate: 16.0 16.0 o2sat: 97.0 98.0 sbp: 114.0 108.0 dbp: 77.0 81.0 level of pain: 0 0 level of acuity: 1.0 3.0

___ with NSCLC with bony mets s/p XRT finished ___ now on taxotere (C2 ___, ANC >1000, who now presents with palpitations and fever. ___ with NSCLC with bony mets s/p XRT finished ___ now on taxotere (C2 ___, with ANC ~700, who presented with palpitations and fever. #FEVER: At first was treated with IV Vancomycin and Cefepime for febrile neutropenia. However, his ANC continued to trend up during this admission and he was not neutropenic. He had a cough and positive sick contact, with CXR possibly concerning for pneumonia. Since he was not neutropenic, his antibiotics were narrowed to PO levofloxacin for a 7 day course, last dose ___. #PALPITATIONS: New diagnosis of atrial fibrillation, could be triggered by likely acute infection and hypovolemia. TSH was wnl. # NEUTROPENIA: Likely secondary to chemo recently. WBC nadired at 1.1 and uptrended to 3.0 on discharge. # NSCLC: Mgmt per primary Oncologist. # H/o PE: No dyspnea or indication that PE is worse. Patient continued rivaroxaban. # H/o MI: Continued metoprolol succinate (50mg QD), statin, aspirin, plavix

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: aspirin / sodium bicarbonate Attending: ___. Chief Complaint: Fall with headstrike Major Surgical or Invasive Procedure: None. History of Present Illness: ___ yo M hx dementia, prior CVA on Plavix who presents from SNF after a mechanical fall. Pt slipped while using the bathroom on his own diarrhea. + headstrike, unknown LOC. Pt was taken to OSH where head CT showed small right frontal IPH and right frontal brain mass. ___ denies HA, numbness, weakness or tingling. Daughter and HCP ___ (living in ___ relays that the brain mass is known and followed by a provider in ___, no surgical intervention planned given age and hx dementia. She reports that the patient sounds to be at his baseline MS which is oriented to self and location and typically the month but not year or day. She confirms that the patient is a DNR however as HCP she would agree to procedures that would allow him to maintain his level of function. He currently ambulates on his own, goes on frequent outings with family members. Past Medical History: Thalamic stroke, DNR, CAD, HTN, HTN, hx prostate CA, right frontal brain mass, dementia Social History: ___ Family History: Non-contributory Physical Exam: ======================== ADMISSION PHYSICAL EXAM ======================== O: T:97.7 104 118/82 16 95% Gen: WD/WN, comfortable, NAD. HEENT: occipital hematoma Neck: Supple. No midline temderness Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam. Orientation: Oriented to person, place with options, and Month but not year or day. Language: Speech fluent with good comprehension and repetition. Naming intact. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light bilaterally. Visual fields grossly intact. 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. Slight Left pronator drift Strength full power ___ throughout. Sensation: Intact to light touch bilaterally. ======================== DISCHARGE PHYSICAL EXAM ======================== Unchanged from admission. Pertinent Results: ===== LABS ===== Blood cultures (___): No growth to date, final result pending ========== IMAGING ========== NCHCT (___): Apparent right frontal mass, unchanged from prior study. It is unclear if the hyperdense material represents hemorrhage or calcification. Consider MRI for further delineation. Medications on Admission: Clopidogrel 75mg daily Atorvastatin 10mg daily Calcium carbonate Metoprolol ER 25 mg daily Oxybutynin chloride ER 10mg daily Tamsulosin 0.4mg daily Discharge Medications: 1. Atorvastatin 10 mg PO QPM 2. Metoprolol Succinate XL 25 mg PO DAILY 3. Oxybutynin 10 mg PO DAILY 4. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: R frontal ___ Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report INDICATION: History: ___ s/p fall, hx of diarrhea, no abd pain; no cough/sob/cp // CXR: eval for consolidation TECHNIQUE: Upright PA and lateral chest COMPARISON: None available FINDINGS: Lung volumes are low. Heart size is normal. The mediastinal and hilar contours are normal. There is no pleural effusion or pneumothorax. IMPRESSION: Low lung volumes. No evidence of pneumonia. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old man with right IPH status post fall. Please perform by 8 am, follow hemorrhage . TECHNIQUE: Contiguous multidetector CT scan through the head was performed without intravenous contrast. DOSE: DLP: 897.12 mGy-cm. CTDIvol: 53.90 mGy. COMPARISON: CT from ___. FINDINGS: There is a right frontal mass with internal hemorrhage or calcification, unchanged from the prior study. Apparent increase in surrounding edema may be related to markedly different angle of scan acquisition. There is no evidence of vascular territorial infarction. Old lacunar infarction in the periventricular white matter on the left. There is no fracture. The imaged paranasal sinuses, mastoid air cells, and middle ear cavities are clear. IMPRESSION: Apparent right frontal mass, unchanged from prior study. It is unclear if the hyperdense material represents hemorrhage or calcification. Consider MRI for further delineation. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: ICH Diagnosed with TRAUMATIC BRAIN HEM NEC, UNSPECIFIED FALL temperature: 97.7 heartrate: 104.0 resprate: 16.0 o2sat: 95.0 sbp: 118.0 dbp: 82.0 level of pain: 0 level of acuity: 2.0

Mr. ___ is an ___ year old man with a past medical history of right frontal brain mass, dementia, and thalamic stroke who was transferred to ___ ___ from an OSH following a mechanical fall at nursing facility with ___ showing a small right frontal hemorrhage and known right frontal brain mass. Pt was admitted to the neurosurgery service for further monitoring. Antiepileptics were held as there was no evidence of seizures. Plavix was held given small hemorrhage and SBP was maintained at <140 with plan to restart plavix in 2 weeks. Repeat NCHCT ___ was stable. Pt was feeling well on day of discharge and was discharged back to his nursing facility. Pt should continue to follow with ___ regarding management of the lesion or he may follow up in the Brain Tumor Clinic here at ___.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / codeine / Ocaliva Attending: ___ Chief Complaint: melena, weakness Major Surgical or Invasive Procedure: EGD ___ History of Present Illness: Ms. ___ is a ___ y/o female w/ a hx of primary biliary cirrhosis c/b portal hypertension, ascites, grade I esophageal varices s/p banding, portal hypertensive gastropathy, GAVE s/p multiple APC treatments, recurrent GI bleeds, and iron deficiency anemia who presents with lightheadedness, DOE, and melena. The patient reports a prolonged history of GAVE requiring frequent blood transfusions and repeat APC. She was also diagnosed with PBC based on liver biopsy showing stage ___ fibrosis and fibroscan in ___ c/w liver cirrhosis. An EGD on ___ showed grade I non bleeding varices, scarring in the distal esophagus, as well as extensive nodular portal hypertensive gastropathy s/p ligation of polypoid mass. She was then admitted to ___ from ___ for acute on chronic anemia secondary to upper GI bleed. At that time, she was transfused prn and treated w/ PPI, suclralfate, octreotide gtt, and ceftriaxone. Repeat EGD re-demonstrated known varices and GAVE, treated w/ APC with plan to repeat EGD in 1 month. Following, discharge the patient felt very well until ___ days ago when she began having progressive fatigue, which she attributed to not receiving an iron infusion. Over this time, she noted recurrent melanic stools (___). No hematochezia, abdominal pain, nausea, vomiting or diarrhea. She then developed ___ days of dyspnea on exertion, intermittent lightheadedness with movement, and palpitations. She describes a rapid heart beat that can happen at rest or with movement and resolves after ~10 seconds without treatment. She has had a history of similar symptoms, often when she is anemic. No shortness of breath at rest, headaches, weakness, numbness/tingling, syncope, chest pain, cough, fever, or chills. In the ED initial VS were T 98.9, HR 98, BP 109/73, RR 18, O2 99% on RA. Exam notable for conjunctival pallor, tachycardic, soft, non-tender abdomen, cold extremities, dark stool, stool guaiac positive Labs were revealing for: - Hbg 9.5 (from 8.8 on last discharge) - AST 44, ALT 24, AP 195, Tbili 0.6, Alb 2.9, lactate 1.2, trop <0.01 Studies performed include: - CXR: No acute cardiopulmonary abnormality Patient was given: - 1L NS, pantoprazole 40 mg IV, octreotide gtt, Zofran 4 mg IV, acetaminophen 1000 mg, 2u pRBC Consults: GI was consulted and recommended octreotide gtt, PPI, CTX, with admission to ET for possible EGD in the morning Vitals on transfer: Temp 98.5F BP 107/63 HR 81 RR 16 99% on RA Upon arrival to the floor, she reports feeling well, specifically with being here and after receiving 2u pRBC. She denies lightheadedness, dizziness, abdominal pain, melena or hematochezia. She refuses octreotide as it has caused recurrent headaches. No leg swelling, weight changes, abdominal distention, or confusion. Past Medical History: Primary biliary cirrhosis Hashimotos thyroiditis GAVE anemia s/p cholecystectomy s/p appendectomy Social History: ___ Family History: aunt with colon cancer in ___ mom with celiac disease Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: Temp 98.0F BP 118/73 HR 76 RR 21 100% on RA GENERAL: Elderly female in NAD. Lying comfortably in bed. HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without injection. MMM. Oropharynx clear. NECK: Supple. CARDIAC: RRR with normal S1 and S2. II/VI systolic murmur throughout, loudest over RUSB. No rubs or gallops. LUNGS: Normal respiratory effort. CTAB without wheezes, rales or rhonchi. ABDOMEN: Normal bowels sounds. Soft, obese, non-tender, non-distended. No guarding or masses. No fluid wave appreciated. EXTREMITIES: Warm, well perfused. Trivial ___ edema, no erythema. SKIN: Warm, dry. No rashes. NEUROLOGIC: A&Ox3. CN2-12 intact. ___ strength and normal sensation throughout. No asterixis. DICHARGE PHYSICAL EXAM: 24 HR Data (last updated ___ @ 742) Temp: 97.9 (Tm 98.4), BP: 92/60 (88-105/56-71), HR: 70 (70-79), RR: 18 (___), O2 sat: 98% (95-98), O2 delivery: Ra, Wt: 134.48 lb/61.0 kg (134.48-141.75) GENERAL: pleasant woman lying comfortably in bed. HEENT: NCAT. EOMI. Sclera anicteric and without injection. MMM. Oropharynx clear. NECK: Supple. CARDIAC: RRR with normal S1 and S2. II/VI systolic murmur throughout, loudest over RUSB. No rubs or gallops. LUNGS: Normal respiratory effort. CTAB. ABDOMEN: Soft, non-tender, non-distended. No guarding or masses. EXTREMITIES: Warm, well perfused. No ___ edema, no erythema. SKIN: Warm, dry. No rashes. NEUROLOGIC: A&Ox3. No asterixis. Pertinent Results: ADMISSION LABS: =============== ___ 03:27PM BLOOD WBC-5.1 RBC-3.44* Hgb-9.5* Hct-30.3* MCV-88 MCH-27.6 MCHC-31.4* RDW-21.5* RDWSD-68.9* Plt ___ ___ 03:27PM BLOOD Neuts-72.4* Lymphs-15.7* Monos-8.0 Eos-2.7 Baso-0.8 Im ___ AbsNeut-3.70 AbsLymp-0.80* AbsMono-0.41 AbsEos-0.14 AbsBaso-0.04 ___ 03:27PM BLOOD ___ PTT-28.0 ___ ___ 03:27PM BLOOD Glucose-92 UreaN-13 Creat-0.5 Na-144 K-3.9 Cl-110* HCO3-22 AnGap-___ 03:27PM BLOOD ALT-24 AST-44* AlkPhos-195* TotBili-0.6 ___ 03:27PM BLOOD cTropnT-<0.01 ___ 06:23AM BLOOD Calcium-8.2* Phos-3.8 Mg-1.9 STUDIES: ======== EGD (___) 3 cords of grade I varices seen in the distal esophagus. The varices were not bleeding. No stigmata of recent bleeding. Multiple nonbleeding ulcers found in the antrum and body of stomach. No active bleeding. All ulcers clean based. Consistent with GAVE and post-APC ulcers. Erythema and congestion in the body and fundus compatible with portal hypertensive gastropathy. DISCHARGE LABS: =============== ___ 05:25AM BLOOD WBC-3.7* RBC-3.38* Hgb-9.4* Hct-29.7* MCV-88 MCH-27.8 MCHC-31.6* RDW-19.8* RDWSD-63.7* Plt ___ ___ 05:25AM BLOOD ___ PTT-28.8 ___ ___ 05:25AM BLOOD Glucose-89 UreaN-14 Creat-0.5 Na-144 K-4.0 Cl-115* HCO3-20* AnGap-9* ___ 05:25AM BLOOD ALT-18 AST-31 LD(LDH)-171 AlkPhos-145* TotBili-0.5 ___ 05:25AM BLOOD Calcium-8.2* Phos-4.0 Mg-2.0 Iron-80 ___ 05:25AM BLOOD calTIBC-325 Ferritn-56 TRF-250 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 125 mcg PO DAILY 2. Rifaximin 550 mg PO BID 3. Sucralfate 1 gm PO QID 4. Ursodiol 900 mg PO DAILY 5. Furosemide 20 mg PO DAILY 6. Lactulose 15 mL PO BID 7. Pantoprazole 40 mg PO Q24H 8. Spironolactone 50 mg PO DAILY 9. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line Discharge Medications: 1. Furosemide 20 mg PO DAILY 2. Lactulose 15 mL PO BID 3. Levothyroxine Sodium 125 mcg PO DAILY 4. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line 5. Pantoprazole 40 mg PO Q24H 6. Rifaximin 550 mg PO BID 7. Spironolactone 50 mg PO DAILY 8. Sucralfate 1 gm PO QID 9. Ursodiol 900 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Melena GAVE Esophageal varices, PHG Primary Biliary Cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with PMH cirrhosis ___ PBC, p/w signs/sx GI bleed,. Recent admission with SOB.// PNA? TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph ___ FINDINGS: Heart size is normal. Mild atherosclerotic calcifications are seen in the aortic knob. 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. Mild S shaped scoliosis of the thoracolumbar spine is again seen. Clips are noted in the right upper quadrant of the abdomen. IMPRESSION: No acute cardiopulmonary abnormality. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Dizziness, Dyspnea Diagnosed with Gastrointestinal hemorrhage, unspecified, Dizziness and giddiness, Dyspnea, unspecified temperature: 98.8 heartrate: 98.0 resprate: 18.0 o2sat: 99.0 sbp: 109.0 dbp: 73.0 level of pain: 0 level of acuity: 2.0

SUMMARY STATEMENT: ================== ___ with history of primary biliary cirrhosis c/b portal hypertension (esophageal varices s/p banding, GAVE), iron deficiency anemia, s/p EGD ___ and repeat ___ with grade I varices and GAVE, who presents with lightheadedness, DOE, and Hgb 8.8 in setting recurrent melena. ACTIVE ISSUES: ============== # UGIB # Acute on chronic blood loss anemia Patient with repeat admissions for melena in setting of known GAVE s/p multiple APC treatments as well as ligation banding, and esophageal varices s/p banding. Patient required 2 u pRBC during hospital stay. Sucralfate was held. She declined octreotide gtt despite discussion regarding benefit and risks. She was treated with IV PPI and CTX 1 g daily until discharge. She remained hemodynamically stable and underwent an EGD on ___ with biopsy performed and pending at discharge. Her Hgb on discharge was 9.4. She was set up for outpatient IV iron transfusions. # Primary Biliary Cirrhosis (Child A/6, MELD 6) Past history of decompensation by HE, esophageal varices and GAVE, as well as ascites. No known history of SBP. Note that although liver transplant candidacy usually discussed after MELD >= 15, patient was interested in learning more about potential transplant. Given age and frailty, patient may not be appropriate transplant candidate at this time but will continue this discussion with her outpatient hepatologist. Her home lactulose and diuretics were held in setting of active upper GI bleed on admission. She did not have any signs of hepatic encephalopathy throughout her admission. CHRONIC/STABLE ISSUES: ====================== # ___ thyroiditis: Continued on home levothyroxine 125 mcg TRANSITIONAL ISSUES: ==================== [] Consider TTE given murmur [] Follow-up with outpatient hepatologist regarding EGD in 1 month for repeat ___ [] Patient should hear about outpatient iron transfusions starting next week for chronic blood loss anemia. [] ___: No concerning lesions on admission US. Will need outpatient screening q6 mo with RUQUS or other appropriate imaging [] HAV Ab negative. Consider vaccination. #CODE: FULL #CONTACT: Health care proxy chosen: No Info. offered to patient?: Yes Offered on date: ___ Comments: Pt wants her husband ___ ___ daughter to be her HCP. Pt advised to file HCP form with family.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal pain, nausea, emesis Major Surgical or Invasive Procedure: ___: Exploratory laparotomy, lysis of adhesions and right inguinal hernia repair with mesh. History of Present Illness: MR. ___ is an affable ___ year old male vasculopath with atrial fibrillation (taking pradaxa), CAD s/p stent placement, and revascularization of RLE including a R fem-AK pop bypass graft, with history of previous ventral incisional hernia repairs who presents with abdominal pain, nausea, and emesis. He has a known right inguinal hernia that is enlarged and intermittently tender. He recounts 3 day history of abdominal discomfort with nausea and NBNB emesis. He has decreased frequency of stools but had liquid stools earlier today. No flatus since this morning. No blood or melena. On evaluation in the ED, he is afebrile VSS. His heart rate is irregular but initially rate controlled. He appears dehydrated but in good spirits. His abdomen is rotund and firm but close to his baseline with diffuse abdominal tenderness. He has a large right inguinal hernia that is easily reducible at bedside. There are no overlying skin changes. Previous midline ventral hernias are without obvious fascial defects. His laboratory values are reassuring with no leukocytosis (WBC 5.1k) and a normalized lactate 2.5->1.3 after IVF resuscitation. A CTAP w/ contrast was initially thought to suggest SBO secondary to a RIH containing a portion of the cecum and terminal ileum. However, due to proximally collapsed small bowel and a narrow elongated intra-abdominal transition point well proximal to the reducible hernia, he likely has a partial SBO from intra-abdominal adhesions. An NGT was placed at bedside with copious bilious and gastric output. Past Medical History: PMH: High Cholesterol, HTN, afib, R femoral arterybypass , cardiac stent, hernia, borderline diabetes PSH: umbilical hernia repair ___) repair of recurrent incisional hernia with mesh ___ ___, exploratory laparotomy/removal of infected mesh/component separation ___ ___, recurrent laparoscopic incisional hernia repair ___ ___ Vascular PSH: Redo R fem-AK pop bypass w/GSV Right fem-AK-pop bypass graft with PTFE ___ ___, ___ ___, angiogram/lysis of occluded graft/stenting of distal anastamosis ___ ___, angiogram/AngioJet thrombectomy of DP artery ___ ___, angiogram/thrombolysis of occluded graft ___ ___, angiogram/PTA of in-stent stenosis ___ ___, diagnostic angiogram ___ ___ Social History: ___ Family History: Mother had heart problems and father died of a cancer that wrapped around his aorta. His brother had emphysema. Physical Exam: Admission Physical Exam: VS: 98.2F 90 126/76 16 99% RA Gen: affable, conversant older man, NAD CV: irregular irregular, initially HR controlled Pulm: b/l wheezing, no obvious crackles Abd: firm abdomen, with moderate diffuse tenderness on exam, no rebound or guarding, no peritoneal signs, old midline surgical scar well healed without any fascial defects right groin with reducible non-tender inguinal hernia, no overlying skin changes Ext: b/l ___ w/ DP pulses 2+; warm well perfused with brisk capillary refill and neurological intact Discharge Physical Exam: VS: T: 98.0, BP: 138/84, HR: 96, RR: 18, O2: 96% RA GENERAL: A+Ox3, NAD CV: regular rate, irregular rhythm PULM: CTA b/l ABD: soft, distended, non-tender, no rebound or guarding. Midline and RLQ surgical incision with staples intact, skin well-approximated without s/s infection. Extremities: warm, well-perfused, no edema. Pertinent Results: ___ 07:08PM LACTATE-1.3 ___ 07:00PM cTropnT-<0.01 ___ 05:10PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 05:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-2* PH-5.5 LEUK-NEG ___ 05:10PM URINE RBC-6* WBC-3 BACTERIA-NONE YEAST-NONE EPI-0 TRANS EPI-<1 ___ 05:10PM URINE HYALINE-52* ___ 05:10PM URINE MUCOUS-FEW ___ 02:10PM K+-4.6 ___ 01:17PM LACTATE-2.5* ___ 12:55PM ___ PTT-47.8* ___ ___ 12:50PM GLUCOSE-143* UREA N-28* CREAT-1.2 SODIUM-135 POTASSIUM-7.1* CHLORIDE-100 TOTAL CO2-21* ANION GAP-21* ___ 12:50PM ALT(SGPT)-23 AST(SGOT)-64* ALK PHOS-82 TOT BILI-0.5 ___ 12:50PM LIPASE-26 ___ 12:50PM cTropnT-<0.01 ___ 12:50PM ALBUMIN-4.1 CALCIUM-8.7 PHOSPHATE-4.7* MAGNESIUM-2.2 ___ 12:50PM WBC-5.1# RBC-5.29 HGB-15.8# HCT-49.2# MCV-93 MCH-29.9# MCHC-32.1 RDW-16.3* RDWSD-55.4* ___ 12:50PM NEUTS-55 BANDS-8* LYMPHS-15* MONOS-21* EOS-1 BASOS-0 ___ MYELOS-0 AbsNeut-3.21 AbsLymp-0.77* AbsMono-1.07* AbsEos-0.05 AbsBaso-0.00* ___ 12:50PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL ___ 12:50PM PLT SMR-NORMAL PLT COUNT-184 IMAGING: ___: EKG: Atrial fibrillation with a controlled ventricular response. Leftward axis. Right bundle-branch block. Other T wave abnormalities. Compared to the previous tracing of ___ the rate is now slower. Precordial voltage somewhat less prominent. Otherwise, unchanged. ___: CXR: A nasogastric tube is coiled within the mid esophagus. The heart size is normal. The hilar and mediastinal contours are within normal limits. There is no lobar consolidation, pneumothorax, or pleural effusion. ___: CT ABD/PELVIS: Right inguinal hernia containing a loop of ileum, with upstream small bowel obstruction. Distally decompressed bowel. No pneumatosis, fluid collection, or free air. ___: PORTABLE PICC: Since a recent radiograph from earlier today, a right PICC has been repositioned, now terminating in the region of the cavoatrial junction. No other relevant change. ___: ART DUP EXT LO UNI;F/U Patent right lower extremity arteries and femoral-popliteal bypass graft without evidence of stenosis. ___: ART EXT (REST ONLY): 1. Right distal tibial disease with resting ABI 1.02. 2. No evidence of arterial insufficiency in the left lower extremity with resting ABI 1.13. ___: Portable Abdomen: 1. No evidence of ileus or obstruction. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Dabigatran Etexilate 150 mg PO BID 2. Digoxin 0.125 mg PO DAILY 3. Diltiazem Extended-Release 360 mg PO DAILY 4. Gabapentin 300 mg PO TID 5. Metoprolol Tartrate 100 mg PO BID 6. Rosuvastatin Calcium 40 mg PO QPM 7. Sildenafil 100 mg PO ASDIR 8. TraZODone 50 mg PO QHS 9. Aspirin 325 mg PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Docusate Sodium 100 mg PO QHS 12. Senna 8.6 mg PO QHS 13. Vitamin E 400 UNIT PO DAILY Discharge Medications: 1. Dabigatran Etexilate 150 mg PO BID 2. Digoxin 0.125 mg PO DAILY 3. Diltiazem Extended-Release 360 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Metoprolol Tartrate 100 mg PO BID 6. Senna 8.6 mg PO BID:PRN constipation 7. Acetaminophen 1000 mg PO Q6H:PRN pain 8. Aspirin 325 mg PO DAILY 9. Gabapentin 300 mg PO TID 10. Multivitamins 1 TAB PO DAILY 11. Rosuvastatin Calcium 40 mg PO QPM 12. Sildenafil 100 mg PO ASDIR 13. Vitamin E 400 UNIT PO DAILY 14. Polyethylene Glycol 17 g PO DAILY:PRN constipation 15. TraZODone 50-100 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: Small bowel obstruction and right inguinal hernia. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with severe diffuse abdominal pain, nausea and vomiting for 3 daysNO_PO contrast // Evaluate for enteritis, colitis, appendicitis, 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: Total DLP (Body) = 910 mGy-cm. COMPARISON: CT abdomen ___, CT chest ___ FINDINGS: LOWER CHEST: There is mild dependent atelectasis bilaterally. There is no evidence of pleural or pericardial effusion. Mitral annular calcification is similar to ___. A 2 mm right base pulmonary nodule is unchanged from ___. 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 suspicious renal lesions or hydronephrosis. Simple cyst in the lateral left upper pole measures up to 2.8 cm, smaller compared to ___. Simple cyst in the medial left upper pole measures up to 2.6 cm, similar to ___. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is distended. There are dilated, fluid-filled proximal small bowel loops with air-fluid levels beginning at the proximal jejunum. In the left lower quadrant, there is a loop of small bowel which gradually narrows with some fecalized small bowel contents in a loop in the lower abdomen (601:33). Distal to this, loops of small bowel are entirely collapsed, leading to a right inguinal hernia which contains a portion of the terminal ileum as well as a portion of the cecum. There is a small amount of free fluid in the hernia sac. Small bowel loops demonstrate normal wall thickness and enhancement. The colon and rectum are predominantly collapsed. Diverticulosis of the transverse, descending, and sigmoid colon is worst in the sigmoid, without evidence of wall thickening or 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 reproductive organs are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: Ventral hernia repair mesh is again seen. IMPRESSION: 1. Small-bowel obstruction without a discrete transition point, but with a long zone of gradual narrowing in the left lower quadrant with distally decompressed small bowel. This distally decompressed small bowel eventually leads into a right inguinal hernia containing cecum and terminal ileum with adjacent free fluid. 2. No fluid collection. Radiology Report EXAMINATION: Chest radiograph INDICATION: ___ man with small bowel obstruction. Evaluate NG tube placement. TECHNIQUE: Portable upright AP radiograph view of the chest. COMPARISON: Chest radiograph dated ___. FINDINGS: The tip of the NG tube projects over the midline, in the distal esophagus. The heart size is mild-to-moderately enlarged. Central pulmonary vascular congestion is minimal. Mild left basilar atelectasis. No frank pulmonary edema, pleural effusion, or pneumothorax. IMPRESSION: 1. NG tube probably in distal esophagus. 2. Cardiomegaly and central pulmonary congestion. RECOMMENDATION(S): Advance NG-tube at least 10-15 cm to the stomach. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man SBO s/p NGT placement // eval for NGT position TECHNIQUE: Single frontal view of the chest COMPARISON: Study performed 3 hours earlier. IMPRESSION: NG tube tip isin the stomach. No other interval change from prior study. Radiology Report INDICATION: SBO. TECHNIQUE: Frontal chest radiograph. COMPARISON: Radiographs from ___. IMPRESSION: A nasogastric tube is coiled within the mid esophagus. The heart size is normal. The hilar and mediastinal contours are within normal limits. There is no lobar consolidation, pneumothorax, or pleural effusion. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 1:21 ___, 12 minutes after discovery of the findings. Radiology Report EXAMINATION: CT abdomen and pelvis with contrast INDICATION: ___ y/o M HD5 w/ SBO, symptoms improving on ___, now w/ decreased bowel function, nausea, NGT reinsertion. Interval change- please use oral and 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) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 21.7 mGy (Body) DLP = 10.8 mGy-cm. 2) Spiral Acquisition 4.8 s, 52.4 cm; CTDIvol = 17.0 mGy (Body) DLP = 888.8 mGy-cm. Total DLP (Body) = 900 mGy-cm. COMPARISON: CT abdomen and pelvis on ___. FINDINGS: LOWER CHEST: There is mild bibasilar atelectasis. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. Again seen are two simple cysts arising from the right kidney, measuring 2.5 cm and 2.8 cm. There is no evidence of suspicious focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: An enteric tube terminates in the stomach. Again seen are multiple dilated loops of small bowel, with a transition point now located in a right inguinal hernia, which also contains a small amount of fluid and a loop of the ileum (601b: ___ 2:86). The cecum was previously included within the hernia on the ___ examination, but is not currently involved. There is a downstream loop of nondistended bowel containing fluid, with more distal complete collapse of the small bowel. There is no pneumatosis or abnormal wall enhancement. There is no free air. Diverticulosis of the colon is noted, without evidence of wall thickening and fat stranding. 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. Moderate atherosclerotic disease is noted. BONES: There is an old spinous process fracture at the level of L3 (2:43). There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: There is a right inguinal hernia containing small bowel with a transition point, and a small amount of free fluid (2:86). There is mesh in the anterior abdominal related to prior ventral hernia repair. IMPRESSION: Right inguinal hernia containing a loop of ileum, with upstream small bowel obstruction. Distally decompressed bowel. No pneumatosis, fluid collection, or free air. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 2:42 ___, 20 minutes after discovery of the findings. Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old man with new line // new right PICC 53 cm ___ ___ Contact name: ___: ___ new right PICC 53 cm ___ ___ IMPRESSION: COMPARED TO CHEST RADIOGRAPHS ___ THROUGH ___. NEW RIGHT PIC LINE EXTENDS INTO THE LEFT SUBCLAVIAN VEIN, NO LESS THAN 8 CM BEYOND THE ORIGIN OF THE SVC. ESOPHAGEAL DRAINAGE TUBE PASSES INTO THE DISTAL STOMACH. MODERATE CARDIOMEGALY IS MORE PRONOUNCED. RIGHT LUNG IS CLEAR ALTHOUGH THE PULMONARY VASCULATURE IS ENGORGED. HETEROGENEOUS OPACIFICATION LATERAL TO THE LEFT HILUS COULD BE EARLY PNEUMONIA. NO PLEURAL ABNORMALITY. Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old man with PICC // Pt had a picc pulled backed 3cm needs repeat ___ ___ Contact name: ___: ___ IMPRESSION: Since a recent radiograph from earlier today, a right PICC has been repositioned, now terminating in the region of the cavoatrial junction. No other relevant change. Radiology Report EXAMINATION: ART DUP EXT LO UNI;F/U RIGHT INDICATION: ___ year old man s/p redo RLE bypass ___ // s/p RLE redo BPG; eval patency TECHNIQUE: Grayscale, color, and spectral Doppler ultrasound images were obtained of the right lower extremity arteries and graft. COMPARISON: ___. FINDINGS: The right common femoral artery is patent with triphasic waveforms and a peak systolic velocity of 99 cm/s. The right femoral popliteal graft is patent with triphasic waveforms throughout and peak systolic velocity is as follows: Proximal anastomosis: 53 cm/s Proximal thigh: 121 cm/s Mid thigh: 95 cm/s Distal thigh: 100 cm/s Distal graft: 85 cm/s Distal anastomosis: 90 cm/s The popliteal artery is patent with multiphasic waveforms and a peak systolic velocity of 49 cm/s. IMPRESSION: Patent right lower extremity arteries and femoral-popliteal bypass graft without evidence of stenosis. Radiology Report EXAMINATION: ART EXT (REST ONLY) INDICATION: ___ year old man s/p redo RLE bypass ___ // s/p redo BPG, eval patency TECHNIQUE: Non-invasive evaluation of the arterial system in the lower extremities was performed with Doppler signal recording, pulse volume recordings and segmental limb pressure measurements. COMPARISON: None FINDINGS: On the right side, monophasic waveforms are seen in the posterior tibial and dorsalis pedis arteries. The right ABI was 1.02. On the left side, triphasic Doppler waveforms are seen in the posterior tibial and dorsalis pedis arteries. The left ABI was 1.13. Pulse volume recordings showed dampened amplitudes at the level of the right ankle and metatarsals as compared the left. IMPRESSION: 1. Right distal tibial disease with resting ABI 1.02. 2. No evidence of arterial insufficiency in the left lower extremity with resting ABI 1.13. Radiology Report INDICATION: ___ y/o M ___ s/p exlap, LOA, R inguinal hernia repair, now w/ abd distention // eval for ileus, dilated loops of bowel TECHNIQUE: Supine abdominal radiograph was obtained. COMPARISON: CT abdomen and pelvis ___ FINDINGS: There are no abnormally dilated loops of large or small bowel. Supine assessment limits detection for free air; there is no gross pneumoperitoneum. A 1.0 cm calcific density projecting over the right upper quadrant is likely contrast containing diverticulum seen on prior CT abdomen and pelvis from ___. Osseous structures are unremarkable. Postsurgical clips are noted along the mid abdomen. Mesh along the anterior abdominal wall is related to prior ventral hernia repair. IMPRESSION: 1. No evidence of ileus or obstruction. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: n/v/d, Abd pain Diagnosed with Unil inguinal hernia, w obst, w/o gangr, not spcf as recur temperature: 96.7 heartrate: 79.0 resprate: 20.0 o2sat: 98.0 sbp: 143.0 dbp: 72.0 level of pain: 10 level of acuity: 3.0

Mr. ___ is a ___ year-old male with history of previous ventral incisional hernia who presented to ___ on ___ with abdominal pain, nausea, and emesis. He had history of a right inguinal hernia was enlarged and tender on admission and he reported a decrease in frequency of stools and flatus. CT abdomen/pelvis revealed a small-bowel obstruction without a discrete transition point and he was admitted to the Acute Care Surgery service for further medical care. The patient was initially managed conservatively and had a nasogastric tube placed, was made NPO with IVF. The patient did not have return of bowel function with conservative management. On ___, the patient was consented for the OR and underwent exploratory laparotomy, lysis of adhesions and right inguinal hernia repair with mesh. The patient tolerated this procedure well and had a nasogastric tube placed for bowel decompression (reader, please refer to operative note for details). The patient remained hemodynamically stable in the PACU and was transferred to the surgical floor. Once the patient passed flatus, the patient's NGT was clamped and did not demonstrate significant residual when placed back to suction. The NGT was removed and the patient's diet was gradually advanced. The patient was alert and oriented throughout hospitalization; pain was initially managed with IV pain medication and then transitioned to oral oxycodone and acetaminophen once tolerating a diet. The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. The patient remained stable from a pulmonary standpoint. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. Patient's intake and output were closely monitored. The patient's foley catheter was removed and the patient voided without issue. The patient's 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. The patient's home Pradaxa was held as an inpatient due to risk of bleeding with surgery and the patient received subcutaneous heparin. ___ 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 patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan.

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: gluten / seasonal allergy Attending: ___. Chief Complaint: Petechiae, easy bruising, night sweats, headaches Major Surgical or Invasive Procedure: bone marrow biopsy, left subclavian central venous line History of Present Illness: ___ with history of Stage I breast cancer s/p XRT completed ___, HTN who presents from ___'s office with leukocytosis of 382. Several months ago, pt began to notice some left-sided abdominal pain. No changes in bowel habits and no issues with nausea/vomiting. Over the past few weeks, has noticed worsening fatigue and DOE, as well as a headache, bruising, and drenching night sweats. In the past few days, DOE and fatigue has become very limiting. She has also noticed a blurry spot in her vision. Went to PCP morning prior to admission for these issues, had blood work done that was remarkable for leukocytosis to 382, and was sent to the ED for further work-up. Seen by ___ in the ED, who recommended q6hr monitoring of tumor lysis labs and DIC labs. Bone marrow biopsy was done, revealing concentrated blasts. In the ED, initial vitals: T 98.8, BP 125/64, HR 89, RR 16, SpO2 96/RA - Exam notable for: - Labs were notable for: WBC 395.2, H/H ___, plt 27, uric acid 8.5, LDH 1341, fibrinogen 242, INR 1.2, Cr 1.0 - Imaging: none - Patient was given: 2L NS, 10mg IV metoclopramide, 300mg PO allopurinol, 1g PO acetaminophen, 1g hydroxyurea - Consults: ___ On arrival to the MICU, pt is stable and reports that her headache and blurry vision has subsided. Vitally stable. Review of systems: As per HPI Past Medical History: breast cancer - R invasive carcinoma with tubular features, s/p partial mastectomy, sentinel node biopsy and radiation atypical Celiac's disease hypertension anxiety arthritis cervical spondylosis with myelopathy Social History: ___ Family History: father with 'heart disease', died ___ of possible CHF, grandfather died MI early ___ no history of early MI, CHF, arrhythmia. Physical Exam: ADMISSION PHYSICAL EXAM ======================= Vitals: T 98.2, BP 97/75, HR 73, RR 20, SpO2 96/RA HEENT: AT/NC, EOMI, PERRL, anicteric sclera, MMM, good dentition NECK: no JVD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, mild TTP in LLQ, no rebound/guarding EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, strength ___ in major muscle groups, sensation is grossly intact DISCHARGE PHYSICAL EXAM ======================= Vitals: 97.8 PO 100 / 60 73 18 98 RA 24Hr I/O: 2036/650 wt: 183.29 (wt 7 days ago: 182.3 lb) Gen: Pleasant, calm female in NAD, lying in bed wearing hat HEENT: No conjunctival pallor. No icterus. MMM. OP clear without thrush. NECK: JVP flat. Normal carotid upstroke without bruits. LYMPH: No cervical or supraclav LAD CV: Normocardic, regular. Normal S1,S2. No MRG. LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. ABD: NABS. Soft, NT, ND. EXT: WWP. No ___ edema. SKIN: Small ecchymosis on L dorsal forearm, R elbow, all stable. Otherwise no rashes/lesions. NEURO: CN II-XII intact. A&Ox3. LINES: Left Hickman, c/d/I mild oozing of blood, no tenderness to palpation. Pertinent Results: ADMISSION LABS ============== ___ 02:30PM WBC-382.0*# RBC-2.66*# HGB-7.7*# HCT-26.2*# MCV-99*# MCH-28.9 MCHC-29.4*# RDW-21.2* RDWSD-56.2* ___ 02:30PM NEUTS-0* BANDS-3 LYMPHS-2* MONOS-0 EOS-1 BASOS-0 ___ METAS-1* MYELOS-0 BLASTS-93* OTHER-0 AbsNeut-11.46* AbsLymp-7.64* AbsMono-0.00* AbsEos-3.82* AbsBaso-0.00* ___ 02:30PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-NORMAL ___ 02:30PM UREA N-17 CREAT-0.9 SODIUM-140 POTASSIUM-3.7 CHLORIDE-99 TOTAL CO2-29 ANION GAP-16 ___ 02:30PM ALT(SGPT)-26 AST(SGOT)-39 ALK PHOS-87 ___ 02:30PM CALCIUM-9.4 ___ 02:30PM TSH-1.1 ___ 02:30PM GLUCOSE-104* ___ 09:53PM RET AUT-1.7 ___ 09:53PM QUAN G6PD-17.6* ___ 09:53PM ___ 09:53PM ___ PTT-27.5 ___ PERTINENT LABS/MICROBIOLOGY/PATHOLOGY ===================================== ___ 01:00AM BLOOD Fibrino-69*# ___ 09:53PM BLOOD QG6PD-17.6* ___ 09:53PM BLOOD Ret Aut-1.7 ___ 09:53PM BLOOD ALT-26 AST-44* LD(LDH)-1341* CK(CPK)-59 AlkPhos-83 TotBili-0.5 ___ 12:40AM BLOOD ___ ___ 09:00PM BLOOD TSH-0.52 ___ BONE MARROW BIOPSY: hypercellular bone marrow with extensive involvement by B lymphoblastic leukemia ___ BONE IMMUNOPHENOTYPING: CD34+ blasts comprise 97% of total analyzed events. Cell marker analysis demonstrates that the majority (97%) of the cells isolated from this peripheral blood/bone marrow are in the CD45-dim/low side-scatter "blast" region. They express CD38, immature antigens CD34, ___, nTdT (subset), and lymphoid associated antigens CD19, cCD79a (small subset). They lack B and T cell associated antigens, are CD10 (cALLa) negative, and are negative for CD13, CD33, CD14, CD64, CD117, cMPO, cCD3, cCD22, and CD15. The CD19+ blasts are negative by cKappa and cLambda. ___ CYTOGENETIC DIAGNOSIS: 46,XX,t(4;11)(q21;q23)[9]/46,XX[9], FISH negative for BCR/ABL, positive for MLL rearrangement, negative high grade lymphoma panel DISCHARGE LABS ============== ___ 12:00AM BLOOD WBC-1.2* RBC-2.44* Hgb-7.2* Hct-21.3* MCV-87 MCH-29.5 MCHC-33.8 RDW-15.0 RDWSD-43.4 Plt ___ ___ 12:00AM BLOOD Neuts-45 Bands-3 ___ Monos-7 Eos-0 Baso-0 ___ Myelos-0 AbsNeut-0.58* AbsLymp-0.54* AbsMono-0.08* AbsEos-0.00* AbsBaso-0.00* ___ 12:00AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL ___ 12:00AM BLOOD ___ PTT-24.8* ___ ___ 12:00AM BLOOD Glucose-118* UreaN-14 Creat-0.6 Na-138 K-4.2 Cl-102 HCO3-26 AnGap-14 ___ 12:00AM BLOOD ALT-70* AST-28 LD(LDH)-230 AlkPhos-75 TotBili-0.4 ___ 12:00AM BLOOD Albumin-4.0 Calcium-8.8 Phos-4.7* Mg-2.2 IMAGING ======= TTE ___ The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF = 70%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the prior study (images reviewed) of ___, findings are similar. CT HEAD WITHOUT CONTRAST ___ No acute intracranial abnormalities. CHEST PA/LAT ___ Low lung volumes with suspected atelectasis in the left lung base. MRI HEAD ___ No evidence of hemorrhage, edema, mass, mass effect, or acute infarction. U/S RIGHT FOOT ___ 1.9 x 1.5 cm cystic structure corresponding to the palpable abnormality is most consistent with a ganglion. TUNNELED CENTRAL LINE ___: Successful placement of a triple-lumen tunneled line via the left internal jugular venous approach. The tip of the catheter terminates in the right atrium. The catheter is ready for use. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Nadolol 20 mg PO DAILY 2. Hydrochlorothiazide 12.5 mg PO DAILY 3. DULoxetine 60 mg PO DAILY 4. mometasone 50 mcg/actuation nasal 2 SPRAYS EACH NOSTRIL, DAILY:PRN 5. Cetirizine 10 mg PO DAILY 6. Vitamin D 1000 UNIT PO DAILY 7. Docusate Sodium 100 mg PO Frequency is Unknown 8. Senna 8.6 mg PO BID:PRN constipation 9. flaxseed oil 1,000 mg oral unknown 10. lutein 6 mg oral unknown 11. lysine 1,000 mg oral unknown Discharge Medications: 1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN Headache RX *butalbital-acetaminophen-caff 50 mg-300 mg-40 mg 1 capsule(s) by mouth twice a day Disp #*10 Capsule Refills:*0 2. Acyclovir 400 mg PO TID RX *acyclovir 400 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 3. melatonin 4 mg oral QHS 4. Omeprazole 40 mg PO DAILY RX *omeprazole 40 mg 1 capsule(s) by mouth once a day Disp #*30 Capsule Refills:*0 5. Ondansetron ODT 4 mg PO Q8H:PRN nausea Duration: 5 Days RX *ondansetron 4 mg 1 tablet(s) by mouth three times a day Disp #*21 Tablet Refills:*0 6. Simethicone 40-80 mg PO QID:PRN bloating RX *simethicone 125 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 8. Zolpidem Tartrate 5 mg PO QHS RX *zolpidem 5 mg ` tablet(s) by mouth at bedtime Disp #*5 Tablet Refills:*0 9. Docusate Sodium 100 mg PO BID:PRN constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*10 Capsule Refills:*0 10. Cetirizine 10 mg PO DAILY 11. DULoxetine 60 mg PO DAILY 12. flaxseed oil 1,000 mg oral unknown 13. lutein 6 mg oral unknown 14. lysine 1,000 mg oral unknown 15. mometasone 50 mcg/actuation nasal 2 SPRAYS EACH NOSTRIL, DAILY:PRN 16. Nadolol 20 mg PO DAILY 17. Senna 8.6 mg PO BID:PRN constipation RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*10 Tablet Refills:*0 18. Vitamin D 1000 UNIT PO DAILY 19. HELD- Hydrochlorothiazide 12.5 mg PO DAILY This medication was held. Do not restart Hydrochlorothiazide until told to by your primary care doctor or oncologist Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY: Acute lymphocytic leukemia SECONDARY: Pancytopenia Headache Transaminitis Obstructive sleep apnea Ganglion cyst Hypertension Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST. INDICATION: ___ year old woman with new diagnosis acute leukemia // eval for e/o ischemia. 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) 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 provided. FINDINGS: There is no evidence of infarction, hemorrhage, edema or mass. Basal cisterns are patent and there is preservation of gray-white matter differentiation. There is no shift of normally midline structures. Ventricles and sulci are normal in overall size and configuration. No osseous abnormalities identified. Minimal mucosal thickening of the bilateral sphenoid sinuses. Otherwise, the remaining visualized paranasal sinuses, mastoid air cells and middle ear cavities are clear. Visualized portions of the orbits are unremarkable. Atherosclerotic calcification of the cavernosal carotid arteries is noted. IMPRESSION: No acute intracranial abnormalities. Please note that MRI is more sensitive in the detection of acute infarction. Radiology Report INDICATION: ___ with history of breast cancer, HTN who presents with significant leukocytosis in the setting of night sweats, weight loss, easy bruising with high concern for new acute leukemia. // r/o mediastinal mass, other acute cardiopulmonary process TECHNIQUE: Chest PA and lateral COMPARISON: ___ FINDINGS: The heart size is normal. The hila are normal. Low lung volumes. Linear opacification the left lung base most likely represents atelectasis. No lobar consolidation. No pleural effusion. Surgical clips in situ in the right breast and right chest wall. IMPRESSION: Low lung volumes with suspected atelectasis in the left lung base. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old woman with acute leukemia, new left subclavian line // left subclavian CVL placement Contact name: ___: ___ TECHNIQUE: Chest single view COMPARISON: ___ 11:50 FINDINGS: Left subclavian central line tip in the low SVC. No pneumothorax. Stable left basilar opacity, likely atelectasis. Surgical clips right breast. Normal heart size, pulmonary vascularity. Postoperative changes, hardware in place in the partially visualized cervical spine. IMPRESSION: New central line, no pneumothorax. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD INDICATION: ___ with history of Stage I breast cancer s/p XRT presenting with ALL, now with RUE paresthesia, evaluate for any evidence of CNS disease TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of 8 mL of Gadavist intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: None. FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or acute infarction. A punctate focus of FLAIR signal hyperintensity in the left centrum semiovale is nonspecific (07:16). The ventricles and cisterns are age-appropriate. Principal intracranial vascular flow voids are preserved and arteries of the circle ___ and ___ venous sinuses enhance appropriately. Fetal origin of the right posterior cerebral artery is noted. There is no abnormal parenchymal or meningeal enhancement. IMPRESSION: No evidence of hemorrhage, edema, mass, mass effect, or acute infarction. Radiology Report EXAMINATION: CHEST (PORTABLE AP) IN O.R. INDICATION: ___ year old woman with newly diagnosed ALL. Receiving consistent fluids for prevention of tumor lysis. // Please eval for pulmonary edema. Please eval for pulmonary edema. IMPRESSION: Compared to chest radiographs since ___, most recently ___. Left subclavian line ends in the low SVC. No pneumothorax pleural effusion or mediastinal widening. Lungs lung volume but clear of any focal abnormality aside from left basal atelectasis. Normal cardiomediastinal and hilar silhouettes. Radiology Report EXAMINATION: US MSK FOOT/TOE RIGHT INDICATION: ___ woman with new ALL with cystic lesion on the dorsum right foot. TECHNIQUE: Targeted grayscale and color Doppler images of the dorsum of the right foot. COMPARISON: None. FINDINGS: A targeted ultrasound in the region of palpable abnormality in the dorsum of the right foot between the first and second digit demonstrates a 1.9 x 1.4 x 1.5 cm anechoic structure, with minimal internal debris and posterior through transmission. There is no associated vascularity. IMPRESSION: 1.9 x 1.5 cm cystic structure corresponding to the palpable abnormality is most consistent with a ganglion. RECOMMENDATION(S): Imaging follow-up can depend on patient's clinical symptoms. Radiology Report INDICATION: ___ year old woman with ALL possible HSCT, needs ___ ___ // please place triple lumen power tunneled access line ___ aware COMPARISON: ___. TECHNIQUE: OPERATORS: Dr. ___ resident 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 100 mcg of fentanyl and 2 mg of midazolam throughout the total intra-service time of 30 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. Fluoro time: 0.1 min, dose: 2 mgy PROCEDURE: 1. Tunneled non-dialysis line placement PROCEDURE DETAILS: Following the explanation of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The access site 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 triple-lumen 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. 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 each lumen was capped. The catheter was sutured in place with 0 silk sutures. Dermabond and Steri-strips were used to close the venotomy incision site. Steri-Strips were applied. Sterile dressings were applied. The patient tolerated the procedure well. The patient's prior temporary left IJ tunneled line was removed at the end of the procedure. FINDINGS: Patent left internal jugular vein. Final fluoroscopic image showing left internal jugular vein approach triple-lumen tunneled catheter with tip terminating in the right atrium. IMPRESSION: Successful placement of a triple-lumen tunneled line via the left internal jugular venous approach. The tip of the catheter terminates in the right atrium. The catheter is ready for use. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Abd pain, Dyspnea, Elevated wbc Diagnosed with Leukemia, unspecified not having achieved remission temperature: nan heartrate: 89.0 resprate: 18.0 o2sat: 97.0 sbp: 130.0 dbp: 75.0 level of pain: 6 level of acuity: 2.0

___ with history of breast cancer, HTN who presents with significant leukocytosis in the setting of night sweats, weight loss, easy bruising with blasts in periphery and bone marrow consistent with acute leukemia. #ACUTE LEUKEMIA: Leukocytosis to 395 on admission. Seen by ___ in ED and continued to follow while in the ICU. Bone marrow biopsy shows high blast count, no Auer rods. She was started on allopurinol and hydroxyurea in ED. Initial labs not concerning for tumor lysis syndrome or DIC and were trended every 6 hours through her ICU course. She was started on fluid resuscitation with urine output maintained at over 100cc/hr. Head CT and CXR were performed that showed no acute processes. Ophthalmology consult performed and found retinal hemorrhage on the L which corresponds to her area of endorsed blind spot. Bone marrow biopsy x 2 was performed. FISH, flow cytometry, cytogeneics, rapid heme panel were performed and were significant for Ph negative pre-B ALL. She was given one dose of rasburicase, started on prednisone, and hydrea. During ICU course WBC count down from 385K to 115K without signs of tumor lysis in ICU. She was given prophylaxis with acyclovir, PPI, and allopurinol. She was subsequently transferred to the floor under the ___ service. She was enrolled in ___ clinical trial ___, which entails: Cytarabine (IT day 1); Daunorubicin (days 1, 8, 15, 22); Vincristine (days 1, 8, 15, 22); Dexamethasone (days ___ Methotrexate (IT day 14). TTE was obtained prior to chemo and showed LVEF 70%. She began chemotherapy on ___ and tolerated it well. She was continued on IVF to target UOP of 100cc/hr. Allopurinol was continued for TLS prevention (days ___, per protocol). She was diuresed as needed for volume overload. She refused transfusion as necessary to treat her anemia and thrombocytopenia. Ciprofloxacin and Fluconazole were also started for prophylaxis. #ALL: Ph- pre-B ALL, with MLL. Patient is D25 of induction chemotherapy as per protocol. She has been enrolled in trial ___, which entails: Cytarabine (IT day 1); Daunorubicin (days 1, 8, 15, 22); Vincristine (days 1, 8, 15, 22); Dexamethasone (days ___ Methotrexate (IT day 14). TTE ___ with EF 70%. Notably, she did not receive Peg-asparaginase as she is >___. Bone marrow biopsy was done prior to discharge, results are pending and will be followed by Dr. ___. Given ANC > 500 will Ciprofloxacin and Fluconazole were discontinued. #NAUSEA: will discharge with zofran ODT 4 mg, ativan 0.5mg PO as needed for nausea. CHRONIC ISSUES ========================== #TRANSAMINITIS. Labs notable for ALT 50-70 chronically otherwise WNL. Possibly due to Ciprofloxacin, Fluconazole. Also possible effect of chemotherapy. Will continue to monitor. #INSOMNIA. Pt currently taking home Melatonin, but reports ongoing insomnia despite receiving this as well as Trazodone. She was also given Diphenhydramine ___ qhs PRN. Finally relief was achieved with ambien. #HYPERTENSION: on nadolol and hydrochlorothiazide at home. SBPs 90-110s on arrival to ___. Held nadolol and HCTZ. #HEADACHE. Patient reported headache intermittently. She was given Fioricet for symptomatic relief. Opiates were avoided. #RIGHT FOOT NODULE. Previously noted to have nodule on dorsal R foot, believed to be consistent with ganglion cyst. No discomfort, pain, itching from this. U/s obtained ___ and was consistent with ganglion. #OXYGEN REQUIREMENT. Pt reports a history of OSA, but does not use CPAP at home. Respiratory therapy consulted ___ and offered CPAP, but pt declined. She used nasal cannula oxygen overnight. #HISTORY OF VESTIBULITIS. Unclear nature of her vestibulitis/ataxia, but per report, she may have been diagnosed by her previous oncologist, Dr. ___, with atypical celiac disease, with neurological manifestations. So far no documentation has been found regarding this. Symptoms resolved without intervention (per patient). We spoke to Dr. ___ ___ ___ they stated she has never been seen by him (had a new patient appt on ___. #DEPRESSION. Well controlled on Cymbalta. Continued home Cymbalta. TRANSITIONAL ISSUES ==================================== [ ] follow-up with line care training at home [ ] follow-up appointment on ___ with Dr. ___ for ongoing ALL management

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Beta-Blockers (Beta-Adrenergic Blocking Agts) / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) Attending: ___. Chief Complaint: left distal tibia, proximal fibula fracture Major Surgical or Invasive Procedure: Left distal tibia fracture and fibula fracture reduction and fixation ___ History of Present Illness: ___ man with history of HTN, CKD, hypothyroidism, GERD, borderline DM who presented after a fall in the bathroom at 3am today, sustaining a spiral distal tibia and proximal fibula fracture. Mr. ___ described he reached out to hold a towel bar which broke and gave way, leading to the fall. He had been feeling fine prior to this, although is using a walker for left hip pain, with a possible planned hip replacement. He denies having had dizziness, lightheadedness, CP, SOB prior to the episode. There was no LOC or head strike. He was not able to weight bear, and crawled out of the bathroom. He was brought to an OSH ED, found to have fractures above, and transferred here for surgical evaluation. Underwent ORIF today which was uncomplicated. Per the anesthesia report, he was given 1L LR, EBL was 100ml, MAPs ___ throughout. Past Medical History: -HTN -CKD (unknown baseline creatinine but follows with renal per pt) -Hypothyroidism -GERD -depression -anxiety -neuropathy (unclear etiology) -s/p small bowel resection and 'stomach surgery' at ___ ___ in ___ (patient cannot recall why he had this surgery) -s/p right hip replacement, right knee replacement, right shoulder replacement Social History: ___ Family History: Father died from unknown cancer at ___. Mother died at ___ from heart disease Physical Exam: ADMISSION PHYSICAL EXAM ======================== In general, the patient is a well appearing ___ lying in stretcher Vitals: T 97.3dF HR 44 BP 152/52 RR 16 SpO2 96% RA Right lower extremity: Skin intact Soft, non-tender thigh and leg Full, painless AROM/PROM of hip, knee, and ankle ___ fire +SILT SPN/DPN/TN/saphenous/sural distributions ___ pulses, foot warm and well-perfused Left lower extremity: Skin intact Soft, non-tender thigh, slight discomfort with palpation at the distal tibia Range of motion testing deferred due to pain ___ fire +SILT SPN/DPN/TN/saphenous/sural distributions ___ pulses, foot warm and well-perfused DISCHARGE PHYSICAL EXAM ======================== Vitals: 98.3 170/61 86 18 93% on RA Orthostatics: Laying 107/42 52 Sitting 101/49 103 (unclear if this heart rate is truely accurate) Standing 97/44 62 General: no acute distress HEENT: NCAT CV: normal rate, regular rhythm, ___ systolic murmur Lungs: crackles heard at lung bases bilaterally, otherwise clear Abdomen: normoactive bowel sounds, soft, nontender, nondistended Ext: LLE in cast/ACE wrap Pertinent Results: ADMISSION LABS =============== ___ 07:53AM BLOOD WBC-12.6* RBC-3.02* Hgb-9.7* Hct-29.5* MCV-98 MCH-32.3* MCHC-33.0 RDW-17.6* Plt ___ ___ 07:53AM BLOOD Neuts-70.5* ___ Monos-6.9 Eos-2.0 Baso-0.6 ___ 07:53AM BLOOD ___ PTT-30.4 ___ ___ 07:53AM BLOOD Glucose-131* UreaN-40* Creat-2.4* Na-142 K-5.0 Cl-98 HCO3-36* AnGap-13 DISCHARGE LABS ============== ___ 05:50AM BLOOD WBC-13.4* RBC-2.72* Hgb-8.7* Hct-26.3* MCV-97 MCH-31.9 MCHC-33.1 RDW-18.2* Plt ___ ___ 05:50AM BLOOD Plt ___ ___ 05:50AM BLOOD Glucose-175* UreaN-30* Creat-1.7* Na-143 K-4.4 Cl-104 HCO3-28 AnGap-15 ___ 05:50AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.0 MICROBIOLOGY ============= ___ 3:44 am URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. FOSFOMYCIN REQUESTED BY ___. ___ ___. ZONE SIZE FOR FOSFOMYCIN IS 22 MM. Zone size determined using a method that has not been standardized for this drug- organism combination and for which no CLSI or FDA-approved interpretative standards exist. Interpret results with caution. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | AMIKACIN-------------- <=2 S CEFEPIME-------------- 2 S CEFTAZIDIME----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM------------- 4 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 8 I RADIOLOGY =========== (PER ORTHO ADMISSION NOTE) IMAGING: Plain film imaging of the LLE demonstrates an angulated, spiral pattern distal tibia fracture which does not extend to the ankle joint, with concomitant proximal fibula fracture. CXR ___ In comparison with the study of ___, there are continued low lung volumes. Mild atelectatic changes are seen at the bases, without definite vascular congestion or pleural effusion. Of incidental note are old healed fractures of several left ribs, prosthetic right shoulder, and metallic device projected over the midline at the lower cardiac level. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ranitidine 150 mg PO BID 2. Pantoprazole 40 mg PO Q24H 3. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 4. Nasonex (mometasone) 50 mcg/actuation nasal daily 5. Sertraline 50 mg PO DAILY 6. CloniDINE 0.2 mg PO BID 7. ALPRAZolam 1 mg PO TID 8. Levothyroxine Sodium 50 mcg PO DAILY 9. Temazepam 15 mg PO HS:PRN insomnia 10. Gabapentin 900 mg PO TID 11. Calcitriol 0.25 mcg PO DAILY 12. Furosemide 20 mg PO DAILY 13. Magnesium Oxide 400 mg PO DAILY 14. CeleBREX (celecoxib) 200 mg oral daily 15. Amlodipine 10 mg PO DAILY Discharge Medications: 1. Calcitriol 0.25 mcg PO DAILY 2. CloniDINE 0.2 mg PO BID 3. Furosemide 20 mg PO DAILY 4. Gabapentin 300 mg PO BID 5. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 6. Levothyroxine Sodium 50 mcg PO DAILY 7. Magnesium Oxide 400 mg PO DAILY 8. Pantoprazole 40 mg PO Q24H 9. Ranitidine 150 mg PO BID 10. Sertraline 50 mg PO DAILY 11. Enoxaparin Sodium 30 mg SC Q24H Duration: 11 Days Start: ___, First Dose: Next Routine Administration Time 12. Multivitamins 1 CAP PO DAILY 13. Nasonex (mometasone) 50 mcg/actuation nasal daily 14. Amlodipine 10 mg PO DAILY 15. ALPRAZolam 1 mg PO TID 16. Fosfomycin Tromethamine 3 g PO ONCE Duration: 1 Dose Dissolve in ___ oz (90-120 mL) water and take immediately To be given on ___ Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY Left tibia/fibula fracture Hypertension Anxiety 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: Status post fall with memory impairment. Evaluate for intracranial hemorrhage. TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without the administration of IV contrast. Reformatted coronal and sagittal and thin section bone algorithm-reconstructed images were acquired. DLP: 891 mGy-cm. CTDIvol: 55 mGy. COMPARISON: None available. FINDINGS: There is no hemorrhage, mass effect, midline shift, edema, or evidence of acute large infarct. The ventricles and sulci are prominent, indicative of global atrophy, age related. Periventricular white matter hypodensities are likely a sequela of chronic small vessel ischemic disease. Additionally, focal hypodensity in the right lentiform nucleus may represent a prior lacunar infarct or a prominent perivascular space. No fractures identified. Minimal mucosal thickening in the ethmoid sinuses bilaterally, otherwise the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are remarkable for bilateral lens resection. Vascular calcifications are noted at the carotid siphons and vertebral arteries bilaterally. IMPRESSION: Chronic changes with otherwise no acute abnormality. Radiology Report HISTORY: ___ male with left tibial fibular fracture. COMPARISON: MR dated ___ FINDINGS: Fluoroscopic assistance was provided to this surgeon without a radiologist present. ___ spot views were obtained. These demonstrate internal fixation of distal end tibial and fibular fractures. For details, please refer to operative report in ___ medical record. IMPRESSION: As above. Radiology Report HISTORY: Pneumonia or edema. FINDINGS: In comparison with the study of ___, there are continued low lung volumes. Mild atelectatic changes are seen at the bases, without definite vascular congestion or pleural effusion. Of incidental note are old healed fractures of several left ribs, prosthetic right shoulder, and metallic device projected over the midline at the lower cardiac level. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: LEFT TIB-FIB FX Diagnosed with FX ANKLE NOS-CLOSED, FX UPPER END FIBULA-CLOS, OTHER FALL, HYPERTENSION NOS temperature: 97.3 heartrate: 44.0 resprate: 16.0 o2sat: 96.0 sbp: 152.0 dbp: 52.0 level of pain: 3 level of acuity: 3.0

___ man with HTN, CKD, hypothyroidism, anxiety/depression, borderline DM presenting after a mechanical fall, found to have left distal tibia, proximal fibula fracture now s/p repair as well as UTI and normocytic anemia. ACTIVE ISSUES ============== # Tibia/Fibula Fracture Now s/p repair by orthopedics. Will continue enoxaparin for a total 2 week course. Will f/u with orthopedics in two weeks (___). Now in splint, LLE is non-weight bearing, okay for touch down. Pain control with tylenol. # O2 requirement Patient has developed new O2 requirement after surgery. Most likely due to atelectasis. Was weaned back to RA and O2 sats were 93% on RA on the day of discharge. # Hyperkalemia Potassium noted to be 5.0 upon admission. Was recently noted to be 4.6 on outpatient labs. Was as high as 5.7 during admission- no EKG changes noted. Decreased with kayexalate and was 4.4 on the day of discharge. # S/p Fall Per history, most likely mechanical in nature, CT head negative. No further workup at this time. # UTI Patient denied any dysuria; however, UA noted to have large ___, nitrites and >172 WBC. Was initially treated with Cefazolin given this was also used as postop ppx. Was then transitioned to Cefpodoxime, however, sensitivities came back on ___ showing a MDR pseudomonal UTI. Was treated with Ceftazadime for 1 day on ___. Sensitivities then came back showing sensitive to Fosfoymcin- he received 1 dose on ___ and will receive one more dose on ___. # Leukocytosis WBC noted to be elevated at 12.6 upon admission. Remained elevated throughout admission and ultimately thought to be due to stress versus UTI as above. # Anemia Per outpatient records, most recent H/H was 9.9/31.8. Per PCP, this is thought to be due to his CKD. H/H 9.7/29.5 upon admission. On ___ H/H noted to be 7.0/21.4 without any active signs of bleeding. Patient was transfused one unit of pRBCs and his Hct bumped appropriately. # ___ on CKD Per recent records, Cr 2.07 as of most recent PCP progress note. Upon admission, Cr was 2.4- thought to be due to pre-renal azootemia in the setting of fall and likely poor PO intake. On the day of discharge, Cr had trended down to 1.7. # Orthostatic Hypotension Patient was noted to be orthostatic during admission. This was felt to be due to volume depletion due to poor PO intake immediately following surgery. He received several small boluses of 500cc NS and orthostatics were negative on the day of discharge.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Celebrex / Norvasc Attending: ___. Chief Complaint: Hypoxia and weakness Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old female with hx. COPD on home ___, pulmonary HTN, hypertrophic obstructive cardiomyopathy, aortic aneurysm s/p repair presenting with c/o weakness. Patient reports fatigue and weakness starting 1 week ago. Says has been going on gradually but worsened over last week. For the last 2 weeks she has increased ___ oxygen use - used to be only at night now pretty much all the time. Has had associated increase in clear sputum production, mostly in the AM. Denies fevers or chills, no sick contacts. No chest pain or palpitations. No weight gain, denies orthopnea or PND. At ___ baseline she could walk to ___ car from ___ house without oxygen, but now is too fatigued to complete even simply activities. In the ED, initial vitals: 98.6 65 147/87 16 81% RA. Labs were notable for a CBC with WBC 3.2, plt 88, nl trop/BNP, chem-7 with Cl 95, Bicarb 44. CXR showed cardiomegaly and no signs of pneumonia. Patient was given duonebs, methylpred 125mg IV, as well as full dose aspirin. Upon arrival to the floor patient says she feels better. Denies dyspnea, wheezing, or chest pain. No other complaints. Past Medical History: 1. Aneurysm of ascending aorta and aortic arch, s/p repair ___ 2. Tortuous dilated thoracic aorta. 3. HOCM - LVOT 10mmHg cath ___ TTE: LVOT 19mmHg, 1+AR, 1+MR 5. L vocal cord dysphagia- ___ 6. Hypertension. 7. Hypercholesterolemia. 8. Diabetes mellitus, type 2. 9. Hypothyroidism. 10. Glaucoma. 11. Osteoarthritis. 12. Osteopenia 13. Status post total abdominal hysterectomy. 14. Status post colonic polypectomy. 15. h/o Left Nasolabial abscess, s/p excision. (___) 16. Status post thoracic aortic stent graft repair for posterior penetrating ulcer. 17. Euthyroid multinodular goiter (left-sided dominant ~3cm solid nodules FNA negative for malignancy). 18. ? h/o asthma 19. ? h/o Tb work-up Social History: ___ Family History: Father, deceased, possibly due to cancer. Mother, deceased, died during childbirth when Ms. ___ was approximately ___ years old. Reports that family members on maternal side have characteristically "died young." Sister with ___, and another sister who died in ___ ___ of cancer, though she does not recall the type. Physical Exam: ADMISSION EXAM Vitals- 98.2 159/57 hr 78 17 96% 2L General- awake, alert, in NAD but mildly tachypneic HEENT- PERRLA, EOMI, OMM no lesions Neck- supple, JVD elevated to manible at 30 degrees Lungs- expiratory wheezing b/l, no crackles CV- RRR, 2+ systolic murmur RUSB Abdomen- soft, NT/ND 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, strength ___ in UE and ___ b/l DISCHARGE EXAM Vitals- 99 120/51 69 18 96% 2L General- awake, alert, NAD, mildly tachypneic HEENT- PERRLA, EOMI, OMM no lesions Neck- supple, JVD elevated to manible at 30 degrees Lungs- mild expiratory wheezing b/l, no crackles CV- RRR, 2+ systolic murmur RUSB Abdomen- soft, NT/ND 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- grossly intact Pertinent Results: ___ LABS ___ 06:00PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-LG ___ 06:00PM URINE RBC-3* WBC-16* BACTERIA-FEW YEAST-NONE EPI-1 ___ 03:20PM BLOOD WBC-3.2* RBC-4.59 Hgb-12.6 Hct-40.7 MCV-89 MCH-27.5 MCHC-31.0 RDW-16.2* Plt Ct-88* ___ 03:20PM BLOOD Plt Smr-LOW Plt Ct-88* ___ 03:20PM BLOOD Glucose-112* UreaN-14 Creat-0.8 Na-145 K-4.2 Cl-95* HCO3-44* AnGap-10 ___ 03:20PM BLOOD Calcium-9.8 Phos-3.2 Mg-2.0 ___ 03:53PM BLOOD ___ Temp-36.6 pO2-43* pCO2-86* pH-7.37 calTCO2-52* Base XS-19 Intubat-NOT INTUBA ___ 03:53PM BLOOD Lactate-1.3 PERTINENT LABS ___ 03:20PM BLOOD proBNP-554 ___ 03:20PM BLOOD cTropnT-<0.01 DISCHARGE LABS ___ 06:35AM BLOOD WBC-5.3# RBC-4.14* Hgb-11.5* Hct-36.5 MCV-88 MCH-27.7 MCHC-31.4 RDW-16.4* Plt Ct-90* ___ 06:35AM BLOOD Glucose-78 UreaN-13 Creat-0.7 Na-147* K-3.6 Cl-98 HCO3-46* AnGap-7* ___ 06:35AM BLOOD Calcium-9.0 Phos-2.9 Mg-2.0 MICRO NONE REPORTS ___ Imaging CHEST (PORTABLE AP) IMPRESSION: No definite acute cardiopulmonary process. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea 2. Amlodipine 5 mg PO DAILY 3. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 5. Vitamin D 50,000 UNIT PO 2X/MONTH 6. HydrALAzine 50 mg PO BID 7. Ipratropium Bromide MDI 2 PUFF IH QID 8. Levothyroxine Sodium 50 mcg PO DAILY 9. Metoprolol Tartrate 50 mg PO BID 10. Pilocarpine 1% 1 DROP BOTH EYES Q8H 11. Travatan Z (travoprost) 0.004 % ophthalmic QHS 12. Aspirin 81 mg PO DAILY Discharge Medications: 1. Amlodipine 5 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 4. HydrALAzine 50 mg PO BID 5. Levothyroxine Sodium 50 mcg PO DAILY 6. Metoprolol Tartrate 50 mg PO BID 7. Pilocarpine 1% 1 DROP BOTH EYES Q8H 8. Azithromycin 250 mg PO Q24H Duration: 4 Doses RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*2 Tablet Refills:*0 9. PredniSONE 40 mg PO DAILY RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*2 Tablet Refills:*0 10. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea 11. Ipratropium Bromide MDI 2 PUFF IH QID 12. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation INHALATION BID 13. Travatan Z (travoprost) 0.004 % ophthalmic QHS 14. Vitamin D 50,000 UNIT PO 2X/MONTH Discharge Disposition: Home Discharge Diagnosis: Acute on chronic COPD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report PORTABLE CHEST: ___. HISTORY: ___ female with dyspnea. COMPARISON: ___. FINDINGS: The cardiac silhouette is severely enlarged and there is a stent graft within the known thoracic aortic aneurysm. The lungs are grossly clear without large confluent consolidation. IMPRESSION: No definite acute cardiopulmonary process. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Hypoxia Diagnosed with HYPOXEMIA, PULMONARY HTN-SECONDARY temperature: 98.6 heartrate: 65.0 resprate: 16.0 o2sat: 81.0 sbp: 147.0 dbp: 87.0 level of pain: nan level of acuity: 1.0

___ year old female with hx. COPD on home ___, pulmonary HTN, hypertrophic obstructive cardiomyopathy, aortic aneurysm s/p repair presenting with c/o weakness #Hypoxia: Ms. ___ was hypoxic to low ___ on arrival to ED and mid ___ on home 2L on arrival to floor. Given progressive requirement in home oxygen, likely etiology is acute on chronic COPD. There was low concern for pulmonary embolism given gradual onset and lack of tachycardia or heart failure (normal BNP). She was treated with albulterol and ipratropium nebulizers, prednisone 40mg x5 days (last day ___, and azithromycin x5 days (last day ___. On day of discharge, ___ breathing was subjectively returned to baseline and O2 saturation was mid-90s on home O2 (2L). #Acute on chronic COPD exacerbation: Patient has severe baseline COPD. Given ___ increased O2 requirement and sputum production at time of admission, she was treated for COPD exacerbation as outlined under Hypoxia. Supplemental O2 was continued to reach goal saturation of low to mid-90s. #Fatigue/weakness: Likely etiology of patient's fatigue and weakness is COPD exacerbation. TSH was recently normal in ___ and she had no signs or symptoms of acute coronary syndrome or acute blood loss. She was treated for COPD exacerbation as outlined above. #Alkalosis: Patient's alkalosis is likely chronic in setting of severe COPD. VBG was indicative of CO2 retention (pCO2 86) that is worse than prior. Contraction alkalosis was also considered but was less likely. She was treated for COPD as above. #Pulmonary HTN: Patient had an ECHO in ___ that demonstrated mild-moderate mitral regurgitation, moderate tricuspid regurgitation, and moderate pulmonary arterial systolic HTN. Etiology is likely multifactorail in setting of cardiac and lung disease. Patient had signs of TR on exam (JVP elevated to level of mandible), but no peripheral edema to suggest right sided heart failure. ___ cardiac status was monitored by physical exam. #Aortic aneurysm/ulcer: Patient is s/p ascending aortic replacement and graft stent repair for penetrating ulcer. CXR on admission demonstrated stable cardiomegaly. #Leukopenia, thrombocytopenia: Etiology for these is unclear. She has had thrombocytopenia in the past. This could represent MDS. ___ blood counts were monitored as an inpatient. WBC count normalized from 3.2 to 5.3 on day of discharge and platelet count remained stable in ___. TRANSITIONAL ISSUES # will complete course of antibiotics and prednisone, total 5d each # CODE STATUS: DNR/DNI # CONTACT: ___ ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Neck swelling and pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old male with history of smoking, intermittent chest discomofort and recent worsening mediastinal lymphadenopathy on chest CT chest who presents with worsening left neck pain and swelling over weeks. He returned today from ___ for concerns of swelling to left sided neck over the last two weeks. He denies dyspnea, reports some mild difficulty swallowing and mild pain with swallowing. Patient denies chest pain. Reports was scheduled to have a CT on ___ of neck, and biopsy next week for concerns of swollen lymph nodes in chest recently. patient denies fevers, chills, dizziness, lightheadedness, nasuea, vomiting, diarrhea, SOB, abdominal pain or dysuria. Patient is followed by Pulm for Hx of borderline mediastinal adenopathy with plans for EBUS ___. Patient former smoker with 25 pack year history. No fever, dysphagia, cough, chest pain, weight loss, or night sweats. Patient had dental work ___ weeks ago on the left side lower mandible. In the ED, initial VS were 5 97.7 96 138/87 18 100% Exam notable for lungs CTAB. Firm, tender left submandibular swelling with erythema extending from the overlying area to the clavicle. Labs showed H/H ___, UA clean, WBC 7.1 Lactate 1.5 CT neck with contrast showed necrotic lymph node measuring 2.2 x 3.4 cm just superior to the left submandibular gland with cervical, submandibular, and upper mediastinal lymph nodes. Constellation of findings is concerning for malignancy such as lymphoma or squamous cell carcinoma. IP was consulted and ___ d/w attending Dr ___ EBUS ___ could be reschedule sooner vs FNA of submandibular necrotic mass by ___. Received IV Vancomycin 1000 mg in the ED Transfer VS were 2 99.1 82 133/74 18 100% RA Decision was made to admit to medicine for further management. On arrival to the floor, patient endorses the above history. Asking for pain medications, feels fatigued as he recently arrived from ___. Past Medical History: GERD Bronchitis SURGICAL HISTORY ___ - total hip replacement ___ laminotomies ___ - L shoulder ___ - R-shoulder Social History: ___ Family History: Father with prior small cell lung carcinoma Multiple family members with colorectal cancer Physical Exam: On Admission Vitals - 99.2 131/70 84 18 99%RA GENERAL: NAD HEENT: AT/NC, EOMI, MMM, good dentition, no dental abscessess appreciated NECK: nontender supple neck, ~3cmx5cm fixed left submandibular firm swelling with extention under chin with overlaying erythema non fluctuant, outlined, CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, otherwise grossly normal SKIN: warm and well perfused, no excoriations or lesions, no rashes On Discharge Vitals- Tc 97.8 Tm 99.2 106-131-64-70 ___ 18 98-99%RA General- Alert, oriented, no acute distress HEENT- Sclerae anicteric, MMM, oropharynx clear though hard to visualize. Neck- supple, ~3cmx5cm fixed left submandibular swelling, painful and firm, extending under chin with overlaying erythema, outlined. 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, normoactive bowel sounds present, no rebound tenderness or guarding Ext- warm, well perfused, no clubbing, cyanosis or edema Neuro- EOMI, tongue midline, face symmetric, motor function grossly normal Pertinent Results: On Admission ___ 01:00PM BLOOD WBC-7.1 RBC-4.14* Hgb-12.0* Hct-36.9* MCV-89 MCH-29.0 MCHC-32.5 RDW-14.1 RDWSD-45.2 Plt ___ ___ 01:00PM BLOOD Neuts-75.1* Lymphs-10.9* Monos-12.0 Eos-0.8* Baso-0.6 Im ___ AbsNeut-5.33 AbsLymp-0.77* AbsMono-0.85* AbsEos-0.06 AbsBaso-0.04 ___ 01:00PM BLOOD Plt ___ ___ 01:00PM BLOOD Glucose-105* UreaN-23* Creat-1.0 Na-138 K-4.2 Cl-100 HCO3-26 AnGap-16 ___ 01:30PM BLOOD Lactate-1.5 On Discharge ___ 06:10AM BLOOD WBC-5.3 RBC-3.77* Hgb-11.0* Hct-34.2* MCV-91 MCH-29.2 MCHC-32.2 RDW-14.2 RDWSD-46.7* Plt ___ ___ 06:10AM BLOOD Plt ___ ___ 06:10AM BLOOD Glucose-91 UreaN-17 Creat-1.0 Na-140 K-4.4 Cl-102 HCO3-29 AnGap-13 ___ 06:10AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.1 Imaging: ___ CT Neck with Contrast Necrotic 2.2 x 3.4 cm lymph node with scattered lymphadenopathy is concerning for malignancy such as lymphoma or squamous cell carcinoma. Superimposed infection is not entirely excluded. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Doxazosin 2 mg PO HS 2. Lisinopril 10 mg PO DAILY 3. Omeprazole 40 mg PO DAILY 4. Simvastatin 80 mg PO QPM 5. calcium carbonate-vit D3-min 600 mg (1,500 mg)-400 unit oral DAILY Discharge Medications: 1. Doxazosin 2 mg PO HS 2. Lisinopril 10 mg PO DAILY 3. Omeprazole 40 mg PO DAILY 4. Simvastatin 80 mg PO QPM 5. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 10 Days RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth every 12 hours Disp #*20 Tablet Refills:*0 6. calcium carbonate-vit D3-min 600 mg (1,500 mg)-400 unit oral DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY Neck pain, swelling SECONDARY Hypertension Hyperlipidemia Gastroesophageal reflux Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK INDICATION: ___ with ___ days of left submandibular swelling and erythema c/f abscess // assess for abscess TECHNIQUE: Imaging was performed after administration of 70 ml of Omnipaque intravenous contrast material. MDCT acquired helical axial images were obtained from the thoracic inlet through the skull base. Coronal and sagittal multiplanar reformats were then produced and reviewed. DOSE: Total DLP (Body) = 519 mGy-cm. COMPARISON: CT chest ___ FINDINGS: Evaluation is somewhat limited by dental hardware. Just superior to the left submandibular gland there is a 2.2 x 3.4 cm (transverse by AP) centrally hypodense soft tissue structure concerning for necrotic mass and there is mild adjacent soft tissue edema. Superimposed infection is not entirely excluded. The airways patent. Extensive cervical and submandibular lymphadenopathy with scattered prominent mediastinal lymph nodes. The thyroid gland appears normal. The imaged portion of the lung apices are clear and there are no concerning pulmonary nodules. There are no osseous lesions. IMPRESSION: Necrotic 2.2 x 3.4 cm lymph node with scattered lymphadenopathy is concerning for malignancy such as lymphoma or squamous cell carcinoma. Superimposed infection is not entirely excluded. Gender: M Race: WHITE - OTHER EUROPEAN Arrive by WALK IN Chief complaint: L Neck pain Diagnosed with CELLULITIS OF HAND, SWELLING IN HEAD & NECK temperature: 97.7 heartrate: 96.0 resprate: 18.0 o2sat: 100.0 sbp: 138.0 dbp: 87.0 level of pain: 5 level of acuity: 3.0

___ is a ___ year old male with history of smoking, worsening mediastinal lymphadenopathy on chest CT (___), who presented with a tender, swollen neck with imaging concerning for malignancy but could not rule out infection.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Heparin Agents / contrast dye Attending: ___. Chief Complaint: Leg/abdominal/L arm swelling Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a ___ with history CKD (baseline Cr ~4), s/p descending aortic dissection repair in ___ requiring ileostomy on TPN, HTN, and anxiety/depression who presents to ___ after a recent admission for LLL PNA (discharged ___ now with increasing leg and abdominal swelling over the past ___ days. Patient states that after she was discharged from the hospital ___, she was unable to make a follow-up appointment with her PCP ___ due to fatigue. During this time she also describes some chills and an ongoing cough production of white sputum (improved since last week when there was green sputum, blood tinged). She decided to call an ambulance yesterday due to progressing leg swelling and abdominal distension, symptoms about which she had been warned by her prior inpatient team. Of note, she denies any worsening SOB, stating that overall her respiratory status has improved after being treated for the pneumonia. No ongoing CP or palpitations. Patient denies any abdominal pain or N/V. Ostomy output has been decreased in the setting of poor PO intake. Patient endorses generalized weakness, though she was up and able to walk at home. No dysuria/frequency. ROS otherwise NEG. In the ED, initial vital signs were: T 98.6 P 86 BP 150/81 R 16 O2 sat ___ on RA, high ___ on 2LNC. - Exam notable for: Bilateral ___ edema - Labs were notable for Cr 4.6(at baseline), BNP 1818, hgb 7.2(recent baseline) - Studies performed include: CXR 1. Mild pulmonary vascular congestion without frank edema. 2. Persistent left basilar consolidation, again concerning for pneumonia. 3. Small left pleural effusion. 4. Changes associated with history of thoracic aorta aneurysm and dissection. - Patient was given 20mg IV Lasix Upon arrival to the floor, the patient recounts the above story. She denies any acute worsening of SOB. Her main complaints are weakness and swelling in her legs. She does note that her R arm is chronically, intermittently swollen s/p TPN catheterization in the past. Her current TPN catheter is a L fem line, she denies any pain, swelling, or redness in the area. Past Medical History: 1. Descending Aortic Dissection ___, s/p repair, c/b bowel ischemia and resection (right/transverse colon and partial SB resection due to mesenteric ischemia in ___. 2. S/p Open cholecystectomy ___. 3. Stage IV sacral Decub (MRSA/VRE) 4. Short gut syndrome, on TPN 5. Bilateral Pneumothorax 6. h/o of G/J tube now removed 7. Anxiety 8. Depression 9. HTN 10. h/o hepatitis 11. h/o Pancreatitis 12. h/o HIT ab 13. h/o MRSA line infection (___) 14. h/o Klebsiella bacteremia ___ as a complication of cholecystectomy) 15. H/o MRSA bacteremia (___) 16. H/o spontaneous vertebral fractures (pain control w/morphine 17. ___ abnormal liver chemistries and liver biopsy showing mild-to-moderate lobular mononuclear cell inflammation, bile duct proliferation and focal canalicular cholestasis, mild steatosis and a slight increase in portal fibrosis. This is consistent with TPN-related liver injury b/l UE DVT Social History: ___ Family History: Mother: HTN Grandmother: HTN Physical Exam: ADMISSION PHYSICAL ================= Vitals- 99.4, 150s/70s, 70s-80s, ___, 95 on 2L GENERAL: AOx3, NAD HEENT: Pupils equal, round, and reactive bilaterally, extraocular muscles intact. No conjunctival pallor or injection, sclera anicteric and without injection. Oropharynx is clear with MMM. NECK: No cervical/submandibular/supraclavicular lymphadenopathy. CARDIAC: Regular rhythm, normal rate, ___ holosystolic murmur best heard at ___, no rubs/gallops. No JVD. LUNGS: Decreased breath sounds and scattered inferior inspiratory crackles in lower lung fields bilaterally. ABDOMEN: Normal bowels sounds, non distended, diffuse tenderness to deep palpation. Ileostomy in RLQ, tissue well vascularized. No HSM. EXTREMITIES: Pulses DP/Radial 1+ bilaterally. 1+ ___ to mid shins bilaterally. L fem line cdi. LUE with 1+ edema. SKIN: No evidence of ulcers, rash or lesions. NEUROLOGIC: CN2-12 intact. ___ strength througout. Normal sensation. No ataxia, dysmetria, disdiadochokinesia. DISCHARGE PHYSICAL ================= 99.7, 148-164/70-88, 70-87, ___ ON RA GENERAL: AOx3, NAD HEENT: Pupils equal, round, and reactive bilaterally, extraocular muscles intact. No conjunctival pallor or injection, sclera anicteric and without injection. Oropharynx is clear with MMM. NECK: No cervical/submandibular/supraclavicular lymphadenopathy. CARDIAC: Regular rhythm, normal rate, ___ holosystolic murmur best heard at ___, no rubs/gallops. No JVD. LUNGS: Decreased breath sounds and scattered inferior inspiratory crackles in lower lung fields bilaterally, scattered wheeze. ABDOMEN: Normoactive bowels sounds, non distended, diffuse tenderness to deep palpation. Ileostomy in RLQ, tissue well vascularized. No HSM. EXTREMITIES: Pulses DP/Radial 1+ bilaterally. No ___. L fem line cdi. LUE with 2+ edema. SKIN: No evidence of ulcers, rash or lesions. NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal sensation. No ataxia, dysmetria, disdiadochokinesia. Pertinent Results: ADMISSION LABS ============= ___ 03:30AM BLOOD WBC-6.9 RBC-2.69* Hgb-7.2* Hct-22.2* MCV-83 MCH-26.8 MCHC-32.4 RDW-13.4 RDWSD-40.6 Plt ___ ___ 03:30AM BLOOD Neuts-77.0* Lymphs-7.0* Monos-13.3* Eos-1.9 Baso-0.4 Im ___ AbsNeut-5.27 AbsLymp-0.48* AbsMono-0.91* AbsEos-0.13 AbsBaso-0.03 ___ 03:30AM BLOOD Plt ___ ___ 03:30AM BLOOD Glucose-158* UreaN-89* Creat-4.6* Na-138 K-3.4 Cl-95* HCO3-28 AnGap-18 ___ 07:00PM BLOOD Glucose-86 UreaN-87* Creat-4.8* Na-139 K-3.6 Cl-96 HCO3-29 AnGap-18 ___ 03:30AM BLOOD proBNP-1818* ___ 07:00PM BLOOD Calcium-8.7 Phos-4.4 Mg-2.1 ___ 06:15AM URINE Color-Straw Appear-Clear Sp ___ ___ 06:15AM URINE Blood-SM Nitrite-NEG Protein-300 Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 06:15AM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-NONE Epi-0 ___ 06:15AM URINE Mucous-RARE MICRO ===== ___ 6:15 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. DISCHARGE LABS ============== ___ 06:00AM BLOOD WBC-7.0 RBC-2.64* Hgb-7.4* Hct-21.9* MCV-83 MCH-28.0 MCHC-33.8 RDW-13.2 RDWSD-40.4 Plt ___ ___ 06:00AM BLOOD Plt ___ ___ 06:00AM BLOOD Glucose-123* UreaN-77* Creat-4.6* Na-141 K-3.7 Cl-97 HCO3-30 AnGap-18 ___ 06:00AM BLOOD Calcium-8.8 Phos-4.3 Mg-2.2 IMAGING/STUDIES ============== FINDINGS: Heart size is normal. There are midline sternotomy wires. The aorta is calcified, indicating atherosclerosis. Again seen is a lobulated contour abutting the aortic arch in projecting over the AP window, compatible with thoracic aortic aneurysm and prior dissection. There is mild pulmonary vascular congestion without frank edema. Underlying emphysematous changes. Again seen is left basilar consolidation, concerning for pneumonia. Small left pleural effusion. No pneumothorax. There are no acute osseous abnormalities. IMPRESSION: 1. Mild pulmonary vascular congestion without frank edema. 2. Persistent left basilar consolidation, again concerning for pneumonia. 3. Small left pleural effusion. 4. Changes associated with history of thoracic aorta aneurysm and dissection. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild 2. amLODIPine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. BuPROPion (Sustained Release) 100 mg PO BID 5. Carvedilol 37.5 mg PO BID 6. Meclizine 12.5 mg PO Q6H:PRN frequent dizziness 7. Minoxidil 5 mg PO DAILY 8. Omeprazole 40 mg PO BID 9. Ondansetron 4 mg PO Q8H:PRN nausea 10. TraZODone 50 mg PO QHS:PRN Sleep 11. Ursodiol 600 mg PO BID 12. Vitamin D ___ UNIT PO 1X/WEEK (WE) 13. Metoclopramide 10 mg PO TID:PRN nausea 14. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB/wheeze 15. Space Chamber Plus (inhalational spacing device) 1 spacer miscellaneous as directed 16. Sodium Bicarbonate 650 mg PO BID Discharge Medications: 1. Furosemide 20 mg PO DAILY RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Omeprazole 40 mg PO DAILY RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 3. TraZODone 25 mg PO QHS:PRN Sleep RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth at bedtime Disp #*15 Tablet Refills:*0 4. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild 5. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB/wheeze 6. amLODIPine 10 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. BuPROPion (Sustained Release) 100 mg PO BID 9. Carvedilol 37.5 mg PO BID 10. Meclizine 12.5 mg PO Q6H:PRN frequent dizziness 11. Metoclopramide 10 mg PO TID:PRN nausea 12. Minoxidil 5 mg PO DAILY 13. Ondansetron 4 mg PO Q8H:PRN nausea 14. Sodium Bicarbonate 650 mg PO BID 15. Space Chamber Plus (inhalational spacing device) 1 spacer miscellaneous as directed 16. Ursodiol 600 mg PO BID 17. Vitamin D ___ UNIT PO 1X/WEEK (WE) Discharge Disposition: Home With Service Facility: ___ ___: Primary Diagnosis ================= Chronic Kidney Disease Hypoxia Secondary Diagnoses =================== Hypertension Normocytic Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with sob // ?pulmonary edema TECHNIQUE: Chest PA and lateral COMPARISON: ___ FINDINGS: Heart size is normal. There are midline sternotomy wires. The aorta is calcified, indicating atherosclerosis. Again seen is a lobulated contour abutting the aortic arch in projecting over the AP window, compatible with thoracic aortic aneurysm and prior dissection. There is mild pulmonary vascular congestion without frank edema. Underlying emphysematous changes. Again seen is left basilar consolidation, concerning for pneumonia. Small left pleural effusion. No pneumothorax. There are no acute osseous abnormalities. IMPRESSION: 1. Mild pulmonary vascular congestion without frank edema. 2. Persistent left basilar consolidation, again concerning for pneumonia. 3. Small left pleural effusion. 4. Changes associated with history of thoracic aorta aneurysm and dissection. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: B Leg swelling, B Arm swelling, Chest pain Diagnosed with Heart failure, unspecified temperature: 98.1 heartrate: 100.0 resprate: 16.0 o2sat: 93.0 sbp: 157.0 dbp: 80.0 level of pain: 0 level of acuity: 2.0

Patient is a ___ with history CKD (baseline Cr ~4), s/p descending aortic dissection repair in ___ requiring ileostomy on TPN, HTN, and anxiety/depression who presented to ___ after a recent admission for LLL PNA (discharged ___ now with increasing leg and abdominal swelling. # Increasing leg and abdominal swelling - Exam initially concerning for volume overload given ___ edema and inspiratory crackles on exam, new O2 requirement of 2L, CXR though without frank edema. Hypervolemia more likely in setting of worsening CKD or fluid overload in the setting of recent treatment of pneumonia. Felt less likely to be new CHF (last TTE ___, low-normal LVEF 50%, mild MR and moderate TR). Patient received IV Lasix 20mg x3 with rapid improvement of symptoms. She was discharged on Lasix 20mg po daily, and was advised to monitor daily weights. # Hypoxia - Patient initially with sats in high ___ to low ___ on RA. She denied any subjective dyspnea, breathing much improved s/p treatment for CAP last week. There may have been some component of volume overload as mentioned above. Worsening pulmonary infectious process unlikely given that patient was afebrile, without leukocytosis. # Left Upper Extremity Swelling - Patient has had waxing and waning swelling of this limb in the past, most likely in setting of central venous manipulation while receiving TPN. Last US on ___ was NEG for DVT. # CKD - Cr slightly improved since last admission, although increased from baseline of 4.1 in ___. Patient will likely need dialysis soon and has had follow-up appointment scheduled ___ with transplant for consideration of a Hero graft. Previous vein mapping showed no good targets for fistula placement. # HTN - Continued Carvedilol 37.5 mg PO/NG BID - Continued Amlodipine 10 mg PO/NG DAILY - Continued Minoxidil 5 mg PO DAILY # Normocytic anemia - Baseline anemia likely secondary to CKD, should likely start Darbepoiten. Hb at baseline ~7.2. She did require a transfusion of 1U PRBCs during her last admission. # GERD - Decreased Omeprazole to 40qd # Short gut syndrome, on TPN - Nutrition consulted, continued TPN via L femoral central line # History of HIT - Mechanical DVT ppx with TEDS # Depression - Continued on home buproprion TRANSITIONAL ISSUES =================== - Patient started on Furosemide 20mg po daily - Discharge weight: ___ - Patient with stable, though profound normocytic anemia in setting of CKD, she should be started on Darbepoiten as outpatient (will follow-up with renal ___ ============================ #Code Status: Confirmed full #Contact: ___ ___

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, polymorphic VT Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ gentleman with history of alcohol dependence, insulin-dependent diabetes, depression, anxiety, chronic pancreatitis, hypertension and hyperlipidemia who arrives via EMS from home with c/o CP and lightheadedness with malaise. Noted to have transient polymorphic VT by EMS. He reported that for the past ___ days he has been feeling progressively worse with chest pain consistent with heartburn, nausea & vomiting, dizziness & lightedheadess (esp. with standing). Today ___, he felt acutely worse with all of these symptoms and called EMS, who brought him to the ED. In this setting, as per EMS patient had several and frequent runs of Vtach ranging in ___ beats. On arrival to ED, labs showed hypomagnesemia, hypokalemia, alkalosis in the setting of prolonged QTc. Patient is taking citalopram 40 mg daily, and quetiapine, both QTc prolonging medications. Patient stated that he had had approximately 1 week of decreased appetite with diarrhea and then nausea and vomiting with the symptoms noted above. Stools have been light colored, but nonbloody and no melena. "Chest pain" is located in the mid-epigastrium and central chest. Patient states it feels like heartburn he has had in the past. He notes that with TUMS the pain resolves, but only for a short time. Maalox is also helpful. Of note, patient also with history of alcoholism with withdrawal and daily drinking. Last drink was 1 beer on ___ ___ at 14:00. He has been "detoxing" from EtOH with psychiatric care. Patient has also had previous electrolyte abnormalities. The patient declined to address these abnormalities however to focus on abstinence and psychiatric issues. These previous labs included K 3.4, hyponatremia, hypochloremia, and low bicarb with transaminitis. In the ED initial vitals were: Temp 98.4 HR 104 BP 126/85 RR 16 100% RA EKG: sinus rhythm, prolonged qtc to 597ms initially Labs/studies notable for: Na 129 K 3.2 Cl 87 BUN 3 Cr 0.7 Ca 8.3 Mg 1.2 P 3.2 AST 107 ALT 55 AP 36 Tbili 0.7 Albumin 2.5 WBC: 10.6 Hgb: 10.5, Hct 32.4 Plt 302 VBG: pH 7.59; pCO2 32; HCO3 32 Trop x 1 <0.01 ___: 14.9 PTT: 30.7 INR: 1.4 UA: glucose 1000 Cardiology was consulted and recommended: - Replete electrolyte to K>4.0 and Mg>2.0 - avoid QT prolonging medication. - Admit to ___ 3. Patient was given: ___ 16:38 IV Magnesium Sulfate 2 gm ___ 17:09 IV Magnesium Sulfate 2 gm ___ 17:30 PO Potassium Chloride 40 mEq ___ 17:30 IVF 40 mEq Potassium Chloride / 1000 mL NS started 250 mL/hr ___ 17:55 IV Thiamine 100 mg ___ 18:27 IV Calcium Gluconate 1 g ___ 18:27 IV Magnesium Sulfate 2 gm ___ 18:38 PO Aluminum-Magnesium Hydrox.-Simethicone 30 mL ___ 19:21 IV FoLIC Acid 1 mg ___ 19:39 SC Insulin 4 Units Vitals on transfer: 91 142/92 18 100% Nasal Cannula On the floor, patient complaining of severe ___ heartburn pain and nausea, same character as before but more severe. Denies fevers, chills, dyspnea. Around 23:00, patient feeling anxious and tremulous--given Ativan for WD symptoms. Past Medical History: -Insulin-dependent Type II Diabetes Mellitus -Chronic Pancreatitis ___ to ETOH -HTN -Hyperlipidemia -Alcohol Abuse -Depression - history of suicide attempt ___ by Listerine ingestion -Generalized Anxiety -Obstructive Sleep Apnea -Erectile Dysfunction -GERD Social History: Born/Raised: ___, raised in ___ Childhood: Struggled with school, father was abusive and alcoholic Income: Used to work at a psych unit at ___, has also worked at a homeless ___, in drug/addiction facilities, and most recently as a ___ at ___. Lost job over a year ago, unemployed Housing: lives with wife (second) of ___ years and 7, 8, and ___ y/o grandchildren whom are the children of his stepdaughter. ___ y/o daughter is in and out of house, getting ___ in psychology Education: through ___ grade, took special education classes Relationships: supportive with wife, church, ___ Religion/Spirituality: was ___ ___ in church, formerly very involved, feels guilty about not being continuously involved Trauma: witnessed domestic violence in parents, abused by father as child, physically abused by daughter's mother once in past SUBSTANCE ABUSE HISTORY: ETOH: history of dependence, no significant withdrawals or seizure, had ___ y sober in 1990s with good mood during that time, has been sober almost one year now but does occasionally drink ___ oz beers to 'self-medicate' his anxiety (nothing near his previous 1 pint brandy/day intake however) MJ: last used ___ y ago Cigarettes: 1-2/day Other: denies FORENSIC HISTORY: ___ Family History: FAMILY PSYCHIATRIC HISTORY: - Alcoholism: Father (deceased), Sister (also with bipolar, depression, anxiety) currently stable on medications. Strong Drinkers in ___ children. - Depression: Mother (deceased ___ - No suicides in the family Physical Exam: PHYSICAL EXAM ON ADMISSION: =========================== VS: T=98.5 BP=165/108 HR=123 RR=22 O2 sat=99% RA GENERAL: Thin adult male, in pain. Alert and Oriented. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with no JVD. CARDIAC: Tachycardic. Normal S1, S2. No murmurs/rubs/gallops. LUNGS: Resp were unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, mildly tender. EXTREMITIES: No c/c/e. Right foot plantar laceration, hemostatic and without purulence, nontender. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Distal pulses palpable and symmetric PHYSICAL EXAM ON DISCHARGE: =========================== Tele: HR 80-90s, with multiple spikes to SVT@130bpm, likely with motion VS: T98.0 (tmax 98.4) BP149/103 (100-160/90-108) HR92 (80s-120s) RR18 O2 sat 99%RA Weight: 61.1 (admit wt: n/a) I/O: ___/void Gen: pleasant, cooperative, appropriate, NAD, AAOx3 HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with JVP of 5 cm. CARDIAC: PMI located in ___ intercostal space, midclavicular line. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Irregular 3-4 cm diameter wound on plantar surface of R heel through full thickness of epidermis. no erythema,induration around it PULSES: Distal pulses palpable and symmetric Pertinent Results: LABS ON ADMISSION: ================== ___ 04:25PM WBC-10.6* RBC-3.96* HGB-10.5* HCT-32.4* MCV-82 MCH-26.5 MCHC-32.4 RDW-14.7 RDWSD-43.5 ___ 04:25PM GLUCOSE-307* UREA N-3* CREAT-0.7 SODIUM-129* POTASSIUM-3.2* CHLORIDE-87* TOTAL CO2-30 ANION GAP-15 ___ 04:25PM ALBUMIN-2.5* CALCIUM-8.3* PHOSPHATE-3.2 MAGNESIUM-1.2* ___ 04:25PM ___ PTT-30.7 ___ ___ 04:25PM ALT(SGPT)-55* AST(SGOT)-107* ALK PHOS-306* TOT BILI-0.7 ___ 04:25PM PO2-105 PCO2-28* PH-7.65* TOTAL CO2-32* BASE XS-10 ___ 04:25PM LIPASE-5 ___ 04:25PM ALT(SGPT)-55* AST(SGOT)-107* ALK PHOS-306* TOT BILI-0.7 ___ 04:25PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 04:25PM ___ PTT-30.7 ___ ___ 06:21PM cTropnT-<0.01 ___ 04:25PM cTropnT-<0.01 LABS ON DISCHARGE: ================== ___ 06:35AM BLOOD WBC-6.4 RBC-3.39* Hgb-9.0* Hct-28.7* MCV-85 MCH-26.5 MCHC-31.4* RDW-15.6* RDWSD-47.7* Plt ___ ___ 06:35AM BLOOD Glucose-388* UreaN-5* Creat-0.6 Na-135 K-4.3 Cl-100 HCO3-27 AnGap-12 ___ 06:35AM BLOOD Calcium-8.7 Phos-4.0 Mg-1.9 STUDIES: ======== TTE ___: The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF = 65%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion Exercise MIBI ___: IMPRESSION: Poor exercise tolerance. No anginal symptoms or ischemic ST segment changes. No exercise-induced VT. Blunted blood pressure response to exercise. Tachycardic at rest with appropriate heart rate response to exercise. Nuclear report sent separately. Nuclear study: FINDINGS: Left ventricular cavity size is normal with an end-diastolic volume of 57 mL. Resting and stress perfusion images reveal uniform tracer uptake throughout the left ventricular myocardium. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction is 63%. IMPRESSION: 1. Normal cardiac perfusion. 2. Normal left ventricular cavity size and ejection fraction. EKG: QTc on discharge 442ms. QTc on admission 597 ms. ___: ====== NONE Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Citalopram 40 mg PO DAILY 2. FoLIC Acid 1 mg PO DAILY 3. Gabapentin 600 mg PO TID 4. Glargine 30 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 5. Creon 12 4 CAP PO TID W/MEALS 6. Omeprazole 20 mg PO DAILY 7. QUEtiapine Fumarate 25 mg PO BID:PRN anxiety 8. Simvastatin 10 mg PO QPM 9. Aspirin 81 mg PO DAILY 10. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. amLODIPine 5 mg PO DAILY RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Lisinopril 5 mg PO DAILY RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Mirtazapine 15 mg PO QHS take 15 mg on ___ and 30 mg starting ___ at night RX *mirtazapine 30 mg ___ tablet(s) by mouth every night Disp #*29 Tablet Refills:*0 4. TraZODone 50 mg PO BID:PRN anxiety RX *trazodone 50 mg 1 tablet(s) by mouth twice a day as needed Disp #*60 Tablet Refills:*0 5. Glargine 30 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 6. Aspirin 81 mg PO DAILY 7. Creon 12 4 CAP PO TID W/MEALS 8. FoLIC Acid 1 mg PO DAILY 9. Gabapentin 600 mg PO TID 10. Multivitamins 1 TAB PO DAILY 11. Omeprazole 20 mg PO DAILY 12. Simvastatin 10 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: ================== chest pain polymorphic ventricular tachycardia prolonged QT interval electrolyte abnormalities Secondary diagnosis: ==================== alcohol abuse insulin dependent diabetes mellitus anxiety depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ with cp // ? effusion TECHNIQUE: Single frontal view of the chest COMPARISON: Chest radiograph on ___ FINDINGS: Cardiac size is normal. The lungs are clear. There is no pneumothorax or pleural effusion. IMPRESSION: No acute cardiopulmonary abnormality Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Epigastric pain, Chest pain, Weakness Diagnosed with Ventricular tachycardia, Hyperkalemia temperature: 98.4 heartrate: 104.0 resprate: 16.0 o2sat: 100.0 sbp: 126.0 dbp: 85.0 level of pain: 8 level of acuity: 3.0

___ gentleman with history of alcohol dependence, insulin-dependent diabetes, depression, anxiety, chronic pancreatitis, hypertension and hyperlipidemia presenting with chest pain, multiple electrolyte abnormalities and polymorphic VT. Mr ___ ruled out for ACS with negative troponins x3. TTE and exercise MIBI also revealed poor exercise tolerance but structurally normal heart with normal EF (65%). Chest pain ultimately resolved with Maalox and tums, as well as with improvement of electrolyte disturbances as described below. On arrival, Mr ___ was noted to be in polymorphic VT that did not require defibrillation. Electrolytes revealed hypomagnesemia to 1.2, hypokalemia, hypochloremia, hypophosphatemia in the context of recent nausea, vomiting, diarrhea. Patient also has history of alcohol abuse raising concern for malnutrition as well. Electrolytes were repleted aggressively and returned within normal limits. Despite patient reporting that he had cut down on his alcohol consumption to a can of beer every few days, he was started on CIWA scale to prevent acute withdrawal symptoms. Of note, correction of electrolytes did not resolve prolonged QT noted on EKG. It was noted that Mr ___ was taking citalopram and quetiapine for his anxiety/depression, both of which are QT prolonging medications. Both were held this hospitalization. At discharge, QTc is 442ms, but review of old EKGs in the system also suggests that patient may have prolonged QT at baseline. Mr ___ has remained completely asymptomatic. Finally, given the discontinuation of quatiapine and citalopram, Psychiatry was consulted for anxiety/depression management. Patient was offered 50 mg Trazodone twice daily as needed for anxiety and started on Mirtazapine 15 mg at night for depression.

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Methyldopa Attending: ___ Chief Complaint: Dyspnea, chest pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year old gentleman with a history of HTN, CVA ___, R hemiparesis) who presented to the ED with chest pain and dyspnea. The chest pain began last night at rest while he was watching TV. It was substernal and without radiation to the arm or neck. Several minutes later he developed shortness of breath (at rest). In the ED, initial vitals were: T97.6, HR 65, BP 148/64, RR 26, 98% RA, Pain ___. Exam was notable for wheezy lung sounds and a respiratory rate of 34. Labs notable for: WBC 11.6, Creatinine 1.3 (baseline 1.1-1.2), troponin negative x1, BNP 1225. EKG revealed: HR 62, low voltage in limb leads, normal axis, delayed R wave progression (transition in V5), no distinct P waves. Appears to be in an accelerated junctional rhythm. CXR notable for: Cardiomegaly with increased interstitial markings suggesting mild failure. He received: Duonebs x3 with little improvement in symptoms, respiratory rate remained ___. He was placed on Bipap and received lasix 20mg IV x2. He respiratory status improved and BiPAP was discontinued. He is admitted to the ___ service for further management. Vitals on transfer: 98.0 HR 70 BP 103/70 RR 20 95% 4L NC Of note, the patient was recently seen by cardiology as an outpatient for evaluation of atrial fibrillation which was first identified in ___. He was started on diltiazem in addition to metoprolol. On review of systems, he denies any prior history of deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of syncope or presyncope. Past Medical History: 1. Prior CVA and intracranial hemorrhage (left basal ganglia and left parietal regions, ___ at ___ 2. Hypertension. 3. Hyperlipidemia. 4. Gout. 5. Atrial fibrillation (diagnosed ___ 6. History of nephrolithiasis. Social History: ___ Family History: He does not think there is any family history of sudden cardiac death or atrial fibrillation or cardiomyopathy. Physical Exam: ADMISSION PHYSICAL EXAM: VS: T 98.4, 108/69, 73, 28, 96% on 4L NC Weight: 100.1 kg General: Middle aged male slightly dyspneic but speaking in full sentences HEENT: Anicteric sclera, PERRL, impaired right lateral gaze, MMM Neck: Unable to discern JVP due to body habitus CV: Soft heart sounds difficult to discern, no murmur/rub Lungs: Crackles in bottom ___ of lung fields, no wheezes Abdomen: NTND, soft GU: No foley Ext: Residual right sided ___ weakness but not markedly different to left Neuro: A&Ox3, impaired right lateral gaze, right homonymous hemianopia. PULSES: 2+ radial pulses and DP pulses DISCHARGE PHYSICAL EXAM: VS: Tm 98.1, 120/78 (SBP 104-124), 65-87, 16, 97%RA Weight: 91.7 kg General: Middle aged male in NAD resting in bed HEENT: Anicteric sclera, PERRL, impaired right lateral gaze, MMM Neck: JVP not elevated CV: Soft heart sounds difficult to discern, no murmur/rub Lungs: Clear to auscultation, no w/r/r Abdomen: NTND, soft Ext: no edema, wwp Neuro: A&Ox3, impaired right lateral gaze, residual right sided ___ weakness PULSES: 2+ radial pulses and DP pulses Pertinent Results: ==== ADMISSION LABS ==== ___ 09:45AM BLOOD WBC-11.6* RBC-5.14 Hgb-17.8 Hct-51.2 MCV-100* MCH-34.6* MCHC-34.7 RDW-14.6 Plt ___ ___ 09:45AM BLOOD Glucose-208* UreaN-28* Creat-1.3* Na-136 K-4.5 Cl-96 HCO3-24 AnGap-21* ___ 07:30PM BLOOD Mg-1.6 ___ 09:45AM BLOOD proBNP-1225* ___ 09:45AM BLOOD cTropnT-<0.01 ___ 07:30PM BLOOD CK-MB-4 cTropnT-<0.01 ==== IMAGING ==== CXR (___): Cardiomegaly with increased interstitial markings suggesting mild failure. No confluent consolidation or effusion. TTE (___): The left atrial volume index is severely increased. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm/premature beats. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#) with focal calcification of the non-coronary cusp. There is no aortic valve stenosis. Mild to moderate (___) aortic regurgitation is seen (moderate in the short axis view). The aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate (___) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of ___, there is worse aortic, mitral and tricuspid regurgitation. Global left ventricular systolic function appears less vigorous, but still within normal range. Pulmonary artery systolic pressure was not reported previously; is moderately elevated on the current study. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 80 mg PO DAILY 2. Allopurinol ___ mg PO DAILY 3. Metoprolol Tartrate 200 mg PO BID 4. Diltiazem Extended-Release 240 mg PO DAILY 5. Pravastatin 40 mg PO QPM 6. Aspirin 325 mg PO DAILY Discharge Medications: 1. Allopurinol ___ mg PO DAILY 2. Diltiazem Extended-Release 240 mg PO DAILY 3. Lisinopril 40 mg PO DAILY RX *lisinopril 40 mg 1 tablet(s) by mouth qday Disp #*30 Tablet Refills:*0 4. Metoprolol Tartrate 200 mg PO BID 5. Pravastatin 40 mg PO QPM 6. Apixaban 5 mg PO BID RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 7. Furosemide 20 mg PO DAILY RX *furosemide 20 mg 1 tablet(s) by mouth qday Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis - Heart failure with preserved ejection fracture (HFpEF) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with dyspnea and chest pain // r/o acute process TECHNIQUE: AP and lateral views of the chest. COMPARISON: None. FINDINGS: Increased interstitial markings are seen in the lungs. There is no confluent consolidation or pleural effusion. Cardiac silhouette is moderately enlarged. No acute osseous abnormalities. IMPRESSION: Cardiomegaly with increased interstitial markings suggesting mild failure. No confluent consolidation or effusion. Radiology Report EXAMINATION: MR HEAD W/O CONTRAST INDICATION: ___ with a history of a left basal ganglia hemorrhage and left parietooccipital ischemic strokes in ___, of unknown etiology, and Afib diagnosed in ___, here with a CHF exacerbation undergoing consideration for anticoagulation. // please assess stroke lesion load TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was performed with gradient echo, FLAIR, diffusion, and T2 technique. COMPARISON: MRI head ___. FINDINGS: There is no acute infarct. There is a chronic infarct with cystic encephalomalacia of the left parietal and occipital lobes. Encephalomalacia has progressed since prior MRI on ___. There are foci of gradient susceptibility throughout the infarct, consistent with chronic blood product deposition. There is associated ex vacuo dilatation of the left lateral ventricle. The ventricles are otherwise normal in size. There is a chronic infarct of the right occipital lobe, much smaller than the left infarct. There is a chronic infarct of the left basal ganglia with associated chronic blood products. There are numerous foci of FLAIR hyperintensity throughout the subcortical, deep, and periventricular white matter consistent with moderate chronic microangiopathy. This has mildly progressed compared to prior MRI from ___. Major intravascular flow voids are preserved. Marrow signal is preserved. The paranasal sinuses and mastoid air cells appear clear. The orbits are normal. IMPRESSION: 1. Multiple chronic infarcts of the left parieto-occipital lobe, right occipital lobe, and basal ganglia. There are chronic blood products associated with some of these infarcts but no acute intracranial hemorrhage. No acute infarct. 2. Moderate chronic microangiopathy, mildly progressed from prior MRI on ___. Gender: M Race: BLACK/CAPE VERDEAN Arrive by WALK IN Chief complaint: Chest pain, Dyspnea Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, RESPIRATORY ABNORM NEC temperature: 97.6 heartrate: 65.0 resprate: 26.0 o2sat: 98.0 sbp: 148.0 dbp: 64.0 level of pain: 2 level of acuity: 2.0

___ with a history of HTN, CVA ___, residual right sided partial loss of motor function) who presents with brief (< 3 minutes) chest pain followed by SOB and hypoxemia, subsequently found to be volume overloaded secondary to HFpEF exacerbation. # HFpEF Exacerbation: Patient presented with lower extremity edema, shortness of breath, pro-BNP 1225, increased interstitial markings and cardiomegaly on CXR. He endorsed a 3 minute episode of chest pain preceding the onset of his shortness of breath, raising concern for cardiac ischemia as the precipitant of his HFpEF exacerbation. However, troponins were negative x2 and EKG without ischemic changes. TTE on ___ revealed preserved LVEF >55%. Patient was diuresed approximately 10 liters net from admission to discharge (dry weight 91.7kg). His weight remained stable on Lasix 20mg PO qday and he was discharged on this dose of diuretic. He will follow up with his PCP for ___ weight and Chem-10 check within 7 days of discharge, and his cardiologist within 3 weeks. # Chest pain: Short duration (3 minutes). Unclear etiology. Differential includes cardiac ischemia (troponin negative x2), pulmonary embolism, anxiety secondary to shortness of breath (although patient states the chest pain preceeded the SOB). He underwent a pharmacologic nuclear cardiac stress test on ___ which was unremarkable. # Atrial fibrillation: CHADS2 score of 4. Patient was not on anticoagulation prior to admission due to prior hemorrhagic stroke and concern regarding risk of recurrent bleeding on anticoagulation. He was, however on ASA 325mg qday. On admission, his rate-control consisted of diltiazem 240mg qday (started on ___ by his cardiologist) and metoprolol tartrate 200mg BID. The stroke/neurology service was consulted during his admission and recommended anticoagulation with a novel anticoagulant (some data for reduced risk of ICH) *without* concomitant use of aspirin. He was started on apixaban 5mg BID on ___ and his aspirin was discontinued. He will follow up with Dr. ___ (Cardiology) within 3 weeks. ==== TRANSITIONAL ==== # HFpEF (new diagnosis): - PCP follow up within 1 week for a weight and Chem-10 check within 7 days of discharge - Cardiology follow up within 3 weeks - Started on lasix 20mg PO qday # Atrial Fibrillation - Cardiology follow up in 3 weeks post-discharge - Started apixaban 5mg BID for stroke prophylaxis given CHADS2 of 4 - Please consider whether this patient would benefit from cardioversion # ? Obstructive Sleep Apnea: - Please strongly consider referral for outpatient sleep study # Dry weight: 91.7 kg # CODE: FULL

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: latex Attending: ___. Chief Complaint: Bilateral foot pain, wound evaluation Major Surgical or Invasive Procedure: Incision and drainage x2 ___ History of Present Illness: ___ male past medical history poorly controlled type 1 diabetes, active IVDU presenting with multiple complaints. His primary complaint appears to be lesions that his back. There are 2 approximately 4 cm round raised lesions that he began noticing 2 days ago. Subjective fevers x2 days. States active IV drug use, last injection yesterday. Prior to that had been abstinent of IV drug use for 9 months secondary to incarceration. Additionally complains of chronic worsening ulceration at right great toe. Draining pus. Painful. Has been seen by podiatrist in prison but none recently. He is a type I diabetic and states that his last blood sugar measurement was read as high. States difficulty obtaining insulin. Additionally complains of pruritic lesions described as water blisters felt between his fingers. - In the ED, initial vitals were: 98.7, 125/61, 95 bpm, 18, 97% RA - Exam was notable for: Const: Comfortable, scratching himself Eyes: No conjunctival injection HENT: NCAT, Neck supple without meningismus CV: RRR, Warm, well-perfused extremities. No murmur. RESP: CTAB, Unlabored respiratory effort GI: soft, non-tender, non-distended MSK: No gross deformities appreciated Skin: Warm, dry. 2 4cm round raised erythematous tender lesions at R mid back. R great toe tender, ulcerated, erythematous. Excoriation between fingers. Neuro: Alert, Speech fluent Psych: Appropriate mood and affect. - Labs were notable for: WBC 12.6, Hgb 11.9, Na 126 (corrected to 131), Glu 402, VBG 7.49/31 - Studies were notable for: RIGHT FOOT X-RAY: Soft tissue ulceration along the plantar aspect of the great toe at the level of the first IP joint without radiographic evidence for osteomyelitis. - The patient was given: Cefepime 2 g IV, Metronidazole 500 mg IV, Insulin 6 u - Podiatry and Social Work were consulted: PODIATRY: Chronic right hallux ulceration that had macerated edges debrided back to reveal granular base, no bone uncovered, does not probe. No pus appreciated on exam. Swollen, erythematous. Left plantar forefoot bulla with serous fluid - no probing, no tracking. Recommend admission to medical service for IV antibiotics - keep broad IV Vanc/Cefepime/Flagyl. No culture taken as likely to yield skin flora - no pus. X-rays unchanged from priors. Betadine dressing applied to both feet. []Admission to medical service given cellulitis []Betadine dressing to both feet []No plan for OR SOCIAL WORK: Pt. is going to be admitted today, will refer to social work and financial counseling to complete MA Health /HSN application so that he can get meds. On arrival to the floor, patient very agitated because he states that he was treated very poorly in the ED. He wants to get help. He endorses back pain as well as occasional fevers/chills. He injected heroin into his left arm two days ago. He does not share needles, does not lick needles; occasionally uses tap water but mostly uses bottled water. He became intermittently tearful alternating with anger with occasional euthymic mood during our conversation. REVIEW OF SYSTEMS: ================== Per HPI, otherwise, 10-point review of systems was within normal limits. Past Medical History: IDDM Substance Use Disorder (crack, cocaine, heroin, methamphetamines, benzos, EtOH) HCV (untreated) Depression w/self-reported multiple suicide attempts Social History: ___ Family History: Unknown Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: ___ Temp: 98.2 PO BP: 142/77 R Sitting HR: 93 RR: 18 O2 sat: 95% O2 delivery: RA GENERAL: Agitated but alert and interactive. Became more cooperative with history and exam. Patient intermittently itching. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. BACK: Two large 3-4 cm tender erythematous lesions on back. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. EXTREMITIES: Right hallux TTP with erythema and swelling. SKIN: Several excoriations all over skin. Track marks antecubital fossa b/l. NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs spontaneously. ___ strength throughout. Normal sensation. PSYCH: Extreme emotional lability. DISCHARGE PHYSICAL EXAM: ======================== 24 HR Data (last updated ___ @ 2329) Temp: 99.0 (Tm 99.8), BP: 133/76 (108-133/67-76), HR: 80 (77-84), RR: 18, O2 sat: 100% (96-100), O2 delivery: Ra GEN: sitting up in bed in NAD HEENT: pupils bilaterally 3mm ___: RRR, nl S1/S2, no murmurs/rubs/gallops PULM: CTABL no increased WOB BACK: two 3-4 cm erythematous lesions both s/p I&D: both open and packed, still tender ABD: soft, NT/ND, +BS EXTR: R hallux with betadine dressing, minimally TTP today L forefoot with betadine dressing, minimally TTP SKIN: excoriations improving. +track marks AC fossa b/l. NEURO: AOx3, CN2-12 intact, moving all 4 limbs spontaneously, ___ strength bilaterally PSYCH: affect appropriate, no longer labile Pertinent Results: ADMISSION LABS: =============== ___ 05:09PM BLOOD WBC-12.6* RBC-3.98* Hgb-11.9* Hct-32.5* MCV-82 MCH-29.9 MCHC-36.6 RDW-12.6 RDWSD-36.5 Plt ___ ___ 05:09PM BLOOD Neuts-69.4 Lymphs-16.4* Monos-11.0 Eos-2.4 Baso-0.4 Im ___ AbsNeut-8.75* AbsLymp-2.06 AbsMono-1.38* AbsEos-0.30 AbsBaso-0.05 ___ 05:09PM BLOOD Glucose-402* UreaN-23* Creat-0.9 Na-126* K-4.0 Cl-88* HCO3-22 AnGap-16 ___ 05:17PM BLOOD ___ pO2-95 pCO2-31* pH-7.49* calTCO2-24 Base XS-1 Comment-GREEN TOP PERTINENT LABS: =============== ___ 01:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 12:11PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-POS* amphetm-POS* oxycodn-NEG mthdone-NEG ___ 07:47PM BLOOD %HbA1c-9.7* eAG-232* ___ 10:46AM BLOOD HIV Ab-NEG ___ 01:30PM BLOOD HCV VL-5.0* DISCHARGE LABS: =============== ___ 07:37AM BLOOD WBC-7.1 RBC-4.06* Hgb-12.1* Hct-35.0* MCV-86 MCH-29.8 MCHC-34.6 RDW-13.3 RDWSD-41.5 Plt ___ ___ 10:46AM BLOOD Glucose-183* UreaN-7 Creat-0.7 Na-141 K-4.3 Cl-102 HCO3-28 AnGap-11 ___ 10:46AM BLOOD ALT-105* AST-112* LD(LDH)-321* AlkPhos-73 TotBili-0.2 ___ 10:46AM BLOOD Albumin-2.8* Calcium-8.4 Phos-3.1 Mg-1.5* IMAGING: =============== ___ XR R Foot FINDINGS: - Soft tissue ulceration along the plantar aspect of the great toe subjacent to the first IP joint is noted with adjacent soft tissue swelling. No cortical destruction or periosteal new bone formation is present. Erosion along the medial head of the first proximal phalanx is unchanged. Mild degenerative changes of the first MTP joint and midfoot are present. No concerning lytic or sclerotic osseous abnormality. No radiopaque foreign body or soft tissue calcification. No acute fracture or dislocation. IMPRESSION: - Soft tissue ulceration along the plantar aspect of the great toe at the level of the first IP joint without radiographic evidence for osteomyelitis. MICROBIOLOGY: =============== BCx NGTD Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Glargine 35 Units Breakfast Glargine 35 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 2. LamoTRIgine Dose is Unknown PO BID 3. Buprenorphine-Naloxone Film (4mg-1mg) 1 FILM SL BID Discharge Medications: 1. Buprenorphine-Naloxone Film (8mg-2mg) 1 FILM SL BID RX *buprenorphine-naloxone 8 mg-2 mg 1 film sublingually twice a day Disp #*8 Film Refills:*0 2. Naloxone Nasal Spray 4 mg IH ONCE MR1 Duration: 1 Dose RX *naloxone [Narcan] 4 mg/actuation 1 spray intranasal once may repeat once Disp #*1 Package Refills:*12 3. Glargine 42 Units Breakfast Glargine 42 Units Bedtime Novolog 4 Units Lunch Novolog 4 Units Dinner Insulin SC Sliding Scale using Novolog Insulin RX *blood sugar diagnostic Please check blood sugar before mealtimes and at bedtime QMEALS and QHS Disp #*50 Strip Refills:*0 RX *insulin glargine [Lantus Solostar U-100 Insulin] 100 unit/mL (3 mL) AS DIR 42 Units before BKFT; 42 Units before BED; Disp #*30 Applicator Refills:*0 RX *blood-glucose meter 1 meter kit once a day Disp #*1 Kit Refills:*0 RX *lancets Please check blood sugars with meals and before bedtime QMEALS & QHS Disp #*100 Each Refills:*0 RX *insulin lispro 100 unit/mL AS DIR Per sliding scale QID Disp #*30 Applicator Refills:*0 4. HELD- DULoxetine ___ 60 mg PO BID This medication was held. Do not restart DULoxetine ___ ___ speaking with your primary care doctor. 5. HELD- LaMICtal XR (lamoTRIgine) 50 mg oral DAILY This medication was held. Do not restart LaMICtal XR until speaking with your psychiatrist Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: ================= #LUMBAR ABSCESSES #RIGHT HALLUX CELLULITIS SECONDARY DIAGNOSES: ===================== #TYPE 1 DIABETES #POLYSUBSTANCE USE DISORDER #SCABIES #HEPATITIS C #TRANSAMINITIS #DEPRESSION Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: History: ___ with R great toe ulcer, drainage of pus// Eval for e/o osteo TECHNIQUE: Right foot, two views COMPARISON: Right foot radiographs ___ FINDINGS: Soft tissue ulceration along the plantar aspect of the great toe subjacent to the first IP joint is noted with adjacent soft tissue swelling. No cortical destruction or periosteal new bone formation is present. Erosion along the medial head of the first proximal phalanx is unchanged. Mild degenerative changes of the first MTP joint and midfoot are present. No concerning lytic or sclerotic osseous abnormality. No radiopaque foreign body or soft tissue calcification. No acute fracture or dislocation. IMPRESSION: Soft tissue ulceration along the plantar aspect of the great toe at the level of the first IP joint without radiographic evidence for osteomyelitis. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: B Foot pain, Wound eval Diagnosed with Cellulitis of right toe temperature: 98.7 heartrate: 95.0 resprate: 18.0 o2sat: 97.0 sbp: 125.0 dbp: 61.0 level of pain: 4 level of acuity: 3.0

___, unstably housed and recently incarcerated, with PMH of uncontrolled T1DM, depression, and polysubstance use disorder (active IV use) c/b untreated HCV, who presents with R toe cellulitis and lumbar abscesses. He was completed his course of antibiotics and underwent I&D x 2 of abscesses. Patient became agitated while awaiting discharge ___ and left prior to receiving discharge appointments, paperwork, or scripts. Will attempt to fax scripts to his pharmacy and call to coordinate appointments.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Penicillins / Lactose Attending: ___. Chief Complaint: rectal foreign body Major Surgical or Invasive Procedure: none History of Present Illness: HPI: ___ w/h/o anal condyloma removal ___, anal fistulectomy ___, presents after having a cylindrical object inserted into his anus three days ago that he was subsequently unable to retrieve. He inserted the sexual toy into his anus on ___ morning during consensual sex with a female. He attempted a fleets enema 2 days PTA without success, just with a small amount of bloody stool. He has not stooled since. +flatus. He complains of no abdominal pain, N/V, now. Past Medical History: Anal condylomata, anal fistula, anxiety, depression, h/o substance abuse Social History: ___ Family History: NC Physical Exam: Physical examination upon admission: ___: Vitals: 98.2 62 126/87 20 96% Gen: Anxious, NAD Resp: CTA CV: RRR Abd: S, NT/ND Ext: No c/c/e Rectal: palpable foreign body in rectum, no gross blood Pertinent Results: no lab work done Medications on Admission: Viagra 50', Wellbutrin 150'', Trazodone 100' Discharge Medications: 1. BuPROPion (Sustained Release) 150 mg PO BID 2. Nicotine Patch 14 mg TD DAILY 3. Docusate Sodium 100 mg PO BID hold for diarrhea 4. traZODONE 200 mg PO HS:PRN sleep Discharge Disposition: Home Discharge Diagnosis: rectal foreign body Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Foreign body in rectum. TECHNIQUE: AP and lateral views of the pelvis. COMPARISON: None. FINDINGS: A cylindrical radiopaque density measuring approximately 12 cm long is noted within the rectum, and corresponds to the known history of foreign body. Imaged bowel gas pattern appears unremarkable. No acute osseous abnormalities are seen, and there are no soft tissue calcifications. Multilevel degenerative changes within the lumbar spine are worse at L4-5 with intervertebral disc space narrowing, subchondral sclerosis and osteophyte formation. IMPRESSION: Radiopaque foreign body within the rectum as described above. Radiology Report HISTORY: Removal of foreign body. TECHNIQUE: Upright AP and lateral views of the pelvis. COMPARISON: ___ at 17:12. FINDINGS: Previously noted cylindrical radiopaque foreign body has been removed. No residual radiopaque foreign body is seen. Imaged bowel gas pattern appears unremarkable. Please note that assessment for free air is limited as the entire abdomen including the diaphragms was not encompassed on these views. There are no acute osseous abnormalities. IMPRESSION: Removal of previously noted radiopaque foreign body. Assessment for free intraperitoneal air is limited on these views, and dedicated supine and AP views of the entire abdomen are suggested for further assessment, if this is of clinical concern. Radiology Report INDICATION: ___ man status post removal of rectal foreign body, to evaluate for free air. COMPARISON: Pelvis radiograph ___ FINDINGS: There is no evidence of intra-abdominal free air. There is mild gaseous distention of the colon. The bowel gas pattern is nonobstructive. A few colonic air-fluid levels are noted, nonspecific. There is mild dextroconvex curve of the lumbar spine. IMPRESSION: No free air. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: FOREIGN BODY Diagnosed with FOREIGN BODY IN ANUS & RECTUM, FB ENTERING OTH ORIFICE temperature: 98.2 heartrate: 62.0 resprate: 20.0 o2sat: 96.0 sbp: 126.0 dbp: 87.0 level of pain: 1 level of acuity: 3.0

___ year old gentleman admitted to the acute care service with a foreign body in his rectum. Upon admission, an x-ray of the abdomen was done which showed a radiopaque foreign body within the rectum. There were no signs of perforation noted. The foreign body was extracted from the patient's rectum at the bedside using lube and abdominal wall counterpressure. The foreign body was removed in its entirety and the patient felt clinical relief after removal. Repeat abdominal film showed no foreign body. The patient's vital signs have been normal and he has resumed a regular diet. He was discharged home on HD #2 with follow-up with his primary care provider.

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: none colonoscopy ___ History of Present Illness: Ms. ___ is a ___ female with a history of HCV/EtOH cirrhosis decompensated by HE with multiple admissions this year for confusion, varices (grade 1 varices x 2 on EGD ___, ascites, recent colitis, depression, who presents with abdominal pain, lactic acidosis, and tachycardia. She noted that pain is most prominent in RUQ. She reports pain is acute in onset with associated nausea and NBNB emesis ___ bouts ofe emesis, ___ loose BM since abd pain yesterday am). She reports similar pain previously when she was admitted for colitis recently. Subjective fever. Denies chest pain, shortness of breath, diarrhea, hematochezia, melena, urinary symptoms. In ED, initial VS were 98 123 178/81 18 100% ra. On exam, pt was noted to be in mild discomfort, w/ tenderness to palpation in RUQ, without rebound or guarding. Labs were significant for normal WBC (83% neutrophils), Hgb 12.5, Plt 83, INR 1.7, HCO3 21, Lactate 5.5, AST 95, ALT 40, AP 121, TBili 2.5, DBili 1.0. RUQ U/S showed cirrhosis with patent portal veins, no focal hepatic mass. Pt was given 2L NS, morphine 5mg x3, and zofran. Of note, patient was admitted in ___ and ___ with similar symptoms including abdominal pain and sinus tachycardia. Her abdominal pain was worked up with CTA which showed no obstruction or ischemia but had concern for infectious colitis in the right colon. She was given cipro/flagyl during both admissions. Her abdominal ultrasound was unremarkable. Stool cultures were sent due to N/V and were negative and flex sig was done without evidence of colitis. Patient's sinus tachycardia was noted to be improved after fluids. On transfer, patients vitals were 98.3 112 145/74 16 97% RA. On the floor patient reitereated that her emesis initiall had 2 drops of blood one first vomiting spell yesterday am, but last ___ vomiting spells had no blood. Reprots 2 X loose bm, no diarrhea. She also reports not taking her lactulsoe for 1 week, and taking miralax instead. ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: PAST MEDICAL HISTORY: - Chronic HCV and Alcoholic Cirrhosis (genotype 1): complicated by ascites, encephalopathy, portal hypertensive gastropathy, grade I varices (___) - Hx of ETOH abuse - Major depressive disorder: multiple psychiatric hospitalizations and prior suicide attempts - Rheumatoid vs osteoarthritis, not medicated - Type II Diabetes Mellitus; not medically managed - Prolapsed uterus s/p pessary, now removed - Rectocele/cystocele - Lateral epicondylitis - VRE Past surgical history: cholecystectomy Social History: ___ Family History: Mother passed away from ETOH cirrhosis. Father had lung ca with liver mets. Daughter with depression. Physical Exam: ON ADMISSION VS:T 98.4 BP 146/84 HR 125 RR 18 O2 100 RA General: NAD, AAOX3 HEENT: slight peteciea indicative of resovled cough soft palate, no active rhinorhhea or epistaxis, no buccal elsions, tongue dry buccal gutters moist Neck: no cervical lad, no thyromegaly CV: RRR, S1 and S2 aucsuclteds over aortic, pulmonic, tricuspid valves Lungs: CTAB on anterior and posterior chest Abdomen: No fluid wave, tender only to periumbilical and suprapubic are (with volutnary guarding), no rebound tenderness or involuntary guarding otherwise GU: no foley in okace GI: external hemorroids present with no active bleeding guaiaic negative. Ext: no peripheral cyanosis/clubbing/edema Neuro: + asterixis. mini cog wnl (can recall at 0 and 3 minutes). Skin: no new rashes ON DISCHARGE VS:T 98.6 BP 119/59 HR 99 RR 20 O2 100 RA General: NAD, AAOX3 HEENT: No cervical lad, no rhinorhhea, no epistaxis, clear oropharynx Neck: no cervical lad, no thyromegaly CV: RRR, S1 and S2 aucsuclteds over aortic, pulmonic, tricuspid valves Lungs: CTAB on anterior and posterior chest Abdomen: No fluid wave, no tenderness with distraction with deep palpation with stehtoscope, mild periumbilical with palpation with hand GU: no foley in place Ext: no peripheral cyanosis/clubbing/edema Neuro: + asterixis. mini cog negative (can recall 3 words) Skin: no new rashes Pertinent Results: ON ADMISSION ___ 02:25AM ___ PTT-38.5* ___ ___ 02:25AM PLT COUNT-83*# ___ 02:25AM NEUTS-81.0* LYMPHS-13.9* MONOS-4.7 EOS-0.2 BASOS-0.2 ___ 02:25AM WBC-5.9# RBC-3.85* HGB-12.5 HCT-38.1 MCV-99* MCH-32.5* MCHC-32.8 RDW-19.4* ___ 02:25AM ALBUMIN-3.5 ___ 02:30AM LACTATE-5.5* ___ 05:50AM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE EPI-2 ___ 05:50AM URINE GRANULAR-1* HYALINE-1* MICROBIOLOGY ___ 1:58 am STOOL CONSISTENCY: SOFT Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. __________________________________________________________ ___ 5:59 am URINE Site: NOT SPECIFIED CHEM# ___ ___. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. __________________________________________________________ ___ 2:25 am BLOOD CULTURE Blood Culture, Routine (Preliminary): GRAM POSITIVE RODS. CONSISTENT WITH CORYNEBACTERIUM OR PROPIONIBACTERIUM SPECIES. Anaerobic Bottle Gram Stain (Final ___: Reported to and read back by ___. ___ ON ___ AT 2155. GRAM POSITIVE ROD(S). RADIOLOGY CT ABD PELVIS ___ ABDOMEN: The liver is diffusely nodular in contour, compatible with known cirrhosis. A tiny, subcentimeter hypodensity within the left hepatic lobe is unchanged from prior examination is too small the characterize. No focal suspicious hepatic lesion is identified. The portal venous system is patent, and there is persistent cannulization of the umbilical vein. There is no evidence of intrahepatic ductal dilation. The gallbladder is surgically absent. The extrahepatic common biliary duct measures up to 1.0 cm, unchanged and within postcholecystectomy limits. The pancreas and bilateral adrenal glands are normal. The spleen is mildly enlarged, measuring up to 12.1 cm. The kidneys enhance symmetrically and are without suspicious solid mass. Multiple, bilateral renal hypodensities measure up to 1.0 cm in size, stable from the prior examination and likely representing simple cysts. The stomach is grossly unremarkable in appearance. Oral contrast is seen extending into the ascending colon. The small and large bowel are normal in caliber and without evidence of wall thickening. The appendix is unremarkable in appearance (2a: 46). There is no retroperitoneal lymphadenopathy by CT size criteria. Nonspecific soft tissue density is noted at the level of the celiac axis, unchanged from ___ and of questionable clinical significance. There is no free abdominal fluid or pneumoperitoneum. The aorta and iliac branches contain calcifications and are normal in course and caliber. The celiac trunk and SMA are grossly patent. PELVIS: The bladder, sigmoid colon, and rectum are grossly unremarkable. There is no pelvic side-wall or inguinal lymphadenopathy by CT size criteria. No free pelvic fluid is identified. OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion concerning for malignancy. IMPRESSION: 1. No evidence of small bowel obstruction, ileus, appendicitis, or colitis to explain the patient's symptoms. 2. Cirrhosis and recanalization of the umbilical vein, unchanged from prior examination. colonoscopy ___ Impression: Polyp in the descending colon (polypectomy) Given very tortuous and long colon, the cecum was unable to be reached. Medium-sized internal hemorrhoids. Otherwise normal colonoscopy to ascending colon Recommendations: - Will followup biopsy pathology report and communicate results as they are available - *Future colonoscopy to be done with adult colonoscope and MAC anesthesia - Given cecum was not reached, next interval colonoscopy to be discussed and determined with primary Liver team LAB RESULTS ON DISCHARGE ___ 06:55AM BLOOD WBC-2.7* RBC-2.90* Hgb-8.9* Hct-28.5* MCV-98 MCH-30.7 MCHC-31.3 RDW-19.1* Plt Ct-58* ___ 02:25AM BLOOD Neuts-81.0* Lymphs-13.9* Monos-4.7 Eos-0.2 Baso-0.2 ___ 06:55AM BLOOD Glucose-111* UreaN-11 Creat-1.0 Na-137 K-3.2* Cl-107 HCO3-28 AnGap-5* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Cyanocobalamin 50 mcg PO DAILY 2. FoLIC Acid 1 mg PO DAILY 3. Lactulose 60 mL PO TID 4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 5. Multivitamins 1 TAB PO DAILY 6. Omeprazole 20 mg PO BID 7. QUEtiapine extended-release 50 mg PO QAM 8. QUEtiapine extended-release 150 mg PO QPM 9. Rifaximin 550 mg PO BID 10. Sertraline 25 mg PO DAILY 11. Spironolactone 25 mg PO DAILY 12. Thiamine 100 mg PO DAILY Discharge Medications: 1. Cyanocobalamin 50 mcg PO DAILY 2. FoLIC Acid 1 mg PO DAILY 3. Lactulose 60 mL PO ___ TIMES DAILY 4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 5. Multivitamins 1 TAB PO DAILY 6. Omeprazole 20 mg PO BID 7. QUEtiapine extended-release 50 mg PO QAM 8. QUEtiapine extended-release 150 mg PO QPM 9. Rifaximin 550 mg PO BID 10. Spironolactone 25 mg PO DAILY 11. Thiamine 100 mg PO DAILY 12. Ondansetron ___ mg PO Q8H:PRN nausea, vomiting RX *ondansetron 4 mg ___ tablet(s) by mouth every 8 hours Disp #*20 Tablet Refills:*0 13. Acetaminophen 325-650 mg PO Q6H:PRN pain RX *acetaminophen 325 mg ___ tablet(s) by mouth every 6 hours as needed for pain Disp #*30 Tablet Refills:*0 14. OxycoDONE (Immediate Release) 2.5-7.5 mg PO Q4H:PRN pain RX *oxycodone 5 mg 0.5 - 1.5 tablet(s) by mouth every 4 hours Disp #*18 Tablet Refills:*0 15. Outpatient Lab Work ICD 280: Anemia Please Draw CBC and ___ Fax to PCP ___ ___ 16. TraZODone 200 mg PO QHS 17. Sertraline 50 mg PO DAILY 18. Polyethylene Glycol 17 g PO DAILY 19. pramipexole 0.125 mg oral qhs 20. Prochlorperazine 5 mg PO Q8H:PRN nausea Discharge Disposition: Home Discharge Diagnosis: Resolved Gastroenteritis Functional 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 history of cirrhosis status post cholecystectomy with right upper quadrant pain. TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: CT of the abdomen and pelvis from ___. FINDINGS: LIVER: The liver is coarsened and nodular in echotexture. There is no focal liver mass. The main portal, right anterior and posterior, and left portal veins are patent with hepatopetal flow. There is no ascites. Of note, the umbilical vein is patent. BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 9 mm and tapers near the pancreatic head. GALLBLADDER: Gallbladder is surgically absent. 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, measuring 7 cm. KIDNEYS: Limited views of the right kidney demonstrate simple cysts with no hydronephrosis. IMPRESSION: 1. Cirrhosis with patent portal veins. No focal hepatic mass. No ascites. 2. Mild prominence of the CBD is within post cholecystectomy limits. Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ year old woman with hcv/etoh cirrosis, controlled hep enceph, new abd pain // r/o ileus, colitis TECHNIQUE: MDCT images were obtained from the lung bases to the pubic symphysis after the administration of intravenous contrast. Axial images were interpreted in conjunction with coronal and sagittal reformats. DLP: 901.62 mGy-cm COMPARISON: ___. FINDINGS: Linear atelectasis is noted at the left lung base. ABDOMEN: The liver is diffusely nodular in contour, compatible with known cirrhosis. A tiny, subcentimeter hypodensity within the left hepatic lobe is unchanged from prior examination is too small the characterize. No focal suspicious hepatic lesion is identified. The portal venous system is patent, and there is persistent cannulization of the umbilical vein. There is no evidence of intrahepatic ductal dilation. The gallbladder is surgically absent. The extrahepatic common biliary duct measures up to 1.0 cm, unchanged and within postcholecystectomy limits. The pancreas and bilateral adrenal glands are normal. The spleen is mildly enlarged, measuring up to 12.1 cm. The kidneys enhance symmetrically and are without suspicious solid mass. Multiple, bilateral renal hypodensities measure up to 1.0 cm in size, stable from the prior examination and likely representing simple cysts. The stomach is grossly unremarkable in appearance. Oral contrast is seen extending into the ascending colon. The small and large bowel are normal in caliber and without evidence of wall thickening. The appendix is unremarkable in appearance (2a: 46). There is no retroperitoneal lymphadenopathy by CT size criteria. Nonspecific soft tissue density is noted at the level of the celiac axis, unchanged from ___ and of questionable clinical significance. There is no free abdominal fluid or pneumoperitoneum. The aorta and iliac branches contain calcifications and are normal in course and caliber. The celiac trunk and SMA are grossly patent. PELVIS: The bladder, sigmoid colon, and rectum are grossly unremarkable. There is no pelvic side-wall or inguinal lymphadenopathy by CT size criteria. No free pelvic fluid is identified. OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion concerning for malignancy. IMPRESSION: 1. No evidence of small bowel obstruction, ileus, appendicitis, or colitis to explain the patient's symptoms. 2. Cirrhosis and recanalization of the umbilical vein, unchanged from prior examination. Radiology Report EXAMINATION: CHEST (PA AND LAT) CLINICAL HISTORY ___ year old woman with hcv/etoh cirrosis, abd pain, recent emesis // r/o pna, acute path r/o pna, acute path COMPARISON: ___ FINDINGS: Streaky bibasilar density consistent with subsegmental atelectasis or scarring persists. The lungs are otherwise clear. The heart is normal in size. Mediastinal structures are otherwise unremarkable. The bony thorax is grossly intact. There is no significant change. IMPRESSION: Bibasilar subsegmental atelectasis and or scarring. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: n/v/d, Abd pain Diagnosed with ABDOMINAL PAIN GENERALIZED temperature: 98.0 heartrate: 123.0 resprate: 18.0 o2sat: 100.0 sbp: 178.0 dbp: 81.0 level of pain: 9 level of acuity: 3.0

Ms. ___ is a ___ female with a history of HCV/EtOH cirrhosis decompensated by HE with multiple admissions this year for confusion, varices (grade 1 varices x 2 on EGD ___, ascites, depression, who presented with abdominal pain, lactic acidosis, and tachycardia, and emesis. BRIEF HOSPITAL COURSE #Abdominal pain/emesis: Patient was recently admitted multiple times for abdominal pain and found to have colitis. No ascites were present on exam. CT abdomen and pelvis on ___ showed no evidence of small bowel obstruction, ileus, appendicitis, or colitis to explain the patient's symptoms, and patient's emesis had completely resolved upon admission. Given patient's recurrent admissions for abdominal pain for presumed colitis, decision was made for colonoscopy for definitive diagnosis. Patient had colonoscopy on ___ which showed no actiive inflammation, but one polyp which was removed. As a result, patient was discharged with diagnosis of presumed prior gastroenteritis given resolution of symptoms on admission. # Alcohol use: Patient is good historian and reported no recent alcohol use (X 1.5 months). She has no signs of alcohol withdrawal and was continued on her home thiamine and folate in house. # Lactic Acidosis: Elevated to 5.5 on admission, after fluid improved to 1.7. Lactate elevation was determined to be due to likely hypovoelmia in the setting of emesis which resolved on hospital stay. #Sinus tachycardia: She has a known history of HR in the 100s during prior admissions, now recurrent. After initial fluid resuscitation (see above) HR stabilized. # ETOH/HCV crrhosis: C/b ascites, encephalopathy (multiple admissions this year for confusion), 2 grade 1 varices on EGD ___ and portal hypertensive gastropathy. HCV genotype 1. MELD 17 (similar to prior admissions). During this admission given HCV history cryoglobins were checked (as possible etiology of ischemic colitis to explain her abdominal pain) and were pending at time of discharge. # Hx HEPATIC ENCEPHALOPATHY: Positive hx in past, not on this admission. Patient reported she has not taken her lactulose for 7 days, though she was not encephalopathic on admission. Her home lactulose was restarted. CHRONIC ISSUES #Depression/psychosis: Patient was continued on her home quetiapine. #GERD: patient was coninued on her home omeprazole in house TRANSITIONAL ISSUES -Patient is being discharged on a very short course taper of oxycodone for her abdominal pain. Please refrain from extending course unless patient has severe, debilitating pain, due to concern for constipation. -Patient colonoscopy showed polyp which was removed; pathology of polyp from ___ will need to be followed. -cryoglobin studies pending at time of discharge (were drawn initially before colonoscopy given history of HCV, and possibility of vasculitic mediated colitis). Patient will follow up with liver clinic as above - After colonoscopy and polyp removal patient had related hgb drop from 10.3 to 8.9 but was in stable condition, with iron studies wnl. Patient given rx for CBC and Chem-10 draw on ___ with results to be faxed to PCP. Patient advised to come in if she has any change in stool color or bleeding. -On day of discharge patient had K of 3.2, Mg of 1.5. These were repleted orally, but as above, patient given RX for chem-10 lab draw prior to PCP ___ replete as needed

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Abdominal pain, nausea Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old M with cholangiocarcinoma s/p whipple in ___ followed by adjuvant chemo/radiation which completed in ___, ventral hernia s/p repair in ___ and inguinal hernia s/p repair 2 weeks ago with acute on chronic abdominal pain, nausea, and vomiting. Pt reports nausea, vomiting and periumbilical abdominal pain since ___ of this year. He has had 8lbs of weight loss in the past two months. His appetite has been poor and he has felt fatigued. However, in the past 3 days he says that his vomiting has been multiple times per day, including in the ER where he was noted to have bilious vomiting. This is an increase from 1/week vomiting he had prior. No blood in vomitus. Bowel movements two days ago. Normal per report. He says that his periumbilical abdominal pain has also worsened. ___ at the time of interview. He has been taking oxcycodone and vicodin given to him post operatively from his recent surgeries. He presented to ___ and was sent to ___ ED. There he had a CT which showed no obstruction. A fluid collection was seen near the site of his recent hernia repair. He was seen by surgery and admitted to the medical service for ___ care. Past Medical History: cholangiocarcinoma s/p whipple s/p ventral hernia repair s/p inguinal hernia repair HTN DM2 Social History: ___ Family History: Father died from complications of DM1 Mother living but has hx breast cancer, bt mastectomies Physical Exam: On admission: ================ Vitals: 98.2 183/84 75 16 100%RA\ Gen: NAD, gaunt appearing HEENT: moist mm, no scleral icterus CV: rrr, no r/m/g Pulm: clear b/l Abd: midline scar, no tenderness to palpation, soft, nondistended, +bs; R inguinal surgical site with clean dressing no erythema; no bulge or tenderness Back: no cva tenderness Ext: no edema Neuro: alert and oriented x 3 On discharge: ================ Vitals: AF/98.2, 140s-170s/60s-70s, 60s-70s, ___, 100% on RA; eating well Gen: NAD, gaunt appearing Eyes: EOMI, sclearae anicteric HEENT: MMM, OP clear CV: RRR, no MRG Pulm: CTA ___ Abd: midline scar, no tenderness to palpation, soft, nondistended, +BS; R inguinal surgical site with clean dressing no erythema; no bulge or tenderness Back: No cva tenderness. No kyphosis. Ext: WWP, no edema, no rash, no arthritis Neuro: AAOx3 GU: No foley Pertinent Results: ON ADMISSION: ================ ___ 08:45PM GLUCOSE-111* UREA N-17 CREAT-0.8 SODIUM-142 POTASSIUM-3.8 CHLORIDE-110* TOTAL CO2-23 ANION GAP-13 ___ 08:49PM LACTATE-0.9 ___ 08:45PM LIPASE-6 ___ 08:45PM ALT(SGPT)-31 AST(SGOT)-19 ALK PHOS-97 TOT BILI-1.0 ___ 08:45PM ALBUMIN-3.8 CALCIUM-9.0 PHOSPHATE-3.6 MAGNESIUM-1.7 ___ 08:45PM WBC-5.4 RBC-3.72* HGB-10.8* HCT-31.1* MCV-83 MCH-29.1 MCHC-34.9 RDW-14.1 ___ 08:45PM PLT COUNT-210 ___ 08:45PM NEUTS-76.5* LYMPHS-16.6* MONOS-4.5 EOS-1.8 BASOS-0.7 CT Abdomen/Pelvis (prelim): 1. No evidence of obstruction. Patient is status post Whipple with trace pneumobilia noted within the liver. Additional trace amount of free fluid is noted about the liver and tracking inferiorly along the right pericolic gutter. 2. Right inguinal fluid and air filled rim enhancing structure with overlying subcutaneous inflammatory changes, findings concerning for an abscess. AFTER ADMISSION: ================ CT Abdomen/Pelvis (final read ~12 hours after prelim read): 1. New or more extensive, difficult to compare given differences in acquisition, soft tissue density extending from the pancreatic head bed and extending posteriorly to the retroperitoneum encasing the celiac and superior mesenteric arteries as well as portal vein. This is concerning for recurrent tumor. 2. Patient is status post Whipple with trace pneumobilia noted within the liver. Additional trace amount of free fluid is noted about the liver and tracking inferiorly along the right pericolic gutter, decreased since prior examination dated ___. 3. Right inguinal fluid and air filled structure with overlying subcutaneous inflammatory changes may reflect postoperative changes status post recent hernia repair with a residual seroma. An abscess in the absence of pain at the site is felt unlikely. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Escitalopram Oxalate 20 mg PO DAILY 2. Glargine 6 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 3. Creon 12 2 CAP PO TID W/MEALS 4. Lorazepam 0.5 mg PO Q6H:PRN anxiety 5. Megestrol Acetate 400 mg PO DAILY Discharge Medications: 1. Creon 12 2 CAP PO TID W/MEALS 2. Escitalopram Oxalate 20 mg PO DAILY 3. Lorazepam 0.5 mg PO Q6H:PRN anxiety 4. Glargine 6 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN abdominal pain RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*84 Tablet Refills:*0 6. Ondansetron 4 mg PO Q8H:PRN nausea RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every 8 hours Disp #*120 Tablet Refills:*3 7. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice daily Disp #*180 Capsule Refills:*3 8. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily Disp #*90 Packet Refills:*3 9. Senna 17.2 mg PO BID RX *sennosides [senna] 8.6 mg 2 tablets by mouth twice daily Disp #*360 Tablet Refills:*3 10. OxyCODONE SR (OxyconTIN) 10 mg PO Q8H RX *oxycodone [OxyContin] 10 mg 1 tablet(s) by mouth every 8 hours Disp #*84 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses - Recurrent cholangiocarcinoma (most likely) - Nausea with vomiting - Periumbilical abdominal pain Secondary diagnoses: Diabetes, hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ male with abdominal pain. TECHNIQUE: Multi detector CT images through the abdomen and pelvis were obtained after the administration of intravenous contrast. Coronal and sagittal reformations were generated and reviewed. DOSE: 388 mGy-cm. COMPARISON: CT dated ___. FINDINGS: Chest: The bases of the lungs are clear bilaterally. Coronary artery calcifications are noted. There is no pericardial effusion, resolved since prior examination. Abdomen: The liver appears homogeneous in attenuation. Patient is status post Whipple procedure with hepaticojejunal anastomasis and expected trace pneumobilia. Patient is status post cholecystectomy. The remaining portion of the pancreas is unremarkable. There appears to be new or more extensive soft tissue density extending from the pancreatic head bed posteriorly to the retroperitoneum encasing the celiac axis, superior mesenteric artery, and portal vein, concerning for recurrent tumor. The spleen is within the upper limits of normal in size without focal lesions. Bilateral adrenal glands are unremarkable. Kidneys enhance symmetrically, unremarkable in appearance. No focal lesion is identified. There is trace amount of fluid which surrounds the liver and descends along the right pericolic gutter which appears to be of low density and decreased in amount when compared to prior examination dated ___. Contrast is seen within the stomach lumen. Contrast is identified distally within loops of small bowel. There is no evidence of obstruction. The appendix is not well visualized. Loops of large bowel demonstrate moderate fecal load and is otherwise unremarkable. There is no free intra-abdominal air. The abdominal aorta is normal in caliber without aneurysmal dilatation. There is no retroperitoneal or mesenteric adenopathy. Pelvis: The bladder is well distended, grossly unremarkable. The prostate gland and seminal vesicles are within normal limits. Trace amount of pelvic free fluid is noted. There is no inguinal or pelvic wall adenopathy. Within the right inguinal canal, there is a 1.9 x 3.2 x 4.5 cm fluid-filled rim enhancing structure with foci of air. This does not appear to be connected to a loop of bowel and is concerning for a focal abscess. Surrounding inflammatory changes are noted within the subcutaneous tissues anterior to this structure. Patient is ___ weeks status post a right inguinal hernia repair and these findings may represent postoperative changes with residual seroma. There is no left-sided inguinal hernia. There is no inguinal or pelvic sidewall adenopathy. Osseous structures: No suspicious lytic or blastic lesions are identified. Multilevel degenerative changes are identified most prominent at the L5-S1 level with disc space narrowing and endplate sclerosis. IMPRESSION: 1. New or more extensive, difficult to compare given differences in acquisition, soft tissue density extending from the pancreatic head bed and extending posteriorly to the retroperitoneum encasing the celiac and superior mesenteric arteries as well as portal vein. This is concerning for recurrent tumor. 2. Patient is status post Whipple with trace pneumobilia noted within the liver. Additional trace amount of free fluid is noted about the liver and tracking inferiorly along the right pericolic gutter, decreased since prior examination dated ___. 3. Right inguinal fluid and air filled structure with overlying subcutaneous inflammatory changes may reflect postoperative changes status post recent hernia repair with a residual seroma. An abscess in the absence of pain at the site is felt unlikely. NOTIFICATION: Updated impression regarding the apparent more extensive mass extending from the pancreatic bed to the retroperitoneal is concerning for recurrent tumor communicated after morning read out with the attending on ___ at 9:23 am to Dr. ___ page text after two failed attempts to page for direct communication via telephone. A call was made to Dr. ___ listed covering the patient in POE, with the updated report at 9:29 on ___. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ year old man with history of cholangiocarcinoma; restaging of extrahepatic cholangiocarcinoma s/p Whipple procedure with new local recurrence based on ab CT from ___. TECHNIQUE: Contrast-enhanced chest CT was performed acquiring sequential axial images from the thoracic inlet through the adrenal glands. Thin section axial, coronal, sagittal and axial MIP's were also obtained. 75 cc of Omnipaque 350 were administered intravenously without reported complication. DOSE: Total DLP = 235.40mGy-cm COMPARISON: No prior chest CT available for comparison. FINDINGS: The thyroid gland is unremarkable. There are no pathologically enlarged supraclavicular, mediastinal, hilar or axillary lymph nodes. Heart size is normal with no pericardial effusion. Scattered coronary artery and mitral annular calcifications are present. The main pulmonary artery and thoracic aorta are normal caliber. No incidental pulmonary embolism is identified. A few punctate pulmonary nodules measuring up to 1 mm are identified (5:105, 106, 116). A few punctate calcified granulomas are also present (5: 175, 205, 273). There is no endobronchial lesion or pleural effusion. Mild bilateral gynecomastia is incidentally noted. Multilevel spinal degenerative changes are stable. A sclerotic lesion involving the T3 vertebral body is most consistent with a bone island. For a detailed discussion of the upper abdomen, please refer to the separate report from the CT abdomen/pelvis performed one day prior. IMPRESSION: A few punctate pulmonary nodules measuring up to 1 mm have a relatively low index of suspicion for malignancy. However, given the known history of diagnosis of cholangiocarcinoma, a three-month followup chest CT is recommended. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: N/V Diagnosed with NAUSEA WITH VOMITING temperature: 99.1 heartrate: 81.0 resprate: 18.0 o2sat: 100.0 sbp: 156.0 dbp: 76.0 level of pain: 0 level of acuity: 3.0

ISSUES THIS HOSPITAL STAY # Recurrent cholangiocarcinoma: Recurrence suggested by findings on abdominal CT from admission. # Abdominal pain, nausea, vomiting: Attributed to problem #1 above. Improved with conservative measures (oxycodone, zofran, IVF). Advanced diet to regular on ___. # Recent hernia repairs: Stable on imaging. Incisions CDI without signs of hernia recurrence. # Anemia: Hct remained at his outpatient baseline. Etiology likely multifactorial (chronic blood loss, anemia of inflammation, prior chemo). # HTN: Hypertensive while here, but attributed to pain. He was asymptomatic, so opted to observe, witholding directed treatment as his pressures will likely improve as his disease progresses or he undergoes chemotherapy. # DM : Continued home Lantus and SSI. NARRATIVE ___ with cholangiocarcinoma s/p Whipple and chemoradiation in ___, recent ventral and inguinal hernia repairs, who presented with acute on chronic abdominal pain, nausea, vomiting. His symptoms improved with conservative therapy (short course of bowel rest, some IV fluids, PO oxycodone, and IV Zofran), and his diet was advanced. His pain regimen was uptitrated; he was placed on Oxycontin q12h for improved long term control, along with oxycodone 5mg q4h as needed for breakthrough. He was also put on a bowel regimen. Unfortunately, his abdominal CT scan showed likely recurrence of cancer. I discussed his case with the oncology fellow ___ ___ and had email correspondence with Dr ___. He underwent restaging chest CT, and outpatient followup was arranged. A palliative care consult was also obtained this admission, since he was not sure if he wanted to pursue chemotherapy or focus only on symptoms. They made some recommendations for pain management. TRANSITIONAL # Likely recurrent cancer: Has outpatient followup arranged. # Code status: He was full code while here. Will need to be discussed with primary providers as his goals of care change. # Contact: ___, ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / latex Attending: ___ Chief Complaint: fever, cough, nasal congestion, myalgia Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year old man with classical Hodgkin's lymphoma now s/p 6 cycles of ABVD who is admitted with fever and upper respiratory symptoms. Patient reports that he began feeling ill day prior to admission. At first, he noticed stuffy nose and head congestion which progressed to diffuse myalgias. Also has associated cough productive of small amount of greenish sputum. He had a temp of 100.3 on day of admission, so he presented to the ED. In the ED, initial VS were T 100.8, HR 97, BP 142/73, RR 18, O2 100%RA. Labs notable for WBC 14.6 (85%N), HCT 38.5, PLT 235, Na 139, K 4.1, HCO3 24, Cr 0.9, ALT 56, AST 32, ALP 60, TBIli 0.3, negative UA. CXR was unremarkable. Patient was given 1g po Tylenol, duonebs, vancomycin, zosyn, acyclovir, and 1L NS prior to transfer for further manamgent. VS prior to transfer were T 98.7, HR 88, BP 135/77, RR 20, O2 97% RA. No fevers or worsening symptoms overnight and since arrival. ROS: Denies headache, dizziness, chest pain, hemoptysis, abdominal pain. Had 1 episode of diarrhea yesterday but none since then. No nausea, vomiting or constipation. No new rashes or lesions. All other ROS negative. Past Medical History: PAST ONCOLOGIC HISTORY, per OMR: He was in his usual state of health until four months ago, when he developed drenching night sweats requiring changing his pajamas and sheets. On self examination noticed soft lump in left supraclavicular area. He did some internet research and became very concern that he may have lymphoma. He saw his PCP who ordered chest CXR and sonogram of the nodules. The sonogram on - ___ revealed pathologically enlarged LN and CXR on ___ showed possibly widened mediastinum that prompted CT chest on - ___. The CT scan revlealed 4 x 2.5 CM left supraclavicular mass, mass in anterior mediastinum 6.8 x 3.7 x 10.0 CM anterior to innominate vein, another mass around 1 CM just above the main pulmonary artery as well as 1.8 CM left hilar LN. He was referred to thoracic surgery for evaluation and ultimately underwent Left supraclavicular lymph node biopsy on ___. the biopsy is consistent with classical Hodgkin lymphoma. - ___ C1D1 of AVD (B omitted due to BMBx results) - ___ C1D15- ABVD, Bleomycin test dose and full dose administered due to repeat BMBx results. - ___: C2D1 ABVD (given bleomycin test dose # 2 and full dose). - ___: C2D15 ABVD (reduced dose of bleomycin as ordered due to shortage of chemotherapy). - ___: Repeat PFT's and restaging PET. - ___: C3D1 ABVD (reduced dose bleomycin d/t shortage) - ___: C3D15 ABVD (reduced dose bleomycin d/t shortage) - ___: C4D1 ABVD (reduced dose bleomycin d/t shortage) - ___: C4D15 ABVD (reduced dose bleomycin d/t shortage) - ___ : C5D1 ABVD full dose - ___: C5D15 AVD Bleomycin stopped due to possible pulmonary toxicity - ___: C6D1 AVD- Bleomycin omitted at last visit. - ___ C6D15 AVD PAST MEDICAL HISTORY: - Hodgkin's lymphoma, as above - Intermittent asthma Social History: ___ Family History: No family history of cancer. Physical Exam: ADMISSION PHYSICAL EXAM: VS: T 99.4 HR 138/64 BP 92 RR 18 SAT 97% O2 on RA GENERAL: Pleasant, lying in bed comfortably HEENT: Anicteric, PERLL, OP clear, MMM CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops LUNG: Appears in no respiratory distress, soft inspiratory wheeze diffusely, otherwise clear to auscultation ABD: Normal bowel sounds, soft, nontender, nondistended, no hepatomegaly, no splenomegaly EXT: Warm, well perfused, no lower extremity edema PULSES: 2+ radial pulses, 2+ DP pulses NEURO: Alert, oriented, CN II-XII intact, motor and sensory function grossly intact SKIN: 1cm tender subcuanteous nodule under right nipple DISCHARGE PHYSICAL EXAM: VS: Tm 100.4 ___ TC 98.6 124/86 75 18 97%RA GEN: Pleasant, lying in bed comfortably HEENT: Anicteric, PERLL, OP clear, MMM CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops LUNG: Appears in no respiratory distress, soft inspiratory wheeze diffusely on RUL, otherwise clear to auscultation ABD: Normal bowel sounds, soft, non-tender, non-distended, no hepatomegaly, no splenomegaly EXT: Warm, well perfused, no lower extremity edema PULSES: 2+ radial pulses, 2+ DP pulses NEURO: Alert, oriented, CN II-XII intact, motor and sensory function grossly intact SKIN: 1cm tender subcutaneous nodule under right nipple ACCESS: POC deaccessed at discharge Pertinent Results: ___ 12:00AM GLUCOSE-139* UREA N-11 CREAT-0.9 SODIUM-136 POTASSIUM-3.5 CHLORIDE-99 TOTAL CO2-25 ANION GAP-16 ___ 12:00AM ALT(SGPT)-49* AST(SGOT)-26 LD(LDH)-220 ALK PHOS-54 TOT BILI-0.4 ___ 12:00AM CALCIUM-8.9 PHOSPHATE-2.5* MAGNESIUM-2.0 ___ 12:00AM WBC-11.7* RBC-4.10* HGB-11.8* HCT-35.9* MCV-88 MCH-28.8 MCHC-32.9 RDW-14.7 RDWSD-47.3* ___ 12:00AM PLT COUNT-208 ___ 10:30PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE ___ 09:15AM URINE HOURS-RANDOM ___ 09:15AM URINE UHOLD-HOLD ___ 09:15AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 09:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 04:43AM LACTATE-0.9 ___ 04:35AM GLUCOSE-117* UREA N-15 CREAT-0.9 SODIUM-139 POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-24 ANION GAP-18 ___ 04:35AM estGFR-Using this ___ 04:35AM ALT(SGPT)-56* AST(SGOT)-32 ALK PHOS-60 TOT BILI-0.3 ___ 04:35AM WBC-14.6*# RBC-4.38* HGB-12.7* HCT-38.5* MCV-88 MCH-29.0 MCHC-33.0 RDW-14.1 RDWSD-45.5 ___ 04:35AM NEUTS-84.7* LYMPHS-7.0* MONOS-6.4 EOS-1.0 BASOS-0.4 IM ___ AbsNeut-12.40*# AbsLymp-1.02* AbsMono-0.93* AbsEos-0.15 AbsBaso-0.06 ___ 04:35AM PLT COUNT-235 ___ 04:35AM WBC-14.6* LYMPH-7* ABS LYMPH-1022 CD3-83 ABS CD3-853 CD4-38 ABS CD4-390 CD8-38 ABS CD8-383 CD4/CD8-0.99 ___ 12:00AM BLOOD WBC-11.7* RBC-4.10* Hgb-11.8* Hct-35.9* MCV-88 MCH-28.8 MCHC-32.9 RDW-14.7 RDWSD-47.3* Plt ___ ___ 04:35AM BLOOD Neuts-84.7* Lymphs-7.0* Monos-6.4 Eos-1.0 Baso-0.4 Im ___ AbsNeut-12.40*# AbsLymp-1.02* AbsMono-0.93* AbsEos-0.15 AbsBaso-0.06 ___ 12:00AM BLOOD Glucose-139* UreaN-11 Creat-0.9 Na-136 K-3.5 Cl-99 HCO3-25 AnGap-16 ___ 12:00AM BLOOD ALT-49* AST-26 LD(LDH)-220 AlkPhos-54 TotBili-0.4 ___ 12:00AM BLOOD Calcium-8.9 Phos-2.5* Mg-2.0 MICROBIOLOGY: ___ Rapid Respiratory Viral Screen & Culture Respiratory Viral Culture-CANCELLED due to inadequate specimen ___ Repeat Respiratory viral screen PND ___ URINE URINE CULTURE-PENDING EMERGENCY WARD ___ BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY WARD ___ BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY WARD IMAGING: ___ Imaging CHEST (PA & LAT) A right chest port terminates in the low SVC. Lungs are clear. There is no pneumothorax. The cardiomediastinal silhouette is unremarkable. There is no pleural effusion. Radiology Report EXAMINATION: Chest radiograph. INDICATION: History: ___ with cancer, fever // ? infectious process TECHNIQUE: Chest PA and lateral COMPARISON: None FINDINGS: A right chest port terminates in the low SVC. Lungs are clear. There is no pneumothorax. The cardiomediastinal silhouette is unremarkable. There is no pleural effusion. IMPRESSION: No acute cardiopulmonary abnormality. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Fever Diagnosed with Shortness of breath temperature: 100.8 heartrate: 97.0 resprate: 18.0 o2sat: 100.0 sbp: 142.0 dbp: 73.0 level of pain: 0 level of acuity: 2.0

ASSESSMENT AND PLAN: Mr. ___ is a ___ year old man with classical Hodgkin's lymphoma now s/p 6 cycles of ABVD who is admitted from the ED with fever. #Fever/Leukocytosis: Patient with fever and leukocytosis with apparent upper respiratory tract infection. Given diffuse myalgias and single episode of diarrhea favor viral etiology (although does have predominance of PMN's on leukocytosis). Regardless, given lack of clear other bacterial source (negative chest CXR, POC in good condition and no clear abdominal process) and overall well appearance; will receive 7D course of levofloxacin (___) per primary oncologist -F/U blood, urine cultures, flu and respiratory screen. -Tamiflu empirically given sick contacts but discontinued prior to d/c #Diarrhea: Had 1 episode yesterday evening and another episode this evening. We will obtain stool for cultures for further evaluation prior to d/c #Hodgkin's Lymphoma: S/p 6 cycles ABVD. No FDG avid disease on PET; some concern for 2 small residual masses on CT. Being considered for adjuvant XRT. Continue acyclovir PPX #Transaminitis, mild: not new and appears to be improving steadily, likely chemotherapy-effect, continue to monitor and trend #Asthma: appears to be mildly exacerbated in the setting of upper respiratory symptoms, improvement with albuterol prn ACCESS: POC CODE: Full (presumed) COMMUNICATION: Patient EMERGENCY CONTACT HCP: Wife, ___ ___ DISPO: discharged ___ with follow up on ___ with Dr. ___

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Shellfish Derived Attending: ___. Chief Complaint: Left foot ulceration Major Surgical or Invasive Procedure: Debridement of left lateral foot History of Present Illness: Mr. ___ is a ___ with history of poorly controlled diabetes with neuropathy, chronic kidney disease, recurrent foot infections, hypertension and hyperlipidemia presenting with left foot inflammation and tenderness for 5 days. 6 days ago, patient saw his PCP for his right foot and his left foot was not bothering him. About 5 days ago he started to notice some erythema and a small blister forming ___ his left lateral foot. He tried to drain it and describes some clear liquid and blood coming out, but no puss. He began to feel burning pain ___ his left foot the same night, but the pain has since subsided. Also noticed warmth ___ his left foot up to his ankle. He denies noticing any trauma to his left foot, and always wears shoes. He has been feeling chills, night sweats and feverish (non-objective) for the past week or so. Also felt some decreased apetite ___ the last few days. Day prior to admission, he noticed significantly increased sweeling, erythema, warmth and clear/bloody drainage from his left foot. Other than this, he relates chronic swelling ___ his right foot up to his calf and pain ___ his right calf for which he takes ___ tyalonl/24hrs. Denies current nausea, vomiting, dyspnea, chest pain. His blood glucose levels are usually ___ the high 100s-200s, but ___ the past few days were ___ the 300s. ___ the ED, initial vitals were 98.4 80 127/92 20 100%. Initial labs showed WBC 13.3 w/ PMN 82.6%, HCT 30.9, Na 129, Cr 1.8. Left foot and ankle xray did not show evidence of osteomyelitis. He was started on vancomycin 1g IV and Ampicillin-Sulbactam 3g IV. The left foot ulcer was debrided by podiatry showing purulent drainage. Wound culture taken. Wet-to-dry dressing placed. He was admitted for antibiotic treatment and surgical debridement ___ the morning. REVIEW OF SYSTEMS: (+)per HPI+ vision changes ___ past few years, R testicle pain for past few years. (-) recent weight loss or gain, recent sleep changes, headache, syncope, sinus tenderness, rhinorrhea, congestion, sore throat, cough, palpitations, abdominal pain, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria, recent change ___ bowel or bladder habits, arthralgias or myalgias. Past Medical History: 1. Diabetes ___: Diagnosed ___ ___, with neuropathy, retinopathy, charcot foot (HgbA1c was 11.5 on ___ 2. Recurrent foot infections 3. Hypertension: since ___ 4. Dyslipidemia 5. Chronic Kidney Disease (baseline Cr: 1.5-1.8) 6. Anemia 7. Vitamin D deficiency 8. Osteopenia 9. Genital herpes 10. Hep B: hep B surface AB + (___) 11. Prostatitis 12. Colonic adenomas 13. Elevated PSA Social History: ___ Family History: Mother: ___ Physical Exam: ADMISSION PHYSICAL EXAM: VS: T 97.8, BP 100/66, HR 87, RR 18, O2 100/RA, wgt 226.4lbs GENERAL: WD WN comfortable ___ NAD HEENT: PERRL EOMI, sclera anicteric, slightly dry MM OP clear NECK: supple, no LAD, no JVD, no thyromegaly CARDIAC: RRR, S1, S2, no m/r/g LUNG: CTAB no w/r/r ABDOMEN: soft NT ND +BS no organomegally GU: no foley EXT: Chronic venous stasis skin changes, especially ___ right to mid-calf. Diminished sensation bilat to mid-calf. Left foot lateral superficial abscess. Left foot is diffusely warm and red to mid calf. Right foot swollen, warm to mid-calf, healing ulcer on R plantar toe. Decreased range of motion bilat ___ ankles and toes. 2+ radial, ___, strength ___ BUE and BLE. NEURO: Mental Status: AAOx3 CN: II-XII intact Motor: normal bulk, tone throughout. No adventitious mvmts, no tremors or asterixis Sensory: nml to light touch and vibratory sense ___ upper extremity, diminished bilat ___ lower extremities to mid-calf DISCHARGE PHYSICAL EXAM: VS: T 98.3, BP 126/82 (SBP 114-147), HR 74, RR 14, O2 99/RA, Gluc 375 notable for 2+ ___. Hyperpigmented skin changes on lower legs. Left foot with large lateral 4cm ulceration. There are deeper areas that cannot be probed to the bone. Right foot swollen, healing ulcer on R plantar toe. No pain on palpation, manipulation. Pertinent Results: ADMISSION LABS: ___ 03:45PM BLOOD WBC-13.3*# RBC-3.73* Hgb-10.0* Hct-30.9* MCV-83 MCH-26.9* MCHC-32.5 RDW-12.3 Plt ___ ___ 03:45PM BLOOD Neuts-82.6* Lymphs-11.6* Monos-5.1 Eos-0.5 Baso-0.2 ___ 03:45PM BLOOD Glucose-430* UreaN-29* Creat-1.8* Na-129* K-4.1 Cl-92* HCO3-26 AnGap-15 ___ 03:52PM BLOOD Lactate-1.9 ___ 07:20AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.6 ___ 07:20AM BLOOD ___ PTT-28.9 ___ DISCHARGE LABS: ___ 07:45AM BLOOD WBC-7.3 RBC-3.83* Hgb-10.2* Hct-31.3* MCV-82 MCH-26.6* MCHC-32.4 RDW-12.5 Plt ___ ___ 07:45AM BLOOD ___ PTT-29.0 ___ ___ 07:45AM BLOOD Glucose-344* UreaN-25* Creat-1.5* Na-134 K-5.2* Cl-96 HCO3-27 AnGap-16 ___ 07:20AM BLOOD Calcium-9.5 Phos-3.9 Mg-1.7 ======================================= MICROBIOLOGY: ___ ___ 4:27 pm SWAB Source: L foot ulcer. GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND ___ SHORT CHAINS. 3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). WOUND CULTURE (Final ___: BETA STREPTOCOCCUS GROUP B. MODERATE GROWTH. PROTEUS MIRABILIS. SPARSE GROWTH. PRESUMPTIVE IDENTIFICATION. ___________________ PROTEUS MIRABILIS AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- 2 S ANAEROBIC CULTURE (Final ___: UNABLE TO R/O OTHER PATHOGENS DUE TO OVERGROWTH OF SWARMING PROTEUS BLOOD CULTURE ___: no growth (final) ======================================= IMAGING: ___ FOOT AP,LAT & OBL LEFT Soft tissue gas adjacent to the distal fifth metatarsal. No definite underlying cortical lucency or irregularity to suggest acute osteomyelitis radiographically. MRI is more sensitive for acute osteomyelitis. ___ MRI left foot: Findings concerning for early osteomyelitis within the distal aspect of the partially resected fifth metatarsal with prominent overlying soft tissue ulceration. Prominent skin thickening with subcutaneous edema extending over the dorsal aspect of the left forefoot. Diffuse muscle edema and atrophy throughout the left forefoot indicative of neuropathic changes. ======================================= Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Simvastatin 40 mg PO DAILY 3. Vitamin D 1000 UNIT PO DAILY 4. lisinopril-hydrochlorothiazide *NF* ___ mg ORAL 2 TABS DAILY 5. Viagra *NF* (sildenafil) 100 mg Oral ___ tab PRN sexual activity 6. 70/30 40 Units Breakfast 70/30 35 Units Dinner 7. Felodipine 2.5 mg PO DAILY 8. Acetaminophen w/Codeine 1 TAB PO BID:PRN pain Discharge Medications: 1. Felodipine 2.5 mg PO DAILY 2. 70/30 40 Units Breakfast 70/30 35 Units Dinner 3. Simvastatin 40 mg PO DAILY 4. Vitamin D 1000 UNIT PO DAILY 5. Amoxicillin-Clavulanic Acid ___ mg PO Q8H RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by mouth every eight (8) hours Disp #*42 Tablet Refills:*0 6. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*42 Tablet Refills:*0 7. Acetaminophen w/Codeine 1 TAB PO BID:PRN pain 8. Aspirin 81 mg PO DAILY 9. lisinopril-hydrochlorothiazide *NF* ___ mg ORAL 2 TABS DAILY 10. Viagra *NF* (sildenafil) 100 mg Oral ___ tab PRN sexual activity Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: Diabetic foot ulcer, early osteomyelitis Secondary Diagnosis: Hyperglycemia and diabetes ___ Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: New ulcer and infection of the left foot and lower leg. Evaluation for osteomyelitis. COMPARISON: Foot radiograph, ___. THREE VIEWS OF THE LEFT FOOT: The phalanx of the fifth digit is absent. There is soft tissue gas underlying the distal fifth metatarsal. There is no underlying cortical lucency or irregularity suggestive of osteomyelitis. There is osteophyte formation area around the navicular bone. No acute fracture or dislocation is identified. A soft tissue defect likely corresponds to the known ulcer. THREE VIEWS OF THE LEFT ANKLE: There are mild degenerative changes including osteophyte formation around the navicular bone. The ankle mortise is preserved on this non-stressed view. There are no focal lytic or sclerotic lesions. IMPRESSION: Soft tissue gas adjacent to the distal fifth metatarsal. No definite underlying cortical lucency or irregularity to suggest acute osteomyelitis radiographically. MRI is more sensitive for acute osteomyelitis. Radiology Report MR EXAMINATION OF THE LEFT FOOT WITH AND WITHOUT INTRAVENOUS CONTRAST COMPARISON: Radiographs of the left foot performed ___. TECHNIQUE: Multisequence, multiplanar MR examination of the left forefoot was performed both pre- and post-intravenous administration of gadolinium. A coronal T1 fat sat post-contrast sequence was performed. FINDINGS: There is prominent skin ulceration along the plantar / lateral aspect of the left forefoot extending to the distal head of the left fifth metatarsal which measures approximately 2.7 cm AP x 2.5 cm TRV x 3.2 cm CC. The patient is status post amputation of the left fifth toe as well as the distal head of the left metatarsal (7:15). There is mild heterogeneous marrow edema within the remaining distal portion of the left fifth metatarsal with mild associated enhancement at this site. The T1-weighted images, however, demonstrate residual intramedullary fat within the remaining portion of the distal left fifth metatarsal. The remaining imaged osseous structures demonstrate normal intramedullary fat signal. There is no evidence of osteomyelitis within the remaining imaged osseous structures. There is apparent skin thickening with subcutaneous edema extending across the dorsum of the left forefoot. There is apparent skin thickening over the dorsomedial aspect of the left forefoot. There is however no MR evidence of underlying osteomyelitis at this site. There is no drainable subcutaneous fluid collection. There is marked atrophy of the musculature of the left forefoot with associated diffuse edema indicative of neuropathic change. The Lisfranc ligament appears intact however somewhat heterogeneous in signal. IMPRESSION: 1. Findings concerning for early osteomyelitis within the distal aspect of the partially resected fifth metatarsal with prominent overlying soft tissue ulceration. 2. Prominent skin thickening with subcutaneous edema extending over the dorsal aspect of the left forefoot. 3. Diffuse muscle edema and atrophy throughout the left forefoot indicative of neuropathic changes. Findings were discussed via telephone with the covering clinical team at 8:30 am on ___. Gender: M Race: BLACK/CAPE VERDEAN Arrive by WALK IN Chief complaint: R FOOT PAIN Diagnosed with IDDM W SPEC MANIFESTATION, CELLULITIS OF FOOT, CELLULITIS OF LEG temperature: 98.4 heartrate: 80.0 resprate: 20.0 o2sat: 100.0 sbp: 127.0 dbp: 92.0 level of pain: 8 level of acuity: 3.0

___ with PMH uncontrolled IDDM, CKD, and recurrent foot infections who presented with left foot inflammation and tenderness for 5 days concerning for diabetic/venous ulcer vs osteomyelitis.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ ___ Complaint: Left knee pain Major Surgical or Invasive Procedure: Left knee washout and revision circlage-wire ORIF. History of Present Illness: ___ yo man who underwent left MPFL reconstruction, lateral release, and tibial tubercle plasty on ___ for left knee wound I&D and VAC placement, and on ___ for I&D and wound closure, now presenting with 1 day of worsening left knee pain, swelling, and wound discharge. Patient was discharged on ___ on vanco BID after his culture grew Staph aureus. Past Medical History: Hypertension Asthma Morbid obesity post-revision right subtalar joint fusion with tibial bone graft, ___ - patellofemoral osteoarthritis depression Social History: ___ Family History: Mother with CVA, sister with valvular heart disease Physical Exam: AFVSS LLE Incision c/d/i, w/o drainage ___ SILT ___ wwp +2dp Pertinent Results: ___ 02:00PM ___ PTT-41.4* ___ ___ 01:08PM URINE HOURS-RANDOM ___ 01:08PM URINE HOURS-RANDOM ___ 01:08PM URINE UHOLD-HOLD ___ 01:08PM URINE GR HOLD-HOLD ___ 01:08PM URINE COLOR-ORANGE APPEAR-Hazy SP ___ ___ 01:08PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-8* PH-5.5 LEUK-NEG ___ 01:08PM URINE RBC-0 WBC-2 BACTERIA-FEW YEAST-NONE EPI-<1 ___ 01:08PM URINE AMORPH-RARE ___ 01:08PM URINE MUCOUS-OCC ___ 08:55AM GLUCOSE-86 UREA N-13 CREAT-1.0 SODIUM-136 POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-23 ANION GAP-17 ___ 08:55AM estGFR-Using this ___ 08:55AM CALCIUM-9.3 PHOSPHATE-3.7 MAGNESIUM-2.3 ___ 08:55AM WBC-6.4 RBC-3.92* HGB-12.2* HCT-36.7* MCV-94 MCH-31.2 MCHC-33.3 RDW-12.0 ___ 08:55AM NEUTS-66.8 ___ MONOS-6.6 EOS-2.9 BASOS-0.7 ___ 08:55AM PLT COUNT-266 Medications on Admission: 1. Rifampin 450 mg PO Q12H 2. Senna 8.6 mg PO BID 3. Aspirin 325 mg PO DAILY Duration: 14 Days Cont for 14 days following discharge. 4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain Discharge Medications: 1. Daptomycin 750 mg IV Q24H RX *daptomycin [Cubicin] 500 mg 750 mg IV daily Disp #*42 Vial Refills:*0 2. Docusate Sodium 100 mg PO BID 3. Rifampin 450 mg PO Q12H 4. Senna 8.6 mg PO BID 5. Aspirin 325 mg PO DAILY Duration: 14 Days Cont for 14 days following discharge. 6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: left knee wound dehiscence Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report INDICATION: ___ year old man with recent picc line placement // verification of picc line placement TECHNIQUE: Single portable view of the chest. COMPARISON: ___ FINDINGS: Hazy bibasilar opacities as on prior likely due to atelectasis. Elsewhere the lungs are clear. Right PICC is seen with tip overlying the upper SVC. Cardiomediastinal silhouette is within normal limits. IMPRESSION: Right PICC tip overlying the upper SVC. Radiology Report INDICATION: ___ with left knee swelling, previous septic arthritis // Osteomyelitis, TECHNIQUE: AP, lateral, and oblique views of the left knee. COMPARISON: ___. FINDINGS: Postoperative changes at tibial tubercle transfer are again seen with hardware unchanged in position since prior. There is no periprosthetic lucency. There is no region of osteolysis. Postprocedure changes also seen in the distal femur and patella. Ossific density just inferior to the patella is unchanged. Diffuse soft tissue swelling is seen and there is a small suprapatellar effusion. IMPRESSION: No significant change since ___ with postoperative changes as detailed above. Small suprapatellar effusion. No radiographic evidence of osteomyelitis. Radiology Report EXAMINATION: KNEE (2 VIEWS) LEFT INDICATION: ___ year old man s/p L knee washout and revision ORIF // s/p L knee washout and revision ORIF TECHNIQUE: Left knee,2 views COMPARISON: Radiographs of the left knee ___. FINDINGS: There are skin staples and a drain overlying the anterior soft tissues. There is redemonstration of two partially threaded screws and cerclage wires through proximal tibial tubercle, status post tibial tubercle transfer, in good alignment. There is no hardware fracture or loosening. There is no region of osteolysis. No fracture, dislocation, or gross degenerative change is detected. No focal lytic or sclerotic lesion is identified. There is an inferior patellar pole enthesophyte. There is a suprapatellar joint effusion. IMPRESSION: Postoperative changes status post revision ORIF/tibial tubercle transfer in good alignment. No evidence of hardware complication or osteomyelitis. Radiology Report EXAMINATION: UNILAT UP EXT VEINS US INDICATION: ___ year old man with redness, swelling, and tenderness in RUE. PICC in place. // Please eval for clot. 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 bilateral subclavian veins. The right internal jugular and axillary veins are patent and compressible with transducer pressure. The right brachial, basilic, and cephalic veins are patent, compressible with transducer pressure and show normal color flow and augmentation. A PICC is visualized within the basilic vein. IMPRESSION: No evidence of deep vein thrombosis in the right upper extremity. Gender: M Race: HISPANIC/LATINO - PUERTO RICAN Arrive by AMBULANCE Chief complaint: WOUND EVAL LEFT KNEE Diagnosed with OTHER POST-OP INFECTION, ABN REACT-SURG PROC NEC, HYPERTENSION NOS temperature: 98.6 heartrate: 79.0 resprate: 16.0 o2sat: 97.0 sbp: 125.0 dbp: 64.0 level of pain: 9 level of acuity: 3.0

Patient presented with 1 day of worsening left knee pain, swelling, and wound discharge. Patient was discharged on ___ on vanco BID after his culture grew Staph aureus and returned to the ED on ___ with complaints of pain and concern for reinfection and was admitted. He was taken to the OR on ___ for another washout and closure. He was also started on Daptomycin. He was placed in a straight leg cylinder cast post operatively and given instructions to follow up in clinic in 2 weeks and with his scheduled infectious disease appointments. On ___ he began to express pain at ___ site and recieved a RUE US which negative for clot. The patient met criteria for discharge and was sent home.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Ativan / Vicodin / Doxycycline / Codeine / lisinopril Attending: ___. Chief Complaint: Bilateral lower extremity edema Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ with a PMHx of HTN, stable LUL nodule, and s/p R THA in ___ (s/p revision by Dr. ___ on ___, now presnting with bilateral lower extremity edema. Pt underwent R hip THR on ___ for DJD. He was subsequently involved in an accident in ___, whereby he was hit with a revolving door. At the time, pt fell directly on his right side, developed a squeaking noise and a discomfort at the prosthesis. Pt had progressively bothersome ceramic squeaking, which prompted him to undergo surgical revision on ___. Patient was discharged home on ___ at which time HCTZ and irbesartan were to be held for HoTN. Pt continued to hold these meds on discharge. Since discharge, pt had pain at the post-operative site. Pain can be as severe as ___, but is currently ___ in severity. 2d prior he noticed a brief episode of LLE (non-operative leg) numbness, which resolved spontaneously. 1d prior to admission, patient noted onset of lower extremity edema, R>L. This swelling has since progressed. Pt also notes testicular swelling, subjective fever to 100.6, and urinary retention. In addition he has a mild headache. Pt initially presented to ___. There he was found to have VS: T 97.6, BP 96/52, P 75, R 18, O2 Sat 96%RA. Labs there were significant for Na 134, Cr 1.27, HCT 24.4. Pt received 500cc NS and oxycodone 10mg prior to transfer to ___, for continuity of Orthopedic care. Of note, shortly after his ___ hospitalization for THR, pt developed RLE edema, fever and AMS. AMS was attributed to delerium and resolved spontaneously. Infectious source was not identified. In the ED intial vitals were: T 98.4 (Tm 101.6), P 80 BP 123/56 R 15 O2 Sat 98% on 2L. Per orthopedic surgery evaluation, there was no evidence of wound infection. Labs were significant for HCT 26.3, PLT 139, lactate 1.3, UA negative. CTA chest was limited by motion but showed no evidence of a central pulmonary embolism to the segmental level. There were small bilateral pleural effusions and subsegmental atelectasis. The right subclavian artery has a separate origin from the aortic arch and coursed behind the esophagus, a normal variant. There was a blind-ending tubular structure, origin dating from the mediastinum and terminating in the left upper lobe has been present since ___, and was thought to be likely congenital. CXR showed trace b/l effusions, linear RLL opacity, suggestive of atelectasis, and low lung volumes. ___ showed no evidence of DVT within the lower extremities, although the right peroneal veins were not visualized. Pt received furosemide 20mg IV x 1, vanc 1g IV x 1, acetaminophen, oxycodone 5mg po x 2 and lidocaine jelly. He was written for CTX but did not receive this medication per MAR. On the floor, pt reports feeling R hip pain but is otherwise at baseline. Review of Systems: (+) + pruritis; pt reports having gained 25lbs in several weeks (-) chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, BRBPR, melena, hematochezia, dysuria, hematuria, rash. Past Medical History: - HTN - LUL lung nodule (stable) - GERD - Depression - History of psychotic reaction during post-operative hospitalization - s/p L5-S1 laminectomy and fusion, epidural mass excision - Osteoarthritis - s/p R total hip replacement on ___ and s/p revision on ___ Social History: ___ Family History: CAD in multiple family members. Physical Exam: ADMISSION PHYSICAL EXAM ======================= Vitals - T: 97.9 BP: 124/57 HR: 78 RR: 20 02 sat: 94%RA GENERAL: NAD, A+Ox3 but with some evidence of inattention (multiple incorrect answers for year prior to correct answer) HEENT: ATNC, EOMI, PERRL, anicteric sclera, pink conjunctiva, patent nares, MMM, good dentition, no sinus tenderness, nontender supple neck, no LAD, no JVD; +facial flushing CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: Proximal/lateral RLE with large well-healing incision. Staples in place; no erythema or discharge. +TTP. 2+ pitting edema bl; R>L PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, strength ___ in distal ___, unable to assess strength in proximal RLE ___ pain. Sensation intact and symmetric bilaterally. SKIN: warm and well perfused, small erythematous lesions on anterior chest. Pt reports pruritis and has some excoriations. RECTUM: Slightly enlarged prostate without tenderness; no stool in vault DISCHARGE PHYSICAL EXAM ======================= VS Tm 98.6 125/59 76 18 95% ___ GEN: middle aged man sitting at edge of bed in NAD CV: No JVD, RRR, no m/r/g PULM: clear bilaterally ABD: soft, non-tender, non-distended EXT: R hip with bandage and mild surrounding erythema. 2+ edema in RLE to hip with some erythema/warmth; non-tender. LLE without edema. GU: no scrotal edema NEURO: alert and oriented, intact attention, cranial nerves intact to confrontation, normal motor exam though antalgic R hip flexion/extension Pertinent Results: ADMISSION LABS -------------- ___ 06:12PM BLOOD WBC-7.1 RBC-2.92* Hgb-8.3* Hct-26.3* MCV-90 MCH-28.5 MCHC-31.7 RDW-13.9 Plt ___ ___ 06:12PM BLOOD Neuts-70.7* ___ Monos-8.4 Eos-2.3 Baso-0.3 ___ 06:35AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-1+ Burr-1+ Tear Dr-1+ Acantho-OCCASIONAL ___ 06:12PM BLOOD ___ PTT-65.1* ___ ___ 06:12PM BLOOD Glucose-113* UreaN-20 Creat-1.2 Na-136 K-4.7 Cl-102 HCO3-22 AnGap-17 ___ 06:12PM BLOOD ALT-14 AST-32 LD(LDH)-138 AlkPhos-68 Amylase-33 TotBili-0.5 ___ 06:12PM BLOOD proBNP-862* ___ 06:12PM BLOOD Lipase-17 ___ 06:12PM BLOOD Albumin-3.3* ___ 06:35AM BLOOD Calcium-8.5 Phos-4.2 Mg-1.3* PERTINENT RESULTS ----------------- ___ 06:12PM BLOOD proBNP-862* ___ 06:12PM BLOOD Lipase-17 ___ 06:12PM BLOOD Hapto-208* ___ 06:12PM BLOOD TSH-6.4* ___ 06:12PM BLOOD Free T4-1.1 ___ 06:35AM BLOOD CRP-91.2* DISCHARGE LABS -------------- ___ 07:20AM BLOOD WBC-6.2 RBC-2.69* Hgb-7.6* Hct-24.1* MCV-90 MCH-28.1 MCHC-31.4 RDW-14.6 Plt ___ ___ 07:20AM BLOOD Glucose-104* UreaN-24* Creat-1.5* Na-136 K-4.7 Cl-101 HCO3-22 AnGap-18 IMAGING ------- ___ LOWER EXTREMITY US W/ DOPPLER: IMPRESSION: No evidence of DVT within the lower extremities, although the right peroneal veins were not visualized. ___ CTA: 1. Interval development of small bilateral non-hemorrhagic pleural effusions and adjacent subsegmental atelectasis. Ground glass opacities could reflect expiratory phase of imaging although some degree of edema is possible. 2. A blind-ending tubular structure extending from the mediastinum to the left upper lobe is of unclear etiology, but has not significantly changed since ___ and likely represents a congenital process such as an atretic supernumerary bronchus with mucoid impaction. 3. No evidence of pulmonary embolism to the segmental level. Subsegmental arteries are difficult to evaluate due to motion artifact. ___ TTE: IMPRESSION: Normal global and regional biventricular systolic function. No diastolic dysfunction, pulmonary hypertension or pathologic valvular abnormality seen. ___ CT R LEG: IMPRESSION: 1. Probable subcutaneous seroma deep to the lateral right thigh skin staples. Allowing for this, no hematoma or rim-enhancing fluid collection. 2. No fracture or evidence of hardware complication. 3. Extensive subcutaneous edema throughout the thigh. Moderate left knee joint effusion. MICRO ----- Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Aspirin 81 mg PO DAILY 2. Avapro (irbesartan) 150 mg oral daily 3. Cyanocobalamin 1000 mcg PO DAILY 4. Hydrochlorothiazide 25 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Omeprazole 20 mg PO DAILY 7. Thiamine 100 mg PO DAILY 8. Vitamin D 1000 UNIT PO DAILY 9. Diazepam 5 mg PO HS:PRN insomina 10. Acetaminophen 1000 mg PO Q8H 11. Docusate Sodium 100 mg PO BID 12. Enoxaparin Sodium 40 mg SC DAILY 13. Senna 8.6 mg PO BID 14. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Aspirin 81 mg PO DAILY 3. Cyanocobalamin 1000 mcg PO DAILY 4. Diazepam 5 mg PO HS:PRN insomina 5. Docusate Sodium 100 mg PO BID 6. Multivitamins 1 TAB PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Senna 8.6 mg PO BID 9. Thiamine 100 mg PO DAILY 10. Vitamin D 1000 UNIT PO DAILY 11. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain 12. Enoxaparin Sodium 40 mg SC DAILY Duration: 3 Weeks Start: Today - ___, First Dose: Next Routine Administration Time day ___ = ___ continued for 1 month 13. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 17 gram/dose 17 gram by mouth daily as needed Disp #*15 Packet Refills:*0 14. Outpatient Lab Work Chem7 and CBC to be drawn ___ or ___. Fax results to PCP: ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: #Status post right total hip arthroplasty #Anemia #Thrombocytopenia #Hypertension #Lower extremity edema #Acute kidney injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Right hip revision on ___, now with edema, warmth, and hematocrit drop. Evaluate for abscess or hematoma. COMPARISON: Radiographs ___. TECHNIQUE: MDCT axial images were acquired through the right hip and femur after administration of Omnipaque intravenous contrast. Bone reconstructions and coronal and sagittal reformations are provided for review. DLP: 1209.78 mGy-cm. RIGHT FEMUR WITH INTRAVENOUS CONTRAST: The study is limited by streak artifact from the hip arthroplasty. The patient is status post right total hip arthroplasty. There is no evidence of hardware loosening or complication. No periprosthetic fracture is seen. A subchondral cyst in the superior acetabulum (401B:52) has been present since at least ___. Skin staples are in place. Blood products are seen within the gluteus muscles, but there is no discrete large hematoma.Probable subcutaneous seroma deep to the skin staples measuring roughly 2.8 x 3.6 (axial) x 10 cm (3:53, 201b:60). Otherwise, no rim-enhancing fluid collection is seen. There is marked subcutaneous edema throughout the thigh extending to the level of the knee, and possibly more inferiorly, although not imaged. There is a moderate knee joint effusion. Amorphous calcifications at the right hamstring tendons adjacent to the ischial tuberosity may represent heterotopic ossification. Hard and soft atherosclerotic plaque is seen at the left distal SFA and popliteal artery. Evaluation of the intra-abdominal contents is limited, but demonstrates a right inguinal hernia containing fluid. Air in the bladder is likely related to recent instrumentation. Scattered diverticula are noted. IMPRESSION: 1. Probable subcutaneous seroma deep to the lateral right thigh skin staples. Allowing for this, no hematoma or rim-enhancing fluid collection. 2. No fracture or evidence of hardware complication. 3. Extensive subcutaneous edema throughout the thigh. Moderate left knee joint effusion. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: LEG SWELLING Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, HYPERTENSION NOS temperature: 98.4 heartrate: 80.0 resprate: 15.0 o2sat: 98.0 sbp: 123.0 dbp: 56.0 level of pain: 5 level of acuity: 3.0

Mr. ___ is a ___ with a PMHx of HTN, stable LUL nodule, and sp R THA in ___ sp revision by Dr. ___ ___ now presnting with bilateral lower extremity swelling and fever. # Bilateral ___ Edema: Unclear etiology why edema was bilateral. Possibly secondary to holding HCTZ at last discharge. Left leg edema resolved with Lasix x 2. Right lower extremitiy edema remained and was attributed to soft tissue inflammation causing impaired venous drainage of the limb. He had normal lower extremity Doppler US, normal TTE, normal albumin, normal liver function, relatively normal renal function without proteinuria. Cellulitis was felt to be unlikely given absent cutaneous pain, no leukocytosis. # Fever: Tm 101.6 in ER on POD#5. There was never an associated leukocytosis or sepsis physiology. The fevers were attributed to post-op inflammation versus drug fever - seen occasionally with enoxaparin. There was no evidence of venous thromboembolism, UTI, diarrhea, PNA, prostate tenderness, sinusitis, or LFT abnormalities. Cellulitis and prosthetic joint infection were felt to be unlikely and the patient was treated with only 2 doses of vancomycin. He was not discharged on antibiotics. # Acute kidney injury: His Cr was rising at discharge (1.5 from 1.1 on admission). This was felt to be related to IV contrast exposure ___ and ___. This elevation fit with the timeline of contrast-induced nephropathy. He had no evidence of RP hemorrhage on ___ CT to indicate ureteral compression and he did not appear hypovolemic. At discharge, a follow up plan was made for repeat chem7 to be drawn at PCP's office. # Thrombocytopenia: RESOLVED. Has a history of recurrent thrombocytopenia. 4T score for most recent admission is 2. Two of three prior PLT count decreases that were associated with heparin administration were also associated with fall of HCT (i.e. blood loss in setting of surgery; pt received lovenox on ___ and ___ and had anemia both times in setting of surgery). DDx includes alcohol related (given hx of etoh use per record), consumption from ongoing mild bleeding associated with surgery. Hemolysis unlikely based on LDH, haptoglobin, and bilirubin. Thrombocytopenia resolved to normal during the admission. # Anemia: Likely ___ post-operative blood loss. Stable from recent admission. Baseline Hgb >14, but here Hgb was ___. Hemolysis labs were negative. Likely loss secondary to surgery into hip, but there was no evidence of significant hematoma on CT ___. We recommended repeat CBC as an outpatient in the next ___ days post-discharge. # Right total hip arthroplast: ___. Weight bearing as tolerated bilaterally. Saw physical therapy who recommended continuing home ___. # Constipation: Likely secondary to home opiates. He was treated with an aggressive bowel regimen. He was discharged with stool softeners. # EtOH Use: Significant historical use per wife. None recently. He did not display signs of alcohol withdrawal. He was given folate, thiamine, B12, and a multivitamin. # HTN: Held HCTZ and irbersartan (held after discharge from arthroplasty). Normotensive here. Defer to PCP to restart when renal function normalized and hypertension requires reinitiation. # GERD: Continued omeprazole # Emergency Contact: ___ (wife): ___ # CODE STATUS THIS ADMISSION: FULL

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: EGD ___ History of Present Illness: Ms. ___ is a ___ with portal vein thrombosis, portal hypertension secondary to schistosomiasis, previous variceal bleed, likely cirrhosis, and splenectomy. She has had abdominal pain for 2 days. It is constant but improves with pain control. It radiates from her epigastrium into her back. She has not identified any provoking or palliating factors. She says the last time she had similar symptoms was when she had variceal bleeding. She denies any black or bloody stools; she reports that her stool is yellow. She has had nausea but denies vomiting or hematemesis. She denies dysuria. She has had a fever for several days, up to 102. She was transferred to ___, where she had a CTA of her chest which was unremarkable. Per radiology, there are varices visible on the CTA but no active extravasation. No stool in the vault. Denies melena. In the ED, initial vital signs were: 100.1 114 117/72 18 98% RA Labs notable for: WBC 11, Hgb 6.5, Plt 493 INR 1.2 UA with 10 WBCs, few bacteria She received IV morphine, octreotide/pantoprazole, ceftriaxone/flagyl, and was not transfused prior to transfer. Vitals prior to transfer to MICU: 100.6 114 106/65 21 100% RA CT abd/pelvis without contrast were ordered and showed acute SMV thrombus. On arrival to the MICU, she says her pain is better. Review of systems: Complete ROS obtained and is otherwise negative. Past Medical History: - schistosomiasis c/b chronic PVT, ? report of portocaval shunt - h/o splenectomy at age ___, pneumovax last ___ - GERD - s/p c-sections - h/o cholelithiasis Social History: ___ Family History: no liver disorders Physical Exam: ADMISSION EXAM Vitals: t 100.6 bP 98/59 HR 107 Pox 100 GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: RUQ tenderness EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: spider angiomas on chest NEURO: no asterixis DISCHARGE EXAM VS: Tmax 98.8 BP 90-110/50-70s HR 80-90s RR 18 ___ on RA GENERAL: NAD. Comfortable Eyes: Anicteric sclera without conjunctival injection ENT: MMM. No oral lesions ___: RRR, no m/r/g LUNGS: CTAB, no w/r/c ABDOMEN: soft, nondistended. No tenderness to palpation. No rebound or guarding. EXT: well perfused, no edema NEURO: AOx3, no asterixis Pertinent Results: ADMISSION LABS ============== ___ 05:54AM BLOOD WBC-11.0*# RBC-2.86*# Hgb-6.5*# Hct-21.7*# MCV-76*# MCH-22.7*# MCHC-30.0* RDW-21.1* RDWSD-55.8* Plt ___ ___ 05:54AM BLOOD ___ PTT-27.4 ___ ___ 05:54AM BLOOD Glucose-84 UreaN-8 Creat-0.6 Na-136 K-6.2* Cl-101 HCO3-16* AnGap-25* ___ 05:54AM BLOOD ALT-81* AST-158* LD(LDH)-901* AlkPhos-124* TotBili-0.6 ___ 10:35AM BLOOD Lipase-25 ___ 05:54AM BLOOD Lipase-34 ___ 06:00AM BLOOD cTropnT-<0.01 ___ 05:54AM BLOOD cTropnT-<0.01 ___ 10:35AM BLOOD Calcium-8.1* Phos-3.5 Mg-2.1 Iron-PND ___ 05:54AM BLOOD Hapto-231* ___ 09:55AM BLOOD K-4.0 ___ 05:58AM BLOOD Lactate-1.2 MICRO ===== ___ BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT ___ URINE URINE CULTURE-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT ___ URINE URINE CULTURE-FINAL EMERGENCY WARD ___ BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY WARD ___ BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY WARD IMAGING ======= CT abd/pelvis ___ 1. No retroperitoneal hematoma. 2. The SMV appears enlarged compared with prior and slightly hyperdense, with surrounding fat stranding, concerning for acute SMV thrombosis. 3. Trace free fluid in the pelvis. CTA abd/pelvis ___ IMPRESSION: 1. SMV and medial splenic vein thrombosis, both vessels are expanded with central filling defect, suggesting acute to subacute to thrombus. There is mild mesenteric stranding and small volume fluid. Single small bowel loop is mildly dilated, has normal wall enhancement, consider follow-up serial radiographs to exclude progressive dilatation. Mild wall thickening of the ascending, transverse, descending ___ be reactive, infectious, inflammatory or ischemic colitis should be considered. 3. Findings of hepatic cirrhosis. No focal enhancing liver lesion is identified. 4. Chronic thrombosis of the portal vein with cavernous transformation of multiple collaterals at the hepatic hilum. DISCHARGE LABS ============== ___ 06:13AM BLOOD WBC-6.6 RBC-4.02 Hgb-9.4* Hct-30.5* MCV-76* MCH-23.4* MCHC-30.8* RDW-21.0* RDWSD-57.1* Plt ___ ___ 06:13AM BLOOD Plt ___ ___ 06:13AM BLOOD ___ PTT-32.4 ___ ___ 06:13AM BLOOD Glucose-91 UreaN-10 Creat-0.6 Na-136 K-5.3* Cl-100 HCO3-24 AnGap-17 ___ 06:13AM BLOOD ALT-91* AST-121* AlkPhos-173* TotBili-0.4 ___ 06:13AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.2 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Nadolol 40 mg PO DAILY Discharge Medications: 1. Enoxaparin Sodium 80 mg SC Q12H Start: ___, First Dose: Next Routine Administration Time RX *enoxaparin 80 mg/0.8 mL 80 mg subQ q12hr Disp #*60 Syringe Refills:*0 2. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 3. Warfarin 3 mg PO DAILY16 RX *warfarin [Coumadin] 3 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Nadolol 40 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary: Symptomatic anemia Secondary: Superior mesenteric vein thrombus Cirrhosis Schistosomiasis s/p Splenectomy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT abdomen and pelvis without contrast INDICATION: ___ with abd pain, severe anemiaNO_PO contrast // RP bleed? 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: total DLP (Body) = 725 mGy-cm. COMPARISON: MRI liver on ___, CT abdomen on ___ FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: Macronodular contour of the liver is stable in appearance. 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 stranding around the pancreatic head and extending along the course of the SMV. SPLEEN: The spleen is surgically absent. Splenosis measuring 3.7 cm in the left upper quadrant is unchanged. 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. Contrast is seen in the bilateral collecting systems related to CTA performed earlier on same date. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber and wall thickness throughout. The colon and rectum are within normal limits. The appendix is normal. There is no evidence of retroperitoneal hematoma. PELVIS: The urinary bladder and distal ureters are unremarkable. There is trace simple free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are within normal limits. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease is noted. There are perigastric varices. The SMV appears enlarged compared with prior, and slightly hyperdense, with surrounding fat stranding, concerning for acute SMV thrombosis (2:34, 602b:33). 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 retroperitoneal hematoma. 2. The SMV appears enlarged compared with prior and slightly hyperdense, with surrounding fat stranding, concerning for acute SMV thrombosis. 3. Fat stranding adjacent to the pancreatic head and extending along the SMV is likely related to the process in the SMV, correlate with labs to exclude pancreatitis. 4. Trace free fluid in the pelvis. Radiology Report EXAMINATION: CTA ABD/PEL WANDW/O C W/REONS INDICATION: ___ year old woman with history of cirrhosis secondary tissue system schistosomiasis, PV thrombus, possible new ___ thrombus, abdominal pain // CT arterial and venous phase of A/P to better assess possible new SMV thrombus, known portal vein thrombus, and look for mesenteric ischemia post splenectomy. 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 5.2 s, 57.5 cm; CTDIvol = 4.3 mGy (Body) DLP = 248.5 mGy-cm. 2) Spiral Acquisition 7.1 s, 55.8 cm; CTDIvol = 16.2 mGy (Body) DLP = 902.0 mGy-cm. Total DLP (Body) = 1,151 mGy-cm. COMPARISON: CT abdomen pelvis without contrast from ___, MRI of liver ___, CT abdomen pelvis from ___. FINDINGS: VASCULAR: There is chronic thrombosis of the main portal vein, with cavernous transformation of multiple collaterals at the hepatic hilum. The SMV is thrombosed with a small amount of adjacent mesenteric fat stranding. SMV thrombosis is more extensive compared with ___, which is the most recent comparison CT evaluated this vasculature with the proper phase of imaging. There is medial splenic vein thrombosis seen today, in a portion the was patent on MRI ___. There is expansion of both SMV and splenic vein, suggesting acute thrombosis. There are multiple mesenteric collaterals. There is persistent enlargement of the IVC . There is no abdominal aortic aneurysm. There is minimal calcium burden in the abdominal aorta and great abdominal arteries. LOWER CHEST: Minimal atelectasis is noted in the lung bases. There is no pleural or pericardial effusion. There is tiny pulmonary artery to pulmonary vein fistula in the right lower lobe medially series 3, image 24. ABDOMEN: HEPATOBILIARY: The right lobe is small in size with enlargement of the left lobe with macrolobular contour. Constellation of findings are consistent with hepatic cirrhosis. No focal enhancing liver lesion is identified. There is mild intrahepatic bile duct dilatation, similar to prior. There is no extrahepatic bile duct 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 again seen mild stranding around the pancreatic head and extending along the course of the SMV. SPLEEN: The spleen is surgically absent. Splenosis in the left upper quadrant is unchanged. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. 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 wall thickness and enhancement throughout. There is single loop wall of mildly dilated small bowel loop in the right abdomen, this should be followed with serial x-rays given ___ thrombosis to monitor for progressive dilatation. There are areas of mild colonic wall thickening involving ascending, transverse and proximal descending ___ be reactive, consider infectious or inflammatory colitis, changes related to venous congestion. There is no pneumatosis intestinalis, bowel wall thickening, or intraperitoneal free air suggest mesenteric ischemia. Appendix contains air, has normal caliber without evidence of fat stranding. There is no evidence of mesenteric lymphadenopathy. There is moderate mesenteric stranding is small volume fluid centrally. Trace perihepatic fluid. 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. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. SMV and medial splenic vein thrombosis, both vessels are expanded with central filling defect, suggesting acute to subacute to thrombus. There is mild mesenteric stranding and small volume fluid. Single small bowel loop is mildly dilated, has normal wall enhancement, consider follow-up serial radiographs to exclude progressive dilatation. Mild wall thickening of the ascending, transverse, descending ___ be reactive, infectious, inflammatory or ischemic colitis should be considered. 3. Findings of hepatic cirrhosis. No focal enhancing liver lesion is identified. 4. Chronic thrombosis of the portal vein with cavernous transformation of multiple collaterals at the hepatic hilum. NOTIFICATION: The findings and recommendations were communicated to the referring physician via telephone to Dr. ___ at 9:23 ___ on ___ by Dr. ___. Gender: F Race: WHITE - BRAZILIAN Arrive by AMBULANCE Chief complaint: Abd pain, Abnormal labs, Transfer Diagnosed with Unspecified abdominal pain, Anemia, unspecified temperature: 100.1 heartrate: 114.0 resprate: 18.0 o2sat: 98.0 sbp: 117.0 dbp: 72.0 level of pain: 9 level of acuity: 2.0

HOSPITAL COURSE =============== ___ female with history of cirrhosis ___ schistosomiasis s/p splenectomy c/b portal vein thrombosis, portal hypertension, gastroesophageal varices who presents with three days of abdominal pain and fever, found to have SMV thrombus and symptomatic anemia with Hgb 6.5 likely multifactorial given hx GIB, heavy menses, and consumptive in setting of acute thrombus, for which she was started on a heparin drip. EGD significant for one small esophageal varix and potential gastric varices, without stigmata of recent bleed. ___ was consulted for possible thrombectomy and TIPS. Given her surgical history of splenectomy and cavernous transformation of her portal vein, the procedure was felt to be technically difficult, and was deferred for a trial of anticoagulation. The patient's pain resolved and the patient was discharged on a Lovenox bridge to ___ with close outpatient follow-up. ACTIVE ISSUES ============= # Abdominal pain # Acute SMV Thrombus # Anemia: She has history of gastric variceal hemorrhage, as well as esophageal varices. Her anemia is notably microcytic which would be consistent with bleed vs ___. Presented with three days of abdominal pain and fever, found to have SMV thrombus and symptomatic anemia with Hgb 6.5 likely multifactorial given hx GIB, heavy menses, and consumptive in setting of acute thrombus, for which she was started on a heparin drip. EGD significant for one small esophageal varix and potential gastric varices, without stigmata of recent bleed. ___ was consulted for possible thrombectomy and TIPS. Given her surgical history of splenectomy and cavernous transformation of her portal vein, the procedure was felt to be technically difficult, and was deferred for a trial of anticoagulation. The patient's pain resolved and the patient was discharged on a Lovenox bridge to ___ with close outpatient follow-up. # SIRS: fever + tachycardia, though no localizing infectious source. Presumed due to infection or from ___ thrombosis itself. Initially receive ceftriaxone but was subsequently discontinued on ___ as no localizing signs of infection, low fevers presumed due to clot as above. # Cirrhosis # Trasaminitis Cirrhosis ___ schistosomiasis with history of PV thrombosis and variceal bleeding. MELD 8 (11 on admission). ___ Class A. AST/ALT mildly elevated, ratio approx 2. AP mildly elevated. T ___ normal at 0.6 on admission. LDH elevated at 900. LFTs downtrended during admission but began to trend up at time of discharge, to be followed up with outpatient labs. # H/o schistosomiasis: Chronic, no treatment. S/p splenectomy. TRANSITIONAL ISSUES =================== [] Medications - Enoxaparin Sodium 80 mg SC Q12H - Warfarin 3mg daily - Pantoprazole 40 mg PO Q24H [] Of note, patient is eligible for a fourteen day supply of medications from ___ free pharmacy, after which time, she will need additional assistance in obtaining her medications [] Patient with slight elevation in LFTs (ALT 91 AST 121) on discharge; has standing labs ordered at ___ (LFTS, CBC, BMP) to be checked on ___ and followed up by Dr. ___ Dr. ___ [] Check INR at ___ on ___ and follow up by Dr. ___ [] Protein C,S, and antithrombin III pending at the time of discharge [] Will attempt to coordinate an earlier appointment with Dr. ___ at the beginning of ___ # Code: Full # Communication: ___ (boyfriend) ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Haldol / Seroquel Attending: ___. Chief Complaint: fall Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a ___ year old woman with a history of narcolepsy with cataplexy and NPH s/p VPS in ___ who presented s/p fall. The patient fell in her bathroom on ___. She hit her head on the toilet, but did not lose consciousness. She crawled to the living room, where a nurse found her. She was originally admitted to ___, where a CT scan showed a 1cm right frontal subdural bleed. She was transferred from ___ to ___. On arrival to the ED, she had vitals T97.4 BP 120/74 HR 74 R 16 O2 98% RA. Exam was deferred because the patient was "uncooperative." A repeat head CT showed that the SDH had not increased in size, there was no new hemorrhage and the VPS shunt was in place. Past Medical History: 1. Narcolepsy w/cataplexy, as above 2. NPH s/p VP shunt in ___ (@OSH) -- last shunt series was in ___, unremarkable, and NCHCT at that time showed decompressed ventricular system (albeit with no prior images for comparison) 3. s/p lumbar spine fusion complicated by MRSA bacteremia, requiring R-knee hardware removal and replacement; chronic Bactrim Tx since that time. 4. s/p bilateral knee replacements and repeat of R-knee after MRSA-bacteremia in ___ 5. Frequent, recurrent UTIs 6. h/o chest pain with + cardiac stress in ___ (details unknown to me at this time -- no echo or vessel/stress data in OMR... ECGs appear benign here and patient has been asx and HDS here) 7. s/p Thyroid ablation, Thyroid nodules, being monitored 8. s/p cholecystectomy 9. Osteoarthritis 10. chronic spastic bladder (Vesicare recently d/c'd) 11. chronic mild dysphagia (cause = ?) on mech soft diet and thin liquids. also, pt has only upper dentures Social History: ___ Family History: Daughter - mitral valve disease. Maternal GM with ateriosclerosis. Breast Ca in Sister. ___ in siblings. Physical Exam: ADMISSION EXAM 98.0 114/71 59 18 96%RA. MS: ___. She is fluent with normal prosody. She did not participate in memory recall or attention questions. Cranial Nerves: CNI: Not tested. CNII: L pupil 3mm-->2mm. R pupil 3mm-->2mm. Visual fields full to confrontation. CNIII, IV, VI: Extraocular movements intact. No nystagmus. V: Sensitive to light touch in V1,2 and 3 distributions. Able to clench jaw. VII: No facial droop. Able to smile without asymmetry. Unable to overcome eye closure bilaterally. VIII: Able to hear finger-rub bilaterally. IX, X: Able to elevate palate. Gag reflex not tested. XI: SCM and shoulder shrug are full strength bilaterally. XII: Tongue protrudes midline. Motor: Normal bulk, tone throughout. No adventitious movements noted. No pronator drift. [Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas] [___] [C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1] [L5] L 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 -Sensory: Sensitive to light touch and pinprick sensation in bilateral upper and lower extremities. -DTRs: Bi Tri ___ Pat Ach L 3 3 3 1 1 R 3 3 3 1 1 Plantar response was flexor on L and R. Coordination: Able to perform finger-to-nose bilaterally. Slowed cadence on L rapid finger movements; right rapid finger movements were normal. DISCHARGE EXAM: 97.9 97.0 131/57 61 18 MS: ___ month/date, but not to place, hospital. Can attend to the examiner. Perserverates on "thank you" but can answer some questions appropriately. Follows most commands. Motor: Normal bulk, tone throughout. No adventitious movements noted. No pronator drift. [Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas] [___] [C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1] [L5] L 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 -Sensory: Sensitive to light touch in bilateral upper and lower extremities. - Coordination: Able to perform finger-to-nose bilaterally. Pertinent Results: Cardiovascular Report ECG Study Date of ___ 2:09:40 ___ Sinus rhythm. Diffuse modest ST-T wave changes which are non-specific. Compared to the previous tracing of ___ there are modest inferior ST-T wave changes which are more pronounced. Read by: ___ Intervals Axes Rate PR QRS QT/QTc P QRS T 89 192 84 384/434 55 44 24 _____________________________ Radiology Report CT C-SPINE W/O CONTRAST Study Date of ___ 2:06 ___ IMPRESSION: 1. Moderate degenerative changes. 2. No evidence for fracture. 3. Findings at the lung apices suggesting pulmonary vascular congestion. 4. Heterogeneous thyroid probably reflecting nodules which could be examined in more detail by ultrasound if clinically indicated. _______________________________ Radiology Report HIP 1 VIEW Study Date of ___ 10:36 ___ CONCLUSION: No good evidence of acute fracture. _______________________________ Radiology Report CT HEAD W/O CONTRAST Study Date of ___ 6:56 AM IMPRESSION: 1. No gross change in the size of the right frontal subdural hematoma or its mild mass effect. 2. No new focus of hemorrhage. 3. Stable prominence of the ventricles with a ventriculostomy catheter in unchanged position. ___ 02:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 02:40PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 02:40PM ___ PTT-32.1 ___ ___ 02:40PM PLT COUNT-232 ___ 02:40PM NEUTS-80.1* LYMPHS-16.1* MONOS-3.2 EOS-0.6 BASOS-0.1 ___ 02:40PM WBC-6.8 RBC-3.61* HGB-10.8* HCT-32.4* MCV-90# MCH-30.0 MCHC-33.4 RDW-12.6 ___ 02:40PM CALCIUM-9.2 PHOSPHATE-3.1 MAGNESIUM-2.0 ___ 02:40PM CK-MB-2 ___ 02:40PM cTropnT-<0.01 ___ 02:40PM CK(CPK)-30 ___ 02:40PM estGFR-Using this ___ 02:40PM GLUCOSE-96 UREA N-28* CREAT-0.9 SODIUM-138 POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-29 ANION GAP-11 ___ 04:02PM PLT COUNT-230 TSH 3.8, FT4 0.99, CRP 31.8, ESR 58 ___ Urine Cx negative ___ Urine Cx ___ 2:07 pm URINE Site: NOT SPECIFIED GRAY TOP HOLD # ___ ___. **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Piperacillin/tazobactam sensitivity testing available on request. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R Medications on Admission: 1. venlafaxine 37.5 mg Capsule, Ext Release 24 hr Sig: Three (3) Capsule, Ext Release 24 hr PO DAILY (Daily). 2. sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain or ___. 11. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days: Course to finish on ___. 13. donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. Zyprexa 2.5 mg Tablet Sig: 0.5 Tablet PO twice a day as needed for agitation. Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily): for MRSA prophylaxis. Disp:*30 Capsule(s)* Refills:*2* 5. donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain or fever > 101.5. 9. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. venlafaxine 150 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day: in the morning. Disp:*30 Tablet Extended Rel 24 hr(s)* Refills:*2* 11. sertraline 50 mg Tablet Sig: Three (3) Tablet PO at bedtime. 12. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO once a day: Take only if systolic blood pressure >160. Disp:*30 Tablet(s)* Refills:*2* 13. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a day. 14. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 6 days: for treatment of E.coli UTI. Disp:*24 Tablet(s)* Refills:*0* 15. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). Disp:*60 Tablet, Chewable(s)* Refills:*2* 16. Xyrem 500 mg/mL Solution Sig: 3.75 mg PO twice nightly: administer 3.75 mg by mouth at bedtime and 3.75 mg by mouth ___ hours later. Disp:*2 weeks* Refills:*0* 17. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis: Right Frontal Subdural Hemorrhage, Urinary Tract Infection Secondary Diagnosis: Cataplexy, Narcolepsy, Normal Pressure Hydrocephalus, Dementia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Neurologic: Awake, alert, oriented to place, hospital, time. Speech fluent and answers most questions appropriately. Otherwise nonfocal. Followup Instructions: ___ Radiology Report CT OF THE CERVICAL SPINE HISTORY: Combative dementia and unwitnessed fall, with presentation to outside hospital with subdural hematoma, hip pain and tenderness overlying T3 and T4 COMPARISONS: An outside head CT is available from ___. TECHNIQUE: Multidetector CT images of the cervical spine were obtained without intravenous contrast. Sagittal and coronal reformations were also performed. FINDINGS: There is no evidence for fracture, dislocation or bone destruction. Moderate degenerative changes involve the cervical spine. The upper thoracic spine including T3 and T4 are not fully imaged. Degenerative changes are moderate at the anterior C1-C2 articulation including fragmented osteophytes and periarticular calcification. The C3-C4 interspace is largely calcified, with a posterior disc bulge and mild neural foraminal narrowing on the right by uncovertebral joint osteophytes. There is also mild right-sided neural foraminal narrowing at C4-C5 and bilaterally at C5-C6 association with facet and uncovertebral joint osteophytes. Facet joint degenerative changes are most striking on the left at C3-C4 and C4-C5 and on the right at C5-C6. Mild facet joint degenerative changes are present at C6-C7 bilaterally. Facet joint changes are moderate at C7-T1 level on the right. Minimal spondylolisthesis of C7 on T1 is probably due to facet joint degenerative changes, which are so again moderately prominent on the right side. The lung apices show thickened interlobular septa and patchy ground glass opacification suggesting pulmonary congestion. The thyroid is heterogeneous, probably reflecting multiple nodules. The right lobe is attenuated with patchy calcification. Patchy vascular calcifications are also noted along each carotid bulb. Vascular calcifications are widespread and striking along the course of the left vertebral artery. IMPRESSION: 1. Moderate degenerative changes. 2. No evidence for fracture. 3. Findings at the lung apices suggesting pulmonary vascular congestion. 4. Heterogeneous thyroid probably reflecting nodules which could be examined in more detail by ultrasound if clinically indicated. Radiology Report STUDY: AP pelvis and mages of left hip. INDICATION: Patient with cognitive dementia, transferred in with history of subdural hematoma and left hip pain. TECHNIQUE: AP pelvis, single view left hip was obtained. COMPARISON: None. REPORT: The examination is markedly limited, but within this limitation, a single AP view of the pelvis does not definitively reveal a fracture. Degenerative changes are noted in the symphysis pubis. Degenerative change also noted in both hips. CONCLUSION: No good evidence of acute fracture. Radiology Report INDICATION: Evaluate for interval change of subdural hematoma. COMPARISONS: CT head ___. CT head ___. TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without the administration of IV contrast. FINDINGS: A left frontal approach ventriculostomy catheter is in an unchanged position near the septum pellucidum. The ventricles are mildly prominent which is unchanged from prior exams. A right frontal hyperdense extra-axial collection appears grossly unchanged in size. The apparent difference in size is likely due to a substantial difference in the plane of scanning. There is mild mass effect with some effacement of the adjacent sulci, but no shift of the normal midline structures or effacement of the cisterns. The basal cisterns appear patent. There are no new foci of hemorrhage. There is no evidence of infarction. No fracture is identified. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The soft tissues are unremarkable. IMPRESSION: 1. No gross change in the size of the right frontal subdural hematoma or its mild mass effect. 2. No new focus of hemorrhage. 3. Stable prominence of the ventricles with a ventriculostomy catheter in unchanged position. Radiology Report INDICATION: ___ female, status post fall with right elbow pain, point tenderness, worse with movement. COMPARISONS: None available. TECHNIQUE: Right elbow, three views. FINDINGS: Assessment of the right elbow is limited as the lateral view was taken with the elbow in extension. Allowing for these limitations, an equivocal positive posterior fat pad sign is present, which is concerning for a periarticular fracture. There are no focal osseous lesions or radiopaque foreign objects. IMPRESSION: Probable periarticular fracture. Further assessment is needed with a proper lateral view with a flexed elbow. These concerns were communicated by Dr. ___ to ___ ___ via telephone on ___ at 4:45 p.m. Radiology Report STUDY: Single lateral view of the right elbow ___. COMPARISON: Radiographs earlier the same day. INDICATION: Multiple falls and right elbow pain. FINDINGS: Unremarkable soft tissues. Anterior fat pad sign and small posterior fat pad, consistent with a small joint effusion. However, on the single view no definite fracture identified. IMPRESSION: Small elbow joint effusion. If there is concern for an occult fracture, recommend further evaluation with CT. Radiology Report CHEST HISTORY: Cough and chest pain, question infiltrate. REFERENCE EXAM: ___. FINDINGS: Shunt tubing is coursing over the right lateral chest. The heart is upper limits normal in size. There are some patchy areas of alveolar opacity. It could represent areas of volume loss or early infiltrate. These are more conspicuous than on the prior exam from ___. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: S/P FALL SDH Diagnosed with TRAUMATIC BRAIN HEM NEC, OPEN WOUND OF SCALP, UNSPECIFIED FALL, DEMENTIA IN CONDITIONS CLASSIFIED ELSEWHERE WITHOUT BEHAVIROAL DISTURBANCE, ALZHEIMER'S DISEASE temperature: 97.4 heartrate: 74.0 resprate: 16.0 o2sat: 98.0 sbp: 120.0 dbp: 74.0 level of pain: 13 level of acuity: 2.0

___ with a history of narcolepsy with cataplexy and NPH s/p VPS in ___ who presented s/p fall with ___ diagnosed on head CT ___. [] Subdural Hemorrhage. On ___, patient was admitted to the SICU and monitored overnight. A repeat Head CT was done on the morning of ___ which showed that the SDH had not increased in size, there was no new hemorrhage and the VPS shunt was in place. No focal deficits were identified on serial neuro exams. She was started on Dilantin 100 mg TID. On ___, the patient was transferred to the step-down unit. She remained neurologically intact. Physical therapy consult was initiated and patient was able to be OOB with assistance. On ___, the Dilantin level was 1.8 and the patient was transitioned to Keppra 500mg po BID. On ___, the patient was transferred to inpatient neurology for further management. She has no further seizures. Levetiracetam, despite its possible behavioral effects, was thought to be the best choice (other than phenytoin) for prevention of seizures from intracranial hemorrhage. [] Narcolepsy. Per daughter, the patient's narcolepsy appears to be worse in the hospital. She was having more episodes of cataplexy and falling asleep more frequently. On ___, the patient's neurologist Dr. ___ was contacted, and he asked that her Venlafaxine be changed from BID dosing to once daily (in the morning) as previously prescribed. After much discussion, her prior medication of Xyrem will likely be restarted as an outpatient (3.75 at bedtime and 3.75 grams ___ hours later). If that is the case, her Olanzapine will need to be stopped, and her Venlafaxine and Sertraline will need to be readdressed as to their utility. She will follow-up with Dr. ___ discharge. ***Once XYREM is restarted, please contact Dr. ___ at ___ to determine what other medications should be discontinued. DO NOT ADMINISTER OLANZAPINE (ZYPREXA) IF XYREM IS RESTARTED.*** [] Combativeness/Aggression. On ___ and ___, the patient was agitated and combative, requiring restraints on both nights. She had not been written for olanzapine as she previously was prescribed. She was found to have received twice her normal dose of Zyprexa in the previous day. The patient was returned to her home (___) dose of the medication on ___. Her mental status improved. She has been alert and oriented x3 and intermittently x2 since then. She has been off restraints for more than 24 hours and has been much calmer after treatment of her UTI and correction of her medications. [] Chest pain. On ___, the patient reported brief chest pain and several gagging episodes associated with coughing but no frank vomiting. EKG was normal. Cardiac enzymes x2 were normal. CXR showed atelectasis. The transient chest pain associated with gagging episode was attributed to GERD, and famotidine was started empirically. Due to potential anticholinergic effects, Geriatrics recommeded changing to an alternate medication. Calcium carbonate was used instead. twice daily [] Right arm pain. On ___ the patient complained of right elbow pain which was diffuse and more painful with movement. A right elbow xray was ordered and appeared grossly normal. [] UTI. The patient has a history of recurrent UTIs. She had a normal UA and UCx on admission but was subsequently catheterized. The second urinary culture grew E.coli resistant to TMP-SMX and Ciprofloxacin but sensitive to Ceftriaxone. She has been afebrile and denies any symptoms. She was treated with Cefpodoxime 200 mg BID x 7 days.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: shellfish derived / lisinopril Attending: ___. Chief Complaint: double vision Major Surgical or Invasive Procedure: None History of Present Illness: ___ is an ___ M with extensive PMHx including ESRD on peritoneal dialysis, prior history of non-arteritic anterior ischemic optic neuropathy of the right eye, HTN who presents with double vision upon waking this morning. Over the past week or so the patient has been feeling increasingly tired and fatigued. He has not been eating well and has been nauseous. He was seen in urgent care two day prior to presentation and was diagnosed with a probable UTI and started on ciprofloxacin. This morning he awoke and noticed that he was having trouble reading due to blurry vision. He looked up and at a distance he noticed double vision which he states is worse when looking farther away and when looking to the left. The double vision goes away when he closes one eye. He states that he has had increasing difficulty walking with his walker over recent days but has not noticed any focal weakness. He has not had any numbness. He denies room spinning dizziness. The patient tells me that he has only been taking his 81mg aspirin 3 times per week, when he remembers due to concerns about anemia and easy bruising. He also tells me that he has had difficulty moving his right foot and toes over the past months. He has had an MRI of his back and his doctors have told ___ that this is due to a pinched nerve in the back. On neuro ROS, the pt denies headache, loss of vision, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. On general review of systems, the pt 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: 1. Colon Cancer s/p resection in ___ 2. BPH s/p TURP 3. Chronic Renal failure, on Peritoneal dialysis since ___ 4. Hypertension 5. Hypothyroidism 6. Aortic Insufficiency 7. First degree AV block 8. Macrocytic Anemia/Myelodysplastic syndrome 9. Shrapnel in leg from WWII 10. Anterior ischemic optic neuropathy (non-arteritic) of the right eye PSH: 1. Laproscopic anterior ___ 2. Right Inguinal hernia ___ 3. Transrectal prostatic biopsy, ___ 4. Laparoscopic Tenckhoff Catheter, ___, ___ 5. Lap Tenckhoff Catheter repositioning ___, ___ 6. Removal and replacment of PD catheter (___) 7. Left inguinal hernia repair (___) Social History: ___ Family History: Father - deceased at ___, CVA, angina in ___. Mother - deceased at ___, "leaky valve." 1 brother - deceased at ___, MI, CVA. 3 children, 4 grandchildren. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== Vitals: 97.6 67 116/24 20 100% GEN: Awake, cooperative, NAD. HEENT: NC/AT, anicteric, MMM, no lesions noted in oropharynx NECK: Supple. RESP: non-labored CV: RRR ABD: soft, NT/ND EXT: No edema, no cyanosis SKIN: no rashes or lesions noted. NEURO EXAM: MS: Alert, oriented x 3. Able to relate history without difficulty. Mildly inattentive Language is fluent with intact comprehension. Normal prosody. There were no paraphasic errors. Speech was not dysarthric. Able to follow both midline and appendicular commands. Good knowledge of current events. No evidence of apraxia or neglect. CN: II: PERRLA 2 to 1mm and brisk. RUQ anopsia bilaterally. Difficulty counting fingers in all peripheral fields on right, able to identify moving fingers. III, IV, VI: EOMI on rightward, upward and downward gaze. On left gaze the right eye does not fully adduct and there is nystagmus of the left eye. Concergence of the right eye also appears to be impaired. V: Sensation intact to LT. VII: Facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate rise symmetric. XI: Trapezius and SCM ___ bilaterally. XII: Tongue protrudes midline. Motor: No pronator drift bilaterally. No adventitious movements. Asterixis noted. Delt Bic Tri WrE FE IO IP Quad Ham TA ___ L ___ ___ 4+ 5 ___ 4- R ___ ___ 5 5 ___ 0 Sensory: No deficits to light touch, pinprick throughout. No extinction to DSS. Reflexes: Bi Tri ___ Pat Ach L ___ 0* 0 R ___ 0* 0 Right toe down, left toe up *s/p ___ TKA Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or foot to hand bilaterally. DISCHARGE PHYSICAL EXAM: ======================== language fluent and appropriate, can give accurate hx. Conjugate gaze, EOMI but unsustained lateral gaze. Impaired visual field on L; vision is ___ -2 b/l. No facial asymmetry, facial sensation intact. No pronator drift. Muscle wasting at thenar eminence and first dorsal interosseous. Asymmetric decreased stregth in R>L TA. No fatiguability in deltoids. No clonus, semi-increased tone in LEs, normal tone in UEs. Patchy distribution of impaired pinprick L>R. LT and temp intact, poor proprioception b/l. Pertinent Results: ADMISSION LABS: =============== ___ 02:25PM BLOOD WBC-6.6 RBC-3.18* Hgb-10.5* Hct-33.3* MCV-105* MCH-33.0* MCHC-31.6 RDW-16.4* Plt ___ ___ 02:25PM BLOOD Neuts-75.4* Lymphs-12.1* Monos-7.0 Eos-4.9* Baso-0.6 ___ 02:42PM BLOOD ___ PTT-33.7 ___ ___ 02:25PM BLOOD Glucose-110* UreaN-91* Creat-8.6* Na-132* K-3.5 Cl-89* HCO3-23 AnGap-24* ___ 02:25PM BLOOD ALT-24 AST-28 AlkPhos-61 TotBili-0.1 ___ 02:25PM BLOOD Albumin-3.2* Calcium-8.5 Phos-6.8* Mg-2.8* ___ 02:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-20 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG PERTINENT LABS: =============== ___ 02:25PM BLOOD cTropnT-0.32* ___ 04:59AM BLOOD CK-MB-13* MB Indx-6.0 cTropnT-0.33* ___ 04:59AM BLOOD %HbA1c-5.5 eAG-111 ___ 04:59AM BLOOD Triglyc-122 HDL-44 CHOL/HD-3.2 LDLcalc-72 ___ 02:25PM BLOOD TSH-13* ___ 02:25PM BLOOD CRP-16.1* DISCHARGE LABS: =============== ___ 04:59AM BLOOD WBC-5.1 RBC-2.79* Hgb-9.3* Hct-29.4* MCV-105* MCH-33.2* MCHC-31.6 RDW-16.5* Plt ___ ___ 04:59AM BLOOD Glucose-72 UreaN-99* Creat-9.4* Na-133 K-3.9 Cl-90* HCO3-22 AnGap-25* ___ 04:59AM BLOOD ALT-22 AST-24 CK(CPK)-216 AlkPhos-52 TotBili-0.1 ___ 04:59AM BLOOD Albumin-2.7* Calcium-8.7 Phos-7.6* Mg-2.9* Cholest-140 RELEVANT STUDIES: ================= - EKG (___): Sinus bradycardia. Right bundle-branch block. Leftward axis. ST-T wave flattening in the inferior leads, similar to that recorded on ___. Baseline artifact persists without diagnostic interim change. - CT HEAD W/O CONTRAST (___): No evidence of acute intracranial abnormality. - MRA HEAD AND NECK (___): 1. Essentially unremarkable noncontrast enhanced MRI of the brain. 2. Unremarkable MRA of the head and neck. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fluoxetine 20 mg PO DAILY 2. Lactulose 15 mL PO DAILY:PRN constipation 3. Levothyroxine Sodium 175 mcg PO DAILY 4. Lotemax (loteprednol etabonate) 0.5 % ophthalmic prn 5. Omeprazole 40 mg PO BID 6. Pravastatin 20 mg PO DAILY 7. sevelamer CARBONATE 1600 mg PO TID W/MEALS 8. Tamsulosin 0.4 mg PO DAILY 9. TraZODone 100 mg PO HS:PRN insomnia 10. Zolpidem Tartrate 5 mg PO HS:PRN insomnia 11. Acetaminophen 1000 mg PO Q8H:PRN pain 12. Aspirin 81 mg PO DAILY 13. Cetirizine 10 mg PO DAILY 14. Docusate Sodium 240 mg PO AFTER EACH MEAL 15. Vitamin D ___ UNIT PO DAILY 16. Polyethylene Glycol ___ g PO DAILY 17. Simethicone 180 mg PO BID:PRN gas pain 18. Nephrocaps 1 CAP PO DAILY 19. Calcitriol 0.25 mcg PO DAILY 20. Calcium Acetate 667 mg PO DAILY 21. Epoetin Alfa 30,000 units SC Q2WEEKS 22. Finasteride 5 mg PO DAILY 23. Ciprofloxacin HCl 500 mg PO Q24H Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN pain 2. Aspirin 81 mg PO DAILY 3. Calcitriol 0.25 mcg PO DAILY 4. Calcium Acetate 667 mg PO TID W/MEALS 5. Docusate Sodium 240 mg PO AFTER EACH MEAL 6. Finasteride 5 mg PO DAILY 7. Fluoxetine 20 mg PO DAILY 8. Lactulose 15 mL PO DAILY:PRN constipation 9. Levothyroxine Sodium 175 mcg PO DAILY 10. Nephrocaps 1 CAP PO DAILY 11. Omeprazole 40 mg PO BID 12. Polyethylene Glycol ___ g PO DAILY 13. Pravastatin 20 mg PO DAILY 14. sevelamer CARBONATE 1600 mg PO TID W/MEALS 15. Simethicone 180 mg PO BID:PRN gas pain 16. Senna 8.6 mg PO BID:PRN constipation 17. Cetirizine 10 mg PO DAILY 18. Epoetin Alfa 30,000 units SC Q2WEEKS 19. Lotemax (loteprednol etabonate) 0.5 % ophthalmic prn 20. Tamsulosin 0.4 mg PO DAILY 21. TraZODone 100 mg PO HS:PRN insomnia 22. Vitamin D ___ UNIT PO DAILY 23. Zolpidem Tartrate 5 mg PO HS:PRN insomnia 24. Ciprofloxacin HCl 500 mg PO Q24H Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: transient diplopia and right medial rectus palsy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: History: ___ with visual field cut // ? stroke TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain, intermediate and bone windows. Coronal and sagittal reformats were also performed. DOSE: DLP: 891 mGy-cm CTDI: 54 mGy COMPARISON: None. FINDINGS: There is no evidence of acute intracranial hemorrhage, edema, mass effect or large territorial infarction. The ventricles and sulci are prominent compatible with age related atrophy. The basal cisterns are patent. Gray-white matter differentiation is preserved. There is no fracture. The included paranasal sinuses, mastoid air cells and middle ear cavities are clear except for minimal mucosal thickening in the ethmoidal air cells. There is no fracture. IMPRESSION: No evidence of acute intracranial abnormality. Radiology Report EXAMINATION: MRI AND MRA BRAIN AND MRA NECK INDICATION: ___ year old man with R INO, left sided weakness // stroke? TECHNIQUE: Sagittal T1 weighted and axial T1 weighted, T2 weighted, FLAIR, susceptibility and diffusion weighted images were obtained through the head. Three dimensional time of flight MR arteriography of the head, and two dimensional time of flight MR arteriography of the neck were performed with rotational reconstructions. COMPARISON: CT head without contrast of ___ for, MR pituitary with and without contrast of ___. FINDINGS: MRI HEAD: There is no intra or extra-axial mass effect, acute hemorrhage or infarct. Sulci, ventricles and cisterns are within expected limits for the degree of age appropriate volume loss. There are minimal subcortical and periventricular nonspecific FLAIR/ T2 white matter hyperintensities, which is commonly seen in setting of small vessel ischemic disease in a patient of this age. The major intracranial flow voids are preserved. Mild mucosal thickening of ethmoid air cells is noted otherwise the paranasal sinuses are essentially clear. The patient is status post bilateral lens replacements otherwise orbits are unremarkable. The mastoid air cells are clear. HEAD MRA: Normal flow related signal is seen in the intracranial internal carotid, middle cerebral and anterior cerebral arteries without significant mural irregularity or stenosis. There is normal symmetric arborization of the MCA branches. There is no aneurysm greater than 3 mm. Normal flow related signal is seen in the right dominant intracranial vertebral arteries, the basilar artery, and the bilateral superior cerebellar and posterior cerebral arteries. NECK MRA: The cervical common carotid, internal carotid and external carotid arteries are normal in course, caliber and contour. They demonstrate normal flow related signal without mural irregularity, stenosis or evidence of dissection. The right dominant vertebral arteries are normal in course, caliber and contour. They demonstrate normal flow related signal without mural irregularity, stenosis or evidence of dissection. IMPRESSION: 1. Essentially unremarkable noncontrast enhanced MRI of the brain. 2. Unremarkable MRA of the head and neck. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Weakness, Vision changes Diagnosed with DIPLOPIA temperature: 97.6 heartrate: 67.0 resprate: 20.0 o2sat: 100.0 sbp: 116.0 dbp: 24.0 level of pain: 0 level of acuity: 2.0

___ is an ___ year old man with an extensive past medical history, including end-stage renal disease on peritoneal dialysis, prior history of possible anterior ischemic optic neuropathy, hypertension, atrial fibrillation, and spinal stenosis, who presents with double vision upon waking the morning before admission. He was admitted overnight, after which his diploplia resolved spontaneously. However, he then noted decreased vision in his left eye. He had impaired left visual field on his right eye on exam (most likely chronic). However, visual acuity appeared to be equal in both eyes and mostly intact. Otherwise, his exam was only notable for findings consistent with cervical spinal stenosis. A non-contrast head CT and an MRI of his head and MRA brain/neck were performed, and all imaging was negative for any signs of acute stroke. Pt was most likely experiencing a microischemic cranial neuropathy, causing transient medial rectus palsy. Myasthenia ___ was also considered, but is a less likely diagnosis.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: sodium pentathol / dust / pollen / ragweed pollen Attending: ___. Chief Complaint: Confusion and falls Major Surgical or Invasive Procedure: - ___: LP attempted and aborted due to small hematoma formation History of Present Illness: ___ with hx metastatic breast cancer (known metastases to bone and liver), blindness ___ congenital glaucoma, depression, and asthma who was referred from ___'s office for subacute mental status decline and increasing falls at home. Patient increased falls over the last several months, she thinks 5 since ___. Her husband notes she has had several in the last few weeks, and she is now entirely dependent on him to help her move around without falling. She reports significant 'shakiness' and weakness when standing, more pronounced in the right leg. She denies vertigo or presycnopal symptoms. Her last fall was 1.5 weeks ago with no head strike or LOC. Her husband also has noted some dysarthria and possible confusion. For these symptoms, she was referred to the ED. In the ED, initial VS were 98.2 83 119/64 14 100% RA. Labs were notable for Chem-7 wnl with Cr 0.8 (baseline Cr 0.8-1.0), LFTs wnl, CBC at baseline with H/H 8.3/25.9 (baseline Hct ___, INR 1.2. CT Head prelim read without acute process. CXR with no acute process but noted widespread osseous metastases. The patient is now admitted to ___ for further treatment and management. VS prior to transfer T 98.1, HR 84, BP 113/62, RR 18, O2 97%RA. On arrival to the floor, patient has no acute complaint. Denies recent fevers or chills. She has occaisional sinus headaches, but non currently. She has some residual vision at baseline which has not changed. No SOB, mild chronic cough, no chest pain. No N/V/D. No abdominal pain. She has increased urinary frequency but no dysuria. No edema. She has had a small skin lesion on her right foot, for which she is currently holding her xeloda. Of note, she recently stopped her diabetes meds several months ago, which seems to correspond with the worsening of her weakness/balance. ROS is otherwise unremarkable. Past Medical History: PAST ONCOLOGIC HISTORY: For full Onco history, please see Atrius records. Briefly: Breast cancer, initially on the right side in ___ with DCIS on the left with microinvasion. First metastasis was in ___ to bone and liver. She has had stable disease now ___ years. She taking the Xeloda and Zometa every three months. PAST MEDICAL HISTORY: Congenital glaucoma and related blindness HTN Asthma GERD CKD, baseline Cr Allergic rhinitis IBS Depression Uterine fibroids +PPD Social History: ___ Family History: Father ___ - Type II; Psych - Depression; Stroke Mother Cancer - ___ Paternal Aunt Cancer Son ___ - Type I Physical Exam: ======================== ADMISSION PHYSICAL EXAM: ======================== VS: BP 108/64 HR 88 RR 20 T 98.5 GENERAL: Pleasant, frail woman. NAD. HEENT: NC/AT, legally blind with marked saccades at rest. PERLL. Anicteric. Dry MM. CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4 LUNG: clear to auscultation, no wheezes or rhonchi ABD: +BS, soft, NT/ND, no rebound or guarding EXT: No lower extremity pitting edema. Right foot with 1cm fissure without surrounding erythema or drainage NEURO: Oriented to person and place. Answers ___ for month. Fair attention. Blind. PERLL. Marked saccades at rest. Moves eyes on command to all four quadrants. Attends to examiner. Slight right facial droop. Tongue and Pharanyx is midline. 3+/5 strength right shoulder. ___ throughout rest of upper extremities, although exam limited by patient. Marked intention tremor bilaterally during FTN and noticeable DDK. Poor HTS, worse on right. Good antigravity strength throughout both lower extremities. ======================== DISCHARGE PHYSICAL EXAM: ======================== VS: 98.7 ___ 70 16 97-99RA GENERAL: Pleasant, frail woman. NAD. HEENT: NC/AT. Blind with saccades at rest. Anicteric sclera. Dry MM. CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4. LUNG: Clear to auscultation, no wheezes or rhonchi. ABD: +BS, soft, NT/ND, no rebound or guarding. BACK: Small soft hematoma at L3, with dressing coming off but no bleeding or erythema. Nontender. EXT: No lower extremity pitting edema. Right foot with 1-cm fissure without surrounding erythema or drainage. NEURO: A&Ox3. Blind with marked saccades at rest. Otherwise CN II-XII intact. 4+/5 strength, overall ___ throughout. Marked tremor and ataxia, worse on right. Normal finger to nose. Pertinent Results: ================== ADMISSION LABS: ================== ___ 01:35PM BLOOD WBC-6.4 RBC-2.61* Hgb-8.3* Hct-25.9* MCV-99* MCH-31.8 MCHC-32.0 RDW-14.2 RDWSD-51.2* Plt ___ ___ 01:35PM BLOOD Neuts-82.6* Lymphs-9.4* Monos-6.6 Eos-0.8* Baso-0.3 Im ___ AbsNeut-5.26 AbsLymp-0.60* AbsMono-0.42 AbsEos-0.05 AbsBaso-0.02 ___:35PM BLOOD ___ PTT-29.3 ___ ___ 01:35PM BLOOD Glucose-254* UreaN-18 Creat-0.8 Na-134 K-3.9 Cl-94* HCO3-29 AnGap-15 ___ 01:35PM BLOOD Albumin-3.7 Calcium-9.5 Phos-3.7 Mg-2.2 ___ 01:35PM BLOOD ALT-17 AST-34 AlkPhos-93 TotBili-0.5 ========= KEY LABS: ========= ___ 09:15AM BLOOD cTropnT-<0.01 ___ 06:55AM BLOOD CK-MB-<1 cTropnT-<0.01 ___ 01:35PM BLOOD VitB12-230* Folate-12.5 ___ 07:00AM BLOOD Ferritn-713* ___ 09:02AM BLOOD %HbA1c-7.0* eAG-154* ___ 07:55AM BLOOD CEA-2.0 ___ ================= DISCHARGE LABS: ================= ___ 07:33AM BLOOD WBC-5.4 RBC-2.84* Hgb-9.1* Hct-28.0* MCV-99* MCH-32.0 MCHC-32.5 RDW-14.3 RDWSD-51.9* Plt ___ ___ 07:33AM BLOOD Glucose-176* UreaN-23* Creat-0.9 Na-137 K-4.3 Cl-97 HCO3-29 AnGap-15 ___ 07:33AM BLOOD Calcium-9.4 Phos-4.3 Mg-2.0 ======== IMAGING: ======== ___ MRI HEAD: Several T1 hypo intense and enhancing calvarial lesions worrisome for metastatic disease. No evidence of intracranial disease involvement. ___ MRI C/T/L SPINE: 1. Diffusely abnormal bone marrow signal in the cervical, thoracic, and lumbar spine, as well as included upper sacrum and medial iliac bones, indicating diffuse metastatic disease. 2. Mild loss of height involving several cervical and thoracic vertebral bodies is noted, unchanged in the thoracic spine compared to the ___ torso CT. No prior cervical spine imaging for comparison. 3. No evidence for epidural or leptomeningeal metastatic disease. 4. Multilevel cervical degenerative disease with moderate spinal canal stenosis and moderate to severe neural foraminal narrowing. 5. Mild thoracic and lumbar degenerative disease without evidence for neural impingement. 6. Stable 15 mm oval nodule in the right upper gluteal subcutaneous soft tissues, of uncertain clinical significance given partial fat density on the prior CT, but no evidence for fat on the present MRI on which it is incompletely evaluated. ___ CT ABD PELVIS: 1. Of the 3 previously identified hypodense liver lesions, only 2 are seen, relatively similar in size. Interval stability is reassuring however not diagnostic for a benign process. 2. Stable thickening of the left adrenal gland. 3. Stable soft tissue mass in the left adnexa, of unclear etiology. 4. Diffuse osseous metastases. No compression deformities in the lumbar spine. ___ CT CHEST 1. No evidence of metastatic disease to the pleura, mediastinum, or pulmonary parenchyma. 2. Numerous osseous metastases, not significantly changed from ___, and no pathologic compression deformity in the thoracic spine or acute pathological rib fractures. 3. Previously identified areas of ground-glass in the upper lobes bilaterally have resolved since the prior study. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Sertraline 200 mg PO DAILY 2. Lorazepam 0.5 mg PO QHS:PRN insomnia/anxiety 3. Acetaminophen w/Codeine ___ TAB PO Q6H:PRN pain 4. Atenolol 25 mg PO DAILY 5. BuPROPion (Sustained Release) 300 mg PO QAM 6. Simvastatin 20 mg PO QPM 7. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation inhalation DAILY 8. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB Discharge Medications: 1. Acetaminophen w/Codeine ___ TAB PO Q6H:PRN pain 2. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB 3. Atenolol 25 mg PO DAILY 4. BuPROPion (Sustained Release) 300 mg PO QAM 5. Lorazepam 0.5 mg PO QHS:PRN insomnia/anxiety 6. Sertraline 200 mg PO DAILY 7. Simvastatin 20 mg PO QPM 8. Fluticasone Propionate NASAL 2 SPRY NU DAILY 9. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation inhalation DAILY 10. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES: - Breast Cancer, metastatic to bone - Right acetabular fracture SECONDARY DIAGNOSIS: - Blindness secondary to glaucoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: History: ___ with breast cancer, confusion TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained without intravenous contrast. Coronal and sagittal reformations and bone algorithms reconstructions were also performed. DOSE: Total DLP (Head) = 1,605 mGy-cm. COMPARISON: None. FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. Mild prominence of the ventricles and sulci are consistent with age-related involutional changes. Periventricular and subcortical white matter hypodensities are seen, likely sequelae of chronic small vessel ischemic disease. Basal cisterns are patent and there is preservation of gray-white matter differentiation. No osseous abnormalities seen. The right mastoid air cells a right ethmoid air cell are partially opacified. Otherwise, the remaining paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: No acute intracranial process. Radiology Report EXAMINATION: CHEST (AP AND LAT) INDICATION: History: ___ with altered mental status// Eval for infiltrate TECHNIQUE: Upright AP and lateral views of the chest COMPARISON: CT chest ___ FINDINGS: Heart size is normal. Mediastinal and hilar contours are unchanged with enlargement of the pulmonary arteries again noted suggestive underlying pulmonary arterial hypertension. Pulmonary vasculature is not engorged. No focal consolidation, pleural effusion or pneumothorax is present. Multiple right axillary clips are re- demonstrated. Diffuse sclerosis of the osseous structures is compatible with widespread metastatic disease. IMPRESSION: No acute cardiopulmonary abnormality. Widespread osseous metastases. Radiology Report EXAMINATION: MR HEAD W/O CONTRAST T9113 MR HEAD INDICATION: ___ year old female with hx of metastatic breast cancer presenting with increasing falls in dysarthria. Evaluate for intracranial metastatic disease. TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was performed with gradient echo, FLAIR, diffusion, and T2 technique were then obtained. COMPARISON None. FINDINGS: Limited and incomplete exam with no contrast administered due to significant patient motion. However, given the limited sequences acquired, in no large mass or midline shift is identified. IMPRESSION: 1. Nondiagnostic and incomplete exam given significant patient motion. A repeat MRI is recommended when the patient is able tolerate the study. RECOMMENDATION(S): Repeat MRI recommended. Radiology Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ year old woman with metastatic breast cancer and new tachycardia // Eval for DVT TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, flow, and augmentation of the bilateral common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the left posterior tibial and peroneal veins. Normal color flow is demonstrated in the right posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No medial popliteal fossa (___) cyst. Small left knee joint effusion. IMPRESSION: 1. No evidence of deep venous thrombosis in the right or left lower extremity veins. 2. Small left knee joint effusion. RECOMMENDATION(S): Updated impression was discussed with ___ by Dr. ___ ___ telephone at 19:56 on ___, 5 min after discovery. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD INDICATION: ___ with metastatic breast cancer presenting with subacute mental status changes and ataxia // TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of 5 mL of Gadavist intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: CT head dated ___. FINDINGS: There is no evidence of hemorrhage, edema, or mass effect. Ventricles and sulci are age appropriate in size and configuration. There is no shift of normally midline structures. Basal cisterns are patent. There is no extra-axial fluid collection. There is no enhancing lesion identified on the postcontrast sequences. No evidence of slow diffusion to suggest acute infarction. Several enhancing T1 hypo intense lesions are identified within the calvarium including the right frontal bone (1000 01:49), right parietal superiorly (1001:135), right parietal bone inferiorly (1001:139) left frontal along the midline (1000:85) worrisome for metastatic disease. Intracranial flow voids are preserved. The orbits are unremarkable. Visualized paranasal sinuses and mastoid air cells are clear. IMPRESSION: Several T1 hypo intense and enhancing calvarial lesions worrisome for metastatic disease. No evidence of intracranial disease involvement. NOTIFICATION: The impression and recommendation above was entered by Dr. ___ on ___ at 17:43 into the Department of Radiology critical communications system for direct communication to the referring provider. Radiology Report INDICATION: ___ old woman with metastatic breast cancer and weeks of mental status decline, right-sided weakness, and ataxia. Please evaluated for metastatic disease. TECHNIQUE: Sagittal T1 weighted, T2 weighted, and fat-suppressed IDEAL images of the cervical, thoracic, and lumbar spine with axial T2 weighted images. Following intravenous gadolinium administration, sagittal and axial T1 weighted images of the cervical, thoracic, and lumbar spine were obtained. COMPARISON: Torso CT from ___ is available for correlation. There is no prior spine MRI available. FINDINGS: Correlation with the prior torso CT demonstrates that there are 7 cervical vertebrae, 12 rib-bearing vertebrae, L1 with transitional anatomy involving a short rudimentary ribs instead of transverse processes, and L2 through L4 with conventional anatomy. The iliolumbar ligament is visualized at L5, as expected. The numbering is documented on images 5:10 and 06:11. CERVICAL SPINE MRI: Evaluation is mildly limited by motion artifact as well as large field of view on the sagittal images. Bone marrow signal is diffusely abnormal, low on precontrast T1 weighted images with heterogeneous high signal on fat-suppressed IDEAL and postcontrast T1 weighted images, consistent with diffuse metastatic infiltration. C5 and C6 vertebral bodies demonstrated mild loss of height with inferior endplate deformities, but due to the motion artifact it is not clear whether the inferior endplate deformities are secondary to metastatic lesions or Schmorl's nodes. No epidural mass is identified. No pathologic leptomeningeal contrast enhancement is seen. Minimal retrolisthesis of C3 on C4 and of C6 on C7 is likely degenerative. The cerebellar tonsils are normally positioned, and the craniocervical junction appears unremarkable. The intracranial compartment is better assessed on the brain MRI from ___. At C2-C3, there is no spinal canal or neural foraminal narrowing. At C3-C4, mild retrolisthesis with posterior endplate osteophytes moderately narrow the spinal canal and indents the ventral spinal cord. Evaluation of cord signal is limited by artifacts on sagittal images. No definite cord signal abnormality seen on axial images. Moderate to severe right and moderate left neural foraminal narrowing by uncovertebral and facet osteophytes is present. At C4-C5, posterior endplate osteophytes moderately narrow the spinal canal and flatten the ventral spinal cord. Evaluation of cord signal on sagittal images is limited by artifacts. No definite cord signal abnormality is seen on axial images. Mild to moderate right and moderate to severe left neural foraminal narrowing by uncovertebral and facet osteophytes is present. At C5-C6, posterior endplate osteophytes and thickening of the ligamentum flavum result in moderate to severe narrowing of the spinal canal with flattening of the ventral spinal cord. Evaluation of cord signal on sagittal images is limited by artifacts. No definite cord signal abnormality seen on axial images. There is moderate right and severe left neural foraminal narrowing by uncovertebral and facet osteophytes. At C6-C7, posterior endplate osteophytes indent the ventral thecal sac but do not contact the spinal cord. There is moderate right and mild left neural foraminal narrowing by uncovertebral and facet osteophytes. At C7-T1, no spinal canal or neural foraminal narrowing is seen. THORACIC SPINE MRI: Bone marrow signal is diffusely abnormal, low on precontrast T1 weighted images with heterogeneous high signal on fat-suppressed IDEAL and postcontrast T1 weighted images, consistent with diffuse metastatic infiltration. Mild anterior wedge compression of T9 vertebral body is unchanged compared to ___. Deformity in the posterior aspect of the T10 superior endplate, likely secondary to a metastasis, appears larger than on the ___ CT, but this could be secondary to differences in modalities. Mild anterior wedging of T12 vertebral body is unchanged since ___. There is no evidence for an epidural mass. There is no pathologic leptomeningeal contrast enhancement. There are small disc protrusions at several thoracic levels, include a T5-T6, T6-T7, T9-T10, and T10-T11, which do not contact the spinal cord. Evaluation of spinal cord signal is limited by motion artifact and large field of view on sagittal images, as well as by the large field of view on axial images, but cord signal appears normal on axial images. LUMBAR SPINE MRI: Bone marrow signal is diffusely abnormal, including within the visualized upper sacrum and medial iliac bones, low on precontrast T1 weighted images with heterogeneous high signal on fat-suppressed IDEAL and postcontrast T1 weighted images, consistent with diffuse metastatic infiltration. Mild L3 and L4 superior endplate deformities are unchanged since ___. There is no evidence for an epidural mass. There is no pathologic leptomeningeal contrast enhancement. The conus medullaris demonstrates normal morphology and signal intensity, terminating at L1. At T12-L1, there is no spinal canal or neural foraminal narrowing. At L1-L2, there is a mild disc bulge without spinal canal or neural foraminal narrowing. At L2-L3, there is a mild disc bulge and minimal facet arthropathy without spinal canal or neural foraminal narrowing. At L3-L4, there is a mild disc bulge and minimal facet arthropathy without spinal canal narrowing. There is mild bilateral neural foraminal narrowing without neural impingement. At L4-L5, there is a mild disc bulge and mild facet arthropathy without spinal canal narrowing. There is mild bilateral neural foraminal narrowing without neural impingement. At L5-S1, there is a mild disc bulge, mild to moderate right and mild left facet arthropathy. There is no spinal canal narrowing. There is mild to moderate bilateral neural foraminal narrowing without evidence for neural impingement. In the right upper gluteal subcutaneous fat, there is a 15 mm circumscribed oval structure, included on axial images only, which demonstrates low signal on T2 weighted images and high signal on postcontrast T1 weighted images (12:35, 19:35). It is stable in size compared to the ___ CT, on which it demonstrated mixed fat and soft tissue density. Fat density is not typical for metastasis. Its clinical significance is uncertain. IMPRESSION: 1. Diffusely abnormal bone marrow signal in the cervical, thoracic, and lumbar spine, as well as included upper sacrum and medial iliac bones, indicating diffuse metastatic disease. 2. Mild loss of height involving several cervical and thoracic vertebral bodies is noted, unchanged in the thoracic spine compared to the ___ torso CT. No prior cervical spine imaging for comparison. 3. No evidence for epidural or leptomeningeal metastatic disease. 4. Multilevel cervical degenerative disease with moderate spinal canal stenosis and moderate to severe neural foraminal narrowing. 5. Mild thoracic and lumbar degenerative disease without evidence for neural impingement. 6. Stable 15 mm oval nodule in the right upper gluteal subcutaneous soft tissues, of uncertain clinical significance given partial fat density on the prior CT, but no evidence for fat on the present MRI on which it is incompletely evaluated. Radiology Report INDICATION: ___ year old woman with breast cancer metastatic to bone presenting with likely progression of disease. // Staging/survey for metastatic disease TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. IV Contrast: 130 mL Omnipaque. Oral contrast was 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 19.4 s, 0.2 cm; CTDIvol = 330.0 mGy (Body) DLP = 66.0 mGy-cm. 5) Spiral Acquisition 6.0 s, 70.6 cm; CTDIvol = 3.8 mGy (Body) DLP = 247.5 mGy-cm. 6) Spiral Acquisition 2.5 s, 32.1 cm; CTDIvol = 3.5 mGy (Body) DLP = 97.0 mGy-cm. Total DLP (Body) = 412 mGy-cm. COMPARISON: CT abdomen pelvis from ___ FINDINGS: LOWER CHEST: Please refer to separate report of CT chest performed on the same day for description of the thoracic findings. ABDOMEN: HEPATOBILIARY: Of the 3 hypodense liver lesions previously identified, only 2 are currently appreciated (05:51, 54). The remainder the liver is homogeneous. The portal vein is patent. 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: There is stable thickening of the left adrenal gland, and normal appearance of the right adrenal gland. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is not visualized. PELVIS: The urinary bladder is decompressed. The uterus is normal. The ovoid soft tissue structure in the left adnexa, separate from the left ovary, is essentially unchanged in size, now measuring 3.7 x 2.5 cm (5:98), previously 4.0 x 2.7 cm in ___. There is no pelvic lymphadenopathy or free fluid in the pelvis. VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease is noted. BONES: As with the prior study from ___, there is diffuse sclerosis of the skeleton in keeping with metastatic disease. There is no compression deformity in the lumbar spine. There is a tiny chip fracture at the posterior wall of the right acetabulum (5:100), which has sclerotic borders, suggesting nonacute nature but new from ___. No other pelvic fractures appreciated. SOFT TISSUES: There is a peripherally calcified soft tissue structure within the right iliacus muscle measuring 1.9 x 1 cm (5:94), and may be a sequela of trauma. This is not have the appearance of and intramuscular metastasis. There is a soft tissue nodule in the subcutaneous fat of the left lower back (5:76), which was not seen on the prior study. Correlation with injection therapy is recommended. No other soft tissue lesions are appreciated. IMPRESSION: 1. Of the 3 previously identified hypodense liver lesions, only 2 are seen, relatively similar in size. Interval stability is reassuring however not diagnostic for a benign process. 2. Stable thickening of the left adrenal gland. 3. Stable soft tissue mass in the left adnexa, of unclear etiology. 4. Diffuse osseous metastases. No compression deformities in the lumbar spine. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: Metastatic breast cancer. Restaging. 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 compared to chest CT scanning since ___. 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 19.4 s, 0.2 cm; CTDIvol = 330.0 mGy (Body) DLP = 66.0 mGy-cm. 5) Spiral Acquisition 6.0 s, 70.6 cm; CTDIvol = 3.8 mGy (Body) DLP = 247.5 mGy-cm. 6) Spiral Acquisition 2.5 s, 32.1 cm; CTDIvol = 3.5 mGy (Body) DLP = 97.0 mGy-cm. Total DLP (Body) = 412 mGy-cm. ** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND PELVIS WITH CONTRAST) COMPARISON: ___. FINDINGS: The imaged thyroid gland is homogeneous. There are no pathologically enlarged mediastinal, hilar, or axillary lymph nodes. Surgical clips are noted in the right axilla, likely from prior lymph node dissection. Heterogeneity of the left breast tissue is noted, of unclear etiology. The esophagus is normal in course and contour. Heart size is normal and there is no pericardial effusion. No pleural effusion is appreciated. No pneumothorax. The lungs demonstrate scattered areas of subpleural scarring. Previously identified areas of ground-glass in the left upper lobe and right upper lobe have resolved. No concerning nodules or areas of consolidation. Heterogeneous appearance of the a entire thoracic spine is indicative of diffuse osseous metastasis, which is similar in appearance to the CT from ___. No compression deformities in the thoracic spine to suggest pathologic fracture. Additionally, there are numerous sclerotic rib lesions bilaterally as well as healed fractures. The sternum and manubrium demonstrate heterogeneous density, indicative of metastatic involvement. IMPRESSION: 1. No evidence of metastatic disease to the pleura, mediastinum, or pulmonary parenchyma. 2. Numerous osseous metastases, not significantly changed from ___, and no pathologic compression deformity in the thoracic spine or acute pathological rib fractures. 3. Previously identified areas of ground-glass in the upper lobes bilaterally have resolved since the prior study. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Confusion, Altered mental status Diagnosed with Altered mental status, unspecified temperature: 98.2 heartrate: 83.0 resprate: 14.0 o2sat: 100.0 sbp: 119.0 dbp: 64.0 level of pain: 0 level of acuity: 2.0

___ with metastatic breast cancer, blindness ___ congenital glaucoma, depression, and asthma referred from ___'s office for subacute mental status decline and increasing falls, confusion, and dysarthria at home. # Falls/Instability: Patient presented with poor cerebellar exam and 'shaking'. CT scan showed no acute lesions. MRI was degraded by with significant movement artifact but showed no evidence of direct CNS involvement. ID work-up was negative and she had no fever or leukocytosis. Repeat MRI head with no clear intraxial mets but calvarial lesions consistent with bony metastases. MRI C/T/L spine with and without contrast showed cervical spine stenosis and e/o bony mets but no intramedullary lesions. Neurology was consulted given her ataxia and felt that her symptoms were concerning for a possible paraneoplastic syndrome. Serologies were sent but did not return until after discharge. Patient was noted to be B12 deficient as a possible cause and repleted during hospitalization. Patient worked with physical therapy daily and had improvement in gait though still was notable to be a significant fall risk. - f/u serologies. - f/u with neurology as an outpatient - please check B12 and replete as needed. # Subacute Right Acetebular Fracture: Likely pathological. Seen by Orthopaedics with no plans for surgery at this time give patient's frail state. Recommended plan below: - Activity: Protected weight bearing until further notice - may weight bear as pt is able but she must do so with a walker. - ___ as patient can tolerate, encourage ambulation - Defer R hip surgery until further notice. - Follow-up with Dr. ___ in ___ ___ clinic in ___ weeks for reassessment # DM: Diagnosis of diabetes, previously on medications, no off for several months after losing weight. Placed on HISS to control sugars. - discharged to rehab on ___, recommend transition to oral medication (metformin) # Metastatic breast cancer: Patient with numerous bony metastases and rising ___. Holding chemotherapy at this time. Will followup with Dr. ___. # Asthma: continued symbicort # Depression: Stable. Continue home Buproprion XL 300mg daily and Sertraline 200mg daily # HTN: Continued home atenolol ====================

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Abdominal distension, weakness, and rectal bleeding Major Surgical or Invasive Procedure: Flexible sigmoidoscopy History of Present Illness: Mr. ___ is a ___ y/o male with ESLD ___ HIV/HBV/HCV (genotype 1b), c/b cirrhosis and varices, also HIV since ___ (with CD4 171 ___, undetectable viral load on HAART), cryoglobulinemia, SCC of anus s/p excision/XRT (___), asthma, prior cerebellar infarct and hemorrhage, who now presents with abdominal distention, weakness, dizziness and rectal bleeding. He underwent umbilical hernia repair with mesh on ___. Post-operatively, his course was complicated by cellulitis around his incisions which were treated with IV Vancomycin and PO Ciprofloxacin, and transitioned to PO Augmentin. On ___, he presented to clinic with watery diarrhoea. At that time he was told to stop antibiotics and collect a specimen for C. diff. He re-presented on ___ with worsening lower abdominal pain and persistent diarrhea. He was admitted for further investigation of c.diff. His stool was positive for C.diff and he was discharged on ___ with PO flagyl. After returning home, he had an episode of dizziness, weakness in his lower limbs and generally feeling lethargic today. His wife noted that he was now passing fresh blood via his stool, which had been absent for a period of time. He also complained of being more bloated. No nausea or vomiting. He was readmitted for further evaluation. Since admission, he had nausea/vomiting which was evaluated with KUB showing gas in scattered non-distended loops of large bowel, with no fecal loading or dilated air-filled loops of bowel to suggest obstruction. He was treated with PO vanc/flagyl. He was evaluated by ___. Orthostatic evaluation at that time was notable for heart rate increase from 92 to 116 from lying to standing. He continued to complain of dizziness and L ear fullness. He had an episode of hypoglycemia to ___ and was transferred to medicine for further management. Past Medical History: 1. HIV dx ___. On ART. 2. Squamous rectal cancer ___ tx with excision and radiation 3. HCV genotype 1b, s/p ribavirin and IFN stage ___ fibrosis on biopsy, grade 2 inflammation, HepC VL: 1,454,840 IU/mL 4. Mild, chronic microvascular ischemic changes and chronic lacunar infarcts in the R. basal ganglia and R. cebellum; small chronic infarct in R. cerebellum ___ 5. Splenomegaly and small liver cysts; massive splenomegaly on ultrasound in ___ 6. HBV - ___: HBsAG negative, HBsAb positive, HBcAb positive. ___: HBsAb negative, HBcAb positive. 7. Asthma 8. Lumbar disk disease 9. Surgical repair of umbilical hernia Social History: ___ Family History: No CAD, MI, mother with stroke at ___. Father with prostate cancer. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals - T 97.9, HR 76, BP 114/77, RR 16, Sats 97%RA Gen: NAD, appears comfortable CV: RRR, normal S1 and S2, no mumurs, rubs, or gallops Resp: clear to auscultation bilaterally, good respiratory effort Abdomen: Abdomen distended, soft to palpate. Palpable splenomegaly. Wound sites healing well. Abdomen generally uncomfortable on deep palpation, more significant around umbilicus. Not peritonitic. No rebound, no guarding. Ext: Trace edema; 2+ DP and ___ pulses, 2+ radial pulses bilaterally PR: Performed by ED. Stool positive guaiac DISCHARGE PHYSICAL EXAM: 99.3 98.3 118/79 70 18 96RA I/Os: ___ +3BM Gen: Lying in bed, NAD HEENT: Sclera anicteric. Extraocular movements intact. No lingual asterixis. Neck supple. No LAD. CV: RRR, S1/S2, no m/r/g Resp: Clear to auscultation bilaterally. Normal respiratory effort. Abdomen: Abdomen distended but non-tense. Soft, tender to deep palpation. Endorses pain with palpation. Surgical incisions c/d/i. No rebound tenderness. +BS, +Flatus. Ext: No edema. 2+ DP pulses Skin: Chronic-appearing skin changes on anterior shins L>R. Otherwise no rash noted. Neuro: Grossly intact, moves all extremities, A/O x3 Pertinent Results: Labs on Admission: ___ 05:58AM BLOOD Cortsol-9.6 ___ 05:58AM BLOOD C3-29* C4-2* ___ 10:40AM BLOOD WBC-3.7* RBC-2.82*# Hgb-9.7*# Hct-26.7* MCV-95 MCH-34.6* MCHC-36.5* RDW-15.6* Plt Ct-67* ___ 11:35AM BLOOD Neuts-57 Bands-0 ___ Monos-5 Eos-1 Baso-0 ___ Myelos-0 Plasma-1* ___ 04:38AM BLOOD ___ PTT-48.9* ___ ___ 04:38AM BLOOD Glucose-103* UreaN-17 Creat-1.3* Na-141 K-3.9 Cl-111* HCO3-28 AnGap-6* ___ 04:38AM BLOOD ALT-59* AST-66* AlkPhos-116 TotBili-0.8 ___ 04:38AM BLOOD Albumin-2.9* Calcium-8.8 Phos-3.8 Mg-2.5 Labs on Discharge: ___ 06:00AM BLOOD WBC-4.5 RBC-UNABLE TO Hgb-UNABLE TO Hct-25.0* MCV-UNABLE TO MCH-UNABLE TO MCHC-UNABLE TO RDW-UNABLE TO Plt Ct-46* ___ 05:55AM BLOOD ___ PTT-45.7* ___ ___ 05:55AM BLOOD WBC-PND RBC-UNABLE TO Hgb-UNABLE TO Hct-28.0* MCV-UNABLE TO MCH-UNABLE TO MCHC-UNABLE TO RDW-UNABLE TO Plt Ct-PND ___ 05:55AM BLOOD Glucose-110* UreaN-22* Creat-1.4* Na-143 K-4.5 Cl-113* HCO3-26 AnGap-9 ___ 05:55AM BLOOD ALT-58* AST-45* AlkPhos-89 TotBili-0.8 ___ 05:55AM BLOOD Calcium-9.8 Phos-4.2 Mg-3.1* CT abd ___: 1. Pancolonic wall thickening with thumbprinting. Findings concerning for C difficile colitis/ pancolitis. 2. No evidence of obstruction, perforation, or pneumatosis. 3. Cirrhotic liver morphology with findings of portal hypertension including ascites and massive splenomegaly. Portable Abdomen KUB ___: 1. No free air. 2. Gasless abdomen. Recommend CT to further evaluate for possible ileus or obstruction. ABD US ___: 1. No focal liver lesions to suggest HCC. Hepatopetal flow in patent portal vein. 2. Coarsened liver with splenomegaly and small amount of ascites. Portable Abdomen KUB ___: Gas seen in scattered non-distended loops of large bowel. No fecal loading or dilated air-filled loops of bowel to suggest obstruction is identified. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB 2. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 3. Etravirine 200 mg PO BID 4. Ipratropium-Albuterol Inhalation Spray 2 INH IH BID 5. Raltegravir 400 mg PO BID 6. Acetaminophen 500 mg PO Q6H:PRN pain 7. MetRONIDAZOLE (FLagyl) 500 mg PO TID Discharge Medications: 1. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB 2. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 3. Etravirine 200 mg PO BID 4. Raltegravir 400 mg PO BID 5. Acetaminophen 500 mg PO Q6H:PRN pain 6. Ipratropium-Albuterol Inhalation Spray 2 INH IH BID 7. Ondansetron 4 mg IV Q8H:PRN N/V 8. Vancomycin Oral Liquid ___ mg PO Q6H 9. Outpatient Lab Work Please check on ___: Na, K, Cl, HCO3, BUN, Cr, WBC, Hgb/Hct, Plt. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Recent history of C diff; still on treatment Acute kidney injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report HISTORY: Nausea and vomiting, status post umbilical hernia repair complicated by C. diff, on Flagyl; evaluate ileus, constipation. ABDOMEN, SINGLE SUPINE PORTABLE VIEW: Diaphragms not included. The extreme left abdominal wall is excluded from the film. No air-filled dilated loops of small or large bowel are detected on the current examination. Gas is seen in non-dilated portions of much of the small bowel from the proximal descending colon through the rectum. No dilated air-filled loops of small bowel are identified. Given the degree of decompression, it is difficult to assess for any evidence of bowel wall thickening. Limited assessment for free air on this supine film reveals no obvious evidence of free air. Multiple metallic radiodensities overlie the left abdomen, suggestive of BBs. Targeted review of a ___ abdominal CT from ___ suggests that these lie in the soft tissues along the lateral chest and upper abdomen posteriorly; likely BBs. IMPRESSION: Gas seen in scattered non-distended loops of large bowel. No fecal loading or dilated air-filled loops of bowel to suggest obstruction is identified. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year old man with known HCV/HBV/ETOH cirrhosis and increasing abdominal distention and pain // Please evaluate for ascites, portal vein thrombosis TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: Ultrasound of the abdomen from ___ and CT scan of the abdomen from ___ FINDINGS: LIVER: The echogenicity of the liver is coarsened. The contour of the liver is nodular. There is no suspicious focal liver mass. There is a tiny subcentimetric hepatic cyst in segment VIII. Main portal vein is patent with hepatopetal flow. There is a small amount of ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures mm. GALLBLADDER: There is no evidence of stones. The gallbladder demonstrates wall thickening likely related to the patient's chronic liver disease. There is no gallbladder distension PANCREAS: Head, body and tail of the pancreas are within normal limits, without masses or pancreatic ductal dilatation. SPLEEN: Normal echogenicity and grossly enlarged, measuring approximately 25 cm. KIDNEYS: The right kidney measures 12.3 cm. The left kidney measures 13 cm. Normal cortical echogenicity and corticomedullary differentiation is seen bilaterally. There is no evidence of masses, stones or hydronephrosis in the kidneys. RETROPERITONEUM: Visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. No focal liver lesions to suggest HCC. 2. Coarsened liver with splenomegaly and ascites. Radiology Report INDICATION: ___ year old man with abdominal distention and pain, rebound tenderness // Please assess for SBO, ileus, abd free air TECHNIQUE: Frontal abdominal radiographs were obtained. COMPARISON: Abdominal radiograph from ___ FINDINGS: Overall there is a paucity of gas in the abdomen. This could be due to ascites, or bowel loops (either normal caliber or distended, that is filled with fluid. There is no evidence of intraperitoneal free air. At least 20 metallic radiodensities are again seen overlying the left lateral thorax, left upper quadrant and left mid abdomen. The bony structures are unremarkable. IMPRESSION: 1. No free air. 2. Gasless abdomen. Recommend CT to further evaluate for possible ileus or obstruction. NOTIFICATION: Recommendations communicated with Dr. ___ by Dr. ___ by telephone at 15:00 on ___. Radiology Report EXAMINATION: CT abdomen and pelvis without intravenous contrast. INDICATION: ___ year old man with abdominal distention and pain, rebound tenderness. Previous KUB non-diagnostic. // Please evaluate for intra-abdominal free air, SBO or anatomic explanation for distention/rebound tenderness TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis without the administration of intravenous contrast. Coronal and sagittal reformations were performed and submitted to PACS for review. Oral contrast was administered. DOSE: DLP: 858.34 mGy-cm (abdomen and pelvis. COMPARISON: CT abdomen and pelvis ___. FINDINGS: LOWER CHEST: There is bibasilar atelectasis. There is no pulmonary nodule or mass in the visualized lung bases. There is cardiomegaly. Abdomen/pelvis: Evaluation of abdominal and pelvic organs is limited due to lack of intravenous contrast. Liver parenchyma has normal attenuation without evidence of steatosis. The gallbladder is contracted. There is no intrahepatic or extrahepatic biliary dilatation. The spleen is markedly enlarged measuring 24.6 cm. The pancreas is grossly unremarkable without evidence of pancreatic ductal dilatation. Kidneys are symmetric in size and shape without evidence of hydronephrosis or hydroureter. Urinary bladder is moderately distended with no gross abnormality. There is pancolonic bowel wall thickening with thumbprinting. There are no dilated loops of bowel. There is no evidence of contrast extravasation. There is no intraperitoneal free air. There is no evidence of pneumatosis. There is edema throughout the mesentery. There is small amount of perihepatic and perisplenic ascites as well as a small amount of free fluid in the pelvis. There are no enlarged inguinal, iliac chain, or retrocrural lymph nodes. There is mild atherosclerotic calcification of the abdominal aorta. There is no suspicious osseous lesion. There are tiny round metallic pellets scattered throughout the posterior left subcutaneous tissues with a single pellet located within the retroperitoneum superior to the left kidney. There is unchanged anterior wall IMPRESSION: 1. Pancolonic wall thickening with thumbprinting. Findings concerning for C difficile colitis/ pancolitis. 2. No evidence of obstruction, perforation, or pneumatosis. 3. Cirrhotic liver morphology with findings of portal hypertension including ascites and massive splenomegaly. Gender: M Race: HISPANIC/LATINO - PUERTO RICAN Arrive by AMBULANCE Chief complaint: BRBPR Diagnosed with RECTAL & ANAL HEMORRHAGE temperature: 97.4 heartrate: 74.0 resprate: 18.0 o2sat: 97.0 sbp: 126.0 dbp: 78.0 level of pain: 6 level of acuity: 2.0

Mr. ___ is a ___ with HIV since ___ (with CD4 171 ___, undetectable viral load on HAART), Hep B, Hep C, SCC of anus treated with excision/XRT (___), asthma, s/p recent umbilical hernia repair c/b cellulitis, c-diff infection, complaining of abdominal distension, weakness, dizziness and rectal bleeding. # Colitis with known C. diff infection: He had abdominal pain and distention on presentation, and CT consistent with pan-colitis in the setting of known C. diff. There was low suspicion for obstruction given imaging findings, good PO intake and ongoing bowel movements. A flexible sigmoidoscopy was performed on ___ which showed petechiae and abnormal vascularity in the rectum, sigmoid colon and distal descending colon compatible with unspecified colitis. A diagnostic paracentesis was considered given suspicion for SBP but deferred due to lack of readily accessible ascites pocket, lack of signs of systemic infection and slowly improving abdominal exam. He was initially treated with vanc/metronidazole and subsequently narrowed to PO vancomycin (given that metronidazole can cause abdominal discomfort confounding his exam). After discharge he will need to complete a course of PO vancomycin pending clinical response (tentatively will continue vancomycin until ___ and will reassess clinical symptoms of C. diff that time). Given concern for alternate cause of colitis, cold forceps biopsies were taken of left colon during flexible sigmoidoscopy and pending at time of discharge; results were pending and will need follow-up after discharge. # ___: He has had slowly worsening renal function over the past 4 weeks. Urine electrolytes were notable for FeNA 0.2%, FeUrea 0.28% suggesting pre-renal etiology in the setting of C. difficile diarrhea. He improved slightly after albumin. The differential diagnosis for a second underlying process contributing to his subacutely worsening renal function remains broad, and in consultation with nephrology, cryoglobulins were sent due to concern for cryoglobulin-mediated renal disease. # Cirrhosis: ___ class B. Likely secondary to ETOH/HBV/HCV. Decompensated by esophageal varices and coagulopathy, also with ascites. Was treated for HIV and HCV as below. He was not given diuretics given ___ and known volume loss from intraabdominal C. difficile infection. # Hypoglycemia: He was noted to have low FSBGs in the ___. He never had symptoms of hypoglycemia. He has not been using insulin. Venous glucose has been consistently higher than FSBGs, raising concern for falsely low values on FSBG possibly due to cryoglobulinemia. Given this finding, further workup for hypoglycemia was deferred. # Thrombocytopenia: He had chronic thrombocytopenia which has been worse for past 3 months. Likely multifactorial, secondary to splenic sequestration (known massive splenomegaly >20cm), cirrhosis and marrow suppression in setting of HIV/HepB/HepC. We continued SC Heparin for prophylaxis. # Leukopenia: He had a history of chronically low WBC since at least ___. Likely related to chronic viral infections, can pursue outpatient workup if indicated. Not neutropenic during this admission. # Vertigo, gait disturbance: Followed by outpatient neurology. On previous neurology assessment, dizziness and imbalance were felt to be likely multifactorial contributed by prior cerebellar insults, orthostasis and peripheral neuropathy. Also possibly contributory hypoglycemia on this admission. Neuro exam with no new neurologic deficit. He was evaluated by physical therapy who recommended rehab placement due to gait instability with a rolling walker. # BRBPR: Hct remained stable and near baseline. His history of BRBPR was most likely secondary to known internal hemorrhoids, seen on colonoscopy in ___. Also had EGD from ___ which showed varices at the distal esophagus, congestive gastropathy. He had no active bleeding during this admission. # Cryoglobulinemia: He likely has mixed cryoglobulinemia in setting of chronic HCV infection. HBV and HIV were also noted to be associated with cryoglobulinemia. With regard to symptoms, he has known peripheral neuropathy but no palpable purpura. Treatment would include immunosuppression and treatment of underlying viral infections. CNS vasculitis from cryoglobulins can manifest as stroke. However unclear that cryoglobulinemia is driving his symptomology at this time. C3, C4 very low this admission. CBC tubes were placed in warm water and taken immediately to lab. He had cryoglobulin level pending at discharge which will need follow-up after discharge. # HIV: On treatment. Viral load undetectable, CD4 count was 247 in ___. Renally dosed HIV meds. # HCV: S/P treatment in past (s/p ribavirin and IFN) but last viral load in ___ over 1,000,000.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Aspirin / Sudafed / Toradol / Levaquin / iv contrast / Amitriptyline / Motrin / Ultram / acetaminophen / latex tape Attending: ___ Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old male initially admitted to the medical service two days ago with complaints of shortness of breath and abdominal pain. The shortness of breath improved but the abdominal pain did not and he was not having bowel movements or passing gas. See admission note/ACS consult note from ___ for full details. In brief, however, he was transferred to the ACS service in the evening of the day of his admission (yesterday) for management of his SBO. He was scheduled to have a CT Chest to rule out a PE given his prior history of PE and not being on anticoagulation and was going premedication. Past Medical History: - COPD: on home O2 at night, still smoking, multiple exacerbations yearly, never intubated. - possible tracheobronchomalacia - h/o pulmonary embolism, no longer on anticoagulation - ___ - medical attention-seeking personality traits, possible factitious disorder per psychiatry - opiate abuse - Neurogenic Bladder - s/p ileal conduit ___ - insomnia - ? h/o of SBO in ___ - Diverticulitis - gastroparesis - L Lung nodule followed q6 months - ? Mental Retardation -chronic pain from spinal cord injury Social History: ___ Family History: mother died at ___ from Lung CA, emphysema father died at ___ from CAD, chronic EtOH Physical Exam: Exam upon admission: ___: 99.6 77 148/82 18 95RA NAD, AAOx3 RRR unlabored respirations abdomen distended, tender to palpation diffusely to moderate palpation - similar in exam to prior, urostomy appears healthy and functional extremities warm Pertinent Results: ___ 07:50PM BLOOD Plt ___ ___ 07:50PM BLOOD Glucose-94 UreaN-12 Creat-1.0 Na-133 K-4.8 Cl-97 HCO3-22 AnGap-19 ___ 07:50PM BLOOD ALT-12 AST-33 AlkPhos-75 TotBili-0.2 ___ 08:02PM BLOOD Lactate-4.6* ___: CT abd. and pelvis: 1. The stomach is severely distended and multiple mildly dilated loops of proximal small bowel are fluid-filled concerning for partial obstruction. 2. Mild left hydronephrosis is likely chronic. 3. An ileal conduit urostomy is again noted. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. QUEtiapine extended-release 800 mg PO QHS 2. Fentanyl Patch 25 mcg/h TD Q72H 3. Morphine Sulfate ___ ___ mg PO BID:PRN Pain - Severe 4. TraZODone 100 mg PO QHS:PRN insomnia Discharge Medications: no prescriptions provided, the patient left the hospital against medical advice. Discharge Disposition: Home Discharge Diagnosis: abdominal pain small bowel obstruciton Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CTA chest and CT abdomen and pelvis INDICATION: ___ year old man with prior history of PE, with shortness of breath, equivocal Wells score, not on anticoagulation, also has SBO// please assess for PE. Needs premedication prior given past IV contrast allergy. Please scan abdomen to assess for SBO, does not need to be CTA protocol for abdomen.**WILL BEGIN PRE-MED AT 5AM, PLEASE SCHEDULE STUDY FOR 10AM (DISCUSSED WITH O/N RADIOLOGIST + TECH) TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of intravenous contrast in the arterial phase. Then, imaging was obtained through the abdomen and pelvis in the portal venous phase. Reformatted coronal and sagittal images through the chest, abdomen, and pelvis, and oblique maximal intensity projection images of the chest were submitted to PACS and reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 2.4 s, 37.7 cm; CTDIvol = 7.2 mGy (Body) DLP = 271.8 mGy-cm. 2) Spiral Acquisition 2.9 s, 46.7 cm; CTDIvol = 10.3 mGy (Body) DLP = 481.3 mGy-cm. 3) Spiral Acquisition 0.7 s, 10.7 cm; CTDIvol = 9.0 mGy (Body) DLP = 96.3 mGy-cm. 4) Stationary Acquisition 4.1 s, 0.5 cm; CTDIvol = 13.8 mGy (Body) DLP = 6.9 mGy-cm. Total DLP (Body) = 856 mGy-cm. COMPARISON: CT abdomen pelvis from ___. FINDINGS: CHEST: HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the subsegmental level without filling defect to indicate a pulmonary embolus. The thoracic aorta is normal in caliber without evidence of dissection. There is mild atherosclerotic calcification of the aortic arch. There is no penetrating atherosclerotic ulcer. The heart is normal in size. There is no evidence of right heart strain. No pericardial effusion is seen. AXILLA, HILA, AND MEDIASTINUM: There are numerous nonenlarged mediastinal lymph nodes, measuring up to 8 mm in short axis, likely reactive secondary to underlying lung disease. There is no mediastinal mass. There are also nonenlarged bilateral hilar lymph nodes. PLEURAL SPACES: There is no pleural effusion or pneumothorax. LUNGS/AIRWAYS: There extensive panlobular emphysema. There is mucous plugging of the right upper lobar bronchus and proximal segmental branches. There is a calcified granuloma in the medial left upper lobe. There is no pulmonary mass or suspicious nodule. There is scattered subsegmental atelectasis of the bilateral lower lobes, right middle lobe and lingula. BASE OF NECK: Visualized portions of the base of the neck show no abnormality. ABDOMEN: HEPATOBILIARY: The liver is normal in size and homogeneous attenuation. No focal hepatic lesion is detected. The gallbladder is within normal limits. There is no intra- or extrahepatic biliary ductal dilatation. PANCREAS: The pancreas is homogeneous in attenuation, without evidence of focal lesion or main ductal dilatation. There is no peripancreatic stranding. 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 demonstrate normal nephrograms. There are surgical clips in the medial interpolar region of the left kidney. There are areas of cortical scarring in the both kidneys, left worse than right. There is mild left hydronephrosis, with a transition point in the mid ureter, obscured by streak artifact from multiple retroperitoneal clips, slightly worsened compared to the prior CT from ___. There is no right hydronephrosis. There is no perinephric abnormality. There are postsurgical changes of cystectomy with right lower quadrant ileal conduit. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops are normal in caliber, with resolution previously seen partial small bowel obstruction on CT of the abdomen/pelvis from ___. The colon is distended with gas and stool. The rectum is within normal limits. There is no free intraperitoneal fluid or free air. PELVIS: There is no free fluid in the pelvis. There is no pelvic or inguinal lymphadenopathy. REPRODUCTIVE ORGANS: The prostate and seminal vesicles are unremarkable. LYMPH NODES: There is no mesenteric or retroperitoneal lymphadenopathy. There are multiple retroperitoneal clips from prior lymph node dissection. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. The major mesenteric branch vessels are patent. BONES AND SOFT TISSUES: There is no suspicious osseous lesion or acute fracture. IMPRESSION: 1. No evidence of pulmonary embolism to the level of the subsegmental arteries. No acute pulmonary parenchymal process. 2. Mild left hydronephrosis, with a transition point in the mid ureter, obscured by streak artifact from multiple retroperitoneal clips, unchanged compared to the prior CT from ___. 3. Interval resolution of previously seen partial small bowel obstruction on CT of the abdomen/pelvis from ___. 4. Postsurgical changes of cystectomy with right lower quadrant ileal conduit. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abd pain Diagnosed with Unspecified intestinal obstruction temperature: 99.6 heartrate: 78.0 resprate: 18.0 o2sat: 95.0 sbp: 149.0 dbp: 82.0 level of pain: 10 level of acuity: 2.0

___ year old male who was admitted to the medical service with shortness of breath and abdominal pain. The shortness of breath improved but the abdominal pain continued. He was not having bowel movements or passing gas. The patient underwent a cat scan of the abdomen on ___ which showed a distended stomach and mildy dilated loops of proximal small bowel concerning for partial obstruction. The patient was transferred to the Acute Care service for management of his SBO. He was made NPO, and given intravenous fluids. He refused placement of a ___ tube. On ___, he refused further medical care and removed his intravenous line. The importance of continued medical care for his safety and well-being were addressed. The patient left the hospital against medical advice.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / morphine / digoxin / lisinopril / Dilaudid Attending: ___. Chief Complaint: right hip pain Major Surgical or Invasive Procedure: ___ s/p right hip incision and drainage and washout History of Present Illness: Ms. ___ is a ___ woman with a past medical history of atrial fibrillation s/p PVI in ___ and ___, HTN, HLD, who presents with severe RLE pain. The patient underwent PVI on ___ via ___ and ___ L femoral sheaths and 8.5F R femoral sheath. Post-procedure, the patient felt unwell, with headache and nausea. On day of this admission, she developed severe RLE pain, limiting her ability to ambulate. She has not previously experienced pain of such severity. The patient denies CP, SOB, fever, chills, or subsequent RLE trauma. A full 10 point review of systems was reviewed and is otherwise negative in detail Past Medical History: Recurrent atrial fibrillation/flutter on warfarin; PVI ___ hx of RVR/atrial tachycardia; s/p CV x3; failed propafenone and amiodarone; Hypertension Hyperlipidemia Hx of DVT - patient denies Appendectomy Social History: ___ Family History: Positive family history of atrial arrythmias: Son (deceased following PVI), brother Physical ___ physical exam: VS: 98.0, 73, 129/69, 16, 98% RA General/Neuro: Comfortable lying flat, significant discomfort R inner upper groin with any RLE movement. NAD. LAert and oriented. Nonfocal. Cardiac: RRR [X] Irregular [] Nl S1 S2 Lungs: CTA [X] No resp distress [X] Abd: NBS [X]Soft [X] ND [] NT [X] Extremities: trace edema [X] ___: doppler [] palpable [X] Severe ttp in R groin and extending medially to knee. ROM limited by pain. 2+ femoral and DP pulses. Strength ___ in distal RLE. No bruit, erythema, swelling, warmth or ecchymosis in RLE. Access Sites: CDI [X] no bleeding, ecchymosis or hematoma Discharge physical exam: Gen: Patient with mild discomfort with movement, cooperative. Pain in right hip area improving HEENT: Face symmetrical, trachea midline. Neuro: A/Ox3. Speaking in complete, coherent sentences. Smile symmetric. MAE equal and strong, strong ___ hand grasps, and L foot pushes; R foot push weaker than L. Pulm: Breathing unlabored. Lungs clear bilaterally. Cardiac: No JVD. S1, S2 RRR. No murmurs, friction rubs heard. Abd: Rounded, soft, non-tender. Vasc: Mild edema in right upper thigh> left. Mild tenderness to inner right thigh with palpation. No pigmentation changes noted in bilateral upper or lower extremities. Skin dry, warm. Bilateral radial, ___ pulses palpable 2+. Right hip with intact dressing-changed by ortho (___), CDI. No hematoma. Pertinent Results: Admit labs: ___ 04:14PM BLOOD WBC-7.4 RBC-4.23 Hgb-13.2 Hct-39.5 MCV-93 MCH-31.2 MCHC-33.4 RDW-14.5 RDWSD-49.7* Plt ___ ___ 04:14PM BLOOD Neuts-72.2* Lymphs-10.1* Monos-16.2* Eos-0.7* Baso-0.3 Im ___ AbsNeut-5.32 AbsLymp-0.74* AbsMono-1.19* AbsEos-0.05 AbsBaso-0.02 ___ 04:14PM BLOOD ___ PTT-34.2 ___ ___ 04:14PM BLOOD Glucose-97 UreaN-9 Creat-0.7 Na-138 K-4.5 Cl-97 HCO3-23 AnGap-18 ___ 04:14PM BLOOD CRP-217.1* ___ 11:43PM BLOOD Lactate-0.8 ___ 12:45PM JOINT FLUID ___ RBC-7000* Polys-97* ___ Macro-2 RIGHT HIP MUSCLE HEMATOMA. GRAM STAIN (Final ___ 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. Blood Culture, Routine (Final ___: NO GROWTH. Discharge labs: ___ 05:41AM BLOOD WBC-9.3 RBC-2.16* Hgb-6.6* Hct-20.2* MCV-94 MCH-30.6 MCHC-32.7 RDW-15.0 RDWSD-51.7* Plt ___ ___ 04:30PM BLOOD Hgb-9.4* Hct-28.6* ___ 04:28AM BLOOD Neuts-80.8* Lymphs-6.6* Monos-11.2 Eos-0.7* Baso-0.3 Im ___ AbsNeut-9.09* AbsLymp-0.74* AbsMono-1.26* AbsEos-0.08 AbsBaso-0.03 ___ 05:41AM BLOOD Glucose-103* UreaN-31* Creat-2.0* Na-136 K-4.8 Cl-99 HCO3-27 AnGap-10 ___ 05:41AM BLOOD Calcium-8.1* Phos-2.5* Mg-2.1 ___ 05:41AM BLOOD CRP-163.2* INRs ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Simvastatin 20 mg PO QPM 2. Amiodarone 100 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Warfarin 2.5 mg PO 6X/WEEK (___) 6. Warfarin 5 mg PO 1X/WEEK (WE) 7. melatonin 10 mg oral QHS: PRN 8. Psyllium Powder 1 PKT PO TID:PRN supplement 9. Vitamin D 1000 UNIT PO DAILY 10. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg calcium- 200 unit oral unk 11. Cetirizine 10 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 2. CeFAZolin 2 g IV Q12H Please take this antibiotic until ___ 3. Ferrous Sulfate 325 mg PO DAILY 4. Gabapentin 300 mg PO BID 5. Lidocaine 5% Patch 1 PTCH TD QAM 6. Pantoprazole 40 mg PO Q24H 7. TraMADol 50 mg PO Q6H:PRN pain 8. Amiodarone 100 mg PO DAILY 9. Aspirin 81 mg PO DAILY 10. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg calcium- 200 unit oral unk 11. Cetirizine 10 mg PO DAILY 12. melatonin 10 mg oral QHS: PRN 13. Multivitamins 1 TAB PO DAILY 14. Psyllium Powder 1 PKT PO TID:PRN supplement 15. Simvastatin 20 mg PO QPM 16. Vitamin D 1000 UNIT PO DAILY 17. Warfarin 5 mg PO 1X/WEEK (WE) 18. Warfarin 2.5 mg PO 6X/WEEK (___) Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Right psoas abscess and septic hip arthritis Hypertension Hyperlipidemia Atrial fibrillation status post PVI ×2, last ___ Acute kidney injury Discharge Condition: Vital signs: 98.4, BP 116-142/68-83, HR 71-78, RR ___, Sats 94-98% RA Weight on discharge: 75.8kg/167.1lb Physical Examination: Gen: Patient with mild discomfort with movement, cooperative. Pain in right hip area improving HEENT: Face symmetrical, trachea midline. Neuro: A/Ox3. Speaking in complete, coherent sentences. Smile symmetric. MAE equal and strong, strong ___ hand grasps, and L foot pushes; R foot push weaker than L. Pulm: Breathing unlabored. Lungs clear bilaterally. Cardiac: No JVD. S1, S2 RRR. No murmurs, friction rubs heard. Abd: Rounded, soft, non-tender. Vasc: Mild edema in right upper thigh> left. Mild tenderness to inner right thigh with palpation. No pigmentation changes noted in bilateral upper or lower extremities. Skin dry, warm. Bilateral radial, ___ pulses palpable 2+. Right hip with intact dressing-changed (___), CDI. No hematoma. ========================= 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: FEMORAL VASCULAR US RIGHT INDICATION: ___ year old woman with recent PVI, now with right groin pain. Evaluation for pseudoaneurysm vs. hematoma TECHNIQUE: Grayscale ultrasound images were obtained of the superficial tissues of the right groin in the area patient's discomfort. COMPARISON: None FINDINGS: Transverse and sagittal images were obtained of the superficial tissues of the right groin in the area of patient's discomfort. No pseudoaneurysm identified. Common femoral artery and vein demonstrate normal waveforms without evidence for fistula. In the superficial soft tissues lateral to the common femoral vasculature, there is a focal hypoechoic fluid collection measuring 0.9 x 2.3 x 0.7 cm, likely compatible with a hematoma. IMPRESSION: 1. No pseudoaneurysm or arteriovenous fistula identified. 2. Focal hypoechoic fluid collection in the superficial soft tissues lateral to the vasculature measures 0.9 x 2.3 x 0.7 cm, likely compatible with a hematoma. Radiology Report EXAMINATION: UNILAT LOWER EXT VEINS RIGHT INDICATION: ___ year old woman with recent PVI, now with right groin pain. Evaluation for DVT TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the right lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, flow, and augmentation of the right common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: No evidence of deep venous thrombosis in the right lower extremity veins. Radiology Report EXAMINATION: CTA PELVIS WANDW/O C AND RECONS INDICATION: ___ year old woman with recent PVI for AF, now with right groin pain// Please evaluate for dissection vs. hematoma 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 8.5 s, 67.1 cm; CTDIvol = 5.2 mGy (Body) DLP = 348.5 mGy-cm. 2) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 24.3 mGy (Body) DLP = 12.1 mGy-cm. 3) Spiral Acquisition 8.6 s, 67.3 cm; CTDIvol = 13.7 mGy (Body) DLP = 923.8 mGy-cm. 4) Spiral Acquisition 8.6 s, 67.3 cm; CTDIvol = 13.7 mGy (Body) DLP = 921.1 mGy-cm. Total DLP (Body) = 2,206 mGy-cm. COMPARISON: Prior ultrasounds from ___ FINDINGS: VASCULAR: There is no abdominal aortic aneurysm. There is no active extravasation identified on this exam. There is moderate calcium burden in the abdominal aorta and great abdominal arteries. URINARY: Partially visualized kidneys demonstrate left interpolar renal cortical thinning. No mid to lower pole nephrolithiasis is seen. There is no hydronephrosis. GASTROINTESTINAL: Partially visualized loops of small and large bowel demonstrate no small bowel obstruction. Large bowel demonstrates multiple diverticula without surrounding inflammation to suggest diverticulitis. 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 bilateral uterus and adnexae are within normal limits. BONES/SOFT TISSUES: There is 4.5 x 1.6 x 1.9 cm (series 5; image 89, series 601; image 43) hypodensity within the right iliopsoas muscle with surrounding stranding in the right groin. Additionally, there is a right hip joint effusion with surrounding stranding. Underlying septic arthritis cannot be excluded. These findings are worrying for intramuscular infection with extension into the joint. There is no right groin hematoma. There is no active extravasation of contrast. IMPRESSION: 4.5 x 1.6 x 1.9 cm hypodensity within the right iliopsoas muscle with surrounding stranding and extension into the right hip joint with small right hip joint effusion could be secondary to an evolving hematoma. Superimposed infectious process cannot be excluded as findings could be seen in the setting of an intramuscular abscess with possible extension into the joint. Radiology Report EXAMINATION: INJ/ASP MAJOR JT W/___ INDICATION: ___ year old woman with R hip pain, CT + for stranding and extension into the right hip joint with small right hip joint effusion// ? of right hip and/or psoas abscess vs septic arthritis. COMPARISON: CT ___ TECHNIQUE: The risks, benefits, and alternatives were explained to the patient and written informed consent obtained. A pre-procedure timeout confirmed three patient identifiers. Under fluoroscopic guidance, an appropriate spot was marked. The area was prepared and draped in standard sterile fashion. 5 cc 1% Lidocaine was used to achieve local anesthesia. Under intermittent fluoroscopic guidance, a 18-gauge spinal needle was advanced into the right hip joint. The hip joint was aspirated and 3 cc of yellow fluid was successfully removed. The fluid was sent to pathology in a purple top tube and a 20 cc syringe. The needle was removed, hemostasis achieved, and a sterile bandage applied. The patient tolerated the procedure well and left the department in stable condition. There were no immediate complications or complaints. FINDINGS: 3 cc of yellow fluid was successfully aspirated from the hip joint. Mild joint space narrowing and bony spurring at the superior hip joint is noted. No suspicious osseous lesion, fracture or dislocation on limited assessment. IMPRESSION: Technically successful fluoroscopic aspiration of the right hip joint. Specimens were taken to pathology following the procedure. Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old woman with new R PICC// R SL Power PICC 40cm ___ ___ Contact name: ___: ___ R SL Power PICC 40cm ___ ___ IMPRESSION: No prior chest radiographs available. New right PIC line ends in the low SVC. Lungs clear. Heart size top-normal. No pleural abnormalities. Radiology Report EXAMINATION: RENAL U.S. INDICATION: ___ year old woman with AF, s/p PVI complicated by right hip arthritis, now with ___ and ___ creatnine// evaluate for acute process/obstruction TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: None. FINDINGS: There is no hydronephrosis, stones, or masses bilaterally. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. Right kidney: 11.1 cm Left kidney: 10.2 cm The bladder is moderately well distended and normal in appearance. IMPRESSION: Normal renal ultrasound. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: R Inguinal pain, Weakness Diagnosed with Postproc hematoma of skin, subcu following other procedure, Oth surgical procedures cause abn react/compl, w/o misadvnt, Oth places as the place of occurrence of the external cause temperature: 98.0 heartrate: 73.0 resprate: 16.0 o2sat: 98.0 sbp: 152.0 dbp: 70.0 level of pain: 10 level of acuity: 2.0

___ PMH atrial fibrillation s/p PVI in ___ and ___, HTN, HLD, ?h/o DVT, who presents with severe RLE pain with possible psoas abscess and septic hip arthritis s/p right hip aspiration and washout by ortho. # Right psoas abscess and septic hip arthritis: S/p ___ guided aspiration of the hip joint ___. Joint fluid analysis showed Staph Lugdunensis which is oxacillin susceptible. Blood cultures with no growth. S/p right hip wash out by ortho on ___. Resumed heparin gtt and warfarin. Heparin gtt discontinued ___, INR therapeutic since. - Ortho recs: Weight bearing as tolerated. Appointment booked for staples removal on ___, at 1240 pm. Call ___ with any appointment related concerns. - ID rec: Continue IV Cefazolin until ___. ID recommends continuing current cefazolin regimen (2 gm IV Q12) for CrCL<30. If CrCL >30, increase Cefazolin to 2 gm Q8 hour regimen. ___ clinic manager (___) will call nursing facility with specific instructions on lab draws per Dr. ___ (ID fellow). OPAT number is ___ for any appointment/antibiotic related concerns - Continue warfarin per home regimen. INR today 3.0 -> reduced dose of Coumadin 1 mg given. Have INR checked ___ times a week in rehab. Goal INR ___. Once discharged from rehab, can follow up with Dr. ___ in ___ Internal Associates, ___ for regular INR checks. - Pain management with standing PO Tylenol, PRN, tramadol, lidocaine patch, and gabapentin and ice - ___ daily # ___, probably multifactorial - volume depletion in the last few days. Cr improved to 2.0 today, downtrending. Renal ultrasound normal. CrCL ___ today. - Renally dose medications - Continue cefazolin at current regimen. If CrCL >30, increase the Cefazolin dose to 2 gm Q8 hours. # Right hip pain: Improving since washout and titrating pain medications. - Continue scheduled Tylenol, lidocaine patch, Gabapentin and PRN tramadol - Ice packs for comfort PRN # S/p recent PVI ___: Not on PPI prophylaxis. Was started on Carafate s/p PVI on ___ that was discontinued on ___ per OMR record due to headaches and GI upset. - Continue newly added Pantoprazole until seen in follow up with ___ - Continue amiodarone 100 daily at least for a month until seen in the clinic by Dr. ___. # PROPHYLAXIS: - DVT prophylaxis with: warfarin - Pain management with: Tylenol, gabapentin, lidocaine patch and PRN tramadol. - Bowel regimen with: Senna/Miralax # Emergency contact: ___, daughter in law, ___ # Family/HCP updated? Yes # Code status: Full (presumed) # DISPO: Rehab tomorrow pending bed availability. Case management on board, will have bed available on ___ on ___ tomorrow. # Transitional issues: IV cefazolin for 4 weeks until ___. PICC line in place. Follow with EP, Ortho and ID as scheduled. [x] Plan discussed and reviewed with Dr. ___ [x] Plan discussed Ms. ___, and her family, who appear to understand and agree to proceed with the outlined treatment plan. All questions answered to apparent satisfaction.

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 hypothyrroidism presents with chest pain x 1 day. A few weeks prior he was in his USOH when he developed a sore throat that mostly resolved over the course of a week. Last night he developed chest pain, substernal, that did not alleviate with rest or position and impaired his ability to sleep. He presented to BI-Miltion this next morning where an EKG was done that showed diffuse ST elevation except in AVR, and he was started on as heparin gtt, aspirin and atorvastatin before transfer to ___. Of note he had a ESR of 30 drawn at ___. In the ED, initial vitals were: 99.7 101 122/82 25 98% RA - Labs were significant for WBC of 12 and Trop negative x 2. - CXR revealed mild cardiomegaly; Echo revealed a moderate pericardial effusion. - The patient was given colchicine 1.2mg, ketorlac ___ IV, morphine, oxycodone and ibuprofen. Upon arrival to the floor, he states that the chest pain is diminished but still present and increasing as the pain medications given in the ED wear off. He has no family history of autoimmune diseases, has never been incarcerated, homeless, or spent significant time in a TB endemic country. Past Medical History: Hypothyroidism Umbilical Hernia Repair Social History: ___ Family History: No history of autoimmune diseases. Physical Exam: ADMISSION Vitals:99.2 94 139/77 16 97% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2; possible small rub appreciated with systole. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation DISCHARGE Pertinent Results: ADMISSION LABS ___ 11:40AM BLOOD WBC-12.1* RBC-4.75 Hgb-13.9 Hct-40.2 MCV-85 MCH-29.3 MCHC-34.6 RDW-13.3 RDWSD-41.0 Plt ___ ___ 11:40AM BLOOD Neuts-71.8* Lymphs-13.4* Monos-13.7* Eos-0.4* Baso-0.3 Im ___ AbsNeut-8.64* AbsLymp-1.62 AbsMono-1.65* AbsEos-0.05 AbsBaso-0.04 ___ 11:40AM BLOOD ___ PTT-61.5* ___ ___ 11:40AM BLOOD Plt ___ ___ 11:40AM BLOOD Glucose-118* UreaN-12 Creat-0.7 Na-136 K-4.4 Cl-100 HCO3-22 AnGap-18 ___ 11:40AM BLOOD cTropnT-<0.01 ___ 06:10PM BLOOD cTropnT-<0.01 ___ 11:40AM BLOOD TSH-3.3 ___ 11:40AM BLOOD CRP-13.2* ___ 11:48AM BLOOD Lactate-1.3 IMAGING Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Colchicine 0.6 mg PO BID RX *colchicine 0.6 mg 1 tablet(s) by mouth twice daily Disp #*60 Tablet Refills:*0 2. Ibuprofen 800 mg PO Q8H RX *ibuprofen 800 mg 1 tablet(s) by mouth every eight hours Disp #*90 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Pericarditis 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: ___ man with chest pain and dyspnea. TECHNIQUE: Chest PA and lateral COMPARISON: None available. FINDINGS: There is no focal lung consolidation. There is no pneumothorax or pleural effusion. There is no pulmonary edema. Heart is mildly enlarged. No acute osseous abnormality. IMPRESSION: Mild cardiomegaly. Otherwise, unremarkable chest radiograph. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Dyspnea Diagnosed with PERICARDIAL DISEASE NOS temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: Critical level of acuity: 1.0

___ with hypothyroidism presenting with signs, symptoms, and imaging consistent with pericarditis. #Pericarditis Patient had positional chest pain, a small pericardial effusion, elevated ESR, and preceding history of sore throat consistent with viral pericarditis. There was no evidence of tamponade on VS or echo and no history consistent with TB or autoimmune disease. He was started on colchicine 0.6mg BID to be continued for 3 months and ibuprofen 800mg TID to be taken for ___ weeks. CRP on discharge = 13.2. Patient will need to follow up with PCP and cardiology and have repeat TTE in one month. #Hypothyroidism Previously on levothyroxine 50mcg but told to stop 1 month prior. TSH 6 at ___, FT4 0.8, qualifying as subclinical hypothyroidism. Has had some fatigue recently, but difficult to tease out whether due to viral infection. Thyroid function will need to be reassessed as outpatient and potentially restart levothyroxine at that time. Transitional Issues - New medications: colchicine, ibuprofen - Recheck CRP in ___ weeks to assess for resolution - Thyroid function tests as outpatient after resolution of pericarditis - Patient with moderate pericardial effusion on admission, should have repeat TTE in 1 month

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Bactrim / tramadol / Vicodin Attending: ___ Chief Complaint: right face and arm numbness, transient facial droop Major Surgical or Invasive Procedure: none History of Present Illness: ___ yo. w/PMH of breast CA dx ___ s/p chemo-radiation, PE while on chemo, HTN, HL, presents with 1 hour of right face and arm numbness; initially also with slight right facial droop. Pt was sitting on a train when she noted the sudden onset of numbness and tingling in her arm that moved up her face. NO leg paresthesias and no weakness. When she arrived home symptoms had improved although when she looked in the mirror and when her husband looked at her, they felt like there was a slight asymmetry to her lips and nasolabial folds. Numbness in the face persists; she describes it as tingling or prickling kind of numbness, like the feeling after one has been given novocain at the dentist's, and it's starting to wear off. The numbness in the arm the pt did not notice herself until it was brought to her attention by the pinprick exam. ___ yo. w/PMH of breast CA dx ___ s/p chemo-radiation, PE while on chemo, HTN, HL, now with 1 hour of R face/arm numbness; initially also with slight R droop but this has almost completely gone away, although when pt looks in mirror, and when husband looks at her, they still feel like there is a slight asymmetry to her lips and nasolabial folds. Numbness in the face persists; she describes it as tingling or prickling kind of numbness, like the feeling after one has been given novocain at the dentist's, and it's starting to wear off. The numbness in the arm the pt did not notice herself until it was brought to her attention by the pinprick exam. Fingerstick glc 114 on arrival. ROS: Yesterday pt had a headache but not currently, and she has been feeling somewhat unwell for the last week, with malaise URI symptoms On neurologic review of systems, the patient denies lightheadedness, or confusion. Denies difficulty with producing or comprehending speech. Denies loss of vision, blurred vision, diplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or dysphagia. Denies muscle weakness. Denies bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the patient denies fevers, rigors, night sweats, or noticeable weight loss. Denies palpitations, dyspnea, or cough. Denies nausea, vomiting, diarrhea, constipation, or abdominal pain. Denies dysuria or hematuria. Denies myalgias, arthralgias, or rash. Past Medical History: PAST ONCOLOGIC HISTORY: ====================== The patient presented with a T2, N0 ER negative/PR negative, HER-2/neu negative invasive breast cancer diagnosed by biopsy performed on ___. A sentinel lymph node biopsy performed on ___ was negative. The patient proceeded with three cycles of neoadjuvant cisplatin and Avastin given on the ___ protocol. The patient came off the study in ___ when she was diagnosed with a pulmonary embolus. In ___, the patient underwent a right skin sparing mastectomy and first stage immediate reconstruction with placement of a tissue expander. Pathology noted a 1.8 cm invasive ductal carcinoma, grade III. - started adjuvant chemotherapy with doxorubicin and cyclophosphamide, with the first cycle administered on ___. The patient is receiving this treatment in a dose-dense regimen. She has completed 4 cycles, every 2 weeks - Taxol to start ___ . PAST MEDICAL HISTORY: ==================== asthma PE HTN Social History: ___ Family History: Breast cancer in mother who was diagnosed at age ___. Her father had lung cancer and she has one sister who has had a kidney cancer. No known family history of TIA or stroke at early age. Physical Exam: Physical Examination: VS T:97.4 HR:66 BP:118/77 RR:18 SaO2:100%RA General: NAD, lying in bed comfortably. Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions Neck: Supple, no nuchal rigidity, no LAD or thyromegaly Cardiovascular: No carotid, vertebral or subclavian bruits; carotids w/ nl volume & upstroke, RRR, no M/R/G Pulmonary: Respirations nonlabored; equal air entry bilaterally, no crackles or wheezes Abdomen: Soft, NT, ND, +BS, no guarding Extremities: Warm, no edema, palpable dorsalis pedis pulses Skin: No rashes or lesions ___ Stroke Scale: Total [2] 1a. Level of Consciousness: 1b. LOC Questions: 1c. LOC Commands: 2. Best Gaze: 3. Visual Fields: 4. Facial Palsy: 1 5a. Motor arm, ___: 5b. Motor arm, right: 6a. Motor leg, ___: 6b. Motor leg, right: 7. Limb Ataxia: 8. Sensory:1 9. Language: 10. Dysarthria: 11. Extinction and Neglect: Neurologic Examination: - Mental Status: Awake, alert, oriented x 3. Recalls a coherent history. Concentration maintained when recalling months backwards. Language fluent without dysarthria and with intact repetition and verbal comprehension. No paraphasic errors. Follows two-step commands, midline and appendicular. High- and low-frequency naming intact. Normal reading and writing. Normal prosody. Registration ___ and recall ___. No apraxia or neglect. Normal performance on Luria hand sequencing. - Cranial Nerves: [II] PERRL. VF full to number counting. Nondilated fundoscopy shows crisp disc margins, no papilledema. [III, IV, VI] EOM intact, only physiologic end-gaze nystagmus. [V] V2-V3 with decrease to pinprick on right, not V1. Pterygoids contract normally. [VII] Minimal right nasolabial fold flattening. [VIII] Hearing intact to conversation. [IX, X] Palate elevation symmetric. [XI] SCM/Trapezius strength ___ bilaterally. [XII] Tongue midline and moves facilely. - Motor: Normal bulk and tone. No pronation or drift. No tremor or asterixis. [ Direct Confrontational Strength Testing ] Arm Deltoids [R 5] [L 5] Biceps [R 5] [L 5] Triceps [R 5] [L 5] Extensor Carpi Radialis [R 5] [L 5] Finger Extensors [R 5] [L 5] Finger Flexors [R 5] [L 5] Leg Iliopsoas [R 5] [L 5] Quadriceps [R 5] [L 5] Hamstrings [R 5] [L 5] Tibialis Anterior [R 5] [L 5] Gastrocnemius [R 5] [L 5] Extensor Hallucis Longus [R 5] [L 5] Extensor Digitorum Brevis [R 5] [L 5] - Sensory: No deficits to light touch, pinprick, or proprioception bilaterally except decreased sensation to pinprick on R arm. - Reflexes [Bic] [Tri] [___] [Quad] [Ankle] L ___ 3 2 R ___ 3 2 Plantar response flexor bilaterally. - Coordination: No dysmetria on finger-to-nose and heel-knee-shin testing. No dysdiadochokinesia - Gait: Normal initiation. Narrow base. Normal stride length and arm swing. Stable stance without sway. No Romberg. Intact heel, toe, and tandem gait. DISCHARGE EXAM: unchanged Pertinent Results: ___ 10:00PM URINE HOURS-RANDOM ___ 10:00PM URINE HOURS-RANDOM ___ 08:55PM GLUCOSE-107* NA+-140 K+-4.0 CL--102 TCO2-26 ___ 08:54PM CREAT-0.8 ___ 08:54PM D-DIMER-560* ___ 08:54PM cTropnT-<0.01 ___ 08:54PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 08:54PM WBC-6.1 RBC-4.11* HGB-12.4 HCT-36.5 MCV-89 MCH-30.1 MCHC-33.9 RDW-14.1 ___ 08:54PM NEUTS-55.9 ___ MONOS-2.9 EOS-4.8* BASOS-0.7 ___ 08:54PM ___ PTT-30.6 ___ ___ 08:30AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.0 Cholest-205* ___ 08:30AM BLOOD Triglyc-77 HDL-56 CHOL/HD-3.7 LDLcalc-134* NC Head CT: No intra or extra-axial hemorrhage, mass effect, or shift of midline structures is present. Differentiation of the gray and white matter is preserved. The sulci, basal cisterns, and ventricles are normal. Mild mucosal thickening is demonstrated within the ethmoid air cells, bilateral maxillary sinuses, and left sphenoid sinus with an air-fluid level noted in the right sphenoid sinus. The mastoid air cells and frontal sinuses are clear. There are no osseous or soft tissue abnormalities otherwise demonstrated. MRI- No evidence of acute ischemia MRA- no evidence of stenosis or calcification of vessels Medications on Admission: Medications: - albuterol inhaler PRN - fluticasone nasal - lisinopril 2.5 mg daily - omeprazole ___ 40 mg daily - pramipexole 0.125 mg qhs (recently added) - pravastatin 40 mg qhs Discharge Medications: 1. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth daily Disp #*30 Tablet Refills:*0 2. Fexofenadine 60 mg PO BID 3. Pravastatin 40 mg PO HS 4. Omeprazole 40 mg PO DAILY *Research Pharmacy Approval Required* Research protocol ___ 5. Fluticasone Propionate NASAL ___ SPRY NU DAILY *Research Pharmacy Approval Required* Research protocol ___ 6. Calcium Carbonate 500 mg PO QID:PRN acid reflux *Research Pharmacy Approval Required* Research protocol ___ 1. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth daily Disp #*30 Tablet Refills:*0 2. Fexofenadine 60 mg PO BID 3. Pravastatin 40 mg PO HS 4. Omeprazole 40 mg PO DAILY *Research Pharmacy Approval Required* Research protocol ___ 5. Fluticasone Propionate NASAL ___ SPRY NU DAILY *Research Pharmacy Approval Required* Research protocol ___ 6. Calcium Carbonate 500 mg PO QID:PRN acid reflux *Research Pharmacy Approval Required* Research protocol ___ Discharge Disposition: Home Discharge Diagnosis: Transient ischemic attack Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Right hand weakness, now resolved. TECHNIQUE: Contiguous MDCT acquired axial images were obtained through the brain without intravenous contrast administration. Coronal and sagittal reconstructions were performed. COMPARISON: CT head ___. MRI head ___. FINDINGS: No intra or extra-axial hemorrhage, mass effect, or shift of midline structures is present. Differentiation of the gray and white matter is preserved. The sulci, basal cisterns, and ventricles are normal. Mild mucosal thickening is demonstrated within the ethmoid air cells, bilateral maxillary sinuses, and left sphenoid sinus with an air-fluid level noted in the right sphenoid sinus. The mastoid air cells and frontal sinuses are clear. There are no osseous or soft tissue abnormalities otherwise demonstrated. IMPRESSION: No acute intracranial abnormality. MRI is more sensitive for the detection of acute ischemia. Pansinus disease, with air-fluid level in the right sphenoid sinus suggestive of acute inflammation. Radiology Report HISTORY: Chest pain. Evaluate for pulmonary embolus. TECHNIQUE: MDCT axial images were acquired from the thoracic inlet to the dome of the liver after the uneventful administration of 100 mL of Omnipaque. Coronal and sagittal reformations are provided and reviewed. Max intensity projection images were created and reviewed as well. COMPARISON: None. FINDINGS: Contrast is seen opacifying the segmental and subsegmental vessels of the pulmonary arterial tree, without a filling defect to suggest a pulmonary embolus. The aorta and main pulmonary artery are normal in caliber. There is no dissection or acute aortic injury. The heart is normal in size and there is no pericardial effusion. The image thyroid is normal. There is no axillary, hilar or mediastinal lymphadenopathy. The esophagus is unremarkable. The trachea is normal in caliber. The airways are patent to the subsegmental level. There is no pleural effusion pneumothorax. There is no focal airspace consolidation. The pleural surfaces are smooth. This study was not designed to evaluate the subdiaphragmatic contents. Images of the arterially enhanced liver and spleen are unremarkable. There is a moderate dextroscoliosis of the thoracic spine. Bilateral prepectoral breast implants are noted. IMPRESSION: No pulmonary embolus. Radiology Report CTA OF THE HEAD AND NECK, ___ HISTORY: ___ female with possible stroke; evaluate for stenosis or dissection. TECHNIQUE: Routine ___ enhanced CTA of the head and neck, comprising helical 1.25-mm axial MDCT sections from the level of the main pulmonary artery through the cranial vertex during dynamic intravenous administration of 70 mL Omnipaque-350. Multiplanar thick-slab MIP-reconstructed and rotational volume-rendered 3D-reconstructed and curved planar reformatted images were prepared and viewed on a separate workstation. FINDINGS: The study is compared with the cranial NECT obtained approximately one hour earlier, as well as the enhanced MR examination, obtained roughly 11 hours later. There is a normal appearance of the aortic arch and great vessel origins, without significant calcified or soft plaque. There is a similarly unremarkable appearance to the common and cervical internal and external carotid arteries, with no significant mural irregularity or flow-limiting stenosis. The proximal and distal ICA minimum diameter (D min) measurements are as follows: On the right, 8 mm and 4 mm and on the left, 6.0 mm and 4 mm, with no flow-limiting or tandem stenosis. There is a slightly dominant left vertebral artery and both vessels demonstrate normal course, caliber and contour and uniform enhancement from their subclavian origins through the vertebrobasilar junction, with no finding to suggest dissection. The intracranial carotid and proximal middle and anterior cerebral arteries are normal with no significant mural irregularity or flow-limiting stenosis. The basilar artery demonstrates normal caliber and contour, with no significant mural irregularity or flow-limiting stenosis. There is a "patulous" basilar summit with conjoined origins of its terminal vessels. There is, including a prominent infundibular origin of the left superior cerebellar artery and the diminutive P1 segment of that posterior cerebral artery, with a fetal-equivalent left PCA. Robust anterior and right posterior communicating vessels are demonstrated, with no aneurysm larger than 2 mm. There is prompt, symmetric opacification of the principal dural venous sinuses and major deep cerebral veins, with no finding to suggest thrombosis. The limited included lung apices are clear, that portion of the superior mediastinum is grossly unremarkable. The thyroid gland is grossly symmetric and unremarkable, and there is no cervical lymphadenopathy. The included aerodigestive tract is grossly unremarkable, with no exophytic mucosal lesion. There is mucosal thickening involving the maxillary antra, with mucus retention cyst on the left, the anterior and posterior ethmoidal and the sphenoid air cells, with likely small amount of layering fluid in the hypoplastic right sphenoid air cell, which may indicate an acute inflammatory component. Noted is reversal of the normal cervical lordosis with severe multilevel degenerative disease and significant spinal canal and neural foraminal narrowing, most marked at the C5-6 and C6-7 levels. IMPRESSION: 1. Unremarkable cranial and cervical vessels with no evidence of steno-occlusive disease or dissection. 2. No finding to suggest cerebral venous thrombosis. 3. Chronic inflammatory disease in the paranasal sinuses, with possible acute inflammatory component involving the right sphenoid air cells; correlate clinically. 4. Severe cervical spondylosis with significant ventral canal and bilateral neural foraminal stenosis, particularly at the C4-5 through C6-7 levels, incompletely evaluated. COMMENT: A preliminary interpretation to this effect was placed on RISweb by Dr. ___ (9:04 p.m., ___. Radiology Report BRAIN MRI WITH AND WITHOUT CONTRAST, ___ INDICATION: ___ woman with history of breast cancer, now with one day of right face and arm numbness. Evaluate for cerebrovascular accident, other process. COMPARISON: ___. TECHNIQUE: Sagittal T1-weighted, and axial T1-weighted, T2-weighted, FLAIR, gradient echo, and diffusion-weighted images of the brain were obtained. Following intravenous gadolinium administration, axial T1-weighted and sagittal MP-RAGE images of the brain with multiplanar reformations were obtained. FINDINGS: There is no evidence for an intra-axial or extra-axial enhancing lesion to suggest intracranial metastatic disease. There is no acute infarction, edema, mass effect, or evidence of blood products in the brain parenchyma. Ventricles, basal cisterns, and cerebral sulci are normal in size and configuration. Major arterial flow voids are grossly preserved. ___ cisterna magna is again noted, a normal variant. Endplate osteophytes are again noted in the imaged upper cervical spine at C3-4 and C4-5, abutting the ventral spinal cord, incompletely evaluated. There is mild-to-moderate mucosal thickening in bilateral ethmoidal air cells, and mild mucosal thickening in bilateral maxillary and sphenoid sinuses. There is also a small mucous retention cyst in the left maxillary sinus. Right frontal sinus is unremarkable. Left frontal sinus is not pneumatized. IMPRESSION: No evidence of an acute infarction or other acute intracranial abnormalities. No evidence of intracranial metastatic disease. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Numbness, Facial numbness Diagnosed with OTHER MALAISE AND FATIGUE, PAINFUL RESPIRATION, PRIM CARDIOMYOPATHY NEC temperature: 97.4 heartrate: 66.0 resprate: 18.0 o2sat: 100.0 sbp: 118.0 dbp: 77.0 level of pain: 7 level of acuity: 1.0

___ yo. w/PMH of breast CA dx ___ s/p chemo-radiation, PE while on chemo, HTN, HL, presents with 1 hour of right face and arm numbness; initially also with slight right facial droop. On arrival to ___, stroke code was called with NIHSS of 2, CT was done with CTA which showed no signs of hemhorrage or ischemia and no vessel stenosis to explain her symptoms. She was admitted and placed on tele with no events seen. MRI was done which showed no ischemia lesion to account for her symptoms. Her symptoms are consistent with TIA, she has elevated LDL (134) and we continued with her dose of statins. However, one should consider switching her statins to Atorvastatin (___) or increase her current brand of statins. She has a remote smoking history and breast CA but otherwise no other obvious risk factors. Homocysteine and fibrinogen levels were sent as workup for a general assessment of possible pro-coagulable state. Fibrinogen was normal 307 and homocysteine is still pending at time of discharge. ___ was deferred as she had normal study in ___. Was discharged on ASA and statin ___. # Neuro: - Distribute stroke information packet and note in the chart - CT/CTA- no stroke or stenosis found - MRI head - no acute ischemia or vessel disease - Assess stroke risk factors with telemetry, fasting lipid panel and HbA1c. LDL was elevated, started statin. HbA1c within norm limits - Give full-dose aspirin in ED, and continue ASA 81 mg daily . # ___: - Telemetry - Allow BP to autoregulate with goal SBP < 180 (goal SBP 140-180s) - Labetalol 200 mg PO Q6H PRN SBP > 180 - Hold home antihypertensives (lisinopril 2.5 mg daily) - TTE with bubble - deferred due to normal echo ___ . # ENDO: - HbA1c - 6.1 - Finger sticks QID . PPX: - DVT: S/C heparin/pneumoboots - GI: PRN laxatives + continue home-dose PPI .

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: 7 weeks of nausea/vomiting Major Surgical or Invasive Procedure: Upper endoscopy with biopsies and nasojejunal tube placement ___ Right breast core biopsy ___ Chest port placement ___ History of Present Illness: ___ yo F w/ PMH of epilepsy (on lamictal), IDDM, HTN, hyperlipidemia, chronic venous insufficiency who presents with nausea & vomiting x 7 weeks. Patient reports inability to tolerate food or water for the past 7 weeks - if she tries to eat some food, she will have emesis. Also with cough over the past several weeks. Last BM was the day before yesterday. Denies fevers. Reports glucose of 83 this AM (on 70/30 insulin). Has been to the ER three times for similar presentations. Had appointment on ___ at ___ - endoscopy yesterday with biopsies - awaiting results. Denies respiratory distress, chest pain, SOB. States she has not eaten in 7 weeks. endorses nausea at this time and is spitting up froth. Denies chest pain, dyspnea, fever, chills. In the ED, initial vitals were: 97.8 148/89 76 18 100%RA - Exam notable for: VSS Well, overweight RRR, no murmurs CTAB Soft, NTND Neuro non-focal - Labs notable for: platelets ___ ---------<140 2.9/28/0.6 normal LFTs negative troponin - Imaging was notable for: CXR PA/LAT AP upright and lateral views of the chest provided. Patient is slightly rotated to the left. Lung volumes are low. There is mild bibasilar atelectasis. No large effusion or pneumothorax. The heart appears mildly enlarged. Mediastinal contour is normal. Bony structures are intact. AC joint arthropathy noted bilaterally. No free air below the right hemidiaphragm. CT abd/pelvis with contrast read pending - Patient was given: 1L NS, 4mg ondansetron, 40mEq KCL IV started - Vitals prior to transfer: 162/64 78 18 98%RA Upon arrival to the floor, patient reports recounts the above. She has been feeling weak, spitting up white frothy phlegm, felt dizzy, and is afraid to fall. She has developed dyspnea with exertion up stairs. REVIEW OF SYSTEMS: (+) Per HPI (-) 10 point ROS reviewed and negative unless stated above in HPI Past Medical History: Hypertension, essential, benign Hypercholesterolemia DM (diabetes mellitus), type 2, uncontrolled s/p right fem/pop bypass graft ___ Seizure disorder Colonic adenoma Obesity Social History: ___ Family History: no FH of colon cancer or stomach cancer or liquid tumors Physical Exam: ADMISSION PHYSICAL EXAM ======================= Vital Signs: 98.2 164/74 87 18 95%RA General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL. Neck: Supple. JVP not elevated. no LAD CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs, gallops. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, mild epigastric tenderness, mildly distended, bowel sounds present, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNIII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, gait deferred. DISCHARGE PHYSICAL EXAM ======================= Vital Signs: 98.6, 115-125/60s, 80s, 16, 96% RA General: Uncomfortable, a&ox3 HEENT: Sclerae anicteric, MMM, EOMI, NJT in right nares, bridled. Neck: Supple. JVP not elevated. no LAD CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs, gallops. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, distended mild epigastric tenderness, no rebound or guarding Ext: Warm, well perfused, 2+ pulses, no clubbing, bilateral venous stasis changes Neuro: Grossly normal. Pertinent Results: ADMISSION LABS ============== ___ 04:38PM BLOOD WBC-6.4 RBC-4.60 Hgb-12.8 Hct-39.1 MCV-85 MCH-27.8 MCHC-32.7 RDW-14.9 RDWSD-46.4* Plt ___ ___ 04:38PM BLOOD Neuts-63.8 Lymphs-16.5* Monos-19.5* Eos-0.0* Baso-0.0 Im ___ AbsNeut-4.10 AbsLymp-1.06* AbsMono-1.25* AbsEos-0.00* AbsBaso-0.00* ___ 04:38PM BLOOD Glucose-140* UreaN-7 Creat-0.6 Na-146* K-2.9* Cl-103 HCO3-28 AnGap-18 ___ 04:38PM BLOOD ALT-9 AST-13 LD(LDH)-239 AlkPhos-63 TotBili-0.4 ___ 04:38PM BLOOD Lipase-12 ___ 04:38PM BLOOD cTropnT-<0.01 ___ 04:38PM BLOOD Albumin-3.5 Calcium-8.8 UricAcd-4.1 PERTINENT LABS ============== ___ 06:40AM BLOOD CEA-25.6* CA125-417* ___ 07:40AM BLOOD PEP-TWO TRACE IgG-961 IgA-259 IgM-50 IFE-TRACE MONO ___ 13:47 BLOOD CA ___ ___ IMAGING ======= CT ABDOMEN & PELVIS WITH CONTRAST ___: IMPRESSION: 1. Retroperitoneal soft tissue lesion detailed above with scattered areas of omental nodularity and small volume ascites. Findings concerning for peritoneal carcinomatosis, possibly in the setting of a GI primary malignancy, please correlate with recent endoscopy results. 2. Probable cystitis with ureteritis. Correlate with UA. 3. Hyperemic thickened stomach, may represent gastritis, possibly related to recent endoscopy. 4. Small pleural effusions, left greater than right lower lobe compressive atelectasis. CT CHEST WITH CONTRAST ___: IMPRESSION: 1. No worrisome pulmonary nodules. 2. Multifocal lucencies within several ribs, of uncertain significance, but might be seen in setting of myeloma. 3. Right sided irregular breast nodule as described. Correlate with prior breast imaging or consider dedicated imaging if clinically indicated and recent breast imaging has not been performed. 4. Left adrenal/retroperitoneal nodularity/soft tissue thickening as described on the CT of the abdomen pelvis from 2 days ago. MR HEAD W/ AND W/O CONTRAST ___: IMPRESSION: 1. No evidence of enhancing mass or abnormal enhancement to suggest metastatic disease. 2. No evidence of infarction, hemorrhage or edema. 3. Mild diffuse parenchymal volume loss. RLE LENIS ___: IMPRESSION: No evidence of deep venous thrombosis in the right lower extremity veins. Limited evaluation the right posterior tibial and peroneal veins. BONE SCAN ___: FINDINGS: The images show no abnormal radiotracer uptake in the axial or appendicular skeleton. The kidneys and urinary bladder are visualized, the normal route of tracer excretion. IMPRESSION: No evidence of osseous metastases. RIGHT BREAST US ___: IMPRESSION: Right breast mass is suspicious. Ultrasound-guided core biopsy is recommended. RECOMMENDATION: Ultrasound-guided core biopsy of right breast mass. NOTIFICATION: Findings and recommendations were communicated to the patient at the time of imaging. Ultrasound-guided core biopsy already was planned for immediately following imaging per prior discussion with referring clinicians. BI-RADS: 4B Suspicious - moderate suspicion for malignancy. CHEST CT WITHOUT CONTRAST ___ Metallic marker in the right chest wall appears to be in relation to the inferior aspect of the previously noted right inferolateral breast nodule Bilateral pleural effusion, slightly increased PORT PLACEMENT ___ Successful placement of a double lumen chest power Port-a-cath via the left internal jugular venous approach. The tip of the catheter terminates in the right atrium. The catheter is ready for use. PERTINENT STUDIES ================= BREAST CORE BIOPSY ___: PATHOLOGIC DIAGNOSIS: Right breast, core needle biopsy: - Dense fibrous stroma. See note. Note: Breast parenchyma is not identified in this limited sample. MNF116 and p63 immunostains support the diagnosis as above. EGD ___: Impression: -Normal mucosa in the whole esophagus -Erythematous, nodular and friable mucosa was noted in the whole stomach. -The gastric folds were thickened and the walls failed to distend on insufflation. These endoscopic findings are suggestive of malignant infiltration of the stomach in the form of Linitis Plastica. Cold forceps biopsies were performed for histology. -No tight strictures amenable to stent placement were found. -Normal mucosa in the whole duodenum -A NJT was successfully placed under endoscopic and fluoroscopic guidance. DISCHARGE LABS ============== ___ 06:10AM BLOOD WBC-3.9* RBC-3.17* Hgb-8.7* Hct-27.4* MCV-86 MCH-27.4 MCHC-31.8* RDW-15.9* RDWSD-50.3* Plt ___ ___ 05:44AM BLOOD Neuts-71.7* Lymphs-9.8* Monos-17.0* Eos-0.6* Baso-0.1 Im ___ AbsNeut-7.72* AbsLymp-1.06* AbsMono-1.83* AbsEos-0.07 AbsBaso-0.01 ___ 06:10AM BLOOD Plt ___ ___ 06:10AM BLOOD Glucose-235* UreaN-22* Creat-0.7 Na-135 K-4.0 Cl-102 HCO3-23 AnGap-14 ___ 06:10AM BLOOD Calcium-7.8* Phos-2.9 Mg-2.0 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetFORMIN (Glucophage) 1000 mg PO BID 2. 70/30 23 Units Breakfast 70/30 23 Units Dinner 3. Benzonatate 100 mg PO TID 4. Ondansetron 4 mg PO Q8H:PRN nausea 5. LamoTRIgine 100 mg PO DAILY 6. Losartan Potassium 50 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Clopidogrel 75 mg PO DAILY 9. Metoprolol Tartrate 25 mg PO DAILY 10. Pravastatin 20 mg PO QPM 11. Pantoprazole 40 mg PO Q24H 12. Metoclopramide 5 mg PO QIDACHS Discharge Medications: 1. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea 2. Glycopyrrolate 1 mg PO BID 3. LOPERamide 2 mg PO QID:PRN diarrhea 4. LORazepam 1 mg PO Q8H:PRN nausea RX *lorazepam 1 mg 1 tab by mouth every eight (8) hours Disp #*21 Tablet Refills:*0 5. Ondansetron ODT 8 mg PO Q8H:PRN nausea 6. Prochlorperazine 25 mg PR Q12H:PRN nausea 7. Glargine 20 Units Bedtime<br> 70/30 56 Units Q24H Insulin SC Sliding Scale using HUM Insulin 8. Clopidogrel 75 mg PO DAILY 9. LamoTRIgine 100 mg PO DAILY 10. Losartan Potassium 50 mg PO DAILY 11. Pantoprazole 40 mg PO Q24H 12. Pravastatin 20 mg PO QPM Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: - Gastric adenocarcinoma - Diarrhea - Nausea - Diabetes mellitus type 2 - Hypertension - Seizure disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (AP AND LAT) INDICATION: ___ with HTN, HL, diabetes who presents with nausea spitting up phlegm x 7 weeks// Rule-out PNA COMPARISON: ___ FINDINGS: AP upright and lateral views of the chest provided. Patient is slightly rotated to the left. Lung volumes are low. There is mild bibasilar atelectasis. No large effusion or pneumothorax. The heart appears mildly enlarged. Mediastinal contour is normal. Bony structures are intact. AC joint arthropathy noted bilaterally. No free air below the right hemidiaphragm. IMPRESSION: As above. Radiology Report EXAMINATION: CT abdomen pelvis INDICATION: ___ with HTN, hyperlipidemia who presents with nausea and vomiting x 7 weeks, endoscopy yesterday TECHNIQUE: Multidetector CT through the abdomen pelvis performed following administration of IV contrast. No oral contrast administered. Multiplanar reformations provided. DOSE: Total DLP (Body) = 821 mGy-cm. COMPARISON: Prior exam from ___. FINDINGS: LOWER CHEST: There is trace right and small left pleural effusion with compressive atelectasis left greater than right. Heart is normal in size and shape. Mild aortic valvular calcifications noted. ABDOMEN: The liver enhances normally without focal concerning lesion. There is small volume perihepatic ascites. No biliary ductal dilation. The main portal vein and central branches appear patent. The gallbladder is decompressed and appears normal. The pancreas enhances normally. No signs of pancreatitis or ductal dilation. Spleen is normal in size. Right adrenal gland appears normal. Kidneys enhance symmetrically and demonstrate prompt excretion of contrast. No hydronephrosis or signs of pyelonephritis. There is mild thickening of the mid and distal ureters which could reflect an ascending infection. Please correlate clinically. The stomach appears diffusely thickened and hyperemic. Abnormal retroperitoneal soft tissue density is seen inferior to and abutting the GE junction, series 601b 33 with loss of fat plane with the adjacent stomach. This soft tissue lesion measures approximately 4.7 x 5.0 x 1.9 cm and is concerning for malignancy. Differential considerations include lymphoma or metastatic disease in the setting of a GI tract malignancy. Soft tissue density extends along the proximal abdominal aorta and appears to encase the left renal artery. This soft tissue lesion is inseparable from the left adrenal gland which is not definitively visualized. Irregular soft tissue density is noted in the left upper abdomen adjacent to the greater curvature of the stomach on series 2, image 22 concerning for omental tumor implant. Additional sites of omental nodularity can be seen in the upper abdomen on series 2, image 27 and on series 2 image 29. A lymph node is noted on series 2, image 49 along the lower retroperitoneal chain measuring 8 mm in short axis. There is a small volume of ascites. The duodenum appears unremarkable. Small bowel loops demonstrate no signs of ileus or obstruction. The appendix is not visualized though no secondary signs of appendicitis seen. The colon is mostly decompressed and contains only a mild fecal load. No free air seen. PELVIS: The urinary bladder is decompressed though the wall appears somewhat hyperemic and thickened, correlate for cystitis. Uterus is surgically absent. No adnexal mass is seen. No pelvic sidewall or inguinal adenopathy. Small volume free fluid tracks into the pelvis. 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. Retroperitoneal soft tissue lesion detailed above with scattered areas of omental nodularity and small volume ascites. Findings concerning for peritoneal carcinomatosis, possibly in the setting of a GI primary malignancy, please correlate with recent endoscopy results. 2. Probable cystitis with ureteritis. Correlate with UA. 3. Hyperemic thickened stomach, may represent gastritis, possibly related to recent endoscopy. 4. Small pleural effusions, left greater than right lower lobe compressive atelectasis. RECOMMENDATION(S): Please correlate with results of endoscopy from outside hospital performed yesterday. Urinalysis to assess for infection. NOTIFICATION: Findings were discussed with Dr ___. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD INDICATION: ___ patient with soft tissue mass in the abdomen, concerning for gastric cancer. Evaluate for metastasis. TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of 8 mL of Gadavist intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: MRI head ___ FINDINGS: There is no evidence of enhancing mass or abnormal enhancement to suggest metastasis. There is no infarction, haemorrhage, or edema. There is mild diffuse parenchymal volume loss. There is mild mucosal thickening of bilateral ethmoid air cells with partial opacification of bilateral mastoid air cells. Patient is status post bilateral lens replacement. The dural venous sinuses appear patent. IMPRESSION: 1. No evidence of enhancing mass or abnormal enhancement to suggest metastatic disease. 2. No evidence of infarction, hemorrhage or edema. 3. Mild diffuse parenchymal volume loss. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ year old woman with progressive nausea/vomiting x6 weeks found to have retroperitoneal mass and potential gastric cancer// Please evaluate for any evidence of metastasis, lymphadenopathy, staging TECHNIQUE: CT of the chest was performed after administration of IV contrast. Omnipaque 350 was given for this examination. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.2 s, 32.8 cm; CTDIvol = 14.6 mGy (Body) DLP = 477.7 mGy-cm. Total DLP (Body) = 478 mGy-cm. COMPARISON: No comparison study. FINDINGS: Visualized aspect of the thyroid gland is homogeneous. There is no axillary, mediastinal, or hilar lymphadenopathy by size criteria. There is a common origin of the innominate artery and the left common carotid ( "bovine arch", normal variant). Heart and pericardium are grossly unremarkable. Small bilateral pleural effusions are seen. Mild associated bibasilar atelectasis is seen at both bases. There is no concerning pulmonary nodule or mass. Coarse calcifications seen at the anterior aspect of the left costophrenic angle in the inferior aspect of the lingula (series 601, image 51) likely related to prior infection, or possibly aspiration of prior oral barium administration. Incidental note made of a lipoma within the level left subscapularis muscle. Limited visualized of the upper abdomen demonstrates a small amount of ascites fluid. Partially visualized is a left adrenal or retroperitoneal nodularity/thickening which measures up to 15 x 22 mm (series 2, image 46). Small retroperitoneal lymph nodes are also notable. Irregularly marginated and probably enhancing right lower lateral deep breast nodule (series 2, image 31) noted, measuring 14 x 17 mm. Tiny focal regions of cortical lucencies are seen in the left second, third, and fourth ribs (series 4, images 108, 61, 51). These are nonspecific, but processes such as myeloma or metastases are in imaging consideration; consider bone scan for further assessment IMPRESSION: 1. No worrisome pulmonary nodules. 2. Multifocal lucencies within several ribs, of uncertain significance, but might be seen in setting of myeloma. 3. Right sided irregular breast nodule as described. Correlate with prior breast imaging or consider dedicated imaging if clinically indicated and recent breast imaging has not been performed. 4. Left adrenal/retroperitoneal nodularity/soft tissue thickening as described on the CT of the abdomen pelvis from 2 days ago. RECOMMENDATION(S): Dedicated breast imaging and bone scan as clinically indicated. Radiology Report EXAMINATION: UNILAT LOWER EXT VEINS RIGHT INDICATION: ___ year old woman with likely gastric cancer and asymmetric lower extremity edema R>L. Assess for deep venous thrombosis. TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the right lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, flow, and augmentation of the right common femoral, femoral, and popliteal veins. Limited evaluation of the right posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. IMPRESSION: No evidence of deep venous thrombosis in the right lower extremity veins. Limited evaluation the right posterior tibial and peroneal veins. Radiology Report EXAMINATION: RIGHT BREAST ULTRASOUND INDICATION: ___ woman with suspicious mass on chest CT ___ for further diagnostic evaluation. Recent gastrointestinal mucosal biopsy due to concern for stomach malignancy. COMPARISON: Chest CT ___, mammogram ___ and ___ TECHNIQUE: Targeted right breast ultrasound was performed. FINDINGS: Targeted ultrasound of the right breast was performed in the location of right breast mass seen on recent CT in the lower outer right breast. At the 8 o'clock position of the right breast 15 cm from the nipple, there is a hypoechoic mass with irregular margins measuring at least 10 x 7 x 4 mm. There is no additional suspicious solid or cystic mass. IMPRESSION: Right breast mass is suspicious. Ultrasound-guided core biopsy is recommended. RECOMMENDATION: Ultrasound-guided core biopsy of right breast mass. NOTIFICATION: Findings and recommendations were communicated to the patient at the time of imaging. Ultrasound-guided core biopsy already was planned for immediately following imaging per prior discussion with referring clinicians. BI-RADS: 4B Suspicious - moderate suspicion for malignancy. Radiology Report EXAMINATION: RIGHT BREAST ULTRASOUND GUIDED CORE BIOPSY WITH CLIP PLACEMENT INDICATION: ___ woman for ultrasound-guided core biopsy of suspicious right breast mass. COMPARISON: The relevant current/recent imaging was available for this procedure. FINDINGS: At the 8 o'clock position of the right breast 15 cm from the nipple, there is hypoechoic mass measuring at least 7 mm in greatest diameter, as seen on diagnostic ultrasound performed immediately prior to the time of the biopsy. This was targeted for ultrasound-guided core biopsy. PROCEDURE: The procedure, risks, benefits and alternatives were discussed with the patient and written informed consent was obtained. Time-out certification: Performed using three patient identifiers. Allergies and/or Medications: Reviewed prior to the procedure. Clinicians: ___, MD. Description: Using ultrasound guidance, aseptic technique and 1% lidocaine for local anesthesia, a 13-gauge coaxial needle was placed adjacent to the lesion and using a 14-gauge Bard spring-loaded biopsy device, 5 cores were obtained. Next, a percutaneous HydroMark coil was deployed under ultrasound guidance. The needle was removed and hemostasis was achieved. Estimated blood loss: < 1 cc. Specimens: Sent to pathology. Anesthesia: ___ cc 1% lidocaine Complications: No immediate complications. Post procedure diagnosis: Same. Postprocedure mammogram was deferred due to health status as inpatient. IMPRESSION: Technically successful US-guided core biopsy of the right breast lesion. Pathology is pending. The patient expects to hear the pathology results from her referring provider ___ ___ business days. Standard post care instructions were provided to the patient. Radiology Report EXAMINATION: CT CHEST W/O CONTRAST INDICATION: ___ year old woman with prior identified right breast nodule s/p US guided biopsy with benign findings// Please perform limited CT of the chest and see if the biopsy marking clip corresponds prior breast nodule found on CT TECHNIQUE: MDCT of the chest was obtained from thoracic inlet to upper abdomen. Axial images were reviewed in conjunction with coronal and sagittal reformats COMPARISON: ___ FINDINGS: The metallic marker appears to be in relation to the inferior aspect of the previously noted right inferolateral breast nodule (5, 150). Aorta and pulmonary arteries are normal in diameter. Multiple small mediastinal lymph nodes are not pathologic heart size is normal. There is no pericardial effusions there is bilateral moderate pleural effusion that appears to be minimally increased since the prior study on the right and unchanged on the left. Bibasal atelectasis related to the presence of pleural effusion is unchanged NG tube tip is in the stomach Lingular calcification is unchanged. No additional nodules masses or consolidations demonstrated. There are no lytic or sclerotic lesions worrisome for infection or neoplasm. IMPRESSION: Metallic marker in the right chest wall appears to be in relation to the inferior aspect of the previously noted right inferolateral breast nodule Bilateral pleural effusion, slightly increased Radiology Report INDICATION: ___ year old woman with gastric cancer, plan to start chemotherapy with FOLFOX as inpatient requires port for access per this protocol// Please place double lumen left-side port. leave accessed to start inpatient chemo. Patient is on clopidogrel. Reviewed with ___. COMPARISON: Chest CT ___. TECHNIQUE: OPERATORS: Dr. ___ resident 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 75 mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service time of 31 minutes during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: None CONTRAST: None ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 0.6 min, 6 mGy PROCEDURE 1. Left internal jugular approach chest double lumen Port-a-cath placement PROCEDURE DETAILS: Following the explanation of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The upper chest was prepped and draped in the usual sterile fashion. Under continuous ultrasound guidance, the patent 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 subcutaneous pocket over the upper anterior chest wall. After instilling superficial and deeper local anesthesia using lidocaine mixed with epinephrine, a 2.5 cm transverse incision was made and a subcutaneous pocket was created by using blunt dissection. The double lumen port was then connected to the catheter. The catheter was tunneled from the subcutaneous pocket towards the venotomy site from where it was brought out using a tunneling device. The port was then connected to the catheter and checks were made for any leakage by accessing the diaphragm using a non-coring ___ needle. No leaks were found. The port was then placed in the subcutaneous pocket and secured with ___ ethilon sutures on either side. The venotomy tract was dilated using the introducer of the peel-away sheath supplied. Following this, the peel-away sheath was placed over the ___ wire through which the port was threaded into the right side of the heart with the tip in the right atrium. The sheath was then peeled away. The subcutaneous pocket was closed in layers with ___ interrupted and ___ subcuticular continuous Vicryl sutures. Steri-strips were used to close the venotomy incision site. Steri-Strips were applied over the sutures. Final spot fluoroscopic image demonstrating good alignment of the catheter and no kinking. The tip is in the right atrium. The port was accessed using a non coring ___ needle and could be aspirated and flushed easily. Sterile dressings were applied. The patient tolerated the procedure well without immediate complication. The port was left accessed as requested. FINDINGS: Patent left internal jugular vein. Final fluoroscopic image showing port with catheter tip terminating in the right atrium. IMPRESSION: Successful placement of a double lumen chest power Port-a-cath via the left internal jugular venous approach. 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 gastric adenocarcinoma with excessive salivation and concern for aspiration complains of shortness of breath// to assess for aspiration pneumonia IMPRESSION: In comparison with the scout there is hazy opacification involving both lungs, more prominent on the right, consistent with layering pleural effusions and underlying compressive atelectasis. Cardiac silhouette is enlarged and there is mild engorgement of the pulmonary vessels consistent with elevated pulmonary venous pressure. Given these extensive changes, it would be impossible to exclude superimposed aspiration/pneumonia in the appropriate clinical setting, especially in the absence of a lateral view. Dobhoff tube extends at least to the lower body of the stomach were crosses the inferior margin of the image. Left IJ Port-A-Cath extends to the junction of the brachiocephalic vein and superior vena cava. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Abd pain, N/V Diagnosed with Unspecified abdominal pain temperature: 97.8 heartrate: 76.0 resprate: 18.0 o2sat: 100.0 sbp: 148.0 dbp: 89.0 level of pain: 5 level of acuity: 3.0

Ms. ___ is a ___ with epilepsy, hypertension, diabetes on insulin who presented with 7 weeks of poor PO intake found to have soft tissue abdominal mass on CT concerning for GI malignancy and then subsequently found to have intestinal type gastric adenocarcinoma on biopsy results from ___ EGD and ___ EGD with metastatic disease in retroperitoneum. Also s/p breast biopsy which was benign. NJT was placed and will likely be definitive nutrition source for now as she was unable to tolerate any POs due to linitis plastica of the stomach. She was given cycled tube feeds and insulin was adjusted accordingly. When path results were finalized, she had a port placed and she was transferred to OMED for initiation of FOLFOX chemotherapy ACTIVE ISSUES: # Intestinal type gastric adenocarcinoma: Biopsy results from ___ EGD and ___ EGD with intestinal type gastric adenocarcinoma with metastatic disease to retroperitoneum. EGD also with linitis plastica. Staging scans were completed. Bone scan did not show evidence of osseous mets though CT had some scattered lucent lesions so SPEP and UPEP were performed to look for evidence of myeloma. Dr. ___ will be primary oncologist. Further staining will be performed to see if may be responsive to trastuzumab or pembrolizumab. She was started on FOLFOX (C1D1 ___, which she tolerated well. She will follow-up with Atrius Oncology on discharge # Nausea/vomiting/fatigue # Severe malnutrition: Likely due to malignant gastric infiltration. She was strict NPO due to probable obstruction at GE junction. She received cycled tube feeds via dobhoff with nepro (75ml/hr x 12 hrs/day). Two surgical attendings declined to place J-tube due to high risk of complications with her disease burden in the upper abdomen. ___ will be the definitive management for now unless chemo is able to improve her ability to swallow and tolerate PO or if it reduces her disease burden to the point that it becomes safe to place a J tube. Started Zofran, Ativan, and Compazine for symptomatic control of nausea. Started glycopyrrolate and scopolamine patch for symptomatic control of increased oral secretions. #Diarrhea: Began having increased liquid stool output. Cdiff was negative. Her diarrhea may be secondary to chemotherapy or her cancer. She was started on loperamide and lomotil for symptomatic control #Hypertension: Continued home losartan #Seizure d/o: Continued home lamotrigine #DM2: ___ consulted for assistance with management given tube feeds. See below in transitional issues for insulin regimen. #PAD: S/p right fem/pop bypass graft ___. On aspirin and Plavix at home but no clear indication for DAPT so aspirin was discontinued. Plavix held prior to port placement and it was restarted afterward. TRANSITIONAL ISSUES =================== # STOPPED Metoprolol tartrate as unclear indication # STARTED Tube feeds (listed below under "Discharge Diet") # STARTED Zofran, Ativan, and Compazine for nausea # STARTED glycopyrrolate for increased oral secretions. Can also try scopolamine patch if secretions worsen # Consider outpatient J-tube placement if she has good response to chemotherapy # Per ___ recs, her insulin regimen should be: -- 70/30 56U at time of initiation of tube feeds -- Lanus 20U at bedtime -- Humalog sliding scale: 6a 12n 6p 10p 150-200 3 1 3 3 ___ 12 ___ 15 # Per ___ recs, if patient is given dexamethasone with chemo, adjustments to insulin will need to be made as follows: - If dex given in the AM, increase dose of 70/30 by 5 units - If dex given in the ___, increase dose of 70/30 by 10 units and change corrective insulin scale to 150:3,200:6,250:9, etc. # CONTACT: Husband. alternate is ___, her son, ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Headache/head collision Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old male was playing rugby when he had a witnessed head to head collision with another player. Patient recalls catching a ball and then nothing until EMS workers were attending to him. According to witnesses, following his loss of conciousness, Mr. ___ had a generalized tonic clonic seizure lasting one to two minutes. EMS arrived and transported the patient to ___ with a GCS of 15. Patient denies any nausea, vomiting or visual changes. He does endorse a slight headache. Past Medical History: Pt reports 2 concussions, one during freshman year in high school and one during ___ year of college. Social History: ___ Family History: NC Physical Exam: O: T:97.4 BP:153/50 HR:70 R18 100RA O2Sats Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL EOMs Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Intact to light touch Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Exam on discharge: A&Ox3 PERRL, face symmetrical No drift MAE ___ Senstaion intact to light touch Pertinent Results: ___: Non contrast head CT IMPRESSION: Small right frontoparietal subdural hemorrhage at the vertex ___: Non contrast head CT IMPRESSION: Interval decrease and redistribution of right subdural hematoma along the cerebellar tentorium. No new areas of hemorrhage or infarction. Medications on Admission: MVI Discharge Medications: 1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN HA RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___ tablet(s) by mouth Q 6hrs Disp #*60 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID 3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain Please do not drive or operate mechanical machinery while taking this medication. RX *oxycodone 5 mg 1 tablet(s) by mouth Q 4hrs Disp #*40 Tablet Refills:*0 4. Senna 1 TAB PO HS 5. LeVETiracetam 500 mg PO BID Please take this medication util you are instructed to stop at your follow up appointment. RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Traumatic head injury with right frontal SDH. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: ___ man with frontoparietal subdural hematoma approximately 6 mm in width. Evaluate interval change in bleed. TECHNIQUE: Contiguous axial MDCT images of the brain were acquired without the administration of IV contrast. Reformatted coronal and sagittal and thin section bone algorithm reconstructed images were obtained. COMPARISON: Nonenhanced CT scan of the head from ___. FINDINGS: There has been interval decrease and re-distribution of the subdural hematoma along the cerebellar tentorium (601b:85). There is no evidence of mass effect or shift of midline structures. There are no new areas of hemorrhage or infarction. Basal cisterns appear patent, and there is preservation of gray-white matter differentiation. The bony structures are unremarkable, and the paranasal sinuses are well aerated. The mastoid air cells and middle ear cavities are clear. The globes unremarkable. IMPRESSION: Interval decrease and redistribution of right subdural hematoma . No new areas of hemorrhage or infarction. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: S/P RUGBY TACKLE Diagnosed with SUBDURAL HEM-BRIEF COMA, IN SPORTS WITH FALL, ACTIVITIES INVOLVING RUGBY temperature: 97.4 heartrate: 70.0 resprate: 18.0 o2sat: 100.0 sbp: 153.0 dbp: 50.0 level of pain: 3 level of acuity: 2.0

Mr. ___ was admitted to the neurosurgical floor on ___ after a head collision while playing Rugby with + LOC and a ___ min seizure. On presentation he was neurologically intact. He was kept over night for observations. On ___, he remained neurologically and hemodynamically stable. A repeat head CT was obtained and showed redistribution of his right frontalparietal SDH, along the cerebellar tentorium. Neurology was consulted for his episode of a tonic clonic seizure post collision. Neurology recommended to continue with Keppra bid until patient follows up with them at out patient clinic. Occupational therapy was consulted and cleared patient to be discharge home. The patient was discharged home in stable conditions.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: dyspnea Major Surgical or Invasive Procedure: EGD History of Present Illness: Mr. ___ is an ___ with recent history of pancreatic adenocarcinoma with known mesenteric and liver metastases, chronic right pleural effusion, recent mini laparotomy with loop transverse colostomy on ___ for colonic obstruction, and recent admission for constipation who presents with worsening shortness of breath. Patient notes acute worsening shortness of breath began yesterday. Patient living at extended care facility where became worse today and was unresponsive to nebs. Patient reports his shortness of breath is worse when eating food. Also, notes that he feels short of breath when laying flat. Reports shortness of breath at baseline that has not significantly improved with nebs recently. He also has a non-productive cough at baseline secondary to post-nasal drip that has not changed recently. Patient denies eating salty foods, including hot dogs, fries, and canned soup. Patient reports decreased appetite and poor PO intake. Notes loss of weight over past several weeks. In the ED, vs were: Temp 98.7 HR 120 BP 103/58 RR 28 O2sat 96% 6L. EKG showed sinus tach @ 115, no ischemic chgs, ? of alternans. Bedside ultrasound was done that showed no pericardial effusion. Exam significant for wheezing and difficulty speaking, patient DNI and placed on BiPAP and became more comfortable. CXR concering for RLL pneumonia. Labs notable for Hct 31, plts 480s, Na 130, lactate 1.8. VBG pH 7.40, pCO2 38, pO2 107. Given 125mg methylpred, cefepime, azithro, and duonebs x3. 2L NS and 2mg Mg IV. On transfer, vs were: Temp 97.4 HR 70 BP 169/69 RR ___ O2sat 98% on 40%. On arrival to the MICU, vs were: Temp 98.5 HR 117 BP 109/82 RR 22 O2 sat 88% RA. Review of systems: (+) Per HPI (-) Denies fever, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough. Denies chest pain, chest pressure, palpitations. Denies nausea, vomiting, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1. Asthma (remote hospitalization, otherwise controlled on inhalers) 2. GERD 3. Pernicious Anemia/B12 Deficiency 4. Depression 5. Osteoarthritis, s/p arthroscopic repair of left knee 6. Gout (2 lifetime episodes, not on meds chronically) 7. PMR 8. BPH 9. History of cardiac tamponade in the setting of pericarditis 10. Metastatic pancreatic cancer to liver and mesenteric 11. Surgical history - Appendectomy, L parotid mass excision, Tonsillectomy, Diverting loop transverse colostomy ___ - Dr. ___ Social History: ___ Family History: No family history of pancreatic cancer Physical Exam: ADMISSION PHYSICAL EXAM Vitals: Temp 98.5 HR 117 BP 109/82 RR 22 O2 sat 88% RA. General- Cachetic appearing man, alert, oriented, no acute distress HEENT- Sclera anicteric, dry mucous membranes, poor skin turgor, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- Bibasilar crackles, no wheezes, rales, ronchi CV- Sinus tachycardic, normal S1 + S2, no murmurs, rubs, gallops Abdomen- distended, no tenderness to palpation, bowel sounds present, no rebound tenderness or guarding, no organomegaly, stoma in LLQ pink/healthy appearing with +stool and +gas output GU- no foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal DISCHARGE PHYSICAL EXAM: Vitals: 98.2 100/58 102 18 94%RA GEN: Alert, oriented X3. Cachetic appearing, no acute signs of distress. HEENT: NCAT, Pupils equal and reactive, sclerae non-icteric, o/p clear, MMM. Neck: Supple, no JVD, no thyromegaly. Lymph nodes: No cervical, supraclavicular or axillary LAD. CV: RRR, good S1, S2, no murmurs, rubs or gallops. RESP: mild bibasilar rales ABD: distended abdomen, firm but not tense, + bowel sounds, colostomy pink/patent with moderate stool output. EXTR: No lower leg edema, no clubbing or cyanosis DERM: No active rash. Neuro: grossly intact PSYCH: Appropriate and calm. Pertinent Results: LABS ========================== ___ 11:30PM BLOOD WBC-9.7 RBC-3.51* Hgb-9.3* Hct-31.5* MCV-90 MCH-26.5* MCHC-29.6* RDW-15.6* Plt ___ ___ 06:40AM BLOOD WBC-10.2 RBC-3.02* Hgb-7.9* Hct-25.7* MCV-85 MCH-26.2* MCHC-30.7* RDW-16.2* Plt ___ ___ 07:25AM BLOOD WBC-11.4* RBC-3.11* Hgb-8.2* Hct-26.3* MCV-85 MCH-26.3* MCHC-31.1 RDW-16.2* Plt ___ ___ 06:30AM BLOOD WBC-8.3 RBC-3.11* Hgb-7.8* Hct-27.1* MCV-87 MCH-25.2* MCHC-29.0* RDW-16.3* Plt ___ ___ 07:20AM BLOOD WBC-7.5 RBC-3.08* Hgb-7.9* Hct-27.2* MCV-88 MCH-25.7* MCHC-29.1* RDW-16.1* Plt ___ ___ 07:00AM BLOOD WBC-7.1 RBC-3.07* Hgb-8.0* Hct-27.0* MCV-88 MCH-26.2* MCHC-29.8* RDW-16.5* Plt ___ ___ 11:30PM BLOOD Glucose-107* UreaN-16 Creat-1.2 Na-130* K-4.8 Cl-95* HCO3-20* AnGap-20 ___ 07:15AM BLOOD Glucose-116* UreaN-23* Creat-1.2 Na-135 K-4.3 Cl-99 HCO3-27 AnGap-13 ___ 07:15AM BLOOD Glucose-121* UreaN-21* Creat-1.0 Na-137 K-3.7 Cl-101 HCO3-27 AnGap-13 ___ 06:30AM BLOOD Glucose-129* UreaN-19 Creat-1.0 Na-138 K-4.2 Cl-102 HCO3-26 AnGap-14 ___ 06:40AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.2 ___ 07:25AM BLOOD Calcium-8.1* Phos-2.8 Mg-2.1 ___ 12:54AM BLOOD ___ pO2-107* pCO2-38 pH-7.40 calTCO2-24 Base XS-0 Intubat-NOT INTUBA ___ 11:30PM BLOOD Lactate-1.8 IMAGING/STUDIES ========================== ___ CXR Worsening right lower lobe opacity is highly concerning for pneumonia or aspiration. Chronic right pleural effusion. Patchy opacity in the left lower lobe has also increased. ___ CXR IMPRESSION: AP chest compared to ___: Heterogeneous opacification at the base of the right lung which worsened substantially after ___, has subsequently improved, still accompanied by a small pleural effusion. Time course is consistent with either resolving pneumonia or atelectasis. ___ CXR IMPRESSION: PA and lateral chest compared to ___ through ___: A tortuous but not particularly dilated esophagus retains contrast agent from the preceding swallowing examination. The distal esophagus has a sharp tapering, and could be occluded either by stricture or mass, better evaluated during fluoroscopic observation earlier. There is no pneumonia. A small right pleural effusion or pleural thickening has been present since at least middle of ___. Heart size is normal. Irregular opacification of the lungs suggests severe emphysema, on the right. video swallow exam ___ FINDINGS: This exam was performed in conjunction with the speech and swallow division. Multiple consistencies of barium were administered. There was no evidence of aspiration or penetration. The esophagus was examined, and there was holdup of barium at the distal esophagus with significant residual barium within the esophagus, which eventually passed into the stomach after a few minutes. After more barium was administered, hold up was again seen, which did not pass into the stomach after several minutes. There were multiple tertiary contractions. IMPRESSION: 1. No evidence of aspiration or penetration. For further details please refer to speech and swallow division note in OMR. 2. Hold up of barium within the distal esophagus, cannot rule out stricture or extrinsic compression of the distal esophagus. Endoscopy recommended. CTA Chest ___ FINDINGS: CT of the thorax: There are multifocal areas of consolidations involving the left upper and lower lobes. Additionally, there is a consolidation or partial lung collapse involving the right lower lobe. There is a stable nonhemorrhagic left pleural effusion. There are prominent bronchovascular bundles raising the concern for lymphatic involvement of the patient's primary malignancy. There is significant dilation of the distal esophagus, the stomach distally is collapsed. CTA thorax: There is atherosclerotic disease of the abdominal aorta. The aorta is normal in caliber throughout the thorax without intramural hematoma or dissection. The pulmonary arteries are opacified to the segmental level. There is no filling defect to suggest pulmonary embolism. Osseous structures:. There are no concerning lytic or sclerotic bony lesions. Although this study is not designed for assessment of the intra-abdominal structures, multiple liver lesions appear stable. IMPRESSION: 1. No evidence of pulmonary embolism. 2. Significant dilation of the distal esophagus and multifocal opacities involving the left upper and left lower lobe as well as a consolidation or partial collapse of the right lower lobe, finding suggest aspiration. 3. Stable nonhemorrhagic left pleural effusion. 4. Multiple hepatic metastases appear stable. 5. Prominence of the bronchovascular bundles within the lungs raise the question of lymphatic involvement of the patient's primary malignancy. EGD report: Impression: Esophagus was mildly dilated. Otherwise no evidence of mucosal abnormalities, lesions or extrinsic compression. GE junction was wide open and the scope traversed easily. Bluish discolouration and distortion along greater curvature of stomach - may represent varices and/or tumour. Normal mucosa in the duodenum Based on the wide patency of GE junction, there is no indication for esophageal stent insertion and/or Botox injection at the GE junction. There is likely a motility defect. MICROBIOLOGY ========================== ___ Blood and urine cultures negative Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO QHS 2. BuPROPion 200 mg PO DAILY 3. Cetirizine 10 mg oral daily 4. Doxazosin 8 mg PO HS 5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 6. Levothyroxine Sodium 100 mcg PO DAILY 7. Montelukast Sodium 10 mg PO DAILY 8. Omeprazole 20 mg PO DAILY 9. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain 10. Sertraline 200 mg PO QHS 11. Tiotropium Bromide 1 CAP IH DAILY 12. TraZODone 50 mg PO HS 13. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough 14. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN sob/wheezing 15. Polyethylene Glycol 17 g PO DAILY 16. Acetaminophen 1000 mg PO Q8H:PRN pain 17. Calcium Carbonate 500 mg PO QID:PRN heart burn 18. HydrOXYzine 25 mg PO QHS:PRN itching 19. Milk of Magnesia 30 mL PO Q 3 DAYS constipation 20. Ondansetron 4 mg PO Q8H:PRN nausea 21. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation q4h SOB Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN pain 2. Acetaminophen 1000 mg PO QHS 3. BuPROPion 200 mg PO DAILY 4. Calcium Carbonate 500 mg PO QID:PRN heart burn 5. Doxazosin 8 mg PO HS 6. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough 7. Levothyroxine Sodium 100 mcg PO DAILY 8. Milk of Magnesia 30 mL PO DAILY:PRN constipation 9. Montelukast Sodium 10 mg PO DAILY 10. Omeprazole 20 mg PO DAILY 11. Ondansetron 4 mg PO Q8H:PRN nausea 12. Polyethylene Glycol 17 g PO DAILY 13. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation q4h SOB 14. Sertraline 200 mg PO QHS 15. TraZODone 50 mg PO HS:PRN insomnia 16. Albuterol 0.083% Neb Soln 1 NEB IH Q4H 17. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN shortness of breath, wheezing 18. Docusate Sodium 200 mg PO BID 19. Ipratropium Bromide Neb 1 NEB IH Q6H 20. Lorazepam 0.25-0.5 mg PO Q4H:PRN anxiety 21. Morphine SR (MS ___ 15 mg PO Q12H 22. Morphine Sulfate (Oral Soln.) ___ mg PO Q4H:PRN pain 23. Senna 1 TAB PO BID:PRN constipation 24. Simethicone 40-80 mg PO QID:PRN gas or bloating 25. Cetirizine 10 mg oral daily 26. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 27. HydrOXYzine 25 mg PO QHS:PRN itching 28. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN sob/wheezing 29. Tiotropium Bromide 1 CAP IH DAILY Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: aspiration pneumonia metastatic pancreatic cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report PA AND LATERAL CHEST, ___ HISTORY: An ___ man with pancreatic adenocarcinoma after respiratory failure. IMPRESSION: AP chest compared to ___: Heterogeneous opacification at the base of the right lung which worsened substantially after ___, has subsequently improved, still accompanied by a small pleural effusion. Time course is consistent with either resolving pneumonia or atelectasis. Left lung is grossly clear. Heart size normal. Small bilateral pleural effusions, right greater than left, are collected posteriorly, and on the right along the lateral chest wall. Radiology Report INDICATION: Possible aspiration pneumonia. COMPARISON: None available. FINDINGS: This exam was performed in conjunction with the speech and swallow division. Multiple consistencies of barium were administered. There was no evidence of aspiration or penetration. The esophagus was examined, and there was holdup of barium at the distal esophagus with significant residual barium within the esophagus, which eventually passed into the stomach after a few minutes. After more barium was administered, hold up was again seen, which did not pass into the stomach after several minutes. There were multiple tertiary contractions. IMPRESSION: 1. No evidence of aspiration or penetration. For further details please refer to speech and swallow division note in OMR. 2. Hold up of barium within the distal esophagus, cannot rule out stricture or extrinsic compression of the distal esophagus. Endoscopy recommended. Radiology Report PA AND LATERAL CHEST, ___ HISTORY: An ___ man with aspiration pneumonia and metastatic pancreatic carcinoma. Followup. IMPRESSION: PA and lateral chest compared to ___ through ___: A tortuous but not particularly dilated esophagus retains contrast agent from the preceding swallowing examination. The distal esophagus has a sharp tapering, and could be occluded either by stricture or mass, better evaluated during fluoroscopic observation earlier. There is no pneumonia. A small right pleural effusion or pleural thickening has been present since at least middle of ___. Heart size is normal. Irregular opacification of the lungs suggests severe emphysema, on the right. Radiology Report HISTORY: ___ with persistent dyspnea on exertion and metastatic pancreatic cancer, evaluate for PE. COMPARISON: CT abdomen and pelvis ___, CTA chest ___. TECHNIQUE: Axial helical MDCT images were obtained from the suprasternal notch to the upper abdomen in the early arterial phase after administration of 150 cc of Omnipaque. . Multiplanar reformatted images in the coronal and sagittal planes were generated. Oblique MIP's were prepared in an independent work station. FINDINGS: CT of the thorax: There are multifocal areas of consolidations involving the left upper and lower lobes. Additionally, there is a consolidation or partial lung collapse involving the right lower lobe. There is a stable nonhemorrhagic left pleural effusion. There are prominent bronchovascular bundles raising the concern for lymphatic involvement of the patient's primary malignancy. There is significant dilation of the distal esophagus, the stomach distally is collapsed. CTA thorax: There is atherosclerotic disease of the abdominal aorta. The aorta is normal in caliber throughout the thorax without intramural hematoma or dissection. The pulmonary arteries are opacified to the segmental level. There is no filling defect to suggest pulmonary embolism. Osseous structures:. There are no concerning lytic or sclerotic bony lesions. Although this study is not designed for assessment of the intra-abdominal structures, multiple liver lesions appear stable. IMPRESSION: 1. No evidence of pulmonary embolism. 2. Significant dilation of the distal esophagus and multifocal opacities involving the left upper and left lower lobe as well as a consolidation or partial collapse of the right lower lobe, finding suggest aspiration. 3. Stable nonhemorrhagic left pleural effusion. 4. Multiple hepatic metastases appear stable. 5. Prominence of the bronchovascular bundles within the lungs raise the question of lymphatic involvement of the patient's primary malignancy. Finding were telephoned to Dr. ___ by Dr. ___ on ___ at 11:30, 10 min after there discovery. Radiology Report HISTORY: Metastatic pancreatic cancer, now with increasing distention and low ostomy output. Evaluate for bowel obstruction. COMPARISON: CT abdomen/pelvis from ___ and portable abdominal radiograph from ___. FINDINGS: Three frontal abdominal radiographs again demonstrate severely dilated air-filled loops of large bowel, measuring up to 8 cm, with a paucity of small bowel loops. The colonic dilation is less extensive, primarily in the right colon, compared to ___. There is residual radiopaque oral contrast within the loops of large bowel. No pneumatosis or free air is visualized. Generalized increased opacity of the abdomen may be secondary to ascites. IMPRESSION: 1. Dilated loops of large bowel, less extensive compared to ___. 2. Ascites. Gender: M Race: WHITE Arrive by UNKNOWN Chief complaint: DYSPNEA Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION temperature: 98.7 heartrate: 120.0 resprate: 28.0 o2sat: 96.0 sbp: 103.0 dbp: 58.0 level of pain: 4 level of acuity: 2.0

Mr. ___ is an ___ with PMHx metastatic pancreatic adenocarcinoma and reactive airway disease who presented with subacute worsening dyspnea. CXR and clinical status was consistent with pneumonia. # Respiratory Distress History of worsening dyspnea over several weeks with acute worsening over last few days. Story is most consistent with pneumonia and bronchospasm. Not overloaded and normal BNP so does not appear to be CHF. PE a possibility given current malignancy but does not fit with his history. Treated for CAP/HCAP with vancomycin, levofloxacin, and cefepime. After 5 days of IV antibiotics, CXR showed improvement and his O2 saturations had improved so he was switched to PO cipro for another 6 days. Continued on bronchodilators throughout. Sputum cultures were contaminated with respiratory flora. Blood cultures were negative. Given his history of asthma he was given a 5 day course of prednisone. Based on the fact his pneumonia seemed to be improving yet he continued to have symptoms, he had CTA ___ which showed no PE but did show signs of aspiration as well as concern for lymphangitic spread of cancer. Both of these are likely contributing to his symptoms. In addition his abdominal ascites, which has not been sampled but is presumably due to his metastatic pancreatic cancer, may be causing restriction of his breathing as well. He has obstructive sleep apnea and was continued on CPAP nightly for this. # Esophageal dysmotility: pt had EGD ___ to evaluate possibility of stricture/obstruction/achalasia seen on video swallow eval. LES was patent with no indication for stenting. stomach may have tumor infiltration. he likely has esophageal dysmotility leading to chronic aspiration. He can have a regular diet but should take aspiration precautions such as sitting up when eating, taking small bites and allowing plenty of time for them to pass through his esophagus and stomach. # Metastatic Pancreatic Adenocarcinoma recently diagnosed, no treatment yet. Dr. ___ I have discussed treatment with him several times during this admission. He is not interested in getting chemotherapy that is only expected to add a few months to his life (chemo would not be curative). He will be treated supportively for symptoms that may arise from his cancer. He currently has ascites which is more than on admission. we discussed a paracentesis for comfort, but the ascites is not currently causing him much discomfort so he deferred. He was seen in consultation by the palliative care team with adjustments to his pain meds (now on MSContin 15 BID and morphine ___ for breakthrough pain). He is aware that he will continue to decline as his cancer progresses but did not feel ready to make plans for hospice yet. He would like to focus on regaining strength and returning home to get his affairs in order. # Constipation Patient was recently admitted for constipation. ON this admission he had days of low ostomy output followed by several large stools. He is on senna and colace daily with several other laxatives PRN. # Depression - continued sertraline and buproprion # Hypothyroidism - continued home levothyroxine # Dispo: [x] Discharge documentation reviewed, pt is stable for discharge. [x] Time spent on discharge activity was greater than 30min. [ ] Time spent on discharge activity was less than 30min. ____________________________________ ___, MD, pager ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: wound drainage Major Surgical or Invasive Procedure: N/A History of Present Illness: ___ male presents after L4-L5 lumbar fusion and laminectomy with spinal wound drainage. The patient had an uncomplicated surgery and post-operative course. At one week follow up he was noted to have wound drainage. A wound vac was placed. Today he presents to the ED because his Praveena wound back has reached capacity. He denies lower extremity numbness, weakness, saddle anesthesia, loss of bowel/bladder control, fevers, headache, chest pain, shortness of breath, nausea, and other medical complaints. Past Medical History: none Social History: SH: Patient lives in ___. Denies tobacco and ilicit drug use. Physical Exam: NAE overnight. Afebrile. VSS. Inflammatory indices mildly elevated c/w perioperative period. Wound vac output zero Main complaint is some spasm like pain in his left buttock No headaches PE: 98.3 PO 126 / 73 66 16 97 Ra NAD, A&Ox4 nl resp effort RRR wound vac with good seal, no drainage, sponge dry Sensory: ___ L2 L3 L4 L5 S1 S2 (Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh) R SILT SILT SILT SILT SILT SILT L SILT SILT SILT SILT SILT SILT Motor: ___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___ R 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 Pertinent Results: ___ 01:19PM BLOOD WBC-10.1* RBC-3.36* Hgb-11.0* Hct-33.0* MCV-98 MCH-32.7* MCHC-33.3 RDW-13.4 RDWSD-47.8* Plt ___ ___ 01:19PM BLOOD Neuts-70.0 Lymphs-18.2* Monos-7.0 Eos-2.3 Baso-0.7 Im ___ AbsNeut-7.04* AbsLymp-1.83 AbsMono-0.70 AbsEos-0.23 AbsBaso-0.07 ___ 01:19PM BLOOD Plt ___ ___ 01:19PM BLOOD ___ PTT-30.6 ___ ___ 01:19PM BLOOD Glucose-111* UreaN-14 Creat-0.6 Na-142 K-5.1 Cl-103 HCO3-26 AnGap-13 ___ 01:19PM BLOOD CRP-7.4* ___ 01:27PM BLOOD ___ pO2-82* pCO2-43 pH-7.44 calTCO2-30 Base XS-4 Medications on Admission: Medications - Prescription CEPHALEXIN - cephalexin 500 mg capsule. 1 capsule(s) by mouth four times a day CYCLOBENZAPRINE - cyclobenzaprine 5 mg tablet. 1 tablet(s) by mouth every eight (8) hours as needed for muscle spasm this medicine may cause drowsiness GABAPENTIN - gabapentin 300 mg capsule. 1 capsule(s) by mouth three times a day OXYCODONE - oxycodone 5 mg tablet. 1 tablet(s) by mouth every ___ hours as needed for pain Do not drive or operate heavy machinery while taking this medication Medications - OTC ASPIRIN [ASPIR-81] - Aspir-81 81 mg tablet,delayed release. 1 (One) tablet(s) by mouth once a day - (Prescribed by Other Provider; Dose adjustment - no new Rx) IBUPROFEN [ADVIL] - Advil 200 mg tablet. 2 (Two) tablet(s) by mouth every six (6) hours as needed for pain (will stop 1 week preop) - (Prescribed by Other Provider; Dose adjustment - no new Rx) Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild may take over the counter 2. Cyclobenzaprine 5 mg PO TID may cause drowsiness 3. Docusate Sodium 100 mg PO BID please take while taking narcotics RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0 4. Methylprednisolone Dose Pack mg PO DAILY Take as Directed This is dose # of tapered doses RX *methylprednisolone [Medrol (Pak)] 4 mg Dose Pack tablets(s) by mouth Daily Disp #*1 Dose Pack Refills:*0 5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Severe please do not operate heavy machinery, drink alcohol or drive RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*50 Tablet Refills:*0 6. Cephalexin 500 mg PO Q6H 7. Gabapentin 300 mg PO TID nerve pain Discharge Disposition: Home Discharge Diagnosis: post operative seroma. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: MRI THORACIC AND LUMBAR PT6 MR SPINE INDICATION: History: ___ with recent TLIF of L4-L5 and increased wound drainage. Question of infection. 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 7 mL of Gadavist contrast agent, additional axial and sagittal T1 images were obtained. COMPARISON: Lumbar spine MRI without contrast from ___. Lumbar spine radiographs from ___. FINDINGS: Localizer sequence demonstrates 7 cervical, 12 thoracic, and 5 lumbar-type vertebrae. The localizer sequence and sagittal images through the thoracic spine demonstrate a disc herniation extending inferiorly, plus/minus endplate osteophytes, severely narrowing the spinal canal at C6-C7. No axial images through this level. The localizer sequence also demonstrates endplate osteophytes moderately narrowing the spinal canal at C5-C6, without diagnostic sagittal or axial images through this level. THORACIC: No evidence for diskitis, osteomyelitis, epidural collection, or paravertebral collection. Mild anterior wedging of multiple mid thoracic vertebral bodies without marrow edema. No subluxation. No pathologic intrathecal contrast enhancement. The conus medullaris terminates at T12-L1. T1-T2: Small central disc protrusion mildly narrows the spinal canal. T2-T3: Disc bulge and right paracentral disc protrusion mildly narrowing the spinal canal. The right ventral spinal cord is mildly remodeled without cord signal abnormality. T3-T4: Right paracentral disc protrusion remodels the right ventral cord without cord signal abnormality. T4-T5: Small right paracentral disc protrusion approaches the ventral spinal cord without cord signal abnormality. T5-T6: Right far paracentral/foraminal disc protrusion minimally indents the ventral thecal sac and narrows the proximal right neural foramen. T6-T7: A disc bulge minimally indents the ventral thecal sac. T7-T8: Central disc herniation extends superiorly above the disc space to the right of midline, mildly remodeling the right ventral spinal cord. Evaluation of cord signal at this level is limited, and mild T2 hyperintensity cannot be excluded. T8-T9: Central disc herniation mildly indents the ventral thecal sac. T9-T10: Large central disc herniation remodels the ventral spinal cord with mild to moderate spinal canal narrowing. Subtle T2 hyperintensity in the cord cannot be excluded. T10-T11: Minimal disc bulge and mild facet arthropathy without significant spinal canal narrowing. Mild right neural foraminal narrowing. T11-T12, T12-L1: No significant spinal canal or neural foraminal narrowing. LUMBAR: The patient is status post anterior fusion of L4 and L5 with an intervertebral graft, as well as laminectomies and instrumented posterior fusion of L4 and L5 with bilateral pedicle screws. The hardware is not assessed by MRI. Grade 1 anterolisthesis of L4 on L5 is unchanged compared to the ___ radiographs and the ___ MRI. There is a fluid collection without evidence for rim enhancement extending from the laminectomy beds through a thin midline tract between the posterior paravertebral muscles into the subcutaneous soft tissues. It measures 5.4 cm craniocaudad on image 15:10, and 2.8 cm transverse on image 16:31. The collection has a large area of surface contact with the dorsal thecal sac. There is surrounding contrast enhancement in the posterior paravertebral muscles. The collection mildly to moderately narrows the thecal sac at the level of L5. Left-sided intrathecal nerve roots from mid L5 through S1 levels appear mildly clumped without definite contrast enhancement, compatible with arachnoiditis. L1-L2: Disc bulge and facet arthropathy mildly narrow the thecal sac without mass effect on the intrathecal nerve roots. Mild right and moderate left neural foraminal narrowing. This is similar to the prior MRI. L2-L3: Disc bulge, left paracentral disc herniation extending inferiorly, and facet arthropathy are present. Traversing left L3 nerve root is contacted in the subarticular zone. The thecal sac is mildly to moderately narrowed with mild crowding of the intrathecal nerve roots. Moderate bilateral neural foraminal narrowing. This is similar to the prior MRI. L3-L4: Mild disc bulge. Moderate facet arthropathy. No significant spinal canal narrowing. Moderate right neural foraminal narrowing. This is similar to the prior MRI. L4-L5: The disc is uncovered by the grade 1 anterolisthesis. Facet joints are obscured by hardware related artifacts. The above-described collection in the laminectomy beds mildly to moderately narrows the thecal sac. The neural foramina are not optimally assessed due to hardware related artifacts, but appear moderately to severely narrowed with mass effect on the exiting L4 nerve roots, similar to the presurgical MRI. L5-S1: Moderate facet arthropathy. Above-described fluid collection mildly narrows the thecal sac. No high-grade neural foraminal narrowing is seen allowing for hardware related artifacts. Multiple sacral nerve root sleeve diverticula are again noted. OTHER: Apparent 6 mm pulmonary lesion in the right lower lobe on image 12:11. Subcentimeter cystic lesion in the right kidney. IMPRESSION: 1. Fluid collection in the laminectomy beds at L4 and L5, extending into the subcutaneous soft tissues, demonstrates no rim enhancement to suggest superimposed infection, though infection cannot be definitively excluded by MRI. Seroma is most likely, but CSF leak cannot be excluded given the large area of contact with the dorsal thecal sac. Please correlate clinically. 2. The above described fluid collection mildly to moderately narrows the thecal sac from L4-L5 through L5-S1 levels. 3. Mild clumping of the left intrathecal nerve roots from mid L5 through S1 levels, without definite contrast enhancement, compatible with arachnoiditis. 4. L4-L5 neural foraminal narrowing, and degenerative changes at other lumbar levels, are similar to the ___ presurgical MRI. 5. No evidence for thoracic spine infection. 6. Multilevel degenerative changes in the thoracic spine with ventral spinal cord remodeling at multiple levels. Faint T2 hyperintensity in the spinal cord, compatible with subtle edema myelomalacia, cannot definitively be excluded at T7-T8 and T9-T10. 7. Incompletely evaluated apparent severe spinal canal narrowing in the lower cervical spine at C6-C7. 8. 6 mm pulmonary lesion in the right lower lobe. RECOMMENDATION(S): Chest CT. NOTIFICATION: Electronic wet reading to the emergency department was provided at the time of final dictation at 17:35 on ___. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Back pain, Wound eval Diagnosed with Postproc seroma of a ms structure fol a ms sys procedure, Oth surgical procedures cause abn react/compl, w/o misadvnt temperature: 87.7 heartrate: 76.0 resprate: 18.0 o2sat: 99.0 sbp: 115.0 dbp: 70.0 level of pain: 5 level of acuity: 3.0

___ is a ___ y/o male s/p L4-L5 tranforaminal lumbar interbody fusion and laminectomy on ___ with Dr. ___. He was admitted for observation of wound drainage, likely from a seroma. Incisional wound vac was placed overnight. He remains Afebrile, labs not c/w infection, no headaches. Wound vac was discontinued and a mepilex dressing was applied. He is cleared for discharge to home.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Haldol / Zyprexa Zydis / Benzodiazepines Attending: ___. Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: ___ with NASH cirrhosis, decompensated with encephalopathy and ascites, DM, HL, HTN, normal pressure hydrocephalus admitted for change in mental status. . The patient has recently experienced waxing and waning mental status found to be secondary to normal pressure hydrocephalus. This was initially treated with therapeutic lumbar puncture, but to avoid ongoing problems his Neurologist recently added acetazolamide to his regimen. This was started ___. The patient took two doses, ___ and ___. His wife stopped the medication after these two doses due to worsening mental status. The patient was confused, weak, and exhausted. He was unable to feed himself, although he was able to eat when fed by his family. His gait also worsened, with more shuffling and slowness. He was "confused" which his wife described as being unable to connect and seeming "lost" from the world. He was not incoherent, rambling, agitated, or hallucinating. He also slept ___ hours for 3 nights which is very unusual. On ___ he tried to get out of bed and was unable to get up or lie back down. These symptoms have occurred before in the setting of hepatic encephalopathy. . The patient presented to the ED on ___ for evaluation. CXR and non-contrast head CT were reassuring. Neurology saw him and concluded that this was likely worsening hepatic encephalopathy due to acetazolamide. . Per neurology evaluation ___: Neuro exam significant for inattention, severe, perseveration and both extrapyramidal and frontal components to his motor exam, with asterixis present. There is no evidence of acutely worsened Parkinsonism, and there have been no changes in his Sinemet in quite some time. His troubles correlated with starting Diamox. Diamox is relatively contraindicated in cirrhosis because it causes metabolic alkalosis, which exacerbates hepatic encephalopathy. While he only took 2 doses, and his bicarb is only 20, we suspect this is the explanation for his symptoms. He will likely improve with treatments for hepatic encephalopathy (increased lactulose/rifaximin), and should be followed closely by outpatient liver and neuro physicians to ensure he does improve. . The patient and his wife were offered admission but declined, hoping that stopping the medication would suffice. However, on returning home the patient became more confused. He also had a large watery bowel movement and was unable to control his bowels. They represented to the ED this morning. . In the ED, the patient stared into the distance, did not spontaneously speak, but when prompted was A&Ox3. No alteration of thought process. No asterixis on exam. . On the floor, the patient has no complaints of pain or discomfort. He is awake and alert, oriented x2 (hospital and self). He is not sure why is in the hospital. His wife, who is at the bedside, states that he has not moved his bowels since the large watery movement last night. She did not give his usual Senna. This is not unusual, as he usually has BMs in the afternoon/evening and has not had lactulose so far today. He has urinated several times without pain and has produced clear yellow urine. He has been continent of urine. She states he seems somewhat better, more alert, and was able to eat a full container of grapes without prompting. . A full ROS is otherwise negative. Past Medical History: NASH Cirrhosis decompensated with encephalopathy and ascites ___ disease Type II diabetes mellitus Familial mediterranean fever Depression Right sided colitis and ileitis in ___ Hyperlipidemia Microalbuminuria CAD: ___ two vessel disease, s/p cath & stent on RCA and LAD,EF 72% Right 11th rib fracture s/p mechanical fall (gait instability from ___ in ___ Basal cell carcimona s/p cataract surgery s/p appendectomy s/p tonsillectomy Social History: ___ Family History: Per OMR his mother died from complications of hypertension. His father died at the age of ___. He has a son with familial ___ fever. Physical Exam: Admission Physical Exam: VS: 97.9 168/80 51 20 100% RA FSBS 84 General: awake, alert, following conversation. He begins to respond to comments appropriately but loses his train of thought and trails off. He follows activity in the room. Grasps for things just outside his reach. HEENT: PERRL, EOMI not fully tested ___ patient cooperation but full on passive gaze, OP clear with lactulose residue on tongue and teeth, trace red blood on left upper teeth, no lesion evident. MMM. Neck: supple, no LAD CV: RRR, nl S1 S2, no MRG Resp: CTAB, no wheezes or rhonchi, bibasilar rales (slight) Abdomen: soft, non-tender, non-distended. + BS Extremities: warm, well-perfused, no cyanosis clubbing or edema. Neurological: strength ___ throughout. CN II-XII tested and intact, III IV and VI not fully tested ___ patient cooperation. sensation grossly normal. Gait not tested. UE minimal cogwheeling. Continued resting tremor of right foot and right hand. Psych: Oriented to self, "hospital", not date. Named pen correctly. Able to read items in the room and intepret them appropriately (TV listing, business card). Serial 7s attempted, he counted from 10 down to 0. Thought process linear, comments begin appropriately, then trails off. . Discharge Physical Exam: Psych: Oriented to self, name of hospital, month but not year. Attention improved, able to answer longer questions and have short discussion of several sentences Neuro exam unchanged Physical exam unchanged Pertinent Results: Admission Labs: ___ 05:00AM BLOOD WBC-6.0 RBC-3.88* Hgb-12.4* Hct-36.4* MCV-94 MCH-32.1* MCHC-34.2 RDW-14.0 Plt Ct-66* ___ 05:00AM BLOOD Neuts-67.2 ___ Monos-5.1 Eos-2.5 Baso-0.9 ___ 05:00AM BLOOD ___ PTT-30.2 ___ ___ 05:00AM BLOOD Glucose-86 UreaN-33* Creat-1.7* Na-137 K-4.5 Cl-105 HCO3-20* AnGap-17 ___ 05:00AM BLOOD ALT-25 AST-25 AlkPhos-77 TotBili-0.6 ___ 05:00AM BLOOD Lipase-27 ___ 05:00AM BLOOD Albumin-4.2 ___ 05:07AM BLOOD Ammonia-95* ___ 05:22AM BLOOD Lactate-1.4 Discharge Labs: ___ 12:20PM BLOOD WBC-5.8 RBC-3.66* Hgb-11.7* Hct-33.8* MCV-92 MCH-31.9 MCHC-34.5 RDW-14.1 Plt Ct-71* ___ 12:20PM BLOOD ___ PTT-31.5 ___ ___ 12:20PM BLOOD Glucose-211* UreaN-32* Creat-1.6* Na-136 K-4.4 Cl-106 HCO3-19* AnGap-15 ___ 12:20PM BLOOD Calcium-9.1 Phos-3.2 Mg-2.0 Microbiology: ___ urine culture no growth ___ blood culture pending Imaging: ___ (___): FINDINGS: There is no evidence of acute intracranial hemorrhage, discrete masses, mass effect or shift of normally midline structures. The ventricles and sulci are prominent consistent with age-related involutional changes. A lacune is noted within the right basal ganglia. Periventricular and subcortical low attenuating regions appear consistent with sequelae of chronic small vessel ischemic disease. Bilateral mastoid air cells and visualized paranasal sinuses are clear. IMPRESSION: No evidence of acute intracranial hemorrhage. Age-related involutional changes are noted with sequelae of chronic small vessel ischemic disease and right basal ganglia lacune. . CXR (___): Low lung volumes are noted with crowding of bronchovascular markings. The cardiac silhouette appears accentuated by low lung volumes. The left hemidiaphragm is elevated, a new finding of uncertain etiology. Recommend follow up radiograph to determine if this is a persistent or transient finding. . ___ lumbar puncture (___): Technique: Risk, benefits and alternative managment were explained to the patient and the patient signed the informed consent. The patient was brought to the fluroscopy room and was placed on the table in prone position. The lower back was prepped and drapped in the usual sterile fashion. After subcutaneos administration of 1% lidocaine, a spinal needle was place at L3-4 level using fluoroscopic guidance. The opening pressure was 10 cmH2o. Then 10 cc of clear CSF were removed and pressure was measured again, which was 7 cmH2o. The needle was then removed. There were no complications. Sedation was not required. Impression: Successful lumbar puncture. No immediate complications. Medications on Admission: *carbidopa-levodopa 25 mg-250 mg 1 Tab four times a day *escitalopram 10mg QAM *Lantus 70 units QAM *Humalog QID per SS (18 units at 12pm and 4pm, SS at 8AM and 8PM) *lactulose 30 ml five times per day to achieve up to 3 BMs per day *omeprazole 20mg BID *pramipexole 1 mg daily *rifaximin 550 mg BID *spironolactone 25 mg daily *ferrous sulfate 325 mg BID *Ex-Lax (sennosides) 15 mg PRN constipation *PRN tylenol *PRN NTG Discharge Medications: 1. carbidopa-levodopa ___ mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 2. escitalopram 10 mg Tablet Sig: One (1) Tablet PO Q8 AM (). 3. Lantus 100 unit/mL Solution Sig: Seventy (70) units Subcutaneous qAM. 4. Humalog 100 unit/mL Solution Sig: as directed units Subcutaneous four times a day: Please take according to your sliding scale. 5. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO five times a day. 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 7. pramipexole 1 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 8. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. spironolactone 25 mg Tablet Sig: One (1) Tablet PO Q 8 AM (). 10. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 13. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual once a day as needed for chest pain: Take one tablet for chest pain, if chest pain persists after 5 minutes, take another tablet and call your doctor. Discharge Disposition: Home Discharge Diagnosis: Confusion due to hepatic encephalopathy and elevated CSF pressures Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report Indication: elevated CSF pressure. Indication: lumbar puncture. Comparison: none. Technique: Risk, benefits and alternative managment were explained to the patient and the patient signed the informed consent. The patient was brought to the fluroscopy room and was placed on the table in prone position. The lower back was prepped and drapped in the usual sterile fashion. After subcutaneos administration of 1% lidocaine, a spinal needle was place at L3-4 level using fluoroscopic guidance. The opening pressure was 10 cmH2o. Then 10 cc of clear CSF were removed and pressure was measured again, which was 7 cmH2o. The needle was then removed. There were no complications. Sedation was not required. Impression: Successful lumbar puncture. No immediate complications. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: ALTERED MENTAL STATUS/MED REACTION Diagnosed with HEPATIC ENCEPHALOPATHY, CHRONIC LIVER DIS NEC, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS, PARKINSON'S DISEASE temperature: 98.0 heartrate: 59.0 resprate: 16.0 o2sat: 100.0 sbp: 150.0 dbp: 69.0 level of pain: 0 level of acuity: 2.0

___ with NASH cirrhosis, decompensated with encephalopathy and ascites, DM, HL, HTN, normal pressure hydrocephalus admitted for change in mental status. . # Altered mental status: Trigger for increased encephalopathy could be acetazolamide, infection, and/or dehydration. Imaging in ED ruled out immediate neurologic or cardiac etiology. Liver function unchanged, renal function slightly worse (baseline 1.5, 1.7 on presentation to ED). Patient had IVF in ED ___ without immediate improvement in his symptoms. Of note, he did not have 3 BM/day for the last 48 hours due to disruption in his dosing schedule. Urine culture negative. Blood cultures showed no growth to date at time of discharge. Lactulose was provided for 3 BM/day. The patient improved rapidly and was observed to feed himself and repsond more appropriately by the second day of his admission. . # Normal pressure hydrocephalus: Per the patient's outpatient Neurologist Dr ___ puncture on ___ successfully increased his activity level and decreased his fatigue. Neurology was consulted and attempted bedside lumbar puncture without success. He was scheduled for ___ LP to drain some CSF in an attempt to further improve his mental status. . # NASH cirrhosis: Diagnosed ___, followed by Dr ___. LFTs stable. Home regimen continued. Lactulose was increased to provide 3 BM/day given 48 hours of reduced output. Mental status improved with this regimen. .

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: PODIATRY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left foot infection Major Surgical or Invasive Procedure: ___: Left foot debridement, Bone biopsy (Dr. ___ History of Present Illness: This is a ___ with PMHx IDDM, who presented to the emergencyroom on ___ for a left foot infection. Patient is approximately 1 month s/p L foot percutaneous bunion with ___ pin fixation. Patient is followed closely by Dr. ___ the podiatric surgery service and was seen ___ clinic where he was found to have a superficial pin tract infection and 1 of the pins was pulled. Since that time he states he developed fevers, chills, malaise. He was seen ___ clinic ___ where the another pin was removed and a large abscess was drained. He was sent to the emergency room for further drainage and admission for IV antibiotics. Stated his blood sugars continue to be under control. Last A1c ___ ___ was 7.6%. Past Medical History: IDDM HTN Depression s/p 3 Right foot surgeries s/p Percutaneous Bunion Procedure ___. Social History: ___ Family History: Denies FH of heart disease, DM Physical Exam: Physical Exam on admission Gen: A+Ox3, NAD Vitals: T 9.0HR 111 BP 124/58 RR 18 100%RA Abd: Soft, NT, ND Resp: no respiratory distress CV: RRR Focused lower extremity exam: DP and ___ pulses palpable. CRT <3 seconds to all digits. Left foot with erythema, edema, warmth to forefoot. + transverse incisions noted along the medial column. 2 stab incisions are noted to dorsal ___ interspace and medial aspect left hallux. + purulent discharge from all incisions. No pain to palpation. Probing noted from distal toe through area of prior pin. Able to dorsiflex and plantarflex at ankle. Physical Exam on admission Gen: A+Ox3, NAD Vitals: AVSS Abd: Soft, NT, ND Resp: no respiratory distress CV: RRR Focused lower extremity exam: DP and ___ pulses palpable. CRT <3 seconds to all digits. Left foot with wound vac ___ place. able to flex extend all digits b/l. Pertinent Results: ___ 12:10PM ___ COMMENTS-GREEN TOP ___ 12:10PM LACTATE-2.3* ___ 11:50AM GLUCOSE-86 UREA N-16 CREAT-1.0 SODIUM-132* POTASSIUM-4.8 CHLORIDE-94* TOTAL CO2-24 ANION GAP-19 ___ 11:50AM estGFR-Using this ___ 11:50AM CALCIUM-9.2 PHOSPHATE-2.0* MAGNESIUM-1.9 ___ 11:50AM CRP-252.2* ___ 11:50AM WBC-11.7* RBC-4.68 HGB-10.2* HCT-33.5* MCV-72* MCH-21.8* MCHC-30.4* RDW-15.9* RDWSD-40.4 ___ 11:50AM NEUTS-83.2* LYMPHS-8.3* MONOS-7.2 EOS-0.4* BASOS-0.3 IM ___ AbsNeut-9.76* AbsLymp-0.97* AbsMono-0.84* AbsEos-0.05 AbsBaso-0.04 ___ 11:50AM PLT COUNT-237 ___ 11:50AM ___ PTT-31.5 ___ Pertinent Imaging: Left foot Xray (___): Transverse osteotomy present at ___ metatarsal with no fixation ___ place. Prominent soft tissue swelling noted medially with open wound. Osteomyelitis impossible to exclude. Chest Xray (___): FINDINGS: AP upright and lateral views of the chest provided. There is no focal consolidation, effusion, or pneumothorax. The heart is normal ___ size. There is prominence of the mediastinum which could reflect lipomatosis though clinical correlation advised. The mediastinal margins are sharp. Imaged osseous structures are intact. No free air below the right hemidiaphragm is seen. IMPRESSION: Mediastinal prominence may reflect lipomatosis though clinical correlation is advised. Pathology: Left foot ___ metatarsal bone: final report pending Microbiology: ___ 11:56 am SWAB LEFT FOOT WOUND. **FINAL REPORT ___ GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CLUSTERS. WOUND CULTURE (Final ___: STAPH AUREUS COAG +. SPARSE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # ___ ___. STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 1 S OXACILLIN-------------<=0.25 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ <=0.5 S ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Citalopram 40 mg PO QAM 2. Humalog 60 Units Breakfast Humalog 60 Units Lunch Humalog 60 Units Dinner Troujec 80 Units Breakfast Troujec 80 Units Dinner 3. MetFORMIN (Glucophage) 1000 mg PO BID 4. Lisinopril 20 mg PO DAILY 5. Pravastatin 20 mg PO QAM Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. Docusate Sodium 100 mg PO BID 3. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain - Moderate RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*0 4. Senna 8.6 mg PO BID:PRN constipation 5. Vancomycin ___ mg IV Q 12H RX *vancomycin 1 gram 2 vials twice a day Disp #*148 Vial Refills:*0 6. Citalopram 40 mg PO QAM 7. Humalog 60 Units Breakfast Humalog 60 Units Lunch Humalog 60 Units Dinner Troujec 80 Units Breakfast Troujec 80 Units Dinner 8. Lisinopril 20 mg PO DAILY 9. MetFORMIN (Glucophage) 1000 mg PO BID 10. Pravastatin 20 mg PO QAM 11.Outpatient Physical Therapy bariatric walker LOS:13 months Prognosis: Good Discharge Disposition: Home With Service 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 INDICATION: ___ with left foot infection. // Osteo? COMPARISON: None FINDINGS: AP, lateral, obliques views of the left foot were provided. There is a fracture through the neck of the first metatarsal. Dorsal and medial soft tissue swelling along the forefoot without subcutaneous gas. A skin defect along the medial forefoot is consistent with provided history of wound. No subcutaneous gas is seen. There is callus formation along the lateral margin of the fracture. The fracture lines appear irregular and the possibility of a subtle osteomyelitis is impossible to exclude. IMPRESSION: Fracture traversing the neck of the first metatarsal with adjacent callus formation suggesting subacute injury. Prominent soft tissue swelling noted medially with open wound. Osteomyelitis impossible to exclude. Findings were discussed with Dr. ___. Radiology Report EXAMINATION: CHEST (AP upper AND LAT) INDICATION: ___ with left foot infection. // pre-op COMPARISON: No priors FINDINGS: AP upright and lateral views of the chest provided. There is no focal consolidation, effusion, or pneumothorax. The heart is normal in size. There is prominence of the mediastinum which could reflect lipomatosis though clinical correlation advised. The mediastinal margins are sharp. Imaged osseous structures are intact. No free air below the right hemidiaphragm is seen. IMPRESSION: Mediastinal prominence may reflect lipomatosis though clinical correlation is advised. Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old man with PICC // Pt had a L PICC, ___ ___ Contact name: ___: ___ Pt had a L PICC, ___ ___ IMPRESSION: In comparison with study of ___, is an placement of a left subclavian PICC line extends to the mid portion of the SVC. Otherwise, no change. Again there is prominence of the superior mediastinum, which could merely reflect mediastinal lipomatosis. Gender: M Race: WHITE - RUSSIAN Arrive by WALK IN Chief complaint: Wound eval Diagnosed with Infection following a procedure, initial encounter, Cutaneous abscess of left foot, Oth places as the place of occurrence of the external cause temperature: 99.0 heartrate: 111.0 resprate: 18.0 o2sat: 100.0 sbp: 124.0 dbp: 58.0 level of pain: 3 level of acuity: 3.0

The patient was admitted to the podiatric surgery service from clinic on ___ for a Left foot infection. On admission, he was started on broad spectrum antibiotics. He was taken to the OR for Left foot I+D on ___. He was evaluated by anesthesia prior to going to the OR. ___ the OR there was noted infection to the ___ interspace so the interspace was opened. Bone biopsy of the ___ metatarsal osteotomy site was obtained intraop and sent to pathology. There were no adverse events ___ the operating room; please see the operative note for details. Afterwards, pt was taken to the PACU ___ stable condition, then transferred to the ward for observation. Post-operatively, the patient remained afebrile with stable vital signs; pain was well controlled oral pain medication on a PRN basis. The patient remained stable from both a cardiovascular and pulmonary standpoint. He was placed on vancomycin, ciprofloxacin, and flagyl while hospitalized. The patient was seen by a member of the infectious disease team who recommended the patient be discharged with IV antibiotics specific to the patients microbiology results from cultures taken intra-op. A wound VAC was placed on ___ which he was discharged with to be changed by ___ Q3 days at home. His intake and output were closely monitored and noted to be adequtae. The patient received subcutaneous heparin throughout admission; early and frequent ambulation were strongly encouraged. The patient was evaluated by ___ who worked with the patient several times on being able to keep weight off the Left foot. A PICC line was placed with verification of proper placement on CXR. The patient was subsequently discharged to home on POD4 with a wound VAC ___ place on the Left Foot and ___ services for wound care and IV antibiotics. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None this admission, but ___ s/p left VATS wedge biopsy x2 History of Present Illness: Mr. ___ is a ___ yo male with ___ CAD s/p MI (___) w/ stent placement, CHF (EF 40%)and bilateral pulmonary lung nodules s/p left VATS wedge biopsy x 2 on ___. He was discharged on ___ after an uneventful post-operative course. Prior to discharge, patient was breathing comfortably, saturating in the low- to mid-90s on RA at rest, and his ambulatory O2 sat was >90%. CXR post-CT pull on POD1 showed small L apical PTX and atelectasis overlying the spine. He awoke from sleep ~6 hours post-discharge (12am) with a "coughing fit". The paroxysm resolved spontaneously, but he developed dyspnea afterwards, which continued unabated. His wife paged the thoracic surgery intern, who recommended return to care for assessment. She opted to call ___ for transport to ___. Per EMT report, his O2 sat was 85% on first assessment, but improved to nearly 100% with non-rebreather. Upon arrival at ___, Mr. ___ reported significant improvement in his respiratory status. He reported no shortness of breath whatsoever and no significant pain. He denied fever, chills, chest pain, abdominal pain, diarrhea, constipation, dysuria, or confusion. In the ED, CXR showed increasing L mid and lower lung opacity and stable small L apical PTX. Patient was afebrile with normal WBC count (9.6). On arrival to the floor, patient was satting mid- to high-90s on 4L NC. Past Medical History: -CAD (Cardiologist = Dr. ___ at ___), MI (___) s/p stent placement in ___ -CHF with EF of 40% and global left ventricular wall motion abnormalities, no reversible ischemia -MV insufficiency -HTN -Cerebrovascular disease -TIA -BCC -Psoriasis -BPH -Prostate cancer ___ (not treated, observation) -Gout -Hyperparathyroidism -GERD -Anemia -Hiatal hernia -OA -Narrow angle glaucoma -Dry eye -Lumbar spondylosis Social History: ___ Family History: No known history of cancer. Physical Exam: VS: Tmax 98.8, Tcur 98.8, BP 135/61, HR 84, RR 20, O2 sat 95% RA GEN: NAD, AA&Ox3 HEENT: PERRL, EOMI, MMM, OP clear NECK: Supple, trachea midline, no cervical lymphadenopathy CARDIAC: RRR, no m/r/g PULM: CTAB ABD: Soft, NT/ND EXT: WWP, no edema, 2+ distal pulses b/l WOUND: Chest incisions c/d/i, no erythema or induration NEURO: Grossly intact Pertinent Results: Admission Labs: ___ 03:00AM BLOOD WBC-9.6 RBC-3.69* Hgb-11.5* Hct-34.3* MCV-93 MCH-31.2 MCHC-33.5 RDW-13.2 RDWSD-44.5 Plt ___ ___ 03:00AM BLOOD Neuts-85.6* Lymphs-6.2* Monos-7.2 Eos-0.3* Baso-0.2 Im ___ AbsNeut-8.21*# AbsLymp-0.59* AbsMono-0.69 AbsEos-0.03* AbsBaso-0.02 ___ 03:00AM BLOOD ___ PTT-32.9 ___ ___ 03:00AM BLOOD Glucose-186* UreaN-26* Creat-1.0 Na-136 K-4.6 Cl-98 HCO3-26 AnGap-17 ___ 05:10AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.0 ___ 03:02AM BLOOD Lactate-1.5 Discharge Labs: ___ 05:10AM BLOOD WBC-8.0 RBC-3.47* Hgb-10.9* Hct-32.2* MCV-93 MCH-31.4 MCHC-33.9 RDW-13.2 RDWSD-44.5 Plt ___ ___ 05:10AM BLOOD Glucose-164* UreaN-28* Creat-1.1 Na-136 K-4.2 Cl-98 HCO3-24 AnGap-18 Imaging: CXR ___: Increasing left mid and lower lung opacity could reflect hemorrhage, aspiration infection, or asymmetrical edema. Unchanged small left apical pneumothorax. CTA Chest ___: 1. No evidence of pulmonary embolism or acute aortic abnormality. 2. Status post VATS wedge biopsy of the previous left lower lobe masslike lesion. Left lower lobe consolidation is of mixed density, indicating pleural effusion and atelectasis. Although attenuation of measurable fluid in the left lower lobe is simple, a small component of hemothorax is not excluded. 3. Small left apical pneumothorax. 4. Bilateral upper lobe lesions are grossly stable in size since ___. CXR ___: In comparison to ___ chest radiograph, opacities in the left mid lung have substantially improved. Bilateral upper lobe nodular opacities persist as well as a small left apical pneumothorax. Interval worsening of left retrocardiac opacity, likely due to atelectasis. Note is also made of bilateral pleural effusions. Medications on Admission: 1. Atenolol 25 mg PO DAILY 2. Finasteride 5 mg PO QHS 3. Omeprazole 20 mg PO DAILY 4. Simvastatin 10 mg PO QPM 5. Acetaminophen 1000 mg PO Q8H 6. Docusate Sodium 100 mg PO BID 7. Milk of Magnesia 30 mL PO QHS:PRN constipation 8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*40 Tablet Refills:*0 9. Aspirin 81 mg PO DAILY 10. Enalapril Maleate 10 mg PO DAILY 11. Ferrous Sulfate 325 mg PO BID 12. Furosemide 20 mg PO DAILY 13. vitamin A-vit C-vit E-zinc-Cu 1 tab oral DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN pain 2. Aspirin 81 mg PO DAILY 3. Atenolol 25 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Enalapril Maleate 10 mg PO DAILY 6. Finasteride 5 mg PO DAILY 7. Furosemide 20 mg PO DAILY 8. Omeprazole 20 mg PO DAILY 9. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain 10. Polyethylene Glycol 17 g PO DAILY 11. Simvastatin 10 mg PO QPM 12. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath, cough, wheezing Use spacer RX *albuterol sulfate [ProAir HFA] 90 mcg 2 puffs IH every 4 hours Disp #*1 Inhaler Refills:*0 13. Space Chamber Plus (inhalational spacing device) 1 miscellaneous Q4H:PRN with albuterol inhaler RX *inhalational spacing device 1 spacer every four hours Disp #*1 Cylinder Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Shortness of breath Atelectasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: History: ___ with s/p VATS todayL wedge biopsy // eval ? pneumothorax, postop changes TECHNIQUE: Chest PA and lateral COMPARISON: ___ at 12:21 FINDINGS: There is a tiny left apical pneumothorax, unchanged from prior. Bilateral upper lobe opacities appear similar to prior. There is increased opacity in the left mid and lower lungs. Stable cardiomediastinal contours. IMPRESSION: Increasing left mid and lower lung opacity could reflect hemorrhage, aspiration infection, or asymmetrical edema. Unchanged small left apical pneumothorax. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 3AM, 2 minutes after discovery of the findings. Radiology Report EXAMINATION: CTA CHEST INDICATION: ___ year old man with multiple pulmonary nodules, ___ s/p left VATS wedge bx x2 now w/ SOB and worsening LLL opacity on CXR. Evaluate for PE vs hemothorax. TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of intravenous contrast. Reformatted coronal, sagittal, thin slice axial images, and oblique maximal intensity projection images were submitted to PACS and reviewed. DOSE: Acquisition sequence: 1) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 0.7 mGy (Body) DLP = 0.7 mGy-cm. 2) Stationary Acquisition 2.0 s, 1.0 cm; CTDIvol = 2.7 mGy (Body) DLP = 2.7 mGy-cm. 3) Spiral Acquisition 8.4 s, 32.3 cm; CTDIvol = 8.7 mGy (Body) DLP = 266.2 mGy-cm. Total DLP (Body) = 276 mGy-cm. COMPARISON: CT chest of ___. FINDINGS: The aorta and its major branch vessels are patent, with no evidence of stenosis, occlusion, or dissection. There is no evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present. Calcifications of the aortic arch are moderate. Tortuous course of the descending thoracic aorta is re- demonstrated. The pulmonary arteries are well opacified to the subsegmental level, with no evidence of filling defect within the main, right, left, lobar, segmental or subsegmental pulmonary arteries. The main and right pulmonary arteries are normal in caliber, and there is no evidence of right heart strain. There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy. The thyroid gland appears unremarkable. There is no evidence of pericardial effusion. Patient is status post VATS wedge biopsy of the previous left lower lobe masslike lesion. Consolidation involving the left lower lobe is of mixed density, suggesting a combination of pleural effusion and atelectasis in the postoperative setting. The attenuation of the fluid appears simple, but a small component of hemothorax is not excluded (6:135, 190). There is a small left apical pneumothorax. The previously described large lesions in the bilateral upper lobes are irregular and marginated with scattered calcifications, as described in ___ (8b:34) these are grossly stable in size, accounting for differences in slice acquisition and postoperative left lung changes. The right upper lobe lesion measures 4.3 x 2.1 cm (6:60). The airways are patent to the subsegmental level. Limited images of the upper abdomen demonstrate multiple calcified gallstones, as well as atherosclerotic disease involving the origin of the celiac trunk and SMA. Small hiatal hernia is unchanged. No lytic or blastic osseous lesion suspicious for malignancy is identified. Postsurgical changes in the soft tissues of the left chest wall are noted. IMPRESSION: 1. No evidence of pulmonary embolism or acute aortic abnormality. 2. Status post VATS wedge biopsy of the previous left lower lobe masslike lesion. Left lower lobe consolidation is of mixed density, indicating pleural effusion and atelectasis. Although attenuation of measurable fluid in the left lower lobe is simple, a small component of hemothorax is not excluded. 3. Small left apical pneumothorax. 4. Bilateral upper lobe lesions are grossly stable in size since ___. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man with small left apical PNX // f/u on left PNX and effusion IMPRESSION: In comparison to ___ chest radiograph, opacities in the left mid lung have substantially improved. Bilateral upper lobe nodular opacities persist as well as a small left apical pneumothorax. Interval worsening of left retrocardiac opacity, likely due to atelectasis. Note is also made of bilateral pleural effusions. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Dyspnea Diagnosed with Cough temperature: 98.4 heartrate: 89.0 resprate: 24.0 o2sat: 96.0 sbp: 159.0 dbp: 62.0 level of pain: 0 level of acuity: 2.0

___ w/ multiple pulmonary nodules s/p left VATS wedge bx x2 on ___ who was discharged on POD1 and re-presented ~6 hours after discharge with acutely worsening shortness of breath. Prior to discharge, patient was breathing comfortably, saturating in the low- to mid-90s on RA at rest, and his ambulatory O2 sat was >90%. CXR post-CT pull on POD1 showed small L apical PTX and atelectasis overlying the spine. When patient re-presented to the ED, CXR showed increasing L mid and lower lung opacity and stable small L apical PTX. Patient was afebrile with normal WBC count (9.6), so there was no clinical evidence that the CXR opacities represented pneumonia. On arrival to the floor, patient was satting mid- to high-90s on 4L NC. Given the acutely worsening SOB, CTA chest was obtained, which showed L effusion and atelectasis, small L apical PTX, and no PE. Patient was given 20mg IV Lasix x1 on ___, and was -1.3L for the day. He was encouraged to ambulate and use IS 10x/hr. He was weaned to RA, O2 sats in low- to mid-90s on RA, and ambulatory O2 sats were >90%. Patient remained afebrile and WBC count downtrended to 8.0 on HD2. Pain was well controlled on PO oxycodone and Tylenol. CXR PA & lateral on HD2 showed markedly improved L mid-lung opacities, minimally improved upper lung opacities, stable small L apical PTX, and small b/l pleural effusions. Given improvement in clinical status and improved CXR, patient was discharged on ___ and will follow up with Dr. ___ on ___.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Erythromycin Base / Demerol Attending: ___ Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: ___ female with alcoholic cirrhosis (c/b variceal bleed and ascites), bipolar disorder, urinary retention with recent initiation of clean intermittent catheterization who presented to ED with altered mental status and was found to have E.coli bacteremia. Pt was last hospitalized ___ on the liver service with alcoholic hepatitis, acute kidney injury, altered mental status (due to ___ and hepatic encephalopathy). During that admission, she had failed several voiding trials and was discharged with foley with plans to f/u with urology. She was seen at ___ clinic for f/u. Urodynamic study revealed hyposensitive bladder and she was taught how to self-cath at home. She began to notice that urine was dark and orange and experienced dysuria. Foley was placed in ED that drained frank blood. Hct was 30 on admission and decreased to 23 (baseline ___. She received 2 units PRBCs and 2 units FFP (INR peaked to 2.2). She was also found to be hypotensive to systolic ___ and admitted to ICU where she required ~7liter IV fluid resuscitation, 150g iv albumin, and levophed. Blood cultures x 2 from ___ and urine culture grew pan-sensitive E.coli. She was initially on ceftriaxone, then broadened to cefepime when blood cultures revealed GNR bacteremia, and narrowed to ciprofloxacin. Urology was consulted for hematuria and manually irrigated the foley to release blood clots. Foley is now draining clear urine. Mental status improved with treatment of UTI and with lactulose for hepatic encephalopathy. Past Medical History: -Alcoholic cirrhosis complicated by variceal bleed (first in ___, ascites, no hx of HE -Variceal bleed c/b arrest and multiple resuscitation attempts -Bipolar disorder -Umbilical herniorrhaphy with a primary repair on ___ -Peripheral neuropathy Social History: ___ Family History: Family History: Pertinent for a father who had arthritis. No family history of liver disease. Physical Exam: ET Admission Vitals: 97 96/61 83 18 96%RA General: alert and appropriate, though often tangential, AAOx3, noted to be slightly jaundiced Skin: jaundiced, with some bruising of lower back, L upper back HEENT: Sclera icteric, MMM, + bruising surrounding her L eye CHEST: slight TTP along R chest wall, though minimal Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: softly distended, non-tender Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: A & O x 3, CN II-XII intact, moving all extremities, no asterixis Discharge: Vitals: 97 96/61 83 18 96%RA General: alert and appropriate, though often tangential, AAOx3, noted to be slightly jaundiced Skin: jaundiced, with some bruising of lower back, L upper back HEENT: Sclera icteric, MMM, + bruising surrounding her L eye CHEST: slight TTP along R chest wall, though minimal Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: softly distended, non-tender Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: A & O x 3, CN II-XII intact, moving all extremities, no asterixis Pertinent Results: Admission: ___ 01:40PM BLOOD WBC-10.9# RBC-2.74* Hgb-10.2* Hct-30.8* MCV-112* MCH-37.1* MCHC-33.1 RDW-17.7* Plt Ct-54* ___ 02:40PM BLOOD ___ PTT-37.7* ___ ___ 01:40PM BLOOD Glucose-183* UreaN-51* Creat-2.3*# Na-123* K-5.7* Cl-92* HCO3-18* AnGap-19 ___ 01:40PM BLOOD ALT-16 AST-41* AlkPhos-78 TotBili-6.1* ___ 12:59AM BLOOD Calcium-7.9* Phos-3.5 Mg-1.4* ___ 01:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Discharge: ___ 05:15AM BLOOD Albumin-3.2* Calcium-8.7 Phos-2.2* Mg-1.7 ___ 05:15AM BLOOD ALT-13 AST-33 AlkPhos-71 TotBili-5.9* ___ 05:15AM BLOOD Glucose-113* UreaN-17 Creat-0.6 Na-131* K-4.1 Cl-103 HCO3-22 AnGap-10 ___ 05:15AM BLOOD ___ PTT-44.7* ___ ___ 05:15AM BLOOD WBC-9.2 RBC-2.54* Hgb-8.9* Hct-26.2* MCV-103* MCH-35.1* MCHC-34.1 RDW-18.7* Plt Ct-77*# Radiology Report HISTORY: Cough, confusion, fall yesterday. TECHNIQUE: Supine AP view of the chest. COMPARISON: ___. FINDINGS: Lung volumes are low. Heart size is normal. Mediastinal and hilar contours are likely within normal limits. There is crowding of the bronchovascular structures with prominence of the pulmonary vascular markings likely due to a combination of supine positioning and low lung volumes. There is mild bibasilar atelectasis. No focal consolidation, pleural effusion or pneumothorax is identified. No acute osseous abnormalities are seen. IMPRESSION: Low lung volumes with bibasilar atelectasis. Radiology Report HISTORY: Fall with blow to the head. TECHNIQUE: Noncontrast MDCT axial images were acquired through the head. Bone reconstructions and coronal and sagittal reformations are provided for review. COMPARISON: No relevant comparisons available. FINDINGS: The study is somewhat limited by motion artifact. There is no acute intracranial hemorrhage, edema, mass effect or major vascular territorial infarct. Prominent ventricles and sulci are more than expected for the patient's age. Basal cisterns are preserved. There is no shift of normally midline structures. Gray-white matter differentiation is preserved. A small hypoattenuation in the left subinsular region appears chronic and may represent an old lacune. Mild hypoattenuation in the subcortical and periventricular white matter is likely sequelae of chronic microvascular ischemic disease. No calvarial fracture is identified. A non-aggressive appearing expansile lucent lesion at the left calvarial vertex does not transgress the inner or outer tables. It has thickened trabeculation and may be a hemangioma (3:55). The visualized paranasal sinuses, mastoid air cells and middle ear cavities are clear. IMPRESSION: 1. Slightly motion limited study. No evidence of acute intracranial injury. 2. Global atrophy, more than expected for patient's age. 3. Nonagressive appearing left vertex calvarial lesion may be a hemangioma. Radiology Report HISTORY: Fall yesterday with neck pain and tenderness. TECHNIQUE: Noncontrast MDCT axial images were acquired through the cervical spine. Bone reconstructions and coronal and sagittal reformations are provided for review. COMPARISON: No relevant comparisons available. FINDINGS: There is no acute fracture or malalignment. There is mild degenerative change with a disk osteophyte complex at C5-6 which mildly narrows the spinal canal. Uncovertebral and facet arthropathy at multiple levels mildly-moderately narrow multiple left neural foramina. No paravertebral hematoma is seen. Prevertebral soft tissue thickness is maintained. No nodules are seen in the thyroid gland. The lung apices are clear. The visualized paranasal sinuses and mastoid air cells are clear. IMPRESSION: No acute fracture or malalignment. Radiology Report INDICATION: Liver disease, status post fall. Evaluate for retroperitoneal bleed. COMPARISON: Ultrasounds ___ and ___. TECHNIQUE: MDCT-acquired axial images from the lung bases to the pubic symphysis were displayed with 5-mm slice thickness without oral or intravenous contrast. No intravenous contrast was administered due to patient's renal function. Coronal and sagittal reformations are provided for review. CT ABDOMEN: The visualized lung bases demonstrate mild dependent bibasilar atelectasis. There is no pleural or pericardial effusion. Hypoattenuation of the blood pool relative to the cardiac musculature is compatible with anemia. A small hiatal hernia is seen. Evaluation of the intra-abdominal organs is limited without intravenous contrast. The liver is shrunken and nodular compatible with cirrhosis. The gallbladder is distended with large stones as seen on the prior ultrasound. Gallbladder wall edema is nonspecific in the setting of liver disease. The spleen is enlarged measuring 15.7 cm craniocaudally, unchanged. The unenhanced pancreas is unremarkable. The bilateral adrenal glands are normal. There are bilateral extrarenal pelvises. Fullness of the collecting system bilaterally without frank hydronephrosis is likely due to marked bladder distention. The small and large bowel are normal in course and caliber without obstruction. There is small- moderate non-hemorrhagic ascites in the abdomen. There is no free air. There is no retroperitoneal hematoma. The abdominal aorta is of normal caliber throughout. Although limited without IV contrast, there appears to be extensive paraesophageal varices. No pathologically enlarged mesenteric or retroperitoneal lymph nodes are identified. CT PELVIS: The rectum and sigmoid colon are normal. The bladder is markedly distended leading to fullness of the bilateral renal collecting systems. Air within the bladder may be related to recent instrumentation. Correlate clinically with patient's history. Mild bladder wall thickening may be related to urinary tract infection. The uterus is normal. Free fluid in the pelvis is tracking from the abdomen. There is no pelvic or inguinal lymphadenopathy. BONE WINDOWS: There is a nondisplaced fracture of the right posterior 11th rib (2:27) and fractures of the L3 and L4 right transverse processes. No bone finding suspicious for infection or malignancy is seen. Non-aggressive appearing sclerotic foci in the sacrum (2:66) and in the right iliac wing (2:70) likely represent bone islands. IMPRESSION: 1. No retroperitoneal bleed. 2. Marked bladder distention leading to renal pelvic fullness without frank hydronephrosis. If the patient is unable to void, she may benefit from a Foley catheter. 3. Air within the bladder may be due to recent instrumentation if there is history of this. Correlate clinically, especially given patient's urinary tract infection. 4. Acute fractures of the right posterior 11th rib and the L3 and L4 right transverse processes. 5. Cirrhosis with small-moderate non-hemorrhagic ascites, splenomegaly and likely paraesophageal varices. 6. Cholelithiasis. Radiology Report CHEST CT HISTORY: Trauma. History of transverse process fractures and eleventh rib fracture. COMPARISONS: Earlier CT of the abdomen from the same day. TECHNIQUE: Multidetector CT images of the chest were obtained without intravenous contrast. Sagittal and coronal reformations were also performed. FINDINGS: The lack of contrast administration is limiting for detection of vascular or solid organ injury. There is no pleural or pericardial effusion. There is no pneumothorax. There is no lymphadenopathy. Contours of the great vessels appear within normal limits. The heart is at the upper limits of normal size. Motion artifact obscures evaluation of parenchymal detail in the inferior lower lobes. Slight scarring is present at each lung apex. No focal opacity worrisome for injury is identified. Patchy lower lung opacities are most suggestive of minor atelectasis. Prominence of the paraesophageal soft tissues at the gastroesophageal junction suggests varices. The spleen is enlarged. The liver shows cirrhosis, which can also explain gallbladder wall thickening and ascites. A calcified gallstone is also present. The degree of ascites about the liver is not significantly changed and appears low in density. Increased attenuation and vascularity in the omentum and central mesentery can also be seen with portal hypertension. Persistent mild fullness of each extrarenal collecting system is noted, but substantially decreased. There is a mildly displaced fracture of the right L3 transverse process as well as a non-displaced right posterior eleventh rib. The vertebral body heights and interspaces appear maintained. IMPRESSION: 1. No evidence for injury not previously elucidated on the earlier CT of the abdomen from the same day. 2. Decreased distention of bilateral extrarenal collecting systems. 3. Cirrhosis with evidence for portal hypertension. Radiology Report INDICATION: Right IJ placement. COMPARISON: Radiograph available from ___. FRONTAL CHEST RADIOGRAPH: A right IJ catheter terminates at the cavoatrial junction. The heart size is top normal. The hilar and mediastinal contours are within normal limits. There is mild pulmonary vascular congestion and interstitial edema. There is no pneumothorax or pleural effusion. IMPRESSION: Right IJ terminating at the cavoatrial junction. Radiology Report AP CHEST, 4:40 A.M., ___ HISTORY: ___ woman with alcoholic cirrhosis, Gram-negative rod sepsis and hypoxia. Evaluate pulmonary edema. IMPRESSION: AP chest compared to ___: Heart is smaller and mediastinal veins are no longer distended. Some edema in the right lower lobe has improved and there is no appreciable right pleural effusion, on the left there is still an extensive region of infrahilar consolidation. It should be followed to make sure it is slowly clearing asymmetric edema rather than something focal in the left lower lobe, likely pneumonia or even pulmonary hemorrhage. No pneumothorax. Pleural effusion is small on the left if any. Tip of the right internal jugular line ends nearly 6 cm below the level of the carina and would need to be withdrawn 2 cm to reposition it in the low SVC. Radiology Report AP CHEST 1 P.M. ___ HISTORY: A ___ woman with cirrhosis and gram-negative sepsis, now hypoxic. Suspect pulmonary edema. IMPRESSION: AP chest compared to ___: Moderate-to-severe pulmonary edema continues to progress with bibasilar predominance. Heart is top normal size. Mediastinal veins are still dilated but improved since ___. Small bilateral pleural effusions are presumed. Displacement of the gastric bubble presumably reflects splenomegaly. Right jugular line ends 5 cm below the level of the carina, would need to be withdrawn 15 mm to be sure it is in the low SVC and not in the upper right atrium. No pneumothorax. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: JAUNDICED Diagnosed with URIN TRACT INFECTION NOS, HYPOSMOLALITY/HYPONATREMIA, ACUTE KIDNEY FAILURE, UNSPECIFIED temperature: 98.0 heartrate: 94.0 resprate: 20.0 o2sat: 100.0 sbp: 103.0 dbp: 74.0 level of pain: 3 level of acuity: 2.0

Ms. ___ is ___ with history of Etoh cirrhosis, urinary retention who has been self cathing for the last month who is presenting with altered mental status and foul smelling urine for the last three days found to have pan sensitive E.coli bacteremia. # E.coli bacteremia/sepsis: The patient presented with altered mental status and dysuria, and was found to by hypotensive. She was started on empiric Ceftriaxone out of concern for UTI (see below), which was latered broadened to Cefepime when blood cultures were positive for GNRs; grew out to be E.coli sensitive to Cipro and abx were downgraded. Pt required 7L NS and 150 grams of albumin for volume resucitation, and was later also started on Levophed for pressure support. The patient was weaned off her Levophed and her home lasix and spironolactone have since been restarted. The patient will complete a 14 day course of Cipro. # E.coli UTI: The patient was found to have pansensitive E.coli UTI; ultimately sensitive to Cipro. The patient had been self-cathing herself because she was having urinary retention (see below), and it is thought that this is how she developed her infection. The patient had CT abd/pelvis which showed evidence of renal pelvic fullness, likely due to her urinary retention. # Hematuria: The patient was noted to have gross hematuria; likely that this was multifactorial, which components of urethral trauma due to self-cath, and hemorrhagic cystitis from her UTI in the setting of her coagulapathy. The patient had Foley placed. Urology was consulted due to her hematuria and they suggested manual irrigation of Foley, as there were many clots noted. Her hematuria improved. She will follow up with urology. # Hematocrit drop: The patient was noted to have a crit drop when she first presented. She does have a history of UGIB, but she was not clinically bleeding from GI tract. Presentation was notable for hematuria, as described above. Her coagulopathy was corrected with Vitamin K and FFP, and her crits were trended. She was also given 2U PRBC. # Coagulopathy: The patient had INR of 2.0 and platelets of 54, likely in the setting of her cirrhosis. The patient was given FFP and Vitamin K, as decribed above because she was having crit drops. # urinary retention: The patient's last hospitalization was complicated by urinary retention and she was d/ced home with a foley. She has been seen by the urology as an outpatient and she was started on intermittent self cathing at home. The patient had CT abd/pelvis done in the ED which showed evidence of renal pelvic fullness without any clear evidence of hydronephrosis. Urology was consulted while in house given her hematuria (see above). She will have to follow up with urology as an outpatient. # hyponatremia: The patient was found to be newly hyponatremic to 123 on presentation which improved after getting NS. Was likeyl multifactorial due to diuretic effect as well as decreased PO intake. The patient was fluid restricted and her sodiuum was trended. # toxic metabolic encephalopathy: It is likely that the patient's altered mental status on admission was due to her underlying sepsis. Her mental status improved while her infection was being treated. She was continued on her home lactulose and the patient was having daily bowel movements. # acute renal failure: The patient initially presented with creat bump and CT pelvis with evidence of renal pelvic fullness in the setting of her urinary retention. Etiology likely mixed picture in the setting possible low blood pressures and obstruction. Creat trending down in response to fluids and after Foley being placed. # alcoholic cirrhosis: The patient has history of etoh cirrhosis c/b encephalopathy, UGIB. Currently LFTs are near baseline, Tbili on presentation noted to be 6.1. MELD on admission 28. Once her blood pressures were stabilized, the patient was restarted on spironlactone and Lasix, as well as her propranolol. # bipolar disorder: con't lithium and seroquel # neuropathy: renally dosed gabapentin

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Lisinopril Attending: ___. Chief Complaint: ___ Major Surgical or Invasive Procedure: L percutaneous nephrostomy placement History of Present Illness: ___ y/o M with history of depression, alcohol abuse, bladder cancer s/p multiple TURBTs/BCG therapy, alcohol abuse, recurrent falls, and recent left subcapsular hematoma who presented to ED at urging of his outpatient physicians. He recently had a PCP appointment where his Cr was found to be 4.8, from a baseline 1.5. On the way home from the doctor he stumbled and fell on the sidewalk (outside ___) but was not injured, no LOC. He went home (where he reports having another fall without LOC) and then heard from his PCP the next day informing him of the abnormal labs, at which point he was referred to the ED. He reports normal urine output but says that his urine was darker last week. He says that he has been feeling at his usual state of health recently. He denies headache, vision changes, weakness, new paresthesias, chest pain, shortness of breath, or abdominal pain. he also denies any neck or back pain. On arrival to the ED, initial vitals were 97.3 68 106/61 16 100%. He had a negative FAST exam. There was no gross hydronephrosis or distended bladder on bedside u/s. Urology was consulted and a renal U/S and CT abd/pelvis were obtained. Urology recommended urgent PCN placement and the patient was taken to ___ from the ED before arrival to the floor. Additionally, in the ED his K was noted to be 5.6 (no symptoms, no ECG changes) and he was given kayexolate with repeat K 4.6. Head CT was unremarkable. He was started on ceftriaxone for a presumed UTI. Also while in the ED he began to show passive suicidal ideation and psych was consulted. Per their evaluation, he did not meet ___ criteria. Psych will continue to follow while inpatient. On arrival to the floor he is now s/p L PCN placement. He is stable, denies pain. Past Medical History: Bladder ca as above Cervical spine disease DM II HTN CKD BPH ETOH abuse Chronic pancreatitis Depression Social History: ___ Family History: Non-contributory Physical Exam: Admission: VS - Temp 98.4 F, BP 140/70, HR 88, R 16, O2-sat 97% RA General: Awake, alert male lying in bed, NAD HEENT: no scleral icterus, poor dentition, OP clear, bandage on forehead Neck: supple, no cervical ___. No carotid bruits. CV: RRR, nl S1 S2, no r/m/g appreciated. Lungs: CTAB Abdomen: soft, NT/ND. No organomegaly. +BS. GU: no Foley. Ext: WWP, +2 pulses. No pedal edema. Neuro: A+Ox3, attentive. CN II-XII intact. Motor and sensory function grossly intact. Skin: 2 small scabs over L shin (pt aware, says they are from recent fall), no rashes. L percutaneous nephrostomy tube noted with bloody urine in bag. Site is dressed, exam deferred, no pain upon minimal palpation. Gait: Deferred due to having just returned from PCN tube placement. Discharge: General: Awake, alert male lying in bed, NAD HEENT: no scleral icterus, poor dentition, OP clear, bandage on forehead Neck: supple, no cervical ___. No carotid bruits. CV: RRR, nl S1 S2, no r/m/g appreciated. Lungs: CTAB Abdomen: soft, NT/ND. No organomegaly. +BS. GU: no Foley. Ext: WWP, +2 pulses. No pedal edema. Neuro: A+Ox3, attentive. CN II-XII intact. Motor and sensory function grossly intact. Skin: 2 small scabs over L shin (pt aware, says they are from recent fall), no rashes. L percutaneous nephrostomy tube noted with clear urine in bag. Site is dressed, no erythema, tenderness or drainage, no pain upon minimal palpation. Pertinent Results: Admission Labs: ___ 10:50PM BLOOD WBC-9.3 RBC-2.96* Hgb-8.7* Hct-26.8* MCV-90 MCH-29.2 MCHC-32.3 RDW-13.3 Plt ___ ___ 10:50PM BLOOD Neuts-78.0* Lymphs-13.5* Monos-6.0 Eos-2.0 Baso-0.4 ___ 10:50PM BLOOD Plt ___ ___ 07:44AM BLOOD ___ ___ 10:50PM BLOOD Glucose-159* UreaN-91* Creat-4.8*# Na-135 K-5.8* Cl-103 HCO3-16* AnGap-22* ___ 10:50PM BLOOD ALT-14 AST-9 AlkPhos-86 TotBili-0.2 ___ 10:24AM BLOOD Lactate-0.9 . COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct ___ 08:45 5.9 2.96* 8.7* 27.1* 92 29.5 32.2 13.5 231 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap ___ 08:45 388*1 55* 2.3* 140 4.7 ___ . MICROBIOLOGY: ___ URINE URINE CULTURE-FINAL {BETA STREPTOCOCCUS GROUP B} INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY WARD ___ BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY WARD ___ URINE URINE CULTURE-FINAL {BETA STREPTOCOCCUS GROUP B} EMERGENCY WARD Imaging: Head CT (___): IMPRESSION: No acute intracranial process. Renal U/S (___): IMPRESSION: 1. New moderate left hydronephrosis and hydroureter. The ureteric dilatation extends from the level of the renal pelvis through its insertion on the bladder. 2. Layering debris within the left renal pelvis and proximal ureter, possibly due to urinary stasis, although correlation with clinical signs/symptoms of pyonephrosis is recommended. 3. Posterior bladder wall thickening, left greater than right, likely corresponding to patient's known bladder mass. CT Abd/Pelv (___): IMPRESSION: 1. Interval removal of the left ureteral stent with new mild left hydroureteronephrosis, likely due to obstruction at the left ureterovesicular junction from known bladder cancer along the posterior left bladder wall. Left ureteral wall thickening and surrounding fat stranding may be due to an underlying infectious or inflammatory process. 2. Interval decrease in size in left subcapsular renal fluid collection, consistent with resolving hematoma. 3. Sigmoid diverticulosis with no evidence of diverticulitis. 4. Cystic lesion in the pancreatic head is unchanged in size since the most recent prior study, and is incompletely characterized on this exam. Followup MRI could be considered for further evaluation. 5. New chyluria, suggestive of injury or obstruction of the lymphatic vessels and communication with the collecting system, possibly due to prior urological intervention Medications on Admission: The Preadmission Medication list is accurate and complete. 1. BuPROPion 100 mg PO BID 2. Finasteride 5 mg PO DAILY 3. GlyBURIDE 5 mg PO BID 4. Labetalol 200 mg PO BID 5. Losartan Potassium 50 mg PO DAILY 6. Paroxetine 20 mg PO DAILY 7. Simvastatin 40 mg PO DAILY 8. Tamsulosin 0.4 mg PO HS 9. Terazosin 5 mg PO HS Discharge Medications: 1. Finasteride 5 mg PO DAILY 2. Labetalol 200 mg PO BID 3. Simvastatin 40 mg PO DAILY 4. BuPROPion 100 mg PO BID 5. GlyBURIDE 5 mg PO BID 6. Paroxetine 20 mg PO DAILY 7. Tamsulosin 0.4 mg PO HS 8. Terazosin 5 mg PO HS 9. Thiamine 100 mg PO DAILY RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 10. Glargine 12 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 11. Multivitamins 1 TAB PO DAILY 12. Levofloxacin 500 mg PO Q48H until ___ Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: ___ Discharge Condition: Mental Status: Clear and coherent. Mental Status: Confused - sometimes. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report INDICATION: Alcohol abuse with multiple falls. Evaluate for acute intracranial hemorrhage. COMPARISON: CT head from ___. TECHNIQUE: Sequential axial images were acquired through the head without administration of intravenous contrast material. Multiplanar reformats were performed. CTDIvol: 64 mGy. TOTAL DLP: 2051 mGy-cm. FINDINGS: There is no evidence of intracranial hemorrhage, edema, shift of normally midline structures, hydrocephalus, or acute large vascular territorial infarction. Prominence of the ventricles and sulci suggests cortical volume loss. Calcifications are seen along the bilateral carotid siphons. The visualized portions of the paranasal sinuses and mastoid air cells are well aerated. The middle ears are clear. IMPRESSION: No acute intracranial process. Radiology Report INDICATION: History of bladder cancer, presenting with acute on chronic renal failure. Assess for evidence of hydronephrosis versus other etiology of obstructive uropathy. COMPARISON: CT abdomen and pelvis from ___. FINDINGS: The right kidney is normal in size, measuring 9.2 cm. A 6 mm cyst is seen within the right interpolar region. There is no right-sided hydronephrosis or hydroureter. There has been interval removal of a left-sided nephroureteral stent. There is new left-sided moderate hydronephrosis and full column hydroureter. Debris is seen within the left renal pelvis and proximal ureter. There is an 8.9 x 4.9 cm collection adjacent to the left kidney, seen to be subcapsular in location on the prior CT from ___, likely representing a subcapsular hematoma, not significantly changed in size allowing for differences in modality. The bladder is somewhat collapsed and difficult to assess. Mobile debris is seen within the dependent portion of the bladder. Probable thickening of the left posterior bladder wall correlates to the CT finding seen on this study dated ___, likely corresponding to the patient's known bladder mass. IMPRESSION: 1. New moderate left hydronephrosis and hydroureter. The ureteric dilatation extends from the level of the renal pelvis through its insertion on the bladder. 2. Layering debris within the left renal pelvis and proximal ureter, possibly due to urinary stasis, although correlation with clinical signs/symptoms of pyonephrosis is recommended. 3. Posterior bladder wall thickening, left greater than right, likely corresponding to patient's known bladder mass. Radiology Report HISTORY: ___ male with bladder cancer and new hydronephrosis. Evaluation for stone or other mass causing hydronephrosis. COMPARISON: Comparison is made to recent prior CT of the abdomen and pelvis from ___. TECHNIQUE: MDCT images were obtained of the abdomen and pelvis without IV or oral contrast. Reformatted coronal and sagittal images were also reviewed. FINDINGS: CT ABDOMEN WITHOUT IV CONTRAST: The bases of the lungs are clear. The lack of intravenous contrast somewhat limits assessment of solid organs and intra-abdominal vasculature. Given these limitations, the liver is unremarkable with no evidence of intra- or extra-hepatic biliary ductal dilatation. The gallbladder is normal in appearance. The spleen and bilateral adrenal glands are normal. A 17 mm hypodensity in the head of the pancreas (2:32)is unchanged in size since the most recent prior CT, and is incompletely characterized on this study. No pancreatic duct dilatation is present. The stomach, duodenum and small bowel are normal in course and caliber with no evidence of wall thickening or obstruction. The intra-abdominal loops of large bowel are also normal. The appendix is well visualized in the right lower quadrant and is normal (2:61). Since the prior study, there has been interval removal of a left ureteral stent and decrease in size of resolving left renal subcapsular hematoma (2:42). Mild hydroureteronephrosis with surrounding inflammatory fat stranding and ureteral wall thickening (601B:23, 2:47) is present. The right kidney is unremarkable with no evidence of hydronephrosis. CT PELVIS WITHOUT IV CONTRAST: Sigmoid diverticulosis is present, with no evidence of diverticulitis. Asymmetric left posterior wall thickening of the urinary bladder (2:75) corresponds to the area of known bladder cancer, and likely results in obstruction at the left ureterovesicular junction. Note is also made of a fat fluid level in the bladder lumen compatible with chyluria (2:74). Stranding about the distal left ureter is similar compared to the prior study. There is no pelvic free fluid. No pelvic sidewall or inguinal lymphadenopathy is present. Small fat containing right inguinal hernia is noted. OSSEOUS STRUCTURES: No lytic or blastic lesion suspicious for malignancy is present. Multilevel degenerative changes are again seen in the lumbar spine. IMPRESSION: 1. Interval removal of the left ureteral stent with new mild left hydroureteronephrosis, likely due to obstruction at the left ureterovesicular junction from known bladder cancer along the posterior left bladder wall. Left ureteral wall thickening and surrounding fat stranding may be due to an underlying infectious or inflammatory process. 2. Interval decrease in size in left subcapsular renal fluid collection, consistent with resolving hematoma. 3. Sigmoid diverticulosis with no evidence of diverticulitis. 4. Cystic lesion in the pancreatic head is unchanged in size since the most recent prior study, and is incompletely characterized on this exam. Followup MRI could be considered for further evaluation. 5. New chyluria, suggestive of injury or obstruction of the lymphatic vessels and communication with the collecting system, possibly due to prior urological intervention. Radiology Report HISTORY: ___ y/o male with history of bladder cancer and new left sided hydronephrosis COMPARISON: CT abdomen ___ OPERATORS: Dr. ___, Dr. ___ (fellow) and Dr. ___ ___ (resident). The attending was present and supervising throughout the entire procedure. ANESTHESIA: Moderate sedation was provided by administering divided doses of fentanyl and Versed throughout the total intra-service time of 35 min. The patient's hemodynamic parameters were continuously monitored by an independent ___ party nurse. A total dose of 150 mcg of fentanyl and 3 mg of Versed were used. 1% local lidocaine was also used subcutaneously. FINDINGS: The procedure was discussed in detail with the patient. The risks and benefits were emphasized. Informed written consent was obtained. When the patient arrived in the angiography suite they were placed prone on the procedure table. The left flank was prepped and draped in usual sterile fashion. A preprocedural time out was performed per ___ protocol. Under sonographic guidance a posterior mid pole calyx was identified within the left kidney. A 22 gauge cook needle was then advanced into the collecting system. Under fluoroscopic guidance an 0.018 Nitinol wire was advanced into the renal pelvis. The needle was then exchanged for an Accustick system. The wire was removed and cloudy white urine drained from the catheter. Contrast was administered into the collecting system demonstrating moderate left -sided hydronephrosis and a mild to moderately dilated proximal left ureter. An Amplatz wire was advanced through the Accustick sheath and coiled within the renal pelvis. The Accustick sheath was removed and 8 ___ dilator was used to open the tract over the Amplatz wire. This was followed by successful placement of an 8 ___ nephrostomy tube with the pigtail locked within the renal pelvis. Nephrostogram confirmed the location of the nephrostomy tube. An urine sample was sent to the lab for culture. The catheter was secured to the skin using a suture and flexitract. The catheter was placed to external bag drainage and bandaged according to protocol. The patient left the department in stable condition. No complications. IMPRESSION: Successful placement of an 8 ___ percutaneous left -sided nephrostomy tube. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: ABNORMAL LABS Diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED temperature: 97.3 heartrate: 68.0 resprate: 16.0 o2sat: 100.0 sbp: 106.0 dbp: 61.0 level of pain: 0 level of acuity: 2.0

ASSESSMENT & PLAN: ___ y/o M with history of depression, alcohol abuse, bladder cancer s/p multiple TURBTs/BCG therapy, alcohol abuse, recurrent falls, and recent left subcapsular hematoma who presented to ED at urging of his outpatient physicians for ___ (creatinine of 4.8, from a baseline 1.5). # ___: Presented with a Cr of 4.8 from a reported baseline of 1.5. He is well known to the Urology service given his h/o bladder cancer s/p multiple interventions and ongoing BCG treatment. Renal u/s showed new L hydronephrosis and hydroureter and CT scan showed obstruction at the level of the UVJ consistent with a stricture at the prior resection site. Given these findings, urology recommended urgent ___ placement of L percutaneous nephrostomy tube. His procedure was uneventful and his Cr quickly downtrended and was 2.3 at time of discharge. Urology will continue to follow. # Bacturia: Found to have positive UA and started on ceftriaxone in the ED. No leukocytosis, no apparent symptoms. ___ reported purulent urine during L PCN placement, so he was cultured from nephrostomy output and urine which both grew >100,000 group B strep, with transition to levofloxacin on discharge with total ___ntibiotics. # Alcohol abuse: Patient with h/o alcohol abuse with last known drink just prior to arrival in ED. He was placed on a CIWA protocol but did not score during this admission and did not require benzodiazepines. No B12 or folate deficiencies on lab studies. He should follow up with his PCP on discharge from rehab who can arrange outpatient psychiatry follow up. # Depression/Suicidal ideation: Pt reported passive SI per ED with no plan and reportedly said "I'm not going to actually do it." Did not meet ___ criteria per psych evaluation. On arrival to the floor he denied suicidal ideation and was consistently talking about future plans including "needing to pay rent". We continued his paxil and his wellbutrin was restarted once it was clear that he was not withdrawing. He should follow up with psychiatrist on discharge from rehab and outpatient social work resources. #Gait: Patient with a history of multiple falls in the setting of EtOH abuse, including two in the past week. Did not report any recent changes in his gait, and it appears to be a chronic rather than acute issue. Head CT was unremarkable. He was placed on strict fall precautions throughout this admission. He had a non traumatic fall inhouse and should continue to be monitored for fall prevention in rehab. # HTN: Stable this admission. Home losartan was held in the setting of ___. Home labetalol was continued. Urology can assess at follow up when to restart losartan. # DM2: He had elevated blood sugars inhouse. His glyburide was held inhouse. He was started on lantus 12U in house. He was discharge on lantus and glyburide. His continued need for insulin should be reassessed at rehab.

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Penicillins / Penicillin V Potassium / atorvastatin Attending: ___. Chief Complaint: Tachycardia, abdominal distention Major Surgical or Invasive Procedure: ___ Exploratory laparotomy with small bowel resection and anastomosis History of Present Illness: ___ with history of paroxysmal atrial fibrillation on apixaban s/p implantable loop recorder (___), peripheral T cell lymphoma s/p 6 cycles of CHOP (last on ___ in complete remission, small intestinal bacterial overgrowth, and dyslipidemia who presents with afib with RVR. Of note, patient has been undergoing work-up for abdominal pain/distention, flatulence, and constipation over the past few months. She was found to have SIBO via positive breath test and completed a 2-week course of rifaximin without significant improvement in her symptoms. Underwent EGD in ___ showing normal mucosa; biopsy with chronic focally active gastritis of antral and corpus mucosa with negative H pylori staining. Small bowel barium study in ___ showed single loop of ileum with a short segment of mucosal wall thickening c/f infection vs inflammation. Her PO intake has been limited in this setting and worsened over the past 2 weeks when she developed gastroenteritis with nausea and vomiting. Has been very fatigued. She reports that she woke up this AM feeling very dehydrated. She presented to ___ for an outpatient CT A/P for evaluation of worsening abdominal lymphadenopathy (c/f recurrent lymphoma) and felt clammy. She was found to have HR 150's and was given IV metoprolol 5mg prior to being transferred to the ___ ED. In the ED, initial vitals were: T97.6, HR 154, BP 105/67, SpO2 97% on RA Exam notable for: She is awake, alert, conversant. Irregular tachycardia, with equal peripheral pulses, warm and well-perfused. Lungs clear to auscultation bilaterally. Abdomen soft with minimal diffuse tenderness. Guaiac negative. Relevant labs: At OSH: WBC 6.2, Hgb 9.9 Na 129, K 3.8, Cr 0.7 Trops negative Repeat labs here: WBC 5.7, Hgb 9.0 Na 135, K 3.5, Cr 0.5, Ca 8.2, Mg 1.5 Trops negative INR 2.1 Relevant imaging: CXR showed no focal consolidation. Consults: EP was consulted. Given patient continued to be afib with RVR s/p IV metoprolol 5mg x2 with relative hypotension (SBP 80-90), decision was made to cardiovert the patient. Patient received: - IV metoprolol 5mg - 2L NSS bolus - IV ketamine prior to cardioversion - IV calcium gluconate 1g - IV Mg 2g Cardioversion was attempted with 100J, followed by 200J, and patient converted to NSR. Admitted to Medicine for further management. Vitals on transfer: T97.9, HR 98, BP 114/51, SpO2 95% on RA Upon arrival to the floor, patient reports generalized fatigue and persistent abdominal pain that is at baseline. Denies palpitations or current N/V. Denies recent fevers, cough, CP, SOB, abdominal pain, dysuria, melena/hematochezia, hematuria. Last BM was this AM. REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise negative. Past Medical History: Peripheral T-cell lymphoma, NOS, in complete remission SIBO s/p rifaximin Psoriasis Paroxysmal atrial fibrillation HLD Anemia Atrial and ventricular ectopy Social History: ___ Family History: Father died at age ___ of emphysema. Mother died at age ___ of a stroke. She has no siblings and no children. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: 24 HR Data (last updated ___ @ ___) Temp: 99.4 (Tm 99.4), BP: 117/61, HR: 98, RR: 21, O2 sat: 92%, O2 delivery: Ra GENERAL: Alert and interactive, laying in bed, in NAD, breathing comfortably on RA HEENT: NCAT, clear oropharynx, flat JVP CARDIAC: Irregularly irregular rhythm, normal rate, S1, S2, no m/r/g LUNGS: Mild bibasilar inspiratory crackles, otherwise clear ABDOMEN: Soft, mildly distended, diffusely TTP especially in LLQ, +rebound tenderness EXTREMITIES: No ___ edema NEUROLOGIC: AOx3 DISCHARGE PHYSICAL EXAM: ======================= Vitals: 24 HR Data (last updated ___ @ 811) Temp: 97.8 (Tm 98.9), BP: 155/74 (112-155/61-79), HR: 94 (70-97), RR: 18, O2 sat: 99% (97-99), O2 delivery: RA Fluid Balance (last updated ___ @ 810) Last 8 hours Total cumulative 276ml IN: Total 1576ml, PO Amt 120ml, IV Amt Infused 1456ml OUT: Total 1300ml, Urine Amt 1300ml Last 24 hours Total cumulative 1093.2ml IN: Total 3868.2ml, PO Amt 1080ml, IV Amt Infused 2788.2ml OUT: Total 2775ml, Urine Amt 2775ml Physical exam: Gen: NAD Pulm: no respiratory distress, non-labored breathing Abd: Softer and less distended, midline periumbilical area tender Wounds: midline incision healing well Pertinent Results: ADMISSION LABS: =============== ___ 02:30PM BLOOD WBC-6.2 RBC-3.59* Hgb-9.9* Hct-30.2* MCV-84 MCH-27.6 MCHC-32.8 RDW-13.2 RDWSD-41.1 Plt ___ ___ 02:30PM BLOOD Neuts-72.4* Lymphs-7.4* Monos-15.7* Eos-3.0 Baso-1.0 Im ___ AbsNeut-4.51 AbsLymp-0.46* AbsMono-0.98* AbsEos-0.19 AbsBaso-0.06 ___ 04:00PM BLOOD ___ PTT-29.4 ___ ___ 02:30PM BLOOD Glucose-115* UreaN-18 Creat-0.7 Na-129* K-3.8 Cl-90* HCO3-27 AnGap-12 ___ 01:10AM BLOOD ALT-12 AST-13 AlkPhos-115* TotBili-0.6 ___ 04:00PM BLOOD TotBili-0.4 ___ 02:30PM BLOOD cTropnT-<0.01 ___ 04:00PM BLOOD cTropnT-<0.01 ___ 04:00PM BLOOD Calcium-8.2* Phos-3.5 Mg-1.5* Iron-18* ___ 04:00PM BLOOD calTIBC-224* VitB12-197* Folate-8 Hapto-235* Ferritn-122 TRF-172* ___ 04:00PM BLOOD TSH-0.64 ___ 04:00PM BLOOD T4-7.2 PERTINENT MICRO: ================ ___ Blood culture x2: negative. ___ Urine culture: negative. ___ Blood culture x2: NGTD. ___ Urine culture: negative. ___ CMV: negative. ___ EBV: IgG positive, IgM negative. ___ C.diff: negative. ___ Stool culture: pending. PERTINENT IMAGING: ================== CXR ___: Worsening bilateral pleural effusions and bibasilar atelectasis. CXR ___: Comparison with the study of ___, the cardiomediastinal silhouette is stable. Little change in the degree vascular congestion and bilateral pleural effusions with compressive atelectasis, more prominent on the left. No evidence of acute focal pneumonia. The right upper lobe nodule and mild hilar adenopathy were much better evaluated on the CT scan from ___. ___ 05:38AM BLOOD Digoxin-0.4* Radiology Report INDICATION: ___ year old woman with h/o PTCL, NOS treated with 6 cycles of CHOP chemotherapy ending in ___. Now with persistent abdominal bloating, with some lymphadenopathy noted on ___ exam.// Reassess lymphadenopathy for change concerning for recurrent lymphoma. TECHNIQUE: PA and lateral scouts obtained prior to CT abdomen, study aborted due to presence of residual barium in bowel loops. DOSE: Acquisition sequence: 1) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 2.4 mGy (Body) DLP = 1.2 mGy-cm. Total DLP (Body) = 1 mGy-cm. COMPARISON: CT abdomen dated ___ FINDINGS: Please note, this is a limited exam, study aborted due to presence of residual barium within small and large bowel loops, that would potentially degrade image quality. IMPRESSION: Limited exam-lateral and AP scouts only-due to presence of residual barium within small and large bowel loops, that were potentially degrade image quality. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with A fib with RVR, please assess for acute cardiopulmonary process// History: ___ with A fib with RVR, please assess for acute cardiopulmonary process TECHNIQUE: Single frontal view of the chest COMPARISON: ___ FINDINGS: No focal consolidation is seen. There is no pleural effusion or pneumothorax. Cardiac and mediastinal silhouettes are unremarkable. IMPRESSION: No acute cardiopulmonary process. Radiology Report INDICATION: ___ year old woman with paroxysmal atrial fibrillation on apixaban and SIBO who presents with afib with RVR s/p cardioversion, with abdominal pain.// obstruction, ileus, perforation TECHNIQUE: Supine and upright abdominal radiographs were obtained. COMPARISON: Small-bowel follow-through from ___. FINDINGS: Retained contrast is seen in the small bowel and colon. Multiple contrast enhanced diverticuli are seen. There are no abnormally dilated loops of large or small bowel. There is a nonobstructive bowel gas pattern. There is no free intraperitoneal air. Osseous structures are unremarkable. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: No evidence of perforation or obstruction. Retained orally ingested contrast from the recent prior CT abdomen is present within nondilated large bowel loops. Inspissated barium is also noted within innumerable colonic diverticuli. Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ with hx of peripheral T cell lymphoma in complete remission as of ___, recent small intestinal bacterial overgrowth and gastroenteritis p/w abd pain// eval progression of mesenteric lymphadenopathy and etiology of periumbilical pain 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 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2 mGy-cm. 2) Stationary Acquisition 3.5 s, 1.0 cm; CTDIvol = 8.1 mGy (Body) DLP = 8.1 mGy-cm. 3) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2 mGy-cm. 4) Spiral Acquisition 14.5 s, 49.9 cm; CTDIvol = 7.1 mGy (Body) DLP = 345.6 mGy-cm. 5) Stationary Acquisition 3.5 s, 1.0 cm; CTDIvol = 8.1 mGy (Body) DLP = 8.1 mGy-cm. 6) Spiral Acquisition 14.5 s, 49.9 cm; CTDIvol = 7.1 mGy (Body) DLP = 345.6 mGy-cm. Total DLP (Body) = 736 mGy-cm. COMPARISON: CT from ___.. FINDINGS: LOWER CHEST: Bilateral pleural effusion measuring 35 mm on the right, and 13 mm on left. Mild passive atelectatic changes. An emphysematous bullae seen in the right lung base. 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. There is a small amounts of perihepatic free fluid. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: Multiple hypodense splenic lesions are new measuring up to 12 mm. There is also mild splenomegaly, measuring 14 cm. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of hydronephrosis. There is a 5 mm hypodensity of the midpole of the right kidney, too small to characterize but likely a cyst. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. There is thickening of a mid small-bowel loop spanning approximately 9 cm in length with wall thickness measuring up to 9 mm. There is near aneurysmal dilation, which is concerning for lymphomatous involvement. We suspect wall thickening of the terminal ileum. There is colonic diverticulosis. 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 not well visualized. LYMPH NODES: There are numerous enlarged lymph nodes in the retroperitoneum, with largest measuring 14 mm in short axis in the left para-aortic location. In the mesentery, multiple lymph nodes, fat stranding and edematous changes are noted with largest lymph nodes measuring up to 18 mm in short axis. Pelvic adenopathies are also noted, measuring up to 7 mm on the left pelvic sidewall and 7 mm on the right. Even though these are of subcentimeter size, they are larger than on prior study. There is nodular thickening of the broad ligament on the left, which is also concerning. VASCULAR:There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Small-bowel wall thickening with aneurysmal dilation, multiple retroperitoneal and mesenteric lymphadenopathies, as well as enlarging pelvic lymph nodes. Ascites and bilateral pleural effusion is noted. This constellation of findings is highly concerning for recurrent lymphoma. 2. New splenic hypodensities, also concerning for recurrent lymphoma Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with fever and cough// eval for PNA TECHNIQUE: Chest PA and lateral COMPARISON: CT abdomen pelvis from earlier today and radiographs dated ___ FINDINGS: There are small bilateral pleural effusions with subjacent atelectasis. No pneumothorax. The size of the cardiac silhouette is within normal limits. An implantable loop recorder projects over the left hemithorax. IMPRESSION: Small bilateral pleural effusions with subjacent atelectasis. No focal consolidation to suggest pneumonia. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ year old woman with h/o peripheral T cell lymphoma w/ CT A/P c/f LAD and bowel involvement c/w recurrence// eval for additional LAD and e/o lymphoma TECHNIQUE: CT chest with IV contrast. DOSE: Acquisition sequence: 1) Spiral Acquisition 8.8 s, 33.6 cm; CTDIvol = 6.7 mGy (Body) DLP = 212.7 mGy-cm. Total DLP (Body) = 222 mGy-cm. COMPARISON: PET-CT ___. FINDINGS: NECK, THORACIC INLET, AXILLAE, CHEST WALL: The thyroid gland is unremarkable. There is no axillary lymphadenopathy. UPPER ABDOMEN: Unremarkable. MEDIASTINUM and HILA: A precarinal lymph node measuring 1.2 cm (03:25) and right hilar lymph node measuring 1.0 cm (03:34) are similar in appearance in comparison to prior PET-CT ___. HEART and PERICARDIUM: The heart is normal in size without pericardial effusion. PLEURA: There are moderate bilateral pleural effusions. LUNG: 1. PARENCHYMA: Scarring at the lung apices right greater than left. Nodular pleural opacity at the right lung apex not definitively seen on the prior exam measures 8 mm (series 4, image 16). 2. AIRWAYS: The central airways are patent. 3. VESSELS: There are mild atherosclerotic calcifications in the aorta. CHEST CAGE: There are degenerative changes in the spine. IMPRESSION: 1. Stable hilar and mediastinal lymph nodes in comparisons prior PET-CT of ___. 2. Right upper lobe pulmonary nodule measuring 8 mm. This was not definitively seen on the prior examination. Continued surveillance is recommended. 3. Moderate sized bilateral pleural effusions. RECOMMENDATION(S): Updated impression was discussed with ___ M.D. by ___, M.D. on the telephone on ___ at 11:01 am. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with edema/dilation of single loop of small bowel. Increasing abdominal pain and tenderness.// Eval perforation TECHNIQUE: AP portable chest radiograph COMPARISON: ___ CT chest FINDINGS: Bilateral pleural effusions remain present with subjacent atelectasis. There is no pneumothorax identified. No evidence of pulmonary edema. The size of the cardiac silhouette is within normal limits. No free air is visualized under the diaphragm. IMPRESSION: No evidence of pneumoperitoneum. Bilateral pleural effusions. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with history of peripheral T-cell lymphoma, in remission following CHOP in ___ was initially admitted to medicine after being found to be inAFib with RVR during outpatient CT scan. Subsequent imaging hasshown aneurysmal dilation and edema of her ileum along withprogressive RP, mesenteric, and pelvic lymphadenopathy concerningfor relapsed lymphoma. Now with new O2 requirement.// evaluate for edema, infection TECHNIQUE: Chest PA and lateral COMPARISON: Multiple prior chest radiographs most recently from ___ CT from ___ FINDINGS: Implantable loop recorder projects over the left chest, stable. Interval increase in opacities at the lung bases bilaterally compared to chest radiograph from ___ likely representing worsening pleural effusions with bibasilar atelectasis. There is evidence of worsening pulmonary vascular congestion without overt pulmonary edema. Cardiomediastinal and hilar contours are unchanged. Right upper lobe pulmonary nodule and mild hilar lymphadenopathy are not definitively appreciated, better evaluated on prior CT chest from ___. IMPRESSION: Worsening bilateral pleural effusions and bibasilar atelectasis. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with history of T cell lymphoma, course c/b afib with RVR.// ?increased size of pleural effusions, pulmonary edema IMPRESSION: Comparison with the study of ___, the cardiomediastinal silhouette is stable. Little change in the degree vascular congestion and bilateral pleural effusions with compressive atelectasis, more prominent on the left. No evidence of acute focal pneumonia. The right upper lobe nodule and mild hilar adenopathy were much better evaluated on the CT scan from ___. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old woman with new R PICC// R DL Power PICC 38cm ___ ___ Contact name: ___: ___ TECHNIQUE: AP portable chest radiograph COMPARISON: Multiple prior chest radiographs most recently from ___ FINDINGS: Interval placement of a right upper extremity PICC line with tip projecting near the mid superior vena cava. Cardiomediastinal and hilar contours are stable. Interval improvement of pulmonary vascular congestion. Stable small right and improved small left pleural effusion. No definite focal consolidation. No pneumothorax. IMPRESSION: Right upper extremity PICC line tip projects near the mid superior vena cava. Radiology Report INDICATION: ___ year old woman with T cell lymphoma with c/f recurrence as abdominal LAD, loop of bowel seen on PET with lymphomatous involvement of small bowel// Please take upright film, eval for signs of bowel obstruction TECHNIQUE: Portable supine abdominal radiograph was obtained. COMPARISON: Multiple prior exams, most recent radiograph dated ___. FINDINGS: Mildly dilated loops of small bowel, measuring up to 4.0 cm. Normal caliber gas and stool-filled large bowel. There is no free intraperitoneal air. Osseous structures are unremarkable. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: Mildly dilated loops of small bowel may represent an early small bowel obstruction versus ileus. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Tachycardia Diagnosed with Unspecified atrial fibrillation, Tachycardia, unspecified temperature: 97.6 heartrate: 154.0 resprate: 18.0 o2sat: 97.0 sbp: 105.0 dbp: 67.0 level of pain: uta level of acuity: 1.0

___ year old woman with history of peripheral T-cell lymphoma, in remission following CHOP in ___, who was initially admitted to medicine after being found to be in AFib with RVR during outpatient CT scan. Subsequent imaging has shown aneurysmal dilation and edema of her ileum along with progressive RP, mesenteric, and pelvic lymphadenopathy concerning for relapsed lymphoma.