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Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: s/p fall Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a pleasant ___ who presents as a transfer from ___ for a T1 compression fracture as well as a right clavicle and ___ rib fractures. She initially had a mechanical fall last night at her nursing home which she did not tell anyone about. This AM her aids noticed swelling and pain of her right shoulder. She presented to the ___ ED where she underwent a CT Head, C-Spine, Chest, Abdomen and Pelvis. In addition to multiple non-acute findings, the work-up revealed the displaced right clavicle fracture, right first and second rib fractures, and a T1 compression fracture of indeterminate chronicity. She was transferred to ___ with concern for the thoracic fracture. On exam here she was found to be pleasant, hemodynamically appropriate, in minimal pain and saturating well on room air. She had no neurological deficit or tenderness over her T spine. Images were not sent with her or electronically so they could not be reviewed. Past Medical History: PAST MEDICAL HISTORY: HTN HLD Hypothyroidism Rectal cancer Iron-deficiency anemia Dementia PAST SURGICAL HISTORY: Denies Social History: ___ Family History: Non-contributory Physical Exam: Afebrile, VSS GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses DRE: normal tone, no gross or occult blood Ext: TTP at right clavicle, contusion of right upper back. RUE in sling. No ___ edema, ___ warm and well perfused Pertinent Results: Right shoulder and clavicle X-ray (___): IMPRESSION: Mildly displaced fracture involving the right mid clavicle. Nondisplaced right first and second rib fractures. CT T-spine ___: IMPRESSION: 1. Study is limited secondary to diffuse osteopenia. 2. Age indeterminate T1 and T6 anterior compression deformities, without prevertebral soft tissue swelling. While findings may be chronic in nature, if concern for acute fracture, consider cyst thoracic spine MRI for further evaluation. 3. Ground-glass opacity in the right lower lobe is similar to 1 day ago and may reflect inflammatory, infectious or neoplastic process. 4. Minimal interval progression of small right basilar atelectasis versus small effusion. If clinically indicated, consider dedicated chest imaging for further evaluation. 5. Multilevel degenerative changes as described, most pronounced at T7-8, where there is at least small vertebral canal stenosis. 6. Moderate hiatal hernia. Medications on Admission: Ensure Compact oral liquid 4oz BID Citalopram 10 mg Daily Colace 100 mg Daily Donepezil 5 mg QHS Levothyroxine 88 mcg Daily Vitamin D3 1,000 unit Daily Vitamin B-12 1,000 mcg/mL injection once a month Discharge Medications: 1. Acetaminophen 650 mg PO TID 2. Ciprofloxacin HCl 250 mg PO Q12H UTI Duration: 5 Days Please continue until ___ for total 5 day course. RX *ciprofloxacin HCl 250 mg 1 tablet(s) by mouth twice a day Disp #*7 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID 4. Senna 8.6 mg PO HS 5. TraMADol 25 mg PO Q6H:PRN Pain - Moderate RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth q6 Disp #*30 Tablet Refills:*0 6. Citalopram 10 mg PO DAILY 7. Donepezil 5 mg PO QHS 8. Levothyroxine Sodium 88 mcg PO DAILY 9. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: 1. R displaced clavicle 2. ___ rib fractures 3. T 1 compression fx Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE INDICATION: ___ year old woman s/p fall with rib fractures and T1 fracture of questionable chronicity evaluate for acute cervical trauma. TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue and bone algorithm images were generated. Coronal and sagittal reformations were then constructed. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.8 s, 22.8 cm; CTDIvol = 32.4 mGy (Body) DLP = 738.1 mGy-cm. Total DLP (Body) = 738 mGy-cm. COMPARISON: Thoracic spine CT dated ___. FINDINGS: The visualized osseous structures are osteopenic. Severe multilevel degenerative changes include minimal anterolisthesis of C2 on C3 and of C7 on T1, likely degenerative in the absence of acute cervical spine fracture (602b:43). Multilevel facet arthropathy, uncovertebral hypertrophy, and posterior osteophyte formation cause moderate right greater than left neural foraminal stenosis throughout the cervical spine, worst at C4-C5 where neural foraminal stenosis is severe (02:53). There is no acute cervical spine fracture. A comminuted mildly displaced right clavicular fracture and minimally displaced posterior right first and second rib fractures are better assessed on outside hospital chest CT ___: 29, 43, 53). Partial opacification of the left mastoid air cells is noted without associated skullbase fracture. IMPRESSION: 1. No acute fracture of the cervical spine. 2. Extensive multilevel degenerative changes including multilevel anterolisthesis and severe C4-5 right sided neural foraminal stenosis. Please note MRI of the cervical spine is more sensitive for the evaluation of ligamentous injury. 3. Comminuted right medial third clavicular fracture and minimally displaced right first and second rib fractures. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 3:39 ___, 2 minutes after discovery of the findings. Radiology Report INDICATION: History: ___ with pain in right shoulder and clavicle TECHNIQUE: Right shoulder, three views and right clavicle, two views COMPARISON: None. FINDINGS: Oblique fracture involving the right mid clavicle is demonstrated with mild medial and superior dislocation of the distal fracture fragment and approximately 15 mm of overlap. No dislocation is seen. Mild degenerative spurring is noted involving the right AC and glenohumeral joints. There are no soft tissue calcifications. No concerning lytic or sclerotic osseous abnormalities seen. Imaged right lung is grossly clear. There appear to be a nondisplaced fractures involving the right first and second ribs posteriorly. IMPRESSION: Mildly displaced fracture involving the right mid clavicle. Nondisplaced right first and second rib fractures. Radiology Report EXAMINATION: CT T-SPINE W/O CONTRAST Q321 CT SPINE INDICATION: ___ female status post trauma. Evaluate for T1 compression 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 7.3 s, 28.8 cm; CTDIvol = 30.9 mGy (Body) DLP = 890.7 mGy-cm. Total DLP (Body) = 891 mGy-cm. COMPARISON: ___ 0706 outside torso CT. FINDINGS: For the purposes of numbering, the highest rib-bearing vertebral body was designate the T1 level. There is mild anterolisthesis of C7 on T1. The visualized osseous structures are osteopenic. There is mild anterior wedge deformity of T1 and T6. There is no prevertebral soft tissue swelling. Within the limits of this noncontrast study, there is no evidence of infection or neoplasm. There is multilevel degenerate changes of the thoracic spine which include extensive loss of intervertebral disc height, endplate sclerosis, vacuum disc phenomenon, endplate subchondral cysts, facet joint arthropathy and disc osteophyte complexes. At T7-8 there is partially calcified disc bulge resulting in at least mild vertebral canal stenosis. Ground-glass opacity in the right lower lobe is similar to prior examination. There is been interval progression of right basilar atelectasis versus small pleural effusion. A 2.6 cm hypodensity in the left kidney is consistent with a simple renal cyst. There is moderate hiatal hernia. Atherosclerotic vascular calcifications are noted. IMPRESSION: 1. Study is limited secondary to diffuse osteopenia. 2. Age indeterminate T1 and T6 anterior compression deformities, without prevertebral soft tissue swelling. While findings may be chronic in nature, if concern for acute fracture, consider cyst thoracic spine MRI for further evaluation. 3. Ground-glass opacity in the right lower lobe is similar to 1 day ago and may reflect inflammatory, infectious or neoplastic process. 4. Minimal interval progression of small right basilar atelectasis versus small effusion. If clinically indicated, consider dedicated chest imaging for further evaluation. 5. Multilevel degenerative changes as described, most pronounced at T7-8, where there is at least small vertebral canal stenosis. 6. Moderate hiatal hernia. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: T-spine fracture Diagnosed with Multiple fractures of ribs, right side, init for clos fx, Unspecified fall, initial encounter temperature: 98.6 heartrate: 80.0 resprate: 18.0 o2sat: 97.0 sbp: 109.0 dbp: 74.0 level of pain: 0 level of acuity: 3.0

The patient is an ___ who was transferred from ___ after a fall at her nursing home. She was found to have a T1 compression fracture as well as a right clavicle and ___ rib fractures. At the outside hospital, she underwent a CT Head, C-Spine, Chest, Abdomen and Pelvis. In addition to multiple non-acute findings, the work-up revealed the displaced right clavicle fracture, right first and second rib fractures, and a T1 compression fracture of indeterminate chronicity. She was transferred to ___ with concern for the thoracic vertebral fracture. She was admitted to the trauma service for pain management of her rib fractures, which was optimized during her stay to allow for adequate respiratory effort in combination with incentive spirometry. She was seen by the orthopedic team for her clavicle fracture and her right arm was placed in a sling. Additionally, she was seen by the neurosurgery team to evaluate her T1 fracture, which was deemed chronic, and no intervention was required. She was discharged home in stable condition with her pain well controlled.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Amoxicillin / Shellfish Attending: ___ Chief Complaint: Chest pain, shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: ___ old woman with a history of heart failure with preserved LVEF (LVEF 46% ___, severe aortic stenosis s/p TAVR (___) c/b ___ cardiac arrest, coronary artery disease status post CABG complicated by in-stent restenosis ___, status post multiple PCIs with persistent stable angina, hypertension, hyperlipidemia, diabetes, ___ stage kidney disease initiated on ___, anemia, and s/p recent DES to Cx and POBAs more distally that was complicated by hypotension. Now coming in for chest pain. During her last admission with discharge ___ she underwent PCI on ___ with DES to Cx and POBAs more distally that was complicated by periprocedural hypotension requiring CCU admission for IABP and dobutamine briefly. CCU course was complicated by small left groin hematoma requiring 1U pRBC, which has since resolved. Was planned for discharge on ___, but had chest pain during HD with slowly uptrending troponins. She received heparin for 24h, and we restarted her Imdur at 120mg PO daily which was the uptitrated to 180mg PO daily as well as uptitrating Metoprolol succinate to 100mg BID for another episode of chest pain 48 hours later after a hemodialysis session. She developed severe left-sided chest pressure before bed last night at about 1am. It developed while she was lying in bed. It was associated with shortness of breath. It does not radiate to her back, arms, or jaw. This does feel like the pain she has with previous ischemic events however not as intense. She was given 3 nitros with only mid symptomatic improvement and subsequently developed a headache. She denies nausea, vomiting, abdominal pain, extremity tingling or numbness. In the ED, initial vitals were: Temp 98.5 HR 65 BP 140/71 RR18 SpO2 94% 2L NC - Exam: General: Appearing stated age HEENT: NCAT, PEERL, MMM Neck: Supple, trachea midline Heart: RRR, no MRG. No peripheral edema. Lungs: CTAB. No wheezes, rales, or rhonchi. Diminished breath sounds bilateral bases Abd: Soft, NTND. GU: No CVA tenderness MSK: No obvious limb deformities. Derm: Skin warm and dry Neuro: Awake, alert, moves all extremities. Psych: Appropriate affect and behavior - Labs: 'CBC/Diff' : WBC: 6.5. HGB: 9.3*. 'Chem 10' : Na: 133* . K: 6.1* Cl: 95*. CO2: 22. BUN: 33*. Creat: 3.0*. Glucose: 92 Ca: 9.1. Mg: 1.6. PO4: 3.2. ___: %HbA1c: 6.0 'Cardiac Labs' CK-MB: 2. proBNP: GREATER TH (GREATER THAN ___ Troponin T: a) 0.23* b) 0.23* - Imaging: ___: Chest X-Ray: CHEST (PA & LAT) - ECG: LAD with PVC's resolved TWI in V3 - Consults: Renal-Dialysis with plan to remove 1L - Patient was given: Epoetin Alfa 8000 UNIT Heparin Dwell (1000 Units/mL) 1600 UNIT Upon arrival to the floor, patient reports that she feels well however is continuing to have chest pain over her left chest that is now very mild. She denies any dyspnea, fever, chills, N/V, abd pain, ___ edema or dysuria. ECG and cardiac markers were repeated and noted to be largely unchanged. Past Medical History: 1. CARDIAC RISK FACTORS - Type 2 diabetes mellitus with nephropathy and retinopathy - Hypertension - Hyperlipidemia 2. CARDIAC HISTORY - CABG ___ - TAVR ___ - Congestive heart failure, diastolic dysfunction (LVEF 46% TTE ___ - Cartotid stenosis s/p CEA - TIA 3. OTHER PAST MEDICAL HISTORY - ESRD ___ DM/HTN) on HD ___ - Chronic anemia likely secondary to chronic renal insufficiency - Iron deficiency anemia - Asthma (FVC 66%, FEV1 76%) - Diverticulosis - Gout - Temporal arteritis Social History: ___ Family History: - Mother had MI in her ___ - Grandmother had diabetes - Father passed away in an accident Physical Exam: ADMISSION EXAM: 24 HR Data (last updated ___ @ 1751) Temp: 98.6 (Tm 98.6), BP: 150/85, HR: 79, RR: 20, O2 sat: 99%, O2 delivery: 1L NC ___: Weight: 88.62 (Standing Scale) GEN: Alert, cooperative, no distress, appears stated age HENT: NC/AT, MMM. Nares patent, no drainage or sinus tenderness. No Teeth present and gums are normal. EYES: PERRL, EOM intact, conjunctivae clear, no scleral icterus. NECK: No cervical lymphadenopathy. No JVD, no carotid bruit. Neck supple, symmetrical, trachea midline. LUNG: inspiratory crackles in bilateral bases L>R, good air movement, no accessory muscle use HEART: RRR, Normal S1/S2, ___ systolic murmur at LUSB, ___ systolic murmur at apex BACK: Symmetric, no curvature. ROM normal. No CVA tenderness. ABD: Soft, non-tender, non-distended; nl bowel sounds; no rebound or guarding, no organomegaly GU: Not examined EXTRM: Extremities warm, no edema, no cyanosis, positive ___ pulses bilaterally SKIN: Skin color and temperature, appropriate. No rashes or lesions NEUR: CN II-XII intact . Moving all extremities, strength, sensation and reflexes equal and intact throughout. PSYC: Mood and affect appropriate DISCHARGE EXAM: 24 HR Data (last updated ___ @ 1457) Temp: 99.0 (Tm 99.0), BP: 115/62 (115-130/62-82), HR: 73 (72-77), RR: 18 (___), O2 sat: 96% (95-100), O2 delivery: 1L (1L-1.5 L), Wt: 85.54 lb/38.8 kg (from 88 lbs on ___ Gen: lying comfortably in bed in NAD HEENT: PERRL, EOMI, OP clear CV: RRR, nl S1, S2, II/VI SEM, JVP flat Chest: crackles resolved R base, decreased BS L base Abd: + BS, soft, NT, ND MSK: lower ext warm without edema Skin: R tunneled HD catheter in place, c/d/I Neuro: AOx3, CN II-XII intact, ___ strength all ext, sensation grossly intact, gait not tested Psych: pleasant, appropriate affect Pertinent Results: CBC: ___ 03:15AM BLOOD WBC-6.5 RBC-3.12* Hgb-9.3* Hct-30.2* MCV-97 MCH-29.8 MCHC-30.8* RDW-18.4* RDWSD-65.0* Plt ___ ___ 06:50AM BLOOD WBC-6.6 RBC-2.82* Hgb-8.5* Hct-27.7* MCV-98 MCH-30.1 MCHC-30.7* RDW-18.6* RDWSD-66.8* Plt ___ CHEM: ___ 03:15AM BLOOD Glucose-92 UreaN-33* Creat-3.0* Na-133* K-6.1* Cl-95* HCO3-22 AnGap-16 ___ 06:50AM BLOOD Glucose-102* UreaN-10 Creat-1.9*# Na-136 K-3.9 Cl-96 HCO3-29 AnGap-11 ___ 03:15AM BLOOD Calcium-9.1 Phos-3.2 Mg-1.6 ___ 08:16AM BLOOD Calcium-8.9 Phos-2.3* Mg-2.2 ___ 08:25AM BLOOD Calcium-8.9 Phos-1.8* Mg-1.9 ___ 06:50AM BLOOD Calcium-9.0 Phos-2.2* Mg-1.7 CARDIAC ENZYMES: ___ 09:15AM BLOOD cTropnT-0.23* ___ 09:25PM BLOOD CK-MB-2 cTropnT-0.26* ___ 02:20PM BLOOD CK-MB-3 cTropnT-0.28* ___ 12:42PM BLOOD CK-MB-2 cTropnT-0.19* ___ 05:45PM BLOOD CK-MB-2 cTropnT-0.21* IMAGING: ======== CXR (___): Comparison to ___. Decreased lung volumes, stable moderate left pleural effusion. Increasing right pleural effusion. Signs of mild to moderate pulmonary edema now present. Moderate cardiomegaly persists. Stable alignment of the sternal wires, stable position of the hemodialysis catheter. EKG ___ after nitro): NSR at 73 bpm, LAD, LVH, PR 214, QRS 108, QTC 408, Q in III, TW flattening I/AVL, TWI V2-V3, significant improvement in ST depressions in V2-V6 compared to early ___ EKG ___ w/chest pain): NSR at 83 bpm, LAD, LVH, PR 212, QRS 110, QTC 406, Q in III, TWI I/AVL with ST depressions II, V2-V6 with reciprocal STE AVR (ST depressions more prominent than ___ EKG (___): NSR at 63 bpm, borderline LAD, PR 190, QRS 108, QTC 427, Q in III, TW flattening inferior leads, TWI and ST depressions V3-V6 (TWI/ST depressions more prominent compared to ___ CXR (___): Mild decrease in extent of the pulmonary edema. Otherwise no significant interval change. TTE (___): Mildly reduced left ventricular systolic function (EF 45%). Mildly dilated right ventricle with moderate global hypokinesis. Increased left ventricular filling pressure. Severe inferolaterally directed mitral regurgitation. Mild tricuspid regurgitation. Small inferolateral pericardial effusion. Moderate pulmonary hypertension. Compared with the prior TTE ___ , the severity of tricuspid regurgitation has decreased. The right ventricle is less dilated. The pericardial effusion has increased in size. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Calcitriol 0.25 mcg PO M, WED, FRI 5. Clopidogrel 75 mg PO DAILY 6. Fluticasone Propionate 110mcg 2 PUFF IH DAILY 7. Fluticasone Propionate NASAL 2 SPRY NU DAILY 8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 9. Levothyroxine Sodium 50 mcg PO ___ 10. Levothyroxine Sodium 100 mcg PO SUN 11. Montelukast 10 mg PO DAILY 12. Nephrocaps 1 CAP PO DAILY 13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 14. Pantoprazole 40 mg PO Q24H 15. Senna 17.2 mg PO BID 16. sevelamer CARBONATE 800 mg PO TID W/MEALS 17. Thiamine 100 mg PO DAILY 18. B complex with C#20-folic acid 1 mg oral DAILY 19. mometasone-formoterol 200-5 mcg/actuation inhalation BID 20. Metoprolol Succinate XL 100 mg PO BID 21. Isosorbide Mononitrate (Extended Release) 180 mg PO DAILY 22. Polyethylene Glycol 17 g PO DAILY 23. amLODIPine 2.5 mg PO DAILY Discharge Medications: 1. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY 2. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN 3. amLODIPine 2.5 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 80 mg PO QPM 6. B complex with C#20-folic acid 1 mg oral DAILY 7. Calcitriol 0.25 mcg PO M, WED, FRI 8. Clopidogrel 75 mg PO DAILY 9. Fluticasone Propionate 110mcg 2 PUFF IH DAILY 10. Fluticasone Propionate NASAL 2 SPRY NU DAILY 11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 12. Levothyroxine Sodium 100 mcg PO SUN 13. Levothyroxine Sodium 50 mcg PO ___ 14. Metoprolol Succinate XL 100 mg PO BID 15. mometasone-formoterol 200-5 mcg/actuation inhalation BID 16. Montelukast 10 mg PO DAILY 17. Nephrocaps 1 CAP PO DAILY 18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 19. Pantoprazole 40 mg PO Q24H 20. Polyethylene Glycol 17 g PO DAILY 21. Senna 17.2 mg PO BID 22. Thiamine 100 mg PO DAILY 23. HELD- sevelamer CARBONATE 800 mg PO TID W/MEALS This medication was held. Do not restart sevelamer CARBONATE until a doctor tells you because you have low phos Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Angina Type 2 NSTEMI CAD HFpEF Severe MR ___ stage renal disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report INDICATION: History: ___ with chest pain, oxygen requirement.// ? acute cardiopulmonary process TECHNIQUE: Chest AP and lateral COMPARISON: Multiple prior chest radiographs, most recently ___. FINDINGS: A right sided central venous catheter terminates in the upper right atrium, as before. Prosthetic valve, mediastinal surgical clips and sternotomy wires are unchanged. The lungs are moderately lax banded. Retrocardiac opacity may reflect atelectasis, although it is difficult to exclude pneumonia. There is pulmonary vascular congestion and mild interstitial edema. Small bilateral pleural effusions are present. No pneumothorax. Cardiomegaly is unchanged. IMPRESSION: 1. Cardiomegaly with small bilateral pleural effusions and mild pulmonary edema. 2. Retrocardiac opacity may be related to atelectasis, although it is difficult to exclude pneumonia if clinically appropriate. Radiology Report INDICATION: ___ year old woman with o2 req, hypotension// Evaluation for pneumonia TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: Unchanged right central venous catheter terminating in the right atrium. The patient has had prior median sternotomy and cardiac replacement. The size of the cardiac silhouette is enlarged but unchanged. A retrocardiac opacity likely reflects atelectasis and a small pleural effusion. A small right pleural effusion is also unchanged. No pneumothorax. Mild pulmonary edema is decreased since prior. IMPRESSION: Mild decrease in extent of the pulmonary edema. Otherwise no significant interval change. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with new cough, dyspnea, decreased right breath sounds// Pneumonia? Pneumonia? IMPRESSION: Comparison to ___. Decreased lung volumes, stable moderate left pleural effusion. Increasing right pleural effusion. Signs of mild to moderate pulmonary edema now present. Moderate cardiomegaly persists. Stable alignment of the sternal wires, stable position of the hemodialysis catheter. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Chest pain Diagnosed with Chest pain, unspecified, Pleural effusion, not elsewhere classified temperature: 98.5 heartrate: 65.0 resprate: 18.0 o2sat: 94.0 sbp: 140.0 dbp: 71.0 level of pain: 7 level of acuity: 2.0

___ with a PMH significant for HFpEF (LVEF 45% ___, severe aortic stenosis s/p TAVR (___) c/b ___ cardiac arrest, coronary artery disease status post CABG complicated by in-stent restenosis ___, status post multiple PCIs with persistent stable angina (last DES to LMCA-Cx ___, HTN, HLD, DM, ESRD on HD ___ p/w angina, likely secondary to demand ischemia in setting of unrevascularized coronary disease, course c/b recurrent chest pain post HD and pulmonary edema. # Angina: # CAD s/p CABG: # NSTEMI: # HTN: # Acute on chronic HFpEF: # Severe MR/mild TR: # Moderate pHTN: # B/l pleural effusions with pulmonary edema: Patient p/w chest pain with dynamic EKG changes (lateral TWI and ST depressions) and stable cardiac enzyme elevation (peaked at 0.28), likely secondary to demand ischemia in setting of volume overload and incompletely revascularized CAD. Low suspicion for acute plaque rupture. TTE revealed stable mildly reduced systolic function (EF 45%) and severe MR compared to ___. Ms. ___ was clear that she is not interested in further invasive interventions for her severe CAD. She was seen by cardiology for assistance with medical management of refractory angina, who initially recommended discontinuation of amlodipine and transition from home Toprol to carvedilol and uptitration of home Imdur for angina. On that regimen, she developed mild, asyptomatic hypotension after HD on ___ (with UF 1L) with SBPs in the ___, resolved with gentle IVF replacement. Her BPs improved, but unfortunately she had recurrence of angina post HD ___ (at which time only 500cc was removed), with more extensive ST depressions in the anterolateral leads and some improvement with SL nitro, suggestive of persistent demand ischemia with HD-related fluid shifts. In discussion with cardiology and renal, ranolazine was thoughtcontraindicated and she was transitioned back to home metoprolol and amlodipine with continuation of uptitrated Imdur. She tolerated HD ___ (with 1L UF) on that regimen without recurrence of chest pain, and is being discharged on Toprol 100mg BID, amlodipine 2.5mg daily, and Imdur 240mg daily, along with her home ASA, plavix, and atorvastatin. Unfortunately, additional pharmacologic management of refractory angina is limited, and fluid management will remain challenging given the need to maintain euvolemia in setting of ESRD, acute on chronic HFpEF, and severe MR while maximizing coronary/systemic perfusion. Dry weight on discharge 85.54 lb/38.8 kg. ___ NP follow-up scheduled for ___. # SOB/cough: # Asthma: Ms. ___ developed mild SOB and cough on ___ prior to HD, likely secondary to pulmonary edema/small b/l pleural effusions. CXR showed no e/o PNA, and her symptoms improved with HD. She was intermittently kept on 1L NC during her hospitalization for comfort, with adequate oxygenation on RA (with goal SpO2 >92%). Home albulterol, fluticasone, Advair (in place of home mometasone-formoterol for formulary reasons), and montelukast were continued. She will need to f/u with her outpatient pulmonologist (Dr. ___ after discharge. # ESRD: # Hypophosphatemia: Renal followed and she was maintained on HD ___. As above, fluid management will remain challenging given the need to maintain euvolemia in setting of ESRD, acute on chronic HFpEF, and severe MR while maximizing coronary/systemic perfusion. Dry weight on discharge 85.54 lb/38.8 kg. Continued home calcitriol and nephrocaps. Home sevelamer was held on d/c for hypophosphatemia per renal recommendations. # Hyponatremia: Likely secondary to ESRD and impaired ability to dilute urine. Improved with HD. # Normocytic anemia: Likely due to ESRD. No evidence of active bleeding. Continued on Epo with HD. # Hypothyroidism: Continued home levothyroxine. # GERD: Continued home PPI. # DM: Diet controlled. Was maintained on an ISS in-house. # Contact: ___ (son) ___ (updated ___ # Code: DNR/DNI (confirmed; no ICU tx and no NIPPV or invasive interventions) TRANSITIONAL ISSUES: ======================= [ ] f/u response to Imdur uptitration for chronic angina [ ] ensure pulmonary f/u; missed appoint while hospitalized [ ] repeat phos; may need to resume sevelamer [ ] continue ESRD ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Lipitor / Influenza Virus Vaccine Attending: ___. Chief Complaint: Orthostatis Major Surgical or Invasive Procedure: none History of Present Illness: ___ yo F with hypothyroidism and HLD with no known CAD who awoke ___ with L leg cramp she's had previously and had gradual onset of chest pressure while at rest. She had associated presyncope without vertigo when getting out of bed, worsened with warm shower but resolving over a few minutes. She had no tachycardia, diaphoresis, radiation of pain, dyspnea, or worsening with exertion and the chest pain did not recur all day. She did have palpitations/irreg HR. This has never occurred previously. Per Dr. ___ the leg cramp "is something that she gets periodically (about every 2 months) and was no different in intensity, quality of discomfort, than usual". In the ED intial vitals were: Temp: 97.7 HR: 63 BP: 153/77 Resp: 18 O2Sat: 96 Normal -Troponins negative x2 -Chest x-ray negative -ETT and went 3.75 min on mod ___ and achieved ___ METs with non-specific ST changes. Her BP dropped from 98/60-->90/60. Overall, due to her limited exercise tolerance, the test is non-diagnostic. -During her ED obs course she was persistently orthostatic after a large PO water challenge (1L free water = 125cc isotonic crystalloid challenge) and 1L IVF. Patient was given: -1L NS in past 2hrs, none previously -81mg ASA yesterday Vitals on transfer: Today 16:58 Sitting 68 161/79 Today 16:58 Standing 76 140/86 RR 17 98% r/a, afebrile Today 16:58 Sitting 68 161/79 Past Medical History: #DCIS ___: cured with lumpectomy #Hyperlipidemia: Last LDL ___, not on tx #Hypothyroidism: on levothyroxine Social History: ___ Family History: Father with first MI at age less than ___. Positive for CAD Physical Exam: ADMISSION EXAM: 97.7 HR: 63 BP: 153/77 Resp: 18 O2Sat: 96 Normal General: Alert, oriented, no acute distress, pleasantly conversing HEENT: malar telangiectasias, conjunctival pallor, sclerae anicteric, MMM, oropharynx clear Neck: JVP < 8 Lungs: CTAB CV: RRR, no m/r/g Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNs2-12 intact, no tremor, no pronator drift, motor ___ throughout, DTRs ___ at patellae, ___ at biceps/triceps, normal FTN DISCHARGE EXAM: VS: 98.4 127/81 53 18 98% General: Alert, oriented, no acute distress, pleasantly conversing HEENT: malar telangiectasias, conjunctival pallor, sclerae anicteric, MMM, oropharynx clear Neck: JVP < 8 Lungs: CTAB CV: RRR, no m/r/g Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNs2-12 intact, no tremor, no pronator drift, motor ___ throughout, DTRs ___ at patellae, ___ at biceps/triceps, normal FTN Pertinent Results: ___ 03:15PM BLOOD WBC-6.3 RBC-4.86 Hgb-14.7 Hct-45.3 MCV-93 MCH-30.4 MCHC-32.6 RDW-13.2 Plt ___ ___ 03:15PM BLOOD Neuts-61.4 ___ Monos-7.2 Eos-1.6 Baso-2.3* ___ 03:15PM BLOOD Glucose-95 UreaN-12 Creat-0.7 Na-140 K-5.3* Cl-103 HCO3-24 AnGap-18 ___ 09:14PM BLOOD cTropnT-<0.01 ___ 03:15PM BLOOD cTropnT-<0.01 ___ 10:02AM BLOOD D-Dimer-265 ___ 03:20PM BLOOD Lactate-1.4 ___: STUDY: Chest radiograph. INDICATION: Chest pain and weakness. Rule out pneumonia. TECHNIQUE: Two views were obtained. COMPARISON: ___. REPORT: There is pulmonary hyperinflation. Some generalized increased lung markings are seen. Heart size is normal. No acute cardiopulmonary finding is noted. Degenerative changes in the spine and bony osteopenia are noted. Biapical calcification is seen. CONCLUSION: No acute findings. ---------- TOTAL EXERCISE TIME: 3.75 % MAX HRT RATE ACHIEVED: 64 SYMPTOMS: ATYPICAL INTERPRETATION: This ___ yo woman was referred to the lab for evaluation of chest pain and pre-syncope. The patient exercised for 3.75 minutes on a Modified ___ protocol and was stopped for a drop in systolic BP accompanied by fatigue, weakness, and mild lightheadedness. The estimated peak MET capacity was 3 which represents a poor exercisetolerance for her age. The patient denied any arm, neck, back, or chest discomfort however she did note fatigue, shortness of breath, heaviness\weakness in the lower extremities as well as mild to moderate lightheadedness. These discomforts resolved by 3 minutes in recovery. At peak exercise there was ~0.5 mm upsloping/scooping ST segment depression in the inferolateral leads which returned to baseline morphology by 6 minutes in recovery. The rhythm was sinus with frequent isolated APBs and several atrial couplets. Blunted HR response to exercise in the absence of beta blockade. Progressive drop in systolic BP at a low workload. IMPRESSION: Mild pre-syncopal symptoms associated with a drop in SBP at a low workload. Non-specific EKG changes in the absence of anginal symptoms. Abnormal HR and BP response. Poor exercise tolerance. ------------ ECG: NSR, rate 58, nl axis and intervals. No ST or TW changes consistent with ischemia. ECG w/ R sided precordial leads also shows NSR w/ no ischemia. PACs. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 88 mcg PO DAILY 2. Aspirin 81 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Levothyroxine Sodium 88 mcg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Orthostatic hypotension Atypical chest pain Hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report STUDY: Chest radiograph. INDICATION: Chest pain and weakness. Rule out pneumonia. TECHNIQUE: Two views were obtained. COMPARISON: ___. REPORT: There is pulmonary hyperinflation. Some generalized increased lung markings are seen. Heart size is normal. No acute cardiopulmonary finding is noted. Degenerative changes in the spine and bony osteopenia are noted. Biapical calcification is seen. CONCLUSION: No acute findings. Gender: F Race: WHITE - OTHER EUROPEAN Arrive by AMBULANCE Chief complaint: CHEST PAIN Diagnosed with CHEST PAIN NOS temperature: 97.7 heartrate: 63.0 resprate: 18.0 o2sat: 96.0 sbp: 153.0 dbp: 77.0 level of pain: 0 level of acuity: 2.0

___ yo F with hypothyroidism and HLD with no known CAD who awoke ___ gradual onset of chest pressure while at rest and came to ED for evaluation. She was ruled out for ACS and PE and had non-diagnostic ETT. She was found to have orthostatic hypotension and was admitted. #Orthostasis: She had prominent orthostatic hypotension with relative bradycardia in the ED. This was concerning for some sympatholytic process though the patient does not take AV nodal blockers or sympatholytics, no did she look hypothyroid. She had no neurologic findings associated with primary autonomic failure or multiple system atrophy. She had normal bowel and bladder function. She received a total of 2L IVF and her orthostasis improved. She remained orthostatic despite fluid resuscitation. EKGs showed normal sinus rhythm and sinus bradycardia with PACs. She had no further CP or presyncope. She was asymptomatic and wanted to discharge with outpatient cardiology follow up. #Atypical Chest Pressure: Found to have non-ischemic EKG changes in ED and negative troponins x2. She did not tolerate an ETT and the findings were inconclusive. It was recommended by cardiology that she get outpatient dobutamine TTE to risk stratify her. She has mild HLD, +family CAD history, but is otherwise low risk. #Hypothyroidism: She was treated with her home levothyroxine.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Ranitidine / Celebrex Attending: ___. Chief Complaint: weakness Major Surgical or Invasive Procedure: None History of Present Illness: This is a ___ year old ___ speaking woman with a history of recurrent UTIs who is presenting with two days of weakness, report of foul smelling urine and one day of dyspnea. She lives alone with care giver who is there for most of the day and has a daughter nearby who was with her in the emergency room. I was unable to reach her daughter ___, ___ overnight. The remainder of this history was obtained from the patient with the help of a ___ translator by phone. She explains that she fell 10 days ago in the corridor of her building and landed on her knees. No headstrike and no LOC. She did not seek medical attention at that time. Her knees have been hurting her since however. She has also been feeling more tired than usual. According to her daughter she has not been getting out of bed for the last two days. When I asked her why she said that it was because it hurt to walk. Of note her daughter reported that she had foul-smelling urine. The patient herself denies any dysuria, urinary frequency, or change in smell. She does confirm that she felt somewhat short of breath earlier today however she states that this was mild and resolved. Otherwise she has not felt much differently than her baseline except for the knee pain. She does note that she has not been eating and drinking much over the last few days primarily because she has been in bed. When asked she states that she does have some nausea but mostly just after drinking water. When asked she said she does have some mild pain with swallowing that she has noticed for the last 10 days or so (roughly since her fall). She does not otherwise have a sore throat. No chest pain, cough, abdominal pain, vomiting, diarrhea, constipation, dysuria, change in urinary frequency, dizziness, light-headedness, headache. Of note she did have a UTI with a urine culture on ___ U growing out E.coli resistant to trim/sulfa, amp, cipro, levoflox which was treated with macrobid. On the floor she is complaining of thirst but otherwise denying any other current pain or symptoms. Her knee pain has resolved. She is not short of breath. Review of Systems: (+) as per HPI (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, chest pain, abdominal pain, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: DEPRESSION DYSPEPSIA HYPERCHOLESTEROLEMIA INSOMNIA LEUKOCYTOSIS OSTEOARTHRITIS PALPITATIONS S/P APPENDECTOMY S/P COCCYX FRACTURE S/P OS VITREOUS DETACHMENT PERIPHERAL EDEMA VITAMIN B12 DEFICIENCY VISITING NURSE H/O COLONIC POLYPS H/O L SHOULDER PAIN H/O SCIATICA H/O VERTIGO H/O ATRIAL FIBRILLATION Social History: ___ Family History: NC Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 97.7 145/63 91 20 98/ra General: elderly woman in NAD HEENT: NCAT, dry MM, EOMI, limited oropharyngeal exam was WNL Neck: no JVD appreciated Lungs: diminished breath sounds anteriorly CV: RRR no murmurs appreciated Abdomen: soft, nontender in all quadrants, +bs Ext: no significant edema, knees mildly swollen, no significant effusions, on initial exam right knee was warm compared to left however this resolved on re-examination Neuro: CN2-12 grossly intact, moving all extremities DISCHARGE PHYSICAL EXAM: Vitals- 97.6 123/56 62 18 95/2L General: elderly woman. Unkempt. AOx2. HEENT: NCAT, MMM, EOMI Neck: JVD<8cm Lungs: Rales bilaterally R>L, extending halfway up. No wheezes, rhonchi. CV: regular rate, regular rhythm, no murmurs appreciated Abdomen: soft, nontender in all quadrants, +bs Ext: no significant edema, knees mildly swollen, no significant effusions. Neuro: CN2-12 grossly intact, strength is grossly intact. Pertinent Results: LABS: On admission: ___ 06:57PM BLOOD WBC-29.0*# RBC-5.20 Hgb-15.3 Hct-49.1* MCV-94 MCH-29.4 MCHC-31.2 RDW-13.7 Plt ___ ___ 06:57PM BLOOD Neuts-49* Bands-0 ___ Monos-5 Eos-2 Baso-0 Atyps-2* ___ Myelos-0 ___ 06:57PM BLOOD ___ PTT-29.2 ___ ___ 09:20PM BLOOD Glucose-132* UreaN-37* Creat-1.1 Na-136 K-4.2 Cl-99 HCO3-30 AnGap-11 ___ 07:08PM BLOOD Lactate-1.6 On discharge: ___ 08:15AM BLOOD WBC-22.4* RBC-4.71 Hgb-13.9 Hct-45.1 MCV-96 MCH-29.5 MCHC-30.9* RDW-13.8 Plt ___ ___ 08:15AM BLOOD ___ ___ 08:15AM BLOOD Glucose-103* UreaN-28* Creat-0.9 Na-143 K-4.2 Cl-102 HCO3-38* AnGap-7* Miscellaneous: ___ 04:55PM BLOOD ESR-52* ___ 04:55PM BLOOD CRP-106.5* ___ 07:00AM BLOOD TSH-2.9 ___ 06:30AM BLOOD CK-MB-14* MB Indx-4.7 cTropnT-0.06* ___ 04:55PM BLOOD CK-MB-9 cTropnT-0.08* ___ 10:15AM BLOOD CK-MB-7 cTropnT-0.07* ___ 06:13AM BLOOD CK-MB-8 cTropnT-0.07* proBNP-___* ___ 05:55PM BLOOD cTropnT-0.05* MICRO: ___ blood cx x2 ___ 7:10 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. ___ 10:01 am URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING: ___ CT abd/pelvis: IMPRESSION: 1. Focal cortical abnormality in the right kidney suggestive of infection or infarction. This is age indeterminate but new since ___. Clinical correlation is recommended. 2. Indeterminate left adrenal nodule again seen but stable compared to prior, likely representing an adenoma or myelolipoma. ___ CXR: FINDINGS: There are low lung volumes and bibasilar atelectasis. There is persistent elevation of the right hemidiaphragm. There is blunting of the left costophrenic angle, which could be due to a small effusion. There are questionable subtle rib deformities along the lateral fifth and sixth ribs of indeterminate age, correlate with history of trauma. The cardiac silhouette is not assessed but is likely top normal to mildly enlarged. Mediastinal contours are unremarkable. No overt pulmonary edema. Mild prominence of the pulmonary vasculature is likely at least in part due to low lung volumes. ___ Knee xray: IMPRESSION: Severe degenerative changes of both knees involving predominantly the medial compartment which appear stable, allowing for differences in patient positioning from the ___ study. ___ CXR: FINDINGS: Mild pulmonary vascular congestion is new. Right middle and right lower lobe atelectasis has slightly worsened, with persistent adjacent elevation of right hemidiaphragm. Slight improvement in left retrocardiac opacity, likely due to atelectasis. Small left pleural effusion is unchanged. No visible pneumothorax ___ The left atrial volume is normal. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Moderate mitral regurgitation with normal valve morphology. Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. Mild pulmonary artery hypertension. CLINICAL IMPLICATIONS: Based on ___ AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. ___ Non-contrast head CT: (wet read) Signficant brain atrophy. Some hypodensity possibly due to small vessel ischemic disease. No evidence of old territorial infarcts suggestive of embolic CVAs. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Metoprolol Succinate XL 100 mg PO DAILY 2. TraZODone 50 mg PO HS:PRN insomnia 3. Vitamin D 1000 UNIT PO DAILY 4. Acetaminophen ___ mg PO BID:PRN pain 5. Aspirin 325 mg PO DAILY 6. Furosemide 20 mg PO TWICE WEEKLY MON + ___ 7. Omeprazole 40 mg PO DAILY 8. Senna 1 TAB PO BID:PRN constipation 9. Cyanocobalamin 1000 mcg IM/SC MONTHLY Discharge Medications: 1. Cyanocobalamin 1000 mcg IM/SC MONTHLY 2. Furosemide 20 mg PO TWICE WEEKLY MON + ___ 3. Metoprolol Succinate XL 100 mg PO DAILY 4. TraZODone 50 mg PO HS:PRN insomnia 5. Citalopram 10 mg PO DAILY 6. Vitamin D 1000 UNIT PO DAILY 7. Senna 1 TAB PO BID:PRN constipation 8. Aspirin 325 mg PO DAILY 9. Acetaminophen 650 mg PO TID Pain 10. Omeprazole 40 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES: DEPRESSION ATRIAL FIBRILLATION DYSPHAGIA OSTEOARTHRITIS (BILATERAL KNEES) DEMENTIA Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report STUDY: Bilateral knees, ___. CLINICAL HISTORY: ___ woman status post fall ___ days ago, now with knee pain. FINDINGS: LEFT KNEE: There are severe degenerative changes involving predominantly the medial compartment where there is marked joint space narrowing. Spurring within all three compartments is seen and there is a small left knee joint effusion. RIGHT KNEE: There is moderate narrowing of the medial compartment; however, these are non-weightbearing views. There is also a small right knee joint effusion. Degenerative changes within all three compartments are present. Vascular calcifications are seen posteriorly. IMPRESSION: Severe degenerative changes of both knees involving predominantly the medial compartment which appear stable, allowing for differences in patient positioning from the ___ study. Radiology Report PORTABLE CHEST, ___ COMPARISON: Radiograph of two days earlier. FINDINGS: There is a worsening area of opacity in the left retrocardiac region, which could potentially be due to aspiration given the history of clinical suspicion for this entity. Lungs are otherwise remarkable for right lower lobe atelectasis, moderate elevation of right hemidiaphragm, and an apparent calcified granuloma in the left lung apex. Cardiomediastinal contours are stable in appearance. Radiology Report PA AND LATERAL CHEST, ___ COMPARISON: Radiograph of earlier the same date. FINDINGS: Mild pulmonary vascular congestion is new. Right middle and right lower lobe atelectasis has slightly worsened, with persistent adjacent elevation of right hemidiaphragm. Slight improvement in left retrocardiac opacity, likely due to atelectasis. Small left pleural effusion is unchanged. No visible pneumothorax. Radiology Report HISTORY: Patient with atrial fibrillation (no anticoagulation) who has no focal deficits but has delirium superimposed on dementia, evaluate for evidence of 1) diffuse global atrophy consistent with Alzheimer's dementia; 2) old ischemic CVA. COMPARISON: NECT of the head on ___. 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. CTDI vol: 162 mGy, DLP: 1560 mGy-cm FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or large vascular territorial infarction. Again seen is an arachnoid cyst in the left temporal lobe, unchanged since prior study. There is diffuse supra and infratentorial atrophy compatible with age without medial temporal predominance to suggest Alzheimer's disease. 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. There is mild mucosal thickening of the right maxillary sinus and air-fluid level in the left sphenoid sinus. The remaining visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. Atherosclerotic mural calcifications of the bilateral cavernous segments of the internal carotid arteries are noted. The globes are unremarkable. IMPRESSION: 1. No evidence of acute intracranial process. Diffuse global atrophy without medial temporal predominance to suggest possible Alzheimer's disease. 2. Chronic small vessel ischemic disease. Gender: F Race: WHITE - RUSSIAN Arrive by WALK IN Chief complaint: Dyspnea, Weakness Diagnosed with OTHER MALAISE AND FATIGUE temperature: 96.6 heartrate: 78.0 resprate: 18.0 o2sat: 100.0 sbp: 174.0 dbp: 74.0 level of pain: 0 level of acuity: 3.0

___ year old ___ speaking woman with a history of hypertension, hyperlipidemia, paroxysmal afib (not on coumadin), depression, chronic leukocytosis (thought to be due to CLL) and recurrent UTIs who is admitted with subjective symptoms of weakness and lethagy. Found to have signficant deconditioning and depression, course complicated by afib with RVR.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abd discomfort, nausea/vomiting Major Surgical or Invasive Procedure: None History of Present Illness: ___ yoM with ESRD ___ DMII and HTN on dialysis, diabetic retinopathy, and gastroparesis who presents with 1 week of epigastric burning and nausea. He was at dialysis today but only received 26 min due to nausea/vomiting, upper abd to throat burning, and hypotension, prompting transfer to the ED. The patient has a chronic history of GERD for which he takes antacids. He usually experiences these symptoms for several hours which resolves with antacids or vomiting. However, his current symptoms have persisted for 1 week. He denies f/c, cough, or dysuria. He endorses diarrhea but think this is due to laxatives as he usually has constipation. - In the ED, initial vital signs were: 97.9 98 173/88 16 97%RA - Labs were notable for: lactate 1, nl coags, trop 0.05, Na 132, BUN/Cr 35/8, alk phos 233, 15.5>12.3/39.4<428 with neutrophilic predominance. - EKG: SR, NA, NI, no acute STT changes - CXR: Moderate sized bilateral pleural effusions with probable associated loculation. An underlying focal opacity however cannot be entirely excluded. - Patient was given: ___ 15:45 IV Ondansetron 4 mg ___ 16:31 PO Pantoprazole 40 mg ___ 16:31 PO Aluminum-Magnesium Hydrox.-Simethicone 30 mL Decision was made to admit for cardiac w/u and dialysis. No emergent need for drainage of pleural effusions given chronic and no new respiratory symptoms. Does not have fevers or cough indicative of empyema. Of note, patient has history of chronic bilateral pleural effusions. Is on 3L NC at baseline. Of note, patient saw PCP ___ when he was experiencing worsening abd pain and nausea despite taking protonix, reglan, and promethazine. His sxs were presumed to be from gastroparesis and his meds were continued. He was referred to GI but never made appointment. He had colonoscopy ___ yrs ago in ___ but was never told of a diagnosis. He has never had an upper endoscopy. He eats 5 small meals per day for gastroparesis. On Transfer Vitals were: 98.3 99 171/88 18 99%RA On the floor, patient denies current nausea or abd pain. He experienced relief with Maalox and Zofran. Past Medical History: PAST MEDICAL HISTORY: - END STAGE RENAL DISEASE: ___ diabetes and HTN. On HD MWF at ___ in ___ - HYPERTENSION - DIABETIC RETINOPATHY - GASTROPARESIS - TOBACCO ABUSE - H/O DIABETES TYPE II: was on insulin for ___ years, lost 60lbs and hgbA1C have been well controlled off of medication PAST SURGICAL HISTORY: - APPENDECTOMY - SPLENECTOMY: after trauma/fall - CATARACT SURGERY - AV FISTULA REPAIR Social History: ___ Family History: Mother with hyperlipidemia, MI s/p PCI Physical Exam: ON ADMISSION: Vitals: 98.2 159/87 100 18 98%3L General: Chronically ill appearing, in NAD HEENT: PERRL, sclera anicteric, oropharynx clear, MMM, JVP 8cm, no cervical LAD CV: RRR, no m/r/g Lungs: Bibasilar crackles, no wheezing or rhonchi Abdomen: Distended but soft, nontender to palpation, midline incision scar (from splenectomy) GU: No foley, anuric Ext: WWP, fistula on R, pulses intact bilaterally, no edema Neuro: AAOx3, non-focal Skin: No rashes ON DISCHARGE: Vitals: 98.3 140s-150s/60s-80s ___ 18 97-98%3L General: Chronically ill appearing, in NAD HEENT: PERRL, sclera anicteric, oropharynx clear, MMM, JVP 8cm, no cervical LAD CV: RRR, no m/r/g Lungs: Bibasilar crackles, no wheezing or rhonchi Abdomen: Distended but soft, nontender to palpation, midline incision scar (from splenectomy) GU: No foley, anuric Ext: WWP, fistula on R, pulses intact bilaterally, no edema Neuro: AAOx3, non-focal Skin: No rashes Pertinent Results: ON ADMISSION: ___ 02:30PM BLOOD WBC-15.5* RBC-3.99* Hgb-12.3* Hct-39.4* MCV-99* MCH-30.8 MCHC-31.2* RDW-13.3 RDWSD-48.0* Plt ___ ___ 02:30PM BLOOD Neuts-80.1* Lymphs-8.3* Monos-8.5 Eos-2.1 Baso-0.5 Im ___ AbsNeut-12.42* AbsLymp-1.29 AbsMono-1.32* AbsEos-0.33 AbsBaso-0.08 ___ 03:17PM BLOOD ___ PTT-30.1 ___ ___ 02:30PM BLOOD Glucose-160* UreaN-35* Creat-8.0* Na-132* K-4.9 Cl-86* HCO3-33* AnGap-18 ___ 02:30PM BLOOD ALT-12 AST-12 CK(CPK)-49 AlkPhos-233* TotBili-0.3 ___ 02:30PM BLOOD CK-MB-2 ___ 02:30PM BLOOD cTropnT-0.05* ___ 07:45AM BLOOD Albumin-4.0 Calcium-9.6 Phos-4.0 Mg-4.5* ___ 03:20PM BLOOD Lactate-1.0 ___ 02:30PM BLOOD Lipase-29 ON DISCHARGE: ___ 07:45AM BLOOD WBC-10.0 RBC-3.68* Hgb-11.4* Hct-36.6* MCV-100* MCH-31.0 MCHC-31.1* RDW-13.3 RDWSD-48.8* Plt ___ ___ 07:45AM BLOOD Glucose-100 UreaN-42* Creat-9.6*# Na-133 K-5.8* Cl-87* HCO3-31 AnGap-21* ___ 07:45AM BLOOD ALT-13 AST-10 LD(LDH)-171 AlkPhos-215* TotBili-0.3 ___ 07:45AM BLOOD CK-MB-1 cTropnT-0.06* ___ 07:45AM BLOOD Albumin-4.0 Calcium-9.6 Phos-4.0 Mg-4.5* OTHER STUDIES: ___ CXR: Possible bilateral pleural effusions with pleural-based thickening and/or prominent extrapleural fat. More rounded opacity posterior on the lateral view may be due to loculated fluid however underlying focal parenchymal opacity is possible. Correlation with prior imaging would be helpful to document stability. If not available, CT should be performed to further characterize, the acuity of which can be determined clinically Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoclopramide 10 mg PO QIDACHS 2. Pantoprazole 40 mg PO Q24H 3. Amlodipine 10 mg PO DAILY 4. CloniDINE 0.2 mg PO BID 5. Promethazine 25 mg PO TID:PRN nausea 6. Nephrocaps 1 CAP PO DAILY 7. TraZODone 100 mg PO QHS 8. Cinacalcet 60 mg PO DAILY Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Metoclopramide 10 mg PO QIDACHS 3. Promethazine 25 mg PO TID:PRN nausea 4. TraZODone 100 mg PO QHS 5. Pantoprazole 40 mg PO Q24H 6. Nephrocaps 1 CAP PO DAILY 7. CloniDINE 0.2 mg PO BID 8. Cinacalcet 60 mg PO DAILY 9. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN abd discomfort RX *alum-mag hydroxide-simeth [Maalox Maximum Strength] 400 mg-400 mg-40 mg/5 mL 15 mL by mouth four times a day Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY: Gastroparesis SECONDARY: Diabetes mellitus type 2 End stage renal disease on hemodialysis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: Chest radiograph. INDICATION: ___ with nausea, vomiting // eval for CHF/pneumonia TECHNIQUE: Chest PA and lateral COMPARISON: None available. FINDINGS: Pleural based opacities, right greater than left are possible bilateral pleural effusions with possible pleural thickening and/or prominent pleural fat. Opacity on the lateral view posteriorly may be a loculated effusion however, an underlying focal parenchymal opacity is possible. There is associated bibasilar atelectasis. There is no pneumothorax. The cardiac silhouette is obscured by the pleural fluid. The hilar and mediastinal contours are normal. Vascular stent projects over the left upper chest. Vascular stents project in the left subclavian/axillary regions. IMPRESSION: Possible bilateral pleural effusions with pleural-based thickening and/or prominent extrapleural fat. More rounded opacity posterior on the lateral view may be due to loculated fluid however underlying focal parenchymal opacity is possible. Correlation with prior imaging would be helpful to document stability. If not available, CT should be performed to further characterize, the acuity of which can be determined clinically Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: n/v/d Diagnosed with Nausea, Dizziness and giddiness temperature: 97.9 heartrate: 98.0 resprate: 16.0 o2sat: 97.0 sbp: 173.0 dbp: 88.0 level of pain: 6 level of acuity: 3.0

___ yoM with ESRD ___ DMII and HTN on dialysis, diabetic retinopathy, and gastroparesis who presents with 1 week of epigastric burning and nausea and inability to complete HD on day of admission due to hypotension. In the ED he was noted to have elevated troponin of 0.05 was therefore admitted to medicine for cardiac w/u and HD. However, patient's EKG showed no ischemic and his CK-MB was flat. Patient also denied chest pain but rather epigastric burning radiating to his throat which is typical of his existing GERD symptoms. His elevated trop was therefore interpreted in the setting of ESRD. Patient received HD day of discharge. Patient's nausea was thought to be due to worsening of his known gastroparesis, as he reported no change in the quality of his nausea or abdominal pain. He was treated with Maalox with notable improvement in his symptoms. He was also continued on his home pantoprazole, metoclopramide, and promethazine. During admission he was able to tolerate po without nausea or vomiting.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: L hip pain Major Surgical or Invasive Procedure: ___ L proximal femur replacement History of Present Illness: ___ hx colon cancer s/p radiation therapy and resection ___ ago now w L hip pain since ___ when getting out of car w L femoral neck fx identified on MRI, pain acutely worse x2days w repeat XR showing displacement of fx. Denies trauma, fevers, chills, other complaints. Past Medical History: HTN pre-diabetes colon cancer s/p colectomy and ileostomy reversal in ___ Social History: denies smoking or illicits, social EtOH Physical Exam: admit: AFVSS AOx3, well appearing LLE: slightly shortened and externally rotated ttp over greater troch, + pain w logroll and hip flexion ___ SILT throughout DP2+, wwp d/c: AFVSS AOx3, well appearing LLE: incision c/d/i ___ SILT throughout DP2+, wwp Pertinent Results: ___ 11:00AM GLUCOSE-208* UREA N-38* CREAT-1.3* SODIUM-134 POTASSIUM-4.5 CHLORIDE-96 TOTAL CO2-27 ANION GAP-16 ___ 11:00AM estGFR-Using this ___ 11:00AM CALCIUM-10.0 PHOSPHATE-2.8 MAGNESIUM-2.0 ___ 11:00AM WBC-9.5 RBC-3.82* HGB-12.0* HCT-35.7* MCV-93 MCH-31.4 MCHC-33.6 RDW-12.9 ___ 11:00AM NEUTS-89.0* LYMPHS-6.7* MONOS-3.8 EOS-0.3 BASOS-0.2 ___ 11:00AM PLT COUNT-153 ___ 11:00AM ___ PTT-26.7 ___ Radiology Report CHEST RADIOGRAPH INDICATION: Left hip pain, preoperative chest x-ray. COMPARISON: No comparison available at the time of dictation. FINDINGS: The lung volumes are normal. Normal size of the cardiac silhouette. Moderate tortuosity of the thoracic aorta. No pulmonary edema. No pneumonia, no pleural effusions. Radiology Report EXAM: AP view of the pelvis and AP and lateral views of the left femur. ___ at 14:32. HISTORY: Known hip fracture on pelvic x-rays. TECHNIQUE: AP view of the pelvis and AP and lateral views of the left femur. FINDINGS: Left femoral neck fracture with foreshortening of the left femur is again seen. There is evidence of sclerosis in the region and just distal to the fracture suggesting that it may be pathologic. No evidence of dislocation is seen. No fracture of the more distal left femur is identified. Degenerative changes are noted at the left sacroiliac joint and mildly at the pubic symphysis as well as at the right hip. There is no diastasis of the pubic symphysis or sacroiliac joints. Chain sutures are noted in the pelvis. IMPRESSION: Left femoral neck fracture with sclerosis in the region and just distal to it with a somewhat mottled appearance raising concern for pathologic fracture. No dislocation is seen. There is no evidence of acute fracture of the more distal left femur. Radiology Report INDICATION: ___ man with recent pathologic fracture. COMPARISON: Hip radiograph dated ___. TECHNIQUE: MDCT-acquired contiguous CT imaging through the abdomen and pelvis was obtained with intravenous contrast. Coronally and sagittally reformatted images are provided. CT OF THE ABDOMEN AND PELVIS: ABDOMEN: There is a small right and a trace left pleural effusion and associated atelectasis. There is a small hiatal hernia and reflux of contrast into the esophagus. There is a 5 mm indeterminate liver lesion in the inferior right hepatic lobe, which is predominantly hypodense though too small to characterize; tiny focus of hyperdensity near its periphery may represent an adjacent vessel or focus of peripheral enhancement. The liver otherwise enhances normally. There is no evidence of intrahepatic or extrahepatic biliary ductal dilatation. The portal vein is patent. The gallbladder is incompletely distended. There is no gallbladder wall edema or pericholecystic fluid collection to suggest acute inflammation. No calcified gallstones are seen within its lumen. The spleen is unremarkable. The pancreas enhances homogeneously without ductal dilatation or peripancreatic fluid collection. The adrenal glands are normal. The kidneys enhance and excrete contrast symmetrically without evidence of hydronephrosis. There are bilateral parapelvic renal cysts. No suspicious renal masses. There is no free air or free fluid within the abdomen. There is no mesenteric or retroperitoneal lymphadenopathy. No evidence of bowel obstruction. CT OF THE PELVIS: There is a Foley catheter within a collapsed urinary bladder. The distal ureters, prostate gland, seminal vesicles are unremarkable. There is a colorectal anastamosis, which appears patent. No free air or free fluid within the pelvis. No pelvic wall or inguinal lymphadenopathy. There is a left hip replacement with adjacent staple and foci of gas, which are consistent with recent surgery. There is a hematoma in the left adductor musculature. There is aortic atherosclerosis and tortuousity. IMPRESSION: 1. 5 mm indeterminate liver lesion in the inferior right hepatic ___ represent a cyst or hemangioma, however, in the current clinical setting, if further characterization is indicated, recommend ultrasound for further evaluation. 2. No definite evidence of malignancy in the abdomen or pelvis. 3. Coloanal anastomosis noted. Review of clinical record indicates a history of colon cancer. Radiology Report HISTORY: ORIF. FINDINGS: Views from the operating suite show placement of a hemiarthroplasty, which appears to be well seated and without evidence of acute complication. Radiology Report HISTORY: Femur replacement. FINDINGS: In comparison with study of ___, there has been a hemiarthroplasty performed with the device apparently well seated. Post-surgical changes are seen in soft tissues. Radiology Report INDICATION: ___ man with recent pathologic fracture. COMPARISON: Hip radiograph dated ___. TECHNIQUE: Multidetector CT imaging of the chest was performed after the uneventful intravenous administration of 130 cc of Omnipaque intravenous contrast. Sagittal and coronal reformations were performed and reviewed. FINDINGS: The heart is normal in size. No pericardial effusion. The mediastinal great vessels are normal. No pathologic mediastinal, hilar or axillary lymphadenopathy. The major airways are patent to subsegmental levels bilaterally. No suspicious pulmonary nodules or masses are seen. There is a small right and a trace left pleural effusion and associated atelectasis. There is a small hiatal hernia and reflux of contrast into the esophagus. No bone lesions worrisome for infection or malignancy are detected. IMPRESSION: No evidence for metastatic disease in the chest. Small right and trace left pleural effusions. Gender: M Race: WHITE - OTHER EUROPEAN Arrive by AMBULANCE Chief complaint: FX L FEMUR Diagnosed with PATHOLOGIC FX FEMUR NECK, SECONDARY MALIG NEO BONE temperature: 98.6 heartrate: 58.0 resprate: 16.0 o2sat: 99.0 sbp: 162.0 dbp: 74.0 level of pain: 8 level of acuity: 3.0

The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have L intertroch hip fx and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for L proximal femur replacement, which the patient tolerated well (for full details please see the separately dictated operative report). The patient was taken from the OR to the PACU in stable condition and after recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given perioperative antibiotics and anticoagulation per routine. The patients home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient was afebrile with stable vital signs that were within normal limits, pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is WBAT in the LLE extremity, and will be discharged on lovenox 40mg x2wks for DVT prophylaxis. The patient will follow up in two weeks per routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course, and all questions were answered prior to discharge.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Penicillins Attending: ___. Chief Complaint: Trauma: fall Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a ___ year old gentleman who was walkign down the street and attempted to avoid a group of children and tripped over a curb striking his head on the side of a building. He developed pain in his posterior cervical spine as well as in his chest. He was taken to an OSH where imaging showed a C2 anterior inferior body frcture without canal compromise, as well as right ___ and 2nd rib fractures. He was transferred to ___ for further care. Past Medical History: none Social History: ___ Family History: none Physical Exam: PHYSICAL EXAM: upon admission: ___ Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL EOMs intact without nystagmus Neck: in hard cervical collar, Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T WE WF IP Q H AT ___ G Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: No Hoffmans No Clonus Propioception intact Toes downgoing bilaterally Pertinent Results: ___ 07:01AM BLOOD WBC-6.3 RBC-4.36* Hgb-14.0 Hct-40.7 MCV-93 MCH-32.2* MCHC-34.5 RDW-12.4 Plt ___ ___ 08:55PM BLOOD WBC-6.4 RBC-4.64 Hgb-15.0 Hct-43.3 MCV-93 MCH-32.4* MCHC-34.7 RDW-12.8 Plt ___ ___ 07:01AM BLOOD Plt ___ ___ 08:55PM BLOOD Glucose-109* UreaN-8 Creat-0.7 Na-139 K-3.6 Cl-102 HCO3-26 AnGap-15 ___ 08:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___: chest cat scan: 1. Right first rib fracture. No other acute traumatic findings. Left first and right second rib fractures were better characterized on outside C-spine study. 2. Small hiatal hernia. ___: cat scan of the c-spine: Hyperextension injury of the ALL with fracture at the base of C2. ___: cat scan of the c-spine: Hyperextension injury of the ALL with fracture at the base of C2. Medications on Admission: none Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain 2. Docusate Sodium 100 mg PO BID 3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*8 Tablet Refills:*0 4. Senna 8.6 mg PO BID:PRN constipation Discharge Disposition: Home Discharge Diagnosis: Trauma: fall: C2 vert body fx bil. 1st rib Right 2nd rib fracture Discharge Condition: Mental Status: Clear and coherent( ___ speaking) Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT CHEST W/O CONTRAST INDICATION: ___ with fall, head-strike injury, ___ and 2nd rib fractures, assess for other rib fractures. // Diffuse chest tenderness, assess for other rib fractures TECHNIQUE: Multidetector helical scanning of the chest was performed without intravenous contrast agent reconstructed as contiguous 5- and 1.25-mm thick axial, 2.5-mm thick coronal and parasagittal, and 8 x 8 mm MIPs axial images. DOSE: DLP: 463.7 COMPARISON: Same day chest radiograph. FINDINGS: The imaged thyroid is unremarkable. Heart size is top-normal. There is no significant pericardial fluid. There are 3 vessel coronary artery calcifications. The thoracic aortic arch is normal in caliber with mild atherosclerotic calcifications. The main pulmonary artery is normal in caliber. There is no supraclavicular, axillary, hilar or mediastinal lymphadenopathy. Though this study is not tailored for subdiaphragmatic diagnosis, note is made of a few colonic diverticula without evidence of diverticulitis as well as a small hiatal hernia. The remainder of the upper abdomen is unremarkable. There is mild bilateral dependent atelectasis. The airways are patent to the subsegmental level. Punctate calcified granuloma is noted in the right upper lobe. There is an additional 4 mm calcified granuloma in the left apex. Lungs are otherwise clear. Pleural surfaces are clear without effusion or pneumothorax. Osseous structures: There is no suspicious focal osseous lesion. There is a right first rib fracture. Thoracic cage is otherwise intact. The thoracic vertebral body heights and alignment are well maintained. Minimal contour irregularity of the mid sternum appears chronic. IMPRESSION: 1. Right first rib fracture. No other acute traumatic findings. Left first and right second rib fractures were better characterized on outside C-spine study. 2. Small hiatal hernia. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: ___ with head strike injury, fall, C2 fracture, ___ and 2nd rib fractures reported by OSH. TECHNIQUE: This of the study obtained at outside hospital and submitted for second read. CTDIvol: 30.27 mGy DLP: 544.85 mGy-cm COMPARISON: None FINDINGS: There is a hyperextension injury with an avulsion fracture at the anterior inferior base of C2 at the insertion of the ALL, which is minimally displaced. There is no additional fracture seen throughout the cervical spine. Bilateral first rib and right second rib fractures are also present. There is no significant prevertebral soft tissue swelling. Multilevel degenerative changes are present with anterior and posterior osteophyte formation and multilevel small disc bulges. The lung apices are clear. The thyroid gland is unremarkable. IMPRESSION: Hyperextension injury of the ALL with fracture at the base of C2. Gender: M Race: HISPANIC/LATINO - DOMINICAN Arrive by AMBULANCE Chief complaint: s/p Fall, Transfer Diagnosed with FX C2 VERTEBRA-CLOSED, FRACTURE ONE RIB-CLOSED, UNSPECIFIED FALL temperature: 98.1 heartrate: 72.0 resprate: 20.0 o2sat: 98.0 sbp: 171.0 dbp: 96.0 level of pain: 0 level of acuity: 2.0

The patient was admitted to the hospital from a fall he sustained after tripping on a curb. Upon admission, he reported pain in his neck and chest. He underwent imaging at an outside hospital where he was reported to have a C2 anterior inferior body fracture. There was no canal compromise and he was neurologically stable. He was also noted to have right ___ and 2nd rib fractures. Because of the C2 fracture, the patient was evaluated by the neurosurgery service. The patient was placed in a cervical collar and a 4 week follow-up visit was recommended with additional imaging. The patient's rib pain was controlled with oral analgesia. His oxygen saturation was closely monitored and he was encouraged to use the incentive spirometer. He was tolerating a regular diet and voiding without difficulty. On HD #4, the patient was discharged home in stable condition. An appointment for follow-up was made with Dr. ___ ___.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Propoxyphene / Methadone / pseudoephedrine / Peanut / Adhesive Bandage / Banana Attending: ___. Chief Complaint: Fevers, RUE swelling Major Surgical or Invasive Procedure: none History of Present Illness: ___ yo incarcerated M with ESRD on HD MWF, HIV (CD4 early ___ ___), HTN, DM who was discharged ___ after being found to have MSSA bacteremia, thought to be ___ an infected femoral HD line. Today he is sent in for evaluation of his R. AV graft, he reports a small amount of purulent drainage from the site as well as warmth and tenderness to the touch. He was given ancef at HD yesterday. The patient has a long and complicated course of access issues. The patient was admitted from ___ for MRSA bacteremia. He completed a course of vancomycin. He has had multiple attempts at UE grafts and fistulas, most recently with a right forearm loop AV graft done by Dr. ___ on ___. . Of note the patient missed the "medicine line" at jail this morning and took none of his BP meds. . In the ED, initial VS: 10 98.4 72 222/104 18 99%. Exam was notable for +bruit/thrill. The patient was given his home BP meds, and morphine for pain. He was also given a metoprolol 5mg IV dose. Transplant surgery saw the patient and requested vancomycin and BP control. The patient is being admitted to medicine for antibiotics, bp control, and further transplant surgery work-up. REVIEW OF SYSTEMS: Denies night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, abdominal pain, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. . Past Medical History: ESRD on HD since ___ years due to HTN HIV (CD4 308 in ___ with undetectable VL) H/O ESBL sepsis last year AV graft failure complicated by amputation of right forearm and hand HTN DMII Asthma GERD Chronic phantom limb pain Social History: ___ Family History: Per patient, hypertension, heart disease, COPD, bone cancer Physical Exam: Admission: VS - 98.5 ___ 93% RA GENERAL - Alert, interactive, chronically ill appearing in mild pain HEENT - PERRL right eye, left eye scarred, EOMI, sclerae anicteric, MMM, OP clear NECK - Supple, no thyromegaly, JVP obscured by habitus, no carotid bruits HEART - PMI non-displaced, RRR, nl S1-S2, no MRG LUNGS - bibasilar crackles ABDOMEN - NABS, soft/NT/ND, no masses or HSM EXTREMITIES - WWP, no c/c/e, 1+ DP pulses, 2+ edema to knees bilaterally, RUE graft with faint thrill, +bruit. Large 4-5cm firm mass at proximal end of graft - +bruit over mass, TTP, no overlying erythema or warmth. Right thigh with firm mass overlying former HD cath site, no drainage/fluctuance appreciated. Right hand amputation. NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, . Discharge: VS - 98.5F, 180-154/80s, 84-66, 18 98% 1L ___ 132 GENERAL - Alert, interactive,NAD HEENT - PERRL right eye, left eye scarred, EOMI, sclerae anicteric, MMM, OP clear NECK - Supple, no thyromegaly, JVP obscured by habitus, no carotid bruits HEART - PMI non-displaced, RRR, nl S1-S2, no MRG LUNGS - faint bibasilar crackles ABDOMEN - NABS, soft/NT/ND, no masses or HSM EXTREMITIES - WWP, no c/c/e, 1+ DP pulses, 2+ edema to knees bilaterally, RUE graft with faint thrill, +bruit. Large 4-5cm firm mass at proximal end of graft - +bruit over mass, TTP, no overlying erythema or warmth. Right thigh with firm mass overlying former HD cath site, no drainage/fluctuance appreciated. Right hand amputation. NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, Pertinent Results: I) Admission Labs: CBC ___ 06:55PM BLOOD WBC-5.0 RBC-4.04* Hgb-9.2* Hct-29.8* MCV-74* MCH-22.8* MCHC-30.9*# RDW-21.7* Plt ___ ___ 06:55PM BLOOD Neuts-60.6 ___ Monos-6.9 Eos-4.8* Baso-1.8 Coags: ___ 06:55PM BLOOD ___ PTT-35.4 ___ Chem: ___ 06:55PM BLOOD Glucose-87 UreaN-31* Creat-7.0*# Na-141 K-3.7 Cl-93* HCO3-37* AnGap-15 ___ 07:45AM BLOOD Calcium-9.7 Phos-5.5* Mg-2.3 Tox: ___ 11:43PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG II) Micro: Blood cultures 2x ___: Pending Blood cultures 2x ___: Pending CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ___: CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. (Reference Range-Negative). A positive result in a recently treated patient is of uncertain significance unless the patient is currently symptomatic (relapse). III) Imaging: Chest Xray: In comparison with the study of ___, there are patchy areas of opacification in the right perihilar region and left base. In view of the clinical history, this could well reflect regions of pneumonia bilaterally. Ill-defined pulmonary vessels may be a manifestation of elevated pulmonary venous pressure in this patient with mild enlargement of the cardiac silhouette. IV) Discharge Labs: Note patient is s/p HD on ___. These labs were drawn PRIOR to HD. ___ 06:12AM BLOOD WBC-5.3 RBC-3.53* Hgb-7.9* Hct-25.8* MCV-73* MCH-22.3* MCHC-30.5* RDW-21.9* Plt ___ ___ 06:12AM BLOOD Glucose-125* UreaN-62* Creat-8.8*# Na-142 K-4.6 Cl-100 HCO3-28 AnGap-19 ___ 06:12AM BLOOD Calcium-9.6 Phos-6.4*# Mg-2.6 ___ 06:12AM BLOOD Vanco-12.8 V) Studies Pending at Discharge: 1. Blood Cultures: no growth to date Medications on Admission: amlodipine 10 mg Tablet DAILY abacavir 600 mg Tablet ___: daily. Tylenol #3 two tabs BID prn pain x 10d albuterol HFA 2 puffs BID CefazoLIN 3 g IV ___ WITH HD last dose ___ CefazoLIN 2 g IV ___ with HD ___ diphenhydramine 25mg prn itch digoxin .25mg qd emtricitabine 200 mg PO QHSMOFRI Epo 10k units MWF Ferric glugconate 62.5mg/5ML INJ 125mg q72 Ferrous gluconate 324 MG tab TID levetiracetam 1000 mg PO BID labetalol 800 mg Tablet ___: PO TID lisinopril 40 mg Tablet PO DAILY minoxidil 10 mg PO bid Dilantin 600mg QD zoloft 50mg qd sevelamer carbonate 3200mg PO TID W/MEALS Nephrocaps 1 mg Capsule daily omeprazole 20 mg Capsule, Delayed Release(E.C.) PO DAILY albuterol sulfate prn Colace 100 mg PO twice a day. lispro Vitamin A-D ointment for feet Discharge Medications: 1. sevelamer carbonate 800 mg Tablet ___: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. B complex-vitamin C-folic acid 1 mg Capsule ___: One (1) Cap PO DAILY (Daily). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) ___: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. ferrous sulfate 300 mg (60 mg iron) Tablet ___: One (1) Tablet PO DAILY (Daily). 5. efavirenz 600 mg Tablet ___: One (1) Tablet PO HS (at bedtime). 6. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler ___: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for SOB/Wheezing. 7. docusate sodium 100 mg Capsule ___: One (1) Capsule PO BID (2 times a day) as needed for constipation. 8. emtricitabine 200 mg Capsule ___: One (1) Capsule PO QMONFRI (). 9. labetalol 200 mg Tablet ___: Four (4) Tablet PO TID (3 times a day). 10. insulin lispro 100 unit/mL Solution ___: SSI units Subcutaneous ASDIR (AS DIRECTED): As directed per sliding scale. . 11. minoxidil 10 mg Tablet ___: One (1) Tablet PO BID (2 times a day). 12. metronidazole 500 mg Tablet ___: One (1) Tablet PO Q8H (every 8 hours) for 2 weeks: Day ___. 13. Ferrlecit 62.5 mg/5 mL Solution ___: One Hundred ___ (125) mg Intravenous qHD. 14. Epogen 10,000 unit/mL Solution ___: ___ units Injection qHD. 15. Vitamin A & D GRx Topical 16. Tylenol-Codeine #3 300-30 mg Tablet ___: Two (2) Tablet PO twice a day as needed for pain for 10 days. 17. lisinopril 40 mg Tablet ___: One (1) Tablet PO once a day. 18. amlodipine 10 mg Tablet ___: One (1) Tablet PO once a day. 19. abacavir 300 mg Tablet ___: Two (2) Tablet PO once a day. 20. Keppra 1,000 mg Tablet ___: One (1) Tablet PO twice a day. 21. vancomycin in D5W 1 gram/200 mL Piggyback ___: One (1) Intravenous Sliding Scale HD protocol for 14 days: Dose at HD per sliding scale protocol. . ***Patient was not placed on dilantin during admission. He was also not placed on digoxin. It is unclear why he is taking these medications and he has never been prescribed them at ___. Evaluate restarting these medications after discussing the risks and benefits of these medications with the patients primary care physician ___ ___ Discharge Disposition: Extended Care Discharge Diagnosis: Primary Diagnosis: 1. Clostridium difficile colitis 2. Right arm seroma 3. MRSA bacteremia Secondary Diagnosis: 4. End stage renal disease 5. HIV 6. Hypertension 7. Chronic phantom limb pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Graft infections with subjective fever, to assess for pneumonia. FINDINGS: In comparison with the study of ___, there are patchy areas of opacification in the right perihilar region and left base. In view of the clinical history, this could well reflect regions of pneumonia bilaterally. Ill-defined pulmonary vessels may be a manifestation of elevated pulmonary venous pressure in this patient with mild enlargement of the cardiac silhouette. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: FISTULA EVAL Diagnosed with SEROMA COMPLIC PROCEDURE, ABN REACT-RENAL DIALYSIS, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE, END STAGE RENAL DISEASE, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, ASYMPTOMATIC HIV INFECTION temperature: 98.4 heartrate: 72.0 resprate: 18.0 o2sat: 99.0 sbp: 222.0 dbp: 104.0 level of pain: 10 level of acuity: 3.0

___ year old male with HIV on ART, end stage renal disease on hemodialysis, type II diabetes, hypertension, recent hospitalization for MSSA bacteremia, who was admitted for fevers and swelling at the site of his AV-graft and was found to have c-diff colitis. Problems: 1. C. Diff colitis 2. Right upper extremity seroma with possible infection 3. End Stage Renal Disease on dialysis 4. HIV 5. Chronic phantom limb pain 6. Hypertension 7. Type 2 Diabetes #Fever/C. difficile colitis: The patient presented to the BI with reports of subjective fevers and frequent loose stools. He was subsequently tested for C-Diff toxin which was positive. Given his age, frequency of bowel movements <10 per day, and lack of leukocytosis, we elected to start treatment for C-Diff with metronidazole. He received his first dose on ___. We would like him to take a two week course of oral flagyl which should end 2 weeks after he completes his course of Vancomycin for empiric coverage of possibly infected seroma (see below). -Oral Flagyl 500mg TID x 28d total (Last day ___. # Right upper extremity seroma: The patient presented to ___ with reported fevers and purulent drainage from his right arm mass although no drainage was noted after presentation to ___. Of note, this mass was previously drained at the beginning of ___ secondary to concern for infection. At that time, he had positive blood cultures for MSSA. He was discharged to prison on cefazolin per hd protocol with the intention of completing therapy on ___. Given his previous history of MRSA positive bacteremia, transplant surgery recommended to start treatment empirically for possibly infected seroma with IV vancomycin per sliding scale HD protocol. Although the site was tender, it was not particularly erythematous and the patient did not have a leukocytosis or systemic symptoms other than fever. That said, given previous infectious complications and location near his AV graft the decision was made to empirically treat with Vancomycin for 2 weeks pending re-assessment at outpatient ID and Transplant Surgery follow up appointments. #End Stage Renal Disease: The patient's right arm mass has not prevented him from getting HD. His AV graft is functioning well and he was dialyzed successfully twice during his stay here. He received hemodialysis on ___. He should remain on his normal HD schedule of ___. Given the lack of vascular access, it is very likely in the future that he will require peritoneal dialysis, as he is not a candidate for femoral access. This will be disscussed at his follow up appointment with Drs. ___ ___ from the Department of Transplant Surgery at ___ in approximately 2 weeks. #Prevous MSSA bacteremia: The patient was treated for MSSA bacteremia from prior admission. He was due to finish his course on ___. All of his blood cultures, during this admission have shown no growth to date. Chronic Problems: #HIV, on ART: His last viral load was undetectable. He had an infectious disease appointment to manage his HAART on ___. Of note, he was admitted on abacavir and emtircitabine. He should also be taking efavirenz. It is unclear as to why the patient was not taking efavirenz. In the hospital, he was put on the HAART, therapy that he had previously been on which is emtircitabine, efavirenz, and abacavir. -Please resume abacavir 600 mg Tablet ___: daily. emtricitabine 200 mg PO QHSMOFRI efavirenz 600 mg # Chronic phantom pain: The patient experiences chronic phantom pain secondary to hand amputation. His pain is chronic in origin and was treated with inpatient oxycodone-apap. He can resume his outpatient regimen of tylenol 3 upon return to prison. #Hypertension: The patient has multi-drug resistant hypertension. Presented with hypertensive emergency as his systolic blood pressure was greater than 200. He was showing no signs of end organ damage such as head ache, altered mental status, agitation, blurred vision ect. His hypertensive emergency was secondary to him missing his anti-hypertensives during the day. His blood pressure corrected after receiving his normal outpatient dose of antihypertensives. Of note, he still remains hypertensive with systolic blood pressures in the 170s prior to dialysis. No signficant changes were made to the patient's anti-hypertensive regimen. #Patient has mild type 2 diabetes. Good glycemic control was achieved with a humalog sliding scale which was continued from prison. Transitional Issues: 1. Appropriate HIV medications: Patient has follow up with infectious disease. However, in the interim he should continue to take triple therapy consisting of abacavir, emtricitabine, and efavirenz. The patient had an appointment with ID at ___ on the ___, however he missed this appointment for unclear reasons. 2. Follow up final results of blood cultures which have shown no growth to date. When the final results of the cultures are available, a member of our team will contact the patient's PCP. 3. We held the patient's digoxin. There is no clear indication as to why the patient should be on digoxin. He has a normal ejection fraction and renal failure. If you feel that there is an indication for restarting digoxin, please let us know why as to aid the transition of care between ___ and prison. Also, dilantin was not given during this hospitalization. The patient has never been on dilantin during hospitalazation at ___. Please meet with the patient on ___ to discuss resuming these medications. 4. Vascular access: The patient is running out of options for dialysis. He will likely require peritoneal dialysis. This will be arranged at his follow up visit with transplant surgery. 5. Antibiotic therapy: The patient should be treated with flagyl for C-diff as stated above. He should be dosed with vancomycin sliding scale per HD protocol as stated above.

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Erythromycin Base Attending: ___. Chief Complaint: s/p fall Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ y/o female with a past medical history of alcohol abuse, depression, COPD, hemochromatosis (homozygosity ___ mutation HFE gene), ?porphyria, h/o multiple falls who presented to the hospital on ___ s/p fall in the setting of alcohol use and was found to have a small left parietal SDH on CT. Patient was admitted to the neurosurgery service and was noted to have a stable neuro exam. She had a repeat head CT on ___ that showed a stable SDH. She was started on keppra 1 g BID for seizure prophylaxis. While hospitalized the patient was placed on a CIWA scale and required benzos for withdrawal. Her home diazepam was restarted. She was started on precedex gtt and received Haldol/valium on ___. On ___ her precedex was discontinued and she was called out of the ICU on ___. The neurosurgery service is requesting transfer to medicine formanagement of alcohol withdrawal, failure to thrive, and management of chronic hemochromatosis. With regards to her hemochromatosis, she has been seeing hematology in the clinic and has been scheduled for therapeutic phlebotomy every ___ weeks to induce iron deficiency (notably she has only attended one appt so far). Her goal Hb is ___, Ferritin ___, TIBC >300, and iron/TIBC ratio ___. She had therapeutic phlebotomy on ___ (which was her first and only session). Past Medical History: COPD - no PFT's in system Alcoholism - drinks 1 pint of vodka daily, last drink 2 days ago Major depression - denies GERD Vestibular Neuritis - taking diazepam prn, controlled as per patient, no recent falls. Nondepressed L skull fracture s/p fall in ___ associated with ETOH Social History: ___ Family History: Her mother passed away at ___ from probable cancer. Father passed away at ___ from a ruptured gallbladder. She has ___ and ___ sisters. Her daughter committed suicide at age ___. She has a ___ son w/ h/o depression. Sister with bladder cancer. Physical Exam: >> ADMISSION PHYSICAL EXAM: O: T: 97.5 BP: 103/71 HR:94 R:20 O2Sats:100%RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: ___, bilat 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. Confused with inappropriate speech at times. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right ___ 2 2 Left ___ 2 2 Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin . >> DISCHARGE PHYSICAL EXAM: VS: Tmax 98.3 BP ___ P ___ RR 16 Sat 97-100% RA Gen: thin woman lying in bed comfortably HEENT: PERRL. Mild R ptosis. MMM, OP clear. Pulm: mild diffuse rhonchi bilaterally Cor: RRR, S1S2nl, no m/r/g Abd: soft, NTND, no rebound or guarding MSK/Ext: WWP no edema Neuro: AOX3, CN III-XII intact Skin: nonblanching red lesions, generally round with irregularly borders, ranging from 2 to 4cm in diameter, concentrated predominantly on forearms and legs bilaterally. Some lesions with ulceration, some with scarring and scabbing, one lesion on L forearm with heaped up necrotic substance. Pertinent Results: >> ADMISSION LABS: ___ 12:55PM BLOOD WBC-6.4 RBC-3.56* Hgb-12.9 Hct-38.6 MCV-108* MCH-36.2* MCHC-33.4 RDW-13.1 RDWSD-52.2* Plt ___ ___ 12:55PM BLOOD Neuts-70.7 ___ Monos-7.6 Eos-0.6* Baso-0.5 Im ___ AbsNeut-4.53 AbsLymp-1.31 AbsMono-0.49 AbsEos-0.04 AbsBaso-0.03 ___ 12:55PM BLOOD ___ PTT-29.8 ___ ___ 12:55PM BLOOD Glucose-97 UreaN-15 Creat-0.6 Na-136 K-3.3 Cl-97 HCO3-25 AnGap-17 ___ 12:55PM BLOOD ALT-33 AST-72* AlkPhos-123* TotBili-0.9 ___ 12:55PM BLOOD Lipase-14 ___ 12:55PM BLOOD Albumin-4.5 Calcium-9.7 Phos-3.1 Mg-2.2 ___ 12:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG ___ 01:06PM BLOOD Lactate-1.8 . >> DISCHARGE LABS: ___ 05:40AM BLOOD WBC-5.3 RBC-3.29* Hgb-12.1 Hct-35.7 MCV-109* MCH-36.8* MCHC-33.9 RDW-13.4 RDWSD-52.8* Plt ___ ___ 05:40AM BLOOD Glucose-92 UreaN-7 Creat-0.4 Na-136 K-3.3 Cl-100 HCO3-21* AnGap-18 ___ 05:40AM BLOOD Calcium-9.3 Phos-4.3 Mg-2.1 ___ 05:40AM BLOOD VitB12-792 Folate-7.9 . >> IMAGING: ___ CHEST (PA & LAT) IMPRESSION: Patchy right base opacity concerning for pneumonia or aspiration. ___ CT HEAD W/O CONTRAST IMPRESSION: Limited examination due to patient motion. 1. 5 mm in width left subdural hemorrhage. No midline shift. 2. Possible additional site of subdural hemorrhage along the anterior falx. 3. Posterior scalp hematoma. ___ CT C-SPINE W/O CONTRAST IMPRESSION: 1. No acute fracture. 2. Mild degenerative disease. ___ CT CHEST/ABD/PELVIS W/ IMPRESSION: 1. No acute intrathoracic or intraabdominal injury. 2. Mucous plugging in the right lower lobe bronchus appears worse compared to the prior chest CT of ___ with associated atelectasis. Bibasilar atelectasis appears unchanged. 3. Bilateral rib and sternal fractures were present on the prior CT of ___. ___ CT HEAD W/O CONTRAST IMPRESSION: 1. Stable left subdural hematoma. ___ CT HEAD W/O CONTRAST IMPRESSION: 1. New linear hyperdensity along a right parietal sulcus is most consistent with a small subarachnoid hemorrhage. 2. Stable small left hyperdense subdural hematoma. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Betamethasone Dipro 0.05% Lot. 1 Appl TP DAILY:PRN psoriasis 2. LamoTRIgine 400 mg PO DAILY 3. Tiotropium Bromide 1 CAP IH DAILY 4. Benzonatate 100 mg PO TID:PRN cough 5. hydrocodone-chlorpheniramine ___ mg suspension Q12H 6. Zolpidem Tartrate 12.5 mg PO QHS 7. Nicotine Patch 21 mg TD DAILY 8. Diazepam 10 mg PO Q8H:PRN anxiety 9. LORazepam 1 mg PO TID:PRN anxiety 10. Cyclobenzaprine 5 mg PO TID:PRN muscle spasm 11. Ranitidine 300 mg PO QHS 12. Multivitamins 1 TAB PO DAILY 13. Pramipexole 1 mg PO QHS 14. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 15. Fluticasone Propionate 110mcg 2 PUFF IH BID 16. Nystatin Cream 1 Appl TP BID 17. Pantoprazole 40 mg PO Q12H 18. albuterol sulfate 5 mg/mL inhalation Q6H:PRN 19. Sertraline 50 mg PO DAILY 20. FoLIC Acid 1 mg PO DAILY Discharge Medications: 1. Benzonatate 100 mg PO TID:PRN cough 2. Fluticasone Propionate 110mcg 2 PUFF IH BID 3. LamoTRIgine 25 mg PO BID 4. Pantoprazole 40 mg PO Q12H 5. Pramipexole 1 mg PO QHS 6. Ranitidine 300 mg PO QHS 7. Sertraline 50 mg PO DAILY 8. Tiotropium Bromide 1 CAP IH DAILY 9. Nicotine Patch 21 mg TD DAILY 10. Ascorbic Acid ___ mg PO BID 11. LevETIRAcetam 1000 mg PO BID 12. albuterol sulfate 5 mg/mL inhalation Q6H:PRN 13. Betamethasone Dipro 0.05% Lot. 1 Appl TP DAILY:PRN psoriasis 14. Cyclobenzaprine 5 mg PO TID:PRN muscle spasm RX *cyclobenzaprine 5 mg 1 tablet(s) by mouth every 8 hours Disp #*12 Tablet Refills:*0 15. FoLIC Acid 1 mg PO DAILY 16. LORazepam 1 mg PO TID:PRN anxiety RX *lorazepam 1 mg 1 tab by mouth every 8 hours Disp #*12 Tablet Refills:*0 17. Nystatin Cream 1 Appl TP BID 18. rOPINIRole 3 mg PO QPM 19. Thiamine 100 mg PO DAILY 20. Multivitamins W/minerals 1 TAB PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRINCIPAL DIAGNOSIS 1. Subdural hematoma 2. Alcohol withdrawal 3. Subarachnoid hemorrhage SECONDARY DIAGNOSIS 1. Alcohol use disorder 2. COPD 3. Hemochromatosis 4. GERD 5. Depression 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 confusion // ? PNA TECHNIQUE: Chest: Frontal and Lateral COMPARISON: ___ FINDINGS: Patient is rotated to the left.Patchy right base opacity raises concern for pneumonia or aspiration. Left base atelectasis is seen. No large pleural effusion is seen. Mid lung linear atelectasis/ scarring is again seen on the lateral view. No evidence of pneumothorax is seen. The cardiac and mediastinal silhouettes are stable. IMPRESSION: Patchy right base opacity concerning for pneumonia or aspiration. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ woman status post fall. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 18.0 s, 18.6 cm; CTDIvol = 48.5 mGy (Head) DLP = 903.1 mGy-cm. 2) Sequenced Acquisition 4.0 s, 4.1 cm; CTDIvol = 48.5 mGy (Head) DLP = 200.7 mGy-cm. Total DLP (Head) = 1,104 mGy-cm. COMPARISON: CT head ___. FINDINGS: Acute subdural hemorrhage layers along the left convexity and has a maximum width of 5 mm. A possible additional small focus of subdural hemorrhage is seen along the anterior falx. There is no midline shift. Gray-white matter differentiation is preserved. The ventricles and sulci are normal in size and configuration. There is no acute evidence of fracture. Old fracture of the left occipital bone is unchanged. There is mucosal thickening in the right maxillary sinus. Otherwise, the visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. There is a left posterior scalp hematoma. IMPRESSION: Limited examination due to patient motion. 1. 5 mm in width left subdural hemorrhage. No midline shift. 2. Possible additional site of subdural hemorrhage along the anterior falx. 3. Posterior scalp hematoma. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE INDICATION: ___ woman status post fall. TECHNIQUE: Non-contrast helical multidetector CT of the cervical spine was performed. Soft tissue and bone algorithm images were generated. Coronal and sagittal reformations were then constructed. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.6 s, 21.8 cm; CTDIvol = 37.1 mGy (Body) DLP = 809.7 mGy-cm. Total DLP (Body) = 810 mGy-cm. COMPARISON: CT cervical spine ___. FINDINGS: There is exaggerated lordosis. No acute fracture is identified. There is mild multilevel degenerative changes including intervertebral disc space narrowing and small posterior osteophytes that are most marked at the C6-C7 and T2-T3 levels. There is no prevertebral soft tissue swelling. The lung apices are clear. IMPRESSION: 1. No acute fracture. 2. Mild degenerative disease. Radiology Report INDICATION: ___ woman status post fall. TECHNIQUE: MDCT axial images were acquired through the chest, abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 6.5 s, 0.5 cm; CTDIvol = 31.3 mGy (Body) DLP = 15.6 mGy-cm. 2) Spiral Acquisition 8.2 s, 64.1 cm; CTDIvol = 7.1 mGy (Body) DLP = 454.5 mGy-cm. Total DLP (Body) = 470 mGy-cm. COMPARISON: CT torso ___. FINDINGS: CHEST: HEART AND VASCULATURE: The ascending aorta is top normal in diameter measuring 4 cm. The thoracic aorta is without evidence of intramural hematoma or dissection. The heart size is normal. No pericardial effusion is seen. There are coronary artery calcifications. AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar lymphadenopathy is present. No mediastinal mass or hematoma. PLEURAL SPACES: No pleural effusion or pneumothorax. LUNGS/AIRWAYS: There is minimal right and moderate left lower lobe atelectasis, unchanged since ___ examination. The right lower lobe bronchi air completely occluded with mucous impaction, slightly increased in severity since the prior examination. There is no focal consolidation. BASE OF NECK: A 5 mm nodule in the left lobe of the thyroid does not warrant follow-up imaging. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesion or laceration. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder contains gallstones without wall thickening or surrounding inflammation. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesion or laceration. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is normal. There is no evidence of mesenteric injury. There is no free fluid or free air in the abdomen. PELVIS: The urinary bladder contains a Foley catheter. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus is of normal size and enhancement. There is no evidence of adnexal abnormality bilaterally. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma. Moderate atherosclerotic disease is noted. BONES: There is no acute fracture. Bilateral old rib fractures were present on the prior CT of ___. A sternal fracture appears chronic. There are multilevel degenerative changes in the spine including grade I anterolisthesis of L4 on L5. SOFT TISSUES: Bilateral inguinal hernias containing fat are noted. IMPRESSION: 1. No acute intrathoracic or intraabdominal injury. 2. Mucous plugging in the right lower lobe bronchus appears worse compared to the prior chest CT of ___ with associated atelectasis. Bibasilar atelectasis appears unchanged. 3. Bilateral rib and sternal fractures were present on the prior CT of ___. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD. INDICATION: ___ year old woman with acute left parietal SDH // eval for interval change - please obtain @ 2300. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 17.0 cm; CTDIvol = 47.1 mGy (Head) DLP = 802.7 mGy-cm. 2) Sequenced Acquisition 4.0 s, 4.3 cm; CTDIvol = 47.1 mGy (Head) DLP = 200.7 mGy-cm. Total DLP (Head) = 1,003 mGy-cm. COMPARISON: CT head without contrast ___ 15:57 FINDINGS: Left subdural hematoma is stable compared to 8 hr ago, measuring 5 mm in thickness. There is no shift of midline structures. Appearance of anterior falx is not changed. The ventricles and sulci are stable in size and configuration. Old left occipital fracture is again noted (image 8, series 3a). There is mucosal thickening of right maxillary sinus. The visualized portion of the orbits are unremarkable. Posterior superior scalp hematoma is stable. IMPRESSION: 1. Stable left subdural hematoma. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman with left subdural hematoma, now with worsening anisocoria. // interval change TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 11.0 s, 18.7 cm; CTDIvol = 48.8 mGy (Head) DLP = 911.9 mGy-cm. Total DLP (Head) = 925 mGy-cm. COMPARISON: Head CT from ___ FINDINGS: A small hyperdense left subdural hematoma along the left lateral convexity is stable. There is a small hyperdensity tracking along a right parietal sulcus which is new compared to the prior examination and likely represents a small subarachnoid hemorrhage (03:26, 602a:66). There is no shift of normally midline structures. Gray-white matter differentiation is preserved. Ventricles are stable in size and configuration. Moderate mucosal thickening in the right maxillary sinus is unchanged. The mastoid air cells and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: 1. New linear hyperdensity along a right parietal sulcus is most consistent with a small subarachnoid hemorrhage. 2. Stable small left hyperdense subdural hematoma. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 7:55 ___, 30 min after discovery of the findings. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Confusion, s/p Fall Diagnosed with Altered mental status, unspecified, Alcohol abuse with intoxication, unspecified, Fall on same level, unspecified, initial encounter temperature: 97.6 heartrate: 94.0 resprate: 20.0 o2sat: 100.0 sbp: 103.0 dbp: 71.0 level of pain: 5 level of acuity: 2.0

___ with a history of alcohol use disorder c/b recurrent falls and aspirations, hemochromatosis, COPD, GERD and depression who presented with L SDH after a mechanical fall and was transferred to medicine for further management of alcohol withdrawal. . >> ACTIVE ISSUES: # Subdural hematoma: On ___, the patient was brought to the ED after her family noted her to be confused after multiple falls. Her CT revealed a small left parietal subdural hematoma. She was admitted to the ICU for close neurologic monitoring and to monitor for withdrawal given her history of alcohol use disorder. Repeat head CT in the ICU was stable. She was started on Keppra for seizure prophylaxis. She was seen by physical therapy who recommended ___ rehab to reduce fall risk. # Subarachnoid hematoma: On ___, a new anisocoria was noted (L>R), so a NCHCT was ordered. This showed a small R parietal sulcus SAH. This finding was discussed with neurosurgery who recommended no changes to her management. # Alcohol withdrawal: On the second hospital day, Ms. ___ became impulsive, attempting multiple times to get out of bed unassisted. She had increased agitation and hallucinations requiring Haldol, Ativan and ultimately precedex. She was placed in restraints for safety. Over the next two days, her agitation improved and Haldol and Precedex were discontinued. She continued to receive diazepam and lorazepam per CIWA for one more day. She was off withdrawal medications for >48 hours prior to discharge. # Alcohol use disorder: Ms. ___ has longstanding alcohol use disorder and exhibited confabulation on the floor concerning for Wernicke-Korsakoff syndrome. She was treated with IV thiamine, folate and multivitamin. She spoke with social worker who recommended outpatient addiction treatment programs. . >> CHRONIC ISSUES: # COPD: The patient has an extensive smoking history with known COPD (FEV1 83% predicted in ___. She had a stable lung exam and oxygen saturations while inpatient. She was continued on her home Flovent, Spiriva and albuterol nebs, in addition to a nicotine patch. She reports she is not interested in smoking cessation at this time. # Depression: Takes sertraline and lamotrigine at home. Home lamotrigine was initially held while she was receiving benzodiazepines for withdrawal. She will restart with slow up-titration of lamotrigine dose to avoid rash associated with abruptly starting high doses. # Restless legs syndrome: Continued on home ropinirole and pramipexole without issue. # Insomnia: Home Zolpidem was held # Anxiety: Home lorazepam and diazepam were held given benzodiazepine administration for withdrawal treatment. . >> TRANSITIONAL ISSUES: # Basal cell carcinoma: It appears that this was biopsied but not excised. Please ensure that the she follows up in ___ clinic for further management. # SDH: Has neurosurgery follow-up appointment on ___. They will contact her to schedule a same-day noncontrast head CT. She will continue on Keppra for seizure prophylaxis until then. # Alcohol use d/o: Met with social worker who provided resources for outpatient treatment. Please encourage her to utilize these resources. # Hemochromatosis: She has scheduled phlebotomy appointments weekly through ___. She will coordinate with Drs. ___ ___ for further management of her hemochromatosis. # Depression: Lamotrigine was held for the first five days of her hospital stay. Due to risk of rash with restarting this medication at a high dose, she will restart with a slow increase (starting ___: 25mg x 2wks, 50mg x 2wks, 100mg x1wk, 200mg x1wk, then 400mg (home dose). # Skin lesions: Vitamin C levels low normal, now receiving supplementation. Please continue follow-up in dermatology and hematology clinics. # ___: Patient meets ___ criteria for We___ encephalopathy. Please continue thiamine, folate, MVI and follow up vitamin B1 level. # Code status: Full # Communication: HCP ___ ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Lithium Benzoate / Tagamet Attending: ___. Chief Complaint: Nausea, vomiting, abnormal labs Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ with a PMHx notable for NASH, GERD, PUD, prediabetes (HgbA1c 6.6 ___, depression with h/o parasuicidal behavior, and multiple somatic complaints including abdominal and back pain which have had negative workups, as well as vauge complaints of memory difficulty who is presenting with 3 weeks of nausea, vomiting and recent abnormal labs after returning from a trip to ___. The patient was seen in clinic on ___ for an epi visit. She had recently returned from a trip to ___ (___), where she ate seafood that she considered "questionable." Several days later, she started to develop a cough and what she described as "the flu." She took Robiussen to help relieve her symptoms (___). Upon her return to the ___, she has been having nausea and vomiting associated with epigastric and RUQ/LUQ pain. She has been having mild diarrhea. She reports seeing "tiny specks of redness" in her stool, but denies any melena. She also denies any blood in her vomit. She endorsed fevers to the low 100s. While she was at her PCP, labs performed demonstated a WBC of 7.8 with 4% atypicals and an H/H of 11.7/33, which is below her baseline (___). Her AST was 51 and ALT 47, which was slightly above her baseline, and her TBili was 1.5. Her Cr was normal but her K was 2.9. Monospot was negative. Hep serologies were sent and were pending. She had a liver U/S, which demonstrated a steatotic liver and splenomegaly (17cm), which was a new finding. She was referred to the ED, but ended up going to ___. Unclear what happened there, but she was sent out and re-presented to clinic on ___ feeling worse. She was then referred to the ___ ED for further evaluation. Of note, she was seen by Hepatology in ___ for evaluation of her underlying NASH. She had a MRI which showed moderate steatosis, without e/o fibrosis or cirrhosis. She was also recently seen by ___ clinic to follow her hematuria, which was found to be glomerular in nature. The plan was to follow this prospectively for now since her Cr was normal. Vitals in the ED: 99.3 113 147/62 18 100% Labs notable for: WBC 6.3 with 18% atypicals. H/h ___, Plt 186. Na 147. Cr 0.7. AST 51, ALT 44, LDH 451, TB 0.9. UA with trace blood Patient given: Nothing Exam: Notable for LUQ TTP with splenomegaly. Negative guaiac. Vitals prior to transfer: 98 88 124/67 14 98% RA On the floor, patient was examined in her bed in NAD. She confirmed the above story and explained that she has been feeling fatigued and weak for the past three weeks since she has returned. She has had poor PO intake and has not been able to keep food down. She denies any headaches, rashes, bleeding, weight loss, or recent sexual activity. She also denies any IVDU. Review of Systems: (+) per HPI, fevers, nausea, vomiting, diarrhea, cough, myalgias, weakness, abdominal pain (-) night sweats, headache, vision changes, chest pain, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: - Allergic Rhinitis - Depression / Borderline Personality / Bulemia / PTSD - Gallstones - GERD / PUD (EGD ___ with antral gastric ulcer) - NASH (s/p MRI in ___ without cirrhosis) - Parasuicidal Behavior - Nephrolithiasis - T2DM - Hematuria (seen by renal in ___ - H/o of benign heart murmur - H/o abnormal pap smear - H/o iron deficiency anemia PAST SURGICAL HISTORY: - S/p cholecystectomy - S/p tonsillectomy Social History: ___ Family History: Mother with T2DM and hx of DVT. Father with ___ and T2DM and HTN. Sister with T2DM. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals - 98.1 116/73 98 18 98% 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, I/VI systolic murmur heard throughout the percordium (chronic) LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, TTP in LUQ with splenomegaly EXTREMITIES: no edema PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: Vitals - 98.6 97.6 86 106/71 18 98% RA GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM CARDIAC: RRR, S1/S2, I/VI systolic murmur LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, TTP in LUQ with splenomegaly EXTREMITIES: no edema PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS ___ 09:04PM BLOOD WBC-6.3 RBC-3.38* Hgb-10.0* Hct-28.0* MCV-83 MCH-29.5 MCHC-35.6* RDW-15.6* Plt ___ ___ 09:04PM BLOOD Neuts-46* Bands-0 ___ Monos-4 Eos-0 Baso-1 Atyps-18* ___ Myelos-0 ___ 09:04PM BLOOD Hypochr-OCCASIONAL Anisocy-1+ Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-1+ ___ 09:04PM BLOOD Plt Smr-NORMAL Plt ___ ___ 09:04PM BLOOD Parst S-NEG ___ 09:04PM BLOOD Ret Aut-4.2* ___ 09:04PM BLOOD Glucose-127* UreaN-6 Creat-0.7 Na-140 K-3.3 Cl-103 HCO3-29 AnGap-11 ___ 09:04PM BLOOD ALT-44* AST-51* LD(LDH)-451* AlkPhos-57 TotBili-0.9 ___ 12:10PM BLOOD Lipase-31 ___ 09:04PM BLOOD Albumin-3.7 Calcium-9.3 Phos-3.1 Mg-2.0 UricAcd-6.3* Iron-64 ___ 09:04PM BLOOD calTIBC-264 Hapto-<5* Ferritn-246* TRF-203 ___ 09:04PM BLOOD GreenHd-HOLD ___ 09:12PM URINE Color-Yellow Appear-Clear Sp ___ ___ 09:12PM URINE Blood-TR Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-6.5 Leuks-NEG ___ 09:12PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1 ___ 09:12PM URINE UCG-NEGATIVE PERTINENT LABS/DISCHARGE LABS ___ 05:38AM BLOOD WBC-5.9 RBC-3.40* Hgb-10.1* Hct-28.9* MCV-85 MCH-29.7 MCHC-34.9 RDW-16.5* Plt ___ ___ 09:04PM BLOOD Neuts-46* Bands-0 ___ Monos-4 Eos-0 Baso-1 Atyps-18* ___ Myelos-0 ___ 05:38AM BLOOD Neuts-44.1* Lymphs-49.1* Monos-4.0 Eos-1.8 Baso-1.0 ___ 03:40AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-1+ Polychr-1+ Ovalocy-OCCASIONAL ___ 06:00AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL ___ 07:35AM BLOOD Ret Aut-4.6* ___ 07:35AM BLOOD ___ 07:35AM BLOOD Parst S-NEGATIVE ___ 05:38AM BLOOD Glucose-165* UreaN-8 Creat-0.6 Na-138 K-4.0 Cl-103 HCO3-27 AnGap-12 ___ 09:04PM BLOOD ALT-44* AST-51* LD(LDH)-451* AlkPhos-57 TotBili-0.9 ___ 07:35AM BLOOD ALT-48* AST-52* LD(LDH)-468* AlkPhos-62 TotBili-1.2 ___ 09:04PM BLOOD calTIBC-264 Hapto-<5* Ferritn-246* TRF-203 ___ 06:00AM BLOOD Hapto-<5* ___ 06:00AM BLOOD ___ HAV-NEGATIVE ___ 03:40AM BLOOD HIV Ab-NEGATIVE IMAGING: CXR In comparison with the study of ___, there is no change or evidence of acute cardiopulmonary disease. No pneumonia, vascular congestion, or pleural effusion. There is suggestion of some enlargement of the splenic shadow, though this is difficult to appreciate on plain radiographs. MICROBIOLOGY Test Result Reference Range/Units CHIKUNGUNYA IGG SCREEN NEGATIVE CHIKUNGUNYA ___ SCREEN POSITIVE A REFERENCE RANGE: NEGATIVE DENGUE FEVER ANTIBODIES (IGG, ___ Test Result Reference Range/Units DENGUE FEVER IGG 5.31 H DENGUE FEVER ___ 0.61 INTERPRETATION PAST INFECTION REFERENCE RANGE: IgG <0.90 ___ <0.90 LEPTOSPIRA ANTIBODY Test Result Reference Range/Units LEPTOSPIRA AB SCREEN NEGATIVE W/REFLEX TO TITER EBV PCR, QUANTITATIVE, WHOLE BLOOD Test Result Reference Range/Units SOURCE Whole Blood EBV DNA, QN PCR <200 <200 copies/mL ANAPLASMA PHAGOCYTOPHILUM (HUMAN GRANULOCYTIC EHRLICHIA AGENT) ___ Test Result Reference Range/Units A. PHAGOCYTOPHILUM IGG <1:64 <1:64 A. PHAGOCYTOPHILUM ___ <1:20 <1:20 ___ 3:40 am BLOOD CULTURE Source: Venipuncture. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 3:40 am Blood (EBV) Source: Venipuncture. **FINAL REPORT ___ ___ VIRUS VCA-IgG AB (Final ___: Test canceled and patient credited due to a prior EBV panel sent on ___ indicating evidence of past infection (EBV VCA-IgG positive, EBNA IgG positive and EBV ___ negative). A repeat panel is unlikely to detect EBV reactivation. Serum will be held for 3 months. For any questions, contact the Microbiology Medical Director. ___ VIRUS EBNA IgG AB (Final ___: TEST CANCELLED, PATIENT CREDITED. ___ VIRUS ___ AB (Final ___: TEST CANCELLED, PATIENT CREDITED. CMV IgG ANTIBODY (Final ___: POSITIVE FOR CMV IgG ANTIBODY BY EIA. 6 AU/ML. Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml. CMV ___ ANTIBODY (Final ___: POSITIVE FOR CMV ___ ANTIBODY BY EIA. INTERPRETATION: SUGGESTIVE OF RECENT/ACTIVE INFECTION. ___ 3:40 am IMMUNOLOGY Source: Venipuncture. **FINAL REPORT ___ HIV-1 Viral Load/Ultrasensitive (Final ___: HIV-1 RNA is not detected. ___ 8:25 am STOOL CONSISTENCY: SOFT Source: Stool. **FINAL REPORT ___ FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO FOUND. ___ 10:05 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN. ___ 6:00 am Immunology (CMV) **FINAL REPORT ___ CMV Viral Load (Final ___: 5,250 IU/mL. ___ 6:00 am Blood (Toxo) CHEM ___ ___. **FINAL REPORT ___ TOXOPLASMA IgG ANTIBODY (Final ___: POSITIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA. 14 IU/ML. Reference Range: Negative < 4 IU/ml, Positive >= 8 IU/ml. ___ 12:09 pm URINE Source: ___. **FINAL REPORT ___ Legionella Urinary Antigen (Final ___: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation as needed Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain, fever 2. Doxycycline Hyclate 100 mg PO Q12H RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*7 Tablet Refills:*0 3. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation as needed Discharge Disposition: Home Discharge Diagnosis: Primary Cytomegalovirus mononucleosis ___ virus infection 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 fever upon returning from ___, now with splenomegaly and anemia. // eval for pneumonia or consolidation eval for pneumonia or consolidation IMPRESSION: In comparison with the study of ___, there is no change or evidence of acute cardiopulmonary disease. No pneumonia, vascular congestion, or pleural effusion. There is suggestion of some enlargement of the splenic shadow, though this is difficult to appreciate on plain radiographs. Gender: F Race: HISPANIC/LATINO - DOMINICAN Arrive by WALK IN Chief complaint: Abnormal labs Diagnosed with ANEMIA NOS, SPLENOMEGALY temperature: 99.3 heartrate: 113.0 resprate: 18.0 o2sat: 100.0 sbp: 147.0 dbp: 62.0 level of pain: 0 level of acuity: 3.0

This is a ___ year old female with past medical history of NASH, recent travel to ___, admitted ___ with constellation of symptoms including cough, malaise, nausea/vomitting, joint pain, abdominal pain, found to have splenomegaly and hemolytic anemia, thought to be reactive to an infectious process, found to have positive chikungunya ___ as well as positive CMV ___ and viral load, seen by ID consult service who believe patient likely had both acute chikungunya and CMV infections (the second possibly being a reactivation), started on empiric doxycycline for leptospirosis coverage, returning to baseline health status, discharged home with close outpatient ___. # Chikungunya / Acute CMV Reactivation Infection: Patient admitted from clinic following sub-acute presentation with abdominal/epigastric pain, diarrhea, slightly elevated LFTs, elevated LDH, atypical lymphocytes, and splenomegaly following a trip to ___. Given her recent travel there was a broad differential for fever in a traveller in an area where several bacterial, viral and parasitic infections are endemic. The patient also had multiple clinic/ED visits with limited work up. The patient was appropriately admitted for further work up. Infectious disease was consulted and recommended a broad work up. Infectious disease evaluation including Dengue, Typhoid, Leptospirosis, Legionella, Chikengunya, Dengue, EBV, CMV, and HIV. Patient tested positive for Chikungunya, and CMV ___ and IgG, suggesting an active/acute infection. She was initiated on doxycycline empirically throughout her evaluation, given that her cough and splenomegaly were potentially consistent with Leptospirosis. She also had endorsed seafood exposure so there was initially concern for Hepatitis or vibrio parahemolyticus. During the work up CMV ___ returned positive. Chikungunya ___ positivity suggested concurrent Chikungunya infection, which possibly led to reactivation of latent CMV (given IgG positivity). Serologies also suggested past Dengue/Toxoplasma exposure. Patient was otherwise treated conservatively with improvement in symptoms to her baseline. She was discharged to complete empiric leptospirosis coverage and with close PCP and subspecialist ___. # Atypical lymphocytosis / Splenomegaly - this was felt to be in response to her ongoing infection; patient is recommended for repeat blood work and splenic ultrasound to reassess. # Acute Hemolytic Anemia: Admitted with elevated LDH, low haptoglobin and elevated reticulocyte. There were no schistocytes on peripheral smear, Coombs was negative. Guaiac negative. Hgb remained stable during admission, thought to be related to a self resolving hemolysis in the setting of her above infections. Hgb at discharge was 10.1. # Psych history: patient has hx of depression and multiple hospital stays. Has been prescribed several medications which she states she has not been taking recently. They were held given she reports she has been off of them for several months. Patient will need outpatient follow up

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillin V / Latuda / shellfish derived Attending: ___. Major Surgical or Invasive Procedure: None attach Pertinent Results: LABORATORY RESULTS: ___ 07:10AM BLOOD WBC-6.6 RBC-4.46 Hgb-12.5 Hct-39.6 MCV-89 MCH-28.0 MCHC-31.6* RDW-13.5 RDWSD-44.1 Plt ___ ___ 03:14PM BLOOD WBC-9.6 RBC-4.43 Hgb-12.1 Hct-39.5 MCV-89 MCH-27.3 MCHC-30.6* RDW-13.7 RDWSD-44.8 Plt ___ ___ 07:10AM BLOOD Neuts-51 ___ Monos-9 Eos-7 Baso-0 Plasma-2* AbsNeut-3.37 AbsLymp-2.05 AbsMono-0.59 AbsEos-0.46 AbsBaso-0.00* ___ 03:14PM BLOOD Neuts-53 Bands-1 ___ Monos-8 Eos-2 Baso-0 Atyps-2* Plasma-2* AbsNeut-5.18 AbsLymp-3.26 AbsMono-0.77 AbsEos-0.19 AbsBaso-0.00* ___ 03:41PM BLOOD ___ PTT-33.8 ___ ___ 03:14PM BLOOD Plt Smr-NORMAL-PLA Plt ___ ___ 07:10AM BLOOD Parst S-NEGATIVE FOR INTRACELLULAR AND EXTRACELLULAR PARASITES ___ 03:14PM BLOOD Parst S-NEGATIVE ___ 07:10AM BLOOD Glucose-96 UreaN-15 Creat-0.9 Na-144 K-4.6 Cl-105 HCO3-26 AnGap-13 ___ 03:14PM BLOOD Glucose-89 UreaN-17 Creat-0.9 Na-144 K-3.8 Cl-103 HCO3-25 AnGap-16 ___ 07:10AM BLOOD ALT-19 AST-21 AlkPhos-95 TotBili-0.3 ___ 04:52PM BLOOD ALT-19 AST-29 AlkPhos-93 TotBili-0.3 ___ 04:52PM BLOOD Lipase-27 ___ 07:10AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.1 ___ 04:52PM BLOOD Albumin-4.0 ___ 04:52PM BLOOD Trep Ab-NEG ___ 03:14PM BLOOD Lyme Ab-PND ___ 07:10AM BLOOD HIV Ab-NEG ___ 07:10AM BLOOD DENGUE FEVER ANTIBODIES (IGG, IGM)-PND ___ 07:10AM BLOOD CHIKUNGUNYA ANTIBODIES W/ REFLEX(ES) TO TITER-PND ___ 04:52PM BLOOD ANAPLASMA PHAGOCYTOPHILUM (HUMAN GRANULOCYTIC EHRLICHIA AGENT) IGG/IGM-PND Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ALPRAZolam 0.5 mg PO BID:PRN anxiety 2. olopatadine 0.1 % ophthalmic (eye) BID:PRN itchiness 3. Verapamil SR 300 mg PO Q24H 4. Levothyroxine Sodium 50 mcg PO 5X/WEEK (___) 5. Levothyroxine Sodium 100 mcg PO 2X/WEEK (___) 6. Fluticasone Propionate NASAL 1 SPRY NU DAILY Discharge Medications: 1. Doxycycline Hyclate 100 mg PO Q12H RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day Disp #*14 Tablet Refills:*0 2. ALPRAZolam 0.5 mg PO BID:PRN anxiety 3. Fluticasone Propionate NASAL 1 SPRY NU DAILY 4. Levothyroxine Sodium 50 mcg PO 5X/WEEK (___) 5. Levothyroxine Sodium 100 mcg PO 2X/WEEK (___) 6. olopatadine 0.1 % ophthalmic (eye) BID:PRN itchiness 7. Verapamil SR 300 mg PO Q24H Discharge Disposition: Home Discharge Diagnosis: Pustular skin lesion 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 fever/chills.***//Pneumonia? COMPARISON: Prior exam is dated ___ FINDINGS: PA and lateral views of the chest provided. A VP shunt is seen crossing the right neck and chest, without definite kink or discontinuity, extending into the upper abdomen along the midline. Lungs are clear. No signs of pneumonia or edema. No large effusion or pneumothorax. The heart appears top-normal in size. Mediastinal contour is normal. Bony structures are intact. IMPRESSION: Top-normal heart size. No signs of pneumonia. VP shunt seen. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Body pain, Fever Diagnosed with Rash and other nonspecific skin eruption temperature: 98.3 heartrate: 75.0 resprate: 18.0 o2sat: 100.0 sbp: 139.0 dbp: 80.0 level of pain: 7 level of acuity: 3.0

On admission, ___ reported feeling back at her baseline, and she had no fevers or any constitutional symptoms. An extensive work up was sent: SMEAR x 2 negative for organisms HIV negative MALARIAL ANTIGEN TEST: negative URINE CULTURE: negative DENGUE: pending CHIKUNGUNYA: pending Anaplasma: pending URINE GC/Chlamidya: PENDING THROAT GC/Chlamidya: PENDING rectal GC/chlamidya: PENDING BLOOD CULTURE x2: PENDING UA: trace protein, few mucous, otherwise normal

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Bactrim / zolpidem Attending: ___. Chief Complaint: Shortness of breath, orthopnea Major Surgical or Invasive Procedure: None History of Present Illness: ___ HTN, HLD, DMII, CKD, a-fib on Xarelto, CHF, cerebellar hemorrhage in ___ presenting as a transfer from ___ for shortness of breath and large left pleural effusion. Patient states that he became short of breath 2 weeks prior, with increasing dyspnea on exertion, and increasing orthopnea preventing him from sleeping starting 2 days prior. He denies any chest pain, cough, fevers, chills, leg swelling, changes in weight, recent changes in medication. He presented to ___ and was found to have a large left pleural effusion and transferred here for further care. He was given 1 inch of Nitropaste and IV Lasix prior to transfer, and remained hemodynamically stable during transport. OSH labs: Trop 0.2, BNP >35,000. Patient had a left pleural effusion at ___ admission which was tapped and found to be transudative. Patient felt much better after thoracentesis. Past Medical History: Sludge in CBD s/p ___ ERCP with sphincterectomy s/p cholecystectomy in ___ HTN DM2 on insulin CKD (baseline Cr ___ diabetic retinopathy A-fib on Xarelto AVNRT CHF with recovered LVEF (20% -> 65%) Nephrolithiasis (uric acid stones) UTI (most recently pan-sensitive Klebsiella in ___ Osteoarthritis Cerebellar hemorrhage/CVA ___ secondary to hypertension per records) BPPV Hypothyroidism Heterozygous for hemochromatosis Bilateral knee replacements. Social History: ___ Family History: Both parents died of CVAs in their ___. Physical Exam: ADMISSION EXAM: =============== VS: 97.7 PO 157 / 90 71 18 94 RA GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM. Stabismus. NECK: supple, no LAD, no JVD HEART: Irregularly irregular with systolic murmur, S1/S2 LUNGS: CTAB, Decreased breath sounds on the left. breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema. JVD not elevated. PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE EXAM: =============== VS: 97.4 PO 126/75 R Lying 66 20 98 RA I/O/FB: ___ (24H), ___ (since MN) Weight: 88.5 from 88.9 kg TELE: NSVT overnight GENERAL: Sleeping comfortably in bed, NAD HEENT: PERRL, EOMI, OP clear, MM dry, neck supple, no LAD, JVD not visualized when seated upright LUNGS: CTAB HEART: Irregular rate, S1 + S2 present, ___ D-C SEM loudest RUSB ABDOMEN: SNTND, +BS, no rebound/guarding EXT: WWP, no ___ edema, PPP SKIN: No rashes/lesions/bruises Pertinent Results: ADMISSION LABS: =============== ___ 08:55PM GLUCOSE-412* UREA N-53* CREAT-3.1* SODIUM-141 POTASSIUM-3.9 CHLORIDE-97 TOTAL CO2-28 ANION GAP-16 ___ 08:55PM CALCIUM-9.5 PHOSPHATE-4.4 MAGNESIUM-1.9 ___ 01:15PM GLUCOSE-433* UREA N-49* CREAT-2.9* SODIUM-141 POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-26 ANION GAP-18 ___ 01:15PM CK(CPK)-51 ___ 01:15PM cTropnT-0.17* ___ 01:15PM CK-MB-5 ___ 01:15PM CALCIUM-9.3 PHOSPHATE-4.3 MAGNESIUM-1.9 ___ 06:10AM COMMENTS-GREEN TOP ___ 06:10AM LACTATE-2.5* ___ 06:00AM GLUCOSE-241* UREA N-46* CREAT-2.9* SODIUM-143 POTASSIUM-5.0 CHLORIDE-98 TOTAL CO2-27 ANION GAP-18 ___ 06:00AM estGFR-Using this ___ 06:00AM CK(CPK)-80 ___ 06:00AM cTropnT-0.21* ___ 06:00AM CK-MB-5 ___ ___ 06:00AM CALCIUM-9.2 PHOSPHATE-4.2 MAGNESIUM-1.9 ___ 06:00AM WBC-9.0 RBC-4.90 HGB-14.2 HCT-44.1 MCV-90 MCH-29.0 MCHC-32.2 RDW-18.2* RDWSD-58.4* ___ 06:00AM NEUTS-64.0 ___ MONOS-5.6 EOS-3.0 BASOS-0.8 IM ___ AbsNeut-5.75 AbsLymp-2.33 AbsMono-0.50 AbsEos-0.27 AbsBaso-0.07 ___ 06:00AM PLT COUNT-234 ___ 06:00AM ___ PTT-37.6* ___ DISCHARGE LABS: =============== ___ 04:18AM BLOOD WBC-8.4 RBC-4.13* Hgb-12.0* Hct-37.5* MCV-91 MCH-29.1 MCHC-32.0 RDW-17.9* RDWSD-59.3* Plt ___ ___ 04:18AM BLOOD Glucose-63* UreaN-55* Creat-3.2* Na-144 K-4.0 Cl-102 HCO3-29 AnGap-13 ___ 04:18AM BLOOD Calcium-9.0 Phos-4.8* Mg-2.1 ___ 03:09PM BLOOD FreeKap-135.5* FreeLam-97.9* Fr K/L-1.38 ECHO ___: ================ The left atrial volume index is moderately increased. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate global left ventricular hypokinesis (LVEF = 35%). The right ventricular free wall is hypertrophied. with moderate global free wall hypokinesis. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion. Bilateral pleural effusions are present. IMPRESSION: Biventricular hypertrophy. Moderate global biventricular systolic dysfunction. Moderate aortic stenosis. Moderate mitral regurgitation. Mild pulmonary hypertension. Compared with the prior study (images reviewed) of ___, LV function has declined. There is a small pericardial effusion. Findings could be compatible with an infiltrative cardiomyopathy. Discussed in person with Dr. ___ at 1327 hours on the day of the study. CHEST X-RAY ___: ======================= Comparison to ___. The left pleural effusion has minimally decreased. The effusion is better visualized on the lateral than on the frontal image and still causes substantial left lower lung atelectasis. Stable borderline size of the cardiac silhouette. No pulmonary edema. CHEST X-RAY ___: ======================= Unchanged, left pleural effusion. There is increased left retrocardiac opacification which is could possibly represent atelectasis and/or consolidation in the appropriate clinical setting. Attention should be paid to the left retrocardiac area on follow up to rule out infectious process. Stable, pulmonary vascular congestion and increased pulmonary edema. The cardiomediastinal silhouette is stable. The right lung is well expanded and clear. There is no evidence of a right pleural effusion. IMPRESSION: Unchanged left pleural effusion. In the appropriate clinical setting, interval increase of left retrocardiac opacification could possibly represent atelectasis and/or consolidation. Stable pulmonary vascular congestion and increased pulmonary edema. PYROPHOSPHATE ___: ========================= FINDINGS: Static planar images of the chest demonstrate tracer uptake in the heart, which on SPECT/CT is consistent with uptake in the myocardium. Limited views of the chest and abdomen demonstrate bilateral pleural effusions with compressive atelectasis at the left lung base. Right-sided eleventh and twelfth rib fractures are also identified. The gallbladder is surgically absent. IMPRESSION: Tracer uptake in the myocardium compatible with transthyretin-related amyloidosis. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Calcitriol 0.25 mcg PO DAILY 3. Levothyroxine Sodium 50 mcg PO DAILY 4. Rivaroxaban 15 mg PO DAILY 5. Tamsulosin 0.4 mg PO QHS 6. TraZODone 100 mg PO QHS 7. Metoprolol Succinate XL 75 mg PO DAILY 8. Acetaminophen 650 mg PO Q6H:PRN Pain 9. Potassium Chloride 40 mEq PO DAILY 10. Torsemide 100 mg PO BID 11. 70/30 25 Units Breakfast 70/30 20 Units Bedtime 12. Lisinopril 10 mg PO DAILY 13. Pravastatin 40 mg PO QPM Discharge Medications: 1. HydrALAZINE 25 mg PO Q8H RX *hydralazine 25 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 2. Isosorbide Dinitrate 20 mg PO TID RX *isosorbide dinitrate 20 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 3. 70/30 25 Units Breakfast 70/30 20 Units Bedtime RX *insulin NPH and regular human [Humulin 70/30] 100 unit/mL (70-30) AS DIR 25 Units before BKFT; 20 Units before BED; Disp #*10 Vial Refills:*0 4. Lisinopril 20 mg PO DAILY RX *lisinopril 20 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 5. Torsemide 100 mg PO DAILY Instructed patient to take 200 mg of Torsemide if notices weight gain RX *torsemide 100 mg 1 tablet(s) by mouth once a day Disp #*60 Tablet Refills:*0 6. Acetaminophen 650 mg PO Q6H:PRN Pain 7. Allopurinol ___ mg PO DAILY 8. Calcitriol 0.25 mcg PO DAILY 9. Levothyroxine Sodium 50 mcg PO DAILY 10. Pravastatin 40 mg PO QPM 11. Rivaroxaban 15 mg PO DAILY 12. Tamsulosin 0.4 mg PO QHS 13. TraZODone 100 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: =================== Acute on chronic systolic heart failure Transthyretin-related cardiac amyloidosis Pleural effusion SECONDARY DIAGNOSIS: ==================== Acute on chronic kidney disease Type II NSTEMI Atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ w/ HTN, HLD, afib on rivaroxaban, CVA,diastolic CHF (EF 48%), presenting for shortness of breath andfound to have left pleural effusion c/f CHF exacerbation.// interval change on effusion? interval change on effusion? IMPRESSION: Comparison to ___. The left pleural effusion has minimally decreased. The effusion is better visualized on the lateral than on the frontal image and still causes substantial left lower lung atelectasis. Stable borderline size of the cardiac silhouette. No pulmonary edema. Radiology Report EXAMINATION: Chest portable radiograph INDICATION: ___ year old man with effusion// Interval change TECHNIQUE: Chest portable radiograph COMPARISON: Chest radiograph done on ___ FINDINGS: Unchanged, left pleural effusion. There is increased left retrocardiac opacification which is could possibly represent atelectasis and/or consolidation in the appropriate clinical setting. Attention should be paid to the left retrocardiac area on follow up to rule out infectious process. Stable, pulmonary vascular congestion and increased pulmonary edema. The cardiomediastinal silhouette is stable. The right lung is well expanded and clear. There is no evidence of a right pleural effusion. IMPRESSION: Unchanged left pleural effusion. In the appropriate clinical setting, interval increase of left retrocardiac opacification could possibly represent atelectasis and/or consolidation. Stable pulmonary vascular congestion and increased pulmonary edema. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Dyspnea, Transfer Diagnosed with Heart failure, unspecified temperature: 97.7 heartrate: 62.0 resprate: 20.0 o2sat: 98.0 sbp: 141.0 dbp: 105.0 level of pain: 0 level of acuity: 2.0

PATIENT SUMMARY: ================ Mr. ___ is a ___ year old man with PMH of HTN, HLD, DMII, CKD, a-fib on Xarelto, CHF, and cerebellar hemorrhage in ___ who presented as a transfer from ___ for shortness of breath and large left pleural effusion. Patient reported that he became short of breath 2 weeks prior, with increasing dyspnea on exertion, and increasing orthopnea preventing him from sleeping starting 2 days prior.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Ilosone / Dicloxacillin / Ace Inhibitors Attending: ___ Chief Complaint: acute kidney injury rhabdomyolysis pulmonary hypertension congestive heart failure Major Surgical or Invasive Procedure: left internal jugular CVC placement History of Present Illness: In the ED, initial VS were:T-97.8 ___ BP-112/70 R-18 O2%-90% RA ___ man with a history of HIV on HAART, hepatitis C, CAD status post CABG in ___, CHF with an EF of 50%, hypertension, hyperlipidemia, and a severe stroke in ___ with residual dysarthria and left greater than right-sided weakness who presents after falling from his wheelchair and hitting his head. On ground for around an hr. Pt recently d/c'd ___ with desats to ___ PNA. Pt denies any CP, SOB, dizziness before the fall or after. IN the ED: ___ triggered for hypoxia to ___. ___ up and did well and came back up to 100% w/ a NRB. hypoT, never tachy . Got labs from art stick. Had no access for peripheral and given L-IJ central line. Pt received 1.5 l NS. Elevated trop with normal CK index. Had negative CT head and neck. On arrival to the MICU: Pt had foley placed with 300CC of tea colored urine produced and received 1.5 L of NS bolus. ABG was drawn. Past Medical History: -HIV: dx ___, likely through IVDU (last CD4 count 438/30% vl 128 on ___ -HCV: no therapy, stage I to II fibrosis on liver biopsy in ___, genotype 1A -CAD: CABB x 1 Lima to LAD ___ s/p MI ___ -Diastolic CHF, EF 50-55% -CVA: ___ intercerebral hemorrhage in medial/superior cerebellar peduncle, wheelchair bound w/ residual L paresis -HTN -hypercholesterolemia Social History: ___ Family History: There is a significant family history of premature coronary artery disease of the father who had an MI at age ___ and uncles who have had heart attacks in the past. Otherwise, there is no other history of unexplained heart failure or sudden death. Physical Exam: Admission physical exam: Vitals: T:afeb BP:113/72 P:82 R:18 O2:96 General: Alert, oriented, HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Wheezing and crackles in all lung fields Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: Hypospadias foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Baseline left facial droop with markedlydysarthric speech,LUE and LLE with ___ strength, RUE and RLE ___. Sensation grossly intact Discharge Physical Exam: VS - 98.7 118/54 70 20 93% on shovel face mask 10L GEN: Awake, alert and oriented. No acute cardiopulmonary distress HEENT: Sclera anicteric, MMM, OP clear NECK: Supple, elevated JVP PULM: Good aeration, CTAB, without w/r/r. CV: RRR normal S1/S2, no mrg/ ABD: Soft, non-tender, obese, nondistended, no rebound or guarding. EXT: WWP. 2+ right radial pulse. left radial pulse not palpable, but left hand is well perfused. ___ pulses difficult to palpate ___ edema. 2+ pitting edema b/l LEs to knee, improved from yesterday. NEURO: awake, A&Ox3, dysarthric. left facial droop. left upper and lower extremities ___ strength. Right extremities ___ strength. SKIN: no ulcers or lesions. venous stasis/chronic edema changes in b/l lower extremities Pertinent Results: Admission labs: ___ 06:30PM BLOOD WBC-11.8* RBC-4.81 Hgb-15.5 Hct-47.7 MCV-99* MCH-32.2* MCHC-32.4 RDW-16.7* Plt ___ ___ 06:30PM BLOOD ___ PTT-33.7 ___ ___ 06:30PM BLOOD Glucose-115* UreaN-42* Creat-3.6*# Na-141 K-3.5 Cl-95* HCO3-32 AnGap-18 ___ 06:30PM BLOOD ___ ___ 06:30PM BLOOD CK-MB-34* MB Indx-0.2 cTropnT-1.67* ___ 06:37PM BLOOD ___ pO2-49* pCO2-53* pH-7.41 calTCO2-35* Base XS-6 ___ 06:37PM BLOOD Lactate-2.6* Pertinent labs: ___ 04:13AM BLOOD CK-MB-26* MB Indx-0.2 cTropnT-1.69* ___ 04:13AM BLOOD ALT-42* AST-316* ___ AlkPhos-52 ___ 04:13AM BLOOD Glucose-154* UreaN-41* Creat-2.9* Na-140 K-3.5 Cl-100 HCO3-33* AnGap-11 ___ 01:14AM BLOOD WBC-11.3* RBC-3.79* Hgb-12.2* Hct-38.7* MCV-102* MCH-32.1* MCHC-31.4 RDW-17.8* Plt ___ ___ 01:35AM BLOOD WBC-9.0 RBC-4.14* Hgb-13.1* Hct-41.0 MCV-99* MCH-31.8 MCHC-32.0 RDW-17.5* Plt ___ 03:43AM BLOOD WBC-7.4 RBC-4.16* Hgb-13.0* Hct-41.7 MCV-100* MCH-31.3 MCHC-31.2 RDW-16.5* Plt ___ ___ 05:11AM BLOOD WBC-7.1 RBC-3.90* Hgb-12.4* Hct-38.5* MCV-99* MCH-31.8 MCHC-32.2 RDW-16.4* Plt ___ ___ 04:54AM BLOOD Glucose-90 UreaN-64* Creat-3.0* Na-143 K-3.9 Cl-108 HCO3-23 AnGap-16 ___ 01:14AM BLOOD Glucose-84 UreaN-67* Creat-2.7* Na-149* K-3.3 Cl-110* HCO3-27 AnGap-15 ___ 01:30AM BLOOD Glucose-93 UreaN-59* Creat-2.2* Na-150* K-3.3 Cl-109* HCO3-32 AnGap-12 ___ 04:32AM BLOOD Glucose-110* UreaN-50* Creat-1.7* Na-150* K-3.3 Cl-107 HCO3-39* AnGap-7* ___ 03:43AM BLOOD Glucose-116* UreaN-37* Creat-1.6* Na-143 K-3.7 Cl-97 HCO3-39* AnGap-11 ___ 05:11AM BLOOD Glucose-108* UreaN-36* Creat-1.7* Na-140 K-4.0 Cl-94* HCO3-40* AnGap-10 ___ 06:30PM BLOOD ___ ___ 04:13AM BLOOD ALT-42* AST-316* ___ AlkPhos-52 ___ 04:45PM BLOOD CK(CPK)-724* ___ 05:05AM BLOOD Type-ART Temp-38.6 pO2-89 pCO2-74* pH-7.17* calTCO2-28 Base XS--3 Intubat-NOT INTUBA ___ 01:34PM BLOOD Type-ART pO2-67* pCO2-59* pH-7.40 calTCO2-38* Base XS-8 ___ 11:21AM BLOOD ___ pO2-40* pCO2-71* pH-7.40 calTCO2-46* Base XS-14 ___ 05:31AM BLOOD ___ pO2-57* pCO2-72* pH-7.39 calTCO2-45* Base XS-14 ___ 01:28AM BLOOD Lactate-2.2* ___ 01:34PM BLOOD Lactate-1.0 Imaging ___ CXR PORTABLE CHEST: ___. HISTORY: ___ man with shortness of breath and acute hypoxia. FINDINGS: Single portable view of the chest is compared to previous exam from ___. Compared to prior, there has been interval improvement of aeration at the lung bases. There are some persistent bibasilar opacities, right greater than left. Cardiomediastinal silhouette is stable as are the osseous and soft tissue structures. IMPRESSION: Mild interval improvement in the previously seen bibasilar opacities which persist. These could be due to resolving infiltrates or atelectasis or potentially aspiration. ___ CT head FINDINGS: There is no acute intra-axial or extra-axial hemorrhage, mass, midline shift, or territorial infarct. Right occipital lobe encephalomalacia as well as regions of encephalomalacia centered in the right middle cerebellar peduncle are again seen. Global volume loss of the cerebellum is again noted. Elsewhere, gray-white matter differentiation is preserved. There is partial opacification of the inferior right mastoid air cells. Mucous retention cyst seen in the right maxillary sinus. Other paranasal sinuses and left mastoids are clear. The skull and extracranial soft tissues are unremarkable. IMPRESSION: No acute intracranial process. Encephalomalacia within the right occipital lobe and right middle cerebellar peduncle, unchanged from prior ___ TTE: Poor image quality.The left atrium is normal in size. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. No late contrast is seen in the left heart (suggesting absence of intrapulmonary shunting). There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is no ventricular septal defect. The right ventricular cavity is dilated with mild global free wall hypokinesis. There is abnormal septal motion/position. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The tricuspid regurgitation jet is eccentric and may be underestimated. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of ___, due to poor image quality on prior study, a direct comparison of RV size nad function is not possible. The current study suggests a more dilated/dysfunctional RV though. ___ lower-extremity venous u/s IMPRESSION: No deep vein thrombosis. ___ CXR 1. Nasogastric tube is seen coursing below the diaphragm with the tip not identified. Left internal jugular central line has its tip in the proximal SVC. There continues to be diffuse bilateral airspace process with probable associated layering effusions. This may reflect worsening pulmonary edema, although superimposed bilateral pneumonia cannot be entirely excluded. Clinical correlation is advised. No pneumothorax is seen. Overall, cardiac and mediastinal contours are likely stable, but somewhat difficult to assess due to diffuse airspace process. ___ Head CT IMPRESSION: No acute intracranial process identified to explain patient's neurologic decline. ___ EEG (from neurology note) EEG was done and showed spikes of 3Hz with right hemispheric predominance. ___ Video Swallow FINDINGS: Barium passes freely through the oropharynx and esophagus without evidence of obstruction. There was evidence of intermittent penetration of thin, as well as intermittent aspiration of nectar consistency. For further details, please refer to speech and swallow division note in OMR. Preliminary Report IMPRESSION: Penetration of thin consistency and aspiration of nectar consistency, both intermittently. Medications on Admission: 1. Aspirin 81 mg PO DAILY 2. Docusate Sodium 50 mg PO TID 3. Metoprolol Succinate XL 12.5 mg PO DAILY 4. Rosuvastatin Calcium 40 mg PO DAILY 5. Saquinavir (Invirase) Cap 400 mg PO BID 6. RiTONAvir 400 mg PO BID 7. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY 8. Levofloxacin 750 mg PO DAILY Day 1= ___, finishes on ___ 9. Tiotropium Bromide 1 CAP IH DAILY 10. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing, shortness of breath 11. oxygen 416.8 Other chronic pulmonary heart diseases Home oxygen @ 5 LPM continuous via shovel mask, conserving device for portablity Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. RiTONAvir 400 mg PO BID 3. Saquinavir (Invirase) Cap 400 mg PO BID 4. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze/SOB 5. Furosemide 40 mg IV BID 6. LeVETiracetam 500 mg PO BID 7. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath/wheezing 8. Docusate Sodium 50 mg PO BID 9. Metoprolol Succinate XL 12.5 mg PO DAILY (being held for continued diuresis) 10. Tiotropium Bromide 1 CAP IH DAILY 11. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Rhabdomyolysis Acute Kidney Injury Acute on chronic diastolic congestive heart failure Non-convulsive seizure activity Discharge Condition: Mental status: clear, oriented Ambulatory status: requires wheelchair. Full assist for transfers Followup Instructions: ___ Radiology Report PORTABLE CHEST: ___. HISTORY: ___ man with shortness of breath and acute hypoxia. FINDINGS: Single portable view of the chest is compared to previous exam from ___. Compared to prior, there has been interval improvement of aeration at the lung bases. There are some persistent bibasilar opacities, right greater than left. Cardiomediastinal silhouette is stable as are the osseous and soft tissue structures. IMPRESSION: Mild interval improvement in the previously seen bibasilar opacities which persist. These could be due to resolving infiltrates or atelectasis or potentially aspiration. Radiology Report HEAD CT WITHOUT CONTRAST: ___. HISTORY: ___ male with fall on to head and hypoxia. TECHNIQUE: Contiguous axial images were obtained from skull base to vertex without intravenous contrast. Coronal and sagittal reformats were reviewed. COMPARISON: Head CT from ___ and brain MR from ___. FINDINGS: There is no acute intra-axial or extra-axial hemorrhage, mass, midline shift, or territorial infarct. Right occipital lobe encephalomalacia as well as regions of encephalomalacia centered in the right middle cerebellar peduncle are again seen. Global volume loss of the cerebellum is again noted. Elsewhere, gray-white matter differentiation is preserved. There is partial opacification of the inferior right mastoid air cells. Mucous retention cyst seen in the right maxillary sinus. Other paranasal sinuses and left mastoids are clear. The skull and extracranial soft tissues are unremarkable. IMPRESSION: No acute intracranial process. Encephalomalacia within the right occipital lobe and right middle cerebellar peduncle, unchanged from prior. Radiology Report INDICATION: ___ male status post fall. Evaluate for cervical spine fracture or any other abnormalities. COMPARISON: CT head without contrast performed prior to this study as well as video oropharyngeal swallow from ___. TECHNIQUE: Axial contiguous MDCT images were obtained through the cervical spine with 2.5-mm slice thickness. Images were obtained from the skull base to the level of T1. Coronal and sagittal reformations were generated as well as thin-slice bone images. FINDINGS: There is straightening with reversal of the cervical lordosis, likely secondary to external collar devise. Otherwise, there is no fracture or malalignment. Mild-to-moderate degenerative changes are noted throughout the cervical spine with disc height loss and enplate osteophyte formation, most notablely posteriorly at C5-C6 with probable mild overall canal narrowing. There is no prevertebral soft tissue swallowing. The aerodigestive tract is unremarkable. Right maxillary mucous retention cyst noted. For further details on intracranial structures, please refer to CT head report from same date in OMR. IMPRESSION: No evidence of fracture or malalignment. Mild-to-moderate degenerative changes as described above. Radiology Report PORTABLE CHEST; ___ HISTORY: ___ male with new left central venous line. FINDINGS: Single portable view of the chest compared to previous exam from earlier the same day. New left IJ central venous line is seen with catheter tip in the proximal superior vena cava. There is no visualized pneumothorax. No other change. Radiology Report INDICATION: Hypoxia and tachycardia. Evaluation for DVT. TECHNIQUE: Grayscale and pulse wave Doppler of the bilateral lower extremities. COMPARISONS: None. FINDINGS: The common femoral veins demonstrate normal respiratory phasicity bilaterally. There is normal compressibility, flow, and augmentation of the bilateral common femoral, superficial femoral, and popliteal veins. Normal flow and compressibility is demonstrated in the bilateral posterior tibial and deep peroneal veins. IMPRESSION: No deep vein thrombosis. Radiology Report AP CHEST, 9:52 A.M. ON ___ HISTORY: ___ man with renal insufficiency and hypoxemia. IMPRESSION: AP chest compared to ___: Lung volumes have decreased since ___, which may account for the apparent worsening of moderately extensive opacification in both lower lungs, left greater than right. Since the mediastinal veins are dilated, I suspect much of this is edema related to intravascular volume. Because it is heterogeneous, concurrent pneumonia is a possibility. Heart size is exaggerated by low lung volumes, not particularly dilated. Left central venous catheter ends in upper SVC. There is no pneumothorax. Small bilateral pleural effusions are new or increased since ___. Radiology Report STUDY: Portable AP chest radiograph. COMPARISON EXAM: Portable AP chest radiograph ___. INDICATION: ___ with new NG placement. FINDINGS: This film is centered in the thoracoabdominal region to assess the placement of the NG tube, and evaluation of the thorax is limited. There is a new NG tube with tip terminating in the GE junction. IMPRESSION: NG tube with tip in the GE junction. Advancement is recommended. Radiology Report PORTABLE AP CHEST FILM, ___ AT 15:51 CLINICAL INDICATION: ___ with respiratory failure, question pneumonia. Comparison is made to the patient's prior study dated ___ at 17:36. A portable AP upright chest film, ___ at 15:51 is submitted. IMPRESSION: 1. Nasogastric tube is seen coursing below the diaphragm with the tip not identified. Left internal jugular central line has its tip in the proximal SVC. There continues to be diffuse bilateral airspace process with probable associated layering effusions. This may reflect worsening pulmonary edema, although superimposed bilateral pneumonia cannot be entirely excluded. Clinical correlation is advised. No pneumothorax is seen. Overall, cardiac and mediastinal contours are likely stable, but somewhat difficult to assess due to diffuse airspace process. Radiology Report PORTABLE AP CHEST FROM ___ AT 19:48. CLINICAL INDICATION: ___ with CHF, pulmonary hypertension, evaluate orogastric tube placement. Comparison is made to the patient's prior study of ___ at 15:51. A portable supine chest film dated ___ at 19:48 is submitted. IMPRESSION: 1. Orogastric tube is seen which courses below the diaphragm and the tip projects over the expected location of the stomach. Left internal jugular central line with its tip in the proximal SVC. There has been some interval improvement in bilateral airspace process associated with layering effusions. Given the interval change, this would favor resolving pulmonary edema, but superimposed pneumonia cannot be entirely excluded. Cardiac and mediastinal contours are likely stable. No pneumothorax is seen, although the sensitivity to detect pneumothorax is diminished given supine technique. Radiology Report INDICATION: The patient with complex medical history and prior history of CVA in ___ with baseline dysarthria, left-sided weakness, treated with heparin GTT this admission, for possible pulmonary emboli. Now presenting with confusion, echolalia and leftward saccades. COMPARISON: CT head from ___. TECHNIQUE: MDCT acquired contiguous axial images were obtained through the head. No contrast was administered. Coronal and sagittal reformats reviewed. FINDINGS: Evaluation of the posterior fossa is limited by motion artifact. There is no acute intracranial hemorrhage, edema, mass, or mass effect. There is no evidence of acute vascular territorial infarction. There is volume loss in the cerebellum, unchanged from the prior examination with malacic change in the right middle cerebellar peduncle. These areas are not well seen on this study. The ventricles and sulci are unchanged. There is no fracture. There is a mucus retention cyst in the right maxillary sinus and mucosal thickening of the ethmoid air cells. The remainder of the paranasal sinuses are clear. There is new, partial fluid opacification of several mastoid air cells bilaterally. The middle ear cavities are clear bilaterally. IMPRESSION: No acute intracranial process identified to explain patient's neurologic decline. Radiology Report HISTORY: ___ old male with shortness of breath and increased O2 requirement. STUDY: Bilateral lower extremity venous ultrasound. COMPARISON: ___. FINDINGS: Grayscale and color Doppler sonographic imaging was performed of the bilateral common femoral, superficial femoral, popliteal, peroneal, and posterior tibial veins. Normal compressibility, flow, and augmentation was demonstrated. IMPRESSION: No evidence of DVT in either lower extremity. Radiology Report INDICATION: ___ male with a history of a right-sided stroke and residual left-sided weakness and dysphagia who presents for evaluation of swallowing for diet modifications. COMPARISONS: Video swallow from ___. TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in conjunction with the speech and swallow division. Multiple consistencies of barium were administered. FINDINGS: Barium passes freely through the oropharynx and esophagus without evidence of obstruction. There was evidence of intermittent penetration of thin, as well as intermittent aspiration of nectar consistency. For further details, please refer to speech and swallow division note in OMR. IMPRESSION: Penetration of thin consistency and aspiration of nectar consistency, both intermittently. Radiology Report CHEST RADIOGRAPH INDICATION: PICC line placement. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, the patient has received a right-sided PICC line. The course of the line is unremarkable. The tip of the line projects over the mid-to-low SVC. There is no evidence of complications, notably no pneumothorax. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: S/P FALL Diagnosed with RHABDOMYOLYSIS, ACUTE KIDNEY FAILURE, UNSPECIFIED, FALL FROM WHEELCHAIR, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA, ASYMPTOMATIC HIV INFECTION temperature: 97.8 heartrate: 103.0 resprate: 18.0 o2sat: 90.0 sbp: 112.0 dbp: 70.0 level of pain: 0 level of acuity: 2.0

Active Problems #rhabdomyolysis- Pt found on the ground for an extended period of time which could be the cause for his rhabdo. ___ received aggressive IV fluid to try to maintaine a 200CC urine output while not compromissing his respiratory status. His CK eventually came down but CR was still elevated. Renal was consulted and recommended no HD. ___ still producing urine and CR was stable. Creatinine stabilized at 1.6-1.7. This likely represents his new baseline. He continued to have good urine output throughtout rest of admission. #elevated trop- Pt has signigicant elevation of trop. EKG similar to previous. Pt received 325 ASA. His CK-MB index was never elevated and trop was not raising so a cards consult was not obtained. #ATN: Muddy brown cast found in urine ___. Most likely ___ to rhabdo. Improving toward baseline. Most likely CKD at this point. Cr remains stable at 1.7. Good urine output maintained throughout admission. Pt. to follow-up with renal as outpatient #Hypoxemia- Chronic O2 requirment likely multifactorial related to pulmonary HTN, COPD, OSA, OHS. Current increase in O2 requirement likely ___ PE vs heart failure. Unable to obtain CTA at this time due to pt ___. Has been improving with diuresis and thus it is most likely ___ CHF/pulmonary edema, less likely PE, heparin was switched to subcut. As patient continues to improve with diuresis, did not pursue further PE work-up. Treated with vanco and cefipime after 8 day HCAP coverage. Currently no clinical evidence of pneumonia. Pt. responded well to IV Lasix 40mg BID. Upon discharge, pt. likely at his baseline hypoxemia. No evidence of significant pulmonary edema on most recent CXR and only mild bibasilar crackles on exam. Still 5 liters net positive for length of stay ___ aggressive fulid resuscitation for severe rhabdo upon initial presentation. Would recommend continued diuresis to achieve euvolemia and optimize respiratory status. Renal function slowly improving, so patient likely able to autodiurese soon. Though not confirmed, pt. likely has significant pulmonary HTN based on old TTE, recent chest CT with enlarged PA, and multiple pulmonary HTN risk factors as outlined above. Pt. scheduled to follow in pulmonary clinic with Dr. ___ further w/u and treatment of this presumed pulmonary HTN. At time of discharge, pt. saturating in low ___ on nasal canula, which is likely around his baseline oxygenation. No pulmonary symptoms. #new onset seizure activity- ___ experienced change in mental status while in the ICU with echolalia, confusion, and leftward gaze deviation with random leftward saccadic eye movements.. A CT head was ordered which showed NAP and EEG which showed epileptiform discharges. Neurology was called and pt was placed on Keppra. His mental status improved significantly back to baseline without any further evidence of seizure activity or changes in mental status. Pt. to be discharged on Keppra 500mg BID. Pt. will f/u in epilepsy clinic in ___ weeks time after discharge for furthur management. #Nutrition - video swallow. Speech therapy recommend ground solids with nectar thickened liquids. Likely chronic aspirator ___ to prior CVA. Pt. to be discharged on this diet. Chronic Problems #HTN - antihypertensives were held throughout admission, particularly in setting of agressive diuresis following resolution of rhabdo. Metoprolol and triamterene-HCTZ can be restarted once pt. back to euvolemia. #HIV - pt. was maintained on his regimen of Saquinavir and Ritonavir Transitional Issues #Volume overload - upon discharge, pt. net positive 5 liters for length of stay. has been getting IV lasix 40mg BID. Would recommend continuing diuresis with goal of euvolemia. Diuresis was associated with significant improvement of pt.'s respiratory status. Discharged on 5L nc, with saturations in low ___. Probably will only require a couple more days of diuresis, as renal function continues to improve toward his baseline. Would recommend checking daily electrolytes while actively diuresing and while Cr continuing to normalize.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left intertrochanteric hip fracture Major Surgical or Invasive Procedure: Open Reduction Internal Fixation ___ History of Present Illness: ___ with a h/o osteoporosis and dementia A&O x1 baseline, who sustained a spontaneeous L hip fx at her nursing home. Patient is ___ at baseline, but does get up to transfer to toilet/chair. Patient had been experiencing pain for several days at the nursing home, which staff attributed to vaginal infection. Upon further evaluation patient was found to have a left intertrochanteric hip fx. She was brought by ambulance to the ED, seen by Orthopedics and brought immediately to the OR for fixation. CT head and ___ were negative. Patient was hypoxic to ___ requiring 4L NC to maintain sats in ___. Anesthesia concerned about chronic aspiration based on trachea suction material intraopertively. No evid of PNA or pneumonitis on initial CXR taken prior to presumed aspiration event. Of note, she is not on home oxygen and does not have a h/o lung disease (remote h/o smoking). She has been on a pureed diet at the nursing home since losing her dentures. Patient was also found to have UTI with UA with postive leukocytestrase, nitrites, many WBCs and Many bacteria. Patient has a h/o of UTI's, but it is unknown how many she has had in the past year. She was started on CTX 1g q24hrs pending culture results. Patient with baseline dementia oriented x1. Per her daughter, she was functional prior to a fall with head strike, with develoopment of a subdural hematoma ___ years ago. On the floor, Patient was sat'ing 95% on 2L O2 by NC, shovel mask with 50% O2. She oriented x1 and was having pain with movement of L ___. Past Medical History: psychosis osteoporosis gerd hyperlipidemia dementia and delusions auditory hallucinations osteoporosis subdural hematoma s/p back surgery Social History: ___ Family History: Reviewed. Not pertinent to this hospitalization Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 98.2 BP:112/50 P: 79 R: O2:96% 2L by NC, humidified 50%O2 by shovel mask General: elderly, frail, oriented x1 (baseline) HEENT: Sclera anicteric, adentulous Neck: supple, JVP not elevated Lungs: Clear to auscultation bilaterally, but with occasional mild crackles CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, suprapubic tenderness on palpation, ___, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. L thigh/hip with surgical dressing c/d/i, pneumoboots and compression stockings Skin: UE echymoses Neuro: Oriented x1 at baseline DISCHARGE PHYSICAL EXAM: 97.9 152/62 64 20 98% 3L NC General: elderly, AAOx1 HEENT: Sclera anicteric, MMM Neck: supple, JVP not elevated Lungs: Clear to auscultation bilaterally CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, NTP, ___, bowel sounds present GU: foley in place Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. L thigh/hip with surgical dressing c/d/i, mild tenderness to palpation Neuro: Oriented x1 at baseline Pertinent Results: ADMISSION LABS: ___ 02:55PM ___ ___ ___ 02:55PM PLT ___ ___ 12:30PM ___ TO ___ TO ___ TO ___ TO ___ TO ___ TO ___ TO ___ TO ___ 12:30PM PLT ___ TO ___ 02:40AM URINE ___ ___ 02:40AM URINE ___ ___ 02:40AM URINE ___ ___ 02:40AM URINE GR ___ ___ 02:40AM URINE ___ SP ___ ___ 02:40AM URINE ___ ___ ___ 02:40AM URINE ___ ___ ___ 02:40AM URINE ___ ___ 02:40AM URINE ___ ___ 02:24AM ___ ___ 02:20AM ___ UREA ___ ___ TOTAL ___ ANION ___ ___ 02:20AM ___ this ___ 02:20AM ___ ___ 02:20AM ___ ___ ___ 02:20AM ___ ___ ___ 02:20AM PLT ___ ___:20AM ___ ___ DISCHARGE LABS: ___ 05:30AM BLOOD ___ ___ Plt ___ ___ 05:30AM BLOOD ___ ___ ___ 05:30AM BLOOD ___ MICROBIOLOGY: Urine culture ___: URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ 8 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S RADIOLOGY: CXR ___: IMPRESSION: No acute abnormality. Chronic interstitial pulmonary abnormality ro emphysema. LEFT FEMUR AP/LATERAL ___: IMPRESSION: Comminuted left femur intertrochanteric fracture in varus alignment. HIP BILATERAL ___: IMPRESSION: Comminuted left femur intertrochanteric fracture in varus alignment. BILATERAL LOWER EXTREMITY DOPPLERS ___: IMPRESSION: Extremely limited study, however no evidence of a DVT in the visualized bilateral lower extremity veins. CT ___ w/ contrast ___: IMPRESSION: No acute cervical spine fractures identified. CT HEAD W/O CONTRAST ___: IMPRESSION: 1. No acute intracranial abnormalities identified. 2. Irregularity of the nasal bones may be secondary to old fractures. Please correlate clinically. LOWER EXTREMITY FLUORO ___: FINDINGS: These views show interval open reduction and internal fixation of a fracture involving the intertrochanteric region of the proximal left femur. HIP NAILING W/O FRACTURE in OR ___: FINDINGS: These views show interval open reduction and internal fixation of a fracture involving the intertrochanteric region of the proximal left femur. CXR PA and Lateral ___: IMPRESSION: Allowing for technical differences, there is new left lower lobe collapse and/or consolidation and possible new opacity at the right base, with equivocal small right effusion. Differential diagnosis includes pneumonia and aspiration. Possibility of some degree of CHF superimposed on existing background COPD would also be difficult to exclude. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Milk of Magnesia 30 mL PO DAILY:PRN constipation 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. ___ 3,875 mg/30 mL oral bid 4. cyanocobalamin (vitamin ___ 1,000 mcg/mL injection q monthly 5. Vitamin D 50,000 UNIT PO QMONTHLY 6. Calcium Carbonate 1000 mg PO QDAILY 7. Lexapro (escitalopram oxalate) 10 mg oral qdaily 8. Lactulose 30 mL PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Pyridoxine 50 mg PO DAILY 11. TraZODone 25 mg PO 5PM 12. Omeprazole 20 mg PO BID 13. QUEtiapine Fumarate 25 mg PO BID 14. Senna 17.2 mg PO BID 15. QUEtiapine Fumarate 50 mg PO QHS 16. Acetaminophen 650 mg PO Q6H:PRN pain/fever 17. DuoNeb (___) 0.5 ___ mg(2.5 mg base)/3 mL inhalation q4hr prn congestion/cough 18. Polyethylene Glycol 17 g PO BID:PRN constipation 19. Guaifenesin 15 mL PO Q4H:PRN cough Discharge Medications: 1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 2. Calcium Carbonate 1000 mg PO QDAILY 3. Omeprazole 20 mg PO BID 4. QUEtiapine Fumarate 25 mg PO BID 5. QUEtiapine Fumarate 50 mg PO QHS 6. Senna 17.2 mg PO BID 7. TraZODone 25 mg PO 5PM 8. Vitamin D 50,000 UNIT PO QMONTHLY 9. ___ Acid ___ mg PO Q12H 10. Guaifenesin 15 mL PO Q4H:PRN cough 11. Lactulose 30 mL PO DAILY 12. Escitalopram Oxalate (escitalopram oxalate) 10 mg ORAL QDAILY 13. Milk of Magnesia 30 mL PO DAILY:PRN constipation 14. Multivitamins 1 TAB PO DAILY 15. Polyethylene Glycol 17 g PO BID:PRN constipation 16. Pyridoxine 50 mg PO DAILY 17. ___ 3,875 mg/30 mL oral bid 18. DuoNeb (___) 0.5 ___ mg(2.5 mg base)/3 mL inhalation q4hr prn congestion/cough 19. Miconazole Nitrate Vag Cream 2% 1 Appl VG HS Duration: 7 Days 20. Morphine Sulfate (Oral Soln.) 2 mg PO Q6H:PRN breakthrough pain RX *morphine 10 mg/5 mL 2 mg by mouth every six (6) hours Refills:*0 21. Enoxaparin Sodium 30 mg SC Q24H Start: Today - ___, First Dose: Next Routine Administration Time 22. Acetaminophen 650 mg PR Q8H pain 23. cyanocobalamin (vitamin ___ 1,000 mcg/mL injection q monthly Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Hip fracture Pneumonia UTI Secondary: Dementia Osteoporosis 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: History of left hip fracture. Please evaluate chest. COMPARISONS: None. TECHNIQUE: Frontal AP radiograph of the chest. FINDINGS: Generalized pulmonary reticulation reflects a chronic pulmonary problem, probably of no active clinical concern in a patient of this age. There is no evidence of intrathoracic trauma, infection, or cardiac decompensation. Heart size is normal. The aorta is tortuous and heavily calcified but not aneurysmal. Mild left lower costal thickening is the only pleural abnormality. There is no evidence of a pneumothorax. IMPRESSION: No acute abnormality. Chronic interstitial pulmonary abnormality ro emphysema. Radiology Report INDICATION: History of fall. Please evaluate for fracture. COMPARISONS: None. TECHNIQUE: Frontal view of the pelvis with two additional views of the left hip and one lateral view of the left knee. FINDINGS: There is an oblique comminuted intertrochanteric fracture with mild superolateral displacement and varus angulation. No other fractures are identified. Vascular calcifications are noted. The femoral head appears to be well seated within the acetabulum. IMPRESSION: Comminuted left femur intertrochanteric fracture in varus alignment. Radiology Report INDICATION: History of bilateral leg swelling. Please evaluate. COMPARISONS: None. TECHNIQUE: Grayscale, color and spectral Doppler evaluation of the bilateral lower extremity veins. FINDINGS: This is a very limited study due to decreased patient's cooperation. There is good flow, compressibility in the left common femoral vein, proximal superficial femoral vein, mid superficial femoral vein, distal superficial femoral vein and popliteal veins. The left calf veins were not visualized. Good compressibility and flow were obtained in the right common femoral vein, superficial femoral vein and popliteal veins. The right calf veins were not visualized. IMPRESSION: Extremely limited study, however no evidence of a DVT in the visualized bilateral lower extremity veins. Radiology Report INDICATION: History of fall, possible intracranial hemorrhage. Please evaluate. COMPARISONS: None. TECHNIQUE: ___ MDCT images were obtained through the brain without the administration of IV contrast. Multiplanar reformatted images in coronal and sagittal axes were generated and reviewed. FINDINGS: There is no evidence of acute intracranial hemorrhage, mass, mass effect or large territorial infarction. Periventricular hypodensities are likely related to chronic small vessel ischemic disease. The basilar cisterns are patent and there is otherwise good preservation of the gray-white matter differentiation. Irregularity of the nasal bones may be secondary to old fractures. Please correlate clinically. No other acute fracture is identified. The visualized paranasal sinuses, mastoid air cells and middle ear cavities are clear. The globes are unremarkable. IMPRESSION: 1. No acute intracranial abnormalities identified. 2. Irregularity of the nasal bones may be secondary to old fractures. Please correlate clinically. Radiology Report INDICATION: History of possible fall. Please evaluate. COMPARISONS: None. TECHNIQUE: ___ MDCT images were obtained through the cervical spine without the administration of IV contrast. Multiplanar reformatted images in coronal and sagittal axes were generated and reviewed. FINDINGS: There is no evidence of fracture or prevertebral soft tissue swelling. There is no evidence of significant malalignment. Multilevel, multifactorial degenerative changes are seen with evidence of intervertebral disc space narrowing, worse from C6/C7. There is also mild anterior and posterior osteophytosis, worse at C5/C6 with mild thecal sac narrowing. The thyroid is normal. The visualized apices of the lungs are clear aside from mild apical scarring. No cervical lymphadenopathy is identified. IMPRESSION: No acute cervical spine fractures identified. Radiology Report INTRAOPERATIVE FLUOROSCOPY OF THE LEFT HIP HISTORY: Ongoing ORIF of left hip fracture. COMPARISONS: Earlier in the same day. TECHNIQUE: Intraoperative left hip fluoroscopy, two views. FINDINGS: These views show interval open reduction and internal fixation of a fracture involving the intertrochanteric region of the proximal left femur. Radiology Report HISTORY: Left hip fracture status post fixation, hypoxia, pneumonia, pneumonitis or other acute process. CHEST, SINGLE AP PORTABLE VIEW: Rotated positioning. As before, there is cardiomegaly. Direct comparison for any increase in cardiac size is difficult due to rotated positioning and technical differences. The possibility of some interval increase in the degree of cardiac enlargement cannot be excluded. As before, as well, the aorta is calcified and unfolded. There is a possible small right effusion as well as some atelectasis and scarring at the right base superimposed on a known elevated right hemidiaphragm. Possibility of some interval worsening of these findings cannot be excluded. There is new increased retrocardiac density with obscuration of the left hemidiaphragm, consistent with left lower lobe collapse and/or consolidation. No gross left effusion. Left apical pleural thickening is more apparent on the current film. IMPRESSION: Allowing for technical differences, there is new left lower lobe collapse and/or consolidation and possible new opacity at the right base, with equivocal small right effusion. Differential diagnosis includes pneumonia and aspiration. Possibility of some degree of CHF superimposed on existing background COPD would also be difficult to exclude. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: s/p Fall Diagnosed with FX NECK OF FEMUR NOS-CL, OVEREXERTION FROM SUDDEN STRENUOUS MOVEMENT temperature: 98.0 heartrate: 78.0 resprate: 24.0 o2sat: 97.0 sbp: 151.0 dbp: 69.0 level of pain: 8 level of acuity: 2.0

___ with h/o dementia A&O x1 baseline and osteoporosis, presents with spontaneous L hip fracture at intertrochanteric hip fracture nursing home now s/p ORIF, with course complicated by PNA and UTI.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Hydralazine And Derivatives / Bumex / Sulfa (Sulfonamide Antibiotics) / Lactose / banax / Neurontin Attending: ___. Chief Complaint: abdominal pain, nausea, vomiting, diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ F with distant history of gastric volvulus s/p repair, s/p appy and s/p CCY, recent admission for ischemic colitis ___ and also with history of prior C.Diff colitis who presents now with abdominal pain and vomiting that started around noon ___. Daughter, ___, accompanies patient and corrobarates story. The patient initiall started feeling slightly unwell last week, with some stomach discomfort and so starting eating a BRAT diet with improvement in symptoms. Symptoms resolved until ___ when after dinne she began feling unwell again, again symptoms resolved. Morning of admission (___) she ate breakfast and then 1 hour later began having terrible abdominal pain, nausea, vomiting and profuse watery diarrhea. Patient reports that pain is mostly left-sided and she has had frequent non-bloody, non-bilious emesis thoughout the afternoon as well as non-bloody, non-melanotic diarrhea. She has not had fevers, chills, has not traveled and has no sick contacts. In the ED, initial VS were: 97.5 89 146/75 16 97%. CT abdomen was peformed showing evidence of colitis but without evidence of obstruction. ED evaluation not concerning for mesenteric ischemia or ischemic colitis and given CT abdominal findings not showing obstruction surgery was not consulted. Lactate was normal so no concern for end organ damage. She received 2L NS, Cipro and Flagyl pior to transfer. Vitals prior to transfer 99.2 67 119/53 18 96 On arrival to the floor, the patient arrives overall stable appearing, continued abdominal pain but without nausea, vomiting or diarrhea. Cipro is infusing. She is in good humor and making jokes throughout interview, she is also accompanied by daughter. REVIEW OF SYSTEMS: (+) pe HPI (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, ___, melena, hematochezia, dysuria, hematuria. Past Medical History: - Gastric volvulus ___ yrs ago) s/p repair - Internal hemorrhoids - legally blind - IBS - C diff colitis - HTN - Hyperlipidemia - CAD - RBBB - DOE s/p extensive negative work up - Hypothyroidism - OA - PUD - GERD - Depression - Prior GYN surgeries remotely - s/p hiatal hernia repair - s/p cholecystectomy - s/p appendectomy - s/p ORIF L radius ___ Social History: ___ Family History: - Mother: CAD, CVA - Aunt: ___ cancer Physical Exam: ADMISSION PHYSICAL EXAM: VS - 98.2 125/59 62 18 98%RA GENERAL - Acutely ill but non-toxic appearing robust ___ F, wearing sunglasses an in good humor HEENT - dry mucous membranes NECK - no JVD no ___ LUNGS - Reduced air movement but clear to auscultation thoughout all lung fields HEART - PMI non-displaced, RRR S1-S2 clear and of good quality, no MRG appreciated ABDOMEN - Distended and obese, prior sugical scars are well healed. Slightly tense with voluntary guarding, tender to palpation over LLQ and LUQ but non tender on right. No rebound. Hyperactive bowel sounds throughout. EXTREMITIES - 1+ ___ bilaterally with tenderness NEURO - awake, A&Ox3 DISCHARGE PHYSICAL EXAM: VS - 97.7 115/50 61 18 96%RA GENERAL - NAD HEENT - mucous membranes moist NECK - no JVD LUNGS - CTABL, no crackles or wheezes, good air movement HEART - RRR S1-S2 clear and of good quality, no MRG appreciated ABDOMEN - Distended and obese, prior sugical scars are well healed. 1 cm umbilical palpated above umbilicus, not reducible, not painful. Minimal voluntary guarding, mildly tender to palpation over LLQ but non tender on right. No rebound. Normal bowel sounds throughout. EXTREMITIES - 1+ ___ bilaterally NEURO - awake, A&Ox3 Pertinent Results: ADMISSION LABS ___ 07:50PM URINE COLOR-Red APPEAR-Clear SP ___ ___ 07:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5 LEUK-MOD ___ 07:50PM URINE RBC-3* WBC-46* BACTERIA-NONE YEAST-NONE EPI-1 ___ 07:50PM URINE HYALINE-2* ___ 07:50PM URINE MUCOUS-RARE ___ 06:11PM LACTATE-1.9 ___ 05:30PM GLUCOSE-155* UREA N-20 CREAT-1.2* SODIUM-138 POTASSIUM-3.4 CHLORIDE-97 TOTAL CO2-28 ANION GAP-16 ___ 05:30PM estGFR-Using this ___ 05:30PM WBC-13.7*# RBC-5.11 HGB-13.4 HCT-42.1 MCV-82 MCH-26.2* MCHC-31.9 RDW-17.7* ___ 05:30PM NEUTS-88.5* LYMPHS-7.4* MONOS-3.6 EOS-0.4 BASOS-0.1 ___ 05:30PM PLT COUNT-283 CT abd and pelvis with contrast 1. Mild bowel wall thickening and mucosal enhancement with surrounding inflammatory change of the sigmoid ___ and to a lesser degree the descending ___ tapering to the level of the splenic flexure, consistent with colitis with etiologies including infectious, inflammatory or ischemic. Of note, the ostia of the celiac and superior mesenteric and inferior mesenteric arteriesdo not appear to have critical stenosis and mesenteric vessels are overall patent. 2. Moderate stable intrahepatic and extrahepatic biliary ductal dilatation, not significantly changed. 3. Prominent intermittent fluid filled loops of small bowel with intervening areas of collapse without secondary evidence of obstruction; however, if abdominal symptoms worsen, low threshold to repeat scan to assess for developing small bowel obstruction. Stool Studies ___ 9:21 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. ADDON FOR CGD FEC CCU ROE ___ PER FAX BY ___ ___ ___ @ 1118. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Reported to and read back by ___ ___ ___ 3PM. CLOSTRIDIUM DIFFICILE. Positive for toxigenic C. difficile by the Illumigene DNA amplification. (Reference Range-Negative). Cryptosporidium/Giardia (DFA) (Final ___: NO CRYPTOSPORIDIUM OR GIARDIA SEEN. FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: NO E.COLI 0157:H7 FOUND. FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA FOUND. DISCHARGE LABS ___ 06:55AM BLOOD WBC-5.2 RBC-4.06* Hgb-10.6* Hct-33.3* MCV-82 MCH-26.0* MCHC-31.7 RDW-18.4* Plt ___ ___ 06:55AM BLOOD Glucose-88 UreaN-7 Creat-0.9 Na-142 K-3.5 Cl-109* ___ AnGap-14 Radiology Report INDICATION: Left abdominal pain and tenderness, history of colitis thought to be due to dehydration on prior admission. Please evaluate for colitis. COMPARISON: Comparison is made to CTA abdomen and pelvis performed ___. TECHNIQUE: Contrast-enhanced axial images were obtained from the lung bases to the pelvic outlet. Coronal and sagittal reformations are provided. FINDINGS: Heart size is normal and without pericardial effusion. Atelectatic changes are noted in the dependent portions of the lung bases. No pleural effusions or pneumothorax identified. Redemonstration of moderate-to-severe intrahepatic and extrahepatic biliary ductal dilatation, relatively unchanged compared to prior study. There is a stable wedge-shaped peripheral hypodensity in hepatic segment VI (2:13) thought to represent prior insult. Multiple tiny hypodensities throughout the right hepatic lobe, too small to fully characterize, statistically represent biliary hamartomas or cysts. The pancreas contains interdigitating fat without concerning mass or lesion. No pancreatic duct dilatation identified. The spleen is unremarkable. Two small splenules are identified. There is stable mild fullness in the left adrenal gland. Right adrenal gland is normal. The bilateral kidneys are without masses or hydronephrosis. Several areas of cortical thinning seen in the left kidney, unchanged, potentially from prior infection. No hydroureter identified. The stomach is unremarkable noting a hiatal hernia. Multiple intermittent loops of small bowel are somewhat prominent and filled with air and fluid (maximum diameter of 2.8 cm), with intervening areas of collapse, likely reflecting peristalsis. There are no secondary indications of small-bowel obstruction with no small bowel wall thickening, mesenteric edema or abnormal enhancement pattern. Scattered diverticula are noted throughout the colon though not focused surrounding inflammatory changes to suggest diverticulitis. However, there is a mild bowel wall thickening with hyperemia mucosa and mild surrounding inflammatory change noted within the sigmoid colon extending to a lesser degree into the descending colon, terminating at the level of the splenic flexure. The rectum, bladder and distal ureters are unremarkable. The uterus and adnexa are normal. Atherosclerotic changes noted throughout the abdominal aorta without evidence of aneurysmal dilatation. Calcifications are present at the ostia of the celiac and superior mesenteric arteries; however, there is no evidence to suggest critical stenosis. The mesenteric vessels are well opacified. Incidental note is made of a replaced right hepatic artery extending from the superior mesenteric artery (2:19). The hepatic, left, right and main portal veins are unremarkable. No free air or fluid noted within the abdomen. No suspicious lytic or blastic lesions identified. Multilevel degenerative changes are identified including joint space narrowing, endplate sclerosis at the L2-L3 level and mild retrolisthesis of L1 on L2 and L2 on L3 and a grade 1 anterolisthesis at L5 on S1. No fractures identified. IMPRESSION: 1. Mild bowel wall thickening and mucosal enhancement with surrounding inflammatory change of the sigmoid colon and to a lesser degree the descending colon tapering to the level of the splenic flexure, consistent with colitis with etiologies including infectious, inflammatory or ischemic. Of note, the ostia of the celiac and superior mesenteric and inferior mesenteric arteries do not appear to have critical stenosis and mesenteric vessels are overall patent. 2. Moderate stable intrahepatic and extrahepatic biliary ductal dilatation, not significantly changed. 3. Prominent intermittent fluid filled loops of small bowel with intervening areas of collapse without secondary evidence of obstruction; however, if abdominal symptoms worsen, low threshold to repeat scan to assess for developing small bowel obstruction. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: ABDOMINAL PAIN Diagnosed with NONINF GASTROENTERIT NEC temperature: 97.5 heartrate: 89.0 resprate: 16.0 o2sat: 97.0 sbp: 146.0 dbp: 75.0 level of pain: 8 level of acuity: 3.0

The patient is a ___ woman with distant history of gastric volvulus s/p repair, s/p appy and s/p cholcystectomy, recent admission for ischemic colitis ___ and also with history of prior C.Diff colitis who presents now with abdominal pain, vomiting, and diarrhea, found to be C diff positive. # C diff infection: likely causing abdominal pain, nausea, diarrhea. The patient has a prior h/o C diff infection, and per daughter she was told she had to take oral Vancomycin for that infection. Since this represents a recurrent infection and the patient required Vancomyin during last infection, we decided to pursue PO vanc as treatment. GI also saw the patient and recommends probiotics as well upon discharge. The patient was able to tolerate a BRAT diet upon discharge, and pain was greatly improved since admission. First day of oral Vancomycin therapy was ___. - Oral Vancomicin 125 mg Q6 for 2 weeks, followed by a taper (1 weeks of BID the 1 week QD). Thus, the patient will get a total of 4 weeks of therapy including the taper. First day of therapy was ___. - Supplement with probiotics: Florastor (Take two sachets daily during treatment with Vancomycin and once daily thereafter) # Colitis: Recent CTA scan did not show evidence of ischemia, lactate not elevated. IV fluids were continued in the hospital to prevent ischemia from developing in the setting of dehydration. HCTZ was held. The patient was also found to have guiac positive stool. Patient was diagnosed with iron deficiency. Because of the prior noted CT findings of extensive colitis in ___ in ABSENCE of C.diff or mesenteric stenosis, GI was consulted. They recommended outpatient follow up once acute C diff infection resolved, and further discussion of the need for colonoscopy vs flex sigmoidoscopy. The patient was also started on iron supplimentation. # Dirty UA: UCx shows contamination. No Sx of UTI - no treatment indicated at this time # PUD: Chronic, stable - Hold off on Omeprazole 40mg BID given C.Diff # CAD, stable angina: No acute changes in SOB or chest pain. - hold HTN meds (See below) - maintain hydration # HTN: Chronic, stable. Held HCTZ and metoprolol on admission given concern for prior ischemic colitis, and current dehydration. Her BP remained well controlled without either of these medications. Metoprolol was restarted at home dose and HCTZ was continued to be held. - recommend holding HCTZ indefinently given history of questionable ischemic colitis and well controlled BP on metoprolol - Coninue Aspirin 81 mg PO DAILY # HYPOTHYROIDISM: Chronic, stable - Continue Levothyroxine Sodium 75 mcg PO DAILY # DEPRESSION: Chronic, stable - Continue Citalopram 20 mg PO DAILY # HLD: Chronic, stable - Continue Simvastatin 20 mg PO DAILY # PPX: heparin SQ, hold off on bowel regimen given diarrhea # CODE: DNR/DNI(confirmed with patient and HCP) # CONTACT: Daughter and HCP ___ ___, ___ Son ___ ___ TRANSITIONAL ISSUES - F/U with GI once infection resolved - follow up with PCP

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: pollen and seasonal Attending: ___. Chief Complaint: Bacteremia Major Surgical or Invasive Procedure: Partial excision left loop forearm graft. Tunneled dialysis line History of Present Illness: Mr. ___ is a ___ y/o male w/ PMHx IDDM c/b neuropathy, PVD, OSA, HTN, obesity, ESRD on HD who presents with positive MRSA blood cultures from dialysis and concern for AV graft infection. The patient was noted to be febrile at HD on ___. He had blood cultures done and was given vancomycin 1.5gm IV. There was concern his graft was infected, however he refused to come to the ED at that time as he felt generally well. Of note they had difficulty accessing the venous limb of his graft but were able to complete a full HD run with both needles in the arterial limb. ___ blood cultures returned positive for GPCs today that are speciated as MRSA and he was instructed to come to the ED. He overall feels well apart from several episodes of diarrhea. Of note, the patient was admitted ___ for graft revision. Since that time the patient has had a small, non-healing wound just proximal to the graft site. In the ED, initial vital signs were 0 100.2 86 132/51 22 96%. Exam showed AV graft is red and tender. Labs showed stable CBC with WBC of 9, Na of 132, Cl of 87, bicarb of 26. Vanco level was 10.2. Lactate was 1.9. CXR was ordered but has not yet been done. Patient was given vancomycin 1gm IV, zofran 4mg IV, acetaminophen 1000mg PO x1 Transplant surgery was consulted who felt the graft site looked ok but was the most likely source of infection. Patient admitted to medicine with txp surgery following. On arrival to the floor, the patient appeared well but was febrile to 102.9. Also with blood glucose of 402. Past Medical History: - Insulin dependent diabetes mellitus 2 - ESRD on HD - History of line infections - Peripheral neuropathy and peripheral vascular disease - Leukocytoclastic Vasculitis - Hypertension - Obstructive sleep apnea - Obesity - GERD - Anemia in setting of ESRD - Secondary hyperparathyroidism in setting of ESRD - Low-attenuation lesions in kidneys detected by CT in ___ - C. difficile infection in ___ and ___ - S/p open cholecystectomy in ___ Social History: ___ Family History: NIDDM in both parents and two siblings. Mother with additional hyperlipidemia, hypercholesterolemia, hypertension, and Alzheimer's. Physical Exam: ADMISSION Vitals: 0 102.9 141/59 92 22 96%RA General: Well appearing and in NAD HEENT: PERRLA, EOMI, anicteric Neck: Large circumference, cannot apprectiate venous pulsations CV: Distant heart sounds, RRR, S1 and S2, no murmur Lungs: CTAB Abdomen: Obese, NT/ND Ext: Left arm fistula with shallow, non-healing wound just proximal. Amputated left toes. DISCHARGE Vitals: 98.3 ___ 18 98% RA General: Seen in HD. obese man in NAD HEENT: PERRLA, EOMI, anicteric Neck: cannot apprectiate venous pulsations d/t body habitus CV: Distant heart sounds, RRR, S1 and S2, no murmur Lungs: Distant lung sounds but CTAB with limitation Chest: Tunneled HD line in place right chest, no erythema or tenderness Abdomen: NTND, NABS Ext: Left arm fistula surgical site with sutures in place, c/d/i Pertinent Results: ADMISSION ___ 05:11PM LACTATE-1.9 ___ 04:18PM GLUCOSE-344* UREA N-49* CREAT-9.6*# SODIUM-132* POTASSIUM-3.9 CHLORIDE-87* TOTAL CO2-26 ANION GAP-23* ___ 04:18PM estGFR-Using this ___ 04:18PM VANCO-10.2 ___ 04:18PM WBC-6.2 RBC-3.39* HGB-10.1* HCT-31.7* MCV-94 MCH-29.8 MCHC-31.9 RDW-15.0 ___ 04:18PM NEUTS-76* BANDS-9* LYMPHS-10* MONOS-3 EOS-2 BASOS-0 ___ MYELOS-0 ___ 04:18PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL TEARDROP-OCCASIONAL ___ 04:18PM PLT SMR-NORMAL PLT COUNT-151 DISCHARGE ___ 05:25AM BLOOD WBC-7.1 RBC-3.10* Hgb-9.4* Hct-28.6* MCV-93 MCH-30.4 MCHC-32.9 RDW-15.5 Plt ___ ___ 05:25AM BLOOD Glucose-155* UreaN-44* Creat-9.5*# Na-136 K-4.6 Cl-91* HCO3-30 AnGap-20 ___ 05:25AM BLOOD Calcium-9.7 Phos-3.8 Mg-2.4 MICROBIOLOGY ___ 6:00 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: Reported to and read back by ___. ___ ___ @ 12:01 ___. STAPH AUREUS COAG +. FINAL SENSITIVITIES. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S Anaerobic Bottle Gram Stain (Final ___: Reported to and read back by ___ @ 2142 ON ___ - ___. GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. ___ 4:00 pm BLOOD CULTURE #1 SOURCE: VENIPUNCTURE. **FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPH AUREUS COAG +. SENSITIVITIES PERFORMED ON CULTURE # ___ ___. Daptomycin Sensitivity testing per ___ ___. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. Daptomycin = SENSITIVE (0.19 MCG/ML), Sensitivity testing performed by Etest. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | DAPTOMYCIN------------ S Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CLUSTERS. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CLUSTERS. ___ 2:00 pm FOREIGN BODY LEFT ARM AV-GRAFT. **FINAL REPORT ___ WOUND CULTURE (Final ___: STAPH AUREUS COAG +. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S Blood Cultures ___ still pending (NGTD) at time of discharge - FINAL, NO GROWTH IMAGING/STUDIES TEE ___ No atrial septal defect is seen by 2D or color Doppler. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. Aortic root calcifications are present. No masses or vegetations are seen on the aortic valve. No aortic valve abscess is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. There is no pericardial effusion. IMPRESSION: No valvular vegetations or abscesses appreciated. No pathologic valvular regurgitation. Suboptimal image quality due to poor patient cooperation despite moderate sedation by anesthesia. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 325 mg PO DAILY 2. Calcium Acetate 667 mg PO TID W/MEALS 3. Cinacalcet 60 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. NPH 28 Units Breakfast NPH 18 Units Dinner Insulin SC Sliding Scale using Humulin Insulin 6. Renal Caps *NF* (B complex-vitamin C-folic acid) 1 mg Oral Daily 7. NexIUM *NF* (esomeprazole magnesium) 40 mg Oral Daily 8. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain Maximum 8 tablets daily , do not combine with tylenol 9. sevelamer CARBONATE 3200 mg PO TID W/MEALS 10. Lisinopril 5 mg PO DAILY Check blood pressure and hold medication for blood pressure less than 110 systolic 11. NIFEdipine CR 60 mg PO DAILY Check blood pressure and hold medication for blood pressure less than 110 systolic Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. Calcium Acetate 667 mg PO TID W/MEALS 3. Docusate Sodium 100 mg PO BID 4. NPH 28 Units Breakfast NPH 18 Units Dinner Insulin SC Sliding Scale using Humulin Insulin 5. NIFEdipine CR 30 mg PO DAILY 6. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain 7. sevelamer CARBONATE 3200 mg PO TID W/MEALS 8. Cinacalcet 60 mg PO DAILY 9. Lisinopril 5 mg PO DAILY 10. NexIUM *NF* (esomeprazole magnesium) 40 mg Oral Daily 11. Renal Caps *NF* (B complex-vitamin C-folic acid) 1 mg Oral Daily 12. Vancomycin 1000 mg IV HD PROTOCOL Discharge Disposition: Home Discharge Diagnosis: MRSA bactermemia ESRD 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: Fever, assess for pneumonia. COMPARISON: ___. FINDINGS: Two views were obtained of the chest. The examination is limited by poor penetration likely secondary to the patient's body habitus. Within this limitation, the lungs appear well expanded without focal consolidation to suggest infectious process. No pleural effusion or pneumothorax is seen. The heart and mediastinal contours are unchanged. IMPRESSION: No acute intrathoracic process. Radiology Report INDICATION: ___ male with end-stage renal disease, graft infection and removal, comes in today for placement of a tunneled hemodialysis catheter. PHYSICIANS: Dr. ___, ___ fellow, Dr. ___, ___ fellow, and Dr. ___ ___, ___ attending, was present and supervising. Moderate sedation was provided by administering divided doses for a total of 125 mcg of fentanyl and 1.5 mg of Versed for this total intraservice time of 115 minutes during which patient's hemodynamic parameters were continuously monitored. Additionally, 1% lidocaine and 1% lidocaine with epinephrine were used for local anesthesia. PROCEDURES: 1. Venogram of the right upper anterior chest wall. 2. Placement of a tunneled hemodialysis catheter through a neck collateral. PROCEDURE DETAILS: Written informed consent was obtained after explaining risks, benefits and alternatives to the procedure. The patient was brought to the angiography suite and placed supine on the imaging table. A preprocedure timeout was performed as per ___ protocol. Using ultrasound guidance, the right internal jugular vein was punctured with a micropuncture needle and a 0.018 nitinol wire was then attempted to advance into the superior vena cava, however, unsuccessful. Following, again under ultrasound guidance, the junction of the IJ with the brachiocephalic vein was punctured, with a micropuncture needle an attempt was made to navigate the wire distally, however, unsuccessful. The wire kept buckling back into the subclavian vein. Following, the inner part of the micropuncture sheath was advanced over the nitinol wire and subsequently a small venogram was obtained. The venogram demonstrated significant reflux into some neck collaterals and the proximal superior vena cava appeared to be occluded. Based on these findings, decision was made to puncture one of these neck collaterals that appeared to connect centrally. Following, using ultrasound guidance, a superficial right anterior chest wall vein was punctured using a micropuncture needle, and a 0.018 nitinol wire was navigated distally; however, the wire did not go centrally. The wire was advanced into the contralateral subclavian vein. Following, initially using a C2 glide and an angled Glidewire, access was attempted into the distal SVC, however, unsuccessful. Subsequently, a digital subtraction angiogram was again performed, which demonstrated significant kinking of the junction of this chest wall collateral with the distal SVC. Attempt again was made to navigate the C2 glide catheter and the Glidewire through the tortuous area, however, was also unsuccessful. Subsequently, an Omniflush 5 ___ catheter was then navigated to this area of tortuosity and with aid of a Glidewire, access was gained further down into the superior vena cava. Following, the catheter was exchanged for a C2 glide, which was then navigated down into the IVC. The wire was exchanged for a ___ wire. Appropriate measurements for the catheter were then performed. Subsequently, we chose a tunnel exit site and applied local anesthesia to the planned tunnel tract. The catheter was then tunneled from the subcutaneous tissue of the upper anterior chest wall into the venotomy site using a metal tunneler device. Following, the venotomy site was dilated using a 10, 12 and finally a 14 dilators. Subsequently, a 16 ___ 30 cm long peel-away sheath was then navigated over the wire down into the inferior vena cava. The inner stiffener and the wire were removed, and the catheter was advanced through the peel-away sheath into the right side of the heart. Final fluoroscopic spot image of the chest demonstrated adequate catheter positioning, with no acute kinks and turns, and tip of the catheter in the right atrium. Both lumens aspirated and flushed easily. The catheter was secured to the skin using a 0 silk suture on either sides. The venostomy site was closed using a subcuticular stitch. Dry sterile dressing was applied. The patient tolerated the procedure well without immediate complications. IMPRESSION: Successful placement of a 31-cm (tip to cuff) 15.5 ___ tunneled hemodialysis catheter, through a right neck collateral, with its tip positioned distally in the right atrium. The catheter is ready for use. Gender: M Race: OTHER Arrive by WALK IN Chief complaint: LEFT ARM INFECTION Diagnosed with DUE TO RENAL DIALYSIS DEVICE,IMPLANT,GRAFT, ACCIDENT NOS, BACTEREMIA NOS temperature: 100.2 heartrate: 86.0 resprate: 22.0 o2sat: 96.0 sbp: 132.0 dbp: 51.0 level of pain: 0 level of acuity: 2.0

___ y/o male w/ PMHx NIDDM c/b neuropathy, PVD, OSA, HTN, obesity, ESRD on HD who presents with positive MRSA blood cultures from AV graft infection. ACTIVE ISSUES # MRSA Sepsis - Patient started on vancomycin on admission. Source found to be left AV graft, which also grew MRSA. Other sources ruled out. Patient underwent TEE to rule out infectious endocarditis, which was negative. He will continue a 2 week total course of vancomycin, to be dosed with HD based on levels. Last day ___. # ESRD on HD - ___ schedule. Missed scheduled dialysis day due to AVG removal as above. Tunneled HD line placed by ___, and patient received HD both ___ and ___. On discharge he should return to ___. Continued calcium acetate 667 mg PO TID W/MEALS, Cinacalcet 60 mg PO DAILY, nephrocaps, sevelamer. # Diabetes - on insulin. Hypoglycemic episode once during admission in early AM in setting of not eating dinner and then NPO after MN. Subsequently, daytime BGs high so AM NPH increased from 28 to 30 units. Evening NPH keep at 18 Units. Continued with home humalog sliding scale. CHRONIC ISSUES # Anemia - Had slow downtrend in Hct from arrival, but mild and likely related to small amount of blood loss related to surgery, stabilized prior to discharge. No signs of bleeding. H/H were above his recent baseline throughout entire admission. # Hypertension - continued lisinopril and nifedipine. # GERD - stable, continued nexium. # Pain - continued home percocet. TRANSITIONAL ISSUES 1. continue IV Vancomycin dosed by HD for MRSA septicemia due to AVG infection till ___ 2. f/u with Transplant Surgery after completing ABX for acute infection for consideration of more permanent HD access 3. continue outpt HD

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Estrogens Attending: ___. Major Surgical or Invasive Procedure: None attach Pertinent Results: ___ 08:00PM ___ PTT-80.4* ___ ___ 02:40PM ___ PTT-93.3* ___ ___ 12:36PM LACTATE-1.6 ___ 12:30PM GLUCOSE-121* UREA N-10 CREAT-0.6 SODIUM-137 POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-22 ANION GAP-14 ___ 12:30PM ALT(SGPT)-31 AST(SGOT)-28 LD(LDH)-196 ALK PHOS-101 TOT BILI-0.7 ___ 12:30PM LIPASE-26 ___ 12:30PM ALBUMIN-3.6 ___ 12:30PM WBC-10.5* RBC-4.14 HGB-12.2 HCT-38.1 MCV-92 MCH-29.5 MCHC-32.0 RDW-13.0 RDWSD-43.5 ___ 12:30PM PLT COUNT-263 ___ 09:13AM ___ PTT-54.8* ___ ___ 03:05AM ___ PTT-104.0* ___ ___ 05:38PM URINE HOURS-RANDOM ___ 05:38PM URINE UCG-NEGATIVE ___ 05:38PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 05:38PM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-TR* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 05:38PM URINE RBC-<1 WBC-<1 BACTERIA-FEW* YEAST-NONE EPI-0 ___ 05:38PM URINE MUCOUS-RARE* ___ 04:28PM ALT(SGPT)-32 AST(SGOT)-28 CK(CPK)-72 ALK PHOS-124* TOT BILI-0.7 ___ 04:28PM LIPASE-30 ___ 04:28PM ALBUMIN-4.2 ___ 04:28PM WBC-10.4* RBC-4.52 HGB-13.4 HCT-41.4 MCV-92 MCH-29.6 MCHC-32.4 RDW-13.0 RDWSD-43.8 ___ 04:28PM NEUTS-57.4 ___ MONOS-6.9 EOS-4.2 BASOS-1.1* IM ___ AbsNeut-5.95 AbsLymp-3.11 AbsMono-0.71 AbsEos-0.44 AbsBaso-0.11* ___ 04:28PM PLT COUNT-273 ___ 04:28PM ___ PTT-30.2 ___ ___ 11:18AM GLUCOSE-101* UREA N-14 CREAT-0.7 SODIUM-137 POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-21* ANION GAP-14 ___ 11:18AM estGFR-Using this ___ 11:18AM D-DIMER-4656* CTA Chest 1. No evidence of pulmonary embolism or aortic abnormality. 2. Findings suspicious for an acute thrombus of the left portal vein as described above, incompletely assessed on the current exam. A dedicated abdominal CT is recommended. 3. Diffuse ground-glass parenchymal changes are nonspecific and may reflect combination of small airways disease and atelectasis. CT A/P 1. Occlusive thrombus is seen within the left portal vein. In addition, nonocclusive thrombus is seen within the distal main portal vein with extension into the anterior right portal vein and likely also to a lesser extent in the posterior branch of the right portal vein. 2. The SMV and splenic vein are patent. No portal venous collaterals are identified. 3. No inflammatory process in the abdomen or pelvis to explain the portal venous thrombosis. 4. Fibroid uterus. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Propranolol 10 mg PO BID:PRN essential tremor 2. Escitalopram Oxalate 10 mg PO DAILY 3. Cetirizine 10 mg PO DAILY Discharge Medications: 1. Apixaban 10 mg PO BID Duration: 6 Days 10mg PO BID through ___, then 5mg PO BID for life RX *apixaban [Eliquis] 5 mg 2 tablet(s) by mouth twice a day Disp #*66 Tablet Refills:*0 2. Cetirizine 10 mg PO DAILY 3. Escitalopram Oxalate 10 mg PO DAILY 4. Propranolol 10 mg PO BID:PRN essential tremor Discharge Disposition: Home Discharge Diagnosis: Portal vein thrombosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK INDICATION: History: ___ with headache// Headache, h/o blood clots currently on heparin TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 802.7 mGy-cm. 2) Stationary Acquisition 7.0 s, 0.5 cm; CTDIvol = 34.9 mGy (Body) DLP = 17.4 mGy-cm. 3) Spiral Acquisition 4.9 s, 38.7 cm; CTDIvol = 15.2 mGy (Body) DLP = 587.6 mGy-cm. Total DLP (Body) = 605 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: None. FINDINGS: Mild degradation of the study secondary to suboptimal contrast enhancement. CT HEAD WITHOUT CONTRAST: There is no evidence of infarction, edema, hemorrhage or mass. The ventricles and frontal sulci are prominent, likely related to involutional changes. There is no gross evidence of acute fracture. The ethmoid, sphenoid, frontal and maxillary sinuses are clear. The middle air cavities are unremarkable. The visualized portion of the orbits are unremarkable. CTA neck: Conventional 3 vessel arch with minimal calcification at the level of aortic arch and carotid bifurcations. No stenosis in the internal carotid arteries by NASCET criteria. CT angiography of the neck shows normal appearance of the carotid and vertebral arteries without stenosis or occlusion or dissection. CTA head: Minimal calcification of the carotid siphons. CT angiography of the head shows normal appearance of the arteries of the anterior and posterior circulation without stenosis or occlusion or aneurysm greater than 3 mm in size. Patent dural venous sinuses. Other: The visualized lung apices and thyroid gland appear unremarkable. No lymphadenopathy by CT criteria. Minimal degenerative changes of the visualized spine without evidence of canal or neural foramen narrowing. IMPRESSION: 1. Normal head CT. 2. Patent circle of ___ without evidence of stenosis,occlusion,or aneurysm. 3. Patent bilateral cervical carotid and vertebral arteries without evidence of stenosis, occlusion, or dissection. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Abnormal CT Diagnosed with Portal vein thrombosis temperature: 98.1 heartrate: 78.0 resprate: 16.0 o2sat: 98.0 sbp: 106.0 dbp: 72.0 level of pain: 3 level of acuity: 2.0

Ms. ___ is a ___ year old lady with a past medical history of pulmonary embolism in the setting of taking birth control and MTHFR mutation who presents with a unprovoked portal vein thrombus. #Portal vein thrombus CT abdomen shows portal vein thrombus without collaterals suggesting an acute process, there is no inflammatory process seen in the imaging as a cause. Hematology was consulted and recommended heparin drip while she is an inpatient but she was transitioned to Apixiban upon discharge (10mg PO BID through ___, then 5mg PO BID ongoing). She will complete a hypercoagulable work-up as an outpatient (scheduled ___. They recommended age-appropriate cancer screenings. At the time of discharge, she was not having any pain, able to tolerate PO with normal LFTs. [] recommend bilateral diagnostic mammogram after discharge given calcifications in left breast noted > ___ year ago. [] Pap/HPV testing normal in ___. Next due ___ [] Hypercoagulable workup with Heme (scheduled ___ #Cough #Shortness of Breath CTA negative for PE but did show Diffuse ground-glass parenchymal changes which could be small airways disease. She does endorse exercise induced asthma. [] Should have PFTs as outpatient #Depression Continue home Lexapro #Seasonal allergies Continue home Zyrtec #Essential tremor Hold propranolol for now in the setting of low blood pressure Transitional issues [] Apixiban 10mg PO BID through ___, then transition to 5mg PO BID for life [] recommend bilateral diagnostic mammogram after discharge given calcifications in left breast noted > ___ year ago. [] Pap/HPV testing normal in ___. Next due ___ [] Hypercoagulable workup with Heme (scheduled ___ [] Outpatient PFTs to further characterize lung disease seen on CT Greater than 40 mins were spent on discharge planning and coordination of care.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Hemturia, lethargy Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ with recent admission from ___ to ___ for MRSA bacteremia, UTI/prostatitis, ___, and subdural hematoma, presenting with persistent gross hematuria from foley and lethargy. Pt was discharged with the foley on ___ per urology and has a history of traumatic foley placements. Urology opted to keep foley in rather than risk failed voiding trial and necessitating potentially traumatic replacement. The foley has been draining cranberry colored urine since its original placement. Color has been stable and without clots. He had an appt with urology today for foley removal; due to continued hematuria urologist decided to schedule cystoscopy for ___ however, urologist noted pt appeared lethargic and requested he come to ___ for medical work up prior to cystoscopy. The family notes he was fine before today and the lethargy is new. Yesterday he was alert, talkative, and reading to family. No fevers/chills/sweats, no CP, no SOB, no N/V, no change in BM, no blood in stool, no rashes. Admits to new c/o left leg and knee pain beginning today. Also has had an occasional "rattly" but non-productive cough recently. Pt states he has not been eating well but this is due to not being given enough food, he does have an appetite. He denies any urinary symptoms and was unaware that he has hematuria. Denies recent falls though states his left elbow is slightly tender. Daughter says patient not drinking fluid like he needs to. . In the ED, initial vs were: 97.7 54 129/52 16 99% ra. On exam patient alter but not oritend to time/yr/place, stool guiaic negative. Labs were remarkable for hematocrit of 28.7 (up from 27.8 at discharge on ___, creatinine of 1.9 (was 1.6 at discharge on ___, troponin indeterminant at 0.05. EKG per report was SR at 56, LAD (LAFB), prolonged QTc (469ms), TWF in III, no ST changes (overall ekg c/w prior). Head CT with no new ICH, stable 4mm R frontal subacute to chronic SDH, age related involution and small vessel ischemic disease. CXR with stable cardiomegaly and no acute process. Blood and urine culture obtained. UA with blood, positive ___, WBC, bacteria - blood and urine culture obtained. ED spoke w/ patient's ID fellow (___) who thought likely asymptomatic bacteruria (just completed course of meropenem). ID recommended continue vanc for MRSA bacteremia, repeat UA on floor, do not treat w/ additional ABX unless develops fever or symptoms. No medications given in ED. Access if PICC in left arm, giving 1L NS infusing at 125cc/hr. Vitals on Transfer: HR:65, RR: 32, BP: 156/64, O2Sat: 100%RA. Admit to medicine for ___ w/ plan to recheck creatinine after IVF, hematuria w/ plan to trend HCT, indeterminate troponin w/ plan to trend biomarkers. ED resident updated patient's daugther. . Review of sytems: Per HPI Past Medical History: HTN Prostate cancer Spinal stenosis Depression GERD BPH Left olecranon ORIF ___, complicated by MRSA bacteremia d/t hardware infection Social History: ___ Family History: Noncontributory. Both parents lived to be quite old - late ___, early ___. Physical Exam: Vitals: T: 97.6 BP: 159/70 P: 72 R: 18 O2: 99% RA General: Alert, cachectic, pale, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, left lower eyelid erythematous but no exudates Neck: supple, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses on LLE, unable to palpate on right ___, no clubbing, cyanosis or edema Skin: papery, no rashes Neuro: CN2-12 intact, LTSI bilaterally, Strength ___ in UE and ___ DISCHARGE EXAM: 97.3, 105/50, 70, 19, 98% RA General: AAOx1, cachectic, pale, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, left lower eyelid erythematous but no exudates Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: no clubbing, cyanosis or edema Skin: papery, no rashes GU: foley draining very slightly pink-tinged urine Pertinent Results: ADMISSION LABS: ___ 03:12PM BLOOD WBC-7.0 RBC-2.89* Hgb-9.1* Hct-28.7* MCV-99*# MCH-31.4 MCHC-31.7 RDW-14.3 Plt ___ ___ 03:12PM BLOOD Neuts-68.8 ___ Monos-5.1 Eos-1.7 Baso-0.6 ___ 03:12PM BLOOD ___ PTT-29.5 ___ ___ 03:12PM BLOOD Glucose-82 UreaN-22* Creat-1.9* Na-138 K-4.0 Cl-105 HCO3-26 AnGap-11 ___ 03:12PM BLOOD CK-MB-2 ___ 03:12PM BLOOD cTropnT-0.05* ___ 06:00AM BLOOD CK-MB-2 cTropnT-0.06* ___ 03:12PM BLOOD CK(CPK)-30* ___ 06:00AM BLOOD CK(CPK)-28* ___ 03:12PM BLOOD Calcium-8.5 Phos-3.1 Mg-2.2 ___ 03:35PM BLOOD Lactate-1.9 IMAGING: CT HEAD: 1. No acute intracranial process. 2. Stable 4 mm right frontal chronic subdural hematoma, unchanged. 3. Age-related involution and small vessel ischemic disease. CXR: No acute cardiopulmonary process such as pneumonia. Stable cardiomegaly. DOPPLER ___: No evidence of DVT in left lower extremity. DISCHARGE LABS: ___ 09:00AM BLOOD WBC-5.4 RBC-2.84* Hgb-8.8* Hct-28.1* MCV-99*# MCH-30.9 MCHC-31.3 RDW-16.8* Plt ___ ___ 09:00AM BLOOD Glucose-106* UreaN-22* Creat-1.7* Na-140 K-4.2 Cl-114* HCO3-20* AnGap-10 ___ 09:00AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.9 ___ 05:39AM BLOOD PSA-1.8 ___ 07:47AM BLOOD Vanco-28.6* Medications on Admission: - Lupron Depot (4 Month) 30 mg Syringe Kit Intramuscular - cholecalciferol (vitamin D3) 800 units PO DAILY. - docusate sodium (100) mg PO BID - multivitamin (1) Tablet PO DAILY - omeprazole 20 mg Capsule, Delayed Release(E.C.)(1) PO BID - calcium carbonate 500 mg calcium (1,250 mg) (1) Tablet PO BID - senna 8.6 mg Tablet (1) Tablet PO HS - cranberry 450 mg Tablet (2) Tablet PO twice a day. - citalopram (20) mg PO DAILY - polyvinyl alcohol 1.4 % Drops Sig: ___ Drops Ophthalmic TID - erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1) drop BID to left eye - Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) PO once a day as needed for constipation. - bisacodyl 10 mg Suppository Sig: One (1) Rectal once a day as needed for constipation. - Fleet Enema ___ gram/118 mL Enema Sig: One (1) enema Rectal once a day as needed for constipation. - doxazosin 1 mg Tablet (2) Tablet PO HS - levetiracetam 100 mg/mL Solution Sig: (500) mg PO BID Discharge Medications: 1. Lupron Depot (4 Month) 30 mg Syringe Kit Sig: One (1) syringe Intramuscular every 4 months. 2. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. cranberry 450 mg Tablet Sig: One (1) Tablet PO once a day. 8. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. erythromycin 5 mg/gram (0.5 %) Ointment Sig: 0.5 inch Ophthalmic BID (2 times a day): LEFT eye. 10. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 11. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO once a day. 12. polyvinyl alcohol 1.4 % Drops Sig: ___ drops Ophthalmic three times a day. 13. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 14. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 15. Fleet Enema ___ gram/118 mL Enema Sig: One (1) enema Rectal once a day as needed for constipation. 16. doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 17. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. Disp:*4 Tablet(s)* Refills:*0* 19. vancomycin 500 mg Recon Soln Sig: Seven Hundred Fifty (750) mg Intravenous Q48H (every 48 hours) for 6 days: last dose ___. Disp:*2250 mg* Refills:*0* 20. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis: Urinary tract infection Dehydration Hematuria Secondary Diagnoses: BPH History of MRSA bacteremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report INDICATION: ___ male with altered mental status and hematuria. Question infectious process. FINDINGS: Single frontal view of the chest demonstrates stable cardiomegaly and mild unfolding of the thoracic aorta, with associated arch calcifications. The lungs are clear, and apical thickening unchanged. There is no pneumothorax, vascular congestion, or pleural effusion. Angulated right proximal humeral fracture and distal right clavicular irregularity appear longstanding. IMPRESSION: No acute cardiopulmonary process such as pneumonia. Stable cardiomegaly. Radiology Report INDICATION: ___ male with altered mental status and hematuria. Question interval change in known history of subdural hematoma. COMPARISON: ___. TECHNIQUE: Contiguous non-contrast axial images were acquired through the brain with multiplanar reformations. FINDINGS: There is no change in the 4 mm right frontal chronic subdural hematoma as previously noted on ___. Prominent bifrontal extra-axial CSF spaces are also stable as compared to prior exams. There is no new hemorrhage, mass effect, edema, or shift of normally midline structures. Ventricles and sulci are prominent, consistent with age-related involution. Mild ventricular asymmetry is longstanding and unchanged. Periventricular and subcortical white matter hypoattenuation is compatible with small vessel ischemic disease. Tiny foci of hypodensity in the basal ganglia particularly on the right may represent small lacunes, unchanged. Suprasellar and basilar cisterns are patent. Paranasal sinuses and mastoid air cells are well aerated. Vascular calcifications are seen in the cavernous, carotid and vertebral arteries. Globes and orbits are intact. Right frontal burr hole is noted. IMPRESSION: 1. No acute intracranial process. 2. Stable 4 mm right frontal chronic subdural hematoma, unchanged. 3. Age-related involution and small vessel ischemic disease. Radiology Report INDICATION: New onset lethargy and left leg/knee pain. Evaluate for DVT. COMPARISON: None. TECHNIQUE: Unilateral lower extremity venous ultrasound (left). FINDINGS: Gray-scale, color and spectral Doppler sonograms were acquired of the left common femoral, superficial femoral, and popliteal veins. Color Doppler images of the posterior tibial and peroneal veins were also obtained. There is normal compressibility, flow, and augmentation throughout. IMPRESSION: No evidence of DVT in left lower extremity. Radiology Report HISTORY: PICC placement. FINDINGS: In comparison with study of ___, the tip of the PICC line again appears to be in the upper to mid portion of the SVC. Low lung volumes but otherwise little change in the appearance of the heart and lungs. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: ?ABN LABS, HEMATURIA Diagnosed with HEMATURIA, UNSPECIFIED, RENAL & URETERAL DIS NOS, ANEMIA NOS, HYPERTENSION NOS, HX-PROSTATIC MALIGNANCY temperature: 97.7 heartrate: 54.0 resprate: 16.0 o2sat: 99.0 sbp: 129.0 dbp: 52.0 level of pain: unable level of acuity: 3.0

The patient is a ___ with recent admission from ___ to ___ for MRSA bacteremia, UTI/prostatitis, ___, and subdural hematoma, presenting with persistent gross hematuria from Foley and lethargy with necrotic tissue at the bladder neck, possibly advanced prostate cancer, seen on cystoscopy. # Hematuria: Onset of hematuria appears to have coincided with traumatic foley placement during prior hospitalization, but has persisted. Ddx included infection vs malignancy vs trauma vs all of the above. U/A positive as below and pt treated with cipro. Pt continued to have hematuria which progressively worsened, ultimately requiring 3 units of PRBC during LOS to stabilize Hct. pt had plan for cystoscopy on ___ with urology, so this was pursued in house. On cystoscopy, necrotic tissue was seen at the bladder neck consistent with advanced prostate cancer invading the bladder was seen and areas of bleeding were cauterized, however, no biopsies were performed and PSA is within normal limits at 1.8 which would argue against an advanced prostate cancer. A three way foley was placed and continuous bladder irrigation was performed until urine was clear, then the CBI was capped. Pt's Hct remained stable after cystoscopy and CBI. Discussion was held with family that pt would likely rebleed unless some treatment of prostate cancer was attempted, such as focal XRT. They will discuss this as an outpatient. Of note, during last hospitalization, prostatitis was considered and he was treated with 2 weeks of meropenem before discontinuing abx due to low suspicion for this diagnosis. # Urinary tract infection: U/A was positive x 2 for >182 WBC and RBC, + ___, + nitrites, + bacteria. Awaited UCx results before starting abx and pseudomonas grew out; started pt on oral cipro based on sensitivities. He was continued on cipro for a 7 day course starting from replacement of the foley during cystoscopy. UTI during this hospitalization was attributed to indwelling foley rather than seeding from prostatitis, however, due to recurrent nature of the infection a plan was made to get repeat U/A after completion of cipro --> if positive pt may require suppressive antibiotic therapy. # Lethargy: thought to be multifactorial ___ volume depletion, as pt has had poor po intake, elevated creatinine elevated, anemia ___ chronic hematuria, and infection upon admission. DVT/PE was considered, since the pt developed the complaint of new left lower extremity pain on the same day that the lethargy was noted, but ___ was negative. CXR neg but U/A floridly positive as described above. Head CT was stable - no change in subdural. EKG also stable. Pt give IVF and reported feeling improvement on HD2. He was also given blood transfusions as above and treated for this infection. # Acute on Chronic Kidney Disease: pt with Cr 1.9 on admission, slightly up from 1.6 at last D/C on ___. Suspected prerenal on admission due to h/o poor po intake but only mild improvement s/p IVF. FeNa was 11% which was consistent with intrarenal pathology. He stabilized around 1.9 for several days but slowly trended down to 1.7 after cystoscopy. Suspect this is a new baseline. # Hypernatremia: pt developed hypernatremia to 150 during hospitalization, though to be ___ volume depletion due to poor po intake. Resolved with D5W and free water repletion. # h/o MRSA bacteremia: followed by ___ OPAT for MRSA bacteremia thought to be ___ retained hardware from ___ ORIF (organism matches the C&S from that hospitalization). Continued current regimen of Vancomycin 1g IV q48 hours but vanc trough elevated to 26 so dose was decreased to 750mg IV q48h. Last dose ___. # Indeterminate troponin: trop minimally increased to 0.06 from 0.05 on admission with stable CK-MB and CPK. no sx of chest pain, SOB, etc, EKG unchanged, and tele unremarkable. likely this is ___ CKD (also could have been ___ zosyn which pt got in ED). no further action taken. # Leg pain: no trauma history. exam unremarkable. ruled out DVT with ___ due to onset of complaint at the same time as lethargy but it was negative. no further action taken. # h/o Subdural hematoma: continued keppra # HTN: continued doxazosin # Depression: continued citalopram # GERD: continued omeprazole

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Trazodone Attending: ___. Chief Complaint: shoulder and chest pain Major Surgical or Invasive Procedure: attempted closed reduction of R anterior glenohumeral dislocation History of Present Illness: ___ year old lady with complex past medical history most notable for COPD (FEV1 59% ___, schizoaffective disorder, R glenohumeral osteoarthritis, and chronic pain on opioid contract, who presents with 3 days of worsening R shoulder pain and substernal intermittent chest pain. Patient noted to be a poor historian from notes dating back to ___. For the past three days, patient has had trouble moving her R arm. Per review of outpatient notes, appears that patient has known history of R shoulder pain thought secondary to R glenohumeral osteoarthritis that has been treated conservatively with injections, most recently ___. To me, she reports that her brother ___ (___) tells her that she twisted her R shoulder/arm several days ago but she does not recall this. She also does not recall any fall or injury, or any assault. Her main complaint is that she has pain in her R shoulder as well as chest, described as sharp and stabbing. She notes that for the past three days she has been unable to raise her R arm up to comb her hair (although has ___ who helps her with this). She has also been having some worsening R chest pain which is non radiating, which she is unable to localize with one finger, but notes that this pain is worse with deep breaths and with activity. She says that she has been walking to the bathroom and also to the kitchen and has noticed that she has been a little more short of breath requiring her to stop and catch her breath. She denies any orthopnea. Notes that her leg swelling is at baseline. No palpitations. She has been taking her pain pills (hydrocodone-acetaminophen ___ BID which has helped with the pain. She denies any fevers or chills. Has chronic cough productive of white sputum. Endorses maybe some urinary frequency starting today, such that she has to go to bathroom q15 minutes, which she also thinks is new. Regarding history of falls, it appears that at least at recent PCP visit in ___ there was report of no falls x ___ year. Review of prior discharge summaries patient did reveal one fall requiring hospitalization in ___ with left sided low anterior column acetabular fracture after a table fell over when she was leaning against it. In the ED, initial VS were: 97.7 68 141/73 20 100% RA Exam notable for: Gen: Obese elderly woman Pulm: CTAB no WRR, unlabored breathing CV: RRR no MRG, no JVD Per ED, patient became hypoxic on ambulation to the bathroom to 87% on room air, no previous history of O2 dependence. EKG per my read: Sinus rate 70, normal axis, normal intervals, TWI in V1-V2, T wave flattening in V3. Early R wave transition. Baseline artifact. Labs showed: WBC 7.5, Hb 14.1, Plt 194 (All lines within recent baseline) INR 1.1 144 | 104 | 10 --------------- 3.8 | 26 | 0.7 (baseline 0.8-1.0) Trop-T: <0.01 proBNP: 30 UA: Moderate leukocyte esterase, 17 ___ Imaging showed: CTA chest: 1. Acute fractures of the right anterolateral second and third ribs with small adjacent extrapleural hematoma. No evidence of pulmonary contusion, laceration, or pneumothorax in the setting of rib fractures. 2. Redemonstration of right anterior glenohumeral dislocation. Tiny ossific densities adjacent to the dislocated right humeral head suggests small fracture fragments. 3. No evidence of pulmonary embolism or aortic abnormality. 4. Unchanged mild narrowing of the bilateral mainstem bronchi, right middle lobe bronchus and bronchus intermedius which again may represent bronchomalacia. 5. Mild dilatation of the main pulmonary artery to 3.3 cm, unchanged, and could reflect pulmonary arterial hypertension. XR R shoulder Right glenohumeral anterior dislocation without fracture. XR R shoulder (post attempted reduction): No substantial interval change in right anterior glenohumeral joint dislocation. Redemonstration of fractures of the right second and third anterolateral ribs. Consults: (1) Orthopedics: Failed closed reduction of shoulder. Consented and added-on for closed vs open reduction of the right shoulder - Admit to medicine - NPO Midnight - AAT, sling to RUE for comfort if necessary - Hold am anticoagulation (2) Trauma surgery Recommend Excellent pain control, frequent I/S,DVT prophylaxis, and O2 sat monitoring. X-ray btl knees and pelvic x-ray please. Admit to medicine for further management of hypoxia and agree with ortho consultation for reduction of right shoulder. Patient received: PO Acetaminophen 1000 mg IV CefTRIAXone 1 g IV Morphine Sulfate 4 mg Past Medical History: - Moderately Severe COPD - Schizoaffective Disorder - CAD - Hypertension - Hyperlipidemia - Chronic dysarthria of unclear etiology - Osteoathritis of the knees s/p left TKL - Osteopenia - Glaucoma - Extirpated L orbit with prosthesis and L ptosis - Mild tracheobronchomalacia - Urinary Incontience - ___ - gallstone pancreatitis s/p successfully ERCP with removal of sludge and sphincterotomy (___) - acute cholecystitis s/p perc chole placement (___) - acute cholecystitis s/p ERCP, lap CCY complicated by intraabdominal abscesses requiring ___ drainage and antibiotics (___) Social History: ___ Family History: T2DM Physical Exam: ADMISSION PHYSICAL EXAM: ====================== ___ ___ Temp: 97.6 PO BP: 140/80 L Lying HR: 69 RR: 18 O2 sat: 96% O2 delivery: Ra GENERAL: NAD, obese lady lying in bed comfortably HEENT: Prosthetic L eye, MMM NECK: supple, no LAD, JVP difficult to appreciate ___ habitus CV: RRR, S1/S2, no murmurs, gallops, or rubs. R chest wall pain. PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles, no flail chest, respirations shallow, no obvious hematoma visible GI: abdomen soft, nondistended, +suprapubic tenderness, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, bilateral knees TTP, TTP over R tib/fib, grossly no deformity. Edema in bilateral ___ to level of knee with venous stasis changes but not significantly pitting. R arm inferiorly displaced. 2+ radial pulses bilaterally. PULSES: 2+ radial pulses bilaterally NEURO: Alert, EOMI on right eye without nystagmus, L prosthetic eye, no facial droop, question of ptosis of L eyelid per patient not new, tongue midline. Moves all four extremities with purpose but ROM in shoulder limited ___ pain. DERM: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: ====================== VS: ___ ___ Temp: 98.3 PO BP: 135/77 HR: 68 RR: 18 O2 sat: 92% O2 delivery: Ra GENERAL: NAD, obese lady lying in bed comfortably HEENT: Prosthetic L eye, MMM CV: RRR, S1/S2, no murmurs, gallops, or rubs. R chest wall pain. PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably on RA without use of accessory muscles GI: NABS. abdomen soft, ND, NT. No rebound/guarding, no hepatosplenomegaly EXTREMITIES: RUE sling. Bilateral ___ edema to knees with venous stasis changes. R arm inferiorly displaced. 2+ radial pulses bilaterally. NEURO: Alert and interactive. No focal neurologic deficits. Moves all four extremities with purpose but ROM in shoulder limited ___ pain. DERM: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS: ============== ___ 01:59PM ___ PTT-29.6 ___ ___ 01:59PM PLT COUNT-194 ___ 01:59PM NEUTS-65.2 ___ MONOS-5.0 EOS-2.0 BASOS-0.4 IM ___ AbsNeut-4.87 AbsLymp-2.01 AbsMono-0.37 AbsEos-0.15 AbsBaso-0.03 ___ 01:59PM WBC-7.5 RBC-4.57 HGB-14.1 HCT-44.7 MCV-98 MCH-30.9 MCHC-31.5* RDW-13.0 RDWSD-46.1 ___ 01:59PM CALCIUM-9.8 PHOSPHATE-3.5 MAGNESIUM-2.0 ___ 01:59PM proBNP-30 ___ 01:59PM cTropnT-<0.01 ___ 01:59PM GLUCOSE-86 UREA N-10 CREAT-0.7 SODIUM-144 POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-26 ANION GAP-14 ___ 04:00PM URINE MUCOUS-RARE* ___ 04:00PM URINE RBC-1 WBC-17* BACTERIA-NONE YEAST-NONE EPI-3 TRANS EPI-<1 ___ 04:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-MOD* ___ 04:00PM URINE COLOR-Straw APPEAR-Clear SP ___ MICROBIOLOGY: ============ __________________________________________________________ ___ 4:00 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION IMAGING: ======= ___ CXR IMPRESSION: 1. Congestion with probable mild interstitial pulmonary edema, difficult to exclude a subtle superimposed pneumonia. 2. Better assessed on right shoulder radiograph is right glenohumeral dislocation. ___ R Glenohumeral Xray IMPRESSION: Right glenohumeral anterior dislocation without fracture. ___ R Glenohumeral xray IMPRESSION: No substantial interval change in right anterior glenohumeral joint dislocation. Redemonstration of fractures of the right second and third anterolateral ribs. ___ CTA Chest IMPRESSION: 1. Acute fractures of the right anterolateral second and third ribs with small adjacent extrapleural hematoma. No evidence of pulmonary contusion, laceration, or pneumothorax in the setting of rib fractures. 2. Redemonstration of right anterior glenohumeral dislocation. Tiny ossific densities adjacent to the dislocated right humeral head suggests small fracture fragments. 3. No evidence of pulmonary embolism or aortic abnormality. 4. Unchanged mild narrowing of the bilateral mainstem bronchi, right middle lobe bronchus and bronchus intermedius which again may represent bronchomalacia. 5. Mild dilatation of the main pulmonary artery to 3.3 cm, unchanged, and could reflect pulmonary arterial hypertension. ___ L Pelvis and Femur Xray IMPRESSION: 1. No evidence of acute fracture or dislocation. 2. Bony callus formation at the left superior and inferior pubic rami are compatible with old healed fractures. 3. Extensive degenerative changes, as described above. ___ R Knee Xray IMPRESSION: 1. No evidence of fracture or dislocation. 2. Severe degenerative changes, as described above. ___ Shoulder Xray IMPRESSION: Single axillary view is very limited and the glenoid is not fully seen. Assessment for persistent anterior shoulder dislocation is suboptimal. There are chronic degenerative changes with irregularity of the glenoid, better assessed on the recent chest CT. If there is high concern for persistent anterior shoulder dislocation, would recommend dedicated right shoulder CT. ___ R Tib/Fib Xray IMPRESSION: No acute osseous injury of the right tibia or fibula. DISCHARGE LABS: ============== No labs on day of discharge Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO BID 2. FLUoxetine 20 mg PO DAILY 3. Simvastatin 40 mg PO QPM 4. Omeprazole 20 mg PO DAILY 5. Methazolamide 25 mg PO BID 6. Lisinopril 10 mg PO DAILY 7. Gabapentin 300 mg PO BID 8. Furosemide 10 mg PO DAILY 9. ARIPiprazole 10 mg PO DAILY 10. Timolol Maleate 0.5% 1 DROP BOTH EYES BID 11. Pilocarpine 4% 1 DROP BOTH EYES Q6H 12. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath/wheezing 13. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation unknown 14. FoLIC Acid 1 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 2. Lidocaine 5% Patch 1 PTCH TD QPM 3. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath/wheezing 4. ARIPiprazole 10 mg PO DAILY 5. FLUoxetine 20 mg PO DAILY 6. FoLIC Acid 1 mg PO DAILY 7. Furosemide 10 mg PO DAILY 8. Gabapentin 300 mg PO BID 9. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO BID 10. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation unknown 11. Lisinopril 10 mg PO DAILY 12. Methazolamide 25 mg PO BID 13. Omeprazole 20 mg PO DAILY 14. Pilocarpine 4% 1 DROP BOTH EYES Q6H 15. Simvastatin 40 mg PO QPM 16. Timolol Maleate 0.5% 1 DROP BOTH EYES BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: Right anterior-inferior glenohumeral dislocation Possible fall Rib fracture Pleuritic chest pain SECONDARY DIAGNOSES: Osteoporosis Sterile pyuria Schizoaffective disorder COPD Tracheobronchomalacia Hypertension Hyperlipidemia Glaucoma GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report INDICATION: ___ with atraumatic right shoulder substernal chest pain// Fractures? COMPARISON: Prior exam from ___ FINDINGS: Three views of the right shoulder provided. There is right glenohumeral dislocation with anterior and inferior dislocation of the right humeral head relative to the glenoid fossa. No definite acute fracture is seen. Degenerative changes at the right AC joint noted. The imaged right upper ribs appear intact. IMPRESSION: Right glenohumeral anterior dislocation without fracture. Radiology Report EXAMINATION: CHEST (SINGLE VIEW) INDICATION: ___ with atraumatic right shoulder substernal chest pain// Fractures? COMPARISON: Prior exam is dated ___ FINDINGS: AP portable upright view of the chest. Right shoulder dislocation better assessed on same-day shoulder radiograph. There is pulmonary vascular congestion and likely mild pulmonary edema. Slightly irregular opacities in the lungs likely reflect edema though difficult to exclude a subtle superimposed pneumonia. No large effusion or pneumothorax. Cardiomediastinal silhouette appears stable. No fracture seen. IMPRESSION: 1. Congestion with probable mild interstitial pulmonary edema, difficult to exclude a subtle superimposed pneumonia. 2. Better assessed on right shoulder radiograph is right glenohumeral dislocation. Radiology Report EXAMINATION: CTA chest with and without contrast INDICATION: History: ___ with substernal chest pain hypoxia// 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 2.5 s, 0.5 cm; CTDIvol = 24.1 mGy (Body) DLP = 12.0 mGy-cm. 2) Spiral Acquisition 3.7 s, 29.3 cm; CTDIvol = 27.1 mGy (Body) DLP = 793.5 mGy-cm. Total DLP (Body) = 806 mGy-cm. COMPARISON: CT chest with without contrast dated ___, right shoulder radiographs ___ at 14:16 FINDINGS: The aorta and its major branch vessels are patent, with no evidence of stenosis, occlusion, dissection, or aneurysmal formation. There is no evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present. The pulmonary arteries are well opacified to the subsegmental level, with no evidence of filling defect within the main, right, left, lobar, segmental or subsegmental pulmonary arteries. The main pulmonary artery is mildly dilated to 3.3 cm, unchanged. There is no evidence of right heart strain. Heart size is mildly enlarged. Diffuse coronary artery calcifications are present. There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy. The thyroid gland appears unremarkable. There is a small hiatal hernia. There is no evidence of pericardial effusion. There is no evidence of hemothorax or pneumothorax. There is no evidence of pulmonary contusion or laceration in the setting of rib fractures. The bilateral mainstem bronchi, right middle lobe bronchus and bronchus intermedius are narrowed and again may reflect the sequela of bronchomalacia, unchanged when compared to most recent prior CT. There is moderate depended bibasilar atelectasis. Limited images of the upper abdomen are unremarkable. The right humerus is anteriorly and inferiorly dislocated relative to the glenoid fossa with tiny adjacent osseous fragmentation suggestive of a small fracture fragment (02:32). Acute fractures of the anterolateral right second and third ribs with adjacent extrapleural hematoma is demonstrated. Mild multilevel degenerative changes are demonstrated in the visualized thoracic spine. IMPRESSION: 1. Acute fractures of the right anterolateral second and third ribs with small adjacent extrapleural hematoma. No evidence of pulmonary contusion, laceration, or pneumothorax in the setting of rib fractures. 2. Redemonstration of right anterior glenohumeral dislocation. Tiny ossific densities adjacent to the dislocated right humeral head suggests small fracture fragments. 3. No evidence of pulmonary embolism or aortic abnormality. 4. Unchanged mild narrowing of the bilateral mainstem bronchi, right middle lobe bronchus and bronchus intermedius which again may represent bronchomalacia. 5. Mild dilatation of the main pulmonary artery to 3.3 cm, unchanged, and could reflect pulmonary arterial hypertension. Radiology Report INDICATION: History: ___ with R shoulder dislocation// s/p reduction trial TECHNIQUE: Right shoulder, three views COMPARISON: Right shoulder radiographs ___ at 14:16, CT chest ___ at 17:46 FINDINGS: Re-demonstrated is a right anterior glenohumeral joint dislocation with anterior, inferior and medial displacement the humeral head relative to the glenoid fossa. Findings appear unchanged from the prior exam. Tiny fracture fragments adjacent to the humeral head seen on the prior CT are not well visualized on the current radiograph. The acromioclavicular joint demonstrates moderate degenerative changes. The imaged right lung demonstrates mild pulmonary vascular congestion. Fractures of the right second and third anterolateral ribs are re-demonstrated. IMPRESSION: No substantial interval change in right anterior glenohumeral joint dislocation. Redemonstration of fractures of the right second and third anterolateral ribs. Radiology Report EXAMINATION: DX PELVIS AND FEMUR INDICATION: History: ___ with fall, pain. Evaluation for fracture TECHNIQUE: Frontal view radiograph of the pelvis with additional frontal and frog-leg lateral views of the left hip. Frontal and lateral views of the left knee. COMPARISON: Comparison to radiograph from CT scan of the abdomen pelvis from ___ FINDINGS: There is no acute fracture or dislocation. Bony callus formation at the left superior and inferior pubic rami are compatible with chronic fractures were present on the ___ study. There are extensive degenerative changes involving the bilateral hip joints, including joint space narrowing and osteophytosis. Degenerative change of the partially visualized lumbar spine. Heterotopic calcification along the left hip is similar to prior studies. There is no suspicious lytic or sclerotic lesion. Contrast material is noted within the urinary bladder. There is a left total knee arthroplasty with no evidence of fracture or hardware complication. No evidence of joint effusion. IMPRESSION: 1. No evidence of acute fracture or dislocation. 2. Bony callus formation at the left superior and inferior pubic rami are compatible with old healed fractures. 3. Extensive degenerative changes, as described above. Radiology Report EXAMINATION: KNEE (AP, LAT AND OBLIQUE) RIGHT INDICATION: History: ___ with fall, pain. Evaluation for fracture. TECHNIQUE: Frontal and cross-table lateral view radiographs of the right knee. COMPARISON: Comparison to radiograph from ___. FINDINGS: No fracture or dislocation is seen. There is significant tricompartmental degenerative changes, including joint space narrowing most severe at the medial compartment, as well as subchondral sclerosis and osteophytosis. There is an enthesophyte noted at the superior pole of the patella. There is no knee joint effusion. There is normal osseous mineralization. No suspicious lytic or sclerotic lesions are identified. IMPRESSION: 1. No evidence of fracture or dislocation. 2. Severe degenerative changes, as described above. Radiology Report EXAMINATION: TIB/FIB (AP AND LAT) RIGHT INDICATION: ___ year old woman with R leg TTP after likely fall// r/o fracture r/o fracture TECHNIQUE: Frontal and lateral view radiographs of the right tibia and fibula COMPARISON: Radiographs of the right knee dated ___ FINDINGS: No fracture is detected in the tibia or fibula. No suspicious lytic lesion, sclerotic lesion, or periosteal new bone formation is detected. No soft tissue calcification or radio-opaque foreign bodies are detected. Severe degenerative changes of the right knee, better evaluated on yesterday's radiograph. IMPRESSION: No acute osseous injury of the right tibia or fibula. Radiology Report INDICATION: Shoulder pain. Closed reduction. COMPARISON: Compared to radiographs and chest CT from ___ IMPRESSION: Single axillary view is very limited and the glenoid is not fully seen. Assessment for persistent anterior shoulder dislocation is suboptimal. There are chronic degenerative changes with irregularity of the glenoid, better assessed on the recent chest CT. If there is high concern for persistent anterior shoulder dislocation, would recommend dedicated right shoulder CT. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Chest pain, R Shoulder pain Diagnosed with Pain in right shoulder, Hypoxemia, Chest pain, unspecified temperature: 97.7 heartrate: 68.0 resprate: 20.0 o2sat: 100.0 sbp: 141.0 dbp: 73.0 level of pain: 7 level of acuity: 3.0

BRIEF HOSPITAL COURSE: ====================== Ms. ___ is a ___ year old woman with complex past medical history most notable for COPD (FEV1 59% ___, schizoaffective disorder, R glenohumeral osteoarthritis, and chronic pain on opioid contract, who presented with 3 days of worsening R shoulder pain and substernal intermittent chest pain found to have a R anterior-inferior glenohumeral dislocation as well as acute fractures of the right anterolateral second and third ribs, s/p attempted closed reduction of shoulder dislocation but ultimately thought to be chronic in nature.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: UROLOGY Allergies: cefepime Attending: ___ Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ___ R PCN and ___ R abscess drain ___ R PCN-->PCNU replacement ___ R power midline placement History of Present Illness: This is a ___ year old female with history of multiple kidney stones who underwent attempted right PCNL and then right ureteroscopy with laser lithotripsy on ___. She had been discharged after an uncomplicated post-op stay on a course of PO Bactrim. She developed flank pain on ___, POD#8 that worsened overnight into severe diffuse abdominal pain prompting her to present to the ER. Past Medical History: -recurrent UTIs: recently admitted ___ for Proteus UTI and again ___, and ___ She has multiple urine cultures positive for Proteus and E coli with resistance. -Nephrolithiasis: s/p Cystoscopy, left ureteroscopy, laser lithotripsy, left ureteral stent placement ___. -h/o urinary retention -sickle cell trait, HTN -cholecystectomy -sCHF with LVEF 35-45% Social History: ___ Family History: -Mother: DM, died at age ___ from diabetes complications -Father: CAD, heart failure, died at age ___ -Brother: colon cancer Physical Exam: 24 HR Data (last updated ___ @ 338) Temp: 98.5 (Tm 99.1), BP: 129/79 (124-152/57-79), HR: 63 (62-80), RR: 18, O2 sat: 98% (96-98), O2 delivery: RA Gen: Awake, alert, NAD Pulm: non-labored breathing, no respiratory distress Abd: obese, soft, right flank JP drain continues with thin purulent yellow drainage GU: right PCNU draining clear yellow, some tenderness around drain site without drainage L/e: no edema. Pertinent Results: ___ 06:05AM BLOOD WBC-11.6* RBC-3.33* Hgb-8.5* Hct-26.4* MCV-79* MCH-25.5* MCHC-32.2 RDW-18.2* RDWSD-53.0* Plt ___ ___ 06:00AM BLOOD Glucose-74 UreaN-12 Creat-1.2* Na-141 K-4.0 Cl-107 HCO3-20* AnGap-14 ___ 9:15 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH ___ 8:30 am ABSCESS Source: Urinoma. **FINAL REPORT ___ GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS. 2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S). FLUID CULTURE (Final ___: MIXED BACTERIAL FLORA. This culture contains mixed bacterial types (>=3) so an abbreviated workup is performed. Any growth of P.aeruginosa, S.aureus and beta hemolytic streptococci will be reported. IF THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT in this culture. ANAEROBIC CULTURE (Final ___: BACTEROIDES FRAGILIS GROUP. SPARSE GROWTH. BETA LACTAMASE POSITIVE. ___ 8:15 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000 CFU/mL. COAG NEG STAPH does NOT require contact precautions, regardless of resistance. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | GENTAMICIN------------ =>16 R LEVOFLOXACIN---------- =>8 R NITROFURANTOIN-------- <=16 S OXACILLIN------------- =>4 R TETRACYCLINE---------- 2 S VANCOMYCIN------------ 1 S Radiology Report INDICATION: ___ year old woman with recent ureteral stent placement.// Evaluate for free air, ureteral stent location COMPARISON: Abdominal CT from ___ FINDINGS: Supine and upright views of the abdomen pelvis were provided. A right ureteral stent is noted with the proximal coil in the expected region of the right renal pelvis. The catheter extends inferiorly though the inferior extent is not clearly visualized. Radiopaque stones are seen within the kidneys. Bowel gas pattern notable for extensive fecal loading of the colon. No free air seen below the right hemidiaphragm. Clips in the right upper quadrant reflect prior cholecystectomy. Imaged lung bases are clear. IMPRESSION: As above. Radiology Report EXAMINATION: RENAL U.S. INDICATION: ___ year old woman with recurrent nephrolithiasis and urinary tract infections s/p recent ureteral stent placement p/w flank pain/diffuse abdominal pain.// Evaluate for hydronephrosis, infection, free peritoneal fluid. TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: Renal ultrasound dated ___ FINDINGS: The right kidney measures 11.9 cm. There is mild to moderate hydronephrosis, and 2 nonobstructing calculi measuring up to 1.3 and 1.6 cm are demonstrated in the inferior pole. A poorly assessed fluid collection is demonstrated medial and inferior to the right kidney, measuring approximately 14 x 3.3 x 4.0 cm. The left kidney measures 11.4 cm. There is mild hydronephrosis. Two nonobstructing calculi in the lower pole measure up to 1.1 and 1.2 cm. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. Several bladder calculi are noted. These measure 1.3 cm and 0.7 cm. IMPRESSION: 1. Moderate right and mild left hydronephrosis with nonobstructing calculi demonstrated bilaterally. 2. Apparent fluid collection adjacent to the right kidney for which CT is recommended to further assess. 3. Bladder stones. Radiology Report EXAMINATION: CT urogram INDICATION: ___ with recent ureteral stent placement and failed PCNL p/w severe flank pain, peritoneal signs on exam. TECHNIQUE: CT through the abdomen pelvis performed without and with IV contrast. Postcontrast imaging utilized a split bolus technique. No oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 2,567 mGy-cm. COMPARISON: Prior CT abdomen pelvis from ___ FINDINGS: LOWER CHEST: The imaged lung bases are clear aside from mild right basal atelectasis in the setting of a right hemidiaphragmatic eventration. The imaged portion of the heart is unremarkable. ABDOMEN: HEPATOBILIARY: Tiny hypodensities are again noted primarily within segment 7, too small to characterize though appear unchanged. There is mild intrahepatic biliary ductal dilation, unchanged likely reflecting prior cholecystectomy. Main portal vein is patent. CBD appears normal in caliber. PANCREAS: The pancreas enhances normally. No acute findings. SPLEEN: The spleen appears intact and normal in size. ADRENALS: A left adrenal nodule is unchanged, measuring 3.0 x 2.2 cm, previously characterized as an adenoma. A second small nodule is seen arising from the lateral limb, also unchanged. The right adrenal gland appears normal. URINARY: Left greater than right renal cortical scarring is again seen with large stones again seen within lower pole calices. There is mild left hydronephrosis, more conspicuous than on prior. No signs of a left ureteral stone. There is a large right retroperitoneal fluid collection with peripheral enhancing rim extending along the psoas inferiorly to the right hemipelvis. This lobulated collection, concerning for an abscess, measures approximately 21.6 cm in craniocaudal dimension. At its widest transverse dimension, this collection measures 13.7 cm, series 3, image 53. The maximal AP dimension is approximately 6.7 cm, series 3, image 54. This collection also extends medially inferior to the third and fourth segments of the duodenum. There is moderate right hydronephrosis with prominence of the right ureter also with urothelial thickening. The possibility of a urine leak and urinoma is difficult to exclude. GASTROINTESTINAL: The stomach and duodenum appear grossly unremarkable. Small bowel loops demonstrate no signs of ileus or obstruction. The appendix is clearly visualized and is normal. The colon contains a moderate fecal load and is without signs of inflammation or obstruction. There is no intraperitoneal free air or free fluid. PELVIS: The urinary bladder is markedly thickened and contains several small stones. No definite stone is seen in the distal ureters or UVJ. There is dilation of the right distal ureter with urothelial thickening and hyper enhancement suggesting ureteritis. No pelvic free fluid is seen. REPRODUCTIVE ORGANS: The uterus appears normal. The right ovary is not clearly visualized as it abuts right pelvic sidewall collection. The left adnexal region is normal. There is no adenopathy in the pelvis or inguinal region. LYMPH NODES: No definite lymphadenopathy in the abdomen or pelvis. VASCULAR: There is no abdominal aortic aneurysm. No significant atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Degenerative changes are noted at L5-S1 with loss of disc space and prominent posterior disc osteophyte complexes. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Large rim enhancing fluid collection in the right retroperitoneal space, most concerning for an abscess. However, given history of recent interventions, difficult to exclude urinoma. 2. Moderate right hydroureteronephrosis without obstructing stone. Urothelial thickening and hyperemia likely reflects ureteritis/infection. 3. Mild left hydronephrosis without obstructing stone. 4. Additional nonemergent findings as described above. RECOMMENDATION(S): -Follow up abdominal radiograph or CT may be performed to assess for presence of excreted contrast within these collections as urinoma not excluded. -Percutaneous drainage may be considered. NOTIFICATION: Initial findings/recommendations discussed with Dr. ___. Radiology Report EXAMINATION: CT abdomen/pelvis, excretory phase INDICATION: ___ year old woman with recent ureteral stent placement now with flank pain and peritoneal signs. CT showed abscess. Repeat CT to evaluate for contrast moving in to the abscess.// Further evaluate intraabdominal abscess TECHNIQUE: Excretory phase CT: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique performed approximately 50 minutes prior.Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 1,418 mGy-cm. COMPARISON: CTU with and without contrast performed approximately 50 minutes prior FINDINGS: URINARY: Bilateral renal contrast excretion is noted. However, on the right side, contrast extravasation is noted at the level of the right ureteropelvic junction, with contrast enhanced urine extending into the right retroperitoneal collection detailed on prior CT. Findings are consistent with large urinoma with probable superinfection. Interval placement of a Foley catheter into the bladder with associated intravesicular gas. Left greater than right renal cortical scarring, bilateral lower pole stones, and moderate right and mild left hydronephrosis are again seen. OTHER: All other abdominopelvic findings are better assessed on the preceding CTU. IMPRESSION: Contrast excreted by the right kidney enters a large right retroperitoneal fluid collection, consistent with urinoma. Site of urinary tract disruption at the right UPJ. Superinfection remains a concern. RECOMMENDATION(S): Percutaneous drainage of collection, right nephrostomy tube. NOTIFICATION: Findings were discussed with ___ staff at the time of initial review. Radiology Report INDICATION: ___ year old woman with infected urinoma// Urinary drainage COMPARISON: CT Abdomen and Pelvis ___ 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 150 mcg of fentanyl and 2.5 mg of midazolam throughout the total intra-service time of 95 minutes during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: Fentanyl, Midazolam, Lidocaine CONTRAST: 20 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 8.2 min, 263 mGy PROCEDURE: 1. Right ultrasound guided renal collecting system access. 2. Right nephrostogram. 3. Right ___ Fr nephrostomy tube placement. 4. ___ Fr abscess catheter placement using Cone Beam CT guidance PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed prone on the exam table. A pre-procedure time-out was performed per ___ protocol. The right flank was prepped and draped in the usual sterile fashion. After the injection of 15 cc of 1% lidocaine in the subcutaneous soft tissues, the right renal collecting system was accessed through a posterior lower pole calyx under ultrasound guidance using a 21 gauge Cook needle. Ultrasound images of the access were stored on PACS. Prompt return of urine confirmed appropriate positioning. Injection of a small amount of contrast outlined a dilated renal collecting system. Under fluoroscopic guidance, a Nitinol wire was advanced into the renal collecting system. After a skin ___, the needle was exchanged for an Accustick sheath. Once the tip of the sheath was in the collecting system; the sheath was advanced over the wire, inner dilator and metallic stiffener. The wire and inner dilator were then removed and diluted contrast was injected into the collecting system to confirm position. A ___ wire was advanced through the sheath and coiled in the collecting system. The sheath was then removed and a 8 ___ nephrostomy tube was advanced into the renal collecting system. The wire was then removed and the pigtail was formed in the collecting system. Contrast injection confirmed appropriate positioning. The catheter was then flushed, 0 silk stay sutures applied and the catheter was secured with a Stat Lock device and sterile dressings. The catheter was attached to a bag. Then, attention was turned to the fluid collection inferior to the right kidney, suspected of being infected urinoma. A cone beam CT was done to delineate the anatomy. Imaging was reviewed on a separate workstation and 3D reformats were created, overseen by Dr. ___. A needle trajectory was planned on CT and the image detector was rotated to a bulls eye orientation. After the injection of 15 cc of 1% lidocaine in the subcutaneous soft tissues, a 21 G needle was advanced towards the collection. The image detector was rotated to the orthogonal plane to monitor progression towards the target. Prompt return of pus confirmed appropriate positioning. Injection of a small amount of contrast outlined the fluid collection. Under fluoroscopic guidance, a Nitinol wire was advanced into the collection. After a skin ___, the needle was exchanged for an Accustick sheath. Once the tip of the sheath was in the collection, the sheath was advanced over the wire, inner dilator and metallic stiffener. The wire and inner dilator were then removed and diluted contrast was injected into the collecting system to confirm position. A ___ wire was advanced through the sheath and coiled in the collection. The sheath was then removed and a 10 ___ APDL tube was advanced into the collection. The wire was then removed and the pigtail was formed. Contrast injection confirmed appropriate positioning. The catheter was then flushed, 0 silk stay sutures applied and the catheter was secured with a Stat Lock device and sterile dressings. The catheter was attached to a bag. A sample of the fluid was sent to microbiology. FINDINGS: 1. Ultrasound demonstrating moderate right hydronephrosis. 2. Ultrasound and cone beam CT demonstrating moderate fluid collection inferior to the right kidney, with aspiration of pus status post needle access. 3. Appropriate position of right 8 ___ PCN tube and right 10 ___ APDL tube in the infected fluid collection. IMPRESSION: 1. Successful placement of 8 ___ nephrostomy on the right. 2. Successful placement of a 10 ___ APDL tube in the infected fluid collection inferior to the right kidney. Radiology Report INDICATION: ___ s/p attempted right PCNL and then right ureteroscopy with laser lithotripsy who presents with acute, severe abdominal pain, leukocystosis with bandemia and CT findings consistent with infected urinoma.// Assess for interval change, fluid collection, abscess TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired without intravenous contrast. Non-contrast scan has several limitations in detecting vascular and parenchymal organ abnormalities, including tumor detection. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 7.5 s, 48.9 cm; CTDIvol = 25.6 mGy (Body) DLP = 1,233.5 mGy-cm. Total DLP (Body) = 1,234 mGy-cm. COMPARISON: Multiple prior CT abdomen pelvis dated back to ___ with the most recent CT abdomen pelvis from ___. FINDINGS: LOWER CHEST: Lung bases are clear. ABDOMEN: HEPATOBILIARY: The liver is unremarkable. The gallbladder surgically absent PANCREAS: Unremarkable. SPLEEN: Unremarkable. ADRENALS: Unremarkable except for a 2.7 cm left adrenal adenoma. URINARY: Right hydronephrosis has improved with only residual hydronephrosis in the upper pole. There are a right percutaneous nephrostomy tube and a right retroperitoneal drain. Mild left hydronephrosis is stable. Again seen are unchanged bilateral renal calculi measuring up to 2.5 cm in the right upper pole. The superior portion of the urinoma not drained by the catheter has not significantly changed measuring approximately 3.9 cm, previously 4 cm (series 3, image 32). Midportion of the urinoma has significantly decreased in size measuring 6.6 cm (series 3, image 48), seen where the catheter was present. The inferior portion of the urinoma has also decreased in size measuring 6.3 cm (series 3, image 58). No new fluid collection. GASTROINTESTINAL: No bowel obstruction. No ascites. No free air. PELVIS: A Foley catheter is noted. No pelvic free fluid. The uterus is unremarkable. No adnexal mass. LYMPH NODES: No abdominal or pelvic lymphadenopathy. VASCULAR: No abdominal aortic aneurysm. BONES: No suspicious osseous lesions. SOFT TISSUES: Mild soft tissue stranding is noted along the course of the percutaneous nephrostomy tube. IMPRESSION: 1. Marked interval improvement of the right retroperitoneal urinoma as detailed above. 2. Improved right and stable left hydronephrosis. 3. Bilateral nephrolithiasis. Radiology Report INDICATION: ___ year old woman with recent ureter stent placement now with intra-abdominal abscess.// PCN to PCNU COMPARISON: CT from ___ TECHNIQUE: OPERATORS: Dr. ___, performed the procedure. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 75mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service time of 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: As above CONTRAST: 10 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 1.2 min, 3 mGy PROCEDURE: 1. Right diagnostic antegrade nephrostogram. 2. Right 8 ___ nephrostomy exchange for PCNU. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient.The patient was then brought to the angiography suite and placed prone on the exam table. A pre-procedure time-out was performed per ___ protocol. The right flank was prepped and draped in the usual sterile fashion. Diluted contrast was injected into the right nephrostomy to confirm catheter position. The image was stored on PACS. Local anesthesia was administered with instillation of lidocaine jelly and 1% subcutaneous lidocaine injection. The catheter was cut. A ___ wire was advanced into the left nephrostomy tube and advanced into the distal ureter. The stay sutures were cut and the catheter was removed over the wire. A 6 ___ sheath was placed. Then over ___ wire Kumpe catheter was placed. Utilizing the ___ wire and Kumpe catheter access was gained to the ureter and eventually to the bladder. The wire was removed and injection confirmed the catheter was in the bladder. Then, the wire was readvanced. The catheter and sheath were removed and a new 8 ___ by 24 cm PCNU tube were advanced. The pigtail was formed. The catheter was attached to a bag for drainage. Final image was saved. StatLock and sterile dressings were applied. The patient tolerated the procedure well and there were no immediate post-procedure complications. FINDINGS: 1. Right antegrade nephrostogram shows flow into the ureter. No definitive disruption seen at this time. Initial tube was pulled back into a calyx. 2. Appropriate final position of Right PCNU tube. IMPRESSION: Technically successful Right 8 ___ PCN to PCNU conversion Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: R Flank pain Diagnosed with Other retroperitoneal abscess temperature: 98.1 heartrate: 112.0 resprate: 16.0 o2sat: 94.0 sbp: 146.0 dbp: 76.0 level of pain: 10 level of acuity: 3.0

The patient was admitted to the Urology service on ___. She was septic on admission. She was started on Zosyn. A foley was placed and drains were placed by interventional radiology in the urinoma and kidney for urinary drainage. Her WBC began to downtrend and her fever curve decreased. She was re-imaged on ___ and on ___ returned to ___ for conversion of PCN to PCNU after which her foley was removed. Her abscess drain was felt to be in good position so it was not manipulated. Infectious diseases was consulted after the patient's cultures resulted who recommended outpatient daily ertapenem administration and repeat imaging to ensure resolution of abscess prior to discontinuing antibiotics. A midline was placed on ___ for outpatient antibiotic therapy. Endocrinology was also consulted for patient's hyperparathyroidism and non-compliance with outpatient follow up who recommended vitamin D supplementation. The patient was deemed stable for discharge home on ___ with PCNU and abscess drain to bulb suction. At the time of discharge the patient was hemodynamically stable, tolerating a regular diet, pain was controlled on an oral pain regimen and she was at her baseline mobility. Post-discharge restrictions, warning signs and follow up was reviewed extensively with the patient and all questions were answered.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Seroquel / Erythromycin Base / Reglan Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: dophoff placement Gtube replacement History of Present Illness: ___ yo F with hx of eating disorder s/p G/J tube placement, bipolar disorder, GERD, gastroparesis who presents with pain at GJ tube site. She was recently admitted at the end of ___ for abdominal pain. Her GJ tube was replaced on ___. She is now here again with abdominal pain. She says pain feels similar to prior episodes of when here tube was malpositioned. Her pain is predominately around the ring of the J tube for the last 24 hours. She has minimal nausea which is her baseline. She denies diarrhea. She had a bowel movement yesterday and has been passing gas. Prior to yesterday she was tolerating tube feeds and minimal po intake. She initially presented to ___ and then was transferred here for further management. She was given dilaudid prior to transfer. In the ED, initial VS: 97.7 53 107/65 16 98%. A bedside ultrasound showed no abscess. She was given IV dilaudid for pain and subsequently admitted for pain control and evaluation of the tube by ___. VS prior to transfer: 98.0, 106/78, 58, 18, 100% Currently, she still has pain around her tube but improved after medication. ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, vomiting, diarrhea, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: h/o Eating disorder/laxative abuse, patient reports is in remission and that she remains in outpatient therapy Chronic constipation Bipolar disorder GERD Gastroparesis Social History: ___ Family History: Pertinent for mother with breast cancer and a half sister with type 1 diabetes and a cousin with ___ disease. Physical Exam: VS - Temp 98.2F, BP 89/61, HR 58, R 16, O2-sat 99% RA GENERAL - well-appearing female in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, slightly dry MM, OP clear NECK - supple, no cervical lymphadenopathy, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft. tender around GJ tube site. non distending. no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout Pertinent Results: admission labs ___ 06:06AM BLOOD WBC-10.2# RBC-4.17* Hgb-13.2 Hct-39.2 MCV-94 MCH-31.6 MCHC-33.6 RDW-12.3 Plt ___ ___ 06:06AM BLOOD Neuts-69.2 ___ Monos-3.7 Eos-2.0 Baso-0.5 ___ 06:06AM BLOOD ___ PTT-29.0 ___ ___ 06:06AM BLOOD Glucose-93 UreaN-11 Creat-0.7 Na-141 K-3.8 Cl-107 HCO3-25 AnGap-13 . discharge labs ___ 07:50AM BLOOD WBC-7.3 RBC-4.22 Hgb-12.7 Hct-40.5 MCV-96 MCH-30.2 MCHC-31.4 RDW-12.2 Plt ___ . imaging G/GJ/GI tube check: FINDINGS: Initial scout AP view of the abdomen demonstrates gastrojejunostomy tube coiled in the stomach. Following the hand injection of Gastrografin through the patient's percutaneous gastrojejunostomy tube, contrast material is noted in the stomach as well as in the proximal duodenum. A third AP view of the abdomen demonstrates contrast moving distally throughout the remainder of the duodenum. There are clips noted in the left upper quadrant. There is a nonspecific bowel gas pattern with no evidence of obstruction. IMPRESSION: The gastrojejunostomy tube again appears coiled in the stomach with the tip located at the fundus of the stomach. . PERC G/J TUBE CHECK/REPLACE (preliminary) -Uncomplicated exchange of old 16 ___ MIC GJ tube with a new 16 ___ G-tube, with its tip in the gastric lumen. It may be used. -Uncomplicated placement of a ___ nasoduodenal tube via the left nostril, with its tip in the distal duodenum. It may be used Medications on Admission: 1. amphetamine-dextroamphetamine 10 mg Tablet Sig: One (1) Tablet PO twice a day. 2. clonazepam 2 mg Tablet Sig: One (1) Tablet PO at bedtime. 3. lithium citrate 8 mEq/5 mL Solution Sig: Three Hundred (300) mg PO qAM and at 2PM. 4. lithium citrate 8 mEq/5 mL Solution Sig: Six Hundred (600) mg PO QHS (once a day (at bedtime)). 5. calcium carbonate Oral 6. domperidone (bulk) Powder Sig: Ten (10) mg Miscellaneous three times a day. 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 8. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 9. ondansetron HCl 8 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 10. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily) as needed for constipation. 12. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. vitamin D Discharge Medications: 1. amphetamine-dextroamphetamine *NF* 10 mg Oral BID Reason for Ordering: Wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. 2. Clonazepam 2 mg PO QHS hold for oversedation, RR<12 3. Lithium Oral Solution 300 mg PO BID give qAM and at 2 pm 4. Lithium Oral Solution 600 mg PO QHS 5. Multivitamins 1 TAB PO DAILY 6. Omeprazole 20 mg PO BID 7. Ondansetron 8 mg PO Q8H:PRN nausea 8. Polyethylene Glycol 17 g PO DAILY:PRN constipation 9. Thiamine 100 mg PO DAILY 10. Vitamin D 400 UNIT PO DAILY 11. traZODONE 50 mg PO HS:PRN insomnia Discharge Disposition: Home Discharge Diagnosis: primary 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: Evaluation of patient with pain at gastrojejunostomy site. COMPARISON: Percutaneous gastrojejunostomy tube replacement on ___, and portable abdominal radiograph from ___. FINDINGS: Initial scout AP view of the abdomen demonstrates gastrojejunostomy tube coiled in the stomach. Following the hand injection of Gastrografin through the patient's percutaneous gastrojejunostomy tube, contrast material is noted in the stomach as well as in the proximal duodenum. A third AP view of the abdomen demonstrates contrast moving distally throughout the remainder of the duodenum. There are clips noted in the left upper quadrant. There is a nonspecific bowel gas pattern with no evidence of obstruction. IMPRESSION: The gastrojejunostomy tube again appears coiled in the stomach with the tip located at the fundus of the stomach. Radiology Report EXCHANGE OF INDWELLING GJ TUBE FOR A G-TUBE AND PLACEMENT OF POST-PYLORIC NASODUODENAL TUBE. INDICATION: ___ woman with eating disorder and gastroparesis with existing GJ tube that is coiled within the stomach. OPERATORS: Drs. ___ (fellow) and ___ (attending physician). Dr. ___ was present during key moments of the procedure. CONTRAST: Sterile 20 mL Optiray 320 in the stomach and proximal small bowel. SEDATION: Moderate sedation with divided doses of intravenous ___ mcg fentanyl and 2 mg Versed over 41 minutes, during which patient's hemodynamic status was continuously monitored by a trained radiology nurse. PROCEDURE AND FINDINGS: Consent was obtained from the patient after explaining the benefits, risks, and alternatives. She was placed supine on the imaging imaged in the interventional suite. Timeout was performed as per ___ protocol. Initial scout fluoroscopic image demonstrated indwelling tube coiled in the left upper abdomen. Under aseptic conditions, a small amount of sterile contrast material was injected through the jejunal port of the tube, which opacified the gastric lumen. After deflating the retention balloon, a 0.035 ___ wire was advanced through the jejunal porAfter removing the wire, a small amountt and coiled within the stomach. The old tube was removed to place a new ___ MIC G-tube. of sterile contrast material was injected through the port to confirm position. About 5 mL of diluted contrast was injected to inflate the balloon, which was then apposed against the inner gastric wall. External disc was apposed against the skin. Patient tolerated the procedure well and no immediate post-procedure complication was seen. A ___ tube was placed via the left nostril and advanced under intermittent fluoroscopic guidance into the stomach. However, it was not possible to advance it beyond the pylorus. Hence, the tube was removed over a 0.035 Glidewire. A 100-cm C1 catheter was placed, and after insufflating the stomach with gas via the percutaneous G-tube, the catheter-wire combination was negotiated into the distal duodenum. Catheter was then removed to place the ___ tube. While its tip was at the level of the pylorus, it was further advanced into the duodenum with the help of 0.035 stiff Glidewire. Eventually, the tube tip was left in the distal duodenum. The wire was removed. A small amount of sterile contrast material was injected to confirm position. The tube was then secured. Patient tolerated the procedure well and no immediate post-procedure complication was seen. IMPRESSION: 1. Uncomplicated exchange of old 16 ___ MIC GJ tube with a new 16 ___ G-tube, with its tip in the gastric lumen. It may be used. 2. Uncomplicated placement of a ___ nasoduodenal tube via the left nostril, with its tip in the distal duodenum. It may be used. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: PAIN AT J TUBE SITE Diagnosed with ABDOMINAL PAIN OTHER SPECIED, COLOSTOMY COMP NOS, EATING DISORDER NOS temperature: 97.7 heartrate: 53.0 resprate: 16.0 o2sat: 98.0 sbp: 107.0 dbp: 65.0 level of pain: 3 level of acuity: 3.0

___ yo F with hx of eating disorder s/p GJ tube placement, bipolar disorder, GERD, gastroparesis who presents with abdominal pain found to have GJ tube coiled in her stomach. # Abdominal Pain - most likely related to malpositioned GJ tube as demonstrated on imaging. She was given IV narcotics in the ED and pain was subsequently treated with with tylenol and oral oxycodone on the floor. Given that patient has had similar problems in the past, both ___ and surgery were consulted to discuss alternative options. Ultimately after discussion with the patient, ___, and surgery, the decision was made to place a dobhoff post pyloric and exchange her GJ tube for a G tube. She tolerated the procedure well. She was discharged with plans to follow up with her surgeon Dr. ___ to discuss J tube placement and with her GI physician. # Bipolar disorder - continued home medications including lithium, clonazepam, and amphetamine-dextroamphetamine. # chronic constipation - docusate, senna, miralax # GERD - continued omeprazole Transitional Issues - no labs pending at time of discharge - patient will need to follow with her gastroenterologist and her surgeon Dr. ___ to discuss J tube placement.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Penicillins Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ___: Laparoscopic cholecystectomy History of Present Illness: ___ with IBS and pancreatic insufficiency is now presented in the ED for RUQ pain. Patient reports he started noticing churning abdominal pain in his RUQ 5 days prior to presentation, few hours after dinner. Pain was severe that he could not sleep. It resolved a few hours later. On ___, it recurred, and is associated with nausea, although he reports no emesis. It lasted more than 6 hours. He has loss of appetite. He last ate yesterday ___ and took a few bites of pasta salad. Given RUQ, he stopped eating. Today he decided to come to the ED for evaluation. At the ED, he was found AVSS. WBC was remarkable at 14.8 with left shift PMN of 82%. LFTs and lipase are normal. During RUQUS, technician reported sonographic ___ sign. Gallbladder wall thickening with stones and sludge while CBD normal. Surgery thus was consulted for surgical management. He denies fever, chills, vomiting, constipation, diarrhea, BRBPR, hematemesis, cough, shortness of breath, chest pain, heart palpitation. Past Medical History: Past Medical History: -IBS -pancreatic insufficiency Past Surgical History: -R inguinal hernia repair, open, with mesh Social History: ___ Family History: noncontributory Physical Exam: Admission Physical Exam: Vitals: 99.0 108 134/89 16 100% RA Gen: AAO3, NAD HEENT: Normocephalic. PERRLA, EOMI. Sclerae anicteric. Hearing grossly intact. No ear drainage. Patent nares. MMM. NECK: Supple without lymphadenopathy. HEART: RRR, normal S1/S2, no m/r/g LUNGS: CTAB. No crackles/wheezes/rhonchi. No respiratory distress. ABDOMEN: Soft, RUQ TTP, no ___ sign in the setting of recent pain meds, nondistended, with good bowel sounds heard. No mass palpated. Well healed R groin hernia scar. BACK: There is no costovertebral angle tenderness EXTREMITIES: Without cyanosis, clubbing or edema NEUROLOGICAL: Gross nonfocal SKIN: Warm and dry without any rash Discharge Physical Exam: VS: 98.1, 99/56, 72, 18, 97 Ra Gen: A&O x3. ambulatory. CV: HRR Pulm: LS ctab Abd: soft, mildly TTP around incisions, nondistended. Lap sites CDI, bruising around umbilical port site. Ext: WWP no edema Pertinent Results: ___ 05:35AM BLOOD WBC-11.5* RBC-3.92* Hgb-11.5* Hct-35.1* MCV-90 MCH-29.3 MCHC-32.8 RDW-12.5 RDWSD-40.7 Plt ___ ___ 05:27PM BLOOD WBC-11.8* RBC-4.12* Hgb-12.3* Hct-36.4* MCV-88 MCH-29.9 MCHC-33.8 RDW-12.4 RDWSD-40.9 Plt ___ ___ 05:35AM BLOOD WBC-11.4* RBC-4.49* Hgb-13.3* Hct-40.3 MCV-90 MCH-29.6 MCHC-33.0 RDW-12.5 RDWSD-41.4 Plt ___ ___ 02:35PM BLOOD WBC-14.8* RBC-5.16 Hgb-15.4 Hct-45.0 MCV-87 MCH-29.8 MCHC-34.2 RDW-12.4 RDWSD-39.6 Plt ___ ___ 05:35AM BLOOD Glucose-136* UreaN-13 Creat-0.9 Na-142 K-4.6 Cl-102 HCO3-27 AnGap-13 ___ 05:35AM BLOOD Glucose-83 UreaN-10 Creat-0.9 Na-142 K-4.0 Cl-101 HCO3-26 AnGap-15 ___ 02:35PM BLOOD Glucose-113* UreaN-10 Creat-1.0 Na-137 K-4.0 Cl-98 HCO3-24 AnGap-15 ___ 05:35AM BLOOD ALT-49* AST-40 AlkPhos-68 TotBili-0.7 ___ 05:35AM BLOOD ALT-24 AST-19 AlkPhos-71 TotBili-0.9 ___ 02:35PM BLOOD ALT-29 AST-20 AlkPhos-68 TotBili-1.2 ___ 05:35AM BLOOD Calcium-9.2 Phos-2.0* Mg-2.0 ___ 05:35AM BLOOD Albumin-3.9 Calcium-9.0 Phos-1.5* Mg-2.0 ___ 02:35PM BLOOD Albumin-4.5 Calcium-9.6 Phos-2.0* Mg-2.0 RUQUS: ___ sign. stones and sludge in a mildly distended gallbladder with associated gallbladder wall thickening. CBD 5mm. Medications on Admission: LIPASE-PROTEASE-AMYLASE [ZENPEP] - Zenpep 20,000 unit-68,000 unit-109,000 unit capsule,delayed release. 2 capsule(s) by mouth with meals one with snacks OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1 Capsule(s) by mouth daily Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) hours Disp #*30 Tablet Refills:*0 2. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*7 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*20 Capsule Refills:*0 4. MetroNIDAZOLE 500 mg PO TID RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*11 Tablet Refills:*0 5. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp #*3 Tablet Refills:*0 6. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 17 gram 1 packet(s) by mouth once a day Disp #*7 Packet Refills:*0 7. Tamsulosin 0.4 mg PO QHS RX *tamsulosin 0.4 mg 1 capsule(s) by mouth once a day Disp #*5 Capsule Refills:*0 8. Omeprazole 20mg PO daily Discharge Disposition: Home Discharge Diagnosis: Acute cholecystitis Urinary retention Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT INDICATION: History: ___ with right upper quadrant pain radiating to the back, subjective fevers, anorexia // Evaluate for acute gallbladder pathology TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: Liver gallbladder ultrasound from ___. CT urogram with and without contrast from ___ FINDINGS: LIVER: The hepatic parenchyma appears within normal limits. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 3 mm GALLBLADDER: There are stones and sludge in the mildly distended gallbladder with gallbladder wall thickening. No definite pericholecystic fluid is identified. PANCREAS: The pancreas is not well visualized, largely obscured by overlying bowel gas. SPLEEN: Not visualized. KIDNEYS: Limited views of the kidneys show no hydronephrosis. Right kidney: 12.3 cm Left kidney: 11.1 cm. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: Stones and sludge in a mildly distended gallbladder with associated gallbladder wall thickening, can be seen in acute cholecystitis, in the appropriate clinical setting. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abd pain Diagnosed with Acute cholecystitis temperature: 99.0 heartrate: 108.0 resprate: 16.0 o2sat: 100.0 sbp: 134.0 dbp: 89.0 level of pain: 7 level of acuity: 3.0

The patient was admitted to the General Surgical Service on ___ for evaluation and treatment of abdominal pain. Admission abdominal ultra-sound revealed a mildly distended gallbladder with stones and associated gallbladder wall thickening. The patient underwent laparoscopic cholecystectomy, which went well without complication (reader referred to the Operative Note for details). After a brief, uneventful stay in the PACU, the patient arrived on the floor tolerating sips, on IV fluids, and oral analgesia for pain control. The patient was hemodynamically stable. He was placed on 4 days of antibiotics for intra-op gallbladder content spillage. Pain was well controlled. Diet was progressively advanced as tolerated to a regular diet with good tolerability. The patient experienced urinary retention POD0 and was started on tamsulosin with good effect. By POD1, he was voiding without problem. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. 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: MEDICINE Allergies: Reclast / Fosamax Attending: ___. Chief Complaint: Eye burning and blurriness Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ yo woman with PMH of temporal arteritis on steroids and DM2 who is transferred to the ___ ED with concern for temporal arteritis flare. Patient was recently admitted to ___ from ___t home. Workup was unrevealing aside from hyponatremia which was corrected with IVF's and she was discharged to ___ rehab on ___. There, she has continued to be very weak with poor excercise tolerance. ESR was noted to be 75, well above her normal baseline. Prednisone was empirically increased to 20mg from 10mg with some initial improvement of subjective symptoms. However, over the past week she has experienced progressive burning sensation in her eyes, right worse than left, initially associated with mild conjuctival erythema and discharge. She was started on erythromycin opthalmic ointment without improvement, followed by lubricating opthalmic ointment without benefit. Over the past ___, she noted worsening vision in her right eye. Her primary rheumatologist Dr. ___ ___ was consulted and recommended urgent opthamologic evaluation in the setting of known giant cell arteritis and she was transferred to ___ for further evaluation. In the ED intial vitals were T 97.7, HR 95, BP 148/45, RR 16, O2 100%. Initial labs were notable for Na of 125, CRP 80.4, ESR 63, and HCT 29.9 with plt 576. Remainder of Chem7 and CBC were unremarkable. Opthalmology was consulted who recommended admission with rheum consult for IV steroids. IOP was 10 and visual acuity was documented at L Eye = ___ Eye = ___ Both = ___. Patient was then admitted to medicine for further management. On the floor, patient reports bilateral eye burning and blurriness as above. She denies any headache. She also denies recent fevers or chills. No CP or SOB. No nausea, vomiting or diarrhea. She does note poor appetite and constipation x4 days. No new rashes or joint pains. Remainder of ROS is unremarkable. Past Medical History: -HLD -Nephrolithiasis -Migraine -Pseudphakia -Vitreous degeneration -Macular degeneration -Blepharatis -Ptosis -GERD -Hiatal hernia -Basal cell carcinoma -Actinic Keratoses -DM2 -BPV -PMR -HTN -Temporal arteritis -Osteoporosis -Iron def anemia -Adrenal insuffeciency Social History: ___ Family History: No known history of autoimmune disease. Physical Exam: ============================= ADMISSION PHYSICAL EXAM: ============================= Vitals- 98.4 165/63 99 16 100%RA General- Alert, pleasant, orientedx4, no acute distress HEENT- Sclera anicteric, dry MM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- Nonlabored on RA. Slightly decreased BS at right lung base. CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding Ext- warm, well perfused, no edema Neuro- AAOx4, CNs2-12 intact, moving all extremities equally . . ============================= OPHTHALMOLOGIC EXAM: ============================= EXAMINATION Visual Acuity; OD (sc): ___ cc near chart OS (sc): ___ cc near chart Mental status: Alert and oriented x 3 Pupils (mm) PERRL Relative afferent pupillary defect: [ X ] none [ ] present OD: 3mm --> 2mm OS: 3mm --> 2mm Extraocular motility: Full ___ Visual fields by confrontation: Full to counting fingers ___ Color Vision (___ pseudo-isochromatic plates): OD: ___ OS: ___ Intraocular pressure (mm Hg): OD: 10.3 OS: 10.3 External Exam: [ X] NL No V1 or V2 hypesthesia Orbital rim palpation: No point-tenderness, deformities, and step-offs ___ Anterior Segment (Penlight or portable slitlamp) Lids/Lashes/Lacrimal: OD: Normal OS: Normal Conjunctiva: OD: White and quiet OS: White and quiet Cornea: OD: Clear, no epithelial defects OS: Clear, no epithelial defects Anterior Chamber: OD: Deep and quiet OS: Deep and quiet ___: OD: Flat OS: Flat Lens: OD: PCIOL trace PCO OS: PCIOL trace PCO Fundus (Indirect Ophthalmoscopy using 20D lens): Dilation approved by patient PLEASE NOTE, PUPILS WILL REMAIN DILATED FOR AT LEAST ___ HRS Media/Vitreous: OD: Clear OS: Clear Discs: OD: pink, sharp margins OS: pink, sharp margins Maculae: OD: multiple soft ___ OS: multiple soft ___ Periphery OD: PRP laser scars OS: PRP laser scars . . ============================= DISCHARGE PHYSICAL EXAM: ============================= Vitals- 97.9 142/46 95 16 99/RA General- Alert, pleasant, orientedx3, no acute distress , somewhat tearful when talking about her family HEENT- Sclera anicteric, dry MM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- Nonlabored on RA. Slightly decreased BS at right lung base. CV- Regular rhythm, tachycardic. normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding Ext- warm, well perfused, no edema Neuro- CNs2-12 grossly intact, moving all extremities equally. Bilateral upper extremity tremors Pertinent Results: ============================= ADMISSION LABS: ============================= ___ 08:30PM BLOOD WBC-8.2 RBC-3.47* Hgb-9.3* Hct-29.8* MCV-86 MCH-26.9* MCHC-31.3 RDW-13.3 Plt ___ ___ 08:30PM BLOOD Neuts-70.3* ___ Monos-5.7 Eos-0.7 Baso-0.4 ___ 08:30PM BLOOD ___ PTT-26.5 ___ ___ 08:30PM BLOOD ESR-63* ___ 08:30PM BLOOD Glucose-184* UreaN-18 Creat-0.6 Na-125* K-4.6 Cl-90* HCO3-25 AnGap-15 ___ 08:30PM BLOOD LD(LDH)-137 TotBili-0.2 ___ 08:30PM BLOOD Iron-17* ___ 08:30PM BLOOD CRP-80.4* . ============================= DISCHARGE LABS: ============================= ___ 07:00AM BLOOD WBC-8.8 RBC-3.72* Hgb-10.0* Hct-32.0* MCV-86 MCH-27.0 MCHC-31.4 RDW-13.3 Plt ___ ___ 07:00AM BLOOD Glucose-169* UreaN-26* Creat-0.8 Na-133 K-4.5 Cl-98 HCO3-24 AnGap-16 ___ 07:00AM BLOOD Calcium-9.0 Phos-2.3* Mg-2.2 ___ 07:00AM BLOOD CRP-34.0* . ============================= IMAGING: ============================= CT HEAD W/O CONTRAST Study Date of ___ 10:24 ___ FINDINGS: There is no acute hemorrhage, edema, mass, mass effect, or acute large vascular territorial infarction. The ventricles and sulci are prominent which suggest normal age-related involutional changes. There are periventricular white matter hypodensities consistent with the sequela of chronic small vessel ischemic disease. The basal cisterns are patent, and there is preservation of gray-white matter differentiation. No fracture is identified. The paranasal sinuses and mastoid air cells are clear. The globes are unremarkable. IMPRESSION: No acute intracranial process. . . ============================= URINE: ============================= ___ 10:20PM URINE Color-Yellow Appear-Clear Sp ___ ___ 10:20PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM ___ 10:20PM URINE RBC-6* WBC-15* Bacteri-FEW Yeast-NONE Epi-<1 . Medications on Admission: The Preadmission Medication list is accurate and complete. 1. GlipiZIDE XL 2.5 mg PO DAILY 2. Sodium Chloride 1 gm PO BID 3. Docusate Sodium 100 mg PO BID 4. Vitamin D 1000 UNIT PO DAILY 5. Denosumab (Prolia) Dose is Unknown SC Frequency is Unknown 6. Ocuvite with Lutein (vit A,C & E-lutein-minerals) 1,000 unit-200 mg-60 unit-2 mg oral daily 7. PredniSONE 20 mg PO DAILY 8. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry eyes 9. krill oil ___ ___ unknown 10. Omeprazole 20 mg PO BID 11. Multivitamins 1 TAB PO DAILY 12. Bisacodyl ___AILY:PRN constipation 13. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES BID 14. Fleet Enema ___AILY:PRN constipation Discharge Medications: 1. Atovaquone Suspension 1500 mg PO DAILY RX *atovaquone [Mepron] 750 mg/5 mL 10 ml by mouth daily Disp #*3000 Milliliter Refills:*0 2. PredniSONE 50 mg PO DAILY RX *prednisone 50 mg 1 tablet(s) by mouth daily Disp #*28 Tablet Refills:*0 3. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry eyes 4. Docusate Sodium 100 mg PO BID 5. Multivitamins 1 TAB PO DAILY 6. Omeprazole 20 mg PO BID 7. Sodium Chloride 1 gm PO BID 8. Vitamin D 1000 UNIT PO DAILY 9. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth daily Disp #*30 Tablet Refills:*0 10. Bisacodyl ___AILY:PRN constipation 11. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES BID 12. Fleet Enema ___AILY:PRN constipation 13. GlipiZIDE XL 2.5 mg PO DAILY 14. Ocuvite with Lutein (vit A,C & E-lutein-minerals) 1,000 unit-200 mg-60 unit-2 mg oral daily 15. krill oil 0 unknown ORAL Frequency is Unknown 16. Denosumab (Prolia) 60 mg SC ASDIR 17. Outpatient Lab Work On ___: please draw CRP, ESR, Na, K, Cl, HCO3, BUN, Cr, Glu and fax results to Dr. ___ at ___ ICD 9 Codes: Giant cell arteritis 446.5, Hyponatremia 276.1 Discharge Disposition: Home With Service Facility: ___ ___: Primary diagnosis: - Temporal arteritis Secondary diagnoses: - Hyponatremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report CLINICAL INDICATION: Blurred vision for one week. TECHNIQUE: Multidetector CT scan through the head without the administration of IV contrast. Coronal and sagittal reformatted images were obtained. DLP: 1025.72 mGy-cm. CTDI VOLUME: 58.79 mGy. FINDINGS: There is no acute hemorrhage, edema, mass, mass effect, or acute large vascular territorial infarction. The ventricles and sulci are prominent which suggest normal age-related involutional changes. There are periventricular white matter hypodensities consistent with the sequela of chronic small vessel ischemic disease. The basal cisterns are patent, and there is preservation of gray-white matter differentiation. No fracture is identified. The paranasal sinuses and mastoid air cells are clear. The globes are unremarkable. IMPRESSION: No acute intracranial process. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: ABNORMAL LABS Diagnosed with GIANT CELL ARTERITIS, VISUAL DISTURBANCES NEC temperature: 97.7 heartrate: 95.0 resprate: 16.0 o2sat: 100.0 sbp: 148.0 dbp: 45.0 level of pain: 0 level of acuity: 2.0

============================= PRIMARY REASON FOR ADMISSION ============================= ___ yo F with a history of biopsy-proven giant cell arteritis admitted with elevated inflammatory markers and bilateral blurry vision concerning for flare of arteritis. . ============================= ACTIVE ISSUES ============================= #) Temporal arteritis: The patient presented with elevated inflammatory markers (CRP 80.4, ESR 63 on admission) and blurry vision concerning for GCA flare. She had not improved as an outpatient even after an empiric increase in prednisone from 10 to 20mg. She received one dose of 1g solumedrol and was evaluated by both Opthalmology and Rheumatology. After recieiving the solumedrol pulse, her symptoms subjectively began to improve. Because the opthalamologic exam did not find anterior ischemic neuropathy on funduscopic examination, Rheumatology recommended a four week course of prednisone 50mg. She will need inflammatory markers checked q2-3 days until a steady downtrend is noted (discharge labs:CRP 34). . #) Hyponatremia: The patient has had hyponatremia noted at her ECF, with Na in the 125-130 range that improves with IV saline. Admission Na was 125 that improved to 133 with small NS boluses, her home salt tabs, and improved po intake. . #) Anemia: She has a history of iron deficiency anemia with likely component of chronic inflammation. Normocytic during this admission with stable blood counts. . ============================= TRANSITIONAL ISSUES ============================= - Will need inflammatory markers checked q2-3 days until downtrending - She should have Ophthalmologic evaluation to monitor dry AMD/diabetic retinopathy - She should continue on prednisone 50mg x 4 weeks with atovaquone prophylaxis - Code status: DNR/DNI

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Nucynta / Hydromet Attending: ___ Chief Complaint: Weakness Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ y/o woman with PMH notable for NASH cirrhosis c/b recurrent admissions for HE and grade 2 varices s/p banding, GAVE s/p APC in ___, HFpEF, HTN, and T2DM, presenting with 3 days of worsening weakness. Per both patient and her husband at bedside, Ms. ___ has been quite weak for sometime now with her chronic medical problems, namely cirrhosis. However, about 3 days ago, her husband noted that she was unable to get up, even with assistance. She began endorsing pain in her bilateral upper thighs long the lateral aspects and almost fell multiple times, including on day of admission due to her weakness. Her husband comments that she may be a little more confused than usual, but has been making about 3 BM's per day. She has been taking her home rifaximin and lactulose as instructed. Otherwise, the patient was sick with a cold about 2 weeks ago, which has resolved. She denies any infectious symptoms of fevers, chills, lingering cough, N/V, abdominal pain, rash, or dysuria/urinary frequency. Her husband does note that her UTI's in the past have been asymptomatic. She also denies any hematochezia, but states that he stool is always dark with iron. Recent medication changes include decrease in her dose of Lasix from 20mg to 10mg PO daily and spironolactone from 50mg to 25mg PO daily about 2 weeks PTA, at instruction of outpatient hepatologist (Dr. ___. She does feel that her legs are swollen, most from her ongoing pyoderma gangrenosum and that her abdomen is slightly more swollen than usual. Denies any shortness of breath or orthopnea. At baseline, she is essentially non-ambulatory, sitting in a sofa most of the day and not walking. This is attributed to chronic fatigue and weakness from her liver disease and chronic pain in her lower extremities due to PG. With regards to mental status, the patient's husband feels that she may be slightly more confused than usual, but they presented to the ED mostly due to worsening of her weakness. In the ED, initial VS were: 98.7 60 163/55 17 99% RA Exam was notable for: -No asterixis -B/l ___ weakness, unable to lift up against gravity -___ strength to upper extremities for muscle bulk, intact cerebellar and sensory function grossly -rectal exam showed guaiac+ dark mucous in vault without frank melena Hepatology was consulted and recommended RUQ ultrasound, Hepatitis A, B, and C serologies, CK, 50g of 25% albumin, lactulose q4h, rifaximin 550 bid, and ___ admission. Work-up was notable for: -Hemolyzed blood sample with K 4.7, Bicarb 14 (without AG), BUN/Cr 35/0.8 (baseline Cr 0.9-1), CK 7758, AST 742, ALT 742, AP 364, Lipase 190, Albumin 3 -Hepatitis serologies pending -Hgb 12, Plt 129 -lactate 1.2 -U/A showing moderate leuks, large blood, negative nitrites, 100 protein, 4 RBC, 17 WBC, few bacteria, albeit with ___ yeast -Ucx and Blood cx x2 sent (pending) Imaging showed: -CXR with no acute cardiopulmonary processes but interval vertebral body ehigh loss at level of T12 -Liver/Gallbladder U/S showing hepatic cirrhosis without focal lesion and patient vasculature without cholelithitasis or acute cholecystitis Patient was given: -500cc IVF -50g of 25% albumin -Ceftriaxone 1g IV x1 -Lactulose 30mg PO x1 On transfer, patient's vitals were 98.2 149/77 78 18 95RA. On the floor, she reports the same history as above and is without acute complaint, endorsing the same b/l leg weakness and pain as well as leg pain overlying sites of pyoderma gangrenosum. Past Medical History: - ___ cirrhosis complicated by hepatic encephalopathy and grade 2 varices s/p banding - HFpEF (LVEF 65%) - Celiac disease - Hypertension - Diabetes mellitus type II complicated by neuropathy - Hyperlipidemia - Pyoderma gangrinosum - Lumbar spondylosis - History of compression fracture - History of bladder surgery - Cough-variant asthma Social History: ___ Family History: No history of liver disease Physical Exam: ADMISSION PHYSICAL EXAM ================= VITALS: 98.2 149/77 78 18 95RA General: chronically ill appearing, malnourished HEENT: temporal wasting appreciated; no scleral icterus; EOMI, PERRL, MMM, tongue midline on protrusion, no appreciable tongue fasciculations Neck: symmetric, supple, brisk carotid upstrokes; no bruits appreciated b/l; JVP appears to be about 8cm with prominent carotid pulsations CV: RRR with ___ mid-systolic murmur, no appreciable radiation to carotids or axilla; no r/g Lungs: CTAB with initial crackles that clear with repeated inspiration; no r/w Abdomen: Soft, mildly distended, mild TTP over RUQ with negative ___ sign; no r/g; GU: no foley Ext: thin, warm well perfused; 1+ pitting edema up to thighs b/l with +erythema and increased warmth surrounding b/l anterior shins, which are bandaged over sites of PG (c/d/I); tenderness to palpation over b/l lateral thighs from hips to knees without tenderness appreciated in hip joints; distal pulses intact Neuro: alert and appropriately interactive on exam; ___ strength in b/l UE; no asterixis appreciated; on strength exam, unable to lift b/l ___ up against gravity; sensation intact and symmetric throughout Skin: b/l PG wounds c/d/i DISCHARGE PHYSICAL EXAM ================= Vitals: 99.1 127/49 75 18 95%RA General: NAD, malnourished HEENT: temporal wasting appreciated; no scleral icterus; EOMI, PERRL, MMM, tongue midline on protrusion, no appreciable tongue fasciculations Neck: symmetric, supple, brisk carotid upstrokes; no bruits appreciated b/l; JVP appears to be about 8cm with prominent carotid pulsations CV: RRR with ___ mid-systolic murmur, no appreciable radiation to carotids or axilla; no r/g Lungs: CTAB, no r/w Abdomen: Soft, mildly distended, NT GU: no foley Ext: thin, warm well perfused; 1+ pitting edema up to thighs b/l with +erythema and increased warmth surrounding b/l anterior shins, which are bandaged over sites of PG (c/d/I); tenderness to palpation over b/l lateral thighs from hips to knees without tenderness appreciated in hip joints; distal pulses intact Neuro: alert and appropriately interactive on exam; ___ strength in b/l UE; no asterixis appreciated; on strength exam, lower extremities ___ in hip flexion, knee flexion, extension, dorsiflexion and plantar flexion; sensation intact and symmetric throughout Skin: b/l PG wounds c/d/I bandaged with mild erythema but not spreading Pertinent Results: ADMISSION LABS =========== ___ 11:45AM BLOOD WBC-7.9 RBC-3.34* Hgb-12.0 Hct-35.2 MCV-105* MCH-35.9* MCHC-34.1 RDW-17.3* RDWSD-66.0* Plt ___ ___ 11:45AM BLOOD Neuts-68.7 Lymphs-12.6* Monos-12.9 Eos-4.3 Baso-0.9 Im ___ AbsNeut-5.45# AbsLymp-1.00* AbsMono-1.02* AbsEos-0.34 AbsBaso-0.07 ___ 11:45AM BLOOD ___ PTT-28.7 ___ ___ 11:45AM BLOOD Glucose-125* UreaN-35* Creat-0.8 Na-139 K-4.7 Cl-112* HCO3-14* AnGap-18 ___ 11:45AM BLOOD ALT-542* AST-742* CK(CPK)-7758* AlkPhos-364* TotBili-0.9 ___ 11:45AM BLOOD Albumin-3.0* Calcium-10.2 Phos-2.2* Mg-2.0 NOTABLE LABS ========= ___ 06:40AM BLOOD Glucose-61* UreaN-22* Creat-0.6 Na-141 K-4.4 Cl-112* HCO3-18* AnGap-15 ___ 06:43AM BLOOD ALT-319* AST-386* CK(CPK)-2207* AlkPhos-285* TotBili-0.9 ___ 06:40AM BLOOD ALT-301* AST-342* CK(CPK)-1856* AlkPhos-276* TotBili-1.2 ___ 07:04AM BLOOD WBC-5.8 RBC-2.53* Hgb-9.1* Hct-26.7* MCV-106* MCH-36.0* MCHC-34.1 RDW-17.6* RDWSD-67.9* Plt ___ ___ 07:04AM BLOOD Glucose-66* UreaN-31* Creat-0.8 Na-149* K-4.5 Cl-122* HCO3-12* AnGap-21* ___ 09:25PM BLOOD ALT-356* AST-481* LD(___)-353* CK(CPK)-3634* AlkPhos-249* TotBili-0.8 ___ 07:04AM BLOOD ALT-333* AST-435* LD(LDH)-334* CK(CPK)-2580* AlkPhos-248* TotBili-0.9 ___ 11:45AM BLOOD HBsAg-Negative HBsAb-Negative HAV Ab-Positive IgM HBc-Negative ___ 09:25PM BLOOD CRP-10.5* ___ 11:45AM BLOOD HCV Ab-Negative ___ 12:07PM BLOOD Lactate-1.2 ___ 09:25PM BLOOD SED RATE-31 MICROBIOLOGY ========== URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. URINE CULTURE (Final ___: ENTEROCOCCUS SP.. >100,000 CFU/mL. CIPROFLOXACIN SUSCEPTIBILITY REQUESTED BY ___ ___ (___) @ 1420 ON ___. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ =>32 R CIPROFLOXACIN--------- =>8 R LINEZOLID------------- 2 S NITROFURANTOIN-------- 64 I TETRACYCLINE---------- <=1 S VANCOMYCIN------------ =>32 R IMAGING ====== ___ CXR No acute cardiopulmonary process. Interval vertebral body height loss at T12 since ___, to be correlated with physical exam as acuity cannot be determined. ___ ABD ULTRASOUND 1. Hepatic cirrhosis without focal lesion. Patent hepatic vasculature. 2. Cholelithiasis without evidence for acute cholecystitis. DISCHARGE LABS ========== ___ 05:38AM BLOOD WBC-8.7 RBC-2.58* Hgb-9.6* Hct-26.9* MCV-104* MCH-37.2* MCHC-35.7 RDW-17.9* RDWSD-66.8* Plt ___ ___ 05:38AM BLOOD ___ PTT-89.2* ___ ___ 05:38AM BLOOD Glucose-50* UreaN-33* Creat-0.8 Na-140 K-4.3 Cl-110* HCO3-17* AnGap-17 ___ 05:38AM BLOOD ALT-196* AST-156* CK(CPK)-124 AlkPhos-280* TotBili-1.1 ___ 05:38AM BLOOD Calcium-10.3 Phos-3.3 Mg-1.8 ___ 09:25PM BLOOD CRP-10.5* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Furosemide 10 mg PO DAILY 2. Spironolactone 25 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Omeprazole 20 mg PO DAILY 5. Nadolol 20 mg PO DAILY 6. Sertraline 50 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Multivitamins W/minerals 1 TAB PO DAILY 9. Vitamin D ___ UNIT PO DAILY 10. Gabapentin 200 mg PO QHS 11. Alendronate Sodium 70 mg PO QWED 12. Rifaximin 550 mg PO BID 13. Lactulose 30 mL PO TID 14. Glargine 24 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 15. Lidocaine 5% Ointment 1 Appl TP QID:PRN pain Discharge Medications: 1. Doxycycline Hyclate 100 mg PO DAILY Duration: 7 Days End date ___ RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth Daily Disp #*7 Tablet Refills:*0 2. Alendronate Sodium 70 mg PO QWED 3. Aspirin 81 mg PO DAILY 4. Furosemide 10 mg PO DAILY 5. Gabapentin 200 mg PO QHS 6. Glargine 24 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 7. Lactulose 30 mL PO TID 8. Lidocaine 5% Ointment 1 Appl TP QID:PRN pain 9. Multivitamins W/minerals 1 TAB PO DAILY 10. Nadolol 20 mg PO DAILY 11. Omeprazole 20 mg PO DAILY 12. Rifaximin 550 mg PO BID 13. Sertraline 50 mg PO DAILY 14. Spironolactone 25 mg PO DAILY 15. Vitamin D ___ UNIT PO DAILY 16. HELD- Atorvastatin 40 mg PO QPM This medication was held. Do not restart Atorvastatin until you talk to your doctor and your blood enzymes return to normal Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnosis: Rhabdomyolysis Urinary tract infection Toxic metabolic encephalopathy Hepatic encephalopathy Secondary Chronic diastolic heart failure Diabetes mellitus Pyoderma gangrenosusm 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 altered mental status // Pneumonia TECHNIQUE: AP and lateral views of the chest. COMPARISON: ___ chest x-ray and ___ torso CT. FINDINGS: The lungs are clear without consolidation, effusion, or edema. Cardiac silhouette is mildly enlarged, unchanged. When compared to ___, there is interval height loss T12. IMPRESSION: No acute cardiopulmonary process. Interval vertebral body height loss at T12 since ___, to be correlated with physical exam as acuity cannot be determined. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ with elevated transaminase, altered mental status // Please eval with dopplers, ? portal vein thrombosis, cholecystitis TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: Abdominal ultrasound dated ___. FINDINGS: LIVER: The hepatic parenchyma appears coarsened. The contour of the liver is nodular, consistent with cirrhosis. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. Hepatic arteries and hepatic veins are all patent. BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 3 mm. GALLBLADDER: Cholelithiasis without gallbladder wall thickening. PANCREAS: The imaged portion of the pancreas appears within normal limits, without masses or pancreatic ductal dilation, with portions of the pancreatic tail obscured by overlying bowel gas. SPLEEN: Normal echogenicity, measuring 7.8 cm. KIDNEYS: Limited views of the right kidney show no hydronephrosis. Right kidney measures 10.9 cm in sagittal dimension. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. Hepatic cirrhosis without focal lesion. Patent hepatic vasculature. 2. Cholelithiasis without evidence for acute cholecystitis. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Weakness, Confusion, Presyncope Diagnosed with Hepatic failure, unspecified without coma, Urinary tract infection, site not specified, Altered mental status, unspecified temperature: 98.7 heartrate: 60.0 resprate: 17.0 o2sat: 99.0 sbp: 163.0 dbp: 55.0 level of pain: 0 level of acuity: 3.0

Ms. ___ is a ___ y/o woman with a PMH notable for NASH cirrhosis c/b recurrent HE, GAVE s/p APC, PG, and brittle T2DM, presenting with acute onset b/l ___ weakness and pain (in proximal distribution) in setting of chronic weakness and labs notable for transaminitis and CK >7000 and UTI now with CK and LFT downtrending after fluid resuscitation. It is likely she developed rhabdomyelisis in the setting of acute confusion caused by the UTI. With volume resuscitation and treatment of the UTI, her symptoms improved. #Rhabdomyolysis, weakness: The patient's elevated CK >7000 on admission. AST and ALT elevation are likely in [large] part due to rhabdo as well. Likely etiology of immobility at home in setting of acute confusion due to UTI. Drug-mediated causes also possible including atorvastatin as potential trigger and statin was held. No crush injuries or compartment syndrome suspected based on history or exam. Inflammatory etiology investigated but inflammatory makers low-normal at CRP 10.5, ESR 31 not suggestive of PMR. She was given 500cc NS, 50g 25% albumin, and total 50g 5% albumin during her hospital course in increments of 12.5g. CK trended down with level at discharge 124. Physical therapy evaluated the patient and recommended rehab. #UTI: Patient has positive blood and WBCs on U/A. History of UTI and three days of confusion coming in may be reflection of infection. She received 1 dose of Ceftriaxone in ED empirically. Urine culture grew mixed bacterial flora. History of Klebsiella oxytoca infection in ___ sensitive only to cipro, ___, zosyn. E. coli resistant to cipro noted in ___. She was started on ciprofloxacin 500mg Q12H on ___ with planned 7 day course; however urine cultures came back as Enterococcus with multiple resistances (Including cipro) and sensitive to doxycycline. We therefore started doxycycline 100mg daily for 7 days (end date ___ #Transaminitis: Attributed to rhabdo with normal bilirubin with labs remaining at baseline synthetic hepatic function would suggest non-liver etiology. #Metabolic and hepatic encephalopathy: Likely secondary to UTI and reduced bowel movements prior to admission. Improved with fluid resuscitation, continuing lactulose and rifaximin, and treatment of UTI. She was at baseline on HD #2. #NASH cirrhosis: History of NASH cirrhosis c/b HE and GE varices and GAVE s/p APC in ___. Appears compensated at this time. She was continue on home PPI, nadolol, nutritional supplements. #HFpEF: Currently euvolemic appearing. ___ edema is likely due to local inflammation and slight hypoalbuminemia. -holding diuretic as above, I/s/o potential rhabdo. Furosemide and spironolactone held with plan to restart at discharge. #Celiac disease: gluten-free diet #Hypertension: Held diuretics and continued home nadolol. #T2 Diabetes mellitus complicated by neuropathy: She was continued on home lantus, ISS, gabapentin. #HLP: holding home statin in the setting of transaminitis and elevated CK #Pyoderma gangrenosum/Venous stasis uclers: Per recent outpatient notes, patient is not on any oral therapy and is recently s/p 10 day course of PO Keflex for ___ cellulitis. She was given local wound care without signs of worsening or cellulitis. #Iron deficiency anemia: per patient she has anemia at baseline, treated with PO iron. #Depression: continued home sertraline TRANSITIONAL ISSUES ============== #NEW MEDICATIONS - Doxycycline #CHANGED MEDICATIONS - None #HELD MEDICATIONS - Atorvastatin was STOPPED [] Restart diuretics on discharge (held for elevated CK and elevated LFT during admission) [] Reassess if a lower dose of a statin or different lipid lowering regimen as CK and LFT improve [] Dermatology follow up for lower extremity ulcers is scheduled for ___ [] Urogynecology follow up is scheduled for ___ #CODE: Full (confirmed with patient and husband) #CONTACT: Husband - ___ ___ #DISCHARGE WEIGHT - 121 Pounds

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: elevated LFTS Major Surgical or Invasive Procedure: ERCP ___ Port ___ History of Present Illness: Mr. ___ is a ___ male with recent diagnosis of metastatic colon cancer who presents for elevated LFTs. Patient established care with Oncologist Dr. ___ at ___ on ___. Labs were notable for ALT 235, AST 190, ALP 1304, Tbili 14.6 (Dbili 8.8) as well as Na 130, WBC 9.5, H/H 12.8/37.5, and Plt 426. He was called by his Oncologist due to concern for biliary obstruction and instructed to present to the ___ ED. He reports increasing pruritus and worsening rectal pain over the last 2 weeks. He also notes left testicular pain. He notes worsening yellowing of the skin over past several days. He has been taking oxycodone for the pain which has helped some. He denies any fever, abdominal pain, and nausea/vomiting. On arrival to the ED, initial vitals were 97.8 ___ 16 100% RA. Labs were notable for WBC 10.9, H/H 12.5/35.6, Plt 419, Na 129, K 3.4, BUN/CR ___, INR 1.2, ALT 261, AST 252, ALP 1687, Tbili 15.8, lipase 11, lactate 1.4, and UA negative. Patient had RUQ US which showed scattered mild intrahepatic biliary dilatation likely due to malignant obstruction secondary to hepatic metastatic masses. ERCP was consulted and recommended obtaining MRCP. Patient was given dilaudid 1mg IV x 3 and 1L NS. Prior to transfer vitals were 98.8 102 163/90 18 97% RA. On arrival to the floor, patient reports ___ rectal and left testicular pain. He notes occasional shortness of breath. He denies fevers/chills, night sweats, headache, vision changes, dizziness/lightheadedness, weakness/numbness, cough, hemoptysis, chest pain, palpitations, nausea/vomiting, diarrhea, hematemesis, dysuria, hematuria, and new rashes. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. PAST ONCOLOGIC HISTORY: Patient evaluated by PCP ___ ___ for symptoms including months of passing mucousy stools streaked with blood. Also 6 months of constipation for which he took laxatives with improvement. He changed his diet and began to eat more fruits and vegetables and then he began to move his bowels more easily. He developed rectal pain and was seen by an MD in ___ who sent him to a colorectal surgeon at ___ who did a banding procedure about 1 month ago. He has lost 40 lbs in 6 months. He underwent CT torso which showed innumerable pulmonary and hepatic nodules and masses, worrisome for metastases, abdominal and pelvic lymphadenopathy and probable left sacral metastases, and long segment of thickened sigmoid with luminal narrowing, correlate with colonoscopy. He underwent FNA of the supraclavicular node which showed metastatic colorectal adenocarcinoma. On ___, PET CT scan at ___ confirmed extensive metastatic cancer: Colon cancer with multiple sites of metabolically active metastatic disease as described above involving pulmonary nodules, liver lesions, left adrenal gland lesion, osseous lesions, retroperitoneal lymph nodes, inguinal lymph nodes, bilateral hilar lymph nodes, a left paratracheal lymph node, and a left supraclavicular lymph node Past Medical History: - Asthma - Hemorrhoids s/p homorrhoidectomy - s/p right ankle surgery Social History: ___ Family History: Father with CAD/PVD in his father and cancer. Physical Exam: ===ADMISSION PHYSICAL EXAM=== VS: Temp 99.3, BP 194/121, HR 102, RR 18, O2 sat 96% RA. GENERAL: Pleasant man, appears in pain. HEENT: Icteric scerae, PERLL, OP clear. CARDIAC: RRR, normal s1/s2, no m/r/g. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: Soft, non-tender, non-distended, normal bowel sounds. EXT: Warm, well perfused, no lower extremity edema, erythema or tenderness. NEURO: A&Ox3, good attention and linear thought, CN II-XII intact. Strength full throughout. Sensation to light touch intact. ===DISCHARGE PHYSICAL EXAM=== VS: 98.8 157/100 98 18 96 RA GENERAL: Pleasant man, appears in pain. HEENT: Icteric scerae, PERLL, OP clear. CARDIAC: RRR, normal s1/s2, no m/r/g. LUNG: CTAB ABD: Soft, non-tender, non-distended, normal bowel sounds. EXT: Warm, well perfused, no lower extremity edema, erythema or tenderness. NEURO: A&Ox3, no focal deficits Pertinent Results: ===ADMISSION LABS=== ___ 04:40PM BLOOD WBC-10.9* RBC-4.42* Hgb-12.5* Hct-35.6* MCV-81* MCH-28.3 MCHC-35.1 RDW-16.4* RDWSD-47.0* Plt ___ ___ 05:07PM BLOOD ___ PTT-33.7 ___ ___ 04:40PM BLOOD Plt ___ ___ 04:40PM BLOOD Glucose-96 UreaN-9 Creat-0.7 Na-129* K-3.4 Cl-88* HCO3-26 AnGap-18 ___ 04:40PM BLOOD ALT-261* AST-252* AlkPhos-1687* TotBili-15.8* DirBili-12.4* IndBili-3.4 ___ 04:40PM BLOOD Albumin-3.4* Calcium-10.4* Phos-3.8 Mg-2.0 ===DISCHARGE LABS=== ___ 07:10AM BLOOD WBC-13.0* RBC-4.21* Hgb-11.5* Hct-33.1* MCV-79* MCH-27.3 MCHC-34.7 RDW-17.9* RDWSD-50.3* Plt ___ ___ 07:10AM BLOOD Glucose-104* UreaN-7 Creat-0.7 Na-131* K-3.5 Cl-92* HCO3-26 AnGap-17 ___ 07:10AM BLOOD ALT-223* AST-212* LD(LDH)-1242* AlkPhos-1537* TotBili-11.6* ___ 07:10AM BLOOD Calcium-9.7 Phos-3.4 Mg-2.1 ===MICRO=== ___ URINE URINE CULTURE-FINAL ===RADIOLOGY=== ___ MRCP 1. Re-demonstration of metastatic disease involving the lungs and liver, with retroperitoneal lymphadenopathy. 2. Extensive hepatic metastases with almost complete replacement of the left hepatic lobe. There is severe attenuation of the left hepatic vein and the left portal vein is not visualized. 3. The right anterior and right posterior branches of the right hepatic duct are each obstructed by the metastatic disease at the hilum. Additionally, extensive metastases in the left hepatic lobe causes multiple regions of peripheral segmental bile duct dilatation. ___ ruq us 1. Segmental intrahepatic biliary ductal dilation due to malignant obstruction. 2. Scattered masses are once again seen throughout the hepatic parenchyma consistent with known metastasis 3. Gallbladder wall is thickened and edematous which is likely secondary to liver disease. There is no evidence of acute cholecystitis. CBD is within normal limits. ___ ERCP •Limited exam of the esophagus was normal •Limited exam of the stomach was normal •Limited exam of the duodenum was normal •The scout film was normal. •The major papilla appeared normal. •The CBD was successfully cannulated with the Hydratome sphincterotome preloaded with a 0.035in guidewire. •The guidewire was advanced into the right IHD. •Contrast injection revealed a CBD of approximately 6mm in diameter and a tight malignant appearing 1 cm stricture at the level of the bifurcation involving the proximal right IHD. •The left IHD system was not opacified. •A sphincterotomy was successfully performed at the 12 o'clock position. •No post sphincterotomy bleeding was noted. •A 8mm X 80mm uncovered WallFlex metal stent (REF ___ ___ was successfully placed across the stricture. •There was excellent drainage of bile and contrast at the end of the procedure. •The PD was cannulated but not injected. Otherwise normal ercp to third part of the duodenum. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 2. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*15 Tablet Refills:*0 2. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*5 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID:PRN constipation RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 4. Fentanyl Patch 37 mcg/h TD Q72H RX *fentanyl 37.5 mcg/hour apply 1 patch to skin every 72 hours Disp #*5 Patch Refills:*0 5. Lactulose 15 mL PO DAILY:PRN constipation RX *lactulose 10 gram/15 mL (15 mL) 15 ml by mouth daily prn: constipation Refills:*0 6. Polyethylene Glycol 17 g PO DAILY:PRN constpation RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily Disp #*30 Packet Refills:*0 7. Senna 8.6 mg PO BID:PRN constipation RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp #*28 Tablet Refills:*0 8. Multivitamins 1 TAB PO DAILY 9. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: malignant biliary obstruction Secondary Diagnoses: cancer-related pain metastatic colon cancer hyponatremia anemia 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 jaundice// assess for mass effect/biliary obstruction TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: PET-CT ___ FINDINGS: LIVER: The hepatic parenchyma demonstrates scattered masses consistent with known metastatic disease. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is scattered mild intrahepatic biliary dilatation likely due to malignant obstruction in the setting of extensive metastatic disease. The CBD is within normal limits measuring 3 mm. GALLBLADDER: The gallbladder wall thickening edematous which is likely secondary to liver disease. There is no evidence of acute cholecystitis. IMPRESSION: 1. Segmental intrahepatic biliary ductal dilation due to malignant obstruction. 2. Scattered masses are once again seen throughout the hepatic parenchyma consistent with known metastasis 3. Gallbladder wall is thickened and edematous which is likely secondary to liver disease. There is no evidence of acute cholecystitis. CBD is within normal limits. Radiology Report EXAMINATION: MRCP INDICATION: ___ year old man with metastatic colon cancer to the liver with elevated bilirubin and RUQ US concerning for biliary obstruction. Evaluate for biliary obstruction for possible ERCP.// Evaluate for biliary obstruction for possible ERCP. TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were acquired in a 1.5 T magnet. Intravenous contrast: 7 mL Gadavist. Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered for oral contrast. COMPARISON: Ultrasound dated ___ and PET-CT from ___. FINDINGS: Lower Thorax: The visualized lung bases demonstrate multiple nodules bilaterally, in keeping with metastatic disease. Liver: Innumerable hepatic metastases are seen in the liver. The left hepatic lobe is almost completely replaced by metastatic disease. Multiple metastases in the right hepatic lobe are seen, the largest at the dome measuring 4.8 x 4.1 cm (17:109). At the hepatic hilum, there is mass effect on the portal vein causing severe attenuation (16:65). The left portal vein is not visualized and presumably thrombosed. The right and middle hepatic veins are patent. The left hepatic vein is severely attenuated secondary to extensive tumor in the left hepatic lobe. Biliary: Both the anterior and posterior branches of the right hepatic duct are obstructed by the metastatic disease at the hepatic hilum. Additionally, there are multiple regions of peripheral segmental bile duct dilatation in the left hepatic lobe secondary to extensive metastatic disease. The central left hepatic and common hepatic ducts are not seen, presumably involved by tumor. The CBD is not obstructed. The gallbladder demonstrates diffuse wall thickening measuring up to 9 mm, likely secondary to the diffuse hepatic disease. Pancreas: Unremarkable. Spleen: Unremarkable. Adrenal Glands: The right adrenal gland is unremarkable. The previously noted left adrenal nodule is not well visualized. Kidneys: The kidneys are unremarkable aside for small right hepatic cyst. Gastrointestinal Tract: No bowel obstruction. Small amount of ascites. Lymph Nodes: Retroperitoneal adenopathy is again noted, the largest measuring 1.6 cm in the left para-aortic region (05:34) Vasculature: There is a retroaortic left renal vein. Osseous and Soft Tissue Structures: The patient's known osseous metastatic disease are not imaged. IMPRESSION: 1. Re-demonstration of metastatic disease involving the lungs and liver, with retroperitoneal lymphadenopathy. 2. Extensive hepatic metastases with almost complete replacement of the left hepatic lobe. There is severe attenuation of the left hepatic vein and the left portal vein is not visualized. 3. The right anterior and right posterior branches of the right hepatic duct are each obstructed by the metastatic disease at the hilum. Additionally, extensive metastases in the left hepatic lobe causes multiple regions of peripheral segmental bile duct dilatation. Radiology Report INDICATION: ___ year old man with colon ca// please place single chest port for chemo thanks ___ COMPARISON: None TECHNIQUE: OPERATORS: Dr. ___, performed the procedure. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 50 mcg of fentanyl and 2 mg of midazolam throughout the total intra-service time of 30 minutes during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: Fentanyl and Versed for moderate sedation as above, 1% local lidocaine, 1% lidocaine with epinephrine, CONTRAST: 0 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 0.4 min, 1 mGy PROCEDURE 1. Right internal jugular approach chest single lumen Port-a-cath placement PROCEDURE DETAILS: Following the explanation of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The upper chest was prepped and draped in the usual sterile fashion. Under continuous ultrasound guidance, the patent right internal jugular vein was compressible and accessed using a micropuncture needle. Permanent ultrasound images were obtained before and after intravenous access, which confirmed vein patency. Subsequently a Nitinol wire was passed into the right atrium using fluoroscopic guidance. The needle was exchanged for a micropuncture sheath. The Nitinol wire was removed and a short ___ wire was advanced to make appropriate measurements for catheter length. The ___ wire was then passed distally into the IVC. Next, attention was turned towards creation of a subcutaneous pocket over the upper anterior chest wall. After instilling superficial and deeper local anesthesia using lidocaine mixed with epinephrine, a 2.5 cm transverse incision was made and a subcutaneous pocket was created by using blunt dissection. The single lumen port was then connected to the catheter. The catheter was tunneled from the subcutaneous pocket towards the venotomy site from where it was brought out using a tunneling device. The port was then connected to the catheter and checks were made for any leakage by accessing the diaphragm using a non-coring ___ needle. No leaks were found. The port was then placed in the subcutaneous pocket and secured with ___ prolene sutures on either side. The venotomy tract was dilated using the introducer of the peel-away sheath supplied. Following this, the peel-away sheath was placed over the ___ wire through which the port was threaded into the right side of the heart with the tip in the right atrium. The sheath was then peeled away. The subcutaneous pocket was closed in layers with ___ interrupted and ___ subcuticular continuous Vicryl sutures. Steri-strips were used to close the venotomy incision site. Steri-Strips were applied over the sutures. Final spot fluoroscopic image demonstrating good alignment of the catheter and no kinking. The tip is in the right atrium. The port was accessed using a non coring ___ needle and could be aspirated and flushed easily. Sterile dressings were applied. The patient tolerated the procedure well without immediate complication. The port was left accessed as requested. FINDINGS: Patent right internal jugular vein. Final fluoroscopic image showing port with catheter tip terminating in the right atrium. IMPRESSION: Successful placement of a single lumen chest power Port-a-cath via the right internal jugular venous approach. The tip of the catheter terminates in the right atrium. The catheter is ready for use. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Abnormal labs Diagnosed with Nonspec elev of levels of transamns & lactic acid dehydrgnse temperature: 97.8 heartrate: 105.0 resprate: 16.0 o2sat: 100.0 sbp: 163.0 dbp: 111.0 level of pain: 9 level of acuity: 3.0

Mr. ___ is a ___ male with recent diagnosis of metastatic colon cancer who presents for elevated LFTs. # Malignant Biliary Obstruction: Significantly elevated ALP and bilirubin consistent with obstructive pattern. Also likely component of extensive replacement of liver parenchyma by metastatic disease. RUQ US showed scattered mild intrahepatic biliary dilatation. MRCP with malignant obstruction, ERCP ___ with sphinterotomy and metal stent placed across a tight malignant appearing 1 cm stricture at the level of the bifurcation involving the proximal right IHD, with excellent drainage of bile and contrast at the end of the procedure. Patient received adequate post-ERCP hydration, and diet was advanced as tolerated. Patient was started on ciprofloxacin 500mg BID x 5 days (___) # Rectal Pain: # Cancer-Related Pain: Rectal pain secondary to localized disease. Continued oxycodone as well as IV dilaudid PRN. Patient was started on a fentanyl patch, as patient was reluctant to uptitrate PO medications, and pain was poorly controlled. Pain was better controlled with this new regimen, and he was discharged with rx for fentanyl patch as well as bowel meds prn. # Metastatic Colon Cancer: Metastatic to liver, lung, left adrenal gland, bone, and lymph nodes. Plan to start FOLFIRI. Port placement ___. # Hyponatremia: Likely hypovolemic, improved with IVF. # Anemia: Likely secondary to colon cancer. Remained stable during admission.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Biaxin / Lorabid / Levaquin / clindamycin / metoprolol / Beta-Blockers (Beta-Adrenergic Blocking Agts) / carbamazepine / Prochlorperazine / Tequin / Allopurinol / Wasp Venom / metformin / Crestor / Actos / Uloric / probenecid / spironolactone / eplerenone Attending: ___. Chief Complaint: fatigue, weakness and DOE Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a very pleasant ___ year old woman with a history of treatment resistant HTN and Type II DM c/b stage IIIb CKD and numerous medication allergies who presented to ED with fatigue, weakness, lightheadedness found to have new mild ___. Ms. ___ reports that over the past several weeks she has noticed increased fatigue, lethargy and poor appetite. She reports that she has nothing particularly to pinpoint as to a cause but has felt just run down. She reports that she has not been eating or drinking normally. She notes no new medications. In this setting she has started to feel very shaky and tremulous. She reports that on the day prior to presentation, she fell on to her knees and struggled to get up from bed. This AM she went to walk her poodle (___) and felt shaky and unable to walk him. She called her PCP/HCP who told her to go to the ER. In the ED, initial vitals: 09:17 0 97.7 90 159/66 20 96% RA Exam was notable for well appearing woman, with clear lungs and no lower extremity edema. Labs were significant for Na 127, BUN/Cr of 103/2.6 (baseline 1.6), AG 19, and HCO3 19. Tnt 0.06 and MB: 15, proBNP: 1109. UA was bland. Imaging showed CXR without PNA or pulmonary edema. EKG showed NSR with RAD In the ED, she received no treatment Decision was made to admit for management of ___. Vitals prior to transfer: 80 120/49 14 94% RA On the floor, she reports that she is feeling well. She does not currently feel shakey. She is hopeful we will determine cause of ___. She reports that she has 5lbs in 5 days. Patient states that walking makes her feel short of breath. Denies any chest pain. No fevers or chills. Denies any abdominal pain, nausea, vomiting or urinary symptoms. No orthopnea. Denies any lotion or swelling. No recent travel or pleurisy. No history of DVT/PE. Past Medical History: - Resistant Hypertension - Type II Diabetes Mellitus - CKD, stage IIIb - Gout - Bipolar disorder - Anxiety - Chronic Rhinitis - Hypothyroidism Social History: ___ Family History: Significant for father with diabetes and mother with colon cancer and lung cancer. Physical Exam: ADMISSION EXAM: VS: 99.2 PO 162 / 74 L Lying 88 16 93 RA WEIGHT: 194lbs from 195.7kg (___) GEN: Well appearing, hair buzzed, Atraumatic HEENT: MMM NECK: JVP not appreciable at 90 degrees PULM: CTAB, no rales COR: RRR, normal S1, preserved S2. II/VI holosytolic EM at ___ ABD: Soft, NT, ND. No CVAT EXTREM: WWP. No ___ edema NEURO: ___. Oriented x3 PSYCH: very upbeat, exuberant. DISCHARGE EXAM: VS: 98.2 ___ 144/80 (142-200/74-100) 18 93RA GEN: Well appearing, hair buzzed, Atraumatic HEENT: MMM NECK: JVP not appreciable at 90 degrees PULM: CTAB, no rales COR: RRR, normal S1, preserved S2. II/VI holosytolic EM at ___ ABD: Soft, NT, ND. No CVAT EXTREM: WWP. No ___ edema NEURO: ___. Oriented x3 PSYCH: very upbeat, exuberant, somewhat pressured speech. LABS: reviewed, see below Pertinent Results: ADMISSION LABS: ___ 09:30AM BLOOD WBC-8.1 RBC-3.27* Hgb-10.4* Hct-30.3* MCV-93 MCH-31.8 MCHC-34.3 RDW-14.7 RDWSD-50.0* Plt ___ ___ 09:30AM BLOOD Neuts-65.1 Lymphs-14.1* Monos-10.0 Eos-8.9* Baso-1.7* Im ___ AbsNeut-5.27 AbsLymp-1.14* AbsMono-0.81* AbsEos-0.72* AbsBaso-0.14* ___ 09:30AM BLOOD ___ PTT-46.2* ___ ___ 09:30AM BLOOD Glucose-103* UreaN-72* Creat-2.6*# Na-127* K-5.1 Cl-89* HCO3-19* AnGap-24* ___ 06:40AM BLOOD ALT-35 AST-58* LD(LDH)-240 AlkPhos-172* TotBili-0.5 ___ 09:30AM BLOOD CK(CPK)-546* ___ 09:30AM BLOOD CK-MB-15* MB Indx-2.7 proBNP-1109* ___ 09:30AM BLOOD cTropnT-0.06* ___ 06:40AM BLOOD Albumin-3.8 Calcium-8.9 Phos-4.2 Mg-2.0 ___ 09:30AM BLOOD Valproa-27* PERTINENT LABS: ___ 05:30AM BLOOD calTIBC-365 VitB12-1135* Folate-12 Ferritn-88 TRF-281 ___ 09:30AM BLOOD Osmolal-292 ___ 09:30AM BLOOD TSH-5.2* ___ 06:40AM BLOOD Free T4-1.4 ___ 09:30AM BLOOD Valproa-27* DISCHARGE LABS: ___ 05:47AM BLOOD WBC-6.1 RBC-3.08* Hgb-9.7* Hct-28.5* MCV-93 MCH-31.5 MCHC-34.0 RDW-15.2 RDWSD-50.4* Plt ___ ___ 05:47AM BLOOD Glucose-100 UreaN-40* Creat-1.5* Na-137 K-4.1 Cl-98 HCO3-24 AnGap-19 ___ 05:47AM BLOOD Calcium-8.9 Phos-4.4 Mg-2.0 MICRO: URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING: CHEST PA+LAT ___ PA and lateral views of the chest provided. Minimal lower lung atelectasis noted. No convincing evidence for pneumonia. No effusion, or pneumothorax. The cardiomediastinal silhouette is normal. Imaged osseous structures are intact. No free air below the right hemidiaphragm is seen. IMPRESSION: No signs of pneumonia or edema. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 2. Lisinopril 80 mg PO DAILY 3. Divalproex (DELayed Release) 125 mg PO BID 4. Colchicine 0.6 mg PO BID 5. HYDROcodone Compound (hydrocodone-homatropine) 15 mg oral TID:PRN 6. Ketoconazole 2% 1 Appl TP BID 7. Clorazepate Dipotassium 3.75 mg PO DAILY 8. MetFORMIN XR (Glucophage XR) ___ mg PO DAILY 9. LORazepam 0.5 mg PO Q6H:PRN ativan 10. Diltiazem Extended-Release 240 mg PO DAILY 11. CloNIDine 0.1 mg PO BID 12. Fluticasone Propionate NASAL 2 SPRY NU DAILY 13. Minoxidil 2.5 mg PO BID 14. Pravastatin 40 mg PO QPM 15. Ethacrynic Acid 50 mg PO BID 16. Aspirin 81 mg PO DAILY 17. Levothyroxine Sodium 88 mcg PO DAILY 18. Nortriptyline 10 mg PO BID 19. Calcitriol 0.25 mcg PO EVERY OTHER DAY 20. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Divalproex (DELayed Release) 250 mg PO BID 2. Aspirin 81 mg PO DAILY 3. Calcitriol 0.25 mcg PO EVERY OTHER DAY 4. CloNIDine 0.1 mg PO BID 5. Clorazepate Dipotassium 3.75 mg PO DAILY 6. Colchicine 0.6 mg PO BID 7. Diltiazem Extended-Release 240 mg PO DAILY 8. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 9. Ethacrynic Acid 50 mg PO BID 10. Fluticasone Propionate NASAL 2 SPRY NU DAILY 11. HYDROcodone Compound (hydrocodone-homatropine) 15 mg oral TID:PRN 12. Ketoconazole 2% 1 Appl TP BID 13. Levothyroxine Sodium 88 mcg PO DAILY 14. Lisinopril 40 mg PO DAILY 15. LORazepam 0.5 mg PO Q6H:PRN ativan 16. Minoxidil 2.5 mg PO BID 17. Nortriptyline 10 mg PO BID 18. Pravastatin 40 mg PO QPM 19. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS acute on chronic kidney failure SECONDARY DIAGNOSIS bipolar disorder anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ with sob, ESRD // eval for DOE, pulm edema COMPARISON: None FINDINGS: PA and lateral views of the chest provided. Minimal lower lung atelectasis noted. No convincing evidence for pneumonia. No effusion, or pneumothorax. The cardiomediastinal silhouette is normal. Imaged osseous structures are intact. No free air below the right hemidiaphragm is seen. IMPRESSION: No signs of pneumonia or edema. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Dyspnea on exertion Diagnosed with Acute kidney failure, unspecified temperature: 97.7 heartrate: 90.0 resprate: 20.0 o2sat: 96.0 sbp: 159.0 dbp: 66.0 level of pain: 0 level of acuity: 2.0

___ year old woman with a history of HTN and Type II DM, c/b stage IIIb CKD (f/b Dr. ___ who presented to ED with fatigue, weakness and DOE, found to have new mild ___. ACTIVE ISSUES: =============== # Acute Kidney Injury on CKD: Found to have new acute on chronic kidney disease w/ cr 2.6 (baseline 1.6) in setting of several weeks of poor PO intake and prescyncopal symptoms. Urine lytes showed that she was partially sodium avid and had relatively low urine osm, consistent w/ prerenal ___ in setting of baseline poor renal dilutional ability with CKD. Initially held lisinopril and ethacrynic acid. Resolved with IVF, and these meds were resumed. continued home calcitriol 0.25 mcg PO EVERY OTHER DAY and Vitamin D 1000 UNIT PO DAILY. # Hyponatremia: Likely hypovolemic hyponatremia, resolved with IVF administration. # Anemia: Noted to have anemia on presentation w/ hgb 10.5 down from 11.4 ___. Iron studies showed no iron deficiency, normal B12/folate levels. Low retic index. Concern for anemia of chronic disease in setting of CKD versus nutritional deficiencies given recent dieting. remained stable. # Concern for malnutrition: patient reported chronic intentional weight loss, increasing fatigue, poor recent PO intake, and was found to have significant anemia without evidence of iron, B12, or folate deficiency and with evidence of mildly inadequate bone marrow response. She reported eating very little, particularly restricting her consumption of protein due to combination of factors, including being too busy, trying to lose weight, and having various dietary restrictions for diabetes, CKD, gout, and hypertension. As a result, she may have an element of protein malnutrition, possibly protein-calorie malnutrition. She tolerated good PO while inpatient, and she was advised not to restrict her calories or her protein as much as she had been, and to follow-up with a nutritionist after discharge from rehab. #Bipolar Disorder: Concern for bipolar decompensation leading to poor self care, limited PO intake and ___ as above, presentation consistent with hypomania, likely bipolar disorder II. Psych was consulted, and after discussion with outpatient psychiatrist, home depakote dose was increase to 250mg BID. ___ and OT were consulted and recommended short term rehab stay prior to returning home. The psychiatry team recommended close follow-up with her primary psychiatrist for ongoing medication optimization. # EKG with RAD and QRS prolongation: no clear RBBB morphology. Given ___ and TCA (Nortriptyline), c/f for possible sodium channel blocker toxicity. Repeat EKG was stable and similar in appearance to prior. Notritptyline was resumed. CHRONIC ISSUES: =============== # Resistant Hypertension: Treatment apprears to be limited by numerous medication allergies. Continued home minoxidil, diltizaem, ethacrynic acid and lisinopril. Per patient, has been on high dose of lisinopril 80mg daily for many years. Decreased dose to 40mg daily given ___ on presentation and concern for poor PO intake. Hypertensive on day of discharge to systolic 170s. No adjustments were made, but BP should be monitored on discharge. # Type II Diabetes Mellitus: held metformin while inpatient, managed w/ ISS as needed. Blood sugars remained in normal range, only requiring insulin administration once. Given CKD and improved sugars, as well as report of poor PO intake prior to admission, we discussed with the patient and it was decided to hold metformin on d/c. # Gout: held colchicine initially for renal function, resumed on d/c. # Chronic Rhinitis: Fluticasone Propionate NASAL 2 SPRY NU DAILY # Hypothyroidism: continued Levothyroxine Sodium 88 mcg PO DAILY. Given malaise, checked TSH on admission, very mildly elevated at 5.2 although difficult to interpret in setting of acute illness. No changes were made to levothyroxine dosing. Can repeat in several weeks to determine if levothyroxine dose needs to be adjusted. # Primary Prevention: continued Pravastatin 40 mg PO QPM, Aspirin 81mg daily. TRANSITIONAL ISSUES: - increased Depakote to 250mg BID. Needs close psych f/u on discharge. Please have someone check on her mood next week to assess for response. - recommend outpatient nutrition counseling given anemia, concerns regarding low protein diet - Noted to have borderline elevated TSH at 5.2. Should repeat outpatient when not acutely ill, may need levothyroxine adjusted - metformin was held on d/c given normal blood sugars, borderline renal function. Post prandial blood sugars should be monitored as she may require therapy with meal time insulin or alternative agent for mild hyperglycemia. - decreased lisinopril dosing to 40mg daily. If persistently hypertensive, recommend uptitrating clonidine rather than lisinopril - continued home colchicine 0.6 mg BID, but renal function should be monitored and dose adjusted if necessary CODE STATUS: Full CONTACT: ___ (PCP and HCP) Phone: ___ Other Phone: ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Codeine Attending: ___. Chief Complaint: left index finger numbness, tingling, and discoloration Major Surgical or Invasive Procedure: ___ angioplasty and stent of the left brachial artery History of Present Illness: ___ w/ h/o upper extremity thromboembolism, including R subclavian thrombosis s/p angioplasty and stenting in ___ and L subclavian ___ in ___, now p/w dusky Left index finger over the past few days. Patient reports that she has noticed duskiness and coolness of her left index finger, as well some numbness and tingling throughout the entire hand over the past three days. She denies any motor weakness or dysfunction. Past Medical History: PMH: thromboembolic syndrome, Hep C, HLD, HTN, morbid obesity, hypothyroidism, bipolar disease, anxiety, chronic knee pain, migraines, vit D deficiency PSH: R subclavian stenting, right axillary artery angioplasty ___ ___ Social History: ___ Family History: Non-contributory Physical Exam: GEN: NAD HEENT: NC/AT, EOMI Pulm: no increased work of breathing, nonlabored respirations CV: RRR Abd: soft, nontender, nondistended Ext: bilateral upper extremities with palpable radial pulses, bilateral dopplerable DPs, fingers non-cyanotic, sensorimotor intact Pertinent Results: Admission labs: ___ 04:47PM WBC-12.5* RBC-4.24 HGB-6.9* HCT-25.6* MCV-60* MCH-16.3* MCHC-27.0* RDW-20.0* RDWSD-42.9 ___ 04:47PM GLUCOSE-105* UREA N-13 CREAT-0.7 SODIUM-137 POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-26 ANION GAP-12 ___ 10:06PM LACTATE-1.6 ___ 04:47PM ___ PTT-36.5 ___ LUE CTA ___: IMPRESSION: 1. Acute thrombus in the left distal subclavian artery extending to the left axillary artery over a 2.7 cm segment with distal reconstitution of flow and patent distal arteries. 2. Prominent left axillary lymph nodes are noted, likely reactive. Medications on Admission: AMMONIUM LACTATE PRN atorvastatin 80 mg tablet' clonazepam 2 mg tablet''' prn clonidine HCl 0.1 mg tablet'' Vitamin D2 50,000 unit capsule weekly gabapentin 800 mg tablet''' levothyroxine 200 mcg tablet' methadone 92 mg daily nystatin 100,000 unit/gram topical cream prn oxycodone 5 mg tablet prn paroxetine 40 mg tablet' Xarelto 20 mg tablet' verapamil ER (___) 100 mg capsule' aspirin 81 mg tablet' Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Cilostazol 100 mg PO BID RX *cilostazol 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 3. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*1 4. Verapamil 20 mg PO Q8H We decreased the dose of this medication due to your low blood pressure. Follow up with your PCP 5. Atorvastatin 80 mg PO QPM 6. ClonazePAM 2 mg PO TID:PRN anxiety 7. CloNIDine 0.1 mg PO BID 8. Gabapentin 800 mg PO TID 9. Levothyroxine Sodium 200 mcg PO DAILY 10. Methadone 90 mg PO DAILY 11. PARoxetine 40 mg PO DAILY 12. Rivaroxaban 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Left subclavian thromboembolism Left lower extremity rest pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CTA left upper extremity INDICATION: ___ year old woman with decreased radial and ulnar pulses in the left wrist and with a cyanotic left index finger.// Evaluate for clot or arterial injury TECHNIQUE: Multidetector CT axial images were obtained of the left upper extremity with the arm in race position within without contrast as well as delayed phase imaging in the distal left upper extremity with coronal and sagittal MIP reconstructions. DOSE: Acquisition sequence: 1) Spiral Acquisition 7.2 s, 79.5 cm; CTDIvol = 2.3 mGy (Body) DLP = 180.5 mGy-cm. 2) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 12.2 mGy (Body) DLP = 6.1 mGy-cm. 3) Spiral Acquisition 9.9 s, 77.6 cm; CTDIvol = 5.4 mGy (Body) DLP = 416.3 mGy-cm. 4) Spiral Acquisition 5.5 s, 43.4 cm; CTDIvol = 3.3 mGy (Body) DLP = 143.4 mGy-cm. Total DLP (Body) = 746 mGy-cm. COMPARISON: None. FINDINGS: VASCULATURE: There is an acute thrombus in the left distal subclavian artery extending into the left axillary artery measuring up to 2.7 cm and length with distal reconstitution of flow. No significant atherosclerotic disease (602; 19). The brachial artery, deep artery of the arm, and radial and ulnar arteries are patent without evidence of occlusion or stenosis. A stent is noted in the proximal right subclavian artery which appears patent. An IV catheter is noted in the left aspect of the wrist. MUSCLES AND SOFT TISSUES: No fatty atrophy. No significant soft tissue stranding. BONES: No acute fracture or dislocation. No joint effusion is noted in the left elbow or glenohumeral joint. Mild degenerative changes are noted in the left glenohumeral joint. No suspicious osseous lesions are identified. VISUALIZED CHEST: Visualized bilateral lungs appear clear. Prominent left axillary lymph node measures up to 0.9 cm in short axis (4; 20). No supraclavicular lymphadenopathy visualized. Prominent AP window lymph node measures 9 mm in short axis (4; 20). VISUALIZED HEAD AND NECK: The thyroid is atrophic. Mild-to-moderate atherosclerotic calcifications are noted in the bilateral carotid bifurcation, right greater than left. Visualized paranasal sinuses and left mastoid air cells are clear. No abnormalities were noted in the visualized portions of the head. IMPRESSION: 1. Acute thrombus in the left distal subclavian artery extending to the left axillary artery over a 2.7 cm segment with distal reconstitution of flow and patent distal arteries. 2. Prominent left axillary lymph nodes are noted, likely reactive. NOTIFICATION: The findings were discussed with Dr. ___. by ___, M.D. on the telephone on ___ at 7:24 pm, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: ART EXT (REST ONLY) CLINICAL HISTORY ___ year old woman with ___ h/o subclavian thromboembolism s/p R subclavian stent and L subclavian ___ p/w 3 days cyanotic L index finger, decreased radial/ulnar signals, now with LLE pain// evaluate LLE vessel runoff evaluate LLE vessel runoff FINDINGS: Doppler waveform analysis reveals monophasic waveforms throughout bilateral lower extremities. Resting ABIs are 0.9 on the right and 0.7 on the left. Toe pressures are 50 on the right and 17 on the left. Pulse volume recordings demonstrate somewhat dampened waveforms in the thigh bilaterally. On the right there is appropriate calf augmentation and minimal further dampening below this. On the left there is further dampening at the calf level and a nearly flat trace at the ankle and metatarsal. IMPRESSION: Bilateral multilevel arterial occlusive disease worse on the left than the right. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: CYANOTIC FINGER Diagnosed with Anemia, unspecified temperature: 98.2 heartrate: 90.0 resprate: 17.0 o2sat: 100.0 sbp: 90.0 dbp: 67.0 level of pain: 8 level of acuity: 2.0

Ms ___ was admitted to the Vascular surgery service with left hand and finger numbness and tingling. CTA of the upper extremity showed acute thrombus in the L SCA extending to the left axillary artery. She was started on a heparin drip and pain management. She also had complained of LLE pain at rest, for which LLE ABI/PVR studies were obtained. These revealed monophasic signals in the legs with L toe pressure of 17. She was continued on the heparin drip and then taken to the OR on ___ for an angiogram and axillary artery stent. Please see the operative note for details. At the end of the procedure, the radial artery pulse was palpable. The heparin drip was then resumed. She was maintained on a heparin drip for POD 1, Plavix was started and the left radial artery was once again palpable. On POD 2, xarelto was restarted, the heparin drip was stopped, and the patient was started on cilostazol. At the time of discharge, the patient was tolerating a diet, her pain was well controlled, she had palpable radial pulses bilaterally, and was able to ambulate. She will follow up with Dr. ___ in clinic.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: ankle pain Major Surgical or Invasive Procedure: ORIF right ankle fracture History of Present Illness: ___ ___ with no known medical history presents from assisted living s/p unwitnessed fall. She is unsure of events, but was found seated on floor. She has been unable to ambulate since the fall. She has no numbness or tingling, no additional complaints. Past Medical History: none ___) Social History: ___ Family History: noncontributory Physical Exam: Exam on Discharge VS: afebrile, BP 150/65, HR 80 Gen: Well appearing in no acute distress PULM: Unlabored breathing CV: RRR Focused exam of RLE: Splint in place, clean, dry, and intact fires ___. Right lower extremity SILT sural, saphenous, superficial peroneal, deep peroneal. Right lower extremity dorsalis pedis pulse 2+ with distal digits warm and well perfused. Large fungating mass at posterior aspect of right leg wrapped in ABD with ace Pertinent Results: ___ 06:40AM BLOOD WBC-9.3 RBC-4.57 Hgb-12.5 Hct-39.4 MCV-86 MCH-27.4 MCHC-31.7* RDW-14.2 RDWSD-44.3 Plt ___ ___ 04:40PM BLOOD ___ PTT-23.2* ___ ___ 06:15AM BLOOD Glucose-123* UreaN-10 Creat-0.5 Na-139 K-3.7 Cl-100 HCO3-27 AnGap-16 ___ 06:15AM BLOOD Calcium-9.1 Phos-3.9 Mg-1.6 Medications on Admission: none Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours Disp #*40 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp #*20 Tablet Refills:*0 3. Enoxaparin Sodium 40 mg SC DAILY Start: Today - ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*28 Syringe Refills:*0 4. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain RX *oxycodone 5 mg ___ to 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills:*0 5. Senna 8.6 mg PO BID RX *sennosides [senna] 8.6 mg 1 tab by mouth twice daily Disp #*20 Tablet Refills:*0 6. Vitamin D 400 UNIT PO DAILY RX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: right bimal ankle fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report INDICATION: ___ with R ankle pain s/p fall // eval for fracture/deformity COMPARISON: None FINDINGS: AP, lateral, oblique views of the right ankle were provided. There is a trimalleolar fracture with subluxation at the right ankle. An oblique fracture through the distal fibula is present with laterally displaced distal fracture fragment. The medial malleolar fracture appears slightly inferiorly displaced. A tibial plafond fracture is also present. Soft tissue gas is noted concerning for an open injury. A fracture is also noted along the tibial plafond to. IMPRESSION: Trimalleolar fracture of the right ankle with associated subluxation. Radiology Report EXAMINATION: CHEST (PRE-OP AP AND LAT) INDICATION: ___ with bad ankle fx, pre-op and ?chest wall injury// eval for rib frx, structural process COMPARISON: None FINDINGS: AP upright and lateral views of the chest provided. Lung volumes are quite low limiting assessment. There is left basal opacity which could represent atelectasis versus pneumonia. Hilar congestion is noted with mild interstitial pulmonary edema. Heart size cannot be assessed. Mediastinal contour is prominent likely due to technique. No large pneumothorax. No acute bony injury. IMPRESSION: Limited study with mild pulmonary edema and left basal opacity concerning for atelectasis versus pneumonia. Radiology Report EXAMINATION: TIB/FIB (AP AND LAT) LEFT INDICATION: ___ with L tib/fib pain, evaluate for fracture TECHNIQUE: Frontal and lateral radiographs of the left tibia and fibula. COMPARISON: None. FINDINGS: No fracture is detected in the tibia or fibula. No suspicious lytic, sclerotic lesion, or periosteal new bone formation is detected. Scattered vascular calcifications are noted. Limited assessment of the left knee and ankle joint is unremarkable. IMPRESSION: No fracture. Radiology Report EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT INDICATION: History: ___ with R ankle fractures, s/p reduction // ? improved alignmnet TECHNIQUE: Three views of the right ankle COMPARISON: ___ at 13:40 FINDINGS: Overlying splint/cast obscures fine bony detail. Trimalleolar fracture is seen in improved process that alignment. The medial ankle mortise does not appear widened however, there is persistent widening of the anterior tibiotalar joint. IMPRESSION: Overall interval improvement in alignment of multiple ankle fractures. Persistent widening of the anterior tibiotalar joint. Radiology Report EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT IN O.R. INDICATION: ORIF RIGHT ANKLE TECHNIQUE: 12 spot fluoroscopic images obtained in the OR without radiologist present. Radiation: 29.1 seconds fluoroscopy time COMPARISON: Right ankle radiographs ___ FINDINGS: The available images show steps related to open reduction internal fixation of the bimalleolar fractures. 2 percutaneous pins, fully threaded screw of cerclage wire transfix the medial malleolus fracture. A lateral fracture plate with proximal and distal transfixing screws, a lag screw and a syndesmotic screw are seen laterally. The ankle mortise appears congruent. Please see the operative report for further details. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: s/p Fall, R Ankle pain Diagnosed with FX BIMALLEOLAR-OPEN, UNSPECIFIED FALL temperature: 98.9 heartrate: 92.0 resprate: 18.0 o2sat: 93.0 sbp: 151.0 dbp: 89.0 level of pain: 5 level of acuity: 3.0

Hospitalization Summary The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a right bimalleolar ankle fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for open reduction and internal fixation of this ankle fracture. She also underwent a surgical biopsy of the large fungating mass at the posterior aspect of her leg, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient opted to not know the result of the mass biopsy as it was in conflict with her religious views. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is touchdown weight bearing in the right lower extremity, and will be discharged on lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: egg Attending: ___ Chief Complaint: Nausea, abdominal pain, poor PO tolerance Major Surgical or Invasive Procedure: EGD on ___ Duodenal Stent Placement ___ Liver Biopsy ___ History of Present Illness: ___ year old patient with chronic back pain on opiate meds, HTN, h/o of a SBO s/p surgery in ___, presents with nausea and vomiting and abdominal pain. Patient has had symptoms of intermittent nausea, vomiting, and abdominal beginning in ___ of this year. Also reports 20 lb weight loss in past month. In this setting, patient had an EGD done 2 weeks ago with Dr. ___ with Core ___ in ___. Per patient, EGD was significant for evidence of obstruction with food remaining in stomach as well as gastric ulcers, and patient reports pathology came back positive for cancer, though though he does not recall which type. Over the last ___ days patient has had worsening burning pain, nausea, and vomiting, with last meal 2 days ago. Reports that he has been able to tolerate pills. Last ___ yesterday AM, during which he noted dark red blood per rectum. Denies fevers/chills, chest pain, SOB, dizziness, changes in urination. He went to ___ ED today for worsening pain and nausea. CT torso at ___ showed gastric distension but no evidence of obstruction or masses. Transferred to ___ ED for surgical evaluation. In the ED, initial vitals were: T 98.3 HR 70 BP 166/78 RR 16 O2 sat 99% RA - Exam notable for: epigastric tenderness with guarding - Labs notable for: Mild anemia (Hgb 13.1) and uremia (BUN 23), negative UA - Patient was given: 1L NS, 4 mg IV morphine, 100 mg thiamine, IV pantoprazole 40 mg Surgery evaluated patient and felt no surgical intervention necessary; recommended admission to medicine for workup of possible GI malignancy. Upon arrival to the floor, patient reports improved pain since an episode of vomiting prior to transfer to the floor. Denies dizziness, shortness of breath, and chest pain. Past Medical History: Chronic pain on opioids SBO s/p surgery in ___ HTN Hypothyoridism Depression GERD Nephrolithaisis s/p lithotripsy (___) BPH PVD Open cholecystectomy (___) TURP (___) Throidectomy due to multi-nodular goiter Social History: ___ Family History: Per OMR - Father has history of diabetes. Father and mother have history of heart disease. Paternal grandmother has history of cancer, of unknown type. Physical Exam: ADMISSION EXAM: ============ VITAL SIGNS: T 97.5 BP 158 / 78 HR 69 RR 20 O2 sat 99%RA GENERAL: Patient is sitting in bed, alert and responsive, appearing mildly uncomfortable but not in acute distress, occasionally retching and spitting up clear fluid HEENT: NCAT, PERRL, sclera anicteric, moist mucus membranes NECK: Supple, no visible JVD CARDIAC: Normal S1S2, RRR, no murmurs LUNGS: Clear bilaterally to auscultation without rales, wheezes, rhonchi ABDOMEN: Distended but soft, non-tender to palpation, no rebound or guarding EXTREMITIES: Warm, well-perfused, no lower extremity edema NEUROLOGIC: AOX3, moves extremities spontaneously SKIN: No bruises or rashes DISCHARGE EXAM: ============ VS: 98.1, 144/73, 72, 20, 98 RA GENERAL: Patient is lying down in bed, not in distress. Using suction intermittently to clear his oral secretions. HEENT: NCAT, sclera anicteric, MMM CARDIAC: Normal S1S2, RRR, no murmurs LUNGS: CTAB and posteriorly without rales, wheezes, rhonchi CHEST: Mild TTP in epigastric area over lowest rib border b/l. ABDOMEN: Soft but obese. Mildly distended. Back pain elicited with deep epigastric palpation, otherwise nontender. No rebound or guarding. +BS EXTREMITIES: warm, trace BLE edema NEUROLOGIC: CN ___ grossly intact. Moving all extremities spontaneously. Pertinent Results: LABS ON ADMISSION: ================= ___ 12:40AM BLOOD WBC-9.1 RBC-4.53* Hgb-13.1* Hct-40.1 MCV-89 MCH-28.9 MCHC-32.7 RDW-17.4* RDWSD-56.3* Plt ___ ___ 12:40AM BLOOD Neuts-80.3* Lymphs-10.9* Monos-8.0 Eos-0.2* Baso-0.3 Im ___ AbsNeut-7.30* AbsLymp-0.99* AbsMono-0.73 AbsEos-0.02* AbsBaso-0.03 ___ 12:40AM BLOOD Glucose-125* UreaN-23* Creat-0.9 Na-143 K-4.2 Cl-100 HCO3-26 AnGap-17* ___ 12:40AM BLOOD ALT-24 AST-15 AlkPhos-58 TotBili-0.5 ___ 12:40AM BLOOD Albumin-4.3 ___ 07:37AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.1 LABS AT DISCHARGE: ================= ___ 05:28AM BLOOD WBC-6.4 RBC-3.21* Hgb-9.2* Hct-29.0* MCV-90 MCH-28.7 MCHC-31.7* RDW-17.2* RDWSD-57.1* Plt ___ ___ 05:28AM BLOOD Glucose-94 UreaN-20 Creat-0.6 Na-139 K-4.2 Cl-102 HCO3-28 AnGap-9 ___ 05:28AM BLOOD ALT-107* AST-52* LD(___)-167 AlkPhos-299* TotBili-0.5 ___ 11:11AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 05:28AM BLOOD Albumin-3.2* Calcium-8.5 Phos-3.4 Mg-1.9 NOTABLE LABS ============================= ___ 05:06AM BLOOD CEA-2.3 ___ 05:35AM BLOOD Triglyc-104 ___ 05:35AM BLOOD calTIBC-241* TRF-185* ___ 05:28AM BLOOD ALT-107* AST-52* LD(___)-167 AlkPhos-299* TotBili-0.5 ___ 06:33AM BLOOD ALT-112* AST-79* AlkPhos-206* TotBili-0.6 ___ 06:00AM BLOOD ALT-59* AST-50* AlkPhos-154* TotBili-0.4 ___ 12:40AM BLOOD ALT-24 AST-15 AlkPhos-58 TotBili-0.5 MICROBIOLOGY: ================= Urine Culture (___): < 10,000 CFU/mL. TISSUE (___) Source: liver lesion. GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. PATHOLOGY: ================= ___ EGD Biopsies Results: (DONE AT ___) FINAL DIAGNOSIS A. Duodenum, bulb, biopsy: Adenocarcinoma B. Stomach, antrum, biopsy: Chronic gastritis, inactive. IHC staining for H. pylori negative. IHC staining on duodenum biopsy: MIB-1 positive in approximately 40% nuclei CD56, Chrmogranin, Synaptophysin negative ___ (repeat exam at BI from OSH) A) Duodenum, bulb, biopsy: - Adenocarcinoma. See note. - Background chronic active duodenitis. Note: Tumor cells are immunoreactive for CK7 (focal), negative for CK20 and CDX-2. Provided immunostains are evaluated, tumor cells are negative for Synaptophysin, chromogranin, CD56 and Mib-1 proliferation index is approximately 40%. Imaging and endoscopic correlation recommended. B) Stomach, antrum biopsy: - Antral and corpus mucosa with chronic inactive gastritis. - The provided immunostain for H. pylori is negative. TOUCH PREP OF CORE, LIVER SEGMENT (___) 3: NEGATIVE FOR MALIGNANT CELLS. Reactive, benign-appearing hepatocytes with scant inflammatory cells including neutrophils and lymphocytes. See also surgical pathology report # ___ and microbiology report ___. IMAGING: ================= ___ CT Chest with contrast IMPRESSION: 1. 10 mm nonspecific semisolid pulmonary nodule in the right upper lobe, could be infectious or inflammatory however in the setting of malignancy, a short-term follow-up chest CT is recommended. 2. Additional smaller pulmonary nodules measuring up to 5 mm, can also be evaluated at the time of follow-up examination. RECOMMENDATION(S): Chest CT in 3 months. ___ CT Abd/Pelvis with contrast IMPRESSION: 1. Mild interval improvement of gastric dilation with abrupt transition at the level of the second portion of the duodenum. Possible mass at the site of transition, better evaluated on prior CT. 2. 1.7 cm lesion in hepatic segment III as well as multiple subcentimeter hypodense liver lesions, described above, in the setting of possible malignancy, correlation with more remote imaging is recommended if available. If no imaging is available, a liver MRI can be obtained for further characterization. 3. No lymphadenopathy. 4. Right adrenal adenoma. RECOMMENDATION(S): Correlation with remote imaging to evaluate for stability of liver lesions otherwise, MRI of the liver is recommended. ___ Liver MRI: FINAL IMPRESSION: 1. Multiple rim enhancing hepatic lesions, the largest measuring 1.4 cm in hepatic segment III, with multiple other subcentimeter lesions some which are clustered in the periphery of segment VI/VII. While findings could represent metastatic disease, in the setting of moderate biliary duct dilation and with the clustered appearance of many of these lesions, hepatic microabscesses related to cholangitis would need to be considered. ERCP could be considered to evaluate biliary ductal dilation and for any underlying cholangitis. 2. Focal soft tissue involving the first portion of the duodenum, consistent with primary malignancy. 3. Bilateral adrenal adenomas. 4. 7 mm gastrohepatic lymph node, attention on follow-up imaging. ___ EGD: Impression:Mass in the duodenal bulb (biopsy) Erythema in the stomach body and fundus Otherwise normal EGD to duodenal bulb Recommendations:The findings account for the symptoms ___ Lower extremity veins U/S IMPRESSION: No evidence of deep venous thrombosis in the left lower extremity veins. ___ EGD Impression: A malignant appearing mass was seen starting at the proximal second part of the duodenum. The scope did not traverse the lesion. Under fluoroscopic guidance, a standard biliary extraction balloon preloaded with a 0.35in guidewire was passed through the therapeutic upper endoscope into the duodenum traversing the stenosis. As contrast was injected a tight stenosis was seen as well as an unobstructed bowel loop distal to the stenosis. The balloon catheter was removed and the guidewire was left in place within the proximal jejunum. A 22 mm by 120 mm uncovered duodenal metal stent (WallFlex duodenal stent REF ___ ___ was slowly advanced over the guidewire through the stenosis under fluoroscopic visualization. Final deployment position of the stent was from the prepyloric antrum to the distal duodenum. Final fluoroscopic views showed adequate luminal patency. ___ IMPRESSION: 1.5 cm hepatic segment III nodule is considered feasible for ultrasound-guided target biopsy. ___ KUB IMPRESSION: No radiographic evidence of bowel obstruction. No free air. Radiology Report EXAMINATION: CT ABDOMEN AND PELVIS WITH CONTRAST. INDICATION: ___ year old patient with chronic back pain on opiate meds, HTN, h/o of a ___ s/p surgery in ___, presents with nausea, vomiting, and abdominal pain and report of recently diagnosed abdominal malignancy of unknown origin. TECHNIQUE: Oncology 3 phase: Multidetector CT of the abdomen and pelvis was done as part of CT torso without and with IV contrast. Initially the abdomen was scanned without IV contrast. Subsequently a single bolus of IV contrast was injected and the abdomen and pelvis were scanned in the portal venous phase, followed by a scan of the abdomen in equilibrium (3-min delay) phase. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 2.4 s, 37.7 cm; CTDIvol = 20.4 mGy (Body) DLP = 767.4 mGy-cm. 2) Spiral Acquisition 5.0 s, 78.7 cm; CTDIvol = 20.3 mGy (Body) DLP = 1,594.3 mGy-cm. 3) Spiral Acquisition 2.3 s, 36.7 cm; CTDIvol = 20.4 mGy (Body) DLP = 746.9 mGy-cm. 4) Stationary Acquisition 6.6 s, 0.5 cm; CTDIvol = 36.3 mGy (Body) DLP = 18.2 mGy-cm. Total DLP (Body) = 3,127 mGy-cm. COMPARISON: Reference CT torso ___ FINDINGS: LOWER CHEST: Please refer to separate report of CT chest performed on the same day for description of the thoracic findings. ABDOMEN: HEPATOBILIARY: The liver is normal in morphology. There is an 1.7 x 1.4 cm hypodense lesion in segment III of the liver, which demonstrates possible low level enhancement on post contrast imaging (series 3, image 61). Additional subcentimeter hypodensities in the periphery of segment VII (series 3, image 53, 54, 58) and in segment V (series 3, image 63), are incompletely characterized. Patient is post cholecystectomy. Mild central intrahepatic and extrahepatic biliary duct dilation, likely reflects post cholecystectomy status. There is no ascites. The portal vein is patent. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The left adrenal gland is thickened without discrete nodules. There is a 1.6 x 1.2 cm right adrenal adenoma (series 2, image 27). URINARY: The kidneys are symmetric in size. There are subcentimeter hypodensity in the left lower and right upper pole (series 3, image 87, 77), statistically likely simple cysts. Note is made of an extrarenal pelvis in the right lower pole. There are no suspicious renal lesions. GASTROINTESTINAL: A nasoenteric tube ends in the gastric body. Again seen, is gastric dilation, overall mildly improved compared to hospital CT from 1 day prior. There is an abrupt transition to normal caliber duodenum in the proximal second portion. There is suggestion of a soft tissue mass at the site of caliber change seen best on the pre contrast CT and coronal image from outside hospital CT (series 2, image 38). There is no small bowel obstruction. Large bowel is notable for mild diverticulosis of the sigmoid colon. Appendix is normal. There is no intra-abdominal free air. PELVIS: The bladder is decompressed. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: Prostate contains coarse calcifications but is not enlarged. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic disease is noted. Hepatic arterial anatomy is conventional. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Mild interval improvement of gastric dilation with abrupt transition at the level of the second portion of the duodenum. Possible mass at the site of transition, better evaluated on prior CT. 2. 1.7 cm lesion in hepatic segment III as well as multiple subcentimeter hypodense liver lesions, described above, in the setting of possible malignancy, correlation with more remote imaging is recommended if available. If no imaging is available, a liver MRI can be obtained for further characterization. 3. No lymphadenopathy. 4. Right adrenal adenoma. RECOMMENDATION(S): Correlation with remote imaging to evaluate for stability of liver lesions otherwise, MRI of the liver is recommended. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with ?gastric outlet obstruction, now with NGT placed.// please obtain film to confirm NGT placement with view of diaphragm and partial view of the abdomen. please obtain film to confirm NGT placement with view of diaphragm and partial view of the abdomen. IMPRESSION: No prior chest radiographs available for review. Single frontal view of the chest shows top-normal size heart. Clear lungs. No pleural abnormality. There is no anatomic detail in the upper abdomen. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ man with chronic back pain, presenting with nausea, vomiting, and abdominal pain and report of recently diagnosed abdominal malignancy of unknown origin. TECHNIQUE: MDCT axial views were obtained through the chest after the uneventful administration of intravenous contrast. Coronal and sagittal as well as axial MIPS reformatted images were acquired. DOSE: Acquisition sequence: 1) Spiral Acquisition 2.4 s, 37.7 cm; CTDIvol = 20.4 mGy (Body) DLP = 767.4 mGy-cm. 2) Spiral Acquisition 5.0 s, 78.7 cm; CTDIvol = 20.3 mGy (Body) DLP = 1,594.3 mGy-cm. 3) Spiral Acquisition 2.3 s, 36.7 cm; CTDIvol = 20.4 mGy (Body) DLP = 746.9 mGy-cm. 4) Stationary Acquisition 6.6 s, 0.5 cm; CTDIvol = 36.3 mGy (Body) DLP = 18.2 mGy-cm. Total DLP (Body) = 3,127 mGy-cm. ** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND PELVIS WITH CONTRAST) COMPARISON: Reference Torso CT ___ FINDINGS: Thyroid is surgically absent. There is no supraclavicular, axillary, mediastinal, or hilar adenopathy. Heart size is normal. There is no pericardial effusion. The main pulmonary trunk is not dilated. Although not optimized for evaluation, no central embolus is identified. The thoracic aorta is normal in caliber, with mild atherosclerosis of the arch. There are no significant aortic valvular calcifications. There is no pericardial effusion. The airways are patent and normal to the subsegmental level bilaterally. There is no pleural effusion or pneumothorax. There is a 10 mm semisolid pulmonary nodule in the right upper lobe (series 302, image 125). Other nodules include a 5 mm solid right upper lobe pulmonary nodule (series 603, image 12) and smaller 2 and 3 mm left lower lobe pulmonary nodules (series 302, image 125, 135). A millimetric nodule in the right posterior upper lobe in continuity with the pleural surface, likely represents an intrapulmonary lymph node (series 302, image 103). There is no focal consolidation. A nasoenteric tube enters the stomach. Thoracic esophagus is otherwise unremarkable. Please see dedicated abdominal and pelvic CT from same day for intra-abdominal details. OSSEOUS STRUCTURES/SOFT TISSUES: Superficial soft tissues are notable for mild bilateral gynecomastia. There are no suspicious bony lesions. IMPRESSION: 1. 10 mm nonspecific semisolid pulmonary nodule in the right upper lobe, could be infectious or inflammatory however in the setting of malignancy, a short-term follow-up chest CT is recommended. 2. Additional smaller pulmonary nodules measuring up to 5 mm, can also be evaluated at the time of follow-up examination. RECOMMENDATION(S): Chest CT in 3 months. Radiology Report EXAMINATION: Portable chest. INDICATION: ___ year old man with SBO likely ___ gastric cancer with NG tube in place, feeling that has pill stuck in throat, evaluate for pill in esophagus TECHNIQUE: Chest PA and lateral COMPARISON: Same-day Chest CT FINDINGS: Nasoenteric tube seen in the esophagus, tip not visualized. No radiopaque foreign body is seen. Cardiomediastinal silhouette is normal. Lungs are clear. No pleural effusion or pneumothorax. IMPRESSION: No radiopaque foreign body. Radiology Report EXAMINATION: MRI of the Abdomen INDICATION: ___ who presents as transfer from ___ for surgical evaluation of adenocarcinoma discovered on EGD on ___. CT on ___ showed lesions in liver c/f mets.// Liver lesions seen on CT on ___. C/f mets in setting of known cancer. Please evaluate. TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were acquired in a 1.5 T magnet. Intravenous contrast: 8 mL Gadavist. COMPARISON: Reference CT ___, CT abdomen and pelvis ___ FINDINGS: Lower Thorax: There is no pleural effusion. Lung bases are clear. Liver: The liver is normal in signal intensity. There are multiple rim enhancing T2 intermediate intensity hepatic lesions including the largest measuring 1.4 cm in hepatic segment III (series 8, image 48). There are at least 7 or 8 additional sub centimeter T2 intermediate intensity rim enhancing lesions, in the periphery of the lobe liver but most apparent and clustered in periphery of hepatic segments VII and VI (series 8, image 29, 37). There is no ascites. Biliary: The gallbladder is surgically absent. Moderate primarily left-sided intrahepatic as well as extrahepatic biliary duct dilation has mildly progressed compared to prior CT. No ductal stone is identified. Primary lesion appears separate from the biliary confluence. Pancreas: Pancreas is normal in signal intensity. There is a tiny 4 mm cystic lesion in the pancreatic head. Spleen: Spleen is normal in size and signal intensity. Adrenal Glands: There is a 1.6 cm right adrenal adenoma. 1.7 cm left adrenal nodule is also noted, likely additional adenoma. Kidneys: There are bilateral peripelvic renal cysts with the largest in the right lower pole measuring 2.5 cm. There is no suspicious renal lesion. There is no hydroureteronephrosis. Gastrointestinal Tract: No hiatal hernia. Compared to prior, gastric distension has normalized. There is increased enhancing soft tissue involving the first portion of the duodenum which is consistent with the primary malignancy (series 19, image 33; series 17, image 19). Lesion appears separate from the biliary duct insertion. Lymph Nodes: There are no enlarged lymph nodes. There are small gastrohepatic lymph nodes measuring up to 7 mm (series 19, image 23). Vasculature: There is no abdominal aortic aneurysm. Hepatic arterial anatomy is conventional. The portal vein is patent. Osseous and Soft Tissue Structures: There is no superficial soft tissue abnormality. There is no suspicious bony lesion. IMPRESSION: 1. Multiple rim enhancing hepatic lesions, the largest measuring 1.4 cm in hepatic segment III, with multiple other subcentimeter lesions some which are clustered in the periphery of segment VI/VII. While findings could represent metastatic disease, in the setting of moderate biliary duct dilation and with the clustered appearance of many of these lesions, hepatic microabscesses related to cholangitis would need to be considered. ERCP could be considered to evaluate biliary ductal dilation and for any underlying cholangitis. 2. Focal soft tissue involving the first portion of the duodenum, consistent with primary malignancy. 3. Bilateral adrenal adenomas. 4. 7 mm gastrohepatic lymph node, attention on follow-up imaging. RECOMMENDATION(S): Consider ERCP to evaluate for underlying cholangitis. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 10:12 am, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: Frontal chest radiograph. INDICATION: ___ year old man with right arm 44cm DL power PICC. ___ ___// Right arm 44cm DL PICC. Contact name: ___: ___ TECHNIQUE: Single portable frontal chest radiograph. COMPARISON: Chest radiograph ___ CT chest ___ FINDINGS: The lungs are moderately well inflated with mild right lower lobe atelectasis and otherwise clear. No pleural effusion or pneumothorax. Heart size, mediastinal contour, and hila are unremarkable. A right PICC tip is entering into the right atrium. An enteric feeding tube is seen coursing midline with tip out of field of view. IMPRESSION: 1. Right PICC tip in right atrium. Consider withdrawing 2-2.5 cm for better positioning. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 5:37 pm, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: UNILAT LOWER EXT VEINS INDICATION: ___ year old man with suspected small bowel adenocarcinoma now with asymmetric LLE swelling.// please evaluate for DVT. TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the left lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, flow, and augmentation of the left common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: No evidence of deep venous thrombosis in the left lower extremity veins. Radiology Report EXAMINATION: Limited ultrasound of the liver INDICATION: ___ year old man with recently diagnosed duodenal adenocarcinoma now with ?mets in liver. (segment III largest).// Please perform "feasibility" ultrasound to assess if biopsy possible for suspected mets. TECHNIQUE: Grey scale and color Doppler ultrasound images of the liver was obtained. COMPARISON: MRI dated ___. FINDINGS: Focused evaluation of the liver demonstrated a 1.5 x 1.2 x 1.1 cm oval-shaped hypoechoic nodule in the inferior aspect of segment III, corresponding to the lesion seen on the most recent MRI. During real-time scanning, this lesion was deemed to be amenable to ultrasound-guided targeted biopsy. IMPRESSION: 1.5 cm hepatic segment III nodule is considered feasible for ultrasound-guided target biopsy. Radiology Report EXAMINATION: Ultrasound-guided targeted liver biopsy INDICATION: ___ year old man with duodenal adenocarcinoma with ?mets to liver. S/p feasibility u/s indicating that 1.5cm mass in segment III may be amendable to biopsy.// as request per oncology, consult for possible biopsy of liver lesion. COMPARISON: Ultrasound dated ___ PROCEDURE: Ultrasound-guided targeted liver biopsy. OPERATORS: Dr. ___ fellow and Dr. ___ radiologist. Dr. ___ supervised the trainee during the key components of the procedure and reviewed and agrees with the trainee's findings. FINDINGS: Limited preprocedure grayscale and Doppler ultrasound imaging of the liver was performed. The lesion for biopsy was identified in the left hepatic lobe. A suitable approach for targeted liver biopsy was determined. TECHNIQUE: The risks, benefits, and alternatives of the procedure were explained to the patient. After a detailed discussion, informed written consent was obtained. A pre-procedure timeout using three patient identifiers was performed per ___ protocol. Based on the preprocedure imaging, an appropriate skin entry site for the biopsy was chosen. The site was marked. The skin was then prepped and draped in the usual sterile fashion. The superficial soft tissues to the liver capsule were anesthetized with 10 mL 1% lidocaine. Under real-time ultrasound guidance 18 gauge core biopsy simple was obtained. The lesion became difficult to visualize after the first pass. 2 additional 18 gauge samples were obtained and sent for cytology. In addition, a fourth simple was also obtained and sent for microbiology evaluation. The skin was then cleaned and a dry sterile dressing was applied. There were no immediate complications. SEDATION: Moderate sedation was provided by administering divided doses of 1.5 mg Versed and 100 mcg fentanyl throughout the total intra-service time of 50 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. IMPRESSION: Uncomplicated 18-gauge targeted liver biopsy x 4, with specimens provided to the cytologist and an additional simple sent for microbiology evaluation. Biopsy was technically challenging. Short-term follow-up imaging is recommended if biopsy results are not concordant. Radiology Report INDICATION: ___ year old man with history of SBO, transfer for surgical eval, found to have stomach adeno, partially obstructing, status post ___ duodenal stent, now complaining of worsening abdominal pain, burping, bloating. Concerned for obstruction TECHNIQUE: Supine and upright abdominal radiographs were obtained. COMPARISON: CT abdomen pelvis from ___ FINDINGS: There is a prominent gas-filled loop of small bowel. Air is seen within the colon. Nonspecific air-fluid levels are likely within the colon. There is no free intraperitoneal air. Osseous structures are notable for degenerative changes of the lumbosacral spine. There are cholecystectomy clips in the right upper quadrant. There is a duodenal stent seen. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: No radiographic evidence of bowel obstruction. No free air. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Abd pain, N/V, Transfer Diagnosed with Unspecified abdominal pain, Nausea with vomiting, unspecified temperature: 98.3 heartrate: 70.0 resprate: 16.0 o2sat: 99.0 sbp: 166.0 dbp: 78.0 level of pain: 9 level of acuity: 2.0

___ with chronic back pain on opioids, HTN, h/o SBO s/p surgery in ___, who presented as transfer from ___ with adenocarcinoma discovered on ___ EGD, found to have e/o obstruction by mass on imaging. He originally required decompression with NG tube, and required repletion of nutrients with TPN. He was tolerating clears, until his diet was slowly advanced after a stent placement. He was weaned off TPN by the time of discharge. Throughout this admission he was afebrile and HDS. Notably, he tolerated a greatly reduced pain regimen (from his home dose) during this stay, which likely contributed to better urinary output. His HTN medication was also titrated up.

Name: ___ Unit ___: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Verapamil / Percocet / Lupron / Chloral Hydrate Analogues / Restoril / Percodan / Ciprofloxacin / Clinoril / Flagyl / Advair Diskus / Abilify / Lexapro / Zyprexa / Seroquel / Codeine / Aspirin / Ibuprofen / Sucralfate / Depakote / Topamax / Risperdal / Lisinopril / Tramadol / Provigil / Nuvigil / Focalin / Lithium / Lyrica / modafinil / morphine / prochlorperazine / Xopenex / pravastatin / Tegaderm Transparent Dressing / pramipexole / Linzess / hyoscyamine / prednisone / ondansetron / granisetron / baclofen / Soma Attending: ___ Chief Complaint: weakness Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ female with history of MS, HTN, PTSD, and chronic pain disorder presenting with acute on chronic pain and increasing subjective weakness. Reports whole body pain and cramping since 0200 this morning (12 hours PTA) with difficulty with ambulation associated with some lightheadedness and nausea. Follows with Dr. ___ MS. ___ chest pain, shortness of breath, abdominal pain. Pt reports she started a new medication: Granisetron x2 days ago for gi problems, decreased appetite, and feels she is having a reaction to the medication. Pt reports the pain is similar to prior MS flares. Pt also reports that she had a tooth extraction recently and is continuing to have pain at the site of the extraction and is concerned that "maybe there is an infection even though I've been on the prophylactic antibiotics". seen by neuro. neuro unconvinced that this is ms flare, but patient still unable to walk and endorsing inability to tolerate pos. In the ED: VS: 97.4 62 148/74 16 96% RA PE: Pain to light touch over all of her legs, arms, back, and head. [X] Dr. ___ ___ cell): This happens right before every renewal of her dilaudid. [ ] Labs - unremarkable [ ] CXR - neg [ ] neuro consult Labs: AST 58, otherwise normal / unremarkable CBC/CMP, UA Imaging: CXR ___ acute cardiopulmonary abnormality. Moderate to large hiatal hernia. Interventions: 2L NS, dilaudid 0.5mg IV x2, dilaudid 2mg po x1 Consults: Neurology: Completed ___ 18:58 "Discussed case with outpatient Neurologist as already done by ED and as suggested by protocol highlighted in Dash. Presents today with disequilibrium, forced flexor posturing of the extremities, and allodynia; ___ recent infectious symptoms to raise concerns for exacerbation of underlying MS. ___ and examination findings similarly not suggestive of coherent underlying neurologic process. Accordingly, ___ indication for further neurologic evaluation or management. As already extensively documented in records, there is appreciable risk for harm in unnecessary inpatient management and overmedication, particularly in context of outpatient attempts to manage opioid use; would therefore urge consideration of outpatient management and follow-up with well-established providers. - ___ indication for further neuroimaging - Would avoid unnecessary opioid administration - Agree with supportive symptom management as completed - Outpatient follow-up with established neurologist Plan discussed with attending physician ___ Impression/Course: "Patient with a history of MS coming in with whole body pain and weakness. Patient was evaluated by neurology who felt like this was not consistent with her multiple sclerosis. There is a significant functional component to her presentations. However, the patient is unable to ambulate or eat. She is refusing a physical therapy consult and rehab placement. She was told that she would not receive any additional medications other than her home medications. She will require admission safety concerns at home and inability to ambulate." On arrival to the floor patient complaining of new pain in the back of the neck as well as headache that started about 2 hours ago, though she fell asleep shortly after and was comfortable appearing. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: DSM 5 DIAGNOSES: Borderline personality disorder PTSD Somatic symptom disorder, anxiety disorder Unspecified mood disorder (some notes label her as MDD, others appear to attribute her melancholic affect to her other conditions) MEDICAL HISTORY Secondary progressive MS- very questionable diagnosis, has lesions on MRI but ___ convincing clinical symptoms Question of a cognitive disorder, although evaluation is heavily confounded by her other issues. Asthma Iron deficiency B12 deficiency Migraines IBS Upper GI bleed Social History: ___ Family History: grandfather with ___. Uncle with ___ cancer Father w/ polio, lung mass, died of PsA infectious mother with superficial skin cancer mother with a chronic hematological malignancy "version that doesn't kill you," either leukemia or lymphoma little sister with breast cancer and bile duct cancer Physical Exam: ADMISSION EXAM VS: Temp: 98.3 PO BP: 153/72 HR: 59 RR: 20 O2 sat: 96% O2 delivery: RA Gen - NAD, non-toxic appearing Eyes - anicteric ENT - MMM, OP clear Heart - RRR, ___ r/m/g Lungs - CTAB, breathing unlabored Abd - soft, nontender, nondistended, ___ guarding or rebound Ext - ___ pedal edema Skin - ___ obvious skin rashes Vasc - WWP Neuro - A&OOx3, moving all extremities, ___ gross sensorimotor deficits Psych - pleasant, calm, cooperative DISCHARGE EXAM Constitutional: VS reviewed, lying in bed and flat with quiet voice and very unactivated and lying fairly flaccid in bed but when I mention Tylenol as a treatment for her HA she somewhat dramatically moves to argue that what she was requesting was her triptan and Tylenol doesn't work for her migraine; later in the day when she is ready to leave to see her dentist she is again very activated HEENT: eyes almost closed and not opening to my exam but appear equal, nose unremarkable, MMM without exudate; later in the day her eyes are wide open CV: RRR ___ mrg Resp: CTAB GI: diffusely ttp to even the lightest touch but much less so with my stethoscope, NABS, soft GU: ___ foley MSK: ___ obvious synovitis Ext: wwp, neg edema in BLEs Skin: ___ rash grossly visible Neuro: A&O grossly, as above is lying without a lot of activity/motion most of the interview but activates physically when discussing medications, ___ BLEs but increases with increasing resistance and giveway weakness, + hoover's sign on ___ strength testing, diffuse tenderness to light touch Psych: flat and annoyed affect initially but then later when wants to see dentist as o/p is much more pleasant and interactive Pertinent Results: ADMISSION RESULTS ___ 03:15PM BLOOD WBC-5.3 RBC-4.92 Hgb-13.0 Hct-40.1 MCV-82 MCH-26.4 MCHC-32.4 RDW-14.1 RDWSD-41.0 Plt ___ ___ 03:15PM BLOOD Neuts-52.0 ___ Monos-8.1 Eos-1.3 Baso-0.4 Im ___ AbsNeut-2.77 AbsLymp-2.02 AbsMono-0.43 AbsEos-0.07 AbsBaso-0.02 ___ 03:15PM BLOOD Glucose-95 UreaN-13 Creat-0.7 Na-141 K-5.6* Cl-102 HCO3-22 AnGap-17 ___ 03:15PM BLOOD ALT-27 AST-58* AlkPhos-96 TotBili-0.3 ___ 03:15PM BLOOD Albumin-4.7 Calcium-10.0 Phos-4.2 Mg-2.0 ___ 04:23PM BLOOD K-3.8 CXR IMPRESSION: ___ acute cardiopulmonary abnormality. Moderate to large hiatal hernia. EKG SB at 57, old anterior infarct, ___ significant change from previous EKG Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 400 mg PO QID 2. amLODIPine 10 mg PO DAILY 3. OXcarbazepine 300 mg PO TID 4. HYDROmorphone (Dilaudid) 2 mg PO TID:PRN BREAKTHROUGH PAIN 5. melatonin 10 mg oral QHS:PRN insomnia 6. Sumatriptan Succinate 100 mg PO ONE TABLET(S) BY MOUTH AT ONSET OF MIGRAINE, MAY REPEAT IN 2 HOURS IF MIGRAINE STILL PRESENT 7. Cyanocobalamin 1000 mcg PO DAILY 8. Vitamin D 1000 UNIT PO DAILY 9. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First Line 10. esomeprazole magnesium 40 mg oral BID 11. Calcium Carbonate 500 mg PO BID 12. Penicillin V Potassium 500 mg PO Q6H Discharge Medications: 1. amLODIPine 10 mg PO DAILY 2. Calcium Carbonate 500 mg PO BID 3. Cyanocobalamin 1000 mcg PO DAILY 4. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First Line 5. esomeprazole magnesium 40 mg oral BID 6. Gabapentin 400 mg PO QID 7. HYDROmorphone (Dilaudid) 2 mg PO TID:PRN BREAKTHROUGH PAIN 8. melatonin 10 mg oral QHS:PRN insomnia 9. OXcarbazepine 300 mg PO TID 10. Penicillin V Potassium 500 mg PO Q6H 11. Sumatriptan Succinate 100 mg PO ONE TABLET(S) BY MOUTH AT ONSET OF MIGRAINE, MAY REPEAT IN 2 HOURS IF MIGRAINE STILL PRESENT 12. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: somatoform disorder multiple sclerosis, chronic, not actively flaring tooth pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (AP AND LAT) INDICATION: History: ___ with MS, whole body pain, h/a, neck pain// Infection, bleeding, MS flair TECHNIQUE: Semi-upright AP and lateral views of the chest COMPARISON: Chest radiograph ___ and CT chest ___ FINDINGS: Lung volumes are low. Heart size is mildly enlarged. The mediastinal and hilar contours are unchanged with a moderate to large hiatal hernia again noted. The pulmonary vasculature is normal. Lungs are clear. No pleural effusion or pneumothorax is seen. There are no acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary abnormality. Moderate to large hiatal hernia. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Weakness Diagnosed with Weakness temperature: 97.4 heartrate: 62.0 resprate: 16.0 o2sat: 96.0 sbp: 148.0 dbp: 74.0 level of pain: 9 level of acuity: 3.0

___ w MS, PTSD, sexual trauma, somatoform disorder, chronic pain, fibromyalgia, IBS, borderline personality disorder, frequent presentations for apparently functional pain/weakness (often around time of renewal/expiry of her home pain meds) presents with functional pain and weakness. Admitted because she would not walk in the ED, decided she was ready to leave on hospital day 1 in setting of wanting to see her outpatient dentist.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Lipitor Attending: ___ Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is an ___ year old woman with a past medical history significant for atrial fibrillation (on rivaroxaban), hyperlipidemia, hypertension, hyperthyroidism, atrial tachycardia s/p pacemaker, COPD, CVA, CHF, and tuberculosis who presents with several days of worsening shortness of breath, with associated productive cough, bilateral lower extremity swelling, and generalized weakness. She was recently hospitalized about a month ago for pneumonia, and 2 weeks ago for cellulitis. Per the patient, has not really improved since discharge. She did complete the antibiotic course, but continued to have significant left leg swelling, especially over her foot although the redness resolved. Per the patient, following her discharge, she saw her cardiologist Dr ___ recommended that she continue xarelto and lasix. In addition, she had worsening shortness of breath with exertion that severely limited her functionality, accompanied by sneezing and a cough productive of yellowish brown sputum for about five days. Denies any chest pain, palpitations, fevers, chills. Reports her weight has remained stable since discharge, did have a 3lb weight gain initially that appears to have resolved, last dose of lasix yesterday. She was scheduled to see Dr ___ (cards) today, but was so short of breath came to the ED instead. In the ED, initial vitals were: 96.7 93 127/95 20 97%. Patient received magnesium repletion; vanc/ceftriaxone/azithro for HCAP coverage; she refused nebs and diuretics. Initial workup showed elevated BNP and CXR concerning for volume overload. In addition, she was found to have Cr elevated to 1.6 from baseline of 1.1-1.2, 1.3 at discharge ten days ago. On the floor, she continues to feel short of breath with minimal exertion but is comfortable at rest. Past Medical History: # Asthma / COPD -- severe obstructive defect -- last PFTs (___) FEV1 and vital capacity 0.95 and 1.8 (55 and 77% predicted respectively). FEV1 to vital capacity ratio is 53% (72% predicted) # Mild Pulmonary Hypertension # Atrial fibrillation -- on rivaroxaban # Atrial tachycardia # Pacemaker -- ___ dual chamber PPM placed ___ -- infra-His AV block (right bundle-branch block, left anterior fascicular block, and procainamide-induced HV prolongation to 156 milliseconds). # Hypertension # Hyperlipidemia # TB History # Right Cerebellar Stroke (___) -- with INR 2.5, likely from small vessel disease # Toxic Multinodular Goiter -- s/p Iodine-131 ablation (___) # Appendectomy # Bilateral Hip Replacement -- ___ years ago at ___ Social History: ___ Family History: Mother had a MI Physical Exam: ADMISSION Vitals: 97.6F 156/91 100 90%2L->97%2L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, mucous membranes slightly dry, oropharynx clear Neck: supple, JVP elevated to about 12 cm, no LAD Lungs: Diffuse inspiratory and expiratory wheezes, mild crackles at bases CV: irregularly irregular Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding Ext: Warm, well perfused, palpable pulses bilaterally, 3+pitting edema in LLE to knee, 2+ pitting edema in RLE to midcalf Skin: hyperpigmented areas over L > R ankle DISCHARGE Vitals: 97.8F 130/76 86 24 94RA I/O ___ Wt 78.6 kg (79.5kg yest, 82.6kg on admission) General: Alert, oriented, no acute distress HEENT: Sclera anicteric, mucous membranes moist, oropharynx clear Neck: supple, JVP elevated to about 11 cm, no LAD Lungs: CTAB, no wheezes, mild crackles at bases CV: irregularly irregular, HR in ___, no murmurs Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding Ext: Warm, well perfused, palpable pulses bilaterally, 1+pitting edema in LLE to midcalf, 1+ pitting edema in RLE to midcalf Skin: hyperpigmented areas over L > R ankle, no erythema Pertinent Results: ADMISSION LABS ___ 09:40PM CK(CPK)-61 ___ 09:40PM CK-MB-3 cTropnT-0.02* ___ 09:40PM MAGNESIUM-1.5* ___ 04:50PM URINE HOURS-RANDOM CREAT-264 SODIUM-34 POTASSIUM-51 CHLORIDE-44 ___ 04:50PM URINE COLOR-Yellow APPEAR-Cloudy SP ___ ___ 04:50PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG ___ 04:50PM URINE RBC-24* WBC-33* BACTERIA-FEW YEAST-RARE EPI-11 ___ 04:50PM URINE HYALINE-10* ___ 04:50PM URINE URIC ACID-MANY ___ 04:50PM URINE MUCOUS-RARE ___ 10:22AM LACTATE-1.6 ___ 10:15AM GLUCOSE-127* UREA N-30* CREAT-1.6* SODIUM-135 POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-24 ANION GAP-15 ___ 10:15AM estGFR-Using this ___ 10:15AM GLUCOSE-127* UREA N-30* CREAT-1.6* SODIUM-135 POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-24 ANION GAP-15 ___ 10:15AM estGFR-Using this ___ 10:15AM CK(CPK)-76 ___ 10:15AM cTropnT-0.01 ___ 10:15AM CK-MB-3 proBNP-5842* ___ 10:15AM CALCIUM-9.7 PHOSPHATE-2.6* MAGNESIUM-1.4* ___ 10:15AM WBC-10.4 RBC-4.03* HGB-12.3 HCT-37.6 MCV-93 MCH-30.6 MCHC-32.8 RDW-14.4 ___ 10:15AM NEUTS-80.4* LYMPHS-7.7* MONOS-11.4* EOS-0.3 BASOS-0.2 ___ 10:15AM PLT COUNT-203 ___ 10:15AM PLT COUNT-203 EKG ___ Atrial fibrillation with a controlled ventricular response with probable ventricular premature beats which are monomorphic. Conducted complexes have marked left axis deviation. There are inferior Q waves. Intraventricular conduction delay of right bundle-branch block type. ST-T wave abnormalities. Since the previous tracing of ___ the rate is now slightly less. Differences in R wave progression is probably related to lead position. Clinical correlation is suggested. ___ LLE US IMPRESSION: No evidence of deep vein thrombosis in the left lower extremity. CXR ___ FINDINGS: Left-sided dual-chamber pacemaker device is noted with leads terminating in right atrium and right ventricle. Severe cardiomegaly with marked left atrial enlargement is re- demonstrated. There is mild pulmonary vascular congestion. The mediastinal and hilar contours are relatively unchanged, with mild atherosclerotic calcification of the thoracic aorta noted. The lungs are hyperinflated which suggests underlying COPD. No pleural effusion, focal consolidation or pneumothorax is present. There are mild multilevel degenerative changes in the thoracic spine. IMPRESSION: Mild pulmonary vascular congestion. ECHO ___ Conclusions The left atrium is elongated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild global left ventricular hypokinesis (LVEF = 40-45%). The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. The branch pulmonary arteries are dilated. Abnormal flow consistent with a patent ductus arteriosus is identified (cine loops ___. There is no pericardial effusion. IMPRESSION: Mild global biventricular systolic function. Mild mitral regurgitation. Moderate tricuspid regurgitation. Moderate pulmonary hypertension. Small patent ductus arteriosus. Compared with the prior study (images reviewed) of ___, a small PDA is seen. Biventricular systolic function has deteriorated. There is more MR and TR; pulmonary hypertension is seen. ___ CXR PA AND LAT IMPRESSION: PA and lateral chest compared to ___ and ___: Severe cardiomegaly has improved. Between ___ and ___, a large cluster of ring shadows developed in the right mid lung, which persists, concerning for cavities or acute bronchiectasis. Confirmation with chest CT scanning is recommended. Lateral view shows that the lung bases are generally clear and there is no pleural effusion. Transvenous right atrial and ventricular pacer leads are in standard placements. Dr. ___ was paged. ___ CT CHEST IMPRESSION: 1. Predominantly central, ___ bronchovascular opacification with changing morphology and distribution across ___ years. Findings could be explained by drug hypersensitivity/toxicity, pulmonary hemorrhage, including vasculitis, e.g., ___ or Wegener's capillerites. No cavitating lesions, bronchiectasis, or fibrosis. 2. Enlarged ascending aorta measuring 4.5cm 3. Pulmonary arterial hypertension. 4. Cardiomegaly. 5. Stable 2.1 cm left thyroid nodule, unchanged since ___. DISCHARGE LABS ___ 07:10AM BLOOD WBC-9.9 RBC-3.85* Hgb-11.9* Hct-35.9* MCV-93 MCH-31.0 MCHC-33.2 RDW-14.3 Plt ___ ___ 07:10AM BLOOD Glucose-114* UreaN-40* Creat-1.2* Na-142 K-4.2 Cl-102 HCO3-28 AnGap-16 ___ 07:10AM BLOOD Calcium-9.5 Phos-3.3 Mg-1.5* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Furosemide 20 mg PO DAILY 2. Rivaroxaban 15 mg PO DAILY Discharge Medications: 1. Rivaroxaban 15 mg PO DAILY 2. Torsemide 20 mg PO DAILY RX *torsemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Xopenex Neb *NF* 0.63 mg/3 mL Inhalation q2h PRN COPD Reason for Ordering: tachycardic with albuterol RX *levalbuterol HCl [Xopenex] 0.63 mg/3 mL 3 ml IH EVERY 4 hours Disp #*120 Vial Refills:*0 4. Outpatient Lab Work Please have Chem 10 checked on ___. Results should be sent to your PCP's office. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Shortness of breath Diastolic heart failure COPD 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 HISTORY: Cough and dyspnea. TECHNIQUE: Upright AP and lateral views of the chest. COMPARISON: ___. FINDINGS: Left-sided dual-chamber pacemaker device is noted with leads terminating in right atrium and right ventricle. Severe cardiomegaly with marked left atrial enlargement is re- demonstrated. There is mild pulmonary vascular congestion. The mediastinal and hilar contours are relatively unchanged, with mild atherosclerotic calcification of the thoracic aorta noted. The lungs are hyperinflated which suggests underlying COPD. No pleural effusion, focal consolidation or pneumothorax is present. There are mild multilevel degenerative changes in the thoracic spine. IMPRESSION: Mild pulmonary vascular congestion. Radiology Report HISTORY: Left lower extremity swelling. COMPARISON: None. FINDINGS: Grayscale color and spectral Doppler evaluation was performed of the left lower extremity veins. There is normal compressibility, flow, and augmentation of the left common femoral, proximal femoral, mid femoral, distal femoral, and popliteal veins. Normal color flow is demonstrated in the left posterior tibial and peroneal veins. There is normal respiratory variation of the common femoral veins bilaterally. IMPRESSION: No evidence of deep vein thrombosis in the left lower extremity. Radiology Report PA AND LATERAL CHEST, ___ HISTORY: ___ woman with COPD and CHF. Worsening cough despite therapy. IMPRESSION: PA and lateral chest compared to ___ and ___: Severe cardiomegaly has improved. Between ___ and ___, a large cluster of ring shadows developed in the right mid lung, which persists, concerning for cavities or acute bronchiectasis. Confirmation with chest CT scanning is recommended. Lateral view shows that the lung bases are generally clear and there is no pleural effusion. Transvenous right atrial and ventricular pacer leads are in standard placements. Dr. ___ was paged. Radiology Report HISTORY: History of tuberculosis, shortness of breath, COPD, and right heart failure with findings on chest x-ray concerning for bronchiectasis or cavitation. Please assess. TECHNIQUE: Volumetric multi detector CT acquisition of the chest was performed without intravenous contrast. Images are presented for review in the axial plane at 5 mm and 1 mm collimation. Coronal reformations are submitted for review. COMPARISON: Comparison is made to chest radiographs most recently dated ___ and CT chest performed ___. FINDINGS: Evaluation of the thoracic inlet is limited due to artifact from a left-sided pacemaker. Within this limitation, there is a 2 cm left thyroid lobe nodule, unchanged compared to ___. No supraclavicular, axillary, mediastinal or hilar lymphadenopathy is identified. Artherosclerotic disease is noted throughout the visualized vasculature, including the coronary arteries and aortic valve. The ascending aorta is enlarged measuring 4.5 cm compared to a descending thoracic aorta diameter of 2.6 cm of the at the same level. In addition, the pulmonary artery is enlarged measuring 4.3 cm suggestive of pulmonary arterial hypertension. The heart demonstrates multichamber enlargement. There is no pericardial effusion identified. Pacemaker leads are positioned within the right atrium and ventricle. Airways are normal to the subsegmental level; specifically, no bronchiectasis identified. No cavitary lesions are present. Predominantly central ground-glass peribronchovascular opacifications are noted, right greater than left, with minimal if any with septal thickening. Of note abnormal lung findings, right greater than left, have been present since ___, but always with different configurations. Specifically, compared to the most recent chest CT on ___, opacifications are less dense and smaller but more numerous and with a greater distribution. No pleural effusion or pneumothorax evident. Limited assessment of the visualized aspects of the upper abdomen are unremarkable. No osseous abnormality evident. IMPRESSION: 1. Predominantly central, ___ bronchovascular opacification with changing morphology and distribution across ___ years. Findings could be explained by drug hypersensitivity/toxicity, pulmonary hemorrhage, including vasculitis, e.g., ___ or Wegener's capillerites. No cavitating lesions, bronchiectasis, or fibrosis. 2. Enlarged ascending aorta measuring 4.5cm 3. Pulmonary arterial hypertension. 4. Cardiomegaly. 5. Stable 2.1 cm left thyroid nodule, unchanged since ___. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: DYSPNEA, CELLULITIS Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, PNEUMONIA,ORGANISM UNSPECIFIED, CHRONIC AIRWAY OBSTRUCTION, HYPERTENSION NOS temperature: 96.7 heartrate: 93.0 resprate: 20.0 o2sat: 97.0 sbp: 127.0 dbp: 95.0 level of pain: 6 level of acuity: 3.0

___ year old woman with a past medical history significant for atrial fibrillation (on rivaroxaban), hyperlipidemia, hypertension, hyperthyroidism, atrial tachycardia s/p pacemaker, COPD, CVA, CHF, and tuberculosis who presents with several days of worsening shortness of breath, with associated productive cough, bilateral lower extremity swelling, and generalized weakness, now improved: #.Shortness of breath: Appears to be multifactorial etiology, with elevated BNP, elevated JVP and ___ edema worsened from recent discharge concerning for acute congestive heart failure. In addition, cough productive of sputum, wheezing and chest xray concerning for COPD exacerbation. Patient diuresed with IV lasix and given IV solumedrol and xopenex nebs; she adamantly refused all other meds. Also completed a five day course of azithromycin. Repeat CXR concerning for cavitations is worrisome given history of TB and persistent cough, CT scan done to r/o further pathology. At the time of discharge, was 4kgs down, had significantly reduced ___ edema. #.Positive UA: No symptoms of dysuria or lower abdominal pain at present, positive UA incidental finding in the absence of fever or leukocytosis. Held off antibiotics for now, patient did receive ceftriaxone in ED. #.Atrial fibrillation: Rate controlled during hospitalization with HR in ___ per tele. Continued xarelto renally dosed at 15mg daily.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: penicillin G / ACE Inhibitors / ampicillin / ceftaroline fosamil / daptomycin Attending: ___. Chief Complaint: Stroke/Seizure Major Surgical or Invasive Procedure: ___ 1. Redo sternotomy. 2. Redo aortic valve replacement with a 23 ___ Ease pericardial tissue valve serial number is ___, model number is ___. 3. Removal of pacemaker. 4. Removal of pacemaker leads. 5. Placement of right ventricular epicardial leads. History of Present Illness: Mr. ___ is a ___ year old man with a history of prior GBS AV endocarditis with aortic root abscess status post aortic valve replacement on ___. His history is also notable for cerebrovascular accident status post right carotid endarterectomy, complete heart block status post permanent pacemaker placement. He was recently hospitalized with a recent E. gallinarum bacteremia with definitive prosthetic valve endocarditis s/p PPM explantation f/b re-implantation on ___ and completion of 6 weeks of oritavancin for recurrent E. gallinarum bacteremia who presents with seizure and concern for stroke. He has a complicated infectious disease and cardiology history. In brief, in ___ he developed GBS aortic valve endocarditis complicated by an aortic root abscess which was treated with an aortic valve replacement with a bioprosthetic valve. His post operative course was complicated by AFib which was treated with Amiodarone and resolved. In ___, the patient had multiple episodes of syncope, at which time he was diagnosed with intermittent complete heart block which was treated with a pacemaker implantation. In ___, the patient was admitted with E. Gallinarum bacteremia, with a TEE showing prosthetic valve endocarditis. His pacemaker was extracted at this time and a temporary screw was placed. He was originally treated with ampicillin which resulted in eosinophila, and was then discharged on Daptomycin and Ceftaroline for a planned ___eftaroline resulted in ___, and the patient completed his 6 week course on Linezolid. On ___, the patient had positive blood cultures suggesting relapsed E. Gallinarum bacteremia. He was admitted at this time with high grade bacteremia, and was treated Daptomycin and Ceftriaxone. ID advocated for removal of his pacemaker and mechanical AV given multiple recurrences of bacteremia, however an interdisciplinary meeting was held with CT surgery and the primary team, and the final plan was to complete treatment with antibiotics and if there was relapse, to consider surgery at that time. CT CAP, TEE, US of pacer leads, full body PET-CT, and flexible sigmoidoscopy, all of which were non-revealing of a AVR vs PPM vs occult source of infection. The patient completed the course of Daptomycin and Ceftriaxone, however a second morphology of E. Gallinarum was isolated which demonstrated resistance to Daptomycin, and the patient was given an additional course of Oritivancin therapy from ___. On this admission, the patient was transferred from ___ ___ for seizures and concern for CVA. Today, the patient woke up and ate breakfast, after which point he vomited and reported feeling unwell. He went back to sleep and slept most of the day. He was waking up easily however, responding to his wife, and his language was fluent. At 6pm, the patient woke up to take a shower when he suddenly yelled for his wife to come upstairs. When she came up, the patient was unable to speak. According to reports from the OSH, he seemed to recognize his wife but was not forming words. EMS was called and the patient was taken to ___ in ___ where a code stroke was called. The patient was about to have his CT/CTA head and neck done when he had a witnessed GTC lasting ___ minutes, which aborting on its own. He was given 2mg of IV Ativan afterwards. He desaturated to the ___ and was somnolent. Intubation was attempted x2 but was esophageal, after which the patient woke up, was tachcyardic to the 100's, and speaking/awake, alert, so the patient was not intubated. He had his CT which showed evidence of an old infarct, but no acute bleed and was transferred to ___ for further evaluation. A code stroke was initiated when the patient arrived here. He was seen to be rigoring, febrile to 102.8, and vomiting bilious fluid. The patient was then transported to ___ where he was found to have RUE pronator drift, altered mental status, temp of 102.8 and vomiting bilious emesis. A code stroke was called in the ED, however an MRI was not obtained given the patient's pacemaker. Neurology saw the patient and believed that seizures were likely secondary to decreased threshold in the setting of an acute infection. They recommended Keppra load of 1G, ASA 81, EEG monitoring, MRI and if no evidence of stroke or aneurism on MRI, to start a Heparin drip for concern of cardioembolic stroke in the setting of AFib. Cardiac surgery was reconsulted due to recurrent bacteremia after completion of antibiotics. Surgery and replacement of the AVR was recommended. Past Medical History: - ___ GBS endocarditis with aortic root abscess secondary to osteomyelitis infection, s/p AVR (23-mm SJM Trifecta tissue valve) with moderate patient prosthesis mismatch. -AF in the setting of AVR surgery. - ___ Symptomatic carotid stenosis c/b R embolic CVA s/p R CEA - Complete heart block with ___ pause s/p PPM ___. - ?CHF - Gallstone pancreatitis/cholangitis s/p CCY ___ - ___ Cervical Spine Decompression/Fusion - ___ L5-S1 discectomy Social History: ___ Family History: Father - esophageal cancer Mother - died at age ___ Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: See MetaVision GENERAL: Alert, oriented to person and place, but difficulty remembering the date. No acute distress. HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, trace rales at the bases. No wheezes CV: Regular rate and rhythm. Normal S1 S2, systolic crescendo decrescendo murmus, no rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: No lesions. NEURO: Alert and oriented to person and place, with some difficulty remembering the date. Cranial nerves intact. Strength and sensation intact in bilateral upper and slower extremities. No pronator drift. DISCHARGE PHYSICAL EXAM: Vital signs Neuro: PERRL, non focal, A&O x 3 Lungs: CTA decreased bases CV: S1S2, no JVD, no murmur Abd: soft + BS, +BM ext: warm, +___dema, + pulse Wounds: CDI Pertinent Results: ADMISSION LABS: ================= ___ 11:05PM BLOOD ___ PTT-24.0* ___ ___ 11:05PM BLOOD Glucose-122* UreaN-19 Creat-1.6* Na-138 K-4.0 Cl-95* HCO3-22 AnGap-21* ___ 11:05PM BLOOD ALT-46* AST-93* AlkPhos-167* TotBili-1.2 ___ 11:05PM BLOOD cTropnT-<0.01 ___ 11:05PM BLOOD Glucose-112* Na-139 K-3.7 Cl-101 calHCO3-21 ___ 11:34PM BLOOD Lactate-5.7* IMAGING: ========== Transesophageal Echocardiogram ___ Well-seated bioprosthetic AVR with mild-moderate paravalvular regurgitation near the left coronary cusp. No vegetations or abscess seen. PET CT ___ 1. New left greater than right inferior rectus muscle heterogeneous fluid collections with focal FDG avidity concerning for superinfection. Ultrasound could further evaluate for drainable collection. 2. Post aortic valve replacement with nonspecific surrounding FDG avidity. 3. Stable trace bilateral pleural effusions. Abdominal Ultrasound ___ Redemonstrated left rectus muscle heterogeneous complex fluid collection with increased central lignification which could represent evolving hematoma or abscess. Cardiac CT ___ 1. No drainable fluid collection. 2. Approximately 1.8 cm pseudoaneurysm with peripheral calcification, located between the RVOT and sinuses of Valsalva, is grossly similar in retrospect to non ECG gated chest CT from ___. 3. Somewhat unusually turbulent flow of intravenous contrast bolus in the right atrium with question of central filling defect raises the question of thrombus in the right atrium adjacent to the leads, although this imaging finding may be artifactual. Normal contrast flow and filling in the right ventricle. Transthoracic Echocardiogram ___ The left atrial volume index is normal. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. Mild symmetric left ventricular hypertrophy with normal cavity size, and regional/global systolic function (biplane LVEF = X61X %). The right ventricular cavity is moderately dilated with borderline normal free wall function. A bioprosthetic aortic valve prosthesis is present. The prosthetic aortic valve leaflets are thickened. The transaortic gradient is higher than expected for this type of prosthesis. The effective orifice area/m2 is severely depressed (0.3; nl >0.9 cm2/m2) No masses or vegetations are seen on the aortic valve. Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of tricuspid regurgitation may be significantly UNDERestimated.] There is borderline pulmonary artery systolic hypertension. No vegetation/mass is seen on the pulmonic valve. There is a trivial/physiologic pericardial effusion. IMPRESSION: Bioprosthetic AVR with thickened leaflets and elevated gradients. Moderate paravalvular aortic regurgitation. No definite valvular endocarditis identified. Normal left ventricular wall thickness, cavity size, and regional/global systolic function. Mild mitral regurgitation. In the setting of moderate paravalvular regurgitation, a trans-esophageal echocardiogram is reasonable if clinically indicated to exclude abscess. If clinically suggested, the absence of a vegetation by 2D echocardiography does not exclude endocarditis. Carotid Ultrasound ___ Moderate homogeneous and heterogeneous atherosclerotic plaque in the left common carotid artery and bulb. However, no hemodynamically significant stenosis bilaterally (less than 40% on left, 0% on right). Cardiac Catheterization ___ Dominance: Right LMCA: normal LAD: normal LCX: normal RCA: normal Transesophageal Echocardiogram ___ PRE-BYPASS: The left atrium is mildly dilated. No spontaneous echo contrast is seen in the left atrial appendage. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. There are focal calcifications in the aortic arch. The prosthetic aortic valve leaflets are thickened. The transaortic gradient is higher than expected for this type of prosthesis. Aortic valve VTI = 70.3 cm. The effective orifice area/m2 is severely depressed (0.5; nl >0.9 cm2/m2) A paravalvular jet of mild aortic regurgitation is seen along the left coronary cusp. No masses or vegetations are seen on the aortic valve. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. No masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. POST-BYPASS: The patient is in an atrially-paced rhythm and receiving a phenylephrine infusion. 1. Biventricular function remains preserved. 2. There has been interval replacement of the aortic valve prosthesis (with a 23 mm ___ Ease) valve. The valve is well-seated with normal leaflet motion. There is trivial regurgitation (cannot ascertain intravalvular vs paravalvular). Peak gradient across the valve is 32 mmg, mean gradient is 16 mmHg at a cardiac index of 2.7 L/min (by CCO ___). Effective orifice area is 1.4 cm2 (0.7 cm2/m2, LVOT VTI = 24.6 cm, pAoV VTI = 55 cm) 3. Remaining valvular function is unchanged. 4. The thoracic aorta is intact following decannulation. ___ PA&lat Stable small bilateral pleural effusions with bibasilar atelectasis most likely related to congestive heart failure. Stable position of the left-sided pacemaker Dischage labs: ___ 02:54AM BLOOD WBC-15.2* RBC-2.78* Hgb-8.0* Hct-24.8* MCV-89 MCH-28.8 MCHC-32.3 RDW-14.6 RDWSD-47.0* Plt ___ ___ 04:04AM BLOOD WBC-13.1* RBC-2.79* Hgb-8.2* Hct-25.0* MCV-90 MCH-29.4 MCHC-32.8 RDW-15.0 RDWSD-48.9* Plt Ct-93* ___ 04:10AM BLOOD Neuts-65.2 Lymphs-10.4* Monos-12.9 Eos-10.3* Baso-0.2 NRBC-0.5* Im ___ AbsNeut-8.53* AbsLymp-1.36 AbsMono-1.69* AbsEos-1.35* AbsBaso-0.03 ___ 04:30AM BLOOD Neuts-69.2 Lymphs-7.7* Monos-12.0 Eos-10.1* Baso-0.3 Im ___ AbsNeut-9.30* AbsLymp-1.04* AbsMono-1.61* AbsEos-1.36* AbsBaso-0.04 ___ 04:04AM BLOOD ___ PTT-29.4 ___ ___ 02:54AM BLOOD Glucose-100 UreaN-10 Creat-1.1 Na-139 K-4.5 Cl-98 HCO3-31 AnGap-10 ___ 03:59AM BLOOD Glucose-114* UreaN-10 Creat-1.0 Na-139 K-4.4 Cl-97 HCO3-31 AnGap-11 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 80 mg PO QPM 2. Metoprolol Succinate XL 150 mg PO DAILY 3. Multivitamins 1 TAB PO BID 4. Omeprazole 20 mg PO BID 5. Pancrelipase 5000 2 CAP PO TID W/MEALS 6. Gabapentin 100 mg PO BID 7. Gabapentin 600 mg PO QHS 8. oritavancin 1200 mg intravenous Q48H 9. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild Discharge Medications: 1. Ampicillin 2 g IV Q4H 2. Aspirin EC 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*1 3. CefTRIAXone 2 gm IV Q12H RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 grams every twelve (12) hours Disp #*60 Intravenous Bag Refills:*0 4. Docusate Sodium 100 mg PO BID Duration: 30 Days RX *docusate sodium [Docuprene] 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 5. Furosemide 40 mg PO BID RX *furosemide 40 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*1 6. LevETIRAcetam 1000 mg PO BID RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 7. Metoprolol Tartrate 37.5 mg PO TID RX *metoprolol tartrate 25 mg 1.5 tablet(s) by mouth three times a day Disp #*150 Tablet Refills:*1 8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN BREAKTHROUGH PAIN RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills:*0 9. Polyethylene Glycol 17 g PO DAILY:PRN constipation hold for loose stool RX *polyethylene glycol 3350 [Purelax] 17 gram/dose 1 powder(s) by mouth daily Disp #*30 Each Refills:*0 10. Potassium Chloride 20 mEq PO BID Duration: 7 Days RX *potassium chloride 20 mEq 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*1 11. Senna 17.2 mg PO DAILY RX *sennosides [Senna Laxative] 8.6 mg 2 by mouth daily Disp #*60 Tablet Refills:*1 12. Tamsulosin 0.4 mg PO QHS Duration: 1 Month RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30 Capsule Refills:*0 13. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 14. Atorvastatin 80 mg PO QPM 15. Gabapentin 600 mg PO QHS 16. Multivitamins 1 TAB PO BID 17. Omeprazole 20 mg PO BID 18. Pancrelipase 5000 2 CAP PO TID W/MEALS Discharge Disposition: Home with Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: ================== Seizure S. viridens bacteremia Stroke History of AV endocarditis s/p Bioprosthetic Aortic Valve Secondary Diagnosis: ==================== Hyperlipidemia Gastroesophageal Reflux Disord Discharge Condition: Alert and oriented x3 non-focal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Edema 2+ Followup Instructions: ___ Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD INDICATION: ___ year old man with endocarditis, stroke// mycotic aneusryms? stroke? TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of 8 mL of Gadavist intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: Prior CTA done ___ at 19:03 FINDINGS: Motion artifact degrades the diagnostic quality of the imaging. There is a 3 mm foci of slow diffusion in the left cerebellar hemisphere (series 6, image 7). No associated T2 or FLAIR hyperintensity.. Evidence of old wedge-shaped infarct in the posterior left parietal area with cortical laminar necrosis as well as associated blooming artifact resulting on artifactual increase in signal on the DWI sequence. A couple of 2 mm round foci of blooming artifact the right frontal superior and middle gyri. Periventricular and deep white matter and pontine T2 and FLAIR hyperintensities are nonspecific, but most likely sequela of microangiopathy. The intracranial arteries demonstrate normal T2 flow void. The mild mucosal thickening involving the paranasal sinuses. The orbits appear normal. There is no abnormal enhancement after contrast administration. IMPRESSION: 1. There is a 3 mm focus of slow diffusion in the left cerebellar hemisphere (series 6, image 7). No associated T2 or FLAIR hyperintensity suggesting this is a hyperacute infarct (but please note that small infarcts may sometimes be difficult to see on the T2 and FLAIR images). 2. Left parietal chronic infarction. 3. White matter hyperintensities most likely reflecting sequela of microangiopathy. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 5:33 pm, 3 minutes after discovery of the findings. Radiology Report EXAMINATION: SECOND OPINION CT NEUROPSO1CT INDICATION: History: ___ with stroke, endocarditis// CTA HEAD and Neck, ?mycotic aneursyms TECHNIQUE: CTA head and neck performed at outside institution 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: Prior CT chest done ___ FINDINGS: Motion artifact degrades the diagnostic quality of the imaging. CT HEAD WITHOUT CONTRAST: There is no evidence of acute infarction, hemorrhage, edema, or mass. The ventricles and sulci are normal in size and configuration. Wedge-shaped hypodensity in the posterior left parietal lobe most likely representing a chronic infarct. Mucous retention cyst present in the right frontal and right maxillary sinus. Mild mucosal thickening involving the ethmoid air cells.. The visualized portion of the orbits are unremarkable. CTA HEAD and neck: Mild atherosclerotic changes of the aortic arch. Three-vessel arch. The vessels of the circle of ___ and their principal intracranial branches are patent with no evidence of stenosis, occlusion, or aneurysm. Mild to moderate atherosclerotic changes of the carotid siphons. Fetal origin of the right PCA. The left vertebral artery terminates as the ___. The dural venous sinuses are patent. Calcific atherosclerotic changes involving the carotid bulbs bilateral (left more than right) but no significant stenosis according to NASCET criteria/less than 50%. Evidence of prior sternotomy. Right prepectoral pacemaker in situ. Evidence of prior C4 to C6 posterior cervical spine decompression. Nasogastric tube terminates in the hypopharynx. Retained secretions present in the trachea. No suspicious pulmonary nodules or masses. No suspicious thyroid nodules. IMPRESSION: 1. Mild atherosclerotic changes of the carotid bulbs, but this is not significant by NASCET criteria. 2. Mild to moderate atherosclerotic changes involving the carotid siphons. 3. No intracranial aneurysm. 4. Wedge-shaped hypodensity in the posterior left parietal lobe most likely representing a chronic infarct. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with GNR sepsis, likely endocarditis, presenting with weakness, SOB// Concern for volume overload Concern for volume overload IMPRESSION: Comparison to ___. Stable alignment of the sternal wires. Stable position of the pacemaker leads. Borderline size of the cardiac silhouette. No pulmonary edema. No pleural effusions. No pneumonia. Radiology Report INDICATION: ___ year old man with pacemaker, history of endocarditis, presenting with seizures// H12 series TECHNIQUE: Portable supine abdominal radiographs COMPARISON: CT abdomen and pelvis ___ FINDINGS: Air is seen throughout the small and large bowel in a nonspecific pattern. There are no abnormally dilated loops of large or small bowel. A small amount of stool is seen within the rectum. Multiple round densities are seen in the right lower quadrant, likely ingested pills. Supine assessment limits evaluation for free intraperitoneal air, although no gross pneumoperitoneum is seen. There are mild degenerative changes of the lumbar spine. A small phlebolith is seen in the lower right hemipelvis. Moderate atherosclerotic calcification is seen in the aortoiliac distribution. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. The partially imaged lower lungs are grossly clear without pleural abnormalities. The 4 inferior-most sternotomy wires are midline and intact. The leads of the cardiac defibrillator device terminate within the right atrium and right ventricle. IMPRESSION: 1. Nonspecific, nonobstructive bowel gas pattern. 2. Multiple round densities in the right lower quadrant likely represent ingested pills. Radiology Report EXAMINATION: US ABDOMINAL WALL, SOFT TISSUE LEFT INDICATION: ___ year old man with h/o endocarditis and strep viridians blood stream infection with PET positive for rectus abdominus muscle fluid collection concerning for infection.// scouting scan of the rectus abdominus muscles to look for tapable pocket-- planning scan per ___ team ___, ___ ___. TECHNIQUE: Grayscale ultrasound images were obtained of the superficial tissues of the anterior abdominal and pelvic wall. COMPARISON: PET-CT from ___ FINDINGS: Transverse and sagittal images were obtained of the superficial tissues of the anterior abdominal and pelvic wall. Heterogeneous expansion of bilateral rectus abdominus muscles are identified below the umbilicus, left larger than the right. No fluid collection is identified. Rectus abdominus muscle is expanded to thickness measuring 1.8 cm on the right and 2.8 cm on the left. IMPRESSION: Heterogeneous expansion of bilateral rectus abdominus muscles below the umbilicus, left larger than the right, likely reflects intramuscular hematomas. No drainable fluid collection is identified. Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old man with new picc// L picc 50cm Contact name: sal, ___: ___ L picc 50cm IMPRESSION: Compared to a chest radiographs ___. Left PIC line passes as far asm level of the superior cavoatrial junction where it is partially obscured by indwelling transvenous right atrial right ventricular pacer leads. Normal cardiomediastinal and hilar silhouettes. Pleural effusions small on the left if any. No pneumothorax. Lungs well expanded and clear. Radiology Report EXAMINATION: US ABDOMINAL WALL, SOFT TISSUE RIGHT INDICATION: ___ year old man with PET with uptake of FDG in rectus muscle and prior US demonstrating likely hematoma with ongoing, unimproved abdominal pain.// interval changes in hematoma TECHNIQUE: Grayscale ultrasound images were obtained of the superficial tissues of the a left abdominal wall. COMPARISON: Abdominal ultrasound from ___. PET-CT from ___. FINDINGS: Again seen in the left rectus muscle is a heterogeneous complex fluid collection which measures approximately 5.7 x 2.7 x 2.6 cm, difficult to truly compare based on differences in scan plane and measurement. There is interval increased central cystic component. No significant peripheral hyperemia noted. IMPRESSION: Redemonstrated left rectus muscle heterogeneous complex fluid collection with increased central lignification which could represent evolving hematoma or abscess. Radiology Report EXAMINATION: CARDIAC STRUCTURE/MORPH, 3D, FUNCTION INDICATION: ___ year old man with history of aortic root abscess and endocarditis in past with persistent bacteremia concerning for ongoing endocarditis/aortic root abscess// ECG gated CT; evaluation of aortic root abscess TECHNIQUE: 320-slice multi-detector CT angiogram of the heart and aorta was obtained from below the aortic arch to the upper abdomen using ECG gating, with 80 cc Omnipaque contrast administered intravenously. Multiplanar reformatted images were created on a separate workstation and reviewed. The patient's heart rate was continuously monitored by a nurse. Prior to this study, the heart rate was 74 beats per min and the blood pressure was 146/73 mm Hg. Procedure complications/allergic reactions: none DOSE: Total DLP: 268.83 mGy-cm COMPARISON: CT chest ___ FINDINGS: MEDIASTINUM: No mediastinal mass or lymphadenopathy identified. HILA: No hilar lymphadenopathy. Imaged portion of the lungs: 1. PARENCHYMA: No focal consolidation. 2. AIRWAYS: The airways are patent to subsegmental levels. 3. VESSELS: The great vessels are normal caliber. PLEURA: Left pleural effusion is trace. No right pleural effusion. No pneumothorax. CHEST CAGE: No concerning lytic or sclerotic lesion. No acute fracture. Patient is status post median sternotomy. CHEST WALL: Imaged soft tissues are unremarkable. IMAGED UPPER ABDOMEN: Unremarkable. CARDIAC: There is a right chest cardiac device with lead tips in the right atrium and right ventricle. There is somewhat unusually turbulent flow of intravenous contrast bolus in the right atrium with question of central filling defect. The right atrium is dilated. The right ventricle is normal. The left atrium is mildly dilated. The left ventricle is normal. The pericardium is normal and there is no pericardial effusion. The aortic valve is is tricuspid with leaflet thickening. Approximately 1 x 1.8 cm pseudoaneurysm with peripheral calcification, located between the RVOT and sinuses of Valsalva (2:106), is grossly similar in retrospect to ___. Dominance of the coronary artery system is left with normal origins and course. Coronary artery calcification is moderate. PULMONARY ARTERIES: The main, right, and left pulmonary arteries are normal and appear patent to the segmental level without filling defects. AORTA: The imaged portion of the thoracic aorta is normal. IMPRESSION: 1. No drainable fluid collection. 2. Approximately 1.8 cm pseudoaneurysm with peripheral calcification, located between the RVOT and sinuses of Valsalva, is grossly similar in retrospect to non ECG gated chest CT from ___. 3. Somewhat unusually turbulent flow of intravenous contrast bolus in the right atrium with question of central filling defect raises the question of thrombus in the right atrium adjacent to the leads, although this imaging finding may be artifactual. Normal contrast flow and filling in the right ventricle. RECOMMENDATION(S): Echocardiogram for evaluation of the right atrium adjacent to the leads. NOTIFICATION: The impression and recommendation were discussed with ___ ___, M.D. by ___, M.D. on the telephone on ___ at 2:44 pm, 25 minutes after discovery of the findings. Radiology Report INDICATION: ___ year old man with endocarditis going for valve replacement and epicardial lead placement on ___// Pre op xray Surg: ___ (Valve replacement) TECHNIQUE: Chest PA and lateral COMPARISON: ___ IMPRESSION: Right-sided pacemaker is unchanged.Small left pleural effusion is stable. Cardiomediastinal silhouette is unchanged. No pneumothorax is seen Left-sided PICC line projects to the SVC. There is no evidence of pulmonary edema Radiology Report EXAMINATION: Carotid Doppler Ultrasound INDICATION: ___ year old man with presumed AV endocarditis with plan for AV replacement. Preop carotid study TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound imaging of the carotid arteries was obtained. COMPARISON: None FINDINGS: RIGHT: The right carotid vasculature has no atherosclerotic plaque. The peak systolic velocity in the right common carotid artery is 61 cm/sec. The peak systolic velocities in the proximal, mid, and distal right internal carotid artery are 76, 92, and 101 cm/sec, respectively. The peak end diastolic velocity in the right internal carotid artery is 33 cm/sec. The ICA/CCA ratio is 1.7. The external carotid artery has peak systolic velocity of 62 cm/sec. The vertebral artery is patent with antegrade flow. LEFT: The left carotid vasculature has moderate heterogeneous atherosclerotic plaque in common carotid artery and moderate heterogeneous plaque in the left carotid bulb. The peak systolic velocity in the left common carotid artery is 103 cm/sec. The peak systolic velocities in the proximal, mid, and distal left internal carotid artery are 96, 105, and 74 cm/sec, respectively. The peak end diastolic velocity in the left internal carotid artery is 30 cm/sec. The ICA/CCA ratio is 1.0. The external carotid artery has peak systolic velocity of 100 cm/sec. The vertebral artery is patent with antegrade flow. IMPRESSION: Moderate homogeneous and heterogeneous atherosclerotic plaque in the left common carotid artery and bulb. However, no hemodynamically significant stenosis bilaterally (less than 40% on left, 0% on right). Radiology Report EXAMINATION: Portable x-ray INDICATION: ___ year old man with s/p Redo AVR// cardiac surgery fast track. eval for ptx, effusions. call ___ house officer at ___ if there is any concern with findings Contact name: ___ house officer, ___: ___ TECHNIQUE: Portable chest x-ray COMPARISON: Comparisons include chest x-ray done on ___. FINDINGS: There is a left-sided PICC which terminates in the proximal to mid SVC. However the distal catheter appears kinked in the SVC. Unchanged position monitoring and supportive devices which include chest tubes and Swan-Ganz catheter. Comparing to prior chest x-ray done on ___ the defibrillator has been removed lung volumes of low. There is increased pulmonary vascular congestion and mild pulmonary edema. There is bibasal atelectasis. Cardiomediastinal silhouette is stable. Sternal wires are intact and aligned. There are no new opacifications. There are several radiopaque lines overlying the patient. IMPRESSION: The left-sided PICC which terminates in the proximal to mid SVC and appears kinked at the distal end. Unchanged position of monitoring and support devices which include chest tube, Swan-Ganz catheter, ET tube. There is increased pulmonary vascular congestion and mild pulmonary edema. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man s/p redo sternotomy, tiss AVr, PPM removal new lead placement// eval for pneumothorax s/p CT removal eval for pneumothorax s/p CT removal IMPRESSION: All monitoring and support devices have been removed, with the exception of the left PICC line. The tip of the line is likely coiled in the azygos vein. There is no evidence of pneumothorax. Small left pleural effusion with retrocardiac atelectasis. Minimal fluid overload but no overt pulmonary edema. Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old man with malpositioned PICC.// PICC pulled back 2cm/power flushed to get out of azygous. Please read for tip position. ___ ___ IMPRESSION: In comparison with the earlier study of this date, the tip of the PICC line is now in the lower SVC. Otherwise little change. Radiology Report INDICATION: ___ year old man PPM implant// lead and generator position TECHNIQUE: Chest AP COMPARISON: ___ IMPRESSION: Lungs are low volume with small bilateral effusions with bibasilar atelectasis. Cardiomediastinal silhouette is stable. Left-sided PICC line projects to the cavoatrial junction. A left-sided pacemaker has been placed in the interim with the lead projecting to the right ventricle. No pneumothorax is seen. There is mild pulmonary vascular congestion and bibasilar atelectasis Radiology Report EXAMINATION: The chest radiograph AP and lateral. INDICATION: ___ year old man with AVR/pacer// interval change in vol overload TECHNIQUE: Chest AP and lateral COMPARISON: Comparison included study done on ___. FINDINGS: Low lung volumes and stable, bibasilar atelectasis. Small bilateral pleural effusions with bibasilar atelectasis are unchanged. Cardiomediastinal silhouette is unchanged. Hilar and mediastinal contours are normal. There is no pneumothorax. Left pacer lead terminates at the right atrium. IMPRESSION: Stable small bilateral pleural effusions with bibasilar atelectasis most likely related to congestive heart failure. Stable position of the left-sided pacemaker Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: CVA, Seizure, Transfer Diagnosed with Oth generalized epilepsy, not intractable, w/o stat epi, Altered mental status, unspecified temperature: 99.3 heartrate: 109.0 resprate: 24.0 o2sat: 96.0 sbp: 129.0 dbp: 86.0 level of pain: 0 level of acuity: 1.0

Mr. ___ is a ___ year old man with a complicated past medical history. He was recently treated for gallinarum bacteremia. He presented to an OSH with seizure and concern for stroke. He was noted to have a generalized tonic clonic seizure at the OSH and again on presentation to ___. He was evaluated by Neurology and Keppra was initiated for seizure management. CT head completed at the OSH was negative for acute hemorrhage but notable for an area of old infarct. An MRI on presentation was notable for hyper acute left cerebellar hemisphere. Due to concern for respiratory compromise, he was transferred to the ICU. He was febrile on admission and given his significant infectious history an echocardiogram was obtained and demonstrated concerns for a paravalvular abscess. Per ID recommendation, he was initiated on Linezolid. He was subsequently transferred to the ___ service for further valvular evaluation. A transesophageal echocardiogram on ___ revealed no paravalvular abscess. LP completed ___ was without obvious signs of infection. Given concern for patient's persistently altered mental status an EEG was initiated on ___ which demonstrated no further seizure activity. Further infectious work up yielded s. viridens bacteremia and he was treated for this. An echocardiogram on ___ was significant for moderate paravalvular aortic regurgitation. with no definite valvular endocarditis identified. Cardiac surgery was consulted and he underwent routine preoperative testing and evaluation. He was evaluated by the dental service and underwent simple extraction of tooth #5 on ___. He was cleared for surgery. He was taken to the operating room on ___ and underwent redo sternotomy, redo aortic valve replacement, and placement of new epicardial leads. Please see operative note for full details. He tolerated the procedure well and was transferred to the CVICU in stable condition for recovery and invasive monitoring. Pt was weaned from sedation, awoke neurologically intact, and was extubated on POD1. He was not started on betablocker due to CHB history and absence of PPM. Epicardial wires remained in place. He was diuresed toward his preoperative weight. He remained hemodynamically stable and was transferred to the telemetry floor for further recovery on POD1. He was followed closely by the cardiology service. Patient underwent PPM om ___ and was started on Lopressor. He was evaluated by the physical therapy service for assistance with strength and mobility. Foley was re-inserted and Flomax initiated for urinary retention. He subsequently passed a void trial. ID continued to follow and the patient transitioned to Ampicillin/Ceftriaxone regimen post-op. He is to continue antibiotic therapy though ___. PICC in place. Will need CBC with diff/chem 7/LFTs/CRP twice a week per ID. By the time of discharge on POD 7 pt was ambulating freely, all wounds were healing, and pain was controlled with oral analgesics. Pt was discharged to home in good condition with appropriate follow up instructions.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Motrin / morphine / codeine / Penicillins / Ativan Attending: ___. Chief Complaint: fever, confusion Major Surgical or Invasive Procedure: None History of Present Illness: ___ female with history of asthma presents with temp of 101 and concern for confusion. Two days prior to admission, patient developed a sore throat and became fatigued. She stayed at her mother's house and notably slept a lot. She had a fever to 100.3 at the time which did not resolved with tylenol. She developed joints pains and aches all over. She was unable to tolerate food or drink on ___. Her mother noted that she was not herself and was speaking slowly and asking where she was. She developed a fever to 101 the day prior to admission. She also developed yellow/bloody rhinorrhea and a cough. The patient has not had any sick contacts. She had a recent GI illness with N/V/D for three days last weekend and many people at work had the same symptoms. No N/V/D currently. She attended a concert with a friend ___ night and felt well. In the ED, initial vitals were: 00:16 T 99.7 HR 90 BP 143/81 RR 20 O2 98% 0; Tmax 100 while in ED. - Labs were signfiicant for wbc 9.9 with lactate 1.0. - CXR showed no acute process and imaging of soft tissues of neck was unremarkable - LP was performed showing 3wbc, 92 lymphs, 29 protein, 61glc. - Patient was given 1g vanc, 1g po tylenol, and 25mcg IV fentanyl. On the floor, initial vitals were: Today 05:54 0 98.5 84 142/57 16 98% RA Patient described feeling tired and achey but otherwise okay. She was alert and oriented x 3. Throat is painful with swallowing only. Denies any palpitations, CP, SOB. Mild frontal headache at times. She is not sexaully active. No tobacco, ETOH, or drug use. ROS: (+) Per HPI (-) Denies recent weight loss or gain. 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: Asthma Congenital deformity of left arm Fracture of left arm s/p surgical fixation Social History: ___ Family History: Mother with sjogrens Physical Exam: ADMSSION PHYSICAL EXAM: VS: T: 98.9 BP 136/58 HR 66 RR 20 O2 100RA GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD, tenderness all anterior neck LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, left arm short SKIN: no rashes NEURO: pupils equally reactive but R>L, EOMI, face symmetric, strength intact, follows commands DISCHARGE PHYSICAL EXAM: GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD, tenderness all anterior neck LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, left arm short SKIN: no rashes NEURO: pupils equally reactive but R>L, EOMI, face symmetric, strength intact, follows commands, visual fields intact, visual acuity intact Pertinent Results: ADMISSION LABS: ___ 02:00AM BLOOD WBC-9.9 RBC-4.46 Hgb-12.7 Hct-38.0 MCV-85 MCH-28.5 MCHC-33.4 RDW-12.4 RDWSD-38.7 Plt ___ ___ 02:00AM BLOOD Neuts-78.5* Lymphs-11.8* Monos-8.8 Eos-0.2* Baso-0.4 Im ___ AbsNeut-7.75* AbsLymp-1.17* AbsMono-0.87* AbsEos-0.02* AbsBaso-0.04 ___ 02:00AM BLOOD ___ PTT-28.0 ___ ___ 02:00AM BLOOD Glucose-94 UreaN-8 Creat-0.7 Na-135 K-3.4 Cl-101 HCO3-21* AnGap-16 ___ 02:19AM BLOOD Lactate-1.0 DISCHARGE LABS: ___ 07:20AM BLOOD WBC-5.4 RBC-4.54 Hgb-12.8 Hct-39.9 MCV-88 MCH-28.2 MCHC-32.1 RDW-12.7 RDWSD-40.5 Plt ___ ___ 07:20AM BLOOD Glucose-80 UreaN-8 Creat-0.7 Na-135 K-4.6 Cl-102 HCO3-22 AnGap-16 ___ 07:20AM BLOOD Calcium-9.3 Phos-3.1 Mg-1.9 MICRO: ___ 02:00AM URINE Color-Yellow Appear-Clear Sp ___ ___ 02:00AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-80 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 02:00AM URINE RBC-1 WBC-3 Bacteri-FEW Yeast-NONE Epi-<1 ___ 02:00AM URINE UCG-NEGATIVE ___ 02:57AM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-1* Polys-0 ___ ___ 02:57AM CEREBROSPINAL FLUID (CSF) TotProt-29 Glucose-61 ___ 2:57 am CSF;SPINAL FLUID LP TUBE # 3. **FINAL REPORT ___ GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ___ 2:00 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. IMAGING: Neck Xray: No tracheal narrowing or thickening of the prevertebral soft tissues is noted. CXR: No acute cardiopulmonary process. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Citalopram 20 mg PO DAILY Discharge Medications: 1. Citalopram 20 mg PO DAILY 2. Acetaminophen 1000 mg PO Q6H:PRN pain Discharge Disposition: Home Discharge Diagnosis: Primary: viral illness Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: NECK SOFT TISSUES INDICATION: History: ___ with sore throat // eval for rpa COMPARISON: No comparison IMPRESSION: No tracheal narrowing or thickening of the prevertebral soft tissues is noted. Radiology Report INDICATION: Evaluate for pneumonia in a patient with fever. COMPARISON: None available. FINDINGS: Frontal and lateral chest radiographs demonstrate a normal cardiomediastinal silhouette and fairly well-aerated lungs which are without focal consolidation, pleural effusion, or pneumothorax. The visualized upper abdomen is unremarkable. IMPRESSION: No acute cardiopulmonary process. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Weakness, Sore throat Diagnosed with FEVER, UNSPECIFIED, ALTERED MENTAL STATUS temperature: 99.7 heartrate: 90.0 resprate: 20.0 o2sat: 98.0 sbp: 143.0 dbp: 81.0 level of pain: 13 level of acuity: 2.0

___ female with history of asthma admitted with temp to 101, mild confusion, and body aches. She had an LP in the ED due to concern for confusion which was unremarkable. Patient was A&Ox3 while inpatient. She had a mild fever, sore throat, rhinorrhea, cough, fatigue and body aches which was likely secondary to a viral illness. She was starting to feel better and tolerating a regular diet on day of discharge. Has a history of asthma but no symptoms during admission. She was discharged to stay with her mother.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Amoxicillin / metformin Attending: ___. Chief Complaint: right abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a ___ female with history of ulcerative colitis, tracheomalacia s/p tracheobronchoplasty, COPD on home O2, and aortic regurgitation who presents with abdominal pain and diarrhea for 3 days. Four weeks ago, she reports onset of diffuse achy lower back and abdominal pain that was intermittent for several weeks. However, starting three days ago, she reports onset of a new, diffuse abdominal cramping that started in the lower abdomen subsequently migrating to the upper abdomen. She reports associated multiple bouts of non-bilious, non-bloody emesis as well as melena after eating cabbage and beans. The pain has evolved to a constant achy pain worst on the right side at time of evaluation today. She labels the pain a 5 out of 10 of severity. She has not vomited since ___ and has since been able to tolerate a regular diet. She reports some dysuria and a possible "orange"-colored urine. No history of kidney stones. No fevers or chills. She reports this episode is unlike her usual UC flares when she instead has high-frequency of loose stools with bright red blood, which she currently denies. Past Medical History: COPD (on 2L home O2) Asthma Allergic rhinitis Atopic dermatitis HTN AoRegurgitation Major Depressive Disorder with Psychotic Features History of Polysubstance Abuse, primarily Cocaine Anxiety Disorder NOS with Situationally Bound Panic Attacks with Agoraphobia Polysubstance abuse hx Ulcerative colitis menorrhagia GERD OSA Narcolepsy Right humerus fx Social History: ___ Family History: No family hx of cancer or CAD or DVT/PE. Mother with DM and emphysema + tobacco use. She died of carbon monoxide poisoning. She doesn't know what diseases her father had. Her brother is in good health. Physical Exam: General- well-appearing, obese, NAD, not jaundiced HEENT- PERRL, EOMI, sclera anicteric, moist mucus membranes Cardiac- RRR Chest- CTAB Abdomen- No bowel sounds, soft, diffuse mild tenderness to deep palpation, worst in RLQ, positive Rovsing sign. No rebound or guarding. Negative psoas or obdurator sign. Back- Bilateral mild CVA tenderness Ext- WWP, 1+ edema Discharge Physical: VS: 98.0PO 120 / 71 93 18 97 2L Gen: sitting at edge of bed, dressed, NAD Pulm: faint wheeze Card:HRR Abd: soft, obese, mild TTP in LLQ Ext: baseline pedal edema Pertinent Results: ___ 04:00AM BLOOD WBC-6.3 RBC-3.88* Hgb-10.6* Hct-33.3* MCV-86 MCH-27.3 MCHC-31.8* RDW-14.8 RDWSD-45.8 Plt ___ ___ 04:04AM BLOOD WBC-5.8 RBC-3.64* Hgb-10.0* Hct-31.3* MCV-86 MCH-27.5 MCHC-31.9* RDW-14.7 RDWSD-46.7* Plt ___ ___ 03:55AM BLOOD WBC-6.6 RBC-3.81* Hgb-10.3* Hct-32.9* MCV-86 MCH-27.0 MCHC-31.3* RDW-14.8 RDWSD-47.2* Plt ___ ___ 03:42AM BLOOD WBC-7.0 RBC-3.84* Hgb-10.4* Hct-33.3* MCV-87 MCH-27.1 MCHC-31.2* RDW-14.9 RDWSD-47.7* Plt ___ ___ 06:05PM BLOOD WBC-8.1 RBC-4.59 Hgb-12.4 Hct-39.4 MCV-86 MCH-27.0 MCHC-31.5* RDW-14.7 RDWSD-46.1 Plt ___ ___ 04:00AM BLOOD Glucose-144* UreaN-9 Creat-0.7 Na-141 K-4.2 Cl-102 HCO3-28 AnGap-11 ___ 04:04AM BLOOD Glucose-114* UreaN-10 Creat-0.7 Na-142 K-4.4 Cl-103 HCO3-28 AnGap-11 ___ 03:55AM BLOOD Glucose-127* UreaN-8 Creat-0.7 Na-141 K-3.8 Cl-101 HCO3-28 AnGap-12 ___ 03:42AM BLOOD Glucose-105* UreaN-9 Creat-0.7 Na-143 K-3.9 Cl-105 HCO3-28 AnGap-10 ___ 06:05PM BLOOD Glucose-190* UreaN-13 Creat-0.9 Na-141 K-4.9 Cl-103 HCO3-22 AnGap-16 ___ 04:00AM BLOOD ALT-113* AST-45* AlkPhos-199* TotBili-0.2 ___ 09:50AM BLOOD ALT-129* AST-42* AlkPhos-209* TotBili-0.3 ___ 04:04AM BLOOD ALT-128* AST-41* AlkPhos-200* TotBili-0.2 ___ 03:55AM BLOOD ALT-162* AST-31 AlkPhos-221* TotBili-0.4 ___ 03:42AM BLOOD ALT-216* AST-54* AlkPhos-241* TotBili-0.4 ___ 04:00AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.8 ___ 04:04AM BLOOD Calcium-8.5 Phos-4.1 Mg-2.0 ___ 03:55AM BLOOD Calcium-8.6 Phos-4.5 Mg-2.2 Imaging: ___ Liver US: 1. Echogenic liver consistent with steatosis. Other forms of liver disease including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded on the basis of this examination. 2. No evidence of biliary pathology. ___ CT A/P: Acute uncomplicated appendicitis. ___ MRCP: 1. Cholelithiasis. No evidence of choledocholithiasis. 2. No focal liver lesions or abnormal hepatic parenchymal signal. Medications on Admission: 1. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*24 Tablet Refills:*0 2. MetroNIDAZOLE 500 mg PO TID RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day Disp #*42 Tablet Refills:*0 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB/wheeze 5. Atorvastatin 20 mg PO QPM 6. FLUoxetine 60 mg PO DAILY 7. Fluticasone Propionate 110mcg 2 PUFF IH BID 8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 9. Lisinopril 20 mg PO DAILY 10. Mesalamine ___ 1600 mg PO TID 11. Modafinil 100 mg PO DAILY 12. Montelukast 10 mg PO DAILY 13. Omeprazole 20 mg PO BID 14. Theophylline SR 300 mg PO BID 15. Tiotropium Bromide 1 CAP IH DAILY 16. TraZODone 50 mg PO QHS:PRN insomnia Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*24 Tablet Refills:*0 2. MetroNIDAZOLE 500 mg PO TID RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day Disp #*42 Tablet Refills:*0 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB/wheeze 5. Atorvastatin 20 mg PO QPM 6. FLUoxetine 60 mg PO DAILY 7. Fluticasone Propionate 110mcg 2 PUFF IH BID 8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 9. Lisinopril 20 mg PO DAILY 10. Mesalamine ___ 1600 mg PO TID 11. Modafinil 100 mg PO DAILY 12. Montelukast 10 mg PO DAILY 13. Omeprazole 20 mg PO BID 14. Theophylline SR 300 mg PO BID 15. Tiotropium Bromide 1 CAP IH DAILY 16. TraZODone 50 mg PO QHS:PRN insomnia Discharge Disposition: Home Discharge Diagnosis: appendicitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: MRCP INDICATION: ___ hx ulcerative colitis, tracheomalcia s/p tracheobronchoplasty, aortic regurg, COPD (home O2) p/w 3 days of abdominal pain, new transaminitis, CT c/f acute appendicitis for reason of transaminitis. TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were acquired in a 1.5 T magnet. Intravenous contrast: 13 mL Gadavist. Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered for oral contrast. COMPARISON: CT abdomen and pelvis ___ FINDINGS: Lower Thorax: The lung bases are clear. Liver: The liver is normal in morphology and signal intensity. There is no significant drop of signal on out-of-phase imaging to suggest steatosis. No focal liver lesions are seen. There is no ascites. Biliary: There is cholelithiasis. No MR evidence of acute cholecystitis. There is no intra or extrahepatic biliary duct dilation. No evidence of choledocholithiasis. Pancreas: The pancreas is normal in morphology and signal intensity. There are no focal pancreatic lesions. There is no pancreatic duct dilation. Spleen: The spleen is normal in size. Note is made of a small accesory spleen. Adrenal Glands: The right and left adrenal glands are unremarkable. Kidneys: The kidneys are symmetric in size. No focal renal lesion is seen. Gastrointestinal Tract: There is no hiatal hernia. Views of the small and large bowel are unremarkable. Lymph Nodes: There is no mesenteric or retroperitoneal adenopathy. Vasculature: There is no abdominal aortic aneurysm. Hepatic arterial anatomy is conventional. Portal vein is patent. Osseous and Soft Tissue Structures: There is no suspicious bony lesion. Note is made of asymmetric atrophy of the right greater than left body wall musculature. IMPRESSION: 1. Cholelithiasis. No evidence of choledocholithiasis. 2. No focal liver lesions or abnormal hepatic parenchymal signal. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Abd pain Diagnosed with Unspecified acute appendicitis temperature: 98.9 heartrate: 118.0 resprate: 16.0 o2sat: 98.0 sbp: 122.0 dbp: 72.0 level of pain: 6 level of acuity: 3.0

The patient is a ___ female with history of ulcerative colitis, tracheomalacia s/p tracheobronchoplasty, COPD on home O2, and aortic regurgitation who presented with abdominal pain and diarrhea for 3 days consistent with appendicitis. Her appendicitis was treated non operatively with cipro and flagyl. An MRCP was done for concern for PSC in the setting of ulcerative colitis. GI was also consulted for elevated LFTs. They recommended an MRCP which showed a normal liver, cholelithasis, and no choledocholithiasis. Hepatitis panel which was also negative. On day of discharge, the patient was not having any nausea, vomiting. She was tolerating PO pain meds and LFTs were downtrending. The patient was discharged from the hospital in stable condition on 2 weeks of antibiotics. She was scheduled for follow up in ___ clinic.

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, fevers Major Surgical or Invasive Procedure: None History of Present Illness: ___ male with a history of hypertension, GERD, dyslipidemia, remote bowel resection for colonic lipoma and peptic ulcer disease s/p vagotomy (in ___ who presents with abdominal pain. 2 weeks ago, the patient developed gradual onset abdominal pain which is been waxing and waning but overall constant per report. He says it is been nonradiating. The pain is intermittently on the left, right and center, but typically is around the umbilical level. The pain is not associated with p.o. intake or improved by p.o. The pain is not improved or worsened by movement or exercise. The pain is typically dull but gets sharp when he presses and he occasionally has sharp pains that have woken him from sleep. He has had nausea without vomiting. He intermittently has small bowel movements which are at his baseline and he denies any hematochezia or melena. He has also had intermittent fevers for the past 3 days up to 38.5 °C yesterday. He has had no difficulty with urination or blood in his urine. Denies chest pain, shortness of breath, palpitations, cough, or lightheadedness. He denies any headache or double vision. He denies any testicular pain or penile discharge. No recent travel and no sick contacts. He has been taking Aleve for the pain, which is mildly effective. His prior encounters at ___ are notable for an admission to general surgery in ___ for abdominal cramping and blood per rectum for 6 weeks. He had a laparoscopy sigmoid colectomy with removal of sigmoid mass. Pathology revealed that the mass was a lipoma. He also presented to ___ ED in ___ with rectal bleeding. His evaluation was benign and he was discharged to the care of his PCP. - In the ED, initial vitals were: T 95.8F HR 104 BP 142/83 RR 20 100% RA - Exam was notable for: "Diffuse abd ttp wo peritonitic signs, worse on R." - Labs were notable for: WBC 18 Hgb 12.9 Plt 355 BMP overall unremarkable ALT 59 Alk phos 156 AST 37 T bili 0.4 INR 1.3 UA w/ small ketones, urobil, and RBCs - Studies were notable for: CT Abd/Pelv w/ contrast: Significant wall thickening of the terminal ileum, cecum, and proximal ascending: With surrounding fat stranding and prominent ileocolic lymph nodes, suggestive of terminal ileitis; however, an underlying mass cannot be excluded. The appendix is normal. Recommend follow-up CT or colonoscopy once the acute process resides to ensure resolution and exclude an underlying mass. - The patient was given: 3L LR IV Morphine Sulfate 4 mg IV Ampicillin-Sulbactam 3 g PO Acetaminophen 1000 mg On arrival to the floor, he reports some continued abdominal pain around his umbilicus and in the right lower quadrant. There is some radiation to the back from this. He thinks that some of his nausea was attributable to the NSAIDs and Tylenol he was taking. He otherwise does not have any current symptoms. Past Medical History: Hypertension GERD Peptic ulcer disease s/p vagotomy Sigmoid lipoma s/p partial sigmoid colectomy (___) Dyslipidemia Social History: ___ Family History: CAD, HTN Physical Exam: ADMISSION PHYSICAL EXAM ========================== VITALS: ___ 2335 Temp: 98.1 PO BP: 134/82 HR: 89 RR: 18 O2 sat: 92% O2 delivery: Ra GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. 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. ABDOMEN: Somewhat hyperactive bowel sounds, non distended, mildly tender to deep palpation throughout, more so in the right lower quadrant. No peritoneal signs. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rashes. NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs spontaneously. ___ strength throughout. Normal sensation. DISCHARGE PHYSICAL EXAM ========================== VITALS: 24 HR Data (last updated ___ @ 1855) Temp: 99.5 (Tm 99.5), BP: 137/90 (125-139/87-90), HR: 88 (84-94), RR: 18 (___), O2 sat: 97% (95-97), O2 delivery: Ra GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. 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. ABDOMEN: Normal bowel sounds, non distended, mildly tender to deep palpation throughout, more so in the right lower quadrant. No peritoneal signs. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rashes. NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs spontaneously. ___ strength throughout. Normal sensation. Pertinent Results: ADMISSION LABS ================= ___ 12:00PM BLOOD WBC-18.0* RBC-4.59* Hgb-12.9* Hct-39.7* MCV-87 MCH-28.1 MCHC-32.5 RDW-14.0 RDWSD-44.5 Plt ___ ___ 12:00PM BLOOD Neuts-84.9* Lymphs-4.7* Monos-9.6 Eos-0.2* Baso-0.2 Im ___ AbsNeut-15.24* AbsLymp-0.85* AbsMono-1.73* AbsEos-0.04 AbsBaso-0.03 ___ 12:00PM BLOOD ___ PTT-41.0* ___ ___ 12:00PM BLOOD Glucose-111* UreaN-14 Creat-0.9 Na-142 K-4.8 Cl-103 HCO3-25 AnGap-14 ___ 12:00PM BLOOD ALT-59* AST-37 AlkPhos-156* TotBili-0.4 ___ 12:00PM BLOOD Albumin-3.7 ___ 12:00PM BLOOD CRP-179.0* PERTINENT LABS ================= ___ 05:10AM BLOOD ALT-88* AST-91* AlkPhos-176* TotBili-0.6 ___ 05:02AM BLOOD ALT-61* AST-31 LD(LDH)-189 AlkPhos-152* TotBili-0.3 ___ 05:10AM BLOOD Calcium-9.0 Phos-2.9 Mg-1.8 Iron-20* ___ 05:10AM BLOOD calTIBC-264 Ferritn-477* TRF-203 ___ 05:02AM BLOOD Hapto-510* ___ 05:10AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG IgM HAV-NEG ___ 08:10PM BLOOD CMV IgG-POS* CMV IgM-POS* CMVI-In the app EBV IgG-POS* EBNA-POS* EBV IgM-PND EBVI-PND ___ 08:10PM BLOOD CMV VL-NOT DETECT ___ 08:10PM BLOOD HERPES SIMPLEX VIRUS 1 AND 2 ANTIBODY IGM-PND ___ 08:10PM BLOOD YERSINIA ENTERCOLITICA ANTIBODIES (IGG,IGA)-PND DISCHARGE LABS ================= ___ 06:43AM BLOOD WBC-10.2* RBC-4.33* Hgb-12.2* Hct-37.8* MCV-87 MCH-28.2 MCHC-32.3 RDW-14.3 RDWSD-46.3 Plt ___ ___ 06:43AM BLOOD Glucose-106* UreaN-13 Creat-1.0 Na-142 K-5.4 Cl-102 HCO3-25 AnGap-15 IMAGING ================= CT A/P ___ IMPRESSION: 1. Marked wall thickening of the terminal ileum in very distal ileum and wall thickening to a lesser extent involving the cecum and proximal ascending colon. 5 x 4.0 cm region of likely phlegmon superior to the thickened terminal ileum. Numerous associated mildly prominent likely reactive right abdominal ileocolic lymph nodes. Consultation of findings most compatible with terminal ileitis and associated phlegmonous change. Differential diagnosis includes inflammatory bowel disease, including Crohn's disease, other inflammatory process, versus infectious ileitis. No free air or extraluminal oral contrast seen. No drainable collection. 2. Normal caliber appendix. RECOMMENDATION(S): Recommend follow-up CT or colonoscopy once the acute process resides to ensure resolution and exclude an underlying mass. RUQUS ___ IMPRESSION: 1. Normal appearance of the liver parenchyma. No focal liver lesions are identified. 2. Nondistended gallbladder with trace wall edema versus pericholecystic fluid. Findings may be related to third spacing. No other sonographic findings to suggest cholecystitis. MICROBIOLOGY ================ ___ 10:26 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA FOUND. Medications on Admission: None Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO BID Duration: 7 Days RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 2. MetroNIDAZOLE 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*21 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS =================== Terminal Ileitis SECONDARY DIAGNOSIS ====================== Peptic Ulcer Disease 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 hx bowel resection here w fevers, diffuse abdominal pain worst on RLQ/RUQ.//eval bowel obstruction vs appy vs biliary infection vs other infectious process 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 6.4 s, 50.1 cm; CTDIvol = 10.7 mGy (Body) DLP = 537.5 mGy-cm. Total DLP (Body) = 546 mGy-cm. COMPARISON: None. FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. There is marked wall thickening of the terminal and very distal ileum and wall thickening to a lesser extent involving the cecum and proximal ascending colon. A 5 x 4.0 cm region likely phlegmonous changes seen superior to the thickened terminal ileum, series 601, image 28. Numerous associated mildly prominent and likely reactive right lower quadrant ileocolic lymph nodes are seen. No free air or drainable fluid collection is seen. The appendix is normal in caliber. Patient is status post partial sigmoid resection, with anastomosis seen. PELVIS: The urinary bladder and distal ureters are unremarkable. LYMPH NODES: Prominent right ileocolic lymph nodes, likely reactive. 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: Bilateral fat containing inguinal hernias are seen. IMPRESSION: 1. Marked wall thickening of the terminal ileum in very distal ileum and wall thickening to a lesser extent involving the cecum and proximal ascending colon. 5 x 4.0 cm region of likely phlegmon superior to the thickened terminal ileum. Numerous associated mildly prominent likely reactive right abdominal ileocolic lymph nodes. Consultation of findings most compatible with terminal ileitis and associated phlegmonous change. Differential diagnosis includes inflammatory bowel disease, including Crohn's disease, other inflammatory process, versus infectious ileitis. No free air or extraluminal oral contrast seen. No drainable collection. 2. Normal caliber appendix. RECOMMENDATION(S): Recommend follow-up CT or colonoscopy once the acute process resides to ensure resolution and exclude an underlying mass. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year old man with transaminitis and abdominal pain of unclear etiology// eval for cause of transaminitis TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: CT abdomen pelvis performed ___. FINDINGS: LIVER: The hepatic parenchyma appears within normal limits. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 4 mm GALLBLADDER: The gallbladder is not distended. There is trace wall edema versus pericholecystic fluid, possibly related to third spacing. PANCREAS: The pancreas is not well visualized, largely obscured by overlying bowel gas. SPLEEN: Normal echogenicity. Spleen length: 9.2 cm KIDNEYS: Limited views of the kidneys show no hydronephrosis. Right kidney: 11.2 cm Left kidney: 11.2 cm RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. Normal appearance of the liver parenchyma. No focal liver lesions are identified. 2. Nondistended gallbladder with trace wall edema versus pericholecystic fluid. Findings may be related to third spacing. No other sonographic findings to suggest cholecystitis. Gender: M Race: WHITE - RUSSIAN Arrive by WALK IN Chief complaint: Abd pain, Fever Diagnosed with Crohn's disease of small intestine without complications temperature: 95.8 heartrate: 104.0 resprate: 20.0 o2sat: 100.0 sbp: 142.0 dbp: 83.0 level of pain: 4 level of acuity: 3.0

SUMMARY =============== ___ male with a history of GERD, peptic ulcer s/p vagotomy, and sigmoid lipoma s/p partial sigmoid colectomy (___) who presented with fevers and abdominal pain with features of enterocolitis noted on imaging. He was started on ciprofloxacin and flagyl with improvement in his symptoms. He was seen by gastroenterology, who recommended outpatient colonoscopy for further follow up. TRANSITIONAL ISSUES ===================== [] At time of discharge, patient did not have an outpatient colonoscopy scheduled but had been ordered. Please confirm with patient that this has been scheduled for the next few weeks after he completes course of antibiotics. [] Patient with " Marked wall thickening of the terminal ileum in very distal ileum and wall thickening to a lesser extent involving the cecum and proximal ascending colon. 5 x 4.0 cm region of likely phlegmon superior to the thickened terminal ileum." found on CT A/P. Recommend that patient has a follow up CT or colonoscopy once the acute process resides to ensure resolution and exclude underlying mass. [] Patient discharged on ciprofloxacin and flagyl for a 10 day course scheduled to end ___. [] Patient found to be CMV IGM and IGG positive. Per GI, there was no indication for antiviral treatment or colonoscopy at this time because patient is immunocompetant. GI will follow with outpatient colonoscopy. [] Recommend outpatient vaccination for hepatitis. ACUTE ISSUES ================= # Terminal ileitis He presented with 2 weeks of abdominal pain and intermittent fevers and was found on imaging to have findings consistent with terminal ileitis. This is typically associated with Crohn's disease although there are other associated conditions such as ulcerative colitis, infection or less likely NSAID ileitis. CRP at admission was elevated to 179. He was started on cipro and flagyl with improvement in his abdominal pain. GI was consulted and recommended sending off serologies. At the time of discharge, patient was noted to be CMV IgM positive, IgG positive, EBV IgG positive. Per GI, since patient was immunocompetant, they believed this was likely infectious and recommended continuing antibiotics and setting up an outpatient colonoscopy once the infection resolved. # Mild normocytic anemia Suspect reactive from illness however pt has prior hx of BRBPR iso lipoma. Low iron. Hemolysis labs negative. No evidence of active bleeding. # Mild transaminitis Initially presented with transaminitis that improved by discharge. RUQUS negative for biliary process. Likely secondary to infection as above. Hepatitis panels negative.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Doxycycline / erythromycin base / Penicillins Attending: ___. Chief Complaint: rash Major Surgical or Invasive Procedure: none History of Present Illness: HISTORY OF PRESENT ILLNESS: ___ year old F with breast cancer with mets to the liver, spine, and brain who is on Herceptin/Pertuzumab/Paclitazel and on dexamethasone daily s/p prior whole brain radiation who presents with painful rash in the R leg. Per family, rash developed about a week ago and has been painful and itchy. Pt brought to the ED where the rash was concerning for disseminated Zoster, so she was admitted for further care. On arrival to the floor, pt is not a good historian, but reports symptoms from rash for about a day w/ burning pain. No fevers or chills. No vision changes. No headache or neck stiffness. No auditory changes or dizziness. No cough or dyspnea. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: PAST ONCOLOGIC HISTORY: ___ Liver biopsy Pathology: Metastatic carcinoma with focal necrosis, consistent with a breast origin, focally positive for mammoglobin and GCDFP, and negative for TTF-1 and Napsin, ER-/PR-/Her2+ ___ Right mastectomy Pathology: Invasive ductal carcinoma (palliative for extensive lesion of right chest wall with ulcerations Dr. ___ ___ Trastuzumab ___ Trastuzumab ___ Paclitaxel-trastuzumab at 60% dosing ___ elevated LFTs and jaundice. Continued weekly trastuzumab + paclitaxel with gradual escalation to 80mg/m2. ___ Paclitaxel-trastuzumab ___ Paclitaxel-trastuzumab ___ Trastuzumab ___ Brain MRI negative ___ Paclitaxel-trastuzumab ___ Trastuzumab ___ Poor balance and fatigue started ___ Fall ___ Brain MRI showed many lesions ___ - ___ Whole brain radiation-C2 5x4 Gy ___ - ___ XRT to T8-L2 5x4 Gy ___ Trastuzumab ___ Trastuzumab ___ Brain MRI improved ___ Trastuzumab ___ Taxol/Pertuzumab PAST MEDICAL HISTORY: Painful bladder syndrome s/p DMSO instillations Recurrent UTIs HTN DM2 HBV on entecavir Social History: ___ Family History: No history of malignancy or bleeding disorders. Physical Exam: ADMISSION PHYSICAL EXAM ====================== Vitals: 97.7 154/90 66 18 100 RA GENERAL: NAD HEENT: no conjunctival injection, pupils equal and reactive NECK: supple neck LUNGS: faint bibasilar rales CV: regular ABD: soft, nontender, nondistended EXT: no edema SKIN: vesicular rash in different stages of evolution w/ few vesicles present on inner thigh on erythematous background w/ other crusted vesicles present throughout proximal thigh, above the knee and up to the groin - crossing L1-L3 dermatome ACCESS: R port DISCHARGE PHYSICAL EXAM ======================= Vitals: 97.9 (afebrile overnight) 119 / 70 79 18 99 RA I/O: residual of 33cc following urinating GENERAL: Sitting comfortably in chair, NAD, appears alert HEENT: Anicteric sclera, MMM, OP clear, no sign of thrush, round face NECK: supple, no LAD LUNGS: CTAB, no wheezes/crackles, breathing comfortably on RA CARD: RRR, S1 + S2 present, no m/r/g ABD: soft, non-distended, mild TTP in central lower abdomen, +BS, no HSM EXT: WWP, no ___ edema, PPP SKIN: R thigh zoster lesions healing well with no purulence. R thigh has superficial erosion c/w skin breakdown, with no purulence. Back: Mepilex in place ACCESS: Port c/d/1, no erythema or tenderness around port. No drainage. Pertinent Results: ADMISSION LABS ==================== ___ 06:05PM BLOOD WBC-5.3 RBC-3.22* Hgb-10.8* Hct-34.6 MCV-108* MCH-33.5* MCHC-31.2* RDW-16.9* RDWSD-67.4* Plt ___ ___ 06:05PM BLOOD Neuts-88* Bands-2 Lymphs-5* Monos-4* Eos-0 Baso-0 ___ Metas-1* Myelos-0 AbsNeut-4.77 AbsLymp-0.27* AbsMono-0.21 AbsEos-0.00* AbsBaso-0.00* ___ 06:05PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-1+* Microcy-NORMAL Polychr-NORMAL ___ 06:05PM BLOOD Plt Smr-NORMAL Plt ___ ___ 06:05PM BLOOD Glucose-227* UreaN-17 Creat-0.4 Na-141 K-4.1 Cl-103 HCO3-24 AnGap-14 ___ 06:05PM BLOOD ALT-41* AST-21 AlkPhos-69 TotBili-0.4 ___ 06:05PM BLOOD Albumin-3.6 ___ 05:00AM BLOOD HBV VL-NOT DETECT ___ 02:11AM BLOOD Type-CENTRAL VE Temp-37.8 pO2-70* pCO2-53* pH-7.33* calTCO2-29 Base XS-0 Comment-GREEN TOP ___ 02:11AM BLOOD Lactate-2.6* MICROBIOLOGY ============ Blood culture (___): Negative Skin scraping VZV culture (___): Negative URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 CFU/mL. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- <=1 S IMAGING ======= CT Head (___): 1. Study is mildly degraded by motion. 2. No evidence of hemorrhage or definite acute large territorial infarct. 3. Vasogenic edema in the left occipital lobe related to known metastatic lesion is grossly unchanged in comparison with MRI from ___. 4. Known metastatic lesions are better evaluated on brain MRI from ___. 5. Probable posttreatment changes in the subcortical white matter, as described, with differential consideration of vasogenic edema. Allowing for difference in technique, finding is grossly similar to ___ prior brain MRI. 6. Left maxillary periodontal disease, as described. CXR (___) In comparison with the study of ___, the cardiac silhouette is at the upper limits of normal in size and there is mild tortuosity of the descending aorta. No evidence of appreciable pulmonary vascular congestion. Mild atelectatic changes are seen at the bases with blunting of the right costophrenic angle. No evidence of acute focal pneumonia. MRI Head (___) 1. Enlargement of innumerable enhancing cortical lesions compatible with a history of metastatic disease. 2. Increased periventricular white matter hyperintensity that may be treatment related. 3. Increased edema surrounding the left frontal and occipital metastases. DISCHARGE LABS ============== WBC-11.2* RBC-3.06* Hgb-10.2* Hct-32.5* MCV-106* MCH-33.3* MCHC-31.4* RDW-17.9* RDWSD-69.2* Plt ___ Neuts-74* Bands-7* Lymphs-7* Monos-3* Eos-0 Baso-0 Atyps-0 Metas-7* Myelos-2* NRBC-1* AbsNeut-9.07* AbsLymp-0.78* AbsMono-0.34 AbsEos-0.00* AbsBaso-0.00* Plt Smr-NORMAL Plt ___ Hypochr-NORMAL Anisocy-OCCASIONAL Poiklo-1+* Macrocy-1+* Microcy-NORMAL Polychr-1+* Ovalocy-1+* Tear ___ UreaN-23* Creat-0.7 Na-144 K-4.6 Cl-102 HCO3-22 AnGap-20* Calcium-9.3 Phos-4.1 Mg-2.0 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Citalopram 20 mg PO DAILY 2. Lidocaine 5% Patch 1 PTCH TD DAILY 3. Ondansetron ODT 8 mg PO Q12H:PRN Nausea 4. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H 5. Prochlorperazine 10 mg PO Q6-8H:PRN nausea 6. Lisinopril 10 mg PO DAILY 7. OxyCODONE (Immediate Release) 15 mg PO Q4H:PRN Pain - Moderate 8. Dexamethasone 2 mg PO DAILY 9. Entecavir 0.5 mg PO DAILY 10. Cyclobenzaprine 10 mg PO DAILY:PRN neck pain 11. Spironolactone 25 mg PO BID 12. MethylPHENIDATE (Ritalin) 5 mg PO BID 13. OxyCODONE SR (OxyconTIN) 15 mg PO NOON 14. Senna 8.6 mg PO BID 15. Docusate Sodium 100 mg PO BID 16. Multivitamins 1 TAB PO DAILY 17. Ensure (food supplemt, lactose-reduced) 1 can oral TID Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 2. Gabapentin 200 mg PO TID RX *gabapentin 100 mg 2 capsule(s) by mouth three times a day Disp #*100 Capsule Refills:*0 3. LevETIRAcetam 1000 mg PO Q12H RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 4. Metoclopramide 10 mg PO QIDACHS HA RX *metoclopramide HCl 10 mg 1 tab by mouth twice a day Disp #*60 Tablet Refills:*0 5. Dexamethasone 1 mg PO DAILY RX *dexamethasone 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*30 Tablet Refills:*0 7. OxyCODONE SR (OxyconTIN) 30 mg PO QAM RX *oxycodone [OxyContin] 30 mg 1 tablet(s) by mouth daily in the morning Disp #*7 Tablet Refills:*0 8. OxyCODONE SR (OxyconTIN) 20 mg PO QPM RX *oxycodone [OxyContin] 20 mg 1 tablet(s) by mouth at night Disp #*7 Tablet Refills:*0 9. OxyCODONE SR (OxyconTIN) 10 mg PO NOON RX *oxycodone [OxyContin] 10 mg 1 tablet(s) by mouth daily at noon Disp #*7 Tablet Refills:*0 10. Citalopram 20 mg PO DAILY 11. Cyclobenzaprine 10 mg PO DAILY:PRN neck pain 12. Docusate Sodium 100 mg PO BID 13. Ensure (food supplemt, lactose-reduced) 1 can oral TID 14. Entecavir 0.5 mg PO DAILY 15. Lidocaine 5% Patch 1 PTCH TD DAILY 16. Lisinopril 10 mg PO DAILY 17. MethylPHENIDATE (Ritalin) 5 mg PO BID 18. Multivitamins 1 TAB PO DAILY 19. Ondansetron ODT 8 mg PO Q12H:PRN Nausea 20. Prochlorperazine 10 mg PO Q6-8H:PRN nausea 21. Senna 8.6 mg PO BID 22. Spironolactone 25 mg PO BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: ================== Disseminated Herpes Zoster Metastatic Breast Cancer Hypernatremia Oral candidiasis Anemia SECONDARY DIAGNOSIS =================== Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD INDICATION: ___ year old woman with with metastatic breast cancer on Herceptin, Pertuzumab, and Paclitazel who is also immunosuppressed with chronic dexamethasone who is admitted for treatment of disseminated zoster.// History of metastatic breast cancer. Please evaluate for interval change. Please also evaluate for ?encephalitis/meningitis in setting of disseminated zoster. TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of 6 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: Brain MR ___. FINDINGS: Again seen are innumerable cortical enhancing masses located in the supra and infratentorial compartments. Most of these lesions were identified previously. However, several are new and almost all have enlarged since the prior study. Of course, the new lesions may have been present on the prior study, but too small to reliably detect. The superficial pattern of these lesions is unchanged and suggests a component of leptomeningeal infiltration. There is no evidence of hemorrhage or infarction. Diffuse periventricular white matter hyperintensity appears to have progressed since the study of ___, this may be treatment related. Left posterior frontal and left occipital regions of edema are more prominent on the current examination than on ___. IMPRESSION: 1. Enlargement of innumerable enhancing cortical lesions compatible with a history of metastatic disease. 2. Increased periventricular white matter hyperintensity that may be treatment related. 3. Increased edema surrounding the left frontal and occipital metastases. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with metastatic breast cacner admitted with disseminated zoster. Hypotensive and obtunded// Eval etiology of hypotension. IMPRESSION: In comparison with the study of ___, the cardiac silhouette is at the upper limits of normal in size and there is mild tortuosity of the descending aorta. No evidence of appreciable pulmonary vascular congestion. Mild atelectatic changes are seen at the bases with blunting of the right costophrenic angle. No evidence of acute focal pneumonia. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman with breast cancer, brain metastases. Now with apneic periods, low RR// please eval for hemorrhage or edema 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) = 856 mGy-cm. COMPARISON: ___ contrast brain MRI. ___ noncontrast head CT. FINDINGS: Study is mildly degraded by motion. There is no evidence of acute hemorrhage. There remains vasogenic edema within the left occipital lobe. Diffuse subcortical white matter hypodensities corresponds to T2 and FLAIR hyperintensities on MRI. The known innumerable metastatic lesions are not well appreciated on noncontrast CT, and are better evaluated on brain MRI from ___. The ventricles and sulci are grossly stable in size and configuration. There is no evidence of fracture. Mild mucosal thickening is noted in the maxillary sinuses and anterior ethmoid air cells, otherwise the visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. Limited imaging the teeth demonstrate left maxillary tooth periapical lucency (see 11:21; 10:20). IMPRESSION: 1. Study is mildly degraded by motion. 2. No evidence of hemorrhage or definite acute large territorial infarct. 3. Vasogenic edema in the left occipital lobe related to known metastatic lesion is grossly unchanged in comparison with MRI from ___. 4. Known metastatic lesions are better evaluated on brain MRI from ___. 5. Probable posttreatment changes in the subcortical white matter, as described, with differential consideration of vasogenic edema. Allowing for difference in technique, finding is grossly similar to ___ prior brain MRI. 6. Left maxillary periodontal disease, as described. Gender: F Race: ASIAN - CHINESE Arrive by WALK IN Chief complaint: Rash Diagnosed with Rash and other nonspecific skin eruption temperature: 98.3 heartrate: 80.0 resprate: 16.0 o2sat: 100.0 sbp: 152.0 dbp: 84.0 level of pain: 6 level of acuity: 3.0

Ms. ___ is a ___ year-old female with metastatic breast cancer (liver, brain, and spinal cord) previously on Herceptin, Pertuzumab, and Paclitaxel admitted for treatment of disseminated zoster, and found to have progressive CNS disease.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: morphine Attending: ___. Chief Complaint: Syncope Major Surgical or Invasive Procedure: LINQ placement by cardiac electrophysiologists History of Present Illness: Mr. ___ is a ___ year old male with history of HCV Cirrhosis complicated by ascites s/p TIPS, hepatic encephalopathy who was taken off of the transplant list in ___ due to multiple DVTs found on his previous admission, on Fondaparinux, presents from OSH after a fall. He woke up in the middle of the night to go to the bathroom, and suddenly fell. He denies lightheadedness, dizziness, palpitations when he stood up. No prodrome symptoms. Did not think he tripped over anything. He did not lose conciousness per the wife who woke up when he fell. She is not sure what he hit, but there was a drawer and the edge of a wall tha the could have hit. He was awake right after the fall but was having difficulty answering her questions for about a minute. She felt a large bruise on the occipital area of the patient's head. She did not witness any seizure like activities, stool or urine incontinence. He went to ___ in ___ where CT head showed small subarachnoid hemorrhage. XR and CT of the shoulder with right distal clavicle fracture, acromion fracture, AC joint separation, glenoid fracture. He is transfered to BI per the wife's request. Of note he was discharged from rehab two weeks ago. He had presistent cough since discharge though no fever or shortness of breath. He saw his PCP ___ week ago and was started on Cefprozil 250mg Q12H. He hasn't felt a significant change in his cough over the last week but he has noticed a significant increase in his BMs. He was having ___ BM watery BMs a day up from his baseline of ___ loose BMs a day and has been intermittently refusing lactulose. Despite worsening diarrhea, patient denied ever feeling lightheaded or dizzy. After he was discharged from home, he was able to ambulate without any assistance at home. Per the wife, he was not unsteady. In the ED, initial vitals: 97.2 77 100/63 16 99% RA Labs were significant for baseline CBC, INR, BUN/Cr of ___. T bili slighly up from discharge of 2.3. Imaging showed stable SAH. Currently, patient c/o of right shoulder pain but otherwise feel well. ROS: No fevers, chills, night sweats, or weight changes. No changes in vision or hearing, no changes in balance. No cough, no shortness of breath, no dyspnea on exertion. No chest pain or palpitations. No nausea or vomiting. No constipation. No dysuria or hematuria. No hematochezia, no melena. No numbness or weakness, no focal deficits. Past Medical History: - HCV cirrhosis (Secondary to blood transfusion following a stabbing in the ___ c/b ascites, hepatic hydrothorax s/p TIPS in ___ - Upper Extremity DVT ___ L jugular and subclavian, ___ L subclavian and R basilic, on coumadin) - Alpha Thalessemia Minor? (Not confirmed) - paroxysmal AFib - Right upper extremity DVT, Left upper extremity DVT (___) - Likely Pulmonary Embolus as evidence of right heart strain on echocardiogram (___). - Small left frontal subarachnoid hemorrhage following syncopal event (___) - Right upper extremity DVT that developed while hospitalized in ___ this DVT developed while anticoagulation was being held ___ small traumatic SAH following syncopal event (___). - Wide-complex ventricular tachycardia noted during hospitaliztion in ___. LINQ placed by EP. Social History: ___ Family History: No family hx of Colon CA, Liver CA, DM or early CAD. No known family members with hemochromatosis. Physical Exam: ADMISSION PHYSICAL EXAM (___): VS: 99.5 102/71 68 18 97%RA GEN: Alert and oriented, lying still in bed in no acute distress, flat affect HEENT: MMM, OP clear, neck supple, JVP not elevated. COR: RRR, nl s1 s2, ___ holosystolic murmur PULM: mildly decreased in lower quadrants but otherwise clear ABD: Soft, non-tender, non-distended, no shifting dullness, no spider angiomas EXTREM: Warm, well-perfused, no edema. Right arm in sling. Right shoulder tender to palpation. able to move fingers of right hand. PULSES: radial and DP pulses present bilaterally NEURO: A&Ox3. CN II-XII grossly intact (unable to do right shoulder shrug because of pain), strength ___ in both hands. Did not test right upper ext. stregth. LUE ___. Bilateral lower extremities ___ strength. Sensation to soft touch throughout. Gait defered. Positive asterixis. DISCHARGE PHYSICAL EXAM (___): Vitals: 98.3 BP 99/62 HR 61 R 20 O2 100% RA. General: Alert and oriented, lying in bed w/ c-collar and right arm sling in place, appears comfortable. HEENT: C-collar in place, anicteric sclera. Lungs: Clear to auscultation bilaterally. CV: Regular rate and rhythm, normal S1 + S2, systolic murmur, no rubs or gallops CHEST: Tenderness to palpation at right lower ribs, left lower ribs. Abdomen: Soft, non-tender, no rebound tenderness or guarding Ext: Right arm mildly swollen, resting flexed at the elbow in sling, range of motion limited by pain. Right forearm is non-tender. Ecchymoses over posterior right shoulder. All extremities are well perfused, no leg edema. Neuro: Not moving right arm at the shoulder ___ shoulder injuries. Sensation/motor function intact in all distal extremities. Positive asterixis. Skin: Tanned skin. Pertinent Results: ADMISSION LABS: ================ ___ 08:15AM BLOOD WBC-7.7 RBC-4.63 Hgb-10.9* Hct-33.4* MCV-72* MCH-23.5* MCHC-32.6 RDW-15.9* RDWSD-38.7 Plt Ct-88*# ___ 08:15AM BLOOD Neuts-76.2* Lymphs-10.9* Monos-11.0 Eos-0.9* Baso-0.5 Im ___ AbsNeut-5.88 AbsLymp-0.84* AbsMono-0.85* AbsEos-0.07 AbsBaso-0.04 ___ 08:15AM BLOOD ___ PTT-37.3* ___ ___ 08:15AM BLOOD Glucose-226* UreaN-19 Creat-0.7 Na-133 K-5.0 Cl-99 HCO3-25 AnGap-14 ___ 08:15AM BLOOD ALT-28 AST-32 AlkPhos-94 TotBili-3.0* ___ 08:15AM BLOOD Lipase-22 ___ 08:15AM BLOOD cTropnT-<0.01 ___ 05:43AM BLOOD cTropnT-<0.01 ___ 04:10PM BLOOD cTropnT-<0.01 ___ 08:15AM BLOOD Albumin-2.8* Calcium-8.9 Phos-3.0 Mg-1.6 ___ 08:29AM BLOOD Lactate-2.1* DISCHARGE LABS: ================ ___ 05:25AM BLOOD WBC-5.4 RBC-4.56* Hgb-10.3* Hct-32.6* MCV-72* MCH-22.6* MCHC-31.6* RDW-16.3* RDWSD-39.9 Plt ___ ___ 05:25AM BLOOD ___ PTT-41.1* ___ ___ 05:25AM BLOOD Glucose-166* UreaN-12 Creat-0.6 Na-135 K-4.0 Cl-99 HCO3-32 AnGap-8 ___ 05:25AM BLOOD ALT-25 AST-21 AlkPhos-144* TotBili-1.9* ___ 05:25AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.8 MICROBIOLOGY: ============== ___ Blood culture pending ___ Urine culture negative ___ Blood culture negative ___ C. diff negative ___ Urine culture negative ___ Blood culture negative IMAGING: ========= CT Head (___): IMPRESSION: 1. No evidence of new hemorrhage, infarcts, or fractures. 2. Interval improvement of layering intermediate density fluid within the bilateral maxillary sinuses. Cardiac MR (___): IMPRESSION: Please note that this report only contains extracardiac findings. There is moderate gynecomastia. An enlarged 22 x 13 mm pretracheal mediastinal lymph node is nonspecific. There are bibasilar opacities and a moderate-sized bilateral pleural effusions, similar to the prior CT of the abdomen and pelvis. The right is slightly loculated. The liver has a cirrhotic morphology with evidence of iron deposition. A TIPSS is partially imaged. The spleen is enlarged, but not included in the entire field of view. There is a small amount of ascites. These findings are better characterized on the prior CT of the abdomen. The entirety of this Cardiac MRI is reported separately in the Electronic Medical Record (OMR) - Cardiovascular Reports. CT Head (___): IMPRESSION: 1. Stable small left frontal probable subarachnoid hemorrhage as described. Recommend clinical correlation and attention on followup imaging 2. No additional areas of hemorrhage. 3. Right parietal convexity soft tissue swelling, without evidence of underlying fracture. 4. Paranasal sinus disease as described. CT C-Spine (___): IMPRESSION: 1. No evidence of acute fracture or traumatic malalignment. 2. Moderate degenerative changes as described. 3. Question minimal C2 on C3 anterolisthesis. While this finding may be degenerative in nature, given the absence of any prior comparison examination, ligamentous injury cannot be excluded on the basis examination. Recommend clinical correlation for site of tenderness. If clinically indicated, MRI of cervical spine may be obtained for further evaluation. RECOMMENDATION(S): Question minimal C2 on C3 anterolisthesis. While this finding may be degenerative in nature, given the absence of any prior comparison examination, ligamentous injury cannot be excluded on the basis examination. Recommend clinical correlation for site of tenderness. If clinically indicated, MRI of cervical spine may be obtained for further evaluation. MRI C-Spine (___): IMPRESSION: 1. No evidence of epidural fluid collection or cord signal abnormalities in the cervical spine. 2. Interspinous ligament edema at C2 through C5, suggestive of ligamentous injury/sprain. 3. Trace prevertebral T2 signal between C2-C5, which may represent minimal edema versus a small amount of non-specific fluid, without evidence of ALL disruption. No airway narrowing. 4. Multilevel multifactorial degenerative changes throughout the cervical spine, resulting in up to mild spinal canal narrowing at C5-C6 and C6-C7. CT A/P (___): IMPRESSION: 1. No acute intra-abdominal or intrapelvic process. 2. Cirrhotic liver with associated varices, splenomegaly and trace ascites is demonstrated, not significantly increased from ___. TIPS remains in unchanged position, however patency of the hepatic vasculature is not well assessed on this single phase examination. 3. Moderate bilateral pleural effusions and consolidative opacities involving the bilateral lower lobes. There are multiple hypodensities within the right lower lobe consolidation, suggesting possible infection. 4. Minimally displaced posterior rib fractures of the ninth and tenth ribs on the right. RUE Ultrasound (___): IMPRESSION: Severely limited study due to patient positioning inability to move the right arm. There is a nonocclusive thrombus in one of the right brachial veins, which is not compressible. TTE (___): The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systoilc function. Moderate tricuspid regurgitation. Mild pulmonary hypertension. Compared with the prior study (images reviewed) of ___, the findings are similar. OTHER RELEVANT LABS: ===================== ___ 05:45AM BLOOD calTIBC-105* Ferritn-408* TRF-81* ___ 05:45AM BLOOD TSH-6.7* ___ 05:45AM BLOOD T4-4.3* ___ 05:25AM BLOOD Cortsol-4.5 ___ 05:10AM BLOOD 25VitD-21* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Furosemide 20 mg PO DAILY 2. Lactulose ___ mL PO TID 3. OxycoDONE (Immediate Release) 10 mg PO Q8H:PRN pain 4. Spironolactone 100 mg PO DAILY 5. Rifaximin 550 mg PO BID 6. Fondaparinux 7.5 mg SC DAILY 7. Metoprolol Succinate XL 25 mg PO DAILY 8. Bisacodyl 10 mg PR QAM constipation 9. Glargine 22 Units Breakfast Glargine 12 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 10. cefprozil 250 mg oral Q12H Discharge Medications: 1. Bisacodyl 10 mg PR QAM constipation 2. Fondaparinux 7.5 mg SC DAILY 3. Furosemide 20 mg PO DAILY 4. Glargine 22 Units Breakfast Glargine 26 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 5. Lactulose ___ mL PO TID 6. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth q6h prn Disp #*15 Tablet Refills:*0 7. Rifaximin 550 mg PO BID 8. Spironolactone 50 mg PO DAILY 9. Vitamin D 1000 UNIT PO DAILY 10. Lidocaine 5% Patch 2 PTCH TD QAM 11. Calcium Carbonate 1500 mg PO DAILY 12. Metoprolol Succinate XL 50 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES: =================== Syncope Subarachnoid hemorrhage C-spine ligamentous injury Shoulder fractures SECONDARY DIAGNOSES: ===================== Cirrhosis Atrial fibrillation Wide-complex ventricular tachycardia Type II diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Requires right shoulder sling for multiple right shoulder fractures and C-collar for ligamentous injury to C-spine. Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ male with syncopal episode status post fall with noted right shoulder fracture and questioned left parietal subarachnoid hemorrhage. Evaluate stability of hemorrhage. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: This study involved 3 CT acquisition phases with dose indices as follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced Acquisition 16.0 s, 18.2 cm; CTDIvol = 49.0 mGy (Head) DLP = 891.9 mGy-cm. Total DLP (Head) = 892 mGy-cm. COMPARISON: ___ 04:04 outside noncontrast head CT. FINDINGS: There is right parietal convexity soft tissue swelling. There is a small stable left frontal area of hyperdensity suggestive of subarachnoid hemorrhage (series 2, image ___. No additional hemorrhage is identified. There is no evidence of infarction, edema or mass. There is prominence of the ventricles and sulci suggestive involutional changes. There is no evidence of fracture. The visualized portion of the mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. Bilateral maxillary and ethmoid sinus mucosal thickening is present. IMPRESSION: 1. Stable small left frontal probable subarachnoid hemorrhage as described. Recommend clinical correlation and attention on followup imaging 2. No additional areas of hemorrhage. 3. Right parietal convexity soft tissue swelling, without evidence of underlying fracture. 4. Paranasal sinus disease as described. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE INDICATION: The ___ male with syncopal episode status post fall with noted right shoulder fracture and subarachnoid hemorrhage. Evaluate for cervical spine fracture. TECHNIQUE: Non-contrast helical multidetector CT was performed. Axial image data was collimated to display separate 2.5 mm soft tissue and bone algorithm axial images. Coronal and sagittal reformations were then constructed. DOSE: This study involved 3 CT acquisition phases with dose indices as follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Spiral Acquisition 5.5 s, 21.6 cm; CTDIvol = 36.8 mGy (Body) DLP = 795.0 mGy-cm. Total DLP (Body) = 795 mGy-cm. COMPARISON: None. FINDINGS: Question minimal anterolisthesis of C2 on C3, and mild reversal of the normal cervical lordosis. No fractures are identified. A C6 vertebral body bone island is present. At C3-4 there is a small disc protrusion resulting in at least mild spinal canal stenosis. Moderate degenerative changes are seen throughout the cervical spine. There is no prevertebral soft tissue swelling.Within limits of this noncontrast examination, there is no evidence of infection or neoplasm. IMPRESSION: 1. No evidence of acute fracture or traumatic malalignment. 2. Moderate degenerative changes as described. 3. Question minimal C2 on C3 anterolisthesis. While this finding may be degenerative in nature, given the absence of any prior comparison examination, ligamentous injury cannot be excluded on the basis examination. Recommend clinical correlation for site of tenderness. If clinically indicated, MRI of cervical spine may be obtained for further evaluation. RECOMMENDATION(S): Question minimal C2 on C3 anterolisthesis. While this finding may be degenerative in nature, given the absence of any prior comparison examination, ligamentous injury cannot be excluded on the basis examination. Recommend clinical correlation for site of tenderness. If clinically indicated, MRI of cervical spine may be obtained for further evaluation. Radiology Report EXAMINATION: CT abdomen and pelvis INDICATION: History: ___ with syncope, fall, R shoulder fx, ? punctate parietal SAH // Eval for progression of ? parietal SAH, evidence of trauma 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: 855 COMPARISON: ___ FINDINGS: LOWER CHEST: There are small to moderate bilateral pleural effusions and adjacent consolidative opacities at the lung bases. Of note, there are rounded areas of hypodensity within the right lower lobe pulmonary consolidation. Thickening of the distal esophagus is again noted, most likely related to increased portal venous pressure. There is minimal, predominantly right-sided cardiac enlargement. HEPATOBILIARY: The liver is nodular in contour consistent with a known history of cirrhosis. The patient is status post TIPS procedure. Detailed evaluation of the hepatic vasculature is limited on this single phase exam. No focal hepatic lesions are identified on this single phase examination. There is no intra or extrahepatic biliary ductal dilatation. Intrahepatic varices are again demonstrated, not significantly changed from ___. SPLEEN: The spleen is enlarged measuring 14 cm. The spleen is homogeneous in attenuation. PANCREAS: The pancreas is atrophic. ADRENALS: The adrenal glands are unremarkable bilaterally. URINARY: The kidneys display symmetric nephrograms with no evidence of hydronephrosis or mass lesion in either kidney. The ureters are symmetrical in their course to the bladder. GASTROINTESTINAL: The small bowel is normal appearing with no evidence of obstruction. The large bowel is filled with stool and is normal. There is trace intra-abdominal ascites. LYMPH NODES: Multiple prominent retroperitoneal lymph nodes are again demonstrated measuring up to 9 mm however none are pathologically enlarged by CT size criteria. There is no mesenteric lymphadenopathy. VASCULAR: Surgical clips are again demonstrated along the anterior abdominal aorta just superior to the bifurcation and along the right iliac artery. There is no aneurysmal dilatation of the abdominal aorta. Note is made of a retroaortic left renal vein. PELVIS: There is trace free fluid in the pelvis. The bladder is within normal limits. The rectum and sigmoid colon are normal appearing. There is no pelvic sidewall lymphadenopathy. BONES AND SOFT TISSUES: No suspicious osseous lesions are identified. Mild degenerative changes noted involving the lumbar spine. Minimally displaced posterior rib fractures involving the ninth and tenth ribs on the right. The patient is status post right-sided inguinal hernia repair. A small sclerotic focus in the left ilium is unchanged from ___. IMPRESSION: 1. No acute intra-abdominal or intrapelvic process. 2. Cirrhotic liver with associated varices, splenomegaly and trace ascites is demonstrated, not significantly increased from ___. TIPS remains in unchanged position, however patency of the hepatic vasculature is not well assessed on this single phase examination. 3. Moderate bilateral pleural effusions and consolidative opacities involving the bilateral lower lobes. There are multiple hypodensities within the right lower lobe consolidation, suggesting possible infection. 4. Minimally displaced posterior rib fractures of the ninth and tenth ribs on the right. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with history of HCV Cirrhosis s/p syncope and fall with subarachoid hemorrage and question of recent PNA. // PNA? IMPRESSION: As compared to previous radiograph of earlier the same date, there has not been a relevant change in the appearance of the chest when consideration is given to differences in positioning and technique. . Radiology Report EXAMINATION: MR CERVICAL SPINE W/O CONTRAST INDICATION: ___ year old man with HCV cirrhosis s/p fall with SAH and right shoulder fractures. CT C-spine ? ligamentous damage. // ligamentous injury? ligamentous injury? TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique. Axial T2 and gradient echo imaging were next performed. COMPARISON: ___ noncontrast cervical spine CT. FINDINGS: Please note that this study is limited by motion. Labeling of the cervical spine is provided on series 2, image 9. There is minimal retrolisthesis of C4 on C5 and C5 on C6. No other alignment abnormalities are detected. There is increased T2 signal at the inferior endplate of C3 and superior endplate of C4, likely representing ___ type 2 changes. No other marrow signal abnormalities are detected in the cervical spine. No cord signal abnormalities are identified. No evidence of infection or neoplasm, within the limitations of this non-contrast study. There is trace T2 signal within the prevertebral space extending from C2 through C5 (2:9), which may represent minimal edema versus a small amount of nonspecific fluid. No evidence of anterior longitudinal ligament (ALL) disruption. Additional note is made of increased edema with the interspinous ligaments between C3-C5, which is suggestive of underlying ligamentous injury. Multilevel, multifactorial degenerative changes are noted throughout the cervical spine, including osteophyte formation, uncovertebral hypertrophy, loss of intervertebral disc space height and disc desiccation. At C2-C3, there is minimal central disc bulge, without narrowing of the spinal canal or neural foramen. At C3-C4, there is minimal central disc bulge, without spinal canal narrowing or neural foraminal stenosis. At C4-C5, there is disc bulging that indents the thecal sac, without critical spinal canal or neural foraminal narrowing. At C5-C6, there is disc bulging with right paracentral protrusion that results in mild spinal canal narrowing, as well as mild left neuroforaminal narrowing (6:24). At C6-C7, there is disc bulging and mild spinal canal stenosis. There is also mild right neural foraminal narrowing at this level (6:27). At C7-T1, there is no significant spinal canal or neural foraminal narrowing. IMPRESSION: 1. No evidence of epidural fluid collection or cord signal abnormalities in the cervical spine. 2. Interspinous ligament edema at C2 through C5, suggestive of ligamentous injury/sprain. 3. Trace prevertebral T2 signal between C2-C5, which may represent minimal edema versus a small amount of non-specific fluid, without evidence of ALL disruption. No airway narrowing. 4. Multilevel multifactorial degenerative changes throughout the cervical spine, resulting in up to mild spinal canal narrowing at C5-C6 and C6-C7. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year old man with HCV cirrhosis and history of deep venous thrombosis with elevated bilirubin. // Please assess for portal vein patency. TECHNIQUE: Grey scale, color, and spectral Doppler ultrasound images of the abdomen were obtained. COMPARISON: Abdominal ultrasound from ___ and CT abdomen pelvis from ___. FINDINGS: Due to the patient's inability to move his right arm, this is a limited study, as the sonographic window was very small. LIVER: The hepatic parenchyma is diffusely coarsened and nodular, consistent with known cirrhosis. There is no focal liver mass. Right pleural effusion is incompletely imaged. The main portal vein is patent with hepatopetal flow. The TIPS is patent and demonstrates wall-to-wall flow. Portal vein and intra-TIPS velocities are as follows: Main portal vein: 16.2 cm/sec, previously 18.5 cm/sec Proximal TIPS: 34.3 cm/sec, previously 23cm/sec Mid TIPS: 55.1 cm/sec, previously 60 cm/sec Distal TIPS: 80 cm/sec, previously 71 cm/sec The left portal vein is not able to be assessed on the current study. Appropriate flow is present in the mid and left hepatic veins. IMPRESSION: 1. Ultrasound study was limited due to the patient's inability to move his right arm. The left portal vein was not assessed on the current study. 2. Patent TIPS, with velocities similar to those obtained on ___. 3. Cirrhotic liver with right-sided pleural effusion. Radiology Report EXAMINATION: VENOUS DUP UPPER EXT UNILATERAL RIGHT INDICATION: ___ year old man with cirrhosis s/p TIPS and factor V leiden w/ history of DVTs, was on fondaparinux when he presented with syncopal event c/b subarachnoid hemorrhage and right shoulder fractures. Anticoagulation has been d/c'ed. // Please evaluate for right upper extremity DVT in setting of increased swelling and pt being off anticoagulation for SAH (baseline AC with fondaparinux for factor V leiden and h/o DVTs). Note that patient has 3 right shoulder fractures and has severe pain with movement of RUE so if possible please limit arm movement during exam. TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper extremity veins. COMPARISON: Upper extremity Doppler from ___. FINDINGS: This study is severely limited, given the patient's inability to move his right arm. Only the right axillary and right brachial veins were able to be assessed, given patient positioning. There is nonocclusive thrombus in 1 of the right brachial veins, which demonstrates no compressibility. Normal color flow seen in the right axillary vein. IMPRESSION: Severely limited study due to patient positioning inability to move the right arm. There is a nonocclusive thrombus in one of the right brachial veins, which is not compressible. NOTIFICATION: The above findings were communicated via telephone by Dr. ___ to Dr. ___ at 22:03 on ___, 5 min after discovery. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with cirrhosis s/p TIPS, factor V leiden with h/o DVTs on fondaparinux, presenting s/p fall on anticoagulation with traumatic SAH and right shoulder fractures x3, now with afib with RVR, right upper extremity DVT, cough, and febrile to 100.8. Question pneumonia. TECHNIQUE: Portable chest x-ray. COMPARISON: Chest x-ray dated ___. FINDINGS: Appearance of bilateral pleural effusions and bibasilar atelectasis is unchanged. There are no new regions of opacity. Cardiomediastinal silhouette is unchanged. IMPRESSION: Unchanged bilateral pleural effusions and bibasilar atelectasis. Superimposed infection cannot be excluded. Radiology Report INDICATION: History of cirrhosis, status post TIPS, with syncopal event and wide complex ventricular tachycardia. Please evaluate. TECHNIQUE: Cardiac MRI was performed by the Department of Cardiology. COMPARISON: CT of the abdomen and pelvis from ___. Right upper quadrant ultrasound from ___. IMPRESSION: Please note that this report only contains extracardiac findings. There is moderate gynecomastia. An enlarged 22 x 13 mm pretracheal mediastinal lymph node is nonspecific. There are bibasilar opacities and a moderate-sized bilateral pleural effusions, similar to the prior CT of the abdomen and pelvis. The right is slightly loculated. The liver has a cirrhotic morphology with evidence of iron deposition. A TIPSS is partially imaged. The spleen is enlarged, but not included in the entire field of view. There is a small amount of ascites. These findings are better characterized on the prior CT of the abdomen. The entirety of this Cardiac MRI is reported separately in the Electronic Medical Record (OMR) - Cardiovascular Reports. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with cirrhosis s/p TIPS, factor V leiden presenting s/p syncopal event while on anticoagulation with traumatic SAH, evaluate subarachnoid hemorrhage. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: This study involved 3 CT acquisition phases with dose indices as follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced Acquisition 10.0 s, 17.5 cm; CTDIvol = 52.7 mGy (Head) DLP = 921.6 mGy-cm. Total DLP (Head) = 936 mGy-cm. COMPARISON: Comparison is made to head CT ___ FINDINGS: Focus of left frontal subarachnoid hemorrhage no longer seen. There are no new areas of hemorrhage identified. The ventricles and sulci are unchanged in size and configuration. The basal cisterns are patent and there is preservation of gray-white matter differentiation. There is no acute osseous abnormality. The globes are unremarkable. There is a small amount of layering intermediate density fluid within the bilateral maxillary sinuses, right greater than left. The remainder of the paranasal sinuses are clear. There is fluid within the bilateral mastoid air cells. IMPRESSION: 1. Small focus of left frontal subarachnoid hemorrhage no longer seen. No new areas of hemorrhage. 2. Layering intermediate density fluid within the bilateral maxillary sinuses, no fracture identified. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old man with DM, cirrhosis s/p TIPS, factor V Leiden with h/o DVTs, presenting s/p syncopal event while on anticoagulation with traumatic SAH and right shoulder fractures x3, hospital course complicated by wide-complex VT (thought to be SVT with aberrancy) as well as afib with RVR, right upper extremity DVT; home fondaparinux has been held ___ SAH but re-started on heparin drip on ___ for DVT given resolved SAH, now patient is therapeutic on heparin (PTT 117 this am) and we would like to repeat head CT to ensure that SAH is still stable. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: This study involved 3 CT acquisition phases with dose indices as follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced Acquisition 16.0 s, 17.5 cm; CTDIvol = 50.9 mGy (Head) DLP = 891.9 mGy-cm. Total DLP (Head) = 892 mGy-cm. COMPARISON: Comparison is made with prior CT head without contrast from ___. FINDINGS: There is no new evidence of infarction, hemorrhage, edema, or mass. There is no midline shift or mass effect. There is no evidence of soft tissue swelling. There is prominence of the ventricles and sulci suggestive involutional changes. There is no evidence of fracture. There is interval decrease in the intermediate density fluid in the bilateral maxillary sinuses, left fluid more prominent than the right. The other visualized portions of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. No evidence of new hemorrhage, infarcts, or fractures. 2. Interval improvement of layering intermediate density fluid within the bilateral maxillary sinuses. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: SAH, R Shoulder injury, Transfer Diagnosed with FX SCAPUL, ACROM PROC-CL, FX CLAVICL, ACROM END-CL, FX SCAP, GLEN CAV/NCK-CL, SUBARACH HEM-COMA NOS, OTHER FALL temperature: 97.2 heartrate: 77.0 resprate: 16.0 o2sat: 99.0 sbp: 100.0 dbp: 63.0 level of pain: 8 level of acuity: 2.0

Mr. ___ was hospitalized at ___ from ___ to ___ for treatment of his injuries following a syncopal event, and for workup of the etiology of his syncope. His hospital course was complicated by a RUE DVT (noted on ___, intermittent wide-complex ventricular tachycardia, and afib with RVR. Anticoagulation was initially held due to the small traumatic subarachnoid hemorrhage noted on admission, but this was restarted for RUE DVT after confirming that a repeat non-contrast head CT showed no evidence of SAH. EP placed a LINQ monitor on ___ and he was transitioned back to ___.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: house dust / dogs and cats / morphine Attending: ___ ___ Complaint: superficial thrombophlebitis/cellulitis Major Surgical or Invasive Procedure: ___ (___) History of Present Illness: Mr. ___ is a ___ year-old gentleman with a history of hearing impairment and transformed DLBCL currently on R-CHOP (___) who presents with fever and worsening superficial thrombophlebitis/cellulitis which reportedly has not responded to oral antibiotics. He was evaluated on ___ in the ___ clinic treatment area for left forearm pain found to have a superficial thrombophlebitis with mild cellulitis. He received vancomycin 1g and was sent home with plan to complete 5-day course of ASA325 and SMX/TMP DS bid. It is unclear per records whether he started SMX/TMP but he called the clinic on ___ reporting chills, worsening pain and erythema. He was seen at ___ and discharged on doxycycline. On ___ he called his oncologist's office due to fever to 101.6 and was advised to go to nearest ED for broad spectrum antibiotics and transfer to ___. ED initial vitals were 99.3 116 117/72 16 99% RA Tmax: 101.2 Prior to transfer vitals were 99.2 98 109/63 16 98% RA Exam in the ED showed : No exam ED work-up significant for: -CBC: 11.6 > 9.0 < 244 -Chemistry: 137/4.0 | ___ | ___ -Lactate: 1.5 -LFTs: ___ | 158/0.5 -UA: +ket -LUE US: no DVT, distal SVT ED management significant for: -Medications: cefepime 2g, vancomycin 1g, 1L NS On arrival to the floor, patient reports via writing having a mild headache and having significant pain in his left arm. He has not received any pain medication since he got to the hospital. He reports having pain in his right biceps. He is worried about being exposed to bacteria in the hospital and requests not having a room mate. Past Medical History: PMH: deaf, asthma, recurrent diverticulitis, non-Hodgkin's lymphoma PSH: repair of supra-umbilical midline incisional hernia (___) Social History: ___ Family History: Sister: ___ (unclear type), in remission Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.8 PO 136 / 78 82 22 97 RA GENERAL: Well-appearing gentleman in no distress lying in bed comfortably. HEENT: Anicteric, PERLL, Mucous membranes moist, OP clear. CARDIAC: Regular rate and rhythm, normal heart sounds, no murmurs, rubs or gallops. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: Non-distended, normal bowel sounds, soft, non-tender, no guarding, no palpable masses, no organomegaly. EXT: Warm, well perfused. No lower extremity edema. Tender and erythematous venous cord in volar aspect of left forearm, demarcated with marker. No axillary or epitrochlear lymphadenopathy. NEURO: CN II-XII intact. Strength full throughout. Sensation to light touch intact. SKIN: No significant rashes. DISCHARGE PHYSICAL EXAM: VS: 97.5PO 103 / 65 87 18 97 RA GENERAL: Well-appearing gentleman in no distress resting flat in bed. Girlfriend at bedside. HEENT: Anicteric sclera, Mucous membranes moist, OP clear. CARDIAC: Regular rate and rhythm, normal heart sounds, no m/r/g LUNG: CTAB, no crackles, wheezes, or rhonchi. ABD: Non-distended, normal bowel sounds, soft, non-tender, no guarding, no palpable masses, no organomegaly. EXT: Warm, well perfused. No lower extremity edema. No axillary or epitrochlear lymphadenopathy. SKIN: Very mild erythema on left forearm Pertinent Results: ADMISSION LABS: ========================= ___ 11:44PM BLOOD WBC-11.6*# RBC-3.06* Hgb-9.0* Hct-26.0* MCV-85 MCH-29.4 MCHC-34.6 RDW-15.5 RDWSD-45.8 Plt ___ ___ 11:44PM BLOOD Neuts-75* Bands-7* Lymphs-3* Monos-9 Eos-0 Baso-1 ___ Metas-2* Myelos-3* AbsNeut-9.51* AbsLymp-0.35* AbsMono-1.04* AbsEos-0.00* AbsBaso-0.12* ___ 11:44PM BLOOD Plt Smr-NORMAL Plt ___ ___ 11:44PM BLOOD Glucose-101* UreaN-13 Creat-0.8 Na-137 K-4.0 Cl-99 HCO3-22 AnGap-16 ___ 11:44PM BLOOD ALT-28 AST-24 AlkPhos-158* TotBili-0.5 ___ 06:20AM BLOOD Calcium-7.8* Phos-3.1 Mg-1.9 ___ 11:44PM BLOOD Albumin-3.4* IMAGING: ========================== ___ UENI: No LUE DVT, distal superficial vein thrombus ___ B/l upper extremity US: IMPRESSION: 1. No evidence of deep vein thrombosis in the bilateral upper extremity veins. 2. Persistent occlusive thrombus within the distal superficial veins in the area of erythema overlying the left wrist. 3. Likely slow flow within the left basilic vein, which compresses well. MICROBIOLOGY: ========================== ___: MRSA screen negative ___: Blood cx negative ___: Urine culture neg DISCHARGE LABS: ========================== ___ 12:00AM BLOOD WBC-8.4 RBC-2.83* Hgb-8.5* Hct-24.5* MCV-87 MCH-30.0 MCHC-34.7 RDW-16.0* RDWSD-49.6* Plt ___ ___ 12:00AM BLOOD Neuts-97* Bands-1 Lymphs-1* Monos-1* Eos-0 Baso-0 ___ Myelos-0 AbsNeut-8.23* AbsLymp-0.08* AbsMono-0.08* AbsEos-0.00* AbsBaso-0.00* ___ 12:00AM BLOOD Plt Smr-NORMAL Plt ___ ___ 12:00AM BLOOD ___ ___ 12:00AM BLOOD Glucose-213* UreaN-18 Creat-0.9 Na-139 K-4.4 Cl-101 HCO3-21* AnGap-17 ___ 12:00AM BLOOD ALT-20 AST-24 LD(LDH)-301* AlkPhos-125 TotBili-0.5 ___ 12:00AM BLOOD Calcium-8.1* Phos-3.1 Mg-2.0 UricAcd-4.1 Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Ondansetron 8 mg PO Q8H:PRN nausea or vomiting 2. Allopurinol ___ mg PO DAILY 3. LORazepam 0.5-1 mg PO Q8H:PRN nausea or vomiting 4. Acyclovir 400 mg PO Q12H 5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate 6. Promethazine 25 mg PO Q6H:PRN nausea or vomiting 7. albuterol sulfate ___ puffs inhalation Q6H:PRN 8. Artificial Tears ___ DROP BOTH EYES PRN dry eye Discharge Medications: 1. PredniSONE 100 mg PO Q24H Duration: 5 Doses 5 days total. 2 days were in hospital. 3 more days, last day is ___. RX *prednisone 50 mg 2 tablet(s) by mouth once a day Disp #*6 Tablet Refills:*0 2. Rivaroxaban 20 mg PO DAILY RX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. Rivaroxaban 15 mg PO BID RX *rivaroxaban [___] 15 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*36 Tablet Refills:*0 4. Acyclovir 400 mg PO Q12H 5. albuterol sulfate ___ puffs inhalation Q6H:PRN 6. Artificial Tears ___ DROP BOTH EYES PRN dry eye 7. LORazepam 0.5-1 mg PO Q8H:PRN nausea or vomiting 8. Ondansetron 8 mg PO Q8H:PRN nausea or vomiting 9. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg ___ tablet(s) by mouth Every four hours Disp #*20 Tablet Refills:*0 10. Promethazine 25 mg PO Q6H:PRN nausea or vomiting Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: ==================== Superficial thrombophlebitis Diffuse large B cell lymphoma Secondary diagnoses: ==================== anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: UNILAT UP EXT VEINS US LEFT INDICATION: History: ___ with left arm pain, swelling, concern for deeper blood clot// DVT or superficial thrombophlebitis TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper extremity veins. COMPARISON: None available. FINDINGS: There is normal flow with respiratory variation in the bilateral subclavian vein. The right internal jugular and axillary veins are patent, show normal color flow and compressibility. The right brachial, basilic, and cephalic veins are patent, compressible and show normal color flow and augmentation. Targeted ultrasound at the area of erythema at the left wrist demonstrates a an occlusive thrombus in the superficial vein. IMPRESSION: 1. No evidence of deep vein thrombosis in the left upper extremity. 2. Occlusive thrombus in the distal superficial vein in the area of erythema in the left wrist. Radiology Report EXAMINATION: BILAT UP EXT VEINS US INDICATION: ___ year old man with diffuse large B cell lymphoma on chemo with superficial thrombophlebitis of the L distal upper extremity. This area is now much more indurated than before; erythema has not expanded. Complaining of some R arm pain now as well.// ?DVT in R arm? Progression/change in L arm thrombophlebitis. TECHNIQUE: Grey scale and Doppler evaluation was performed on the bilateral upper extremity veins. COMPARISON: Ultrasound from ___ FINDINGS: There is normal flow with respiratory variation in the bilateral subclavian veins. As previously noted, occlusive thrombus within the distal superficial veins in the area of erythema overlying the left wrist is grossly unchanged in appearance. The most distal portion of the left basilic vein demonstrate echogenic debris along the wall, which may represent slow flow. The vein compresses without expansile echogenic clot. The bilateral internal jugular and axillary veins are patent, show normal color flow and compressibility. The bilateral brachial, and cephalic and right basilic veins are patent, compressible and show normal color flow and augmentation. IMPRESSION: 1. No evidence of deep vein thrombosis in the bilateral upper extremity veins. 2. Persistent occlusive thrombus within the distal superficial veins in the area of erythema overlying the left wrist. 3. Likely slow flow within the left basilic vein, which compresses well. NOTIFICATION: The findings were discussed with ___ , M.D. by ___, M.D. on the telephone on ___ at 12:29 pm, 10 minutes after discovery of the findings. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old man with new line. Evaluate right PICC placement. TECHNIQUE: Frontal view of the chest. COMPARISON: Chest x-ray ___. FINDINGS: The right PICC terminates in the lower SVC. The heart size is normal. The right lateral chest and costophrenic angle are not imaged. With this in consideration, the lungs are clear. No left pleural effusion or pneumothorax. Surgical clips in the mid upper abdomen. IMPRESSION: The right PICC terminates in the lower SVC. Gender: M Race: WHITE - OTHER EUROPEAN Arrive by WALK IN Chief complaint: Fever Diagnosed with Fever, unspecified temperature: 99.3 heartrate: 116.0 resprate: 16.0 o2sat: 99.0 sbp: 117.0 dbp: 72.0 level of pain: 8 level of acuity: 2.0

Mr. ___ is a ___ year-old man with a history of deafness and transformed DLBCL currently on R-CHOP (___) who presents with fever and worsening superficial thrombophlebitis/cellulitis which reportedly did not responded to oral antibiotics.

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: ___ past medical history includes HTN, diabetes, depression, reflux and ? history of cerbrovascular ischemia vs. demylination per MRI in ___ who presents with acute on sub-acute abdominal pain. . Was well untill 1 month ago when started experiencing periumbilical and RUQ pain accompanied by loose non-bloody stools X 2 per day and per his report 15kg weight loss. Over the past 4 days gradual worsening of RUQ pain now with radiation to the mid back. Pain is constant and waxes and wanes from ___ in intensity. Not related to food. Patient also sees been nauseous no vomiting. No other exacerbating or relieving factor. He does say that about a year ago he stopped taking alcohol due to similar pains which were related to dringing ETOH. Before that he would dring ___ glasses of rum per day for many years. He is also a current smoker of 1 PPD > ___ years. Current pain is not similar to reflux symptoms he had before. Also noticed some diarrhea. No chest pain, no shortness of breath. Past Medical History: - HTN - HLD - DM II - GERD/Reflux ? - ___: investigated for headaches with MRI scan showing white matter hyperintensities suggestive of either ischemia or demyelinating disease. - s/p LLE # ___ years ago. Social History: ___ Family History: ___ Physical Exam: Admission: Vital Signs: 98.2 131/84 68 18 99RA GEN: Alert, comfortable, NAD EYE: EOMI, PERRL, no conjuctival pallor or irritation. ENT: MMM, no oral lesions Neck: no LAD, no nuchal rigidity, JVP WNL CV: RRR, no M/R/G RESP: CTAB, no wheezes or crackles GI: Soft, NTND, no HSM, Normal Bowel Sounds EXT: No cyanosis, clubbing or edema. No signs of DVT. SKIN: no rash, no Pressure Ulcers NEURO: A+OX3, Non-Focal, Fluent Speech, Normal concentration PSYCH: Calm and Appropriate Discharge: 98.0 150/68 68 18 GEN: Alert, comfortable, NAD EYE: EOMI, PERRL, no conjuctival pallor or irritation. ENT: MMM, no oral lesions Neck: no LAD, no nuchal rigidity, JVP WNL CV: RRR, no M/R/G RESP: CTAB, no wheezes or crackles GI: Soft, NTND, no HSM, Normal Bowel Sounds EXT: No cyanosis, clubbing or edema. No signs of DVT. SKIN: no rash, no Pressure Ulcers NEURO: A+OX3, Non-Focal, Fluent Speech, Normal concentration PSYCH: Calm and Appropriate Pertinent Results: ___ 06:24AM BLOOD WBC-7.2 RBC-4.19* Hgb-12.8* Hct-39.9* MCV-95 MCH-30.6 MCHC-32.1 RDW-13.3 Plt ___ ___ 12:30AM BLOOD Neuts-64.0 ___ Monos-4.7 Eos-2.7 Baso-0.2 ___ 06:24AM BLOOD Plt ___ ___ 06:24AM BLOOD Glucose-217* UreaN-9 Creat-0.7 Na-139 K-4.4 Cl-102 HCO3-29 AnGap-12 ___ 12:30AM BLOOD ALT-20 AST-20 AlkPhos-79 TotBili-0.2 ___ 06:24AM BLOOD Calcium-9.4 Phos-3.0 Mg-1.6 ___ 12:30AM BLOOD WBC-9.6 RBC-4.06* Hgb-12.7* Hct-38.4* MCV-95 MCH-31.3 MCHC-33.1 RDW-13.6 Plt ___ ___ 12:30AM BLOOD Neuts-64.0 ___ Monos-4.7 Eos-2.7 Baso-0.2 ___ 12:30AM BLOOD Plt ___ ___ 12:30AM BLOOD Glucose-136* UreaN-16 Creat-0.7 Na-140 K-4.4 Cl-102 HCO3-27 AnGap-15 ___ 12:30AM BLOOD Lipase-147* ___ 12:30AM BLOOD Albumin-4.0 EXAMINATION: CT ABD AND PELVIS W AND W/O CONTRAST, ADDL SECTIONS INDICATION: ___ male with past medical history of hypertension, diabetes, depression, reflux, alcohol use, and smoking with acute on subacute abdominal pain and elevated lipase. Evaluation for pancreatitis and pancreatic malignancy. TECHNIQUE: Helical axial MDCT images were obtained from the bases of the lungs through the pubic symphysis, after the administration of IV contrast (130 cc of Omnipaque 350). Reformatted images in coronal and sagittal axes were generated. DLP: 606 mGy-cm. COMPARISON: None available. FINDINGS: The bases of the lungs are clear. There is no pleural or pericardial effusion. LIVER: The liver enhances homogeneously without focal lesion or intrahepatic biliary duct dilation. The portal vein is patent.The nondistended gallbladder is within normal limits, without wall thickening or pericholecystic fluid. SPLEEN: The spleen is homogeneous and normal in size. PANCREAS: There is minimal haziness between the head of the pancreas and the duodenum. Subtle early groove pancreatitis cannot be excluded. Please continue to correlate clinically and biochemically. No focal lesions, masses, pancreatic calculi, or pancreatic ductal dilatation are identified. ADRENALS: The adrenal glands are unremarkable. KIDNEYS: The kidneys demonstrate symmetric nephrograms and excrete contrast promptly. There is no focal lesion or hydronephrosis. GI:The stomach is unremarkable, without obvious intraluminal mass or wall thickening.The small and large bowel are within normal limits, without wall thickening or evidence of obstruction.A normal, air-filled appendix is visualized. RETROPERITONEUM: The aorta is normal in caliber, with mild atherosclerotic calcifications.There is no retroperitoneal or mesenteric lymph node enlargement by CT size criteria. CT PELVIS: The urinary bladder appears normal.No pelvic wall or inguinal lymph node enlargement by CT size criteria is seen.There is no pelvic free fluid. OSSEOUS STRUCTURES:No focal lesion suspicious for malignancy present. IMPRESSION: 1. Minimal haziness noted between the head of the pancreas and the duodenum. Subtle early groove pancreatitis cannot be excluded. Both clinical and biochemical correlation are recommended. 2. No focal pancreatic lesions or masses identified. No pancreatic ductal dilatation or pancreatic calculi noted. NOTIFICATION: The above findings were communicated on the phone by Dr. ___ to Dr. ___ at 16:01 on ___, 10 min after discovery. The study and the report were reviewed by the staff radiologist. ___. ___ ___. ___ ___: WED ___ 4:40 ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 30 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. MetFORMIN (Glucophage) 1000 mg PO BID 4. GlipiZIDE 10 mg PO BID Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Lisinopril 30 mg PO DAILY 3. GlipiZIDE 10 mg PO BID 4. MetFORMIN (Glucophage) 1000 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Mild Acute Pancreatitis 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: ___ male with past medical history of hypertension, diabetes, depression, reflux, alcohol use, and smoking with acute on subacute abdominal pain and elevated lipase. Evaluation for pancreatitis and pancreatic malignancy. TECHNIQUE: Helical axial MDCT images were obtained from the bases of the lungs through the pubic symphysis, after the administration of IV contrast (130 cc of Omnipaque 350). Reformatted images in coronal and sagittal axes were generated. DLP: 606 mGy-cm. COMPARISON: None available. FINDINGS: The bases of the lungs are clear. There is no pleural or pericardial effusion. LIVER: The liver enhances homogeneously without focal lesion or intrahepatic biliary duct dilation. The portal vein is patent.The nondistended gallbladder is within normal limits, without wall thickening or pericholecystic fluid. SPLEEN: The spleen is homogeneous and normal in size. PANCREAS: There is minimal haziness between the head of the pancreas and the duodenum. Subtle early groove pancreatitis cannot be excluded. Please continue to correlate clinically and biochemically. No focal lesions, masses, pancreatic calculi, or pancreatic ductal dilatation are identified. ADRENALS: The adrenal glands are unremarkable. KIDNEYS: The kidneys demonstrate symmetric nephrograms and excrete contrast promptly. There is no focal lesion or hydronephrosis. GI:The stomach is unremarkable, without obvious intraluminal mass or wall thickening.The small and large bowel are within normal limits, without wall thickening or evidence of obstruction.A normal, air-filled appendix is visualized. RETROPERITONEUM: The aorta is normal in caliber, with mild atherosclerotic calcifications.There is no retroperitoneal or mesenteric lymph node enlargement by CT size criteria. CT PELVIS: The urinary bladder appears normal.No pelvic wall or inguinal lymph node enlargement by CT size criteria is seen.There is no pelvic free fluid. OSSEOUS STRUCTURES:No focal lesion suspicious for malignancy present. IMPRESSION: 1. Minimal haziness noted between the head of the pancreas and the duodenum. Subtle early groove pancreatitis cannot be excluded. Both clinical and biochemical correlation are recommended. 2. No focal pancreatic lesions or masses identified. No pancreatic ductal dilatation or pancreatic calculi noted. NOTIFICATION: The above findings were communicated on the phone by Dr. ___ to Dr. ___ at 16:01 on ___, 10 min after discovery. Gender: M Race: HISPANIC/LATINO - DOMINICAN Arrive by AMBULANCE Chief complaint: Abd pain Diagnosed with ABDOMINAL PAIN OTHER SPECIED temperature: 99.0 heartrate: 74.0 resprate: 16.0 o2sat: 97.0 sbp: 127.0 dbp: 77.0 level of pain: 6 level of acuity: 3.0

___ past medical history includes HTN, diabetes, depression, reflux, ETOH and smoking who presented with acute on subacute abdominal pain and elevated lipase. Also reported chronic mild diarrhea over the past month and significant weight-loss. Bed side US in ED did not show evidence of bile/gallbladder issues. CT contrast of his abdomen showed minimal haziness between the head of the pancreas and the duodenum which may be consistent with subtle early groove pancreatitis. In discussion on day of discharge with the radiology attending ___. ___ the findings are not concerning for malignancy and no further imaging is indicated. Mr. ___ did very well clinically throughout his admission. Abdominal pain resolved without any specific intervnetion. Did not require analgesia. Diet was advanced and tolerated well. problem summary: - Acute on Subacute RUQ pain: likely ___ mild acute ___, ___ have a mild chronic pancreatitis in the backround. Also has history of EGRD which may explain some of his more chronic abdominal pain and discomfort. - Diarrhea 1 month: etiology is unclear, most of his pancreatic tissue appears normal on imaging so exocrine failure seems unlikely. - significant weight loss: as reported by patient. this will require further work-up in the out-patient setting. - elevated lipase - likely ___ to mild acute pancreatitis. - normocytic anemia - further work-up including iron profile and B12 should be pursued following discharge. - h/o of alcohol and tobbaco consumptions. - HTN, DM - oral diabetic meds were held and restarted on discharge. Other meds were continued. Transitional Issues: - follow-up with PCP and GI for health maintnance and further work-up of diarrhea, chronic abdominal dyscomfort and weightloss. - please also check Triglyceride levels to r/o hypertriglyceridemia as a cause of pancreatitis. - normocytic anemia - further work-up including iron profile and B12 should be pursued following discharge.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: ___, ___ edema, chest pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with CAD s/p PCI ___ (unknown details), CKD (recent baseline ___, evaluated last admission with renal ultrasound, consistent with longstanding kidney disease, likely secondary to microvascular changes from HTN), HTN, former smoker, ___ (EF >55%), recently discharged from ___ ___ for acute on chronic diastolic heart failure here from ___ office with increased peripheral edema worsening over past few months markedly worse past week, also c/o chest pain since ___ worse past 2 weeks. Patient reports that he came today to the ED because his PCP told him that his kidney function was worse. He endorses that his ankles have gotten more swollen. Chronic chest pain has become more frequent. Chest pain is a dull pain over his chest that radiates to the neck and left side of his face which happens after walking approximately 20 feet. He stops when the chest pain starts and rests and after 15 minutes rest the chest pain goes away. However the severity of the chest pain has increased over the past 2 weeks compared to before. He sleeps with 2 pillows which is unchanged and he denies any orthopnea or PND. He noticed decreased urine output for the last 4 or 5 days. Notes he's gained ~5lbs over the past week. Denies any diet changes, actually has had decreased appetite and been eating smaller portions. No increased salt intake. Has been adherent to his torsemide at home. Denies fevers/chills, dizziness, cough, abdominal pain. +chronic constipation. Does not endorse other associated symptoms with his chest pain. In the ED, initial vitals: 97.6 100 173/67 18 100% RA - Exam notable for: JVD to ear at 45 degrees in bed. decreased breath sounds throughout, no crackles. 2+ pitting edema b/l and chronic skin changes. - Labs notable for: cr 5.7 (recent baseline ___, Na 138, proBNP: 1227, trop neg, H/H ___ (baseline ___ - ECG: sinus rhythm with no ST changes - Imaging notable for: CXR: Possible minimal pulmonary vascular congestion with top-normal to mildly enlarged cardiac silhouette. - Patient given: Furosemide 40 mg IV x 1 - Vitals prior to transfer: 98.3 77 151/61 16 100% RA On arrival to the floor, pt denies any shortness of breath, chest pain. Past Medical History: - CAD s/p 1x stent (placed in ___ in ___ - Hypertension - CKD (unknown baseline) Social History: ___ Family History: No family history of early MI or history of heart failure. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 97.6 176/85 88 20 97%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops. JVP to midneck at 30 degrees. Abdomen: obese, soft, non-tender, mildly distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, no cyanosis or edema Skin: Without rashes or lesions Neuro: A&Ox3. Face symmetric. DISCHARGE PHYSICAL EXAM: General: Alert, no acute distress Lungs: CTAB CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops. JVP at 12cm Abdomen: obese, soft, non-tender, mildly distended Ext: Warm, well perfused, no cyanosis or edema Pertinent Results: ADMISSION LABS: ___ 05:35PM BLOOD WBC-6.3 RBC-2.63* Hgb-7.6* Hct-23.0* MCV-88 MCH-28.9 MCHC-33.0 RDW-12.3 RDWSD-38.7 Plt ___ ___ 05:35PM BLOOD Neuts-81.0* Lymphs-9.7* Monos-5.4 Eos-3.3 Baso-0.3 Im ___ AbsNeut-5.11 AbsLymp-0.61* AbsMono-0.34 AbsEos-0.21 AbsBaso-0.02 ___ 05:35PM BLOOD ___ PTT-30.2 ___ ___ 05:35PM BLOOD Glucose-113* UreaN-83* Creat-5.7*# Na-138 K-4.8 Cl-103 HCO3-21* AnGap-19 ___ 05:35PM BLOOD proBNP-1227* ___ 05:35PM BLOOD Albumin-3.5 Calcium-8.2* Phos-5.2* Mg-2.1 STUDIES: ___ Cardiac Cath: Right dominant LM: No disease. LAD: Patent stent, no significant disease. LCx: Small true LCx is subtotally occluded, distal vessel fills via R to L collaterals. RCA: Mid vessel 30% disease. PDA with 80% proximal stenosis. Interventional Details After discussion with the patient and the referring team, we elected to pursue PCI of the LCx. Attempts to wire the vessel were made with a Prowater and ___ XT. The ___ XT went subintimal. The lesion was behaving more like a CTO with continued passage of the wire into the subintimal space. Due to not wanting to embark on a complex CTO reentry given the patient's renal failure, we elected to stop at this point, and consider staged intervention of the PDA lesion instead. TR band to right radial. Impressions: Subtotally occluded LCx, behaving as a chronic lesion. Unable to wire luminally with conservative attempt given renal failure. PDA 80% disease. ___ Cardiac Cath: Interventional Details AL0.75 guide catheter engaged the RCA. The vessel was wired with a Prowater wire. IVUS was performed to size the lesion and to minimize contrast use. Angioplasty followed by placement of a 2.5 x 24 mm Promus Premier DES. Post-dilated after IVUS using a 3.0 NC balloon and a 3.75 NC balloon proximally. IVUS confirmed excellent stent expansion and apposition throughout. TIMI III flow, 0% residual. Impressions: Successful IVUS-guided PCI of the RCA using a single DES. DISCHARGE LABS: ___ 07:00AM BLOOD WBC-8.5 RBC-2.98* Hgb-8.6* Hct-27.2* MCV-91 MCH-28.9 MCHC-31.6* RDW-12.8 RDWSD-41.3 Plt ___ ___ 10:30AM BLOOD ___ PTT-26.6 ___ ___ 03:33PM BLOOD Glucose-121* UreaN-89* Creat-4.9* Na-142 K-4.8 Cl-106 HCO3-21* AnGap-20 ___ 07:00AM BLOOD Calcium-8.4 Phos-5.9* Mg-2.3 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Calcitriol 0.25 mcg PO 3X/WEEK (___) 3. Cephalexin 250 mg PO Q8H 4. HydrALAZINE 25 mg PO Q8H 5. Isoniazid ___ mg PO DAILY 6. Pyridoxine 50 mg PO DAILY 7. sevelamer CARBONATE 1600 mg PO TID W/MEALS 8. Sodium Bicarbonate 650 mg PO BID 9. Torsemide 20 mg PO BID 10. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY 11. Aspirin 81 mg PO DAILY 12. Atorvastatin 80 mg PO QPM Discharge Medications: 1. Carvedilol 6.25 mg PO BID RX *carvedilol 6.25 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. Clopidogrel 75 mg PO DAILY Please do not stop taking without discussing with your cardiologist RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. HydrALAZINE 50 mg PO Q8H RX *hydralazine 50 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 4. Torsemide 40 mg PO BID RX *torsemide 20 mg 2 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 5. amLODIPine 10 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 80 mg PO QPM 8. Calcitriol 0.25 mcg PO 3X/WEEK (___) 9. Isoniazid ___ mg PO DAILY 10. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY 11. Pyridoxine 50 mg PO DAILY 12. sevelamer CARBONATE 1600 mg PO TID W/MEALS 13. Sodium Bicarbonate 650 mg PO BID 14.Outpatient Lab Work E87.5- Hyperkalemia Please check chem7 and fax results to ___ clinic ___ Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Acute exacerbation of heart failure with preserved ejection fraction Secondary Diagnoses: Acute gout coronary artery disease chronic kidney disease latent TB hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: Chest: Frontal and lateral views INDICATION: History: ___ with CHF w/ increased DOE, chest pain // eval for pulmonary edema TECHNIQUE: Chest: Frontal and Lateral COMPARISON: None. FINDINGS: The lungs show no focal consolidation. No pleural effusion or pneumothorax is seen. Cardiac silhouette is top-normal to mildly enlarged. Mediastinal contours are unremarkable. Minimal pulmonary vascular congestion may be present. IMPRESSION: Possible minimal pulmonary vascular congestion with top-normal to mildly enlarged cardiac silhouette. Radiology Report EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT INDICATION: ___ year old man with R ankle pain, tender posterior to medial malleolus, unable to ambulate. no trauma hx. ongoing diuresis in pt with h/o gout // ?fx TECHNIQUE: Right ankle three views COMPARISON: None FINDINGS: There are prominent calcaneal plantar, Achilles bone spurs, with chronic discontinuity of the Achilles bone spur. No acute fractures. Mild soft tissue swelling about ankle. Mild degenerative arthritis right ankle. IMPRESSION: No acute fractures. Gender: M Race: ASIAN Arrive by WALK IN Chief complaint: Chest pain, Dyspnea on exertion, Leg swelling Diagnosed with Other chest pain temperature: 97.6 heartrate: 100.0 resprate: 18.0 o2sat: 100.0 sbp: 173.0 dbp: 67.0 level of pain: 3 level of acuity: 2.0

Mr. ___ is a ___ with CAD s/p PCI ___ (unknown details), CKD (unknown baseline), HTN, former smoker, dCHF (EF >55%), recently discharged from ___ on ___ for acute on chronic diastolic heart failure presenting with acute on chronic DOE and ___ edema concerning for CHF exacerbation vs worsening renal failure, also with chest pain with ambulation. Underwent PCI of PDA on with DES ___. #Acute on Chronic Diastolic Heart Failure: Increased ___ edema w/ pulm vascular congestion on CXR was concerning for exacerbation of diastolic heart failure. Unclear precipitating factor, no obvious dietary indiscretion or medication nonadherence. He was managed as below: - PRELOAD: Torsemide 40 BID - AFTERLOAD: continue amlodipine and imdur, increased hydralazine to 50mg TID, - NHBK: Started carvedilol #Chest pain/CAD: s/p 1x stent in ___ in ___, unknown artery. Reports increased frequency of pain. Trop neg, no acute changes on ecg. Exertional, likely stable angina in setting of known CAD. Trop was x 2 negative. He was continued ASA 81mg, atorva 80mg, imdur. He underwent a pmibi without areas of ischemia, but symptoms were concerning for stable angina so patient underwent cardiac cath which demonstrated a subtotal occlusion of the mid LCx and a 80% distal RCA stenosis. Initially attempt was made to the stent the LCx, but this lesion behaved like a chronic total occlusion so PCI was aborted. To avoid excessive contrast load, the patient was brought back the next day for PCI of the distal RCA lesion with ___ 1 and a good angiographic result. Following the PCI, the patient reported that his exertional chest pain had resolved. #Gout flare Likely in setting of diuresis in patient with h/o gout. NSAIDs, colchicine limited due to CKD. Ankle xray without fx. Finished a Prednisone taper. # CKD: Unclear etiology, baseline cr unknown, now stage 5 w/ reported decreased urine output. No urgent indications for initiating HD. He was evaluated by renal during a recent admission, USG with small echogenic kidney s/o longstanding kidney disease. Likely due to microvascular changes from HTN w/ possible contribution from cardiorenal syndrome. Continued calcitriol, sodium bicarb, sevelemar. Was supposed to have AV graft placed ___ but deferred due to PCI and Plavix. Hyperkalemia was managed by restarting diuretic and a dose of kayexylate. # Latent TB: H/o pos TST, born in ___ BGC status unknown. INH 300 mg initiated ___ (___voiding rifampin due to drug interaction with statins). Continued INH, pyridoxine # HTN: elevated BP on arrival to the floor after not receiving home meds. He was continued on home amlodipine, hydralazine, and imdur

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Amitiza / Oxybutynin / Bactrim Attending: ___. Chief Complaint: multidrug resistant uti treatment Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is an ___ year old man with a hypotonic bladder, BPH, chronic indwelling foley and multiple recent multidrug resistant urinary tract infections who was sent to the ED by his PCP for admission and iv antibiotics for a UTI. He has multiple other chronic medical problems (see below). He was last admitted to ___ from ___ to ___ for treatment of a UTI. He was treated with meropenem initially then narrowed to po ciprofloxacin on which he was discharged home. Patient denies fevers or chills, but he complains of a dull suprapubic ache which has worsened over the course of the last three days. He does not have back pain. In the ED, initial VS were:97.6, hr 88, bp 86/47, rr 20, sat 95%. His subsequent blood pressures ranged from 108-118/71-76, even before he recieved fluid. He was given NS x 1 Liter and cefepime 2g iv once.A #20 right EJ was inserted. Transfer vitals were 97.2 oral, HR 79, BP 108/74, RR ___, O2 sat 2L NC. On arrival to the floor, he had mild suprapubic discomfort. Past Medical History: 1. Hypotonic bladder with incomplete emptying, s/p indwelling foley since ___ c/b frequent Multidrug resistent UTIs, incl MRSA and ESBL E Coli 2. BPH 3. CAD s/p CABG x 3 in ___ - CABG anatomy: LIMA to LAD, SVG to OM, and SVG to RCA - s/p stenting ___ of mid RCA, PTCA of proximal RCA and PDA - redo single vessel CABG in ___ with Dr. ___. 4. Bovine AVR in ___. Type 2 Diabetes Mellitus: diet controlled 6. Hypertension 7. Hx of Chronic constipation 8. Hyperlipidemia 9. Depression /Anxiety 10. Asbestosis 11. Spinal stenosis 12. R kidney mass - Followed by urology w/ serial imaging, likely RCC 13. Osteoarthritis 14. Carotid stenosis - chronic occlusion of ___, ___ with 40% Social History: ___ Family History: Daughter- died at ___,breast cancer. Father- died from MI in his ___. Physical Exam: Admission exam: VS - Temp 97.9 F, BP 105/76, HR 76, R 20, O2-sat 97% 3LNC GENERAL - NAD, comfortable HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MM dry, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat except for fine crackles in the bases bilaterally, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/ND, no masses or HSM, no rebound/guarding. There is mild ttp in the suprapubic area. BACK: no cva tenderness EXTREMITIES - There is moderate edema in both lower extremities with discoloration and erythema especially in the left leg--it is not warm nor tender, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ on flexion of r hip, 4- on flextion of left hip, upper extremity strength is ___ bilaterally, sensation grossly intact throughout, gait was not assessed. Discharge exam: VS - Temp 97.7 F, BP 110-130/60-64, HR 78-86, R 20, O2-sat 92-94%/RA GENERAL - NAD, comfortable HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat except for fine crackles in the bases bilaterally, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/ND, no masses or HSM, no rebound/guarding. Non-tender. BACK: no cva tenderness EXTREMITIES - There is moderate edema in both lower extremities with discoloration and erythema especially in the left leg--it is not warm nor tender, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ on flexion of r hip, 4- on flextion of left hip, upper extremity strength is ___ bilaterally, sensation grossly intact throughout, gait was not assessed. Discharge exam: T 97.9 112-142/61-70 ___ 94%/RA 20 GENERAL - elderly man, lying in bed in no apparent distress LUNGS - CTA bilat HEART - RRR, no MRG, nl S1-S2 ABDOMEN - soft, non-tender, non-distended BACK: no cva tenderness EXTREMITIES - trace edema in both lower extremities with discoloration and erythema especially in the left leg--it is not warm nor tender Skin: Rash on right check with crusted blood, erythematous rash on face. NEURO - A&Ox3. Pertinent Results: Admission labs: ___ 11:30PM BLOOD WBC-6.6 RBC-4.15* Hgb-12.3* Hct-36.0* MCV-87 MCH-29.7 MCHC-34.2 RDW-17.6* Plt ___ ___ 11:30PM BLOOD Neuts-66.0 ___ Monos-6.8 Eos-5.8* Baso-0.4 ___ 05:32AM BLOOD ___ PTT-31.5 ___ ___ 10:15PM BLOOD Glucose-126* UreaN-25* Creat-1.0 Na-138 K-4.3 Cl-101 HCO3-28 AnGap-13 ___ 08:00PM BLOOD CK-MB-6 cTropnT-0.09* ___ 05:25AM BLOOD CK-MB-6 cTropnT-0.08* ___ 10:15PM BLOOD Calcium-9.2 Phos-4.5 Mg-2.2 Microbiology: ___ 7:25 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. Piperacillin/Tazobactam sensitivity testing performed by ___ ___. FOSOMYCIN Susceptibility testing requested by ___. ___ PAGER ___. . ZONE SIZE FOR FOSOMYCIN IS 27 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-------------- 4 S CEFEPIME-------------- 8 S CEFTAZIDIME----------- 2 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM------------- =>16 R PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ =>16 R ___ 11:05 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. SENSITIVITIES PERFORMED ON CULTURE # ___-___ ___. ___ 9:01 am URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: ___ PARAPSILOSIS. >100,000 ORGANISMS/ML.. IDENTIFICATION REQUESTED BY ___ ___ ___ ___. ___ 5:19 pm DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS **FINAL REPORT ___ DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS (Final ___: Negative for Varicella zoster by immunofluorescence. Refer to culture results for further information. ___ 5:19 pm Direct Antigen Test for Herpes Simplex Virus Types 1 & 2 **FINAL REPORT ___ Direct Antigen Test for Herpes Simplex Virus Types 1 & 2 (Final ___: Negative for Herpes simplex by immunofluorescence. Refer to culture results for further information. Imaging: ___ CXR: As compared to the previous radiograph, there is unchanged evidence of elevation of the left hemidiaphragm and subpleural partly calcified scars. Status post CABG. Minimal atelectasis at the right lung base but no evidence of current pneumonia or fluid overload. Unchanged appearance of the cardiac silhouette. ___ Abdominal X-ray: There is moderate colonic fecal load with minimally dilated cecum. Air is seen in scant loops of nondilated small bowel. This is a nonobstructive bowel gas pattern. Remnant contrast material is seen in the large bowel. There is no supine radiographic evidence of pneumoperitoneum or pneumatosis. IMPRESSION: Moderate colonic fecal load. Nonobstructive bowel gas pattern. CXR ___ Cardiac size is top normal. The main pulmonary arteries are larger as before. Elevation of the left hemidiaphragm is longstanding. There are low lung volumes. Bibasilar atelectases have increased. Bilateral calcified pleural plaques are again noted. There are probably small bilateral pleural effusions. There is no pneumothorax. Kidney ultrasound ___: The right kidney measures 10.2 cm. The left kidney measures 10.4 cm. Bilateral kidneys are without evidence of hydronephrosis or stones. The vascular right upper pole tumor is again noted measuring 3.3 x 3.6 x 2.9 cm. The bladder is decompressed and not evaluated. There is no evidence of distinct collections. IMPRESSION: No evidence of distinct collections. Right upper pole solid tumor is again identified measuring 3.3 x 3.6 x 2.9 cm. Abdominal X-ray ___ There is a nonobstructing bowel gas pattern. There is air in the ascending and transverse colon. There is fecal material in the descending colon. There is no air in the rectum. There are few air fluid levels in the small bowel loops that are nondistended. There are severe degenerative changes in the lumbar spine. There are vascular calcifications. CXR ___ Elevated left hemidiaphragm is redemonstrated. No definitive opacity except for minimal bibasilar atelectasis is demonstrated. Pulmonary nodules seen in the left mid lower lung are demonstrated and might represent at least in part pleural calcifications. No pneumothorax is seen. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO DAILY 3. Bisacodyl 10 mg PO DAILY:PRN constipation 4. Calcium Carbonate 500 mg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Duloxetine 30 mg PO DAILY 7. Furosemide 40 mg PO DAILY 8. Lactulose 30 mL PO DAILY 9. Metoprolol Succinate XL 50 mg PO DAILY hold for HR<55, bp<95 10. Multivitamins 1 TAB PO DAILY 11. Omeprazole 20 mg PO DAILY 12. Polyethylene Glycol 17 g PO DAILY 13. Senna 1 TAB PO BID 14. traZODONE 100 mg PO HS:PRN insomnia 15. Vitamin D 800 UNIT PO DAILY 16. Milk of Magnesia 30 mL PO Q6H:PRN constipation 17. Naproxen 500 mg PO Q8H:PRN pain 18. Lidocaine Jelly 2% 1 Appl TP DAILY: PRN penile pain/foley pain Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Calcium Carbonate 500 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Furosemide 20 mg PO DAILY 5. Metoprolol Succinate XL 50 mg PO DAILY hold for HR<55, bp<95 6. Milk of Magnesia 30 mL PO Q6H:PRN constipation 7. Multivitamins 1 TAB PO DAILY 8. Omeprazole 20 mg PO DAILY 9. Polyethylene Glycol 17 g PO DAILY 10. Senna 1 TAB PO BID 11. Vitamin D 800 UNIT PO DAILY 12. Acetaminophen 650 mg PO Q6H:PRN pain 13. Lidocaine Jelly 2% 1 Appl TP DAILY: PRN penile pain/foley pain 14. Bisacodyl 10 mg PR HS constipation 15. Bisacodyl 10 mg PO DAILY constipation 16. Atorvastatin 40 mg PO DAILY 17. CefePIME 2 g IV Q12H 18. Fluconazole 200 mg PO Q24H Duration: 5 Days 19. Mirtazapine 7.5 mg PO HS 20. Lactulose 30 mL PO BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Complicated urinary tract infection Hypotonic bladder Constipation 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 CHEST RADIOGRAPH INDICATION: Chronic heart failure, evaluation for edema and effusion. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, there is unchanged evidence of elevation of the left hemidiaphragm and subpleural partly calcified scars. Status post CABG. Minimal atelectasis at the right lung base but no evidence of current pneumonia or fluid overload. Unchanged appearance of the cardiac silhouette. Radiology Report HISTORY: ___ man with UTI, chronic constipation presents with severe abdominal pain, not passing gas. COMPARISON: Abdominal radiograph, ___. FINDINGS: There is moderate colonic fecal load with minimally dilated cecum. Air is seen in scant loops of nondilated small bowel. This is a nonobstructive bowel gas pattern. Remnant contrast material is seen in the large bowel. There is no supine radiographic evidence of pneumoperitoneum or pneumatosis. IMPRESSION: Moderate colonic fecal load. Nonobstructive bowel gas pattern. Wet read was entered into the system by Dr. ___ on ___ at 22:33. Radiology Report SINGLE FRONTAL VIEW OF THE CHEST REASON FOR EXAM: Increased lethargy, assess for pneumonia. Comparison is made with prior study, ___. Cardiac size is top normal. The main pulmonary arteries are larger as before. Elevation of the left hemidiaphragm is longstanding. There are low lung volumes. Bibasilar atelectases have increased. Bilateral calcified pleural plaques are again noted. There are probably small bilateral pleural effusions. There is no pneumothorax. Radiology Report SINGLE FRONTAL VIEW OF THE CHEST REASON FOR EXAM: Assess line. Right PICC tip is in the low SVC. The patient is very rotated. Assessment of the cardiomediastinum is very limited. There is a probable new large opacity in the left lower lobe that would correspond to a large area of atelectasis. A conventional frontal radiograph without rotation is recommended for further and better evaluation. There is no evident pneumothorax. Radiology Report ABDOMEN REASON FOR EXAM: Increasing abdominal pain and distention. Assess for obstruction. There is a nonobstructing bowel gas pattern. There is air in the ascending and transverse colon. There is fecal material in the descending colon. There is no air in the rectum. There are few air fluid levels in the small bowel loops that are nondistended. There are severe degenerative changes in the lumbar spine. There are vascular calcifications. Radiology Report HISTORY: Right renal tumor and indwelling Foley with positive urine culture. COMPARISON: CT abdomen pelvis from ___ FINDINGS: The right kidney measures 10.2 cm. The left kidney measures 10.4 cm. Bilateral kidneys are without evidence of hydronephrosis or stones. The vascular right upper pole tumor is again noted measuring 3.3 x 3.6 x 2.9 cm. The bladder is decompressed and not evaluated. There is no evidence of distinct collections. IMPRESSION: No evidence of distinct collections. Right upper pole solid tumor is again identified measuring 3.3 x 3.6 x 2.9 cm. Radiology Report REASON FOR EXAMINATION: PICC line placement and assessment of left lower lobe opacity. AP radiograph of the chest was reviewed in comparison to ___ and ___. Elevated left hemidiaphragm is redemonstrated. No definitive opacity except for minimal bibasilar atelectasis is demonstrated. Pulmonary nodules seen in the left mid lower lung are demonstrated and might represent at least in part pleural calcifications. No pneumothorax is seen. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: UTI COMPLAINTS Diagnosed with URIN TRACT INFECTION NOS, HYPERTENSION NOS temperature: 97.6 heartrate: 88.0 resprate: 20.0 o2sat: 95.0 sbp: 86.0 dbp: 47.0 level of pain: 7 level of acuity: 1.0

Acute issues: # Urinary tract infection: Patient with BPH and hypotonic bladder with incomplete emptying, s/p indwelling foley since ___ c/b frequent multidrug resistent UTIs, including MRSA, ESBL E Coli, Pseudomonas, and Klebsiella. Had multiple ED visits the week of admission, initially treated with Cipro then switched to Keflex when culture grew Klebsiella resistant to Cipro. Repeat culture grew Pseudomonas, so patient admitted to the hospital for IV antibiotics and was started on cefepime. He was trialed on fosfomycin, but deteriorated clinically so cefepime was resumed. Patient continued to complain of suprapubic pain, repeat UA suggestive of infection and culture grew yeast ___ PARAPSILOSIS) and patient was started on fluconazole to complete a ___onstipation: Patient with significant abdominal pain and distension, abdominal X-ray on ___ showed large amount of dense stool. Patient disimpacted without significant success, given MoviPrep with good result. Bowel regimen up-titrated, but patient with no bowel movements for next 3 days. MoviPrep given again, again with good success. # Tremors: Patient with intermittant somnolence and tremor of chin and hands in the context of possibly worsening UTI. Patient had similar tremors on hospitalization in ___, which were thought to be myoclonus secondary to infection. Neurology consulted, recommended discontinuing duloxetine, trazodone, oxycodone and starting clonazepam, as that seemed to help previuosly. However, clonazepam then held due to patient lethargy. # Depression: Patient's duloxetine held due to tremors. Patient with decreased appetite, tearfulness, hopelessness. Started on low dose ___ likely need uptitration on an outpatient basis. # Delirium/acute encephalopathy: patient with waxing and waning mental status throughout hospitalization. UTI and constipation thought to be main contributing factors, treated as above. EKG repeatedly unchanged from baseline, electrolytes and LFTs normal, CXR normal. # Hypoxia: patient with intermittant desats into the high ___ on room air. No signs of acute pulmonary process on multiple chest x-rays, improved with deep breathing/incentive spirometry. # Facial rash: patient with crusted rash on right side of face, DFA negative for zoster or HSV. Also with erythematous rash on forehead.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Lower extremity swelling, EKG changes Major Surgical or Invasive Procedure: Blood transfusion History of Present Illness: The patient is a ___ with HTN, CKD (baseline creatinine of 3.3-3.8) , and anemia of CKD. Had a routine visit with Dr. ___ ___ and was noted to have new deep TWI in V3-V6 so was referred to ED for further evaluation. Notes new bilateral lower extremity edema since 2d prior, denies hx of edema. Denies chest pain/pressure/tightness, SOB, palpitations, either at rest or with exertion. Is still able to climb his 5 steps at home without having to rest. Sleeps on 1 pillow and is able to sleep flat, denies PND or orthopnea. . In the ED, initial vs were:97 50 130/64 16 100%. On exam, he was guiaic negative, JVP elevated, 1+ pedal edema, faint bibasilar rales but poor respiratory effort, a/a/o x3, hard of hearing, independent. Labs were remarkable for HCT of 21.3 (baseline ___, creatinine of 4.2 (baseline 3.3-3.8) with BUN of 94, BNP 3404 (no prior), troponin-T 0.3. EKG per report showed sinus brady at 53, NA, QRS 116, QTc 498, TWI in II/III/AVF (old) and TWI in V3-V6 (new and deeper). CXR obtained and showed findings suggestive of pulmonary vascular engorgement without frank pulmonary edema. He was given aspirin 325mg. Vitals on Transfer: 70, RR: 18, BP: 125/49, O2Sat: 99, Pain: 0. Past Medical History: -Hypertension -chronic kidney disease (baseline 3.3-3.8) due to chronic IgA nephropathy(biopsy proven) followed by nephrology -Anemia due to chronic kidney disease Social History: ___ Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 97.2 147/62 68 18 97RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP ~2-3cm above clavicle @45 degrees, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi but poor inspiratory effort CV: Regular rate and rhythm, s4 appreciated, -m/r. Abdomen: soft, non-tender, mildly distended (baseline per pt), bowel sounds present, no rebound tenderness or guarding. +hepatojugular reflex. Liver not pulsatile. Ext: Warm, well perfused. 1+ pitting edema to mid shin bilaterally. 2+ pulses, no clubbing, cyanosis. Neuro: AOx3, CN grossly intact DISCHARGE PHYSICAL EXAM: O:PHYSICAL EXAM: Vitals: 98.0 148/60 64 18 98RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP flat while upright, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi but poor inspiratory effort CV: Regular rate and rhythm, s4 appreciated, -m/r. Abdomen: soft, non-tender, mildly distended (baseline per pt), bowel sounds present, no rebound tenderness or guarding. +hepatojugular reflex. Liver not pulsatile. Ext: Warm, well perfused. trace to 1+ pitting edema to mid shin bilaterally. 2+ pulses, no clubbing, cyanosis. Neuro: AOx3, CN grossly intact Pertinent Results: ___ 11:45AM BLOOD WBC-6.6 RBC-2.27* Hgb-7.6* Hct-21.7* MCV-96 MCH-33.3* MCHC-34.8 RDW-14.4 Plt ___ ___ 06:00AM BLOOD WBC-6.1 RBC-2.13* Hgb-7.0* Hct-20.1* MCV-95 MCH-32.7* MCHC-34.5 RDW-14.4 Plt ___ ___ 11:45AM BLOOD Neuts-71.0* ___ Monos-6.5 Eos-2.3 Baso-0.5 ___ 11:45AM BLOOD ___ PTT-30.9 ___ ___ 11:45AM BLOOD Glucose-104* UreaN-94* Creat-4.2* Na-140 K-4.6 Cl-105 HCO3-23 AnGap-17 ___ 06:00AM BLOOD Glucose-89 UreaN-95* Creat-4.1* Na-143 K-4.8 Cl-109* HCO3-20* AnGap-19 ___ 11:45AM BLOOD CK(CPK)-33* ___ 07:28PM BLOOD CK(CPK)-31* ___ 06:00AM BLOOD CK(CPK)-32* ___ 11:45AM BLOOD CK-MB-3 proBNP-3404* ___ 11:45AM BLOOD cTropnT-0.03* ___ 07:28PM BLOOD CK-MB-3 cTropnT-0.03* ___ 06:00AM BLOOD CK-MB-2 cTropnT-0.02* ___ 07:28PM BLOOD Iron-64 ___ 07:28PM BLOOD calTIBC-189* Ferritn-343 TRF-145* CXR ___: IMPRESSION: Findings suggestive of pulmonary vascular engorgement without frank pulmonary edema. Trace bilateral pleural effusions. Medications on Admission: -Aranesp 60 mcg once a month (gets in ___ clinic) -Calcitriol 0.25 mcg once a week (started in ___ -nifedipine 60mg daily -carvedilol 3.125 BID -calcium acetate 667mg BID Discharge Medications: 1. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. nifedipine 60 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO DAILY (Daily). 3. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a week. 5. Aranesp (polysorbate) 60 mcg/mL Solution Sig: One (1) Injection once a month. 6. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 7. Outpatient Lab Work Please get your bloodwork drawn at ___ clinic tomorrow (___). There is a standing order in the system. Show up to the lab at any time. Dr ___ will follow-up on the lab result. Discharge Disposition: Home Discharge Diagnosis: non-specific EKG changes Acute on chronic renal failure Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report CHEST, TWO VIEWS: ___ HISTORY: ___ man with lower extremity swelling, question CHF. FINDINGS: Frontal and lateral views of the chest are compared to previous exam from ___. There is no confluent consolidation identified. There is however engorgement of central vasculature with indistinct pulmonary vascular markings seen particularly at the bases. There are also trace bilateral pleural effusions. Cardiac silhouette is slightly enlarged but stable. Osseous and soft tissue structures are stable. IMPRESSION: Findings suggestive of pulmonary vascular engorgement without frank pulmonary edema. Trace bilateral pleural effusions. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: ABNORMAL EKG Diagnosed with ABNORM ELECTROCARDIOGRAM, ANEMIA IN END-STAGE RENAL DISEASE, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED, CHRONIC KIDNEY DISEASE, UNSPECIFIED temperature: 97.0 heartrate: 50.0 resprate: 16.0 o2sat: 100.0 sbp: 130.0 dbp: 64.0 level of pain: 0 level of acuity: 3.0

___ hx worsening CKD, HTN who presents with EKG changes from PCPs office, asymptomatic. . #EKG changes: New deep TWI in V3-V6 with new AV nodal delay. No hx suggestive of coronary disease although on exam appears with volume overload (JVD, edema, S4 from ?longstanding HTN). Cardiac risk factors include hypertension, age. Has no hx of DM2, previous remote smoking hx. DDx includes ischemia (although no s/s, no hx), LV strain (anemia below baseline although not symptomatic), neurogenic T waves (although neuro exam and hx reassuring), memory T waves (does have new AV nodal delay on EKG but no evidence for RBBB/LBBB). Other more chronic etiologies such as ___ syndrome less likely due to previously normal EKG in ___. He was ruled out for MI with serial CE x3 (all negative). TTE was deferred to the outpatient setting. It is unclear what these EKG changes were due to. . #Volume overload: evidence of edema, JVD with +HJR, lung vasculature engorged but no signs of pulmonary edema on CXR or clinically. Etiology likely secondary to worsening renal failure although cardiac etiology cannot be ruled out. TTE was deferred to the outpatient setting as the patient was quite stable. His volume status was managed with IV lasix; to 40IV lasix he only put out approximately 250-300cc, so he was discharged with 80mg PO with close follow-up and labwork the day after discharge to evaluate electrolytes and renal function. His dose of lasix will likely have to be altered as an outpatient. . #Anemia: HCT 21 on admission, below baseline of 25, secondary to CKD. On aranesp as outpt. Hemodynamically stable and asymptomatic. Unlikely to be causing his EKG changes, however he was transfused 1 unit RBCs due to HCT 20 on HD2. He tolerated this well, receiving 40IV lasix before and after the transfusion for volume management. He will have a repeat HCT drawn the day after discharge. . #AOCKD: baseline Cr rising from mid 3.5 to now 4.2. BUN near his recent baseline. Etiology secondary to progressive chronic IgA nephropathy. Initially pt declined HD/PD. In further discussion with patient, he is going to weigh the risks/benefits of the various options tomorrow at his appointment with his nephrologist. There were no urgent indications for dialysis during this admission. . #HTN: Maintained on his home medications. Added lasix on this admission. .

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: fever Major Surgical or Invasive Procedure: none History of Present Illness: Mrs. ___ is a ___ female with multiple myeloma with adverse cytogenetics who has had progressive disease through multiple treatment regimens, most recently treated with D-PACE and bortezomib/pomalidomide. Patient now presents with fever 100.4 at home and chills from OSH. Infectious workup at OSH unrevealing thus far but CXR consistent with interval improvement in PNA but noted progressive disease. Patient was initiated on cefepime. Urine and blood cultures NTD, admitted for further management. Past Medical History: PAST ONCOLOGIC HISTORY: DIAGNOSIS: Multiple myeloma, ISS stage II, Durie-Salmon stage III, high risk cytogenetics Multiple numerical and structural abnormalities, including 6q deletion, gain of 1q, monosomy 13 and a possible t(14;16) most likely resulting in an IGH/MAF rearrangement. TREATMENT HISTORY: On clinical trial ___, randomized to arm B (early transplant): RVD = lenalidomide 25 mg daily D1-14, bortezomib 1.3 mg/m2 D1,4,8,11, dexamethasone 20 mg D1,2,4,5,8,9,11,12 3 cycles ___ - ___ Found to have disease progression (new plasmacytoma) on ___ and taken off treatment on ___ Dexamethasone 40 mg PO x4 on ___, Cytoxan 1000 mg/m2 IV on ___, Bortezomib 1.3 mg/m2 D1,4,8,11 on ___ -> stable M-protein RCVD (Cytoxan 300 mg/m2 + Dex ___ mg + bortexomib 1.5 mg/m2 on D1,8,15,22 and lenalidomide 25 mg D1-21 in a 28 day cycle) CyBorD started on ___, All 4 drugs started on ___ -C1 Carfilzomib/dex/revlmid Starting ___ -C2 Carfilzomib/dex/revlmid Starting ___ - D-PACE since ___ PAST MEDICAL HISTORY: -Multiple Myeloma as above -HSV-2 -Asthma Social History: ___ Family History: In terms of family history, there is a fairly substantial family history of malignancy. Her oldest sister had some sort of cancer of the spine. A different sister had lung cancer. A brother died from leukemia. Another brother had prostate cancer. She has three other siblings who are well. She is the youngest of eight children. Her father died at age ___ of an unknown cause and her mother passed away at age ___. Her children and grandchildren are healthy. Physical Exam: ADMISSION PHYSICAL EXAM: GEN: Chronically appearing female in no distress, cachetic VS: Tc 98.2 HR 96 BP 112/60 Resp 19 spO2 96%RA Pain (___): 0 HEENT: MMM, no OP lesions, no cervical, supraclavicular, or axillary LAD CV: RRR. Normal S1 and S2. No S3/S4. No M/R/G PULM: Crackles on LLL. Otherwise, CTA. No increased WOB, wheezing or rhonchi. Tenderness over L ribs, chronic ABD: Multiple bruising from lovenox injections. Hypoactive BS, soft, mild distention, no tenderness, Left abdominal wall induration LIMBS: No edema/inguinal adenopathy SKIN: Bruising as noted above. No rashes or skin breakdown NEURO: Grossly non-focal, alert and oriented x 3 DISCHARGE PHYSICAL EXAM: GEN: Chronically appearing female in no distress, cachetic VS: Tc 98.7 HR 101 BP 108/60 Resp 101 spO2 97%RA Pain (___): 0 HEENT: MMM, no OP lesions, no cervical, supraclavicular, or axillary LAD CV: RRR. Normal S1 and S2. No S3/S4. No M/R/G PULM: Crackles on LLL, diminished at bilateral bases. Otherwise, CTA. No increased WOB, wheezing or rhonchi. Tenderness over L ribs, chronic ABD: Multiple bruising from lovenox injections. Hypoactive BS, soft, mild distention, no tenderness, 4 subcutaneous nodules, remain assumed to be plasmocytoma no pain LIMBS: No edema/inguinal adenopathy SKIN: Bruising as noted above. No rashes or skin breakdown NEURO: Grossly non-focal, alert and oriented x 3 Pertinent Results: ___ 07:52AM BLOOD WBC-2.8* RBC-2.67* Hgb-7.9* Hct-24.2* MCV-91 MCH-29.6 MCHC-32.6 RDW-18.8* RDWSD-59.4* Plt Ct-24* ___ 12:02PM BLOOD WBC-3.0* RBC-2.36* Hgb-7.2* Hct-21.8* MCV-92 MCH-30.5 MCHC-33.0 RDW-19.1* RDWSD-62.9* Plt Ct-20*# ___ 07:52AM BLOOD Neuts-66 Bands-0 Lymphs-4* Monos-29* Eos-0 Baso-0 ___ Metas-1* Myelos-0 NRBC-2* AbsNeut-1.85 AbsLymp-0.11* AbsMono-0.81* AbsEos-0.00* AbsBaso-0.00* ___ 12:02PM BLOOD Neuts-77* Bands-10* Lymphs-3* Monos-6 Eos-0 Baso-1 ___ Metas-3* Myelos-0 AbsNeut-2.61 AbsLymp-0.09* AbsMono-0.18* AbsEos-0.00* AbsBaso-0.03 ___ 07:52AM BLOOD Glucose-147* UreaN-9 Creat-0.5 Na-129* K-4.2 Cl-100 HCO3-23 AnGap-10 ___ 12:02PM BLOOD UreaN-12 Creat-0.7 Na-131* K-4.8 Cl-100 HCO3-24 AnGap-12 ___ 07:52AM BLOOD ALT-37 AST-17 LD(LDH)-174 AlkPhos-91 TotBili-0.4 ___ 12:02PM BLOOD ALT-40 AST-25 LD(LDH)-165 AlkPhos-84 TotBili-0.4 ___ 07:52AM BLOOD Albumin-2.8* Calcium-8.1* Phos-2.5* Mg-1.7 ___ 12:02PM BLOOD Calcium-8.9 Phos-4.3 Mg-1.8 UricAcd-2.3* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q8H 2. Clotrimazole 1 TROC PO TID 3. Gabapentin 300 mg PO QHS 4. Lorazepam 0.5 mg PO QHS:PRN insomnia 5. Lorazepam 0.5 mg PO Q4H:PRN nausea/vomiting 6. Metoprolol Succinate XL 25 mg PO DAILY 7. OLANZapine 2.5-5 mg PO BID:PRN nausea/vomiting 8. Omeprazole 20 mg PO BID 9. Ranitidine 300 mg PO QHS 10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 11. Bisacodyl 10 mg PO DAILY:PRN constipation 12. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral DAILY 13. Docusate Sodium 100 mg PO BID 14. Magnesium Oxide 400 mg PO DAILY 15. Senna 8.6 mg PO BID Discharge Medications: 1. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 2. Senna 8.6 mg PO BID 3. Ranitidine 300 mg PO QHS 4. Omeprazole 20 mg PO BID 5. OLANZapine 2.5-5 mg PO BID:PRN nausea/vomiting 6. Metoprolol Succinate XL 25 mg PO DAILY 7. Magnesium Oxide 400 mg PO DAILY 8. Lorazepam 0.5 mg PO QHS:PRN insomnia 9. Gabapentin 300 mg PO QHS 10. Docusate Sodium 100 mg PO BID 11. Clotrimazole 1 TROC PO TID 12. Bisacodyl 10 mg PO DAILY:PRN constipation 13. Lorazepam 0.5 mg PO Q4H:PRN nausea/vomiting 14. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral DAILY 15. Acyclovir 400 mg PO Q8H 16. Levofloxacin 500 mg PO Q24H Duration: 5 Days RX *levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*5 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: MM fever of unknown origin Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with progressive MM // febrile at home, R/o PNA febrile at home, R/o PNA IMPRESSION: In comparison with the study of ___ from an outside hospital, there is continued enlargement of the cardiac silhouette with some indistinctness of engorged pulmonary vessels consistent with elevated pulmonary venous pressure. Continued left pleural effusion with compressive atelectasis at the base. Probable atelectatic changes are also seen on the right. Continued irregular pleural opacifications about the border of the left hemithorax, consistent with the pleural myeloma circumferentially involving the left lung on the CT of ___. Radiology Report INDICATION: ___ woman with a history of multiple myeloma, now with fever and abdominal pain. Evaluate for obstruction. TECHNIQUE: Supine abdominal radiograph. COMPARISON: Abdominal radiograph from ___. FINDINGS: There are no abnormally dilated loops of large or small bowel. There is no free intraperitoneal air. Osseous structures are unremarkable. Small phlebolith in the left pelvis. IMPRESSION: No evidence of obstruction. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ yo woman with multiple myeloma here with fever and now with new abdominal pain // Please evaluate for free air. COMPARISON: ___. IMPRESSION: As compared to the previous radiograph, no relevant change is seen. No evidence of free intra-abdominal air. Extensive pleural left-sided changes, combined to a left pleural effusion, are constant. Moderate cardiomegaly, signs of mild pulmonary edema and bilateral apical thickening, accompanied by apical fibrosis is constant. Gender: F Race: WHITE - BRAZILIAN Arrive by AMBULANCE Chief complaint: Fever, Pneumonia, Transfer Diagnosed with FEVER, UNSPECIFIED, OTHER PANCYTOPENIA, PNEUMONIA,ORGANISM UNSPECIFIED, MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION temperature: 98.5 heartrate: 81.0 resprate: 18.0 o2sat: 96.0 sbp: 100.0 dbp: 61.0 level of pain: 0 level of acuity: 2.0

Mrs. ___ is a ___ female with adverse cytogenetics and an aggressive multiple myeloma. She has had multiple prior lines of therapy outlined in the treatment history above. She was transfered from OSH where she presented with fever and chilss. She is currently ___ s/p C8 D-PACE #Abdominal cramping: Resolved. most likely due to constipation, received multiple stool medication as no BM x 4 days. Had 3 stools since yesterday. -KUB neg -Lactate 1.1 -oxycodone prn -continue bowel regimen #Fever/PNA: transferred from OSH ___ to ___ due to fever + chills. Was febrile 100.4 at home and OSH. Patient has been afebrile since admission. CXR at OSH showed interval improvement of lung aeration, with decreased perihilar interstitial and alveolar opacities compared to previous CXR on ___. However, concerning for progressive disease. Previous Chest CT ___ at OSH was consistent with right infiltrate vs metatases -d/c IV ABX after afebrile 48hrs, changed to po levaquin x 5 days -blood culuture ___ NTD -urine culture ___ neg -will continue to monitor closely outpatient #Pericardial Effusion: Was noted to have a small pericardial effusion on ___ at OSH. Continue to monitor I/O, weights and diurese prn. -Last BNP 114 on ___ -TTE ___ clinically insignificant effusion per CARDs #Progressive Multiple Myeloma: Initiated C8 D-PACE per Br J Haematol. ___ Jul;138(2):176-85 on ___. However, has had temporary benefit from each cycle in terms of symptomatic improvement and decrease in LDH. -Received 1 dose of Marizomib on ___ as part of the ___ clinical trial but pt currently not enrolled due to progressive disease -IgG ___, repeat ___ IgG 5702, IgG 6700 ___ -free kappa ___: 39 -> ___: 306 -> ___: 455 -> ___: 330 -C9 D-PACE due end of this week but may be on hold due to infectious w/u, plan for ___ -f/u with Dr ___, aware to call with any persistent fevers at home. #SIADH: Most likely due to pseudohyponatremia from paraprotein. Will consider repeating paraproteins. could be SIADH but ___ s/p D-PACE -urine osmo 407/serum 275 -NA+ 129 today -continue trending lytes outpatient #Anemia and thrombocytopenia: Due to extensive marrow involvement by myeloma, compounded by recent chemotherapy with C8 D-PACE/POM/Bortezimib. Platelet 24K today. Hgb 6.8, received 1 unit prbcs ___. Will continue to monitor for sxs of bleeding/anemia. Completed neupogen prior to admission. -transfuse for hgb <7 and/or plt <20K outpatient #History of DVT (in the setting of lenalidomide, despite prophylactic ASA) - diagnosed on ___. Held lovenox per Dr. ___ note on ___. Re-started on 60mg daily on previous admission -holding lovenox on admission due to thrombocytopenia (plts 37) -monitor for sxs of bleeding #Hypertension: Hx of PAF, received amiodarone gtt ___ at OSH during previous admission. will continue home metoprolol BID #Constipation: +hypoactive BS. No BM x 4 days upon admission. Had 1 stool this AM. Maximizing stool regimen, pt has had poor-fair appetite. - currently on senna, colace, dulcolax ATC and miralax prn - will continue to monitor closely #Electrolyte imbalance (hypokalemia): may be related to infectious lung process. will be repleting prn, continue to monitor lytes closely # Infectious prophylaxis: - PCP: ___ - HSV/VZV: Acyclovir

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, vomitting Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ male with Hx of diverticulitis and IBS, s/p multiple abdominal surgeries, most recently ex lap with ileostomy takedown and end descending colostomy on ___, who was discharged ___ from ___ and now presented on ___ with nausea, bilious vomiting and increased abdominal pain. Patient was discharged yesterday, at which point he was tolerating a regular diet without nausea or vomitting. When he got home yesterday he was able to have a small meal (spaghetti) with minimal discomfort. Late on the night prior to admission, patient starting having diffuse abdominal pain and green/bilious vomiting, with 3L of total emesis volume (measured by wife). He continued to vomit this morning so they called Dr. ___ recommended he come to the ED. He denies hematemesis, coffee ground emesis, fever, or chills. He has received 1L of normal saline and IV zofran in the ED. Currently, denies active N/V. Colostomy continues to have output although patient estimates that total output is slightly less and stool appears more dehydrated. Past Medical History: Past Medical History: psoriasis (previously on methotrexate), diverticulitis, OSA, depression, IBS Past Surgical History: sigmoid colectomy (OSH, ___ c/b leak, diverting ileostomy (OSH, ___, ileostomy reversal (___) c/b leak ___ foreign body, resection of prior colorectal anastomosis/VAC placement (___), washout/open abdomen (___), washout/partial closure of abdomen (___), ex ___ separation closure w/ SurgiMend (___), colostomy takedown/primary repair of colostomy/LOA/diverting double-barrel ileostomy Social History: ___ Family History: Non-contributory Physical Exam: Admission PE ___: Temp: 98.5 HR: 74 BP: 122/90 Resp: 18 O(2)Sat: 99 Normal Constitutional: Comfortable HEENT: Normocephalic, atraumatic, Pupils equal, round and reactive to light, Extraocular muscles intact Oropharynx within normal limits Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm Abdominal: diffusely tender with packing in 2 abscesses, normal colostomy outpt GU/Flank: No costovertebral angle tenderness Extr/Back: No cyanosis, clubbing or edema Skin: No rash Neuro: Speech fluent Discharge PE: ___ Vitals: 98.3, HR: 70, BP: 95/58, RR: 18, 95% on RA General: comfortable appearing man Lungs: CTAB, diminished at the bases CV: RRR, no murmurs, rubs or gallops Amdominal: soft, non tender, non distended, colostomy with well perfused stoma and brown stool. Healing midline incision, lower portion of the incision epithealizing well, no packing required. Extremities: warm, well perfused, +PP Neuro: Alert and oriented X3, MAE to command, PERRL Pertinent Results: ___ 04:28AM PLT COUNT-507* ___ 04:28AM NEUTS-45.0* LYMPHS-44.4* MONOS-6.1 EOS-4.0 BASOS-0.5 ___ 04:28AM WBC-3.2* RBC-3.42* HGB-9.5* HCT-30.7* MCV-90 MCH-27.8 MCHC-31.0 RDW-14.5 ___ 04:28AM GLUCOSE-89 UREA N-21* CREAT-0.7 SODIUM-138 POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-26 ANION GAP-15 ___ 07:45AM ___ PTT-35.1 ___ ___ 07:45AM PLT COUNT-713* ___ 07:45AM NEUTS-60.0 ___ MONOS-9.8 EOS-1.0 BASOS-1.0 ___ 07:45AM WBC-3.3* RBC-4.13* HGB-11.4* HCT-36.5* MCV-88 MCH-27.6 MCHC-31.2 RDW-14.5 ___ 07:45AM ALBUMIN-4.7 ___ 07:45AM LIPASE-67* ___ 08:08AM LACTATE-2.4* ___ 04:48AM BLOOD WBC-1.8* RBC-3.11* Hgb-8.5* Hct-27.5* MCV-89 MCH-27.4 MCHC-31.0 RDW-14.3 Plt ___ ___ 07:45AM BLOOD Neuts-60.0 ___ Monos-9.8 Eos-1.0 Baso-1.0 ___ 04:48AM BLOOD Glucose-108* UreaN-18 Creat-0.7 Na-138 K-4.3 Cl-106 HCO3-26 AnGap-10 ___ 04:48AM BLOOD Calcium-9.1 Phos-2.5* Mg-2.0 ___: CT ABD/Pelvis:IMPRESSION: 1. Further slight decrease in size of the known abdominal and pelvic fluid collections. No new collections identified. 2. Findings raising concern for partial small-bowel obstruction at the level of a proximal small bowel anastomosis in the jejunum. ___: CXR: Left PICC with the tip in the mid to low SVC. Medications on Admission: 1. Acetaminophen 1000 mg PO Q8H 2. Duloxetine 90 mg PO DAILY 3. Gabapentin 800 mg PO Q8H 4. Daptomycin 300 mg IV Q24H 5. Fentanyl Patch 25 mcg/h TD Q72H chronic pain 6. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain 7. Meropenem 1000 mg IV Q8H 8. Pantoprazole 40 mg PO Q24H 9. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line flush 10. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP TID:PRN psoriasis 11. Multivitamins W/minerals 1 TAB PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Docusate Sodium 100 mg PO BID 3. Duloxetine 90 mg PO DAILY 4. Fentanyl Patch 25 mcg/h TD Q72H 5. Gabapentin 800 mg PO Q8H 6. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain 7. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP TID:PRN psorisis 8. Pantoprazole 40 mg PO Q24H Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: partial small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Recent surgery with 3 L of bilious vomiting. TECHNIQUE: Upright PA and supine AP views of the abdomen. COMPARISON: CT abdomen pelvis ___ and abdominal radiographs ___. FINDINGS: A nonobstructive bowel gas pattern is demonstrated. No air-fluid levels are seen on the upright view. Multiple chain sutures are seen within the abdomen. A left lower quadrant colostomy is present. There is no free intraperitoneal air identified. No acute osseous abnormalities are seen. IMPRESSION: Nonobstructive bowel gas pattern without free intraperitoneal air. No significant air-fluid levels are present. Radiology Report CT OF THE ABDOMEN AND PELVIS WITH IV CONTRAST INDICATION: ___ man with complicated surgical history, assess for fluid collection or ileus. CT OF THE ABDOMEN AND PELVIS WITH IV CONTRAST TECHNIQUE: Multidetector scanning is performed from the diaphragm through the symphysis during dynamic injection of Omnipaque. Comparison is made to ___. DLP: 672 mGy-cm. CT OF THE ABDOMEN WITH IV CONTRAST: There is mild atelectasis at the lung bases, not significantly changed. The liver is without focal lesions. The gallbladder is unremarkable. The spleen is normal in size. An NG tube is identified in the stomach and oral contrast is seen in the small bowel and can be followed into the pelvis. The pancreas enhances homogeneously and there is no dilatation of the pancreatic duct. The adrenal glands are normal. The kidneys enhance homogeneously. There is no evidence for hydronephrosis. There is no retroperitoneal lymphadenopathy. The aorta is normal in caliber. Some focal dilatation of jejunal loops in the left upper quadrant proximal to an anastomosis contrast is seen distally to this, however, and the distal loops are normal in caliber. Proximal loops measure up to 5.1 cm. This is a new finding from prior examination. The previously identified fluid collection immediately underneath the abdominal wall is decreased in size. Previously, it measured approximately 8.4 cm in length, currently only 4.7 cm. Its depth is relatively unchanged measuring 0.7 cm. There is a 1.4 x 1.0 cm fluid collection in the left upper quadrant (series 2, ___ 31) which contains a small focus of air. This is slightly decreased in size, previously measuring 1.5 x 1.3 cm. CT OF THE PELVIS WITH IV CONTRAST: A ___ pouch is identified and immediately above the suture line, there is a 3.2 x 2.8 x 1.2 cm fluid collection. This is slightly decreased in size, previously measuring 3.6 x 2.9 x 1.4 cm. No new collections are identified. There is no free fluid in the pelvis. There is no pelvic or inguinal lymphadenopathy. The prostate gland is normal in size. On bone windows, there are no concerning osteolytic or osteosclerotic lesions. IMPRESSION: 1. Further slight decrease in size of the known abdominal and pelvic fluid collections. No new collections identified. 2. Findings raising concern for partial small-bowel obstruction at the level of a proximal small bowel anastomosis in the jejunum. Radiology Report HISTORY: Chronic TPN requirements, admitted with PICC line. Evaluate placement. COMPARISON: Chest radiograph from ___. FINDINGS: A portable frontal chest radiograph demonstrates a left PICC with the tip in the mid to low SVC and a nasoenteric tube that likely enters the small bowel. The cardiomediastinal silhouette is normal and the lungs are clear. There is no pleural effusion or pneumothorax. IMPRESSION: Left PICC with the tip in the mid to low SVC. Radiology Report PORTABLE ABDOMEN, ___ COMPARISON: ___. FINDINGS: A non-obstructive bowel gas pattern is visualized. Colostomy is noted in the left lower quadrant, and surgical chain sutures present bilaterally. Oral contrast is present within non-distended small bowel in the left upper quadrant and within non-distended colon in the right side of the abdomen. Recently described dilated jejunal loop on CT of one day earlier is not evident, but additional upright or lateral decubitus views may be helpful if warranted clinically. Residual oral contrast within bowel is related to the recent CT. Gender: M Race: HISPANIC/LATINO - PUERTO RICAN Arrive by WALK IN Chief complaint: Abd pain, N/V Diagnosed with ABDOMINAL PAIN GENERALIZED, VOMITING temperature: 98.5 heartrate: 74.0 resprate: 18.0 o2sat: 99.0 sbp: 122.0 dbp: 90.0 level of pain: 8 level of acuity: 3.0

Mr ___ is a ___ year old with a history of diverticulitis and a complex surgical history who presented to ___ with nausea, large volume emesis, and abdominal pain on ___. He was most recently discharged on ___ after a lengthy admission s/p exploratory laparotomy, ileostomy reversal and end colostomy complicated by intraabdominal collections. He had been home less than 24 hours when he experienced diffuse abdominal with emesis after a small meal. CT scan on admission revealed a partial small bowel obstruction and the previous fluid collection had decreased in size. At this time, the patient was made NPO with IVF and a NGT was placed to low wall suction. He continued to have ostomy output at this time. The NGT was clamped on ___ with little residual and was removed on ___. On admission, he was placed on TPN to optimize his nutrition status; although, it had been discontinued prior to his previous discharge. His diet was advanced on ___. He was tolerating a regular diet with supplements on the day of discharge so it was decided that his TPN would be discontinued and his L PICC removed. He continued to pass stool through his colostomy. On the day of discharge, the patient was alert and oriented and pain was controlled on his home pain regimen. He was hemodynamically stable. He had remained afebrile. His white blood cell count trended down to 1.8 throughout this hospitalization which was deemed to be the effect of Meropenum. He completed his antibiotic course of Meropenum and Daptomycin on ___ for the intraabdominal fluid collections. He was ambulating independently. Throughout his hospitalization he was maintained on Heparin subcutaneously for deep vein thrombosis prophylaxis. He will follow up on ___ in the Acute Care Surgery Clinic.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ___ Attending: ___ Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: HISTORY OF PRESENT ILLNESS: Mr. ___ is a ___ y/o man w/PMH FSGS s/p failed deceased donor transplant, previously on peritoneal dialysis c/b encapsulating peritoneal sclerosis, now on HD MWF presenting with abdominal pain, nausea/vomiting, and inability to tolerate PO for the past two weeks. Also with hx papillary thyroid cancer s/p thyroidectomy, non-secretory pituitary adenoma, and eosinophilic gastritis. Of note, patient presented to ___ earlier this month 3 weeks ago for the same symptoms. According to patient's mother, he had a CT scan that just showed a large amount of stool in the colon, and he was treated supportively with morphine for pain and enemas for constipation. Discharged w/ persistent pain. Pain is in left upper quadrant radiating to back. Constant, was taking oxyocodone ___ that he was discharged with for pain without relief. Also having daily nausea with vomiting every time he tried to eat. Vomiting initially bilious, last episode of emesis was yesterday was when he tried to eat soup, vomit consisted of undigested soup. Last bowel movement was yesterday, only because he had a suppository, has not been able to have regular bowel movements. Not passing gas. No fevers/chills, chest pain, palpitations, SOB, ___ edema, bloody stools. Anuric. Due for HD today, did not go since he presented to ED. Tolerated sandwich in ER today. In the ED: - Initial VS: T97.8, HR101, BP 94/63, RR18, PO2 99% RA - Exam notable for: chronically ill, dry MM, +subcutaneous scar tissue in LUQ, multiple well-healed scars in RUQ (peritoneal dialysis port site), RLQ/right flank (s/p renal transplant). +b/l flank tenderness - Labs were notable for: hgb 10.7, wbc 8.1, plt 349, phos 7.8, Cr 9.6, K 4.7, LFTs wnl - Studies performed include: *CT A/P w/IV contrast: 1. Mildly dilated loops of small bowel in the right upper quadrant may be consistent with early partial small bowel obstruction. 2. Re-demonstrated extensive peritoneal calcifications likely secondary to chronic peritoneal dialysis and compatible with encapsulating peritoneal sclerosis. 3. Diffuse sclerotic changes to the visualized osseous structures, compatible with renal osteodystrophy. - Patient was given: IV HYDROmorphone (Dilaudid) .5 mg IV HYDROmorphone (Dilaudid) .5 mg IV Pantoprazole 40 mg - Consults: Renal Upon arrival to the floor, patient is still in ___ pain in LUQ radiating to the back. Heat packs and sitting upright somewhat helping. Tolerated sandwich in the ER. No N/V and still not passing gas. Feels bloated. Past Medical History: PITUITARY MASS H/O THYROID CANCER FSGS END STAGE RENAL DISEASE H/O RENAL TRANSPLANT ENCAPSULATING PERITONEAL SCLEROSIS PANCREATITIS STROKE HYPERPROLACTINEMIA HYPOGONADISM EOE/GERD LACTOSE INTOLERANCE CONSTIPATION/DYSMOTILITY Social History: ___ Family History: Maternal grandmother with diabetes Physical Exam: ADMISSION PHYSICAL EXAM: ================== VITALS: T98.4, BP 97/65, HR 101, RR 16, PO2 100 Ra GENERAL: Alert and interactive. In no acute distress. EYES: NCAT. PERRL, EOMI. Sclera anicteric and without injection. ENT: MMM. No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds, firm on palpation, not bloated; non-tender to deep palpation in all four quadrants. No organomegaly. MSK: No spinous process tenderness. No CVA tenderness. SKIN: Warm. Cap refill <2s. No rash. DISCHARGE PHYSICAL EXAM: =================== 24 HR Data (last updated ___ @ 843) Temp: 98.3 (Tm 98.6), BP: 105/67 (93-113/54-72), HR: 76 (73-85), RR: 18 (___), O2 sat: 99% (98-100), O2 delivery: Ra GENERAL: Alert and interactive. Lying in bed. NAD EYES: NCAT. PERRL, EOMI. Sclera anicteric and without injection. ENT: MMM. No cervical lymphadenopathy. CARDIAC: RRR, no murmurs/rubs/gallops. RESP: CTAB. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: normoactive BS+, firm on palpation particularly around midline, no tenderness. No rebound tenderness or guarding. SKIN: Warm. No rash noted. Pertinent Results: ADMISSION LABS: ============ ___ 12:45PM BLOOD WBC-8.1 RBC-3.82* Hgb-10.7* Hct-36.2* MCV-95 MCH-28.0 MCHC-29.6* RDW-15.9* RDWSD-55.1* Plt ___ ___ 12:45PM BLOOD Neuts-74.3* Lymphs-13.9* Monos-9.6 Eos-1.4 Baso-0.6 Im ___ AbsNeut-5.99 AbsLymp-1.12* AbsMono-0.77 AbsEos-0.11 AbsBaso-0.05 ___ 12:45PM BLOOD Plt ___ ___ 12:45PM BLOOD Glucose-73 UreaN-50* Creat-9.6*# Na-139 K-4.7 Cl-88* HCO3-23 AnGap-28* ___ 12:45PM BLOOD ALT-6 AST-10 AlkPhos-104 TotBili-0.7 ___ 12:45PM BLOOD Albumin-4.1 Calcium-9.7 Phos-7.8* Mg-2.1 ___ 04:42AM BLOOD calTIBC-109* Ferritn-998* TRF-84* ___ 04:42AM BLOOD PTH-14* ___ 04:42AM BLOOD 25VitD-62* DISCHARGE LABS: =========== ___ 06:31AM BLOOD WBC-5.4 RBC-3.13* Hgb-8.9* Hct-30.1* MCV-96 MCH-28.4 MCHC-29.6* RDW-17.2* RDWSD-58.6* Plt ___ ___ 06:31AM BLOOD Glucose-75 UreaN-45* Creat-9.0*# Na-140 K-4.0 Cl-99 HCO3-23 AnGap-18 ___ 06:31AM BLOOD Calcium-8.5 Phos-4.3 Mg-2.0 IMAGING: ======= ___ CT ABD/PELVIS: 1. Mildly dilated loops of small bowel in the right upper quadrant with collapse of the terminal ileum may be consistent with early and/or partial small bowel obstruction. 2. Re-demonstrated extensive peritoneal calcifications likely secondary to chronic peritoneal dialysis and compatible with encapsulating peritoneal sclerosis. Re-demonstrated low-density ascites encased by the peritoneal calcifications. 3. Diffuse sclerotic changes to the visualized osseous structures, compatible with renal osteodystrophy. ___ KUB: Persistently dilated small bowel in the right upper quadrant measuring up to 3.6 cm. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Pantoprazole 40 mg PO Q12H 2. Levothyroxine Sodium 200 mcg PO 5X/WEEK (___) 3. Levothyroxine Sodium 300 mcg PO 2X/WEEK (MO,FR) 4. sevelamer CARBONATE 2400 mg PO TID W/MEALS Discharge Medications: 1. Polyethylene Glycol 17 g PO DAILY 2. PredniSONE 30 mg PO BID RX *prednisone 10 mg 3 tablet(s) by mouth twice a day Disp #*180 Tablet Refills:*0 3. 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 4. Levothyroxine Sodium 200 mcg PO 5X/WEEK (___) 5. Levothyroxine Sodium 300 mcg PO 2X/WEEK (MO,FR) 6. Pantoprazole 40 mg PO Q12H 7. sevelamer CARBONATE 2400 mg PO TID W/MEALS Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: ============== Partial small bowel obstruction SECONDARY DIAGNOSIS: ================ FSGS s/p failed deceased donor transplant on iHD (previously on peritoneal dialysis) Papillary thyroid cancer s/p thyroidectomy Hypothyroidism Eosinophilic gastritis 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 FSGS s/p failed deceased donor transplant, formerly on peritoneal dialysis, complicated by peritoneal sclerosis, presenting with abdominal pain, nausea/vomiting, and inability to tolerate PO intake. Now on hemodialysis MWF. R/o bowel obstruction, acute abdomen TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 2.5 s, 0.5 cm; CTDIvol = 12.0 mGy (Body) DLP = 6.0 mGy-cm. 2) Spiral Acquisition 5.9 s, 46.1 cm; CTDIvol = 9.0 mGy (Body) DLP = 414.2 mGy-cm. Total DLP (Body) = 420 mGy-cm. COMPARISON: CT abdomen and pelvis dated ___ FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. A hemodialysis catheter is partially visualized. ABDOMEN: Re-demonstrated is diffuse, extensive peritoneal calcification encasing multiple loops of small bowel. There is also ascites encased in calcification. 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, besides vicarious excretion of contrast. 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: Bilateral kidneys are severely atrophic and not well visualized. GASTROINTESTINAL: The stomach is unremarkable. There is mild distension of small bowel loops measuring up to 3.6 cm in the right upper quadrant, with collapse of the distal ileum. There is change in caliber of the bowel loops in the right lower quadrant. The colon and rectum are within normal caliber, with stool and air. The appendix is not definitely visualized. There is air within the colon. PELVIS: The urinary bladder is decompressed. There is free-fluid, slightly decreased compared to prior. LYMPH NODES: There is no retroperitoneal abdominopelvic lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. BONES: There is diffuse sclerosis throughout the visualized osseous structures, compatible with renal osteodystrophy. SOFT TISSUES: Focal skin thickening in subcutaneous soft tissue induration along the bilateral gluteal clefts, right greater than left, extending into the anal verge is again re-demonstrated. IMPRESSION: 1. Mildly dilated loops of small bowel in the right upper quadrant with collapse of the terminal ileum may be consistent with early and/or partial small bowel obstruction. 2. Re-demonstrated extensive peritoneal calcifications likely secondary to chronic peritoneal dialysis and compatible with encapsulating peritoneal sclerosis. Re-demonstrated low-density ascites encased by the peritoneal calcifications. 3. Diffuse sclerotic changes to the visualized osseous structures, compatible with renal osteodystrophy. Radiology Report INDICATION: ___ year old man with hx of FSGS s/p failed transplant, on iHD, presented with nausea/vomiting, constipation concerning for SBO.// SBO TECHNIQUE: Supine abdominal radiograph was obtained. COMPARISON: CT abdomen/pelvis dated ___. KUB dated ___. FINDINGS: Persistently dilated loop of small bowel in the right upper quadrant measuring up to 3.6 cm. Supine assessment limits detection for free air; there is no gross pneumoperitoneum. Hyperdensities overlying the abdomen correspond to known peritoneal calcifications, better evaluated on CT dated ___. Osseous structures are unremarkable. IMPRESSION: Persistently dilated small bowel in the right upper quadrant measuring up to 3.6 cm. Radiology Report INDICATION: ___ year old man with SBO, now with n/v and worsening abdominal pain.// Does this patient have perf? Worsening of obstruction? TECHNIQUE: Supine and upright radiographs of the abdomen and pelvis COMPARISON: Radiographs from ___ FINDINGS: Diffuse peritoneal calcification is seen again and similar to prior. There are several prominent loops of small bowel located centrally within the abdomen, and on the upright images there are multiple fluid-filled level suggestive of a small bowel obstruction. There is no free intraperitoneal air. Lumbar spine degenerative change. IMPRESSION: Prominent small bowel loops with multiple fluid-filled levels on the upright images suggest ongoing small bowel obstruction. Radiology Report INDICATION: ___ y/o w/FSGS s/p failed transplant s/p peritoneal dialysis c/bperitoneal sclerosis, now on HD presenting who is admitted with partial bowel obstruction iso peritoneal sclerosis// Complaining of burning abdoninal pain. getting KUB to asses SBO TECHNIQUE: Supine abdominal radiograph COMPARISON: Multiple prior abdominal radiographs, most recently ___. CT abdomen and pelvis dated ___ FINDINGS: Again seen is diffuse peritoneal calcification in keeping with known history of encapsulating peritoneal sclerosis. Unchanged, centrally displaced prominent loops of small bowel. Supine technique limits evaluation of free air. Osseous structures are unremarkable. IMPRESSION: 1. Diffuse peritoneal calcification is unchanged and in keeping with known history of encapsulation peritoneal sclerosis 2. Unchanged, centrally displaced prominent loops of small bowel are suggestive of persistence/partial SBO 3. Supine view limits evaluation of free air Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abd pain, N/V Diagnosed with Unspecified abdominal pain temperature: 97.8 heartrate: 101.0 resprate: 18.0 o2sat: 99.0 sbp: 94.0 dbp: 63.0 level of pain: yes level of acuity: 3.0

BRIEF HOSPITAL COURSE: ================= Mr. ___ is a ___ yo M with history of FSGS s/p failed transplant s/p peritoneal dialysis s/p peritoneal sclerosis now in iHD who presented with ongoing abdominal pain, nausea, vomiting, and few bowel movements admitted for partial small bowel obstruction in the setting of encapsulating peritoneal sclerosis. He was treated conservatively with bowel rest, strict NPO, and nausea/pain medications. We talked with the patient about how opioid pain medication was likely prolonging this small bowel obstruction and encouraged him to use alternative pain medication treatments and the patient was amendable. He was given IV tylenol and toradol and did well. His nausea and vomiting slowly improved and he began to have bowel movements. He was also seen by the tranpslant surgery team who did not feel that any surgical intervention was necessary at this time. He was evaluated by GI and he was started on steroids for treatment of peritoneal sclerosis. His diet slowly advanced and he did well.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Gabapentin / Bactrim Attending: ___. Chief Complaint: Right ankle pain. Major Surgical or Invasive Procedure: None. History of Present Illness: ___ yo male with history of uncontrolled diabetes with last A1C 9.2 who presents for right ankle pain and swelling. He has a history of a right foot diabetic wound followed by podiatry s/p debridement on last ___. Since that time, the patient endorses fevers at home to 99-100 with right ankle pain and swelling. He reports decreased PO intake but denies nausea or vomiting. He denies any other symptoms. He wears a diabetic shoe on the right foot at baseline. On arrival to the ED, initial vitals were: pain 5 97.8 71 142/49 16 96% RA. Podiatry felt that his right foot ulcer was stable and recommended CAM walker or aircast to restrict ankle range of motion. They felt he could have been discharged with Bactrim DS but the ED felt his right leg was concerning for cellulitis. Ankle xrays were done and were without evidence of osteo. He was not given any antibiotics or medications. Most recent vitals prior to transfer: 98.1 67 125/62 18 99% on RA. Currently, he reports mild pain in the right ankle. ROS: per HPI, denies 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. Past Medical History: 1. Hepatitis C genotype 1 (s/p interferon plus ribavirin x at least six months and relapsed) - Treated in the 2000s by Dr. ___ at ___. He was treated with interferon plus ribavirin x at least six months and was a relapser on nadolol. 2. HCV Cirrhosis with portal hypertension including grade 2 esophageal varices - EGD (___) - varices at the lower third of the esophagus, friability and erythema in the antrum and pre-pyloric area compatible with gastritis, erythema in the duodenal bulb compatible with Duodenitis - easy to control ascites - HE on lactulose and rifaximin - Now followed by Dr. ___ at ___ 3. Insulin dependent diabetes, with last A1C 9.2, managed by his PCP. 4. Hypertension. 5. Hyperlipidemia. 6. BPH. 7. History of HBV exposure (core Ab positive/surface ag negative) 8. Overweight/obese state 9. Right foot drop 10. Chronic median neuropathy at the L wrist, as in carpal tunnel syndrome, w/associated axonal loss ___ EMG), s/p neurolysis and release (___) 11. s/p Colonic and rectal polypectomies (___) 12. GERD 13. Recurrent herpes simplex (on acyclovir) 14. Moderate to severe AS (valve area 1.0-1.2cm2) 15. Low back pain ___ discitis 16. Right tib-fib fracture ___ with indwelling screws Social History: ___ Family History: Father with heart valve replacement. Mother with diabetes. Both are deceased. Physical Exam: Admission exam: GENERAL - NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD HEART - PMI non-displaced, RRR, nl S1-S2, ___ SEM best heard RUSB that radiates to carotids LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, 1+ bilateral ___ edema, 2+ peripheral pulses (radials, DPs), erythema and mild increase in warmth on the right medial calf and ankle, nontender to touch, no pus; right plantar foot with small 1cm round ulcer without pus, erythema or warmth, borders c/d/i; no pain with passive ROM of right ankle NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout Discharge exam: VS - 98.0 137/60 65 20 100% on RA 147kg GENERAL - NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD HEART - PMI non-displaced, RRR, nl S1-S2, ___ SEM best heard RUSB that radiates to carotids LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, 1+ bilateral ___ edema, 2+ peripheral pulses (radials, DPs), no further erythema on right medial calf, small area of erythema on medial ankle over malleolus, nontender to touch, no pus; right plantar foot with small 1cm round ulcer without pus, erythema or warmth, borders c/d/i; no pain with passive ROM of right ankle NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout Pertinent Results: Labs: ___ 03:45PM BLOOD WBC-4.0 RBC-3.49* Hgb-10.7* Hct-32.2* MCV-92 MCH-30.5 MCHC-33.1 RDW-15.3 Plt Ct-86* ___ 03:45PM BLOOD Neuts-60.7 ___ Monos-10.0 Eos-2.0 Baso-0.4 ___ 05:19AM BLOOD WBC-3.3* RBC-3.40* Hgb-10.1* Hct-30.9* MCV-91 MCH-29.7 MCHC-32.7 RDW-15.3 Plt Ct-87* Micro: ___ blood cxrs pending x2 Imaging: ___ Unilat Lower Ext Veins Right -- No evidence of deep venous thrombosis in the right lower extremity. ___ Ankle (Ap, Mortise & Lat) Right / Foot Ap,Lat & Obl Right -- No radiographic evidence for osteomyelitis. No subcutaneous emphysema. No fracture or dislocation. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q12H 2. Clotrimazole Cream 1 Appl TP BID feet 3. Felodipine 2.5 mg PO DAILY 4. Finasteride 5 mg PO DAILY 5. Furosemide 80 mg PO DAILY 6. GlipiZIDE XL 10 mg PO DAILY 7. Glargine 42 Units Breakfast Glargine 42 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 8. Lactulose 30 mL PO QID 9. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN lower back pain 10. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY Do Not Crush 11. Nadolol 20 mg PO DAILY 12. Omeprazole 40 mg PO BID 13. Rifaximin 550 mg PO BID 14. Simvastatin 20 mg PO HS 15. Tamsulosin 0.4 mg PO HS 16. Calcium Carbonate 500 mg PO BID 17. cranberry *NF* 1000 mg Oral daily 18. Ferrous Sulfate 325 mg PO TID 19. Glucosamine *NF* (glucosamine sulfate) 750 mg Oral bid 20. Multivitamins 1 TAB PO DAILY 21. Fish Oil (Omega 3) ___ mg PO DAILY Discharge Medications: 1. Acyclovir 400 mg PO Q12H 2. Calcium Carbonate 500 mg PO BID 3. Clotrimazole Cream 1 Appl TP BID feet 4. Felodipine 2.5 mg PO DAILY 5. Ferrous Sulfate 325 mg PO TID 6. Finasteride 5 mg PO DAILY 7. Fish Oil (Omega 3) ___ mg PO DAILY 8. Furosemide 80 mg PO DAILY 9. Lactulose 30 mL PO QID 10. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN lower back pain 11. Multivitamins 1 TAB PO DAILY 12. Nadolol 20 mg PO DAILY 13. Omeprazole 40 mg PO BID 14. Rifaximin 550 mg PO BID 15. Simvastatin 20 mg PO HS 16. Tamsulosin 0.4 mg PO HS 17. Doxycycline Hyclate 100 mg PO Q12H Duration: 6 Days RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day Disp #*12 Tablet Refills:*0 18. cranberry *NF* 1000 mg Oral daily 19. Glucosamine *NF* (glucosamine sulfate) 750 mg Oral bid 20. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY 21. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 6 Days RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab by mouth twice a day Disp #*12 Tablet Refills:*0 22. Glargine 42 Units Breakfast Glargine 42 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: cellulitis, uncontrolled Type 2 diabetes, right foot ulcer 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: Lower extremity infection. TECHNIQUE: Right ankle, 3 views and right foot, 3 views. COMPARISON: ___. FINDINGS: 4 screws within the distal right tibia demonstrate no evidence of hardware failure. No acute fracture or dislocation is present. The ankle mortise is symmetric. No cortical destruction is noted. There is no subcutaneous gas. Mild degenerative changes are noted within the tibiotalar joint with osteophytic spurring. A small plantar calcaneal spur. The patient is status post resection of the ___ metatarsal head. Hammertoe deformities are re- demonstrated. There is degenerative spurring within the mid foot. Deformity of the ___ metatarsal head is unchanged, likely related to remote trauma. There are mild to moderate degenerative changes of the ___ MTP joint with joint space narrowing and osteophytic spurring. No subcutaneous gas or radiopaque foreign body is identified. There is no cortical destruction to suggest osteomyelitis. No suspicious lytic or sclerotic osseous abnormalities are seen. IMPRESSION: No radiographic evidence for osteomyelitis. No subcutaneous emphysema. No fracture or dislocation. Radiology Report HISTORY: Lower extremity swelling in the right greater than the left, here to evaluate for deep venous thrombosis of the right lower extremity. COMPARISON: Venous duplex ultrasound of the right lower extremity dated ___. TECHNIQUE: Grayscale, color and spectral Doppler evaluation was performed of the right lower extremity veins. FINDINGS: There is normal compressibility, flow and augmentation of the right common femoral, right proximal, mid and distal superficial femoral, and right popliteal veins. Normal color flow is demonstrated in the right posterior tibial and peroneal veins. There is normal respiratory variation of the common femoral veins bilaterally. IMPRESSION: No evidence of deep venous thrombosis in the right lower extremity. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: FOOT SWELLING Diagnosed with DIAB W MANIF NEC ADULT, CELLULITIS OF LEG temperature: 97.8 heartrate: 71.0 resprate: 16.0 o2sat: 96.0 sbp: 142.0 dbp: 49.0 level of pain: 5 level of acuity: 3.0

___ yo male with uncontrolled diabetes and stable right plantar foot ulcer presented with low grade fevers and right ankle erythema admitted for right ankle cellulitis. # right ankle cellulitis: Erythema and warmth around the right ankle in a patient with uncontrolled diabetes. No evidence for osteo or septic joint on exam or imaging. Area of erythema not near ulcer and does not seem to be confluent. Prior history of MRSA and pseudomonas but these bugs have been cultured when patient has had a leukocytosis and pus on exam. Improved dramatically overnight with bactrim/unasyn so was discharged on doxycycline and augmentin for a one week course. He was discharged with a CAM walker for control of the ankle joint with follow up planned with his PCP, ___ and podiatry. Blood cultures were pending at the time of discharge. # HTN: Continued felodipine, furosemide. # HCV cirrhosis: Currently stable. No recent hx of acsites, HE, or bleeding varices. Continued rifaximin, lactulose, nadolol, and furosemide. # History of duodenitis: Continued omeprazole but encourage that dose reduction to 40mg daily be considered as an outpatient. # DM2: Uncontrolled with complications. He was continued on lantus with uptitrated HISS. Metformin and glipizide were held during admission. Only metformin was restarted prior to discharge. He was referred back to ___ to reinitiate care with his provider. CHRONIC ISSUES: # Chronic back pain: Continued lidocaine patch. # HLD: Continued simvastatin, fish oil. # BPH: Continued finasteride and tamsulosin. # Med rec: Continued acyclovir for ppx, clotrimazole cream, calcium, MVI, and iron. Glucosamine and cranberry were held during admission but restarted on discharge.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Tetanus / Ibuprofen Attending: ___. Chief Complaint: Syncope Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ gentleman with a history of recurrent syncope, hypothyroidism, Waldenstrom's macroglobulinemia, CKD, and anemia of chronic disease presented to the ED early in the morning of ___ after a syncopal episode at home. Patient reported that he has been in the bathroom on early morning of ___ when he felt suddenly quite nauseous and warm, and when he went to get a receptacle to vomit in, he felt faint and fell forward. Since he felt that he might lose consciousness, he was able to put his arms out to brace himself. He denies chest pain or palpitations prior to symptoms onset. Per ED report, he was unable to get up and called ___. He has denied any similar symptoms since the event. Mr. ___ and his wife were apparently having diarrhea leading up this event. He described his stools as loose and light in color. He denied any abdominal pain or emesis associated with the diarrhea. Of note, Mr. ___ has had multiple syncopal episodes in the past several months with ___ in the past month according prior records. He has been undergoing outpatient workup for this with an implantable LINQ loop recorder and is followed by Dr. ___ (___). At the time of this note, no clear cardiac source had been discovered as the cause of his syncope. Past Medical History: 1. ___ macroglobulinemia. 2. Schatzki's ring. 3. Eyelid entropion. 4. Chronic kidney disease. 5. Anemia of chronic disease. 6. Ankle edema. 7. BPH. 8. History of lung nodule and thyroid nodule. 9. History of basal cell carcinoma. 10. History of dizziness. 11. Status post inguinal hernia surgery in ___ and ___. Social History: ___ Family History: His mother died of old age in her ___. His father died from a stroke complications. Physical Exam: PHYSICAL EXAM: On Admission: Vital Signs: T 97.8 HR 59 BP 138/65 RR 20 O2 98% RA General: Awake and Alert, oriented x4. No acute distress. Extremely hard of hearing but does not wear hearing aids anymore. HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI. PERRL with appearace c/w previous cataract removal surgery. Neck: JVP not elevated CV: Regular rate and rhythm, normal S1 + S2. ___ systolic murmur best heard at sternal border. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, mildly obese. Bowel sounds present, no organomegaly, no rebound or guarding. Ext: Warm, well perfused. 1+ DP pulses. 1+ ___ edema. No discoloration of skin. Neuro: CNII-XII intact,. Intact ___ strength in upper and lower extremities. Grossly normal sensation. Reflexes and gait exam deferred. On Discharge: VITALS - Tmax 97.9 | 127-146/ ___ | 56-65 | ___ | 94-97% RA orthostatics (from ___: Lying- 117/65, HR 66; sitting 117/66, Hr 65; standing 143/73 HR 71 GENERAL - Sitting and eating breakfast. HEENT - PERRL, EOMI, anictric. Mucous membrane moist NECK - no LAD, no JVD CARDIAC - soft heart sounds, regular rate and rhythm, grade III holosystolic murmur best heard R ___ costal sternal border, radiates to up the carotids. LUNGS - CTAB ABDOMEN - soft, non tender, non distended EXTREMITIES - ___ strength in all extremities. 2+ ___ pulses. bilateral ankles 2+ edema, 2+ pitting edema up to mid-tibia SKIN - thin skin with excess laxity NEUROLOGIC - A&Ox3, later conversational. CN II-XII intact, though very hard at hearing and not wearing hearing aids. Gait (assessed ___ ___- slow to start with small steps, required multiple steps to turn. Improved slightly with longer walks Pertinent Results: On Admission ___ 04:15AM BLOOD WBC-6.8 RBC-2.61* Hgb-9.2* Hct-27.9* MCV-107* MCH-35.2* MCHC-33.0 RDW-13.1 RDWSD-50.4* Plt ___ ___ 04:15AM BLOOD Neuts-85.3* Lymphs-7.5* Monos-5.3 Eos-1.3 Baso-0.3 Im ___ AbsNeut-5.84# AbsLymp-0.51* AbsMono-0.36 AbsEos-0.09 AbsBaso-0.02 ___ 08:50PM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL ___ 04:15AM BLOOD Plt ___ ___ 04:15AM BLOOD Glucose-103* UreaN-46* Creat-1.4* Na-138 K-4.9 Cl-105 HCO3-20* AnGap-18 ___ 04:15AM BLOOD ALT-12 AST-20 CK(CPK)-54 AlkPhos-172* TotBili-0.3 ___ 04:15AM BLOOD proBNP-833 ___ 04:15AM BLOOD cTropnT-<0.01 ___ 04:15AM BLOOD Albumin-3.7 Calcium-9.8 Phos-3.3 Mg-1.9 ___ 04:46AM BLOOD Lactate-1.6 At Discharge ___ 06:49AM BLOOD WBC-3.7* RBC-2.23* Hgb-7.9* Hct-24.0* MCV-108* MCH-35.4* MCHC-32.9 RDW-13.2 RDWSD-52.2* Plt ___ ___ 06:49AM BLOOD ___ PTT-29.8 ___ ___ 06:49AM BLOOD Glucose-91 UreaN-32* Creat-1.2 Na-141 K-3.9 Cl-110* HCO3-22 AnGap-13 ___ 06:49AM BLOOD Calcium-9.2 Phos-3.1 Mg-1.9 Iron-49 Imaging ___ CXR: IMPRESSION: Retrocardiac opacity which may reflect pneumonia. ___ Non-contrast CT head: IMPRESSION: No acute intracranial abnormality. Specifically, no evidence of acute infarct or hemorrhage. ___ CT C-spine without contrast IMPRESSION: No acute fracture, malalignment, or prevertebral soft tissue edema. ___ TTE: Conclusions The left atrium is elongated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is no left ventricular outflow obstruction at rest or with Valsalva. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with normal free wall contractility. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Microbiology ___ Bcx: NO GROWTH. ___ Ucx: URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. Metoprolol Succinate XL 25 mg PO DAILY 3. Omeprazole 40 mg PO DAILY 4. magnesium chloride 71.5 mg oral DAILY 5. Aspirin 81 mg PO DAILY 6. Levothyroxine Sodium 25 mcg PO DAILY 7. Vitamin D 800 UNIT PO DAILY Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. Aspirin 81 mg PO DAILY 3. Levothyroxine Sodium 25 mcg PO DAILY 4. Metoprolol Succinate XL 25 mg PO DAILY 5. Omeprazole 40 mg PO DAILY 6. Vitamin D 800 UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis Vasovagal Syncope Mild Aortic stenosis Secondary Diagnosis Supraventricular tachycardia with aberrancy Waldenstrom macroglobulinemia Benign Prostate Hyperplasia Chronic Kidney Disease Chronic lower extremity edema 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: History: ___ with syncope// Eval for acute process TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 18.0 s, 18.9 cm; CTDIvol = 47.9 mGy (Head) DLP = 903.1 mGy-cm. Total DLP (Head) = 903 mGy-cm. COMPARISON: Noncontrast CT head from ___. FINDINGS: There is no evidence of acute infarcthemorrhage,edema,or mass. A chronic lacunar infarct is again noted in the right internal capsule. Prominent ventral and sulci are suggestive of age-related involutional changes. There is no evidence of fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: No acute intracranial abnormality. Specifically, no evidence of acute infarct or hemorrhage. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE INDICATION: History: ___ with syncope// Eval for 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) Spiral Acquisition 5.9 s, 22.8 cm; CTDIvol = 37.1 mGy (Body) DLP = 846.8 mGy-cm. Total DLP (Body) = 847 mGy-cm. COMPARISON: Thyroid ultrasound from ___. FINDINGS: Alignment is normal. No fractures are identified. There is no evidence of spinal canal or neural foraminal stenosis. There is no prevertebral soft tissue swelling. There is no evidence of infection or neoplasm. A 1.6 x 1.8 cm nodule arising from the lower pole of the left thyroid lobe has been previously evaluated on dedicated ultrasound and is similar in size compared to ___. IMPRESSION: No acute fracture, malalignment, or prevertebral soft tissue edema. Radiology Report INDICATION: History: ___ with syncope// Eval for acute process TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiographs from ___. FINDINGS: Frontal and lateral chest radiographs demonstrate slightly low lung volumes resulting in exaggeration of the cardiac silhouette and bronchovascular crowding. Allowing for this, the cardiomediastinal silhouette is normal. There is a retrocardiac opacity, better seen on lateral view, which may reflect pneumonia. No pleural effusion or pneumothorax is seen. IMPRESSION: Retrocardiac opacity which may reflect pneumonia. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Diarrhea, Dizziness Diagnosed with Syncope and collapse temperature: 97.6 heartrate: 76.0 resprate: 14.0 o2sat: 100.0 sbp: 124.0 dbp: 73.0 level of pain: 0 level of acuity: 3.0

___ male with a history of CKD, anemia, mild AS, and recurrent syncope presents after an episode of syncope at home. ACTIVE ISSUES: # Syncope: Patient with recurrent episodes of syncope in recent months. Outpatient work up negative so far. ED workup negative for acute cardiac ischemia. Echo no e/o of structural heart disease. History most consistent with vasovagal. Orthostatics negative, however done after 1L of fluid in ED. Pt is at high risk for orthostatic syncope. Pt was encouraged to make lifestyle adaptations to avoid orthostasis, such as drinking before getting out of bed. If vasovagal syncope persist, consider using smelling salts. ___ evaluated patient and recommended home ___. # Diarrhea: No recent antibiotic or other new medication exposure per OMR history tab. C. diff and Norovirus PCR negative. Possibly other viral enteritis/colitis. Guaiac negative in ED. Magnesium was discontinued as it may contribute to diarrhea. Patient did not have diarrhea while inpatient. # Macrocytic anemia: Folate 9, B12 569. Normal ferritin with low TIBC and low transferrin, may be consistent with "anemia of chronic disease" though this would not typically be macrocytic. # Hypothyroidism with thyroid nodule: Continues on home synthroid. Most recent TSH borderline high at 4.5 with T4=6.2, however TSH is higher in elderly. Incidentally identified thyroid nodule, been stable and worked up as benign. Continued home levothyroxine 25mcg daily. CHRONIC ISSUES: # Hypertension and H/O SVT with aberrancy: continued home metoprolol and ASA # GERD with Schatzki's Ring: Symptoms well-controlled with PPI. Continued home omeprazole 40mg daily. # ___'s macroglobulinemia: Followed by Dr. ___ in hematology, to follow up as needed. # CKD: Stable. Per previous note, baseline creatinine=1.5. On admission, creatinine=1.3-1.4. # Lower extremity edema: Chronic. No discoloration or venous stasis changes. Encouraged elevation and compression stockings # Aortic stenosis: No obvious heart failure or decompensation. TTE grossly unchanged from prior. Continued home metoprolol ===============================================================

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Bilateral Subdural hematomas Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a vibrant ___ year-old male who underwent a non-contrast head CT today, ___, for staging of questionable skin cancer on his face. The images revealed bilateral subacute subdural hematomas. The patient was transferred to ___ for further Neurosurgical evaluation. Mr. ___ acknowledges that he has fallen approximately 1 - 2 months ago. He takes aspirin 325mg daily due to a history of vascular disease. He had no neurologic deficits, loss of consciousness or further issues after that fall. Past Medical History: Throat polyps, hepatitis, right femoral bypass, stenting of left leg vessel (pt unsure what vessel), right hip fracture s/p repair Social History: ___ Family History: NC Physical Exam: On Admission: O: T: 98.2 HR 85 BP 121/73, RR 14, O2 Sat 93% on room air Gen: WD/WN, comfortable, NAD. HEENT: PERRL, EOMs intact. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. 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 On Discharge: Intact Pertinent Results: CT Head ___: Stbale bialteral subdural hematomas, formal read pending at time of discharge Medications on Admission: Aspirin 325', simvastatin (unknown dose) daily, iron daily, Zantac daily Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN pain 2. Ranitidine 75 mg PO BID 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*30 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Bilateral Subdural Hematomas Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Bilateral subdural hematomas, preoperative planning. TECHNIQUE: Frontal and lateral chest radiographs were obtained. COMPARISON: None. FINDINGS: On the lateral projection, there is a posterior airspace opacity without a definitive correlation on the PA projection, which may represent consolidation in the appropriate clinical setting. Diffuse, coarse interstitial markings and biapical bulla formation are compatible with interstitial lung disease. Additionally, a band of linear atelectasis is seen within the left mid lung. There is no evidence of frank pulmonary edema, pleural effusion, or pneumothorax. The cardiomediastinal silhouette is stable. No bony abnormality is detected. IMPRESSION: 1. Posterior airspace opacity visualized on the lateral projection alone. Recommend clinical correlation, as this may indicated and airspace consolidation in the appropriate clinical setting. 2. Diffuse coarse interstitial lung markings and biapical bulla. These findings may be compatible with interstitial lung disease. If there is no evidence of acute infection, a dedicated chest CT could be obtained for further characterization. Radiology Report EXAMINATION: CT HEAD WITHOUT CONTRAST INDICATION: ___ year old man with bilateral subacute subdural hematomas. // Assessment for interval change. 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: 54 mGy COMPARISON: Outside non contrast head CT performed at ___ on ___ at 15:07 (18 hours earlier). FINDINGS: HEAD CT: There is no significant interval change in predominantly hypodense subdural collections along the bilateral superior cerebral convexities in comparison to the most recent prior head CT of ___, measuring up to 15 mm in thickness on the left and 10 mm in thickness on the right. The left subdural collection appears chronically compartmentalized with layering hyperdensity in some compartments suggesting a subacute component of hemorrhage. There is no edema, mass effect or shift of normally midline structures. The gray-white matter interface is preserved without evidence of acute major vascular territorial infarction. The ventricles and sulci are prominent, compatible with age related global atrophy. The basal cisterns appear patent. The orbits and globes are unremarkable. The right maxillary sinus is completely opacified with sclerotic thickening of its lateral wall, representing chronic osteitis. The remainder of the imaged paranasal sinuses, middle ear cavities and mastoid air cells are clear bilaterally. The bony calvaria appear intact. IMPRESSION: 1. No significant interval change in predominantly hypodense bilateral subdural collections along the cerebral convexities without evidence of an acute hemorrhage, compared to the CT performed 18 hours earlier. The right subdural collection may represent a true subdural hygroma or chronic hematoma. The chronically compartmentalized left subdural collection shows evidence of subacute on chronic hemorrhage. 2. No midline shift or evidence of herniation. 3. Right maxillary sinus chronic inflammatory disease. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: s/p Fall, ABNORMAL CT SCAN Diagnosed with OPEN SUBDUR HEM W/O COMA, FALL FROM OTHER SLIPPING,TRIPPING,STUMBLING, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA temperature: 98.2 heartrate: 85.0 resprate: 18.0 o2sat: 93.0 sbp: 121.0 dbp: 73.0 level of pain: 0 level of acuity: 2.0

Patient presented to ___ for evaluation of bilateral subdural hematomas found on work up for skin cancer. He was admitted to the floor for observation and remained stable overnight into ___. He was NPO in case surgical intervention was required however repeat CT head showed stable bilateral subdural hematomas and decision was made that he was safe to discharge to home with followup. He agreed with this plan and was given prescriptions for required medications, instructions for follow-up, and all questions were answered prior to discharge. We recommended that he hold his aspirin for the time being and discuss it with his cardiologist/PCP regarding the utility of continuing in setting of intracranial bleed.

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: ___ Left VATS decortication ___ Left chest tube place by IP History of Present Illness: Mr. ___ is a ___ hx prior empyema in the setting of an aspirated macadamia nut s/p R VATS decortication and empyemectomy w/bronchoscopy and lavage ___ with recurrent left pleural effusion who presents with two days of dyspnea, fever to 101 x2 days, productive cough and left chest wall pain. Of note, in ___ pt was found to have a 3cm LLL mass c/w abscess, s/p 2 weeks of levofloxacin, for which he underwent thoracentesis ___, and then had a repeat thoracentesis ___ for recurrence of his pleural effusion for which he completed 2 weeks of Augmentin. In the ED, initial vitals: 97.0 115 138/66 26 95% RA Initial labs notable for: WBC 25.8 (87.5% polys) H/H 12.5/37.8 Plt 257 Na 130 K 4.7 Cl 95 HCO3 24 BUN 18 Cr 1.2 (baseline 0.7) Glc 85 Lactate 1.5 INR 1.5 CXR showed near complete opacification of left hemithorax due to pleural effusion and collapse. IP was consulted in the ED and placed a ___ chest tube and drained 750ccs serous fluid, sent for analysis. Follow-up CXR showed no pneumothorax. Pleural fluid studies: pH 6.97 Protein 5.1 glucose 31 LDH 410 amylase 25 albumin 2.5 WBC 4300 (83 polys, 14 lymphos, 0 monos, 3 macros) RBC 5025. The patient was given 1L NS, vanc/cefepime, and a total of 7 mg IV morphine. After chest tube drainage, the patient became more tachypneic to the ___ and desatted to 94% on 4L NC and decision was made to transfer to MICU for further management. On transfer, vitals were: 91 119/73 35 92% Nasal Cannula On arrival to the MICU, patient states that he feels crummy. Endorses L-sided chest and back pain, mostly in the mid-axillary line. Denies abdominal pain, nausea, vomiting, diarrhea, constipation, dysuria, myalgias, arthralgias. Review of systems: (+) Per HPI Past Medical History: Hepatitis C - genotype 1a h/o IVDU on Suboxone Tobacco abuse Obesity Recurrent strep tonsillitis Cleared HBV (positive HBsAb, HBcAb) Social History: ___ Family History: Father with diabetes, HTN, who is deceased. He also has a brother with diabetes. Physical Exam: ADMISSION EXAM Vitals: 83 104/57 17 95% 4L NC GENERAL: speaks slowly, NAD HEENT: eyes NECK: supple, JVP not elevated, no LAD LUNGS: very diminished breath sounds L side, R side is clear CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: chest tube site appears clean NEURO: AOx4 DISCHARGE EXAM VITALS: 97.9 (98.6) 134/74 (120-140/60-80) 69 (60-80) 18 94%RA GENERAL: Alert, awakes and engages easily, oriented, no acute distress. HEENT: Sclerae anicteric, MMM, oropharynx clear NECK: Supple, JVP not elevated, no LAD RESP: Clear right lung with crackles at bases. Diminished breath sounds on left with transmitted bronchial sounds. Prior chest tube site with clean dressing. CV: Regular rhythm, systolic murmur LLSB ABD: soft, nontender, nondistended. BS+ EXT: warm, well perfused, 2+ pulses. Hyperpigmented discoloration of ___ distal shins, no edema. NEURO: CNs2-12 intact, motor function grossly normal SKIN: site around prior L subclavian CVL site w/o overlying erythema or pus. Pertinent Results: ADMISSION LABS ___ 12:09PM BLOOD WBC-25.8*# RBC-4.44* Hgb-12.5* Hct-37.8* MCV-85 MCH-28.2 MCHC-33.1 RDW-12.9 RDWSD-40.1 Plt ___ ___ 12:09PM BLOOD Neuts-87.5* Lymphs-4.5* Monos-6.7 Eos-0.0* Baso-0.2 Im ___ AbsNeut-22.58* AbsLymp-1.15* AbsMono-1.73* AbsEos-0.00* AbsBaso-0.05 ___ 12:09PM BLOOD ___ PTT-33.1 ___ ___ 12:09PM BLOOD Glucose-85 UreaN-18 Creat-1.2 Na-130* K-4.7 Cl-95* HCO3-24 AnGap-16 ___ 12:09PM BLOOD Osmolal-274* ___ 03:56AM BLOOD Calcium-7.9* Phos-3.2 Mg-1.6 ___ 07:32PM BLOOD Type-ART pO2-65* pCO2-35 pH-7.44 calTCO2-25 Base XS-0 IMAGES/STUDIEs + CXR ___ Near complete opacification of left hemithorax due to large pleural effusion and collapse. + CXR ___ 1. No significant interval change in near complete opacification of the left hemithorax due to pleural effusion and collapse. 2. Interval placement of left-sided pleural drainage catheter. No pneumothorax identified. CT CHEST ___: IMPRESSION: Recurrence of large nonhemorrhagic left pleural effusion responsible for left lung collapse. Substantial growth since ___ in the left lower lobe abscess or necrotic mass. Possible new small left pericardial effusion, probably secondary to pleural effusion. Right pleural reaction and small effusion, and reactive right hilar and mediastinal lymph nodes have all increased since ___. New splenomegaly. Upper esophageal distention could be secondary to the effusion or in indication of esophageal dysfunction and possibly a propensity to reflux and aspiration. CXR ___ IMPRESSION: 1. Persistent left hydropneumothorax. 2. Stable left pleural effusion and left lateral wall pleural thickening. 3. Unchanged loculated fluid collection in the posterior left hemithorax. DISCHARGE LABS ___ 06:33AM BLOOD WBC-8.2 RBC-3.45* Hgb-9.6* Hct-29.8* MCV-86 MCH-27.8 MCHC-32.2 RDW-13.5 RDWSD-41.7 Plt ___ ___ 06:33AM BLOOD Plt ___ ___ 06:33AM BLOOD Glucose-98 UreaN-9 Creat-0.7 Na-137 K-3.8 Cl-102 HCO3-29 AnGap-10 ___ 06:33AM BLOOD Calcium-8.0* Phos-4.0 Mg-1.8 ___ 06:33AM BLOOD Vanco-21.2* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 800 mg PO QID 2. ClonazePAM 2 mg PO DAILY 3. Methadone 65 mg PO DAILY 4. Promethazine 50 mg PO DAILY 5. Albuterol Inhaler 2 PUFF IH Q6H 6. Benzonatate 100 mg PO DAILY Discharge Medications: 1. ClonazePAM 0.5 mg PO BID 2. Methadone 65 mg PO DAILY 3. Promethazine 12.5 mg PO BID 4. Albuterol Inhaler 2 PUFF IH Q6H 5. Benzonatate 100 mg PO DAILY 6. Gabapentin 800 mg PO QID 7. Acetaminophen 1000 mg PO Q8H 8. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing/dyspnea 9. Docusate Sodium 100 mg PO BID 10. Polyethylene Glycol 17 g PO DAILY 11. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain 12. Heparin 5000 UNIT SC BID 13. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush 14. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush 15. Senna 8.6 mg PO BID 16. Vancomycin 1000 mg IV Q 8H Last day ___. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Left lung abscess Left pleural effusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: History: ___ with dyspnea // r/o infiltrate TECHNIQUE: Portable semi-upright chest radiograph. COMPARISON: Radiographs of the chest dated ___ through ___, and CT of the chest dated ___. FINDINGS: There is near complete opacification of the left hemithorax, with rightward shift of the mediastinal structures, consistent with large pleural effusion and collapse. A small portion of the left upper lung appears minimally aerated. Mild blunting of the right costophrenic angle appears chronic, but may reflect a small amount of pleural effusion. Assessment of the cardiac silhouette is limited. No pneumothorax. IMPRESSION: Near complete opacification of left hemithorax due to large pleural effusion and collapse. Radiology Report INDICATION: ___ year old man with new Rt sided pleural effusion // r/o PTX TECHNIQUE: Portable semi-upright chest radiograph. COMPARISON: Chest radiographs dated ___ through ___. FINDINGS: Again seen is near complete opacification of the left hemithorax due to large pleural effusion and collapse. There has been interval placement of a left-sided pleural drainage catheter. No pneumothorax is identified. IMPRESSION: 1. No significant interval change in near complete opacification of the left hemithorax due to pleural effusion and collapse. 2. Interval placement of left-sided pleural drainage catheter. No pneumothorax identified. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with chest tube, decreasing O2 sats // Eval for reexpantion pulmonary edema TECHNIQUE: Single frontal view of the chest COMPARISON: ___ at 14:05 FINDINGS: Again seen is near complete opacification of the left hemi thorax with slight increase in aeration of the left upper lung. The majority of the left hemi thorax remains opacified. A pigtail catheter is seen projecting over the lateral left lower hemi thorax. The right lung is grossly clear. IMPRESSION: Near complete opacification of the left hemi thorax with slight improvement and slight increase in aeration at the left upper lung. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ year old man with L pleural effusion/hemithorax collapse, s/p chest tube // progression of L pleural effusion TECHNIQUE: Multi detector helical scanning of the chest was coordinated with intravenous infusion of nonionic iodinated contrast agent and reconstructed as 5 and 1.25 mm thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP axial images. All images were reviewed. DOSAGE: TOTAL DLP 5 and 5.0mGy-cm COMPARISON: Chest CT ___. Examination is also read in conjunction with conventional chest radiographs since ___ most recently ___ at 04:36. FINDINGS: Large nonhemorrhagic left pleural effusion has recurred since ___ and interval thoracenteses, now nearly entirely collapsing the left lung, not appreciably drained following insertion of a left basal pigtail pleural drain. The attenuation values of the effusion range from ___ ___. At the medial aspect of the collapsed lower lobe is a 3 x 9 cm region of relative low attenuation, compared to the enhancing collapse lower lobe, but with attenuation values 40-50 ___, and two small gas bubbles. This abnormality conforms to the 27 mm wide mass or abscess seen on ___. Most of the fluid between the left upper lobe and the heart is loculated pleural fluid, but there may be a new very small pericardial effusion. Small right pleural effusion with hyperemic pleural thickening or subpleural atelectasis has increased. Moderate distension of the upper esophagus to the level of the carina is new, and may indicate esophageal dysfunction and a propensity to reflux and aspiration. Mild wall thickening of the lower esophagus is chronic. Cm size lymph nodes are numerous in the mediastinum, new at the thoracic inlet in the left tracheoesophageal groove, 02:15 more numerous in the prevascular station at the level of the left brachiocephalic vein, 02:21. There are larger lymph nodes in the right hilus, 18 x 23 mm, 02:31 and in the azygoesophageal recess. Significant air trapping in the right lower lobe is not explained by relatively mild narrowing of the right lower lobe basal trunk and milder right hilar lymph node enlargement. There are no enlarged nodes in the diaphragmatic or internal mammary or retro crural stations. This study is not designed for subdiaphragmatic diagnosis but shows normal-size adrenal glands and a cyst in the upper pole of the left kidney, but significantly no sub diaphragmatic fluid collections or abscesses in the upper abdominal organs. Spleen is newly enlarged since ___, but with no findings to suggest splenic infection. There are no findings in the chest cage suspicious for malignancy or infection. IMPRESSION: Recurrence of large nonhemorrhagic left pleural effusion responsible for left lung collapse. Substantial growth since ___ in the left lower lobe abscess or necrotic mass. Possible new small left pericardial effusion, probably secondary to pleural effusion. Right pleural reaction and small effusion, and reactive right hilar and mediastinal lymph nodes have all increased since ___. New splenomegaly. Upper esophageal distention could be secondary to the effusion or in indication of esophageal dysfunction and possibly a propensity to reflux and aspiration. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old man with L empyema s/p chest tube placement with new L subclavian CVL placement // confirm L subclavian CVL placement Contact name: ___: ___ confirm L subclavian CVL placement COMPARISON: ___ IMPRESSION: Left pigtail catheter has been placed. In unchanged position. No substantial difference in the opacification of the left hemi thorax is seen but the mediastinum is shifted more to the right does consistent with internal accumulation of pleural effusion. Small amount of right pleural fluid is seen. Left subclavian line tip is at the level of superior SVC. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with left side pleural effusion s/p chest tube // assess interval change assess interval change IMPRESSION: In comparison with the study of ___, there again is almost complete opacification of the left hemithorax despite a pigtail catheter in place. Little change in the degree of shift of the mediastinum to the right. Pulmonary vascular congestion may be more prominent than on the previous study. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man s/p left VATS decortication // Eval for chest tube placement, PTX Eval for chest tube placement, PTX IMPRESSION: In comparison with the earlier study of this date, there has been placement of 2 chest tubes following vats decortication on the left. The degree of opacification related to pleural effusion has substantially decreased, though some fluid and atelectasis is still seen at the left base. Specifically, there is no evidence of pneumothorax. Otherwise, little change. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man s/p left VATS decortication // AM rounds ___ AM rounds ___ IMPRESSION: In comparison with the study of ___, there is little overall change. 2 chest tubes remain on the left following vats decortication. There may be slight increase in pleural fluid along the left lateral chest wall. Continued opacification at the left base most likely relating to pleural fluid and volume loss in the left lower lobe. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with asthma, prior R lung empyema s/p VATS now L sided pleural effusion s/p VATS on ___ // interval change in pleural effusion (Please perform at 7 AM) TECHNIQUE: Portable AP chest radiograph. COMPARISON: Chest radiograph ___ FINDINGS: Supportive lines and tubes are unchanged in appearance when compared to the prior study. There is persistent pleural fluid along the lateral chest wall. This is unchanged in extent compared to the prior study. Left lower lobe atelectasis persists. Continued airspace opacity at the left lung base likely due to a atelectasis. IMPRESSION: No significant interval change when compared to the prior study. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man s/p L VATS decortication now with apical chest tube removed. // Assess for interval PTX. TECHNIQUE: AP and lateral chest radiographs. COMPARISON: Chest radiograph obtained earlier on the same date FINDINGS: There has been interval removal of 1 of the left-sided chest drains without evidence of of a pneumothorax. A small amount of pleural fluid tracks along the left chest wall. Airspace opacity in the left mid lung likely reflects re-expansion pulmonary edema and is unchanged compared to the prior study. Infection cannot be definitively excluded. Linear atelectasis of the right lung base. Persistent left basilar atelectasis. A left subclavian catheter terminates at the proximal SVC. IMPRESSION: As above. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with recurrent pleural effusion now s/p VATS on ___ // interval change in effusion with lateral CT (please perform at 7AM) interval change in effusion with lateral CT (please perform at 7AM) IMPRESSION: In comparison with the study of ___, there is little overall change. Left chest tube remains in place without evidence of pneumothorax. Opacification along the left lateral chest wall is consistent with pleural fluid. The opacification in the left mid and lower zone most likely reflects re-expansion edema combined with residual pleural fluid and atelectatic changes. In the appropriate clinical setting, it would be impossible to exclude superimposed pneumonia. Cardiac silhouette again is prominent and there is mild elevation of pulmonary venous pressure and atelectatic changes at the right base. The left subclavian catheter is no longer seen. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with recurrent L pleural effusion s/p VATS and posterior CT // interval change in pleural effusion TECHNIQUE: Portable AP chest. COMPARISON: Chest radiograph ___ FINDINGS: A right-sided PICC is unchanged compared to the prior study, likely terminating in the right brachiocephalic vein. A left-sided chest tube is unchanged in appearance. There is persistent left pleural fluid with slight improvement in the hazy in the left mid lung opacity. There is a small loculated air within the pleural fluid at the left costophrenic angle. Left basilar atelectasis persists. No pneumothorax seen. IMPRESSION: 1. Slight interval improvement in the left mid lung airspace opacities. 2. Persistent left hydro pneumothorax. 3. A right-sided PICC terminates likely in the distal right brachiocephalic vein. Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old man with new picc // R picc 55cm ___ ___ Contact name: ___: ___ R picc 55cm ___ ___ IMPRESSION: In comparison with the earlier study of this date, this and placement of a right subclavian PICC line that extends to the upper portion of the SVC. Otherwise little change in the appearance of the heart and lungs. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old man with new line // new right PICC 60 cm ___ ___ Contact name: ___: ___ TECHNIQUE: Portable AP chest radiograph. COMPARISON: Chest radiograph ___ FINDINGS: The previously seen right PICC has been exchanged and is now low in the right atrium. This could be withdrawn at least 5 cm for better seating within the SVC. 2 left-sided chest tubes are in-situ. Unchanged in appearance when compared to the prior study. There is a persistent left pleural effusion tracking along the lateral chest wall. Left basilar atelectasis is also unchanged. Persistent hazy opacity in the left lung. Small amount of loculated air in the pleural space on the left. IMPRESSION: The right-sided PICC is position distally in the right atrium. This should be withdrawn at least 5 cm for better positioning in the SVC. NOTIFICATION: The findings were discussed with ___ (IV nurse) at 14:04 on ___, within 5 min of discovery. Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old man with new line // please check PICC tip 60 cm ___ ___ Contact name: ___: ___ TECHNIQUE: Portable AP chest radiograph. COMPARISON: Chest radiograph obtained earlier on the same date. FINDINGS: The right-sided PICC has been withdrawn somewhat but is still within the right atrium. This could be withdrawn a further 5-6 cm for better seating within the SVC. The left-sided chest drains are unchanged in position. Persistent left pleural fluid and left basilar atelectasis. No pneumothorax seen. IMPRESSION: The right-sided PICC terminates in the right atrium. NOTIFICATION: Findings discussed with ___ (IV nurse) by telephone at 15:30, within 5 min of discovery. Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old man with new line // PICC pulled back 6 cm please check tip ___ ___ ___ name: ___: ___ TECHNIQUE: Portable AP chest radiograph. COMPARISON: Chest radiograph obtained earlier on the same date. FINDINGS: The right-sided PICC has been withdrawn further, this is likely now in the distal SVC/cavoatrial junction allowing for low lung volumes and suboptimal inspiration. Lungs are otherwise unchanged in appearance including the left-sided chest drains, left hydro pneumothorax and left lung airspace opacity. IMPRESSION: The right-sided PICC is likely at the distal SVC/ cavoatrial junction given the lung volumes and is suboptimal inspiratory effort. The catheter could safely be withdrawn a further 3 cm and still remain in the SVC. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with empyema with CT // interval change in effusion TECHNIQUE: Portable AP chest radiograph. COMPARISON: Chest radiograph ___ FINDINGS: The right-sided PICC remains in the right atrium, this could be withdrawn 5 cm for better seating in the SVC. 2 left-sided chest tubes are unchanged in appearance. A small left hydro pneumothorax is also unchanged. Persistent right basilar atelectasis. Unchanged left lung airspace opacity. IMPRESSION: No significant interval change when compared to the prior study. The right-sided PICC remains with the tip in the right atrium. This could be withdrawn 5 cm for better seating in the SVC. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with empyema with CT // interval change in effusions; s/p 1 chest tube removed on ___ interval change in effusions; s/p 1 chest tube removed on ___ IMPRESSION: In comparison with the study of ___, there has been removal of a chest tube from they left with no evidence of pneumothorax. The small left hydro pneumothorax is unchanged, as is the fluid along the left lateral chest wall. The overall, there is little change in the opacification in the left hemithorax. A lateral view would be necessary to assess changes in the empyema. Little change in the right hemithorax. The right PICC line has been pulled back so that the tip lies in the mid portion of the SVC. Radiology Report EXAMINATION: Chest: Frontal and lateral views INDICATION: ___ year old man with persistent bilateral pleural effusions; please evaluate for PTX post- L-sided chest tube pull. // evaluate for pneumothorax TECHNIQUE: Chest: Frontal and Lateral COMPARISON: Portable chest x-ray ___ Chest PA and lateral ___ FINDINGS: A right-sided PICC terminates at the mid to distal SVC. Left anterior hydropneumothorax is unchanged. Pleural thickening along the left lateral chest wall is unchanged. A loculated fluid collection contiguous with the major fissure in the posterior left superior hemithorax appears unchanged compared to chest x-ray from ___. Bibasilar atelectasis and left pleural effusion are stable. No evidence of pneumothorax. IMPRESSION: 1. Persistent left hydropneumothorax. 2. Stable left pleural effusion and left lateral wall pleural thickening. 3. Unchanged loculated fluid collection in the posterior left hemithorax. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Dyspnea Diagnosed with Pleural effusion, not elsewhere classified temperature: 97.0 heartrate: 115.0 resprate: 26.0 o2sat: 95.0 sbp: 138.0 dbp: 66.0 level of pain: 10 level of acuity: 2.0

Mr. ___ is a ___ hx prior empyema in the setting of an aspirated macadamia nut s/p R VATS decortication and empyemectomy w/bronchoscopy and lavage ___ with recurrent left pleural effusion who presents with two days of dyspnea, fever to 101 x2 days, productive cough and left chest wall pain, found to have a large left empyema with lung collapse, transferred to the ICU for management of hypoxia and tachypnea, now s/p L VATS and L-sided chest tube placement with significant improvement on IV antibiotics. # Left lung abscess/pleural effusion. In ___ of this year, Mr. ___ developed a productive cough with 'salmon' colored sputum, pleuritic chest pain, fevers and chills. A CXR ordered by his PCP showed ___ lung lesion, which was confirmed on a follow up chest CT as a 3cm LLL lung mass with appearance consistent with abscess. A 2 week course of levofloxacin had no effect on his symptoms. On ___ he underwent an ultrasound guided thoracentesis for 720cc of serous fluid. Cytology showed no malignant cells or organisms, but 4+ PMNs. On ___ he was seen by Dr. ___ a CXR at that time showed a recurrent left pleural effusion. Thoracentesis was repeated, and he was started on a 2 week course of augmentin. He re-presented this admission for intolerable dyspnea and fevers after completion of the augmentin course. Chest imaging at admission showed significant L-sided pleural effusion and LLL abscess/necrotic mass. Thoracics Surgery placed chest tubes bilaterally which confirmed an exudative process; pleural fluid cultures grew Strep anginosus sensitive to IV vancomycin. Regarding the LLL abscess/necrotic mass, Thoracics Surgery felt that drainage would be very difficult given the significant inflammatory changes and fibrosis of the left lung base. Both chest tubes were discontinued prior to discharge and patient will have follow-up with Thoracics. Last day of vancomycin will be ___ (total 2 week course per Thoracic Surgery). Of note, work-up for immunodeficiency syndromes including Ig levels and HIV were negative. # chronic stable Asthma: Receiving duonebs. # Opiate Dependence, Chronic: Methadone replacement therapy dose confirmed 65mg PO daily ___ clinic ___. # Panic disorder: Home clonazepam restarted at reduced dose. ***TRANSITIONAL ISSUES*** - IV vancomycin to continue for total 2 week course (d 14 on ___ - Vancomycin level on ___. Dosing decreased to 1 gm q8h. Please re-check vanc level on ___. - Please check EKG to monitor QTc on ___ as patient is on promethazine (discharge dose is lower than his home dose) - Patient to have outpatient follow-up with Pulmonary and Thoracics Clinics - Patient will need CT chest in ___ weeks (after ___ with follow up with Thoracics for LLL abscess (already scheduled)

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: amoxicillin / codeine / Flonase / sertraline / fluoxetine / hydrochlorothiazide / Macrolide Antibiotics / Iodinated Contrast Media - IV Dye / Ativan Attending: ___. Major Surgical or Invasive Procedure: None attach Pertinent Results: ___ 05:10AM BLOOD WBC-6.2 RBC-3.43* Hgb-11.8 Hct-37.3 MCV-109* MCH-34.4* MCHC-31.6* RDW-20.3* RDWSD-81.5* Plt ___ ___ 05:10AM BLOOD ___ PTT-38.0* ___ ___ 01:38PM BLOOD Glucose-101* UreaN-21* Creat-1.1 Na-140 K-4.2 Cl-101 HCO3-24 AnGap-15 ___ 05:10AM BLOOD Calcium-8.9 Phos-2.7 Mg-2.0 HMVA BLOOD CX: GNR Medications on Admission: The Preadmission Medication list is accurate and complete. 1. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN asthma flare 2. Enalapril Maleate 20 mg PO BID 3. ALPRAZolam 0.25 mg PO BID:PRN anxiety 4. Vitamin D 1000 UNIT PO DAILY 5. Digoxin 0.125 mg PO DAILY 6. Metoprolol Succinate XL 100 mg PO BID 7. olaparib 200 mg oral BID 8. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First Line 9. Warfarin 2.5 mg PO DAILY16 Discharge Medications: 1. LevoFLOXacin 500 mg PO Q24H RX *levofloxacin 500 mg 1 tablet(s) by mouth once a day Disp #*4 Tablet Refills:*0 2. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN asthma flare 3. ALPRAZolam 0.25 mg PO BID:PRN anxiety 4. Digoxin 0.125 mg PO DAILY 5. Enalapril Maleate 20 mg PO BID 6. Metoprolol Succinate XL 100 mg PO BID 7. olaparib 200 mg oral BID Resume dose tonight, ___ 8. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First Line 9. Vitamin D 1000 UNIT PO DAILY 10. Warfarin 2.5 mg PO DAILY16 Discharge Disposition: Home Discharge Diagnosis: Acute GNR bloodstream infection - E.coli Sinusitis h/o VTE Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: Chest: Frontal and lateral views INDICATION: History: ___ with history of ovarian cancer, fever, positive blood culture // Pneumonia? Mass? TECHNIQUE: Chest: Frontal and Lateral COMPARISON: No prior chest radiograph available for comparison. Reference made to chest CT from ___ FINDINGS: The lungs are clear without focal consolidation. No pleural effusion or pneumothorax is seen. The aorta is tortuous. The cardiac silhouette is mildly to moderately enlarged. Chronic irregularity of the posterior right seventh rib with better assessed on prior CTs; possibly representing fibrous dysplasia, chronic fracture not excluded radiographically. IMPRESSION: No acute cardiopulmonary process. Gender: F Race: PORTUGUESE Arrive by WALK IN Chief complaint: Positive blood cultures Diagnosed with Bacteremia temperature: 97.4 heartrate: 91.0 resprate: 22.0 o2sat: 99.0 sbp: 177.0 dbp: 98.0 level of pain: 0 level of acuity: 3.0

___ w/ HTN, asthma, Afib on warfarin, remote DVT, and met high grade serous ovarian cancer s/p TAH-BSO and chemo, now on maintenance olaparib (follows with Dr ___ s/p ureteral stent exchange 1 week ago for chronic hydronephrosis, who p/w F/C, sinus pain, and positive GNR BSI from an OP blood culture. 1. E.coli blood stream infection: Source is presumed acute Sinusitis vs Urological source given recent stent exchange. She was started on levaquin outpatient when her culture came back positive but did not take any doses as she was referred to the ER. She was hemodynamically stable with no fevers, abnormal blood work and so was continued on PO levaquin pending blood cultures. Her blood cultures have been negative to date. Her blood culture from ___ medical records show 1 out of 2 bottles positive for E.coli, sensitive to levaquin. The other bottle was with no growth. Possible contamination however given her immunocompromised state and symptoms of infectious outpatient, she was continued with levaquin for total of 10 days. Her olaparib was held but resumed on discharge after discussion with Dr ___. 2. She was found to have an elevated INR > 4 so her coumadin was initially held and resumed after it was maintained within goal. No signs of bleeding. She is to have an INR check in 2 days for close monitoring. Her last INR was 2. She was given 3.75mg dose day of discharge instead of her 2.5mg. Patient has her GYN/ONC appointment on ___ and her HEME/ONC appointment is ___. Will monitor for inpatient finalized blood culture results and if any changes, patient will be contacted.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Depakote Attending: ___. Chief Complaint: sent from PCP with lab abnormalities (hyponatremia & ___ Major Surgical or Invasive Procedure: None History of Present Illness: ___ (given name ___ is a ___ transitioning trans-female with a history of migraines, HTN, HLD, and depression who is sent from PCP office with findings ___ and hyponatremia after presenting with malaise and vomiting. Patient was in usual state of health until the day prior to admission w/ general malaise, mild headache, one episode of nausea with vomiting (non-bloody non-bilious). Of note, patient recently had spironolactone increased to 100mg bid, which she is taking for transition from male to female. In the ED, labs were notable for Na 128, Cr 1.8 (baseline 1.0), K 4.7, WBC 14.1. Received 1L NS. Past Medical History: Currently transitioning male to female on hormonal supplements HTN, HLD Depression, anxiety, insomnia, migraines Social History: ___ Family History: - Mother: Died age ___ of lung cancer - Father: Does not know Physical Exam: ADMISSION PHYSICAL EXAM: Vital signs: T 98.8, BP 148/104, P 98, RR 18, O2 93% RA Gen: Well appearing, in no apparent distress HEENT: NCAT, oropharynx clear Lymph: no cervical lymphadenopathy CV: No JVD present, regular rate and rhythm, no murmurs appreciated Resp: CTA bilaterally in anterior and posterior lung fields, no increased work of breathing GI: soft, non-tender, non-distended. No hepatosplenomegaly appreciated. GU: No suprapubic tenderness Extremities: no clubbing, cyanosis, or edema Neuro: no focal neurologic deficits appreciated. Moves all 4 extremities purposefully and without incident, no facial droop. Psych: Euthymic, speech non-tangential, appropriate DISCHARGE PHYSICAL Vitals: 99.1F, HR 99, BP 127/75, RR 18, SpO2 96% General: no acute distress, lying comfortably in bed HEENT: moist mucus membranes, PERRL Cardio: RRR, no murmur Pulm: clear b/l, no wheeze Abdomen: soft, nontender, nondistended, bowel sounds present Extremities: no pedal edema Neuro: no focal neurological deficits, AAOx3 Pertinent Results: ___ 06:18PM BLOOD WBC-14.1* RBC-5.32 Hgb-15.8 Hct-45.4 MCV-85 MCH-29.7 MCHC-34.8 RDW-13.8 RDWSD-42.5 Plt ___ ___ 05:25PM BLOOD WBC-7.7 RBC-5.53 Hgb-16.2 Hct-46.5 MCV-84 MCH-29.3 MCHC-34.8 RDW-13.2 RDWSD-41.1 Plt ___ ___ 06:18PM BLOOD Glucose-130* UreaN-33* Creat-1.8* Na-128* K-4.7 Cl-89* HCO3-23 AnGap-21* ___ 07:55AM BLOOD Glucose-111* UreaN-17 Creat-1.1 Na-136 K-4.9 Cl-94* HCO3-26 AnGap-21* ___ 04:29PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-POSITIVE * CXR: no acute cardiopulmonary process Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO QHS 2. Spironolactone 100 mg PO BID 3. Lisinopril 20 mg PO QHS 4. TraZODone 50 mg PO QHS:PRN insomnia 5. melatonin 3 mg oral QHS:PRN insomnia 6. Sumatriptan Succinate 50 mg PO ONCE:PRN migraine 7. Simvastatin 40 mg PO QPM 8. Estradiol Transdermal Patch (estradiol) 0.1 mg/24 hr transdermal weekly 9. Naproxen 500 mg PO Q12H:PRN Pain - Mild Discharge Medications: 1. OSELTAMivir 75 mg PO Q12H RX *oseltamivir 75 mg 1 capsule(s) by mouth twice a day Disp #*8 Capsule Refills:*0 2. Aspirin 81 mg PO QHS 3. Estradiol Transdermal Patch (estradiol) 0.1 mg/24 hr transdermal weekly 4. Lisinopril 20 mg PO QHS 5. melatonin 3 mg oral QHS:PRN insomnia 6. Naproxen 500 mg PO Q12H:PRN Pain - Mild 7. Simvastatin 40 mg PO QPM 8. Sumatriptan Succinate 50 mg PO ONCE:PRN migraine 9. TraZODone 50 mg PO QHS:PRN insomnia 10. HELD- Spironolactone 100 mg PO BID This medication was held. Do not restart Spironolactone until you discuss restarting this with your PCP. Discharge Disposition: Home Discharge Diagnosis: Hyponatremia, hyperkalemia, ___ Influenza B Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with hyponatremia and ___ now with fever.// ?pneumonia TECHNIQUE: Chest single view COMPARISON: None FINDINGS: Normal heart size, pulmonary vascularity. No effusion. Lungs are clear. No pneumothorax. IMPRESSION: No acute findings. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abnormal labs Diagnosed with Acute kidney failure, unspecified, Hypercalcemia, Abn lev hormones in specimens from female genital organs temperature: 98.3 heartrate: 104.0 resprate: 18.0 o2sat: 98.0 sbp: 114.0 dbp: 73.0 level of pain: 3 level of acuity: 3.0

___ (given name ___ is a ___ year old trans-female with a history of migraines, HTN, HLD, and depression who is sent from PCP office with findings ___ and hyponatremia after presenting with malaise and vomiting. 1. ___ w/ hyponatremia and hyperkalemia Patient initially presented with ___ and hyponatremia thought to be due to increased dose of spironolactone. Urine studies were somewhat conflicting: elevated sodium and osm suggesting SIADH, FeNa 0.2% suggesting prerenal, and FeUrea (patient on spironolactone) 43.5% suggesting intrinsic renal disease. She appears to be euvolemic, which is more consistent with intrinsic renal disease or SIADH. Initially sodium worsened with NS and improved with fluid restriction, and creatinine improved with fluids and then stabilized with fluid restriction. Suspect that influenza may also have contributed to abnormalities. At time of discharge sodium normalized and creatinine at baseline; she received one dose of kayexylate with correction of potassium. At discharge resumed lisinopril but will continue to hold spironolactone. Patient has an appointment with PCP ___ where BMP will be repeated and discussion of resuming spironolactone had. 2. Sepsis due to Influenza B SIRS (fever, tachycardia) with influenza B. Patient started on Tamiflu the evening of ___ and will continue 75mg PO BID for total of 5 days. 3. Transgender Patient currently transitioning from male to female on hormonal therapy: estradiol patch and spironolactone. Incidentally she had a testicular torsion some yeas ago and is s/p removal of affected testis. At this point will hold spironolactone. Informed PCP of admission and holding of spironolactone with plans for close follow up ___ and discussion on whether to resume this in setting of ___. Patient mentioned discussion of removal of remaining testicle, which she can discuss further with PCP. Chronic Medical Problems 1. HLD: continue simvastatin 2. Insomnia: continue trazodone 3. HTN: lisinopril and spironolactone held in setting of ___. Plan to resume lisinopril at discharge and hold spironolactone. >30 minutes spent on discharge planning

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: ___ hx HTN, HL who presents with worsening exertional chest pain. He was in his usual health until ___ wks prior to admission, when he notes onset of discomfort with eating; he cannot further describe the characteristics. The pain lasted several hours and spontaneously resolved. Since that episode he notes worsening exertional chest pain. In the last ___ now pain is constant and feels like chest pressure, without radiation to the neck, jaw, or upper extremity. He has never felt this discomfort before. Today, he ate a hamburger about 1h PTA; he thinks this exacerbated the pain. He tool 3x ASA, so he came into the ED for further evaluation. In the ED, initial vitals: 98.0 44 144/67 18 100% RA - Labs: Chemistry, CBC, and Tn were normal. - Imaging: CXR showed no acute process. ECG was read in ED as "NSR w/ PVCs. NANI. No STEMI." - Interventions: ASA 81, SL NTG (apparently relieved her CP), 1L NS. - Consults: none Per discussion with ED providers, this patient would usually have remained in the ED for biomarker monitoring and stress test on ___ however, because stress test was not available, she was admitted to the Cardiology service for ACS rule out. VS on transfer 97.9 48 117/62 22 98% RA. On the floor, the patient recounts the history above. Additionally, he reports that he has been getting very fatigued when climbing a flight of stairs. He becomes very lightheaded and has almost passed out. Denies orthopnea, PND, ___ edema. He also reports significant LUTS, including weak stream, urgency, frequency, nocturia, and occasional incontinence. Of note, he has had this problem for years, but is on solifenacin alone. Otherwise, denies pain anywhere. Denies HA, visual changes, overt syncope, dyspnea, cough, abd pain, n/v/d/c. Past Medical History: - HTN - hyperlipidemia - colonic adenoma - osteoarthritis - GERD Social History: ___ Family History: - father: CAD, HTN - cousin: colon cancer Physical Exam: ADMISSION PHYSICAL EXAM ======================= VS: afebrile, 136/72, (86*), 20, 100/ra GEN: Alert, lying in bed, no acute distress COR: -- His VS were taken while observing the screen on the telemetry box. Though his electrical rate is recorded as ___, he is noted to have bigeminy, and a pulse is only palpable during the initial QRS complex of the couplet ("morphology 1" - appears to be native P->QRS). Heart sounds can only be auscultated during the initial QRS complex (not the second complex, "morphology 2," which appears to be a non-conducted PVC). There appears to be no cardiac activity in response to the second beat (morphology 2), making his actual pulse ___ despite recorded electrical activity in the ___. -- I asked the patient to exercise through a series of about 30 "prisoner squats," which increased his HR to 100s. he did not develop lightheadedness, syncope, or other symptoms. on telemetry, his HR increased, and there were more native QRS complexes and fewer non-conducted PVCs -- Heart sounds regular, with distant S1/S2. NMRG. HEENT: Moist MM, anicteric sclerae, no conjunctival pallor PULM: Generally CTA b/l without wheeze or rhonchi ABD: Soft, non-tender, non-distended EXTREM: Warm, well-perfused, no edema NEURO: AOx3. CN II-XII grossly intact, motor function grossly normal DISCHARGE PHYSICAL EXAM ======================= VS: 98.1 ___ 18 96%RA GEN: Alert, lying in bed, no acute distress COR: Heart sounds irregular, with distant S1/S2. NMRG. HEENT: Moist MM, anicteric sclerae, no conjunctival pallor PULM: Generally CTA b/l without wheeze or rhonchi ABD: Soft, non-tender, non-distended EXTREM: Warm, well-perfused, no edema NEURO: AOx3. CN II-XII grossly intact, motor function grossly normal Pertinent Results: ADMISSION LABS ============== ___ 03:48PM BLOOD WBC-7.2 RBC-5.00 Hgb-15.5 Hct-46.2 MCV-92 MCH-31.0 MCHC-33.5 RDW-13.6 RDWSD-45.8 Plt ___ ___ 03:48PM BLOOD Neuts-66.3 ___ Monos-6.6 Eos-3.8 Baso-0.8 Im ___ AbsNeut-4.74 AbsLymp-1.60 AbsMono-0.47 AbsEos-0.27 AbsBaso-0.06 ___ 03:48PM BLOOD Glucose-115* UreaN-19 Creat-1.0 Na-142 K-4.1 Cl-105 HCO3-27 AnGap-14 ___ 03:48PM BLOOD cTropnT-<0.01 ___ 03:48PM BLOOD Calcium-9.0 Phos-3.6 Mg-2.1 DISCHARGE AND PERTINENT LABS ============================ ___ 06:10AM BLOOD WBC-5.4 RBC-4.67 Hgb-14.4 Hct-42.4 MCV-91 MCH-30.8 MCHC-34.0 RDW-13.4 RDWSD-43.8 Plt ___ ___ 06:10AM BLOOD Glucose-101* UreaN-17 Creat-0.8 Na-142 K-3.8 Cl-109* HCO3-26 AnGap-11 ___ 06:10AM BLOOD CK-MB-4 cTropnT-<0.01 ___ 11:20PM BLOOD CK-MB-4 cTropnT-<0.01 ___ 06:10AM BLOOD Calcium-8.5 Phos-2.7 Mg-2.1 MICROBIOLOGY ============ none IMAGING ======= ___ CXR PA&L FINDINGS: The lungs are clear. There is no focal consolidation, effusion, or edema. The cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary process. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. esomeprazole magnesium 20 mg oral DAILY 2. lisinopril-hydrochlorothiazide ___ mg oral DAILY 3. Simvastatin 40 mg PO DAILY 4. solifenacin 5 mg oral DAILY 5. Cetirizine 10 mg PO DAILY Discharge Medications: 1. Tamsulosin 0.4 mg PO QHS RX *tamsulosin 0.4 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 2. Cetirizine 10 mg PO DAILY 3. esomeprazole magnesium 20 mg oral DAILY 4. lisinopril-hydrochlorothiazide ___ mg oral DAILY 5. Simvastatin 40 mg PO DAILY 6. Flecainide Acetate 75 mg PO Q12H RX *flecainide 50 mg 1.5 tablet(s) by mouth twice a day Disp #*90 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary: - angina without acute coronary syndrome - symptomatic PVCs Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with chest pain, cough // ?pna TECHNIQUE: PA and lateral views of the chest. COMPARISON: ___. FINDINGS: The lungs are clear. There is no focal consolidation, effusion, or edema. The cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary process. Gender: M Race: ASIAN - SOUTH EAST ASIAN Arrive by WALK IN Chief complaint: Chest pain Diagnosed with Other chest pain temperature: 98.0 heartrate: 44.0 resprate: 18.0 o2sat: 100.0 sbp: 144.0 dbp: 67.0 level of pain: 5 level of acuity: 3.0

___ with history of HTN, HL who presented to ___ ED with symptomatic PVCs and questionable exertional chest pain for several days. #Bradycardia: Most likely PVC induced concealed mechanical bradycardia with symptomatic lightheadedness. His ECGs were notable for ventricular bigeminy, with each native QRS associated with a PVC. On physical exam, the PVCs seen on telemetry did not produce palpable pulses or audible heart sounds, and on TTE dated ___ it can be observed producing ineffective beats. He was able to augment his sinus rate with exercise, which decreased frequency of PVCs. He was started on flecainide 75 mg bid to suppress the PVCs. He may benefit from event monitoring to determine the frequency of these PVCs to better ascertain whether they are the cause of his symptoms, and he will follow up with Dr. ___ who ___ determine further steps and a cardiac stress test if necessary. #ACS Rule out: He underwent ACS rule out with nonischemic serial ECGs and negative cardiac biomarkers x 3, and will be referred for outpatient stress testing after he follows up with electrophysiologist Dr. ___ as an outpatient. #BPH: Patient described significant LUTS, but is prescribed solifenacin (approved for overactive bladder); however, his incontinence is most likely overflow, as it is occuring in the setting of weak stream, urgency, frequency, and nocturia consistent with BPH. We discontinued solifenacin and started tamsulosin. TRANSITIONAL ============ - Follow up appointments: PCP, ___ (not scheduled at d/c) - Started on flecainide 75mg BID - ___ need outpatient stress test, Holter monitoring - to be determined at cardiology follow up - ___ need Urology eval for lower urinary tract symptoms/BPH - No AVN blocking agents for now given symptomatic PVCs

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Major Surgical or Invasive Procedure: None attach Pertinent Results: ADMISSION LABS: ============= ___ 10:48AM BLOOD WBC-9.5 RBC-3.56* Hgb-11.2 Hct-36.2 MCV-102* MCH-31.5 MCHC-30.9* RDW-12.7 RDWSD-47.5* Plt ___ ___ 10:48AM BLOOD Neuts-88.9* Lymphs-3.3* Monos-5.5 Eos-1.1 Baso-0.2 Im ___ AbsNeut-8.42* AbsLymp-0.31* AbsMono-0.52 AbsEos-0.10 AbsBaso-0.02 ___ 10:48AM BLOOD ___ PTT-19.5* ___ ___ 10:48AM BLOOD Glucose-165* UreaN-13 Creat-0.8 Na-143 K-5.3 Cl-104 HCO3-21* AnGap-18 ___ 10:48AM BLOOD ALT-19 AST-60* AlkPhos-44 TotBili-0.4 ___ 10:48AM BLOOD cTropnT-0.01 proBNP-294 ___ 10:48AM BLOOD Lipase-8 ___ 10:48AM BLOOD Albumin-4.2 Calcium-9.6 Phos-2.7 Mg-1.5* ___ 10:54AM BLOOD ___ pO2-27* pCO2-46* pH-7.41 calTCO2-30 Base XS-2 ___ 10:54AM BLOOD Lactate-2.0 DISCHARGE LABS: ============== ___ 06:13AM BLOOD WBC-10.3* RBC-3.72* Hgb-11.8 Hct-39.3 MCV-106* MCH-31.7 MCHC-30.0* RDW-12.7 RDWSD-49.3* Plt ___ ___ 06:13AM BLOOD Glucose-110* UreaN-10 Creat-0.8 Na-144 K-4.1 Cl-99 HCO3-27 AnGap-18 ___ 06:13AM BLOOD Calcium-9.8 Phos-4.3 Mg-2.0 DISCHARGE PHYSICAL EXAM: ======================= VITALS: ___ 0235 Temp: 97.8 PO BP: 155/76 HR: 94 RR: 18 O2 sat: 97% GENERAL: Chronically ill appearing female in NAD. Lying comfortably in bed. HEENT: Sclera anicteric and without injection. MMM, but poor dentition. Neck: Supple. FROM without pain. CARDIAC: Regular rate and rhythm with normal S1 and S2. II/VI systolic murmur, loudest over the left sternal border. No rubs or gallops. RESP: Normal respiratory effort. Scattered faint inspiratory crackles at bilateral bases. No wheezes or rhonchi. ABDOMEN: Normal bowels sounds, soft, NT/ND. Normoactive BS. No guarding or masses. MSK: Warm, well perfused. No ___ edema or erythema. TTP over right lumbar paraspinal muscles and SI joint. TTP over lower sacrum. No TTP over right greater trochanter. full active ROM of right hip, pain with extension and abduction. full ROM of right knee, without any pain. no ___ edema. SKIN: Warm, dry. No rashes. no overlying skin changes @ right hip. NEUROLOGIC: AOx3. face symmetric, speech fluent, moving all 4 extremities purposefully. Strength exam: Lower extremities: L HF: ___ HE: ___ KF: ___ KE: ___ DF: ___ PF: ___ R HF: 4+/5 HE: ___ KF: ___ KE: 4+/5 DF: ___ PF: ___ L Delt: ___ EF: ___ EE: 4+/5 Int: ___ Thumb abd: ___ R Delt: ___ EF: ___ EE: 4+/5 Int: ___ Thumb abd: ___ Decreased sensation over lateral and plantar aspect of foot and lateral lower leg. neg straight leg Reflex 3+ in left lower extremity and 2+ in right lower extremity. Downgoing toes bilaterally. +clonus bilaterally with R>L. MICRO DATA: ========== ___ 07:00PM CEREBROSPINAL FLUID (CSF) TNC-1 RBC-18* Polys-21 ___ Macroph-7 ___ 07:00PM CEREBROSPINAL FLUID (CSF) TotProt-50* Glucose-100 ___ 04:15PM OTHER BODY FLUID FluAPCR-NEG FluBPCR-NEG ___ 5:45 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT ___ MRSA SCREEN (Final ___: POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. ___ 7:00 pm CSF;SPINAL FLUID SOURCE: LP #3. **FINAL REPORT ___ GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count, if applicable. FLUID CULTURE (Final ___: NO GROWTH. ___ 11:09 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 11:00 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. IMAGING: ======== NCHCT ___: 1. No acute intracranial hemorrhage. 2. Prominent ventricles out of portion of sulci suggestive of central atrophy. 3. Left frontal lobe encephalomalacia. 4. Mild periventricular white matter disease. CTA Chest ___: 1. No evidence of pulmonary embolism or acute aortic abnormality. 2. Grossly similar appearance of chronic interstitial lung disease. 3. Small hiatal hernia. 4. Mild pulmonary artery dilation suggestive of pulmonary hypertension. Hip X-ray ___: Mild degenerative changes in the bilateral hip joints MRI Right Hip ___: Unchanged right hip MRI with a small degenerative labral tear. No evidence of avascular necrosis, fracture or other acute abnormality. MRI lumbar spine with and w/o contrast ___: 1. Severe canal narrowing with compression of the cauda equina nerve roots at L3-4 due to a disc bulge and superimposed right paracentral disc extrusion. The extruded disc fragment also narrows the right L4 lateral recess, displaces the traversing nerve root, and compresses the traversing/exiting right L4 nerve root. 2. Moderate to severe canal narrowing is also present at L4-5. 3. Other levels of severe neural foraminal narrowing including on the left at L3-4, bilaterally at L4-5 and on the right at L5-S1 as described above. 4. No evidence of an epidural collection. No signal abnormality in the sacrum to explain sacral tenderness. MRI cervical spine with and w/o contrast ___: 1. No epidural collection or evidence of discitis/osteomyelitis. 2. Multilevel degenerative changes of the cervical spine, most prominent at C5-6 where there is moderate to severe canal narrowing with remodeling of the cord, but no cord signal abnormality. Evaluation of neural foramina is somewhat limited due to motion, but is likely moderate to severe at this level. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Fluticasone Propionate NASAL 1 SPRY NU DAILY 3. LORazepam 0.5 mg PO BID:PRN anxiety 4. Omeprazole 20 mg PO DAILY 5. albuterol sulfate 90 mcg/actuation inhalation TID 6. Lovastatin 10 mg oral DAILY 7. AzaTHIOprine 100 mg PO DAILY 8. Baclofen 10 mg PO BID 9. ipratropium bromide 42 mcg (0.06 %) nasal TID prn 10. Lisinopril 20 mg PO DAILY 11. meloxicam 7.5 mg oral daily 12. Nystatin Oral Suspension 5 mL PO QID 13. PredniSONE 20 mg PO DAILY 14. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral daily Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Atovaquone Suspension 1500 mg PO DAILY 3. Ibuprofen 400-600 mg PO Q8H:PRN Pain - Mild 4. Lidocaine 5% Patch 1 PTCH TD QAM right hip/lower back 5. Multivitamins W/minerals 1 TAB PO DAILY 6. albuterol sulfate 90 mcg/actuation inhalation TID 7. Aspirin 81 mg PO DAILY 8. AzaTHIOprine 100 mg PO DAILY 9. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral daily 10. Fluticasone Propionate NASAL 1 SPRY NU DAILY 11. ipratropium bromide 42 mcg (0.06 %) nasal TID prn 12. Lisinopril 20 mg PO DAILY 13. LORazepam 0.5 mg PO BID:PRN anxiety 14. Lovastatin 10 mg oral DAILY 15. Nystatin Oral Suspension 5 mL PO QID 16. Omeprazole 20 mg PO DAILY 17. PredniSONE 20 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY: ========= SIRS SECONDARY: ========== Piriformis Pain Syndrome Degenerative Joint Disease (Hips & Lumbar Spine) Hypokalemia Hypomagnesemia Severe Malnutrition Interstitial Lung Disease Anxiety Hypertension Thrush 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 confusion fever // PNA? TECHNIQUE: Portable semi-upright AP view of the chest COMPARISON: CT chest ___ and chest radiograph ___ FINDINGS: Lung volumes remain low. Cardiac silhouette size is mildly enlarged, unchanged. Mediastinal and hilar contours are similar. Redemonstrated are chronic interstitial opacities with scattered parenchymal opacifications, potentially in the left lung base, compatible with known chronic interstitial lung disease. Superimposed infection in the left lung base is difficult to exclude. There appears to be a small left pleural effusion. No pneumothorax. Crowding of bronchovascular structures without frank pulmonary edema. No acute osseous abnormality. IMPRESSION: Low lung volumes with chronic interstitial lung disease redemonstrated. Superimposed infection in the left lung base is difficult to exclude. Probable small left pleural effusion. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: History: ___ with altered mental status // Rule out bleed TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 18.0 s, 18.3 cm; CTDIvol = 49.5 mGy (Head) DLP = 903.1 mGy-cm. 2) Sequenced Acquisition 2.0 s, 4.1 cm; CTDIvol = 49.5 mGy (Head) DLP = 200.7 mGy-cm. Total DLP (Head) = 1,104 mGy-cm. COMPARISON: None. FINDINGS: There is no evidence of fracture, acute large territorial infarction,hemorrhage,edema,or mass. The ventricles are prominent out of portion of sulci suggestive of central atrophy. There is left frontal lobe encephalomalacia. There is mild periventricular white matter disease. The visualized portion of the mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are normal. There is mucosal thickening in the right maxillary sinus with air-fluid level and aerosolized secretions. Moderate atherosclerotic calcifications of the cavernous carotid arteries.. IMPRESSION: 1. No acute intracranial hemorrhage. 2. Prominent ventricles out of portion of sulci suggestive of central atrophy. 3. Left frontal lobe encephalomalacia. 4. Mild periventricular white matter disease. Radiology Report EXAMINATION: CTA CHEST WITH CONTRAST INDICATION: History: ___ with shortness of breath, tachycardia // Assess for pulmonary embolism TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of intravenous contrast. Reformatted coronal, sagittal, thin slice axial images, and oblique maximal intensity projection images were submitted to PACS and reviewed. DOSE: Acquisition sequence: 1) Stationary Acquisition 2.0 s, 0.5 cm; CTDIvol = 12.1 mGy (Body) DLP = 6.1 mGy-cm. 2) Spiral Acquisition 3.6 s, 28.3 cm; CTDIvol = 16.0 mGy (Body) DLP = 454.2 mGy-cm. Total DLP (Body) = 460 mGy-cm. COMPARISON: CT chest dated ___ and ___. FINDINGS: HEART AND VASCULATURE: The main pulmonary artery measures 3.2 cm suggestive of pulmonary artery hypertension. There is no filling defect visualized to the level of subsegmental pulmonary artery suggestive of pulmonary embolism. The thoracic aorta is normal in caliber without evidence of dissection or intramural hematoma. There is mild atherosclerotic calcification involving the thoracic aorta. There is mild mitral annular calcification. The heart is mildly enlarged. Pericardium and great vessels are within normal limits. No pericardial effusion is seen. AXILLA, HILA, AND MEDIASTINUM: There are multiple subcentimeter mediastinum lymph nodes which are likely reactive. No axillary or hilar lymphadenopathy is present. No mediastinal mass. PLEURAL SPACES: No pleural effusion or pneumothorax. LUNGS/AIRWAYS: The airways are patent to the level of the segmental bronchi bilaterally. There is grossly unchanged scattered bilateral lung peribronchovascular ground-glass opacification and reticulation, interlobular septal thickening and traction bronchiectasis consistent with chronic interstitial lung disease. No new focal consolidation. BASE OF NECK: Visualized portions of the base of the neck show no abnormality. ABDOMEN: There is a small hiatal hernia. Included portion of the upper abdomen is unremarkable. BONES: No suspicious osseous abnormality is seen.? There is no acute fracture. There is mild multilevel degenerative changes of the thoracic spine. IMPRESSION: 1. No evidence of pulmonary embolism or acute aortic abnormality. 2. Grossly similar appearance of chronic interstitial lung disease. 3. Small hiatal hernia. 4. Mild pulmonary artery dilation suggestive of pulmonary hypertension. Radiology Report EXAMINATION: HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) RIGHT INDICATION: ___ year old woman with fever and right hip pain // Evaluate for infection, effusion TECHNIQUE: AP pelvis, two views right hip COMPARISON: Pelvis and right hip radiographs ___ FINDINGS: No fracture or dislocation seen. There are mild degenerative changes in the bilateral hip joints as seen previously. More severe degenerative changes are noted in the lower lumbar spine, similar to slightly progressed when compared to the prior study. No destructive lytic or sclerotic bone lesions. Evaluation of the sacrum is limited due to overlying bowel gas. IMPRESSION: Mild degenerative changes in the bilateral hip joints Radiology Report EXAMINATION: MR HIP ___ CONRAST RIGHT INDICATION: ___ year old woman with long term steroid use, hx of greater trochanteric bursitis, and piriformis pain syndrome, now with acute on chronic right hip pain // e/o AVN or other cause for acute on chronic right hip pain? TECHNIQUE: Multiplanar images of the right hip were performed without the administration of intravenous contrast using a unilateral hip MR protocol. COMPARISON: None FINDINGS: Dedicated right hip imaging is limited by motion artifact. There is normal marrow signal within the proximal femurs bilaterally. There is no evidence of avascular necrosis, fracture, stress fracture. The marrow signal throughout the rest of the pelvis is within normal limits. There is normal signal at the sacroiliac joints, without evidence of sacroiliitis. Focused imaging of the right hip demonstrates no significant joint effusion. The articular cartilage is grossly preserved. The previously seen small degenerative labral tear is better assessed on prior MRI, but not significantly changed. There is no greater trochanteric bursitis. The hamstring insertion onto the ischial tuberosity is normal. Limited assessment of intra-pelvic soft tissue structures is grossly unremarkable. No gross intrapelvic fluid or enlarged intrapelvic lymph nodes detected. Limited assessment of the lower lumbar spine is grossly unremarkable. IMPRESSION: Unchanged right hip MRI with a small degenerative labral tear. No evidence of avascular necrosis, fracture or other acute abnormality. Radiology Report EXAMINATION: MR ___ AND W/O CONTRAST INDICATION: ___ year old woman with ILD on chronic steroids initially with fever and with tenderness over sacrum. // ?acute infectious process TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique, followed by axial T2 imaging. This was followed by sagittal and axial T1 images obtained after the uneventful intravenous administration of ___ contrast agent. COMPARISON: None. FINDINGS: There is approximately 5 mm retrolisthesis of L3 on L4. There is minimal grade 1 anterolisthesis of L4 on L5 with bilateral spondylolysis. Vertebral body height and signal intensity is preserved. There is disc desiccation signal and height loss throughout the lumbar spine. The conus medullaris terminates at L2. Post-contrast images demonstrate no abnormal enhancement of the conus or cauda equina nerve roots. At T12-L1 and L1-L2, there is a disc bulge with no canal or neural foraminal narrowing. At L2-3 there is a broad disc bulge, mild facet and ligamentum flavum hypertrophy which results in mild canal narrowing and minimal bilateral neural foraminal narrowing. At L3-4, there is a broad disc bulge with superimposed central/right paracentral disc extrusion extending inferiorly which in combination with facet hypertrophy, ligamentum flavum hypertrophy and epidural fat results in severe canal narrowing with compression of the cauda equina nerve roots. The extruded disc fragment extends inferiorly into the right right lateral recess at L4, where it likely affects the traversing right L4 nerve root. Overall, the extrusion measures 2.3 cm cc x 1.3 cm TRV x 1.2 cm AP. Neural foraminal narrowing is severe on the left and moderate to severe on the right. At L4-5, there is a broad disc bulge with right central annular fissure and superimposed left paracentral protrusion. This in combination with ligamentum flavum thickening and facet hypertrophy results in moderate to severe canal narrowing with crowding of the cauda equina nerve roots. The superimposed disc protrusion on the left narrows the extraforaminal and subarticular zone. In combination with facet joint hypertrophy, there is severe bilateral subarticular recess and neural foraminal narrowing. At L5-S1, there is a disc bulge and facet joint hypertrophy resulting in moderate canal narrowing. There is severe right and moderate to severe left neural foraminal narrowing. Other: Cholelithiasis is partially imaged. IMPRESSION: 1. Severe canal narrowing with compression of the cauda equina nerve roots at L3-4 due to a disc bulge and superimposed right paracentral disc extrusion. The extruded disc fragment also narrows the right L4 lateral recess, displaces the traversing nerve root, and compresses the traversing/exiting right L4 nerve root. 2. Moderate to severe canal narrowing is also present at L4-5. 3. Other levels of severe neural foraminal narrowing including on the left at L3-4, bilaterally at L4-5 and on the right at L5-S1 as described above. 4. No evidence of an epidural collection. No signal abnormality in the sacrum to explain sacral tenderness. PREVALENCE: Prevalence of lumbar degenerative disk disease in subjects without low back pain: Overall evidence of disk degeneration 91% (decreased T2 signal, height loss, bulge) T2 signal loss 83% Disk height loss 58% Disk protrusion 32% Annular fissure 38% Jarvik, et all. Spine ___ 26(10):1158-1166 Lumbar spinal stenosis prevalence- present in approximately 20% of asymptomatic adults over ___ years old ___, et al, Spine Journal ___ 9 (7):545-550 These findings are so common in asymptomatic persons that they must be interpreted with caution and in context of the clinical situation. NOTIFICATION: The findings were discussed with ___, m.D. by ___, M.D. on the telephone on ___ at 925 am, 30 minutes after discovery of the findings. Radiology Report EXAMINATION: MR ___ WAND W/O CONTRAST ___ MR ___ SPINE INDICATION: ___ year old woman with ILD on immunosuppression, here with hip pain, found to have severe lumbar DDD and also with triceps weakness. // ? acute spinal process TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique. Axial T2 and gradient echo imaging were next performed. After administration of Gadavist intravenous contrast, sagittal and axial T1 weighted imaging was performed. COMPARISON: None. FINDINGS: There is about 2 mm anterolisthesis of C4 on C5 and about 4 mm anterolisthesis of C5 on C6. This is appears chronic, as there is no prevertebral edema or evidence of ligamentous injury. The spondylolisthesis results in somewhat exaggerated cervical lordosis. Vertebral body signal intensity is within normal limits. There is disc desiccation signal throughout the cervical spine. Spinal cord is normal in caliber and configuration. No evidence of infection or malignancy. At C2-3, there is no canal or neural foraminal narrowing. At C3-4, a posterior disc osteophyte complex results in minimal canal narrowing. Left greater than right facet uncovertebral osteophytes result in moderate left and mild right neural foraminal narrowing. At C4-5, a posterior disc osteophyte complex results in mild canal narrowing with flattening of the ventral thecal sac. Evaluation of the neural foramina is somewhat motion limited, but is likely moderate bilaterally. At C5-6, a central posterior disc osteophyte complex results in moderate to severe canal narrowing with remodeling of the cord. There is no cord signal abnormality. Once again, motion limits evaluation of the neural foramina but narrowing is likely moderate to severe bilaterally due to facet and uncovertebral osteophytes. At C6-7, a small posterior disc osteophyte complex results in mild canal narrowing with flattening of the ventral thecal sac. Complete assessment of the neural foramina is limited due to motion, but there are facet and uncovertebral osteophytes probably causing mild narrowing bilaterally. C7-T1: There is no canal or neural foraminal narrowing. The remainder of the imaged upper thoracic spine is grossly unremarkable, without canal or neural foraminal narrowing. IMPRESSION: 1. No epidural collection or evidence of discitis/osteomyelitis. 2. Multilevel degenerative changes of the cervical spine, most prominent at C5-6 where there is moderate to severe canal narrowing with remodeling of the cord, but no cord signal abnormality. Evaluation of neural foramina is somewhat limited due to motion, but is likely moderate to severe at this level. 3. Additional degenerative changes of the cervical spine as described above. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Confusion, Dyspnea Diagnosed with Sepsis, unspecified organism, Fever, unspecified, Dyspnea, unspecified temperature: 99.9 heartrate: 134.0 resprate: 28.0 o2sat: 98.0 sbp: 184.0 dbp: 114.0 level of pain: UTA level of acuity: 2.0

BRIEF HOSPITAL COURSE ================================= Ms. ___ is a ___ y/o female with a history of ILD on azathioprine/prednisone, and piriformis pain syndrome, who presented initially with worsening hip pain and confusion. The confusion, which was marked by word finding difficulties at home, resolved by time pt arrived to the hospital and was believed to be possibly ___ toxic metabolic encephalopathy in the setting of infection vs. TIA vs. medication side effect (on baclofen at home). Noncontrast head CT w/o evidence of bleed. In the ED she was found to be febrile to ___. Broad infectious workup including LP did not find cause for her fever. She was placed on empiric abx for 48 hours which were discontinued at that point in time as cultures remained negative and fever had not returned. Regarding her acute on chronic right hip pain, pt underwent x-ray and MRI imaging which revealed no evidence of avascular necrosis or other acute process. She was provided analgesics for sx relief and additionally worked with ___. She also complained of focal lower back pain which given history of immunosuppression was concerning for infection. Lumbar MRI without evidence of abscess, but did show extensive degenerative disc disease and possible compression of cauda equina for which neurosurgery was consulted. Cervical spine MRI also obtained for triceps weakness which again demonstrated degenerative disease. Will plan for follow up with neurosurgery as outpatient. TRANSITIONAL ISSUES: ================================= []Pulmonology: started Ms. ___ on atovaquone for PCP ppx while on pred 20mg. []PCP: please follow up on hip and back pain []PCP: note that patient became confused with tramadol and oxycodone and would avoid those medications []PCP: ___ to be hypertensive during admission. ___ benefit from additional antihypertensive agent. []PCP: ___ weaning benzodiazepines given age. []Neurosurgery: --Recommend EMG as outpatient to evaluate neuropathy; follow up with Neuromuscular Neurology. Call ___ to schedule. --Please follow up with Neurosurgery in 4 weeks (after EMG). Call ___ to schedule with Dr. ___.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Aspirin / Niacin / Tape ___ / Percocet / ibuprofen / house dust / house dust mite Attending: ___. Chief Complaint: cough, shortness of breath, leg swelling Major Surgical or Invasive Procedure: none History of Present Illness: HISTORY OF PRESENT ILLNESS: ___ with a PMG of h/o CHF (last TTE ___ showing mild systolic and diastolic dysfunction, on Lasix 80mg QD) CAD s/p PPM, DVT/PE not on anticoagulation, IDDM (on metformin and insulin), asthma, OSA, CKD, lymphedema presenting from assisted living with increased SOB and bilateral pedal edema. Of note, patient was hospitalized at ___ in ___ for PNA. Per repot, patient reports chronic SOB, orthopnea, ___ edema, worsened over the past couple of days. She describes a sensation of SOB only with bending over at the waist. When she is lying flat or sitting upright the SOB is not present. She does not walk anymore given her lymphedema and lower extremity edema. She denies any change in her Lasix dosing or dietary indiscretion. ROS positive for non productive cough and lightheadedness over the past several days. Does not feel like a cold. ROS negative for LOC, CP, fever, chills, abdominal pain, N/V/D/C, dysuria. In the ED, initial VS were: 98.9, 88, 125/63, 20, 96% RA Exam notable for: On stretcher, in visible distress when lying down AOx3. RRR, no /r/g Labs showed: - CBC: 9.2/10.8/___.4/222 - Chem 7: K4.8, Cr 1.1 - BNP 661 - Trp 0.01 negative x2 - Lactate 3.3-4-4-2.5 Imaging showed: Bilateral US negative for DVT, CXR showing mild pulmonary vascular congestion without frank pulmonary edema. Received: ___ 12:47 IV Furosemide 80 mg ___ ___ 12:47 IV Vancomycin ___ Started ___ 13:01 SC Insulin 30 ___ ___ 14:10 IV Vancomycin 1 mg ___ Stopped (1h ___ ___ 19:48 SC Insulin 8 Units ___ ___ 22:33 SC Insulin 10 Units ___ ___ 23:14 SC Insulin 20 UNIT ___ Transfer VS were: 93, 141/67, 20, 98% RA On arrival to the floor, patient reports the above symptoms. She is most bothered by the cough. Denies any SOB with lying flat in the bed. No pain with deep inspiration. Specifically denies any urinary symptoms aside from increased urinary frequency in the setting of Lasix. Past Medical History: --complete heart block s/p PPM --Congestive heart failure --Cardiac history: Dilated cardiomyopathy diagnosed ___ following spine surgery, with subsequently normalized cardiac function --obesity --diabetic neuropathy --DVT-R.popliteal vein and PE ___ --Lymphedema of legs, R>L for many years --Obstructive sleep apnea (uses CPAP) --Gastroesophageal reflux disease --Anemia (baseline Hct = ___ --osteoarthritis --Sciatica --Cervical stenosis --Restless leg syndrome --Cataracts s/p surgery in left eye -allergic rhinitis -asthma -overactive bladder -bilateral carpal tunnel release about ___ yrs ago -trigger finger - headaches --Gout vs pseudogout ___ PAST SURGICAL HISTORY: --Right knee replacement --Lumbar spondylosis and disk degeneration s/p laminectomy and fusion ___ --Tonsillectomy --Cervical fusion Social History: ___ Family History: Mother with CAD Sister with CABG in ___ Other sister with heart issues, unsure what kind Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.6, 126/80, 87 18 97 RA GENERAL: NAD, appears fatigued HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, JVD 8 lying flat in bed HEART: RRR, occasional extra beats, no murmurs LUNGS: CTAB, no wheezes, rales, rhonchi, coughing with deep breathing. ABDOMEN: nondistended, obese, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: bilateral lymphedema, large 5cm diameter region pretibial surface of right leg warmth and erythematous. 2+ pitting edema bilaterally to knees. Distal extremities WWP. No open ulcerations. PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose DISCHARGE PHYSICAL EXAM: VITALS: Tm 98.2 HR 92 BP 124/81 RR 16 SPO2 96%CPAP GENERAL: Elderly woman laying in bed in NAD HEENT: MMM CV: Soft heart sounds. Nl s1/s2. No m/r/g. Minimal JVD RESP: CTAB anteriorly. No w/r/r. Not using accessory muscles. GI: Obese. Soft. NT ND +BS EXT: 1+ ___ edema in bilateral LEs. No calf tenderness. No cyanosis or clubbing. No redness of LEs. SKIN: Warm and well-perfused NEURO: AAOx3. Able to move around in bed by herself. Pertinent Results: =============== Admission labs =============== ___ 11:30AM BLOOD WBC-9.2 RBC-4.06 Hgb-10.8* Hct-34.4 MCV-85 MCH-26.6 MCHC-31.4* RDW-15.4 RDWSD-46.9* Plt ___ ___ 11:30AM BLOOD Neuts-70.4 Lymphs-18.6* Monos-7.8 Eos-2.4 Baso-0.4 Im ___ AbsNeut-6.45* AbsLymp-1.70 AbsMono-0.71 AbsEos-0.22 AbsBaso-0.04 ___ 11:30AM BLOOD Glucose-258* UreaN-25* Creat-1.1 Na-136 K-4.8 Cl-99 HCO3-22 AnGap-15 ___ 12:29AM BLOOD ALT-15 AST-15 AlkPhos-120* TotBili-0.2 ___ 11:30AM BLOOD proBNP-661* ___ 11:30AM BLOOD cTropnT-0.01 ___ 12:29AM BLOOD Calcium-9.5 Phos-3.6 Mg-1.9 ___ 12:04PM BLOOD Lactate-3.3* =============== Pertinent labs =============== ___ 06:15AM BLOOD Calcium-9.3 Phos-4.4 Mg-2.2 UricAcd-7.8* ___ 02:51AM BLOOD %HbA1c-13.7* eAG-346* =============== Discharge labs =============== ___ 07:45AM BLOOD WBC-9.3 RBC-4.25 Hgb-11.0* Hct-35.6 MCV-84 MCH-25.9* MCHC-30.9* RDW-14.8 RDWSD-45.3 Plt ___ ___ 06:15AM BLOOD Glucose-184* UreaN-34* Creat-1.3* Na-139 K-4.1 Cl-92* HCO3-31 AnGap-16 =============== Studies =============== ___: ANKLE (AP, MORTISE AND LAT) LEFT IMPRESSION: Comparison to ___. No relevant change is noted. No fracture or dislocation. The more ties and hilar dome are stable in appearance. Plantar and posterior calcaneal spurs are again demonstrated. Stable moderate periarticular soft tissue swelling. ___: Lower Extremity US 1. Limited evaluation of the calf veins bilaterally. Within these limitations, no evidence of deep venous thrombosis in the right or left lower extremity veins. 2. Subcutaneous edema of the calves bilaterally. ___: CXR IMPRESSION: Possible mild pulmonary vascular congestion without frank pulmonary edema. =============== Microbiology =============== ___: blood culture pending ___: urine culture pending ___: URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMIKACIN-------------- 4 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- <=1 S Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. Allopurinol ___ mg PO DAILY 3. Cetirizine 10 mg PO DAILY 4. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN rhinitis 5. Gabapentin 100 mg PO TID 6. Montelukast 10 mg PO DAILY 7. Pantoprazole 40 mg PO Q24H 8. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral DAILY 9. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H:PRN 10. Furosemide 80 mg PO DAILY 11. Detemir 30 Units Breakfast Detemir 20 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 12. Colchicine 0.6 mg PO 2X/WEEK (___) 13. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 14. Potassium Chloride 40 mEq PO DAILY 15. Ferrous Sulfate 325 mg PO DAILY 16. mometasone 50 mcg/actuation nasal DAILY 17. Multivitamins 1 TAB PO DAILY 18. Ascorbic Acid ___ mg PO DAILY 19. trospium 20 mg oral BID 20. TraZODone 50 mg PO QHS:PRN insomnia Discharge Medications: 1. Lidocaine 5% Ointment 1 Appl TP DAILY 2. Allopurinol ___ mg PO DAILY 3. Gabapentin 100 mg PO BID 4. Detemir 30 Units Breakfast Detemir 20 Units Bedtime Humalog 8 Units Breakfast Humalog 8 Units Lunch Humalog 8 Units Dinner Insulin SC Sliding Scale using HUM Insulin 5. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 6. Ascorbic Acid ___ mg PO DAILY 7. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral DAILY 8. Cetirizine 10 mg PO DAILY 9. Colchicine 0.6 mg PO 2X/WEEK (___) 10. Ferrous Sulfate 325 mg PO DAILY 11. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN rhinitis 12. Furosemide 80 mg PO DAILY 13. mometasone 50 mcg/actuation nasal DAILY 14. Montelukast 10 mg PO DAILY 15. Multivitamins 1 TAB PO DAILY 16. Pantoprazole 40 mg PO Q24H 17. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H:PRN 18. trospium 20 mg oral BID 19. HELD- Potassium Chloride 40 mEq PO DAILY This medication was held. Do not restart Potassium Chloride until you see your Cardiologist 20. HELD- TraZODone 50 mg PO QHS:PRN insomnia This medication was held. Do not restart TraZODone until you see your primary care doctor Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnoses =============== #Acute on chronic HFrEF #Acute on chronic ___ edema #Dyspnea #IDDM, poorly-controlled #Chronic #Chronic knee pain Secondary Diagnoses ================ #OSA #Gout #Hx of DVT/PE #CKD stage III #asthma #seasonal allergies Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: ANKLE (AP, MORTISE AND LAT) LEFT INDICATION: ___ year old woman with pain to palpation of left lateral ankle and complaining of pain// r/o fracture r/o fracture IMPRESSION: Comparison to ___. No relevant change is noted. No fracture or dislocation. The more ties and hilar dome are stable in appearance. Plantar and posterior calcaneal spurs are again demonstrated. Stable moderate periarticular soft tissue swelling. Gender: F Race: OTHER Arrive by AMBULANCE Chief complaint: Pedal edema Diagnosed with Heart failure, unspecified temperature: 98.9 heartrate: 88.0 resprate: 20.0 o2sat: 96.0 sbp: 125.0 dbp: 63.0 level of pain: 4 level of acuity: 3.0

SUMMARY: ==================== ___ with a PMH of HFrEF (EF 45%) s/p permanent pacemaker placement, CAD, hx of DVT/PE not on anticoagulation, IDDM (on metformin and insulin), asthma, OSA on CPAP, CKD, lymphedema presenting from assisted living with cough x2 weeks, shortness of breath, and ___ edema concerning for CHF exacerbation. ======================= ACUTE MEDICAL PROBLEMS ======================= #HFrEF exacerbation Patient with known LVEF 45-50%, status-post placement of permanent pacemaker. She presented with subacute cough and mild SOB, concerning for HFrEF exacerbation. A chest x-ray showed some mild pulmonary vascular congestion without frank edema. Her proBNP was 661, with a history of >4000 during heart failure exacerbations. She was treated with IV Lasix 80 mg instead of her baseline PO Lasix 80 mg. She is not on a beta-blocker or ___ at home and follows with the heart failure clinic at ___. She diuresed net negative 7.5L during her admission. Her discharge weight was 110.3 kg. Due to concern for aspiration contributing to her respiratory distress, she was evaluated by speech and swallow who recommended a heart healthy diet with thin liquids. # Type 2 DM - Insulin dependent Blood sugars elevated on admission, possibly in setting of medication non-compliance (HbA1C 13.7). Continued Lantus 30U qAM and 20U qPM for standing insulin and her was put on a high dose sliding scale. There was some concern that she may not have been taking her insulin regularly as an outpatient. Her discharge insulin regimen was insulin glargine 30 units at breakfast and 20 units at bedtime, and insulin Humalog 8 units at breakfast, lunch, and dinner with sliding scale on top of it. Metformin was discontinued given her significant HbA1C elevation and unlikely benefit. She has an outpatient appointment with ___ Diabetes ___ to further titrate her insulin. # Lower extremity swelling # History of provoked DVT/PE Patient with chronic lymphedema. Initially had concern for lower extremity DVT due to erythema of right lower extremity but resolved and lower extremity US negative for DVT. In addition, she was briefly treated with vancomycin/doxycycline for presumed cellulitis as her one legs (R) was more red than the other, but this was stopped as the redness resolved quickly with diuresis. # Lactatemia Patient with initial labs showing lactate 3.3, but patient was not hypotensive or in shock. This trended down to 2.5 and then we stopped checking it. This may have been secondary to relative hypoperfusion from cardiorenal syndrome. # Asymptomatic bacteriuria Patient had urinalysis with WBC>27, large leuks, positive nitrates. Urine culture with Ecoli>100k. In setting of no symptoms, fever or WBC, the decision was made to hold off on antibiotics. A repeat urinalysis was done that showed no abnormalities. # Acute on chronic knee and right ankle pain # Hx of gout Patient complaining of bilateral knee pain for which she received Tylenol and topical lidocaine gel for. She also had complaints of pain on her left lateral malleolus, so an X-ray was done of her left ankle which showed soft tissue swelling and bone spurs, but no evidence of fracture. Due to her history of gout, her allopurinol was increased to 150 mg PO daily based on renal function. Uric acid was checked for purposes of titrating outpatient medications which was 7.8. She was restarted on colchicine on discharge as she takes it twice a week at home. CHRONIC MEDICAL ISSUES ====================== # CKD Stage III Cr 1.1 on admission below recent baseline 1.5-2.0. This increased to 1.3 with diuresis, till below recent baseline. # OSA Continued on CPAP at night. # Asthma/Allergies Continued home Cetirizine, Monteleukast, Albuterol ================= TRANSITIONAL ISSUES ================= [] Speech and swallow recs for diet: Heart healthy, carb consistent diet with thin liquids [] Discharge weight: 110.3 kg (bed weight) [] Discharge creatinine: 1.3 [] Allopurinol increased to 150 mg PO daily (uric acid 7.8), continue to titrate as able given chronic renal disease [] Follow up with Cardiology, ___, PCP [] Discharge insulin: Lantus 30 units qAM, 20 units qbedtime; Humalog 8 units qac with additional sliding scale [] HbA1c 13.7% --> suspect she was not getting insulin at assisted living facility, so please ensure she is receiving her medications [] Metformin stopped due to little relative benefit with this degree of HbA1C elevation [] Daily KCl was held given no issues with hypokalemia throughout her admission despite ongoing intravenous diuresis [] Patient complaining of L hallux pain after putting on socks day of discharge, no concern for acute gouty flare based on clinical exam, please continue to monitor [] Urine culture from ___ pending [] Blood culture from ___ pending Advanced Care Planning #CONTACT: Name of health care proxy: ___ ___: son Phone number: ___ Cell phone: ___ #CODE STATUS: Full, presumed, not specifically discussed

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Ativan Attending: ___ Chief Complaint: fall Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a medically complex ___ with PMH significant for poorly controlled T1DM c/b retinopathy, ESRD s/p living kidney xplant in ___, neuropathy with neurogenic bladder and gastroparesis, CAD s/p MI in ___ and with 3 DES placed in ___, hypothyroidism and h/o multiple MDR UTIs (Klebsiella, E.coli, Enterococcus), sclerodermda/CREST and antiphospholipid antibody syndrome with h/o PE in ___ who presents to the ED with intractable N/V and mechanical fall with head strike. Patient was in her usual state of health until one week prior to admission when she developed nausea and vomiting. This nausea and vomiting seemed to occur after she took an oral antibiotic while on vacation in ___ (unclear why this was prescribed - clinic paperwork said for inguinal ___. She became concerned that she was not able to tolerate PO intake and specifically that she was not keeping down her anti-rejection meds so she went to ___ urgent care. Vitals at urgent care were: 97.3, 127/65, 122, 97%RA. She was given 500cc NS and IV Zofran 4mg x1. Labs were checked which showed an INR of 4.9. Urgent care recommended that she be seen at the ___ ED for further evaluation. Patient decided to drive herself to ___ but unfortunately fell while exiting a restaurant (she felt better after the Zofran and stopped for food on the way to ___. She fell down some stairs and struck her head but did not lose conciousness. At this point in time, EMS was called and brought her to ___. Initial vitals in the ED were: 97.2, 135, 168/69, 18, 100% RA Exam was notable for: laceration to right forehead and right wrist swelling. Labs were notable for: H/H 8.4/25.1 (recent baseline 9.5/28.8 but decline is recent in last 4 months), INR 4.8, plts 292, BNP 1547, Cr 1.4 (baseline 1.2-1.4), lactate 1.4, UA grossly positive. Blood and urine cultures were sent. Imaging showed: No acute fractures or intracranial pathology but with right supraorbital soft tissue hematoma. C-spine intact. No fracture of the right wrist. Patient was given: IV ciprofloxacin 400mg x1 Consults: transplant nephrology who recommended medicine admission. Vitals prior to transfer were: 98.9, 115, 153/60, 18, 95% RA On the floor, patient reports that she feels better and only complains of right wrist pain. She denies nausea since she received Zofran at the urgent care clinic. ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: - Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catherization) - most recent HgbA1c 12.4 in ___ - End-stage renal disease ___ diabetes s/p L-sided living kidney transplant in ___ - Scleroderma w/ CREST syndrome - Antiphospholipid antibody syndrome and remote PE history on Coumadin ___ - CAD s/p MI in ___ c/ LAD PTCA; s/p PTCA ___: one vessel disease with LAD 60% apical lesion and 90% ___ diagonal lesion. ___ diagonal branch was treated with ballon angioplasty w/o stenting. Final angiography demonstrated ___ residual stenosis and improved flow down the diagonal branch. - LVH - Gastroparesis/GERD/Hiatal hernia - Hypothyroidism - Gout diagnosed ___ years ago - Herniated disk - OSA - Carpal tunnel s/p release - H/o multiple UTIs (Enterococcus vanc & amp sensitive, Klebsiella, E. Coli) - Hx of TIA? Social History: ___ Family History: Mother-Multiple myeloma Sister and ___ Sister-RA ___ disease Nephewsx2-Alopecia Daughter ___, celiac disease, MS Physical Exam: ADMISSION EXAM VS: 98.3, 152/67, 117, 19, 97% RA wt 76.2kg. General: well appearing Caucasian female in NAD HEENT: NC, sclerae anicteric. Significant bruising and soft tissue swelling of the right periorbital area. PERRL, EOMI. OP clear without lesion or exudate. Neck: Supple, no ___, no thyromegaly CV: Tachycardic but regular. Normal s1/s2, no m/r/g Lungs: CTAB posteriorly, no w/r/r Abdomen: Distended but soft and nontender. Normal bowel sounds, no rebound or guarding. Unable to appreciate organomegaly. GU: no foley Ext: WWP, DP pulses 1+ bilaterally. No cyanosis, clubbing or edema Neuro: CN ___ grossly intact, moving all 4 extremities with purpose. Gait deferred. Skin: Ecchymoses around right eye, right wrist, above right breast and scattered throughout lower extremities. DISCHARGE EXAM Vitals 98.3 ___ 18 100RA General: obese, NAD HEENT: swollen erythematous R eye that has overall improved but has some crusting; now L eye has some ecchymoses Heart: borderline tachycardic, normal rhythm, no murmurs Lungs: CTAB Abdomen: Obese, NT, NABS, several well-healed scars Extremities: 1+ pitting edema bilaterally Skin: bruising on stomach, R breast, R eye Pertinent Results: ADMISSION LABS ___ 04:10PM BLOOD WBC-10.0 RBC-2.70* Hgb-8.4* Hct-25.1* MCV-93 MCH-31.1 MCHC-33.5 RDW-13.8 RDWSD-45.7 Plt ___ ___ 04:10PM BLOOD ___ PTT-60.1* ___ ___ 04:10PM BLOOD Glucose-114* UreaN-21* Creat-1.4* Na-136 K-3.7 Cl-101 HCO3-24 AnGap-15 ___ 04:10PM BLOOD ALT-16 AST-14 CK(CPK)-99 AlkPhos-85 TotBili-0.2 ___ 06:41AM BLOOD Calcium-9.6 Phos-2.5* Mg-1.6 ___ 06:41AM BLOOD tacroFK-7.4 DISCHARGE LABS ___ 04:42AM BLOOD WBC-5.5 RBC-2.72* Hgb-8.1* Hct-26.1* MCV-96 MCH-29.8 MCHC-31.0* RDW-15.3 RDWSD-53.1* Plt ___ ___ 04:42AM BLOOD ___ PTT-35.9 ___ ___ 04:42AM BLOOD Glucose-304* UreaN-24* Creat-1.5* Na-140 K-4.0 Cl-105 HCO3-27 AnGap-12 ___ 04:42AM BLOOD Calcium-9.5 Phos-3.3 Mg-1.8 ___ 04:42AM BLOOD tacroFK-5.6 MICRO ___ 4:57 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: YEAST. >100,000 ORGANISMS/ML.. ___ 8:02 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 7:37 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. IMAGING WRIST XRAY ___ Dorsal soft tissue swelling along the wrist without underlying fracture. Extensive vascular calcification. CT HEAD ___. No acute intracranial hemorrhage. 2. Right frontal supraorbital superficial soft tissue hematoma. No underlying fracture seen. CT C-SPINE ___ No fracture or malalignment in the C-spine. RENAL TRANSPLANT US ___ Mildly elevated intrarenal resistive indices which are slightly higher than ___. CT ABD/PELVIS ___. No intra or retroperitoneal or intramuscular hematoma noted in the abdomen or pelvis. 2. Transplant kidney in the left lower quadrant demonstrates no hydronephrosis. 3. Moderate amount of stool throughout the colon without bowel obstruction. CT HEAD ___. No acute intracranial hemorrhage. 2. Small, residual, supraorbital, right frontal scalp hematoma. CXR ___ IN COMPARISON WITH THE STUDY OF ___, THERE IS LITTLE CHANGE AND NO ACUTE CARDIOPULMONARY DISEASE. THE CARDIAC SILHOUETTE IS ENLARGED AND THERE IS NO EVIDENCE OF VASCULAR CONGESTION, PLEURAL EFFUSION, OR ACUTE FOCAL PNEUMONIA. CT HEAD ___. No evidence of fracture, infarction or intracranial hemorrhage. 2. Minimal residual right frontal/supraorbital scalp swelling. Radiology Report INDICATION: ___ with pain swelling COMPARISON: None FINDINGS: AP, lateral, obliques views as well as a dedicated navicular view of the right wrist provided. Overlying IV limits assessment. There is extensive vascular calcification noted. Carpal alignment appears preserved. The scaphoid appears intact. Distal radius and ulna appear intact. No acute fracture or dislocation. No significant DJD. Soft tissue swelling is seen dorsally at the wrist. IMPRESSION: Dorsal soft tissue swelling along the wrist without underlying fracture. Extensive vascular calcification. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: History: ___ with head trauma // head trauma on coumadin TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 903.1 mGy-cm. Total DLP (Head) = 903 mGy-cm. COMPARISON: CT from ___ FINDINGS: There is no acute intracranial hemorrhage, mass, mass effect or large territorial infarction. An old infarction is seen within the left centrum semiovale. Bilateral basal ganglia mineralization is identified. The ventricles and sulci are normal in size and configuration. The basilar cisterns are patent, and there is otherwise good preservation gray-white matter differentiation. A right frontal supraorbital superficial soft tissue hematoma is identified. No underlying fracture is seen. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The globes are unremarkable. Extensive carotid calcifications are seen. IMPRESSION: 1. No acute intracranial hemorrhage. 2. Right frontal supraorbital superficial soft tissue hematoma. No underlying fracture seen. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: ___ with head trauma. Please evaluate. 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) = 861 mGy-cm. COMPARISON: None. FINDINGS: There is no fracture, or alignment. There is no prevertebral soft tissue swelling. No significant degenerative changes are seen throughout the cervical spine. The thyroid is normal. There is no cervical lymphadenopathy. The visualized apices of lungs are clear. IMPRESSION: No fracture or malalignment in the C-spine. Radiology Report EXAMINATION: RENAL TRANSPLANT U.S. INDICATION: ___ year old woman with renal transplant presenting with n/v and inability to take rejection meds // eval for evidence of rejection TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images of the renal transplant were obtained. COMPARISON: Renal transplant ultrasound ___. FINDINGS: The left iliac fossa transplant renal morphology is normal. Specifically, the cortex is of normal thickness and echogenicity, pyramids are normal, there is no urothelial thickening, and renal sinus fat is normal. There is no hydronephrosis and no perinephric fluid collection. The resistive index of intrarenal arteries ranges from 0.76 to 0.82, which is mildly elevated and slightly increased since prior exam. The main renal artery shows a normal waveform, with prompt systolic upstroke and continuous antegrade diastolic flow, with peak systolic velocity of 59 cm/sec. Vascularity is symmetric throughout transplant. The transplant renal vein is patent and shows normal waveform. IMPRESSION: Mildly elevated intrarenal resistive indices which are slightly higher than ___. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with recent fall with INR 4.8, lots of bruising, decreased breath sounds on R // pulmonary contusion, effusion pulmonary contusion, effusion IMPRESSION: IN COMPARISON WITH THE STUDY OF ___, THERE IS LITTLE CHANGE AND NO ACUTE CARDIOPULMONARY DISEASE. THE CARDIAC SILHOUETTE IS ENLARGED AND THERE IS NO EVIDENCE OF VASCULAR CONGESTION, PLEURAL EFFUSION, OR ACUTE FOCAL PNEUMONIA. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD. INDICATION: ___ woman with a recent mechanical fall in the setting of a supratherapeutic INR, now with increased lethargy. Evaluate for evidence of acute intracranial hemorrhage. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 16.2 cm; CTDIvol = 49.7 mGy (Head) DLP = 802.7 mGy-cm. 2) Sequenced Acquisition 2.0 s, 4.0 cm; CTDIvol = 49.7 mGy (Head) DLP = 200.7 mGy-cm. Total DLP (Head) = 1,003 mGy-cm. COMPARISON: ___ noncontrast head CT. FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles and sulci are normal in size and configuration. An old infarct is again seen in the left centrum semiovale. Stable, bilateral basal ganglia calcification. Mild periventricular white-matter hypodensities are nonspecific, but likely reflect chronic microvascular ischemic disease. Dense calcification of the carotid siphons and vertebral arteries at the V4 segments appear unchanged. Small, residual, supraorbital, right frontal scalp hematoma. There is no evidence of fracture. Mild mucosal thickening in the sphenoid sinuses, maxillary sinuses, and ethmoid air cells. Otherwise, the visualized portion of the frontal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. No acute intracranial hemorrhage. 2. Small, residual, supraorbital, right frontal scalp hematoma. Radiology Report EXAMINATION: CT ABD AND PELVIS W/O CONTRAST INDICATION: ___ year old woman presenting after fall and recent cardiac catheterization in setting of supratherapeutic INR, now with downtrending Hgb/Hct concerning for bleed. // ?RP bleed TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis without intravenous contrast administration. Coronal and sagittal reformations were performed and submitted to PACS for review. Oral contrast was not administered. IV contrast: 130ml Omnipaque DOSE: Acquisition sequence: 1) Spiral Acquisition 4.9 s, 53.4 cm; CTDIvol = 15.6 mGy (Body) DLP = 834.5 mGy-cm. Total DLP (Body) = 834 mGy-cm. COMPARISON: CT abdomen pelvis dated ___ FINDINGS: Optimal evaluation of organ pathology and vasculature is limited without the benefit of intravenous contrast. LOWER CHEST: There is minimal bibasilar dependent atelectasis. Mild mitral valve calcification is present. Trace pericardial fluid noted. ABDOMEN: GENERAL: There is no intra-abdominal free air or free fluid. No intra or retroperitoneal hematoma identified. HEPATOBILIARY: Within limitations of a non contrast-enhanced scan, the hepatic parenchyma demonstrates a homogeneous attenuation. Punctate calcification in segment 7 is likely capsular and benign. The gallbladder is surgically absent. PANCREAS: There is diffuse pancreatic parenchymal atrophy without main duct dilation. SPLEEN: No splenomegaly. ADRENALS: No adrenal nodules. URINARY: The native kidneys are highly at trophic with severe thinning of the renal cortical parenchyma. In the absence of intravenous contrast presence of any enhancing mass cannot be evaluated. No hydronephrosis. There is a transplant kidney in the left lower quadrant with no hydronephrosis. GASTROINTESTINAL: There is a moderate amount of stool throughout the colon. No bowel obstruction. There is mild hyperdense fluid within the gastric fundus that may be related to enteric contents. LYMPH NODES: Within limitations of a non contrast-enhanced scan, there are sub cm retroperitoneal (para-aortic, bilateral common iliac) lymph nodes. There are numerous small mesenteric lymph nodes measuring up to 9 mm in short axis. VASCULAR: Extensive atherosclerotic calcification of the abdominal aorta and its branches is noted without aneurysmal dilation. PELVIS: The bladder is distended, unremarkable. The uterus and adnexae are unremarkable. There is no free fluid in the pelvis.. BONES AND SOFT TISSUES: There are no suspicious osteolytic or blastic bone lesions. There are scattered soft tissue nodules in the subcutaneous fat of the anterior abdominal wall, likely related to subcutaneous injections. No intramuscular hematoma noted in the body wall. There is a small fat containing umbilical hernia. IMPRESSION: 1. No intra or retroperitoneal or intramuscular hematoma noted in the abdomen or pelvis. 2. Transplant kidney in the left lower quadrant demonstrates no hydronephrosis. 3. Moderate amount of stool throughout the colon without bowel obstruction. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 1:15 ___, 2 minutes after discovery of the findings. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman with R vision changes and worsening n/v. // ?head bleed TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 4.8 s, 16.4 cm; CTDIvol = 51.6 mGy (Head) DLP = 848.0 mGy-cm. Total DLP (Head) = 848 mGy-cm. COMPARISON: Noncontrast head CT ___. FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles and sulci are normal in size and configuration. Minimal bilateral periventricular white matter hypodensities are nonspecific, but likely represent a sequela of chronic small vessel disease. 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. Residual right frontal/supraorbital scalp swelling is minimal. IMPRESSION: 1. No evidence of fracture, infarction or intracranial hemorrhage. 2. Minimal residual right frontal/supraorbital scalp swelling. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: s/p Fall, Abnormal labs Diagnosed with Abrasion of other part of head, initial encounter, Fall (on) (from) other stairs and steps, initial encounter temperature: 97.2 heartrate: 135.0 resprate: 18.0 o2sat: 100.0 sbp: 168.0 dbp: 69.0 level of pain: 4 level of acuity: 2.0

___ yo F with history of T1DM and ESRD s/p living kidney transplant ___ on MMF, tacro, prednisone, also with history of CAD s/p multiple MI's and recent ___ 3 ___, and h/o multiple UTI's (mostly enterococcus, Klebsiella, coag neg staph) who presents for elevated INR and a mechanical fall down some stairs at ___. Suffered trauma but no head bleed. Nausea/vomiting resolved on admission. Experienced labile blood pressures and orthostatic hypotension a/w anemia, improved after transfusion of 1 unit of blood. INR drifted to <2 with improved nutrition and warfarin resumed prior to d/c. Investigations/Interventions 1. Elevated INR: patient is on coumadin for history of PE, and she presented with INR 4.8 in setting of 1 week of nausea and vomiting. Elevated INR likely due to poor nutrition. INR was trended and coumadin restarted ___ when INR was 1.8. INR 1.5 on day of discharge. 2. Fall: patient fell down some stairs at restaurant and had no preceding symptoms. EKG on admission was at baseline. We felt fall to be mechanical in nature due to poor vision related to diabetic nephropathy. 3. Hypotension: patient initially presented with hypertension sbp in 190s, then became hypotensive when working with ___ sbp in ___. She was orthostatic. Home anti-hypertensives discontinued. In setting of fall with elevated INR there was concern for internal bleeding so CT abd/pelvis, CT head, and CXR (PA & lateral) were obtained which were negative for evidence of bleeding. She refused IVF so we encouraged po intake which resulted in stabilization of blood pressures. Discharging home on blood pressure medication regimen of metoprolol succinate 12.5 mg daily and losartan 50 mg daily. Amlodipine discontinued in favor of increasing losartan. 4. Anemia: pt has baseline anemia but Hgb downtrended to 6's in house. As this was associated with hypotension, bleeding was ruled out with imaging described above. She was transfused 1 unit PRBC's with return of her hgb to baseline. No evidence of GI bleeding during hospitalization. 5. Vitreous, retinal hemorrhage: patient reported blurry vision during hospitalization. Ophthalmology consulted who diagnosed vitreous and retinal hemorrhage. Recommended to keep HOB elevated, avoid bending over or straining. Instructed to follow up with ___ clinic. 6. Diabetes mellitus: patient followed at ___. Home regimen continued in house initially but patient experienced hypoglycemia into the 70's in the morning. ___ consulted and patient agreed to change pm Lantus from 20 units to 16 units. She will also change her correction factor to 14. 7. History of UTI's: patient has history of many UTI's. UA on admission c/w UTI so patient placed on ciprofloxacin. UCx grew yeast which we did not treat. Due to her history of infection we decided to discharge her on ciprofloxacin for 14 days, last day being ___. 8. CKD, ESRD s/p kidney transplant: patient is s/p living donor kidney transplant in ___. Maintained on tacro, MMF, prednisone as outpt. Her graft has CKD, likely related to diabetic nephropathy. Serial tacro levels were within goal range and she was maintained on her home regimen of 1mg q12h. Home prednisone dose changed from 6mg qd to 5mg qd. Patient also is on Bactrim DS tab qd which was changed to SS tab qd for PCP ___. 9. CAD: patient with recent ___ 3 placed. Continued on Asa, Plavix, statin in house.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Lisinopril Attending: ___. Chief Complaint: S/p fall, PleurX catheter management Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a pleasant ___ year old male with metastatic NSCLC presenting s/p unwitnessed fall at rehab. He was recently discharged on ___ for an admission for nausea, vomiting and anion-gap metabolic acidosis. The patient states he was sitting on the edge of his bed with the urge to urinate and fell reaching for the urinal. He landed directly onto his face. He denies loss of consciousness. He complains of right sided head pain and right shoulder pain. He also notes some difficulty moving his right arm, but denies complete weakness numbness or tingling. He complains of a chronic cough and shortness of breath. In the ED, initial VS were 99.6 110 123/75 12 97% 4L. In the ED he received albuterol 0.083% Neb Soln, morphine sulfate 4mg IV, ipratropium bromide neb 2.5mL, GlyBURIDE 5 mg Tab, Benzonatate 100mg Capsule, Diltiazem Extended-Release 120 mg x2, Senna 1 Tablet, Guaifenesin 200 mg / 10 mL, Morphine SR 15mg Tab, Aspirin 81mg Tab and Levofloxacin 750mg IV. Labs significant for anion gap metabolic acidosis (AG = 19) and slightly elevated troponin (0.03->0.04). Imaging significant for CT C-spine w/ no fractures and severe degenerative disease; CT Head with small subgaleal hematoma, no intracranial hemorrhage and non-displaced left nasal and right lamina papyracea fractures. CT Chest with lingular mass with post-obstructive pneumonitis, chronic effusions, innumerable nodal/liver/osseous metastases and right middle lobe inflammation or early infection. No fractures on shoulder x-rays. Transfer VS 97.0 100 134/79 16 96%. On arrival to the floor, the patient reports significant right shoulder pain. He complains of shortness of breath which has not significantly changed over the last 24 hours. He denies productive cough, fevers and chills. He denies chest pain. He has a mild headache which he only admitted to on direct questioning. His right hand function is improving; he has no other focal weakness. REVIEW OF SYSTEMS: Denies fever, chills, night sweats, vision changes, rhinorrhea, congestion, sore throat, chest pain, abdominal pain, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. All other 10-system review negative in detail. Past Medical History: 1. Hypertension 2. Hyperlipidemia 3. Type 2 diabetes mellitus 4. Chronic shoulder pain, arthritis 5. S/P right toe surgery for a bone cyst ___ 6. S/P Pleur-X cath placement for malignant effusion 7. Admitted ___ for sepsis and pneumonia 8. Hypoxemia 88% RA, on 2L home O2 9. Cervical stenosis with radiculopathy 10. Non-small cell lung cancer ONCOLOGY HISTORY: Mr. ___ is a ___ year-old ___ male former smoker (50 pack-years) who presented to medical care in ___ with subacute worsening of shortness of breath and cough productive of purulent sputum. He also had low grade fevers. He denied prior cardio-pulmonary complaints or constitutional symptoms. At the time of admission he was quite hypoxemic on room air and required supplemental oxygenation. He was admitted to ___ from ___ to ___ for evaluation. Imaging studies with CT chest from ___ disclosed a consolidation of the lingula, bronchial narrowing, mediastinal lymphadenopathy, liver hypodense lesions and a large loculated left pleural effusion. A PET/CT Scan from ___ disclosed the presence of an extensive FDG-avid consolidative process in the lingula, lymphangitic carcinomatosis, non-FDG avid pleural effusion, FDG-avid lymphadenopathy involving the bilateral supraclavicular regions, mediastinum, subcarinal stations, hilar portacaval and retroperiotenal nodes. FDG-avid liver lesions and FDG-avid osseous metastases. Head MRI from ___ did not disclose evidence of lesions. The patient was symptomatically treated with antibiotics (completed a course of cefpodoxime - 14 days), supplemental oxygen and a left-sided thoracentesis. The patient reported significant improvement of his cardio-pulmonary function with the pleural drainage. The malignant pleural fluid removed on ___ disclosed a carcinoma. Immunohistochemical stains of the tumor cells were positive for CK5/6, and CK7; and negative for CK20, p63, and TTF-1. This immunoprofile is nonspecific but compatible with a non-small-cell lung cancer not otherwise specified. Since his inpatient discharge, the patient's condition has slowly deteriorated. His dyspnea with exertion has worsened since his diagnosis. His cough is present but w/o significant sputum production. He is no longer smoking. He denies much in the way of chest pain. A PleurX catheter was recently placed to manage his chronic left pleural effusion. Social History: ___ Family History: Father with a stroke; mother with cancer; sister with diabetes, hypertension. Physical Exam: ADMISSION PHYSICAL EXAM: VS: T 98.5 bp 123/78 HR 96 RR 20 ___ NC Wt 160 lbs GEN: NAD, awake, alert HEENT: EOMI, sclera anicteric, conjunctivae clear, OP dry and without lesion NECK: Supple CV: Reg rate, normal S1, S2. No m/r/g. CHEST: Resp unlabored, no accessory muscle use. CTA on right, decreased breath sounds on left w/ dullness to percussion, Pleur-X cath in place with clean dressing ABD: Soft, NT, ND, bowel sounds present MSK: normal muscle tone and bulk EXT: No c/c, normal perfusion; right foot has bandage after operation on foot ___ SKIN: No rash, warm skin NEURO: oriented x 3, normal attention, ___ upper extremity strength, ___ lower extremity strength, (right upper extremity difficult to assess in detail due to recent injury and pain), intact sensation to light touch throughout PSYCH: appropriate DISCHARGE PHYSICAL EXAM: Pertinent Results: Admission labs: ___ 03:14AM BLOOD WBC-9.6# RBC-3.57* Hgb-9.2* Hct-28.8* MCV-81* MCH-25.9* MCHC-32.1 RDW-16.1* Plt ___ ___ 03:14AM BLOOD Neuts-81.6* Lymphs-10.8* Monos-6.4 Eos-1.1 Baso-0.2 ___ 03:14AM BLOOD Glucose-165* UreaN-23* Creat-0.9 Na-135 K-4.6 Cl-96 HCO3-20* AnGap-24* ___ 03:14AM BLOOD cTropnT-0.03* ___ 09:15AM BLOOD cTropnT-0.04* ___ 03:14AM BLOOD Calcium-9.4 Phos-4.0 Mg-1.8 Discharge labs: ___ 06:05AM BLOOD WBC-12.0* RBC-3.44* Hgb-8.9* Hct-29.0* MCV-85 MCH-26.0* MCHC-30.7* RDW-17.0* Plt ___ ___ 06:05AM BLOOD Plt ___ ___ 06:05AM BLOOD UreaN-37* Creat-0.9 Na-133 K-6.2* Cl-98 HCO3-15* AnGap-26* ___ 09:20AM BLOOD UricAcd-9.2* ___ 06:05AM BLOOD Calcium-9.4 Phos-4.0 Mg-2.2 ___ 04:21PM BLOOD Lactate-6.6* ___ 04:21PM BLOOD ___ pH-7.39 CT SPINE ___ FINDINGS: There are no fractures or malalignments. Chronic loss of height in the C3 through C6 vertebrae. Moderate loss of disc height, bridging anterior osteophytes, and mild uncovertebral/facet joint hypertrophy throughout the cervical spine. Broad-based disc osteophyte complexes are mild at C2-3, large at C3-4, and moderate at C4-5, C5-6, and C6-7. These markedly efface the ventral thecal sac and obliterate the dorsal CSF space. There is mild left neural foraminal narrowing at C4-5 on the left, and moderate narrowing at C5-6 on the left. Anterior osteophytes impinge on the esophagus. Visualized posterior fossa demonstrates atrophy. Mastoid air cells, middle ear cavities, and maxillary sinuses are clear. Note is made of right palatine tonsillith. Retained secretions in the oropharynx. Thyroid gland is heterogeneous. Calcifications of the bilateral carotid artery bifurcations. No pathologically enlarged cervical lymph nodes. Moderate centrilobular/paraseptal emphysema and pleuroparenchymal scarring at the lung apices. Chronic left pleural thickening and effusion, better evaluated on accompanying chest CT. IMPRESSION: No fractures. Severe degenerative disease with thecal sac compression at all levels, particularly C3-4 and C4-5. CT HEAD ___ FINDINGS: No intracranial hemorrhage, edema, mass effect, or vascular territorial infarct. Ventricles and sulci are prominent, compatible with age-related involutional changes. Periventricular and subcortical white matter hypodensities reflect small vessel ischemic disease. Calcifications in the cavernous carotid and basilar arteries. No shift of the normally midline structures. Non-displaced nasal bone fractures (___), with mild overlying soft tissue swelling. There is also minimally displaced fracture of the right lamina papyracea (3:10), with overlying focus of gas. 6 mm right frontal subgaleal hematoma and mild left frontal scalp swelling. Mastoid air cells and middle ear cavities are clear. IMPRESSION: 1. Small subgaleal hematoma. No intracranial hemorrhage. 2. Non-displaced left nasal and right lamina papyracea fractures. ATTENDING NOTE: The fractures described are of undetermined age. CT CHEST ___ IMPRESSION: 1. Lingular mass with post-obstructive pneumonitis, peribronchovascular and possible lymphangitic spread. 2. Extensive left pleural and pericardial invasion, with chronic effusions. 3. Innumerable nodal, liver, and osseous metastases. 4. Right middle lobe inflammation or early infection. 5. Innumerable osseous metastases, without pathologic fracture. R SHOULDER XR ___ RIGHT SHOULDER, AP INTERNAL/EXTERNAL ROTATION, Y, AND AXILLARY VIEWS: There is an oblique linear lucency along the mid-to-distal medial humeral shaft, likely a nutrient foramen. Mildly prominent deltoid tuberosity. No dislocation. Mild glenohumeral joint space narrowing. Mild cromioclavicular joint spurring. Right elbow joint is grossly normal. The right lung apex is unremarkable. IMPRESSION: Mild degenerative changes of the right shoulder. BILATERAL HIP XR ___ There is no evidence of fracture. Moderate right and mild left degenerative changes are seen with osteophytes, sclerosis of joint surfaces, and decrease in the joint space. There are vascular calcifications. There are surgical clips in the left pelvis. MR HEAD ___ FINDINGS: The study is compared with the recent NECT dated ___, and (motion-degraded) enhanced MR examination dated ___. There is significant image distortion of the diffusion-weighted sequence, particularly at the vertex and a second acquisition is even further degraded, for unclear reasons (with no additional notation by the MR technologist). Allowing for this artifactual limitation, and comparing the two acquisitions, there is no definite focus of slow diffusion to suggest acute ischemia. The principal intracranial vascular flow voids, including those of the dural venous sinuses are preserved, and these structures enhance normally. Again demonstrated is both discrete and confluent FLAIR-hyperintensity in bihemispheric, subcortical and periventricular, as well as central pontine white matter, likely the sequelae of chronic small vessel ischemic disease. There is only mild bifrontal cortical atrophy, the midline structures are in the midline, and there is no intra- or extra-axial hemorrhage. There is no pathologic parenchymal, leptomeningeal or dural focus of enhancement. There is no space-occupying lesion, and the sella, parasellar region and remainder of the skull base, and orbits are unremarkable. The mastoid air cells and included paranasal sinuses are grossly clear. The regional bone marrow signal is overall preserved, with no suspicious osseous lesion. Incidentally noted is severe degenerative disease involving the limited included upper cervical spine with marked ventral canal narrowing at the C2-3 and C3-4 levels, and frank compression and angulation of the cervical spinal cord at the latter, as on the recent NECT of ___ this has likely progressive since the MR examination of ___. IMPRESSION: 1. The diffusion-weighted sequence is very limited, particularly at the cranial vertex, likely due to technical factors (unclear, at present); however, there is no definite large focus of slow diffusion to suggest acute ischemia. 2. No pathologic focus of enhancement or cerebral edema to suggest intracranial metastatic disease. 3. Bifrontal cortical atrophy and moderately severe sequelae of chronic small vessel ischemic disease. 4. Severe degenerative disease in the limited included upper cervical spine, with significant compression and angulation of the spinal cord at the C3-4 level. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Benzonatate 100 mg PO TID 3. Sildenafil 50 mg PO DAILY:PRN sex 4. urea *NF* 40 % Topical BID Apply to affected areas of both feet 5. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using HUM Insulin 6. Docusate Sodium 100 mg PO BID 7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain 8. OxycoDONE (Immediate Release) 5 mg PO DAILY:PRN prior to pleurx drainage 9. Polyethylene Glycol 17 g PO DAILY 10. Senna 1 TAB PO BID 11. Simvastatin 10 mg PO DAILY 12. Megestrol Acetate 80 mg PO TID 13. Mirtazapine 15 mg PO HS 14. Morphine SR (MS ___ 15 mg PO Q12H 15. Prochlorperazine 10 mg PO Q6H:PRN nausea 16. Ondansetron 4 mg PO Q8H:PRN nausea 17. Diltiazem 15 mg PO QID 18. Dextromethorphan-Guaifenesin (Sugar Free) 5 mL PO Q6H Discharge Medications: 1. urea *NF* 40 % Topical BID Apply to affected areas of both feet 2. Tiotropium Bromide 1 CAP IH DAILY 3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 4. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath 5. Morphine Sulfate (Concentrated Oral Soln) 5 mg PO Q3H pain/dsypnea/PleurX drainage RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 5 mg by mouth every 3 hours Disp ___ Milliliter Refills:*0 6. Morphine Sulfate (Concentrated Oral Soln) ___ mg PO Q2H:PRN pain, dyspnea concentration 20mg per mL please dispense 30mL RX *morphine concentrate 100 mg/5 mL (20 mg/mL) ___ mg by mouth every 2 hours Disp ___ Milliliter Refills:*0 7. Bisacodyl ___AILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Non-small cell lung cancer Malignant pleural effusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Somnolent but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report INDICATION: Unwitnessed fall on face. COMPARISON: CT head from ___ and MR brain from ___. TECHNIQUE: Contiguous non-contrast axial images were obtained through the brain. 5 mm soft tissue and 2.5 mm bone kernel images were generated in the axial plane. 2 mm coronal and sagittal multiplanar reformats were created. FINDINGS: No intracranial hemorrhage, edema, mass effect, or vascular territorial infarct. Ventricles and sulci are prominent, compatible with age-related involutional changes. Periventricular and subcortical white matter hypodensities reflect small vessel ischemic disease. Calcifications in the cavernous carotid and basilar arteries. No shift of the normally midline structures. Non-displaced nasal bone fractures (___), with mild overlying soft tissue swelling. There is also minimally displaced fracture of the right lamina papyracea (3:10), with overlying focus of gas. 6 mm right frontal subgaleal hematoma and mild left frontal scalp swelling. Mastoid air cells and middle ear cavities are clear. IMPRESSION: 1. Small subgaleal hematoma. No intracranial hemorrhage. 2. Non-displaced left nasal and right lamina papyracea fractures. ATTENDING NOTE: The fractures described are of undetermined age. Radiology Report INDICATION: Unwitnessed fall on face. No prior examinations for comparison. TECHNIQUE: Helical MDCT images were acquired through the cervical spine without intravenous contrast. 2.5-mm axial images were generated in soft tissue and bone kernels. 2-mm coronal and sagittal multiplanar reformats were created. FINDINGS: There are no fractures or malalignments. Chronic loss of height in the C3 through C6 vertebrae. Moderate loss of disc height, bridging anterior osteophytes, and mild uncovertebral/facet joint hypertrophy throughout the cervical spine. Broad-based disc osteophyte complexes are mild at C2-3, large at C3-4, and moderate at C4-5, C5-6, and C6-7. These markedly efface the ventral thecal sac and obliterate the dorsal CSF space. There is mild left neural foraminal narrowing at C4-5 on the left, and moderate narrowing at C5-6 on the left. Anterior osteophytes impinge on the esophagus. Visualized posterior fossa demonstrates atrophy. Mastoid air cells, middle ear cavities, and maxillary sinuses are clear. Note is made of right palatine tonsillith. Retained secretions in the oropharynx. Thyroid gland is heterogeneous. Calcifications of the bilateral carotid artery bifurcations. No pathologically enlarged cervical lymph nodes. Moderate centrilobular/paraseptal emphysema and pleuroparenchymal scarring at the lung apices. Chronic left pleural thickening and effusion, better evaluated on accompanying chest CT. IMPRESSION: No fractures. Severe degenerative disease with thecal sac compression at all levels, particularly C3-4 and C4-5. Radiology Report INDICATION: Smoker with metastatic non-small lung cancer, unwitnessed fall on face. COMPARISON: PET-CT from ___, CT chest from ___, CT abdomen/pelvis from ___. TECHNIQUE: Helical MDCT images were acquired through the chest following uneventful administration of 75 ml of intravenous Omnipaque. 5 mm and 25 mm axial images were generated in the soft tissue and lung kernels. 2.5 mm coronal and sagittal multiplanar reformats, as well as 8 mm maximum intensity projection axial images, were created. FINDINGS: Interval PleurX catheter placement at the left lung base, with adjacent locule of air and slight decrease in a moderate basilar pleural effusion. There is also a large loculated anterior effusion tracking superiorly into the lung apex. Circumferential nodular pleural thickening throughout the left hemithorax, including the mediastinal pleura. There is also pericardial invasion, as evidenced by obscuration of fat planes with the heart and great vessels (2:42, 31). Vaguely defined hypoenhancing lingular mass (602b:50) with abrupt bronchial occlusion (2:32). Secondary chronic lingular collapse, with convex margins and heterogeneous enhancement reflecting bronchial mucoid impaction. Volume loss in the left hemithorax, with ipsilateral mediastinal shift. Lingular pulmonary artery and branches are encased and narrowed, but no large occlusion identified on this non-angiographic study. Irregular soft tissue thickening extends along the remaining left lobar and segmental pulmonary artery and bronchi, compatible with peribronchovascular spread of tumor. Numerous areas of septal thickening indicate superimposed pulmonary edema, though scattered areas of irregularity raise the question of lymphangitic spread of tumor. Moderate, apical-predominant centrilobular and paraseptal emphysema. Faint ground-glass centrilobular opacities in the right middle lobe with a ___ distribution (___:19), suggesting early inflammation or infection. Heart is normal in size, with small pericardial effusion. Dense coronary artery and aortic arch calcifications. Central pulmonary arteries are within normal limits. Again seen are numerous enlarged intrathoracic lymph nodes measuring 8 and 11 mm in the paraaortic region, 8 mm in the aortopulmonary window, 13 mm in the superior right paratracheal region, 12 mm in the mid right paratracheal region, 20 mm in the inferior right paratracheal region, 17 mm in the inferior left paratracheal region, 11 mm in the precarinal region, 14 mm in the subcarinal region, 16 mm in the right hilus, 14 mm in the right pulmonic region, 16 mm in the left hilus, and 10 mm in the left pulmonic region. Axillary nodes are not pathologically enlarged. Examination is not tailored for subdiaphragmatic evaluation, but reveals innumerable rounded, hypoenhancing metastases throughout the liver, many with a targetoid appearance. Calcifications in the upper abdominal aorta. Diffuse permeative mixed lysis and sclerosis throughout the vertebrae, sternum, and ribs with multiple areas of irregular periostitis, corresponding to known metastases. No pathologic fractures. Thoracic vertebrae and disc spaces are preserved in height and alignment. Prominent anterior osteophytes in the lower cervical spine. IMPRESSION: 1. Lingular mass with post-obstructive pneumonitis, peribronchovascular and possible lymphangitic spread. 2. Extensive left pleural and pericardial invasion, with chronic effusions. 3. Innumerable nodal, liver, and osseous metastases. 4. Right middle lobe inflammation or early infection. 5. Innumerable osseous metastases, without pathologic fracture. Radiology Report INDICATION: Unwitnessed fall on face. COMPARISON: CT chest ___. RIGHT SHOULDER, AP INTERNAL/EXTERNAL ROTATION, Y, AND AXILLARY VIEWS: There is an oblique linear lucency along the mid-to-distal medial humeral shaft, likely a nutrient foramen. Mildly prominent deltoid tuberosity. No dislocation. Mild glenohumeral joint space narrowing. Mild acromioclavicular joint spurring. Right elbow joint is grossly normal. The right lung apex is unremarkable. IMPRESSION: Mild degenerative changes of the right shoulder. Radiology Report PELVIS, BILATERAL HIPS, FIVE IMAGES. REASON FOR EXAM: Fall and continuous pain. There is no evidence of fracture. Moderate right and mild left degenerative changes are seen with osteophytes, sclerosis of joint surfaces, and decrease in the joint space. There are vascular calcifications. There are surgical clips in the left pelvis. Radiology Report MR EXAMINATION OF BRAIN WITHOUT AND WITH CONTRAST, ___ HISTORY: ___ male with metastatic NSCLC, admitted from rehab after fall, now with right-sided weakness; evidence of stroke. TECHNIQUE: Routine ___ enhanced MR examination, including T1-weighted sagittal MP-RAGE sequence, post-gadolinium, with axial and coronal reformations. N.B. No axial T1-weighted SE sequence was obtained, post-contrast, due to MR technologist error. FINDINGS: The study is compared with the recent NECT dated ___, and (motion-degraded) enhanced MR examination dated ___. There is significant image distortion of the diffusion-weighted sequence, particularly at the vertex and a second acquisition is even further degraded, for unclear reasons (with no additional notation by the MR technologist). Allowing for this artifactual limitation, and comparing the two acquisitions, there is no definite focus of slow diffusion to suggest acute ischemia. The principal intracranial vascular flow voids, including those of the dural venous sinuses are preserved, and these structures enhance normally. Again demonstrated is both discrete and confluent FLAIR-hyperintensity in bihemispheric, subcortical and periventricular, as well as central pontine white matter, likely the sequelae of chronic small vessel ischemic disease. There is only mild bifrontal cortical atrophy, the midline structures are in the midline, and there is no intra- or extra-axial hemorrhage. There is no pathologic parenchymal, leptomeningeal or dural focus of enhancement. There is no space-occupying lesion, and the sella, parasellar region and remainder of the skull base, and orbits are unremarkable. The mastoid air cells and included paranasal sinuses are grossly clear. The regional bone marrow signal is overall preserved, with no suspicious osseous lesion. Incidentally noted is severe degenerative disease involving the limited included upper cervical spine with marked ventral canal narrowing at the C2-3 and C3-4 levels, and frank compression and angulation of the cervical spinal cord at the latter, as on the recent NECT of ___ this has likely progressive since the MR examination of ___. IMPRESSION: 1. The diffusion-weighted sequence is very limited, particularly at the cranial vertex, likely due to technical factors (unclear, at present); however, there is no definite large focus of slow diffusion to suggest acute ischemia. 2. No pathologic focus of enhancement or cerebral edema to suggest intracranial metastatic disease. 3. Bifrontal cortical atrophy and moderately severe sequelae of chronic small vessel ischemic disease. 4. Severe degenerative disease in the limited included upper cervical spine, with significant compression and angulation of the spinal cord at the C3-4 level. Radiology Report SINGLE FRONTAL VIEW OF THE CHEST REASON FOR EXAM: Patient with metastatic lung cancer with new hypoxia. Comparison is made with prior studies CT ___, chest x-ray ___. There is almost complete white out of the left hemithorax, consistent with almost complete collapse of the left lung. There is minimal aeration in the left apex. Patient has known left lung cancer and large loculated effusion. Cardiac silhouette cannot be evaluated, is obscured by the lung abnormalities. In the right, right upper lobe opacities are better seen in prior CT. There is no pneumothorax or effusion. Findings were discussed with Dr. ___ by phone on ___ at 9:54 a.m., five minutes after discovery of the finding. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: UNWITNESSED FALL Diagnosed with CONTUSION OF FACE, SCALP, & NECK EXCEPT EYE(S), NASAL BONE FX-CLOSED, CL SKUL BASE FX W/O COMA, FALL FROM BED temperature: 99.6 heartrate: 110.0 resprate: 12.0 o2sat: 97.0 sbp: 123.0 dbp: 75.0 level of pain: nan level of acuity: 2.0

___ year old male with metastatic NSCLC presenting s/p unwitnessed fall at rehab. He was recently discharged on ___ for an admission for nausea, vomiting and anion-gap metabolic acidosis. #FALL Mr. ___ fell off the side of his bed after reaching for the urinal. He recalls the entire event and denies any loss of consciousness. He was advised by nursing to call for help if he needed to use the urinal. He ignored this advice. The fall appears to be mechanical, however the patient reported right upper extremity weakness after the event. His weakness was difficult to assess initially due to pain in his right shoulder, grip strength was decreased to ___ on presentation. He sustained a minor amount of head trauma. CT scan in the ED revealed a small subgaleal hematoma, no intracranial hemorrhage and non-displaced left nasal and right lamina papyracea fractures. His most significant complaint after the fall was right shoulder pain. XR in the ED demonstrated no fracture or pathology of the ___ joint. He received IV morphine with good effect. He used a sling during the early part of his hospitalization. Pain control was provided with morphine ___ and morhpine IV PRN. After he was unable to swallow, he was placed on morphine oral concentrate 5q3h standing and ___ PRN. #RIGHT ARM WEAKNESS Mr. ___ presented with right arm weakness which was initially difficult to assess because of his right upper extremity pain after the fall. On the second day of his hospitalization his strength improved, however was clearly different from the left upper extremity. His right upper extremity strength remained at ___ and he later developed right lower extremity strength. A facial droop was noted by the pulmonary consult team, but was felt to be facial asymmetry with preserved function of all facial nerves and muscles by the medicine team. An MR head was obtain on ___ which showed no evidence of stroke and evere degenerative disease in the upper cervical spine, with significant compression and angulation of the spinal cord at the C3-4 level. This was thought to be the culprit lesion. Full C-spine MR imaging was not obtained as the patient was subsequent made CMO, therefore a compressive metastatic lesion could not be totally excluded. The patient responded well to dexamethasone 10mg IV x1 followed by 4mg IV Q6hrs. His extremity strength improved to ___. It remained unclear whether the fall and associated neck trauma precipitated further cord compression or if the weakness was present before the fall. Dexamethasone was discontinued when the patient became unable to swallow. #FACIAL FRACTURES Non-displaced left nasal and right lamina papyracea fractures. Case discussed with ENT; non-operative, antibiotics recommended. Patient was started on a 7 day course of amoxicillin, which was later discontinued with initiation of post-obstructive pneumonia treatment. #SHORTNESS OF BREATH Mr. ___ complained of shortness of breath since his discharge on ___. He was admitted on 24hr nasal cannula oxygen. He has a chronic cough which is unchanged. He denied sputum production, worsening chest pain, fevers and chills on presentation. His SOB is likely related to his primary lung cancer and large, malignant effusion on the left. The patient received a dose of levofloxacin in the ED, which was not continued on the floor. Chest CT noted focal RML ___ opacities suggestive of inflammation or early infection. He had no lower extremity swelling or other evidence of DVT. The patient developed low grade temperatures on his ___ and ___ hospital days; treatment for post-obstuctive HCAP was started with cefepime and vancomycin. His fevers resolved, however his shortness of breath did not significantly change. His PlearX catheter was drained as necessary. Output was quite poor compared to his previous admission, <250mL per 2 days. The patient was made CMO and his IV was not replaced. Cefepime and vancomycin were changed to levofloxacin, but this was discontinued when the patient became unable to swallow. He was on morphine oral concentrate as above for dyspnea as well. #METASTATIC NSCLC Patient presented with dyspnea, cough and community acquired pneumonia in ___. Imaging studies included CT chest on ___ which disclosed a consolidation of the lingula, bronchial narrowing, mediastinal lymphadenopathy, liver hypodense lesions and a large loculated left pleural effusion. A PET/CT Scan from ___ disclosed the presence of an extensive FDG-avid consolidative process in the lingula, lymphangitic carcinomatosis, non-FDG avid pleural effusion, FDG-avid lymphadenopathy involving the bilateral supraclavicular regions, mediastinum, subcarinal stations, hilar portacaval and retroperiotenal nodes. FDG-avid liver lesions and FDG-avid osseous metastases. Pleural fluid removed on ___ disclosed a carcinoma. Immunohistochemical stains of the tumor cells were positive for CK5/6, and CK7; and negative for CK20, p63, and TTF-1. This immunoprofile was nonspecific but compatible with a non-small-cell lung cancer not otherwise specified. Extensive discussions between family, patient and primary oncologist lead to the decision for no further cancer directed therapies, including palliative chemo, radiation or surgery. #AG METABOLIC ACIDOSIS Issue on previous admission, attributed to lactic acidosis from malignancy, and metformin. Metformin discontinued on previous admission. Lactate on ___ 6.6. Anion gap stable, no improvement with IVFs. #TYPE II DIABETES MELLITUS Metformin and glyburide discontinued during previous hospitalization due to reports of hypoglycemia and lactic acidosis. Insulin sliding scale continued during hospitalization in the setting of dexamethasone administration. Aspirin discontinued after CMO decision was made. #HYPERTENSION Blood pressures well controlled this admission. Diltiazem 15 mg PO/NG QID continued until CMO decision was made. #PROLAPSED HEMORRHOIDS Stable issue. Outpatient follow up suggested during prior admission. Patient ordered for an aggressive bowel regimen. TRANSITIONAL ISSUES ******************* -PleurX catheter care, drainage PRN -Continue concentrated morphine solution for dyspnea and pain, may increase to 5mg q5min as needed -Continue inhaler for shortness of breath

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ lady with hypothyroidism and h/o Afib s/p cardioversion and pacemaker a few months ago who presented to the ED due to shortness of breath and chest discomfort. . At her baseline, she has exertional dyspnea with limited exercise capacity. No wheezing but she does have a cough with whitish sputum that is worse at night. She began to feel constant dull left-sided chest discomfort on the morning of presentation so she decided to go to the ED. The pain is dull, pleuritic, nonradiating. Not related to exertion. Not at the site of her pacemaker. . In the ___ ED, initial VS were: T 97.3, HR 71, BP 106/81, RR 18, POx 100%RA. Received ASA 325mg. EKG was not concerning for ischemia and troponin was negative. CXR was unchanged from prior. CTA ruled out PE. Bedside ultrasound showed no pericardial effusion. She received 1L normal saline, IV Morphine and NTG paste; her pain was relieved. She was given IV steroids and duonebs. She was admitted to Medicine to rule out MI with imaging stress. VS prior to transfer were: T 97.1, HR 70, BP 121/63, RR 18, POx 97%RA. . Currently, she feels great. She is at her baseline SOB. Her pain is present, worsened by pressing on the left side of her chest. She states this is the pain she has been having . Past Medical History: hypothyroidism atrial tachycardia/atrial fibrillaton ___ ---s/p cardioversion ___ Tachy-Brady Syndrome ---s/p PPM ___ Dobutamine stress echo ___ with no active ischemia (B+W) plantar fasciitis hysterectomy tachycardia-induced CM (EF 49% prior to cardioversion and pacer placement). Social History: ___ Family History: Father died of MI at ___. Mother had a valve replacement, pt unsure what valve or underlying diagnosis. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: PE: VS - Temp 96 117/53 70 18 92%RA, Standing weight 191 lbs GENERAL: Well appearing in NAD HEENT: Poor dentition. MM dry NECK: Supple with no JVD. CARDIAC: PMI located in ___ intercostal space, midclavicular line. normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Palpating the area just lateral to the LLSB reproduces her dull chest pain LUNGS: Upper left chest wall with well-healed scar from PPM. No fluctuance or erythema. No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. EXTREMITIES: No c/c. b/l non-pitting pedal edema. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Radial 2+ Left: Carotid 2+ Radial 2+ Pertinent Results: ___ 12:45PM BLOOD WBC-6.6 RBC-4.09* Hgb-13.1 Hct-39.2 MCV-96 MCH-32.1* MCHC-33.5 RDW-13.0 Plt ___ ___ 12:45PM BLOOD Neuts-55.1 ___ Monos-6.8 Eos-1.9 Baso-1.0 ___ 12:45PM BLOOD Glucose-94 UreaN-20 Creat-1.2* Na-140 K-3.3 Cl-98 HCO3-28 AnGap-17 ___ 09:41AM BLOOD Glucose-197* UreaN-18 Creat-0.9 Na-138 K-3.9 Cl-102 HCO3-26 AnGap-14 ___ 12:45PM BLOOD CK-MB-1 ___ 12:45PM BLOOD cTropnT-<0.01 ___ 11:23PM BLOOD CK-MB-1 cTropnT-<0.01 ___ 12:45PM BLOOD CK(CPK)-33 ___ 11:23PM BLOOD CK(CPK)-31 ___ 12:45PM BLOOD D-Dimer-684* . EKG: A-V sequential pacing at 70 beats per minute with occasional premature ventricular contractions. Compared to the previous tracing of ___ the paced rhythm is new. . CXR: FINDINGS: There is little change in comparison to prior study from ___. The lungs remain clear with no evidence of consolidation, effusion, or pneumothorax. The cardiomediastinal silhouette remains normal. Pacemaker leads remain in place. The osseous structures remain grossly unremarkable. IMPRESSION: No acute cardiopulmonary process. . IMPRESSION: 1. No pulmonary embolus or aortic dissection detected. 2. 4-mm nodule at the right lower lobe. Per ___ guidelines, no followup is necessary if there are no high-risk factors such as smoking or history of malignancy; otherwise a 12 month follow up chest CT is advised. 3. Cardiomegaly with biatrial enlargement. Medications on Admission: Pradaxa 150 mg BID Furosemide 40 mg daily Amiodarone 200 mg daily Premarin 0.3 mg daily Levothyroxine 88 mcg daily Gabapentin 300 mg BID Discharge Medications: 1. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day: Please restart this medication on ___. 3. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. conjugated estrogens 0.3 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 7. acetaminophen 500 mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain: Do not take more than 3 grams per day. 8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Please apply to the affected area of your chest. Disp:*7 Adhesive Patch, Medicated(s)* Refills:*0* 9. Outpatient Physical Therapy Evaluate and treat, activity as tolerated Discharge Disposition: Home Discharge Diagnosis: Atypical chest pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Evaluation of patient with chest pain and shortness of breath. COMPARISON: Chest radiograph from ___. FINDINGS: Frontal and lateral chest radiographs were obtained. FINDINGS: There is little change in comparison to prior study from ___. The lungs remain clear with no evidence of consolidation, effusion, or pneumothorax. The cardiomediastinal silhouette remains normal. Pacemaker leads remain in place. The osseous structures remain grossly unremarkable. IMPRESSION: No acute cardiopulmonary process. Radiology Report INDICATION: Chest pain. No comparison studies available. TECHNIQUE: MDCT-acquired 2.5-mm axial images of the chest were obtained following the uneventful administration of 100 cc of Optiray intravenous contrast. Coronal and sagittal reformats were performed at 5-mm slice thickness. Additional right and left oblique reconstructions were performed for further evaluation of the pulmonary vessels. FINDINGS: The great vessels are patent and normal in caliber. There is no aortic dissection. No pulmonary embolus is detected to the subsegmental levels. Left and right atrial enlargement is present (4:45). Pacemaker wires terminate in the right atrium and ventricle. There is no axillary or mediastinal lymphadenopathy. A 4-mm nodule is located within the right lung base (3:49). Lungs are otherwise clear. Airways are patent to the level of segmental bronchi. No pleural or pericardial effusion is present. Included views of the liver, pancreas, kidneys, adrenal glands, spleen, and stomach are normal. OSSEOUS STRUCTURES: There is no acute fracture. No concerning blastic or lytic lesions are identified. IMPRESSION: 1. No pulmonary embolus or aortic dissection detected. 2. 4-mm nodule at the right lower lobe. Per ___ guidelines, no followup is necessary if there are no high-risk factors such as smoking or history of malignancy; otherwise a 12 month follow up chest CT is advised. 3. Cardiomegaly with biatrial enlargement. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: SOB Diagnosed with CHEST PAIN NOS, RESPIRATORY ABNORM NEC temperature: 97.3 heartrate: 71.0 resprate: 18.0 o2sat: 100.0 sbp: 106.0 dbp: 81.0 level of pain: 5 level of acuity: 2.0

Summary: Ms. ___ is a ___ lady with ___ and subsequent tachycardia induced cardiomyopathy (EF 49%) s/p PPM admitted for shortness of breath and new atypical, reproducible chest discomfort. # Atypical chest pain: Musculoskeletal. Pain is 100% reproducible. It was not directly at the pacemaker pocket, and she had nothing to suggest the pacer site is infected. No CAD history, and there were no warning signs for cardiac disease. She ruled out for MI with normal cardiac enzymes, and was prescribed tylenol and a lidocaine patch for relief. . #. Shortness of breath: unclear etiology but chronic and long-standing. She reports being at her baseline. Has previously been attributed to her tachycardia and subsequent cardiomyopathy. TTE is to be repeated next month by her cardiologist, she has excellent outpatient cardiology ___. CTA did not show any evidence for PE, and she is very dry on exam - unlikely to be CHF exacerbation. COPD is unlikley as she has no history, and she reports having spirometry done by her PCP. Dabigatran and amiodarone and lasix were continued. . # ___: Improved back to baseline without intervention. Suspected to be pre-renal in setting of lasix use and dry mucous membranes. . # Pulmonary nodules: Noted on CTA obtained by emergency room. Pt a previous smoker, and will likely need a 12 month follow up CT scan. . .# Hypothyroidism: stable -continued synthroid . #. h/o fasciitis: stable -continued outpatient gabapentin . # s/p hysterectomy: stable -continued premarin (conjugated estrogen) . ======

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Lisinopril / Codeine / ertapenem Attending: ___ Chief Complaint: Rlq ABD Pain, UTI Major Surgical or Invasive Procedure: LEFT PICC PLACEMENT ___ by ___ guidance History of Present Illness: ___ with history of COPD, CAD, HTN, DM2, ESRD s/p renal transplant in ___, disseminated aspergillosis with CNS, lung and mediastinal involvement on life long suppression therapy and recurrent UTIs presenting with persistent UTI on oral antibiotics. She was recently admitted from ___ to ___ for E. coli UTI treatment with IV cefepime. She was then diagnosed with UTI and started on PO cipro on ___. However, she has continued to have cloudy urine. She has also developed RLQ pain and right back pain. She states she has no pain now, but that she develops pain when moving around. She was experiencing burning with urination, but this resolved over last 2 days. Continues to experience increased frequency and urgency. No N/V/fevers/chills. Has had normal appetite. Of note, she has grown Enterobacter in the past with an extensive resistance pattern (see UCx ___ she has grown E. coli in the past resistant to Bactrim and Ampicillin. In the ED, initial vitals were: 97.8 92 121/45 18 97% RA - Labs were significant for: WBC 10.1, Hgb 10.5, Na 131, Cl 95, lactate 0.9. UA was grossly positive. - Renal transplant U/S showed: 1. Increased resistive indices rela tive to prior examination dated ___ which in the lower pole measure up to 0.97. Additionally new is lack of convincing diastolic flow within the intrarenal arteries of the mid and lower pole. 2. Patent main renal artery and vein. Main renal artery demonstrates normal waveform. 3. Multiple renal cysts and moderate hydronephrosis not significantly changed. No perinephric fluid collection. - The patient was given: IV CefePIME 2g Vitals prior to transfer were: 97.9 68 140/68 18 97% RA Upon arrival to the floor, patient is comfortable, denies current abdominal pain. She reports that the urine has been an issue for two months, and recently she's had worsening of the cloudy urine, pain with urination and increased urinary frequency. She denies urinary incontinence but is wearing a diaper here; she denies doing so at home (she has a LLQ colostomy bag to collect her stools). She denies f/c, n/v, cp/sob, abdominal pain, diarrhea, muscle aches, new joint pains (has chronic knee pains). She is compliant with her medications at home, as her daughters sort them out for her and she takes them day by day. Past Medical History: - ERSD ___ to DM vs HTN. - S/p renal transplant in ___. Followed by Dr. ___. - IDDM, followed at the ___. HbA1c 6.5% in ___ - Disseminated aspergillosis, in ___. Followed by Dr. ___, on voriconazole - colon cancer s/p colectomy and colostomy placement - CAD - dCHF followed by Dr. ___. - HTN - HLD - Osteoporosis, on risendronate (h/o intolerance of alendronate). - Pulmonary nodules, have been reported as stable - Right breast mass, noted as stable since ___ on mammogram in ___. Patient has declined further mammograms - H/o rectal squamous cell cancer. In ___, s/p ___ (abdominoperineal resection) with colostomy as well as ChT ___ and mitomycin-C) and XRT. Last colonscopy was in ___ and was wnl (sig for diverticulosis. - H/o hepatic fibrosis related to chronic biliary obstruction? - S/p craniostomy with evacuation of aspergilloma - Recurrent urinary tract infections. - Requires intermittent straight catheterizations due to urinary retention. Social History: ___ Family History: Sister had ovarian cancer. No other cancers or coronary artery disease known. No history of renal disease. Physical Exam: ADMISSION: Vitals: 97.6 157/56 76 16 98%RA General: Thin, elderly lady, alert, oriented, no acute distress HEENT: NCAT, EOMI, PERRLA, anicteric sclera, edentulous, clear OP 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: +RLQ tenderness, LLQ colostomy bag, otherwise benign exam GU: Wearing diaper Ext: WWP, no edema Neuro: Face symmetric, moving all four extremities on command DISCHARGE: Vitals: Tmax 98.2 BP 123/38 HR 79 RR 18 98 % RA BS: 100s-200s General: Thin woman sitting up in bed, alert, oriented, no acute distress HEENT: NCAT, EOMI, PERRLA, anicteric sclera, clear posterior OP Neck: Supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, anterior and posterior chest, no wheezes, rales, rhonchi Abdomen: soft, non distended, non tender to palpation, LLQ colostomy bag with pink ostomy, otherwise benign exam GU: Wearing diaper, no CVA tenderness Ext: WWP, no edema; RUE AV fistula with thrill, no bruit Neuro: CNII-XII intact, face symmetric, Lines: L PICC line in place without surrounding erythema, no tenderness to palpation Pertinent Results: ADMISSION: ___ 06:13PM BLOOD WBC-10.1* RBC-2.99* Hgb-10.5* Hct-31.1* MCV-104* MCH-35.1* MCHC-33.8 RDW-14.1 RDWSD-53.3* Plt ___ ___ 06:13PM BLOOD Neuts-78.1* Lymphs-10.3* Monos-10.5 Eos-0.1* Baso-0.1 Im ___ AbsNeut-7.88* AbsLymp-1.04* AbsMono-1.06* AbsEos-0.01* AbsBaso-0.01 ___ 06:13PM BLOOD Plt ___ ___ 06:13PM BLOOD Glucose-254* UreaN-14 Creat-1.0 Na-131* K-4.2 Cl-95* HCO3-25 AnGap-15 ___ 06:25PM BLOOD Lactate-0.9 DISCHARGE: ___ 05:40AM BLOOD WBC-7.6 RBC-2.86* Hgb-9.9* Hct-29.9* MCV-105* MCH-34.6* MCHC-33.1 RDW-14.2 RDWSD-53.6* Plt ___ ___ 05:40AM BLOOD Plt ___ ___ 05:40AM BLOOD Glucose-203* UreaN-14 Creat-1.0 Na-132* K-4.5 Cl-97 HCO3-26 AnGap-14 MICRO: ___ 4:23 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMIKACIN-------------- 16 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- 16 R CEFTAZIDIME----------- 16 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- =>16 R ___ BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY WARD IMAGING: CXR ___ FINDINGS: 1. The accessed vein was patent and compressible. 2. Brachialvein approach single lumen left PICC with tip in the distal SVC. IMPRESSION: Successful placement of a left 45 cm brachial approach single lumen PowerPICC with tip in the distal SVC. The line is ready to use. Radiology Report EXAMINATION: RENAL TRANSPLANT U.S. INDICATION: ___ with UTI diagnosed on ___, on cipro, persistent symptoms // eval for pyelonephritis TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images of the renal transplant were obtained. COMPARISON: Renal ultrasound dated ___. FINDINGS: The right iliac fossa transplant renal morphology is normal. Relative to prior examination dated ___, numerous cysts are again identified, the largest cyst measures 4.9 x 3.8 x 4.8 cm within the inferior pole. There is moderate hydronephrosis, not significantly changed. There is no perinephric fluid collection. Within the upper pole, intrarenal resistive indices measure 0.79 previously 0.76. Within the mid pole, resistive indices within the intrarenal arteries measure 0.86, previously 0.81. Within the lower pole, resistive index approaches 1 as no significant diastolic flow is seen, potentially technical. It had previously been 0.76. The main renal artery is patent with brisk upstroke. The main renal vein is patent. IMPRESSION: 1. Slightly increased resistive indices within the lower and mid pole renal transplant relative to prior examination, potentially technical. Short term follow up is advised. 2. Patent main renal artery and vein. Main renal artery demonstrates normal waveform. 3. Multiple renal cysts and moderate hydronephrosis not significantly changed. No perinephric fluid collection. RECOMMENDATION(S): Short-term follow-up renal ultrasound. Radiology Report INDICATION: ___ year old woman with ESRD s/p transplant with multiple UTIs presenting with resistant UTI found to have ESBL E coli. Requires 14 days of IV abx, ___ nursing team unable to thread catheter. // please place PICC for 14 day IV antibiotics. Thank you COMPARISON: None available TECHNIQUE: OPERATORS: Dr. ___, Interventional Radiology Fellow and Dr. ___, attending radiologist performed the procedure. Dr. ___ ___ personally supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings. ANESTHESIA: 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: None CONTRAST: None FLUOROSCOPY TIME AND DOSE: 0.8 min, 0 mGy PROCEDURE: 1. Single lumen PICC placement through the brachial vein on the left. PROCEDURE DETAILS: Using sterile technique and local anesthesia, the brachial vein on the left was punctured under direct ultrasound guidance using a micropuncture set. Permanent ultrasound images were obtained before and after intravenous access, which confirmed vein patency. A peel-away sheath was then placed over a guidewire. The guidewire was then advanced into the superior vena cava using fluoroscopic guidance. A single lumen PIC line measuring 45 cm in length was then placed through the peel-away sheath with its tip positioned in the distal SVC under fluoroscopic guidance. Position of the catheter was confirmed by a fluoroscopic spot film of the chest. The peel-away sheath and guidewire were then removed. The catheter was secured to the skin, flushed, and a sterile dressing applied. The patient tolerated the procedure well. There were no immediate complications. FINDINGS: 1. The accessed vein was patent and compressible. 2. Brachialvein approach single lumen left PICC with tip in the distal SVC. IMPRESSION: Successful placement of a left 45 cm brachial approach single lumen PowerPICC with tip in the distal SVC. The line is ready to use. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: RLQ abdominal pain, UTI Diagnosed with Right lower quadrant pain temperature: 97.8 heartrate: 92.0 resprate: 18.0 o2sat: 97.0 sbp: 121.0 dbp: 45.0 level of pain: 0 level of acuity: 3.0

Ms. ___ is a ___ year old woman with history of COPD, CAD, HTN, DM2, ESRD s/p renal transplant in ___, disseminated aspergillosis with CNS, lung and mediastinal involvement on life long suppression therapy and recurrent UTIs presenting with dysuria and UTI found to have ESBL Ecoli UTI. Patient was started on IV zosyn to be continued with home infusions for total ___SBL ECOLI UTI: Patient with abdominal pain, found to have ESBL Ecoli urinary tract infection resistant to ciprofloxacin. Likely secondary to straight catheterizations and unsterile technique. Given patient's allergy history (seizures with ertapenem) and ESBL Ecoli, infectious disease consulted and recommended IV zosyn, for total ___, last dose ___. LEFT PICC placed ___. Additionally ecoli sensitive to ertapenem and fosfomycin for future reference. Patient will need to resume prophylactic fosfomycin at renal transplant follow up with Dr. ___. Patient was counseled on importance of sterile straight catheterization technique. CHRONIC MEDICAL ISSUES: # Disseminated Aspergillosis involving mediastinum and brain s/p evacation of cerebral aspergilloma. -continued levetiracetam 750 mg BID. -continued voriconazole. # s/p Kidney Transplant: - Continued mycophenolate, prednisone - Continued bisphosphonate & Ca supplementation - Continued Bactrim, Valacyclovir ppx # CAD: - continued aspirin 81 mg daily - continued atorvastatin 20 mg daily. - continued metoprolol succinate 12.5 mg daily. # IDDM: - Continued home 70-30 (insulin asp prt-insulin aspart) 12U QAM - held home repaglinide - Humalog insulin sliding scale used for meal time coverage while inpatient. # Hypertension: - Continued amlodipine & losartan - Continued metoprolol succinate as noted above. # Cough/Sinusitis/Asthma: - Continued tessalon pearles - Continued Flonase & Duoneb prn, tiotropium, switch Symbicort to Advair # GERD: - Continued PPI, rantidine # Anemia: Stable and at baseline. - Continued home iron supplementation # Constipation: - Continued docusate, senna. # Eye drops: - Continued prednisone eye drops # Psych: - Continued quetiapine QHS

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ___: Laparoscopic appendectomy History of Present Illness: ___ with 1 day history of abdominal pain. Reports it began as vague and diffuse abdominal discomfort and then last evening became localized to RLQ. Denies nausea/vomiting. No anorexia. Denies fevers/chills/sweats. Does report that about 5 days ago, he had subjective fevers and diarrhea but that resolved prior to yesterday's abdominal pain. Past Medical History: ___: BEHAVIOR PROBLEMS ___ Referred to ASK in past. History of multiple suspensions in middle school for being late, fighting, not listening to rules ___: per ___ and ___ no concerns regarding behavior at school or home. No suspensions since middle school. PHQ2 score 0. Denies feeling sad for long periods of time or getting angry easily. ___ and ___ both decline ___ referral. PSH: None Social History: ___ Family History: HTN Physical Exam: Admission Physical Exam: T 98.4, HR 120, BP 133/75 GEN: NAD, AAOx3 HEENT: neck supple CV: regular rhythm, tachycardic PULM: CTAB ABD: soft, ND, tender to palpation focally in RLQ, negative Rovsing's, negative Psoas, negative Obturator BACK: no CVA tenderness EXTR: no calf swelling or tenderness Discharge Physical Exam: VS: T: 97.8, BP: 142/92, HR: 62, RR:18, O2: 99% RA CV: RRR PULM: CTA b/l ABD: laparoscopic sites c/d/I, no erythema or s/s infection. Abd soft, mildly distended and mildly tender at incision sites Extremities: warm, well-perfused. Pertinent Results: ___ 09:38PM GLUCOSE-86 UREA N-14 CREAT-0.9 SODIUM-136 POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-27 ANION GAP-14 ___ 09:38PM ALT(SGPT)-15 AST(SGOT)-16 ALK PHOS-91 TOT BILI-0.3 ___ 09:38PM LIPASE-24 ___ 09:38PM ALBUMIN-4.4 ___ 09:38PM WBC-12.3*# RBC-5.07 HGB-15.7 HCT-46.4 MCV-92 MCH-31.0 MCHC-33.8 RDW-12.7 RDWSD-41.6 ___ 09:38PM NEUTS-69.9 ___ MONOS-5.1 EOS-0.6* BASOS-0.2 IM ___ AbsNeut-8.61* AbsLymp-2.93 AbsMono-0.63 AbsEos-0.08 AbsBaso-0.03 ___ 09:38PM PLT COUNT-227 ___ 09:38PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 09:38PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 09:38PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 09:38PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE EPI-0 ___ 09:38PM URINE MUCOUS-RARE Imaging: ___: US Appendix: The appendix was not seen, but there are no fluid collections or signs of inflammation in the right lower quadrant. ___: CT Abd&Pel: 1. Dilated, hyperemic retrocecal appendix with mild surrounding fat stranding suggests acute appendicitis. No fluid collection or extraluminal air. 2. Diverticulosis of the descending colon is seen. Medications on Admission: None Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Docusate Sodium 100 mg PO BID please hold for loose stool 3. Ibuprofen 800 mg PO Q8H:PRN pain please take with food 4. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain do NOT drink alcohol or drive while taking this medication RX *oxycodone 5 mg ___ tablet(s) by mouth every three (3) hours Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Acute appendicitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: US APPENDIX INDICATION: ___ year old man with RLQ pain // Appendicitis? TECHNIQUE: Grey scale ultrasound images of the right lower quadrant were obtained. COMPARISON: None available. FINDINGS: In the right lower quadrant, in the area of the patient's pain, normal structures are seen. The appendix is not seen, but there are no echogenic areas to suggest inflammation, nor are there fluid collections identified. IMPRESSION: The appendix was not seen, but there are no fluid collections or signs of inflammation in the right lower quadrant. Radiology Report INDICATION: NO_PO contrast; History: ___ with RLQ painNO_PO contrast // Eval for 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: Acquisition sequence: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Stationary Acquisition 6.5 s, 0.5 cm; CTDIvol = 31.3 mGy (Body) DLP = 15.6 mGy-cm. 4) Spiral Acquisition 4.9 s, 53.0 cm; CTDIvol = 14.2 mGy (Body) DLP = 752.4 mGy-cm. Total DLP (Body) = 768 mGy-cm. COMPARISON: None available. FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. Diverticulosis of the descending colon is noted, without evidence of wall thickening and fat stranding. The appendix is dilated up to 11 mm, is slightly hyperemic, and there is mild surrounding fat stranding. No fluid collection or extraluminal air. 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 mesenteric lymphadenopathy. Scattered retroperitoneal lymph nodes are not pathologically enlarged. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Dilated, hyperemic retrocecal appendix with mild surrounding fat stranding suggests acute appendicitis. No fluid collection or extraluminal air. 2. Diverticulosis of the descending colon is seen. Gender: M Race: BLACK/CAPE VERDEAN Arrive by WALK IN Chief complaint: R Flank pain Diagnosed with Unspecified abdominal pain temperature: 99.4 heartrate: 120.0 resprate: 18.0 o2sat: 100.0 sbp: 133.0 dbp: 75.0 level of pain: 7 level of acuity: 3.0

Mr. ___ is an ___ year-old male who was admitted to the General Surgical Service on ___ for evaluation and treatment of abdominal pain. Admission abdominal/pelvic CT revealed acute appendicitis. The patient was admitted to the Acute Care Surgery service for further medical management. The patient underwent laparoscopic appendectomy on ___, which went well without complication (reader referred to the Operative Note for details). After a brief, uneventful stay in the PACU, the patient arrived on the floor tolerating on IV fluids, and pain medicine for pain control. The patient was hemodynamically stable. When tolerating a diet, the patient was converted to oral pain medication with continued good effect. Diet was progressively advanced as tolerated to a regular diet with good tolerability. The patient voided without problem. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. 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: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: R ankle trimalleolar fracture dislocation Major Surgical or Invasive Procedure: R ankle open reduction internal fixation History of Present Illness: ___ male with history of DM 2 presents with right ankle fracture/dislocation after being a bicyclist struck by a vehicle going 10 to 15 mph. Patient was struck in the right ankle and was thrown from the bike. Reports pain in the right ankle but denies any other joint pain. No numbness or paresthesias distally. No history of surgery on that ankle. Past Medical History: Diabetes, HTN, depression, HLD Social History: ___ Family History: NC Physical Exam: GEN: AOx3, WN, in NAD HEENT: NCAT, EOMI, anicteric CV: RRR PULM: unlabored breathing with symmetric chest rise, no respiratory distress EXT: Right lower extremity: Short leg splint in place, clean dry intact Fires ___ SILT sural, saphenous, superficial peroneal, deep peroneal and tibial distributions Dorsalis pedis pulse 2+ with distal digits warm and well perfused Pertinent Results: See OMR Medications on Admission: sertraline 125mg qhs lisinopril 20mg daily metformin 500mg BID Asa 81mg daily Simvastatin 20mg daily Trazadone 100mg qhs Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Aspirin 325 mg PO DAILY Start after discharge from rehab and take 1 tab daily until 28 days (4 weeks) after surgery RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*28 Tablet Refills:*0 3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 4. Docusate Sodium 100 mg PO BID 5. Enoxaparin Sodium 40 mg SC QHS Take this in rehab, after discharge home this can be replaced with aspirin 325mg daily RX *enoxaparin 40 mg/0.4 mL 40 mg subcutaneous once a day Disp #*14 Syringe Refills:*0 6. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Moderate Reason for PRN duplicate override: oxycodone to be discontinued RX *hydromorphone 2 mg 1 tablet(s) by mouth Every 4 hours as needed Disp #*35 Tablet Refills:*0 7. Senna 8.6 mg PO DAILY 8. Aspirin 81 mg PO DAILY Resume taking 4 weeks after surgery once your lovenox and full-dose aspirin are completed. 9. Lisinopril 20 mg PO DAILY 10. MetFORMIN (Glucophage) 500 mg PO BID 11. Sertraline 125 mg PO QHS 12. Simvastatin 20 mg PO DAILY 13. TraZODone 100 mg PO QHS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: R trimalleolar ankle fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (crutches, walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: TIB/FIB (AP AND LAT) RIGHT INDICATION: History: ___ with lateral mal fracture // Fracture TECHNIQUE: Frontal and lateral view radiographs of COMPARISON: Right ankle x-ray dated ___ at 9:48 a.m. FINDINGS: There is casting material overlying the right lower extremity obscuring the underlying structure. There is redemonstration of oblique distal fibular fracture. There is also redemonstration of acute medial malleolar/transverse fracture and posterior malleolar fracture. There is moderate overlying soft tissue swelling. IMPRESSION: Redemonstration of distal fibular and medial and posterior malleoli fracture. No fracture seen of the more proximal tibia or fibula. Radiology Report EXAMINATION: CT LOW EXT W/O C RIGHT Q61R INDICATION: ___ year old man with ankle fracture / dislocation // Please obtain CT of right ankle to further characterize ankle fracture TECHNIQUE: Axial CT images of the distal tibia fibula and ankle with sagittal coronal reformats. DOSE: Acquisition sequence: 1) Spiral Acquisition 8.7 s, 18.5 cm; CTDIvol = 14.2 mGy (Body) DLP = 262.9 mGy-cm. Total DLP (Body) = 263 mGy-cm. COMPARISON: Prior radiographs of the right tibia and fibula. FINDINGS: There is a minimally displaced vertically oriented fracture of the posterior malleolus with approximately 3 mm of posterior displacement. There is a horizontal fracture through the medial malleolus with intra-articular extension and minimal widening of the medial clear space. There is a well corticated osseous fragment inferior to the medial malleolus fracture that likely reflects an old avulsion injury involving the deltoid ligament (series 2, image 53). There is a comminuted mildly displaced fracture of the distal fibula and lateral malleolus level the. There is slight posterior displacement of the major distal fracture fragment by approximately 4 mm. There is no fracture identified in the talus and the talar dome is intact. Multiple small calcific densities anterior to the ankle in the expected location of the deltoid and anterior talofibular ligament, highly suspicious for ligamentous injury. No acute fracture or dislocation in the hindfoot or midfoot. Small well corticated osseous fragment medial to the navicular likely represents an os navicularis (series 2, image 69). Small plantar calcaneal spur. Small enthesophyte at the insertion of the Achilles tendon. The comminuted distal lateral malleolus fracture abuts the peroneus longus and brevis tendons without evidence of tendon entrapment. There is soft tissue swelling surrounding the foot and ankle. Multiple foci of gas within the anterior soft tissues suggestive of an open fracture or prior intervention. Casting material overlies the right lower extremity. Mild chronic degenerative changes with subchondral sclerosis of the subtalar joint. There is spurring of the intercuneiform joint (series 2, image 84). IMPRESSION: 1. Comminuted trimalleolar fracture of the right ankle as described. There are multiple osseous fragments at the expected location of the deltoid and anterior talofibular ligaments, highly suspicious for ligamentous injury. 2. No evidence of tendon entrapment. 3. multiple scattered foci of subcutaneous gas suggestive of an open fracture or prior intervention. Radiology Report EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT INDICATION: ___ male with trimalleolar right ankle fracture TECHNIQUE: As below. COMPARISON: Same-day right ankle radiograph and CT FINDINGS: 14 intraoperative images were acquired without a radiologist present. Images show placement of a lateral fixation plate with interlocking screws, 2 which are syndesmotic, along the lateral distal fibula as well as placement of 2 additional cannulated screws transfixing a fracture of the medial malleolus. IMPRESSION: Intraoperative images were obtained during ORIF of the right ankle. Please refer to the operative note for details of the procedure. Radiology Report EXAMINATION: WRIST(3 + VIEWS) LEFT INDICATION: ___ year old man with L wrist pain s/p trauma // R/o fx TECHNIQUE: Frontal, oblique, and lateral view radiographs of the left wrist. COMPARISON: None FINDINGS: No acute fractures or dislocation are seen. There are mild degenerative changes. Carpal bones are well aligned. Mineralization is normal. There are no erosions. IMPRESSION: No acute fractures or dislocations are seen. Mild degenerative changes involving the carpal bones. Radiology Report EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT INDICATION: History: ___ with R ankle deformity after bike accident // PORTABLE?dislocaiton/fracture PORTABLE?dislocaiton/fracture TECHNIQUE: Right ankle x-ray two views. COMPARISON: Right foot x-ray dated ___. FINDINGS: There is a medially displaced oblique fracture of the distal fibula. There is also acute intra-articular fracture involving the medial malleolus. Posterior malleolar fracture is also likely present. There is an acute anterior tibia dislocation at the tibiotalar joint. Disrupted ankle mortise. There is a 8 mm bone fragment superior to the talus. The evaluation of talar dome is limited due to overlying bone fragments. There is severe overlying soft tissue swelling. IMPRESSION: Right ankle fracture dislocation, with the distal tibia is dislocated anteriorly in relation to the talus. Trimalleolar fracture. Disrupted ankle mortise. There is significant overlying soft tissue swelling. Additional x-ray of the proximal fibula is recommended. Radiology Report EXAMINATION: ANKLE (2 VIEWS) RIGHT INDICATION: History: ___ with R ankle fx s/p reduction // eval for dislocation eval for dislocation TECHNIQUE: Right ankle two views. COMPARISON: Right ankle x-ray dated ___ at 9:05 a.m. FINDINGS: There is interval reduction of the tibiotalar dislocation. There is redemonstration of acute trimalleolar fracture involving the distal fibula and medial and posterior malleoli, with interval improvement in alignment. Oblique distal fibular fracture demonstrates mild posterior displacement on the current study. There is overlying soft tissue swelling. IMPRESSION: Interval reduction of the tibiotalar dislocation. Redemonstration of trimalleolar fracture, in improved alignment. Radiology Report EXAMINATION: Chest: Frontal and lateral views INDICATION: History: ___ with pre-op // PNA TECHNIQUE: Chest: Frontal and Lateral COMPARISON: None. FINDINGS: No focal consolidation is seen. There is no large pleural effusion. No evidence of pneumothorax is seen. Cardiac silhouette is borderline in size. Mediastinal contours are unremarkable. No pulmonary edema is seen. IMPRESSION: No acute cardiopulmonary process. Gender: M Race: HISPANIC/LATINO - PUERTO RICAN Arrive by AMBULANCE Chief complaint: Ped struck, R Ankle injury Diagnosed with Displaced trimalleolar fracture of right lower leg, init, Pedl cyc driver inj pick-up truck, pk-up/van in traf, init temperature: 97.8 heartrate: 90.0 resprate: 18.0 o2sat: 99.0 sbp: 152.0 dbp: 110.0 level of pain: 9 level of acuity: 2.0

The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a right ankle trimalleolar fracture dislocation. He was closed reduced in the emergency department and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for right ankle open reduction internal fixation, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. The ___ hospital course was otherwise unremarkable. Patient had left wrist pain and is referred and has a scheduled appointment with hand surgery on ___. He was given a prefabricated wrist splint while admitted; XR were negative for bony injury. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is nonweightbearing in the right lower extremity in a short leg splint, and will be discharged on Lovenox for DVT prophylaxis while he is in rehab, which boot will be transition to aspirin 325 mg daily for the remainder of the 4-week postoperative course when discharged home. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: glyburide / erythromycin base Attending: ___ ___ Complaint: Fever Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old lady with history of hypertension, DM2, depression, asthma, SVT, with now diagnosis of intravascular B cell lymphoma, currently receiving R-CHOP chemotherapy. She is presenting to the ED with fevers and hypotension. She was feeling moderately unwell at home with mild fevers and chills (did not take her temperature). Denies CP/SOB, N/V/abdominal pain. She does endorse dysuria which is chronic for her and no change in her medications. Per chart review, she was recently hospitalized ___ for pancytopenia when she presented with 2 months of fatigue, night sweats, fevers, lightheadedness, and weight loss of over 20 pounds. She had an essentially negative work-up including HIV, Hepatitis B and C, Multiple Myeloma, Parasitic and viral infections, as well as nutritional deficiencies. CT imaging did not show any adenopathy and EDG and colonoscopy did not show reason for anemia. She underwent bone marrow biopsy with pending results at her discharge on ___. Unfortunately, she had recurrent symptoms of fatigue, lightheadedness, fevers, cough, and chills and was readmitted on ___. For further disease assessment, it was arranged for Ms. ___ to undergo bilateral bone marrow biopsies under ___ and with sedation on ___ but, when she presented for the procedure, she was noted for SVT and was admitted. She has a known history of SVT, felt due to AVRT/AVNRT. She has been on Atenolol but had noted increasing episodes of palpitations. SVT initially broken with IV adenosine. While in the hospital, she continued to have episodes of hemodynamically stable AVNRT, broken with both carotid massage and IV metoprolol boluses. TTE showed normal cardiac function and negative pharmacologic nuclear myocardial perfusion test. She was started on Sotalol for better management of her SVT. She was given Cycle 5 of RCHOP on ___. ___ cycle of treatment was complicated by readmission with dysphagia after eating a piece of meat. An EGD was performed on ___ which revealed food impaction with some evidence of esophagitis and hypertonic LES suggesting dysmotility disorder. The obstructive piece of food was retrieved without complications. She spent a few days in the hospital as her diet was advanced. She was also noted for UTI with yeast and was treated with 3 days of Fluconazole. She underwent bilateral bone marrow biopsy with sedation in radiology on ___, ___ which showed no evidence of her lymphoma. She received her 6 cycle of R-CHOP on ___. Following her ___ cycle, Ms. ___ has been followed with noted lower counts requiring transfusion support. She has had increasing bone pain which has been an issue with her while on Neupogen. She has continued with urinary symptoms with pain with urination. She has been evaluated by Dr. ___ urology. Renal ultrasound was normal. Urine cultures have repeatedly showed yeast. She has received short course of Fluconazole. She was evaluated by Dr. ___ Infectious disease on ___. When she was seen on ___, Ms. ___ required transfusion of red cells with noted complaints of chills without fevers. Her ANC was recovering over 500. She had urine culture sent which again grew out yeast. Blood cultures x 2 are negative to date. She returned today with noted fever to 101.9. ANC now ___ with counts slowly recovering. Urine culture sent again; blood cultures sent x 2. She was given Cefepime 2 gms IV and another dose of Neupogen. Blood pressure was 122/71 when resented to clinic but SBP is now 89 to 91. With concern for infection, Ms. ___ was admitted for further evaluation. On the floor, she was no longer hypotensive and was in no acute distress Past Medical History: ONCOLOGY HISTORY: The ___ bone marrow biopsy on ___ showed a hypercellular bone marrow with trilineage hematopoiesis and rare clusters of very large basophilic cells with cytoplasmic blebs and fragmentation, of undetermined origin. Repeat bone marrow biopsy was done on ___ showed a hypercellular bone marrow with extensive sinusoidal infiltration by CD5 positive intravascular large B cell lymphoma. The large lymphoma cells were also positive for CD20, PAX5, CD5, and CD45. MIB-1 revealed a high proliferation fraction. Head MRI excluded cerebral involvement of her disease. She was started on CHOP therapy on ___ and completed her first cycle with no major complications. Her B-symptoms resolved a few days after starting her chemotherapy. She did note some abdominal pain which was felt related to known peptic ulcer disease; improved with increasing PPI dosing. CT scan showed mild splenomegaly but, otherwise, nothing concerning. She received Neupogen for support during her nadir and required transfusion support. She received Rituxan and then cycle 2 of RCHOP on ___, again supported with Neupogen and transfusion. She has needed more Magnesium replacement in the setting of her diabetes and PPI. She received Cycle 3 of treatment as an outpatient on ___. She was supported with Neupogen and her insulin requirements were increased during her steroids. She required less transfusion support but still needed magnesium replacement. She received Cycle 4 RCHOP on ___. PMH: - Intravascular lymphoma - Asthma - Type 2DM (A1C 5.8% in ___ - Esophageal Reflux - Lower back pain - Hematuria - Osteopenia - Hyperlipidemia Social History: ___ Family History: Brother has prostate cancer, otherwise no history of cancer in her family. Physical Exam: ADMISSION PHYSICAL EXAM GENERAL: Tired appearing female, no acute distress. VITAL SIGNS: 97.1 HR: 79 BP: 103/82 Resp: 18 O(2)Sat: 98 room air HEENT: Oropharynx moist, no lesions or thrush noted. NECK: Supple without adenopathy HEART: RRR, normal S1, S2. No murmurs CHEST: CTAB, no wheezing or rales noted ABDOMEN: Soft without tenderness. ND, BS+. No HSM noted. EXTREMITIES: No edema of LEs. SKIN: No rashes. NEURO: Alert and oriented x3, full affect, appropriately conversational DISCHARGE PHYSICAL EXAM VITAL SIGNS: 98.0 110/68 78 18 95% on RA GENERAL: sleeping prior to interview, AOx3, no acute distress, speaking quickly. HEENT: diffuse alopecia covered by headwrap, oropharynx moist, no lesions or thrush noted, EOMI, PERRLA NECK: Supple without adenopathy, no JVD HEART: RRR, normal S1, S2. No murmurs CHEST: CTAB, no wheezing or rales noted ABDOMEN: Soft without tenderness. ND, BS+. No HSM noted. No suprapubic tenderness. EXTREMITIES: No c/c/e, pulses 2+ symmetric SKIN: No rashes. NEURO: Alert and oriented x3, full affect, appropriately conversational Pertinent Results: ADMISSION LABS ___ 01:45PM BLOOD WBC-1.8*# RBC-2.45* Hgb-7.7* Hct-22.6* MCV-92 MCH-31.4 MCHC-34.1 RDW-13.8 RDWSD-46.6* Plt Ct-49* ___ 01:45PM BLOOD Neuts-89* Bands-0 Lymphs-4* Monos-6 Eos-0 Baso-1 ___ Myelos-0 AbsNeut-1.60 AbsLymp-0.07* AbsMono-0.11* AbsEos-0.00* AbsBaso-0.02 ___ 01:45PM BLOOD Glucose-390* UreaN-16 Creat-1.0 Na-132* K-3.7 Cl-97 HCO3-26 AnGap-13 ___ 06:30AM BLOOD ALT-10 AST-16 LD(LDH)-141 AlkPhos-248* TotBili-0.4 ___ 01:45PM BLOOD Albumin-3.2* Calcium-9.2 Mg-1.3* ___ 06:30AM BLOOD Hapto-233* DISCHARGE LABS ___ 05:04AM BLOOD WBC-2.1* RBC-3.52* Hgb-10.6* Hct-31.9* MCV-91 MCH-30.1 MCHC-33.2 RDW-14.0 RDWSD-46.8* Plt Ct-91* ___ 05:04AM BLOOD Glucose-184* UreaN-14 Creat-0.9 Na-140 K-4.0 Cl-101 HCO3-30 AnGap-13 ___ 05:04AM BLOOD Calcium-9.6 Phos-4.5 Mg-1.4* ___ 02:45PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 02:45PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG ___ 02:45PM URINE RBC-15* WBC->182* Bacteri-NONE Yeast-FEW Epi-2 ___ 09:18AM URINE HISTOPLASMA ANTIGEN-PND ___ 05:05PM URINE BK VIRUS BY PCR, URINE-PND IMAGING ___ CT Torso IMPRESSION: 1. 2-mm left lower lobe opacity is less conspicuous from the prior exam. 2. Persistent mild diffuse peribronchiolar thickening suggests chronic small airway disease. IMPRESSION: 1. Mild bladder wall thickening and fat stranding suggests cystitis. 2. Sequelae of papillary necrosis including clubbed calyx as well as cortical scarring in the left upper and mid kidney. 3. Nonspecific small amount of free fluid in the pelvis and inferior tip of the liver could be reactive. 4. Persistent mild splenomegaly up to 13 cm, unchanged. 5. Prominent endometrium and possible left adnexal cyst, more than expected for the patient's postmenopausal status in age. A nonemergent ultrasound is recommended to further evaluate. RECOMMENDATION(S): Nonemergent pelvic ultrasound to further evaluate the endometrium and adnexa. ___ CXR FINDINGS: Right-sided Port-A-Cath terminates in the cavoatrial junction without evidence of pneumothorax. No focal consolidation is seen. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are stable. IMPRESSION: No acute cardiopulmonary process. No focal consolidation to suggest pneumonia. MICROBIOLOGY ___ 2:50 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 2:50 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 2:45 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: YEAST. 10,000-100,000 ORGANISMS/ML.. ___ 9:15 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). ___ 5:05 pm URINE Source: ___. VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q12H 2. Sotalol 80 mg PO BID 3. Acetaminophen 650 mg PO Q6H:PRN pain/fever 4. Fluticasone Propionate NASAL 1 SPRY NU DAILY 5. Magnesium Oxide 140 mg PO TID 6. MetFORMIN (Glucophage) 500 mg PO TID 7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain 8. Polyethylene Glycol 17 g PO DAILY:PRN constipation 9. Promethazine 25 mg PO Q8H:PRN nausea 10. QUEtiapine Fumarate 200 mg PO QHS 11. Senna 8.6 mg PO BID 12. LOPERamide 2 mg PO QID:PRN diarrhea 13. Glargine 15 Units Bedtime 14. Fexofenadine 60 mg PO Q24H 15. Phenazopyridine 100 mg PO QHS 16. Miconazole Nitrate Vag Cream 2% 1 Appl VG BID 17. Multivitamins 1 TAB PO DAILY 18. Omeprazole 40 mg PO BID 19. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing, shortness of breath Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain/fever 2. Acyclovir 400 mg PO Q12H 3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob/wheeze 4. Fexofenadine 60 mg PO Q24H 5. Fluticasone Propionate NASAL 1 SPRY NU DAILY 6. Glargine 15 Units Bedtime 7. LOPERamide 2 mg PO QID:PRN diarrhea 8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain 9. Polyethylene Glycol 17 g PO DAILY:PRN constipation 10. QUEtiapine Fumarate 200 mg PO QHS 11. Sotalol 80 mg PO BID 12. Senna 8.6 mg PO BID 13. Omeprazole 40 mg PO BID 14. MetFORMIN (Glucophage) 500 mg PO TID 15. Miconazole Nitrate Vag Cream 2% 1 Appl VG BID 16. Multivitamins 1 TAB PO DAILY 17. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing, shortness of breath 18. Fluconazole 200 mg PO Q24H RX *fluconazole 200 mg 1 tablet(s) by mouth daily Disp #*26 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnosis: Cystitis Intravascular B-cell lymphoma Secondary diagnosis: Anemia Type II, diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: Chest: Frontal and lateral views INDICATION: ___ year old woman with neutropenic fever // eval for pneumonia TECHNIQUE: Chest: Frontal and Lateral COMPARISON: ___ FINDINGS: Right-sided Port-A-Cath terminates in the cavoatrial junction without evidence of pneumothorax.No focal consolidation is seen. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are stable. IMPRESSION: No acute cardiopulmonary process. No focal consolidation to suggest pneumonia. Radiology Report EXAMINATION: CT abdomen and pelvis INDICATION: ___ woman with primary effusion lymphoma, s/p RCHOP, p/w fevers and chronic dysuria. Evaluate for extramedullary sites of lymphoma, infection. TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9 mGy-cm. 2) Stationary Acquisition 17.6 s, 0.2 cm; CTDIvol = 300.2 mGy (Body) DLP = 60.0 mGy-cm. 3) Spiral Acquisition 6.2 s, 68.6 cm; CTDIvol = 4.1 mGy (Body) DLP = 275.5 mGy-cm. Total DLP (Body) = 337 mGy-cm. COMPARISON: CT abdomen and pelvis dated ___. FINDINGS: LOWER CHEST: Please refer to the dedicated CT chest report from the same day for description of thoracic findings. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. No evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is surgically absent with clips in the gallbladder fossa. There is a small amount of ascites at the inferior tip of the right lobe (series 5, image 63). PANCREAS: There is uniform lipomatosis of the pancreas, a normal variant. The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. No peripancreatic stranding. SPLEEN: The spleen is top-normal in size, measuring up to 13.5 mm, similar to the prior exam. The attenuation of the spleen is normal 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 nephrograms. A tiny hypodensity in the left mid pole renal cortex is unchanged and too small to characterize on CT (series 5, image 64). Mild cortical thinning in the left upper renal pole is unchanged and likely reflects scarring, sequelae of prior insult (series 5, image 59). Rounded appearance of the renal calyces in the upper and mid poles suggest sequelae of papillary necrosis (series 8, image 32). Mild prominence of the right renal pelvis without overt hydronephrosis is unchanged. No perinephric abnormality. GASTROINTESTINAL: Ingested oral contrast reaches the splenic flexure. 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. No bowel obstruction, free air, or intra-abdominal fluid collection. The terminal ileum is within normal limits. PELVIS: The the urinary bladder is relatively decompressed but there appears to be mild wall thickening and perhaps minimal fat stranding, suggesting cystitis. Fat stranding around the distal ureters bilaterally is mild. Dependent excreted intravenous contrast is seen in the urinary bladder. Bilateral ureteral jets of contrast are visualized. A small amount of simple free fluid is seen in the pelvis and nonspecific (series 8, image 24). REPRODUCTIVE ORGANS: The endometrium is thickened, measuring up to 8 mm, more than is normal for the patient's age. There is a possible left adnexal cyst verses free fluid. LYMPH NODES: No retroperitoneal or mesenteric lymphadenopathy. No pelvic or inguinal lymphadenopathy. VASCULAR: No abdominal aortic aneurysm. Mild atherosclerotic disease is noted. BONES: No evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits other than probable injection granuloma in the right lower abdominal wall (series 5, image 87). IMPRESSION: 1. Mild bladder wall thickening and fat stranding suggests cystitis. 2. Sequelae of papillary necrosis including clubbed calyx as well as cortical scarring in the left upper and mid kidney. 3. Nonspecific small amount of free fluid in the pelvis and inferior tip of the liver could be reactive. 4. Persistent mild splenomegaly up to 13 cm, unchanged. 5. Prominent endometrium and possible left adnexal cyst, more than expected for the patient's postmenopausal status in age. A nonemergent ultrasound is recommended to further evaluate. 6. Please refer to the dedicated CT chest report from the same day for description of thoracic findings. RECOMMENDATION(S): Nonemergent pelvic ultrasound to further evaluate the endometrium and adnexa. NOTIFICATION: The impression and recommendation above was entered by Dr. ___ on ___ at 21:43 into the Department of Radiology critical communications system for direct communication to the referring provider. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ woman with a history of primary effusion lymphoma, status post RCHOP,, now presenting with fevers and chronic dysuria. Evaluate for extra medullary sites of lymphoma or infection. TECHNIQUE: Multidetector helical scanning of the chest was coordinated with intravenous infusion of nonionic iodinated contrast agent reconstructed as contiguous 5- and 1.25-mm thick axial, 2.5-mm thick coronal and parasagittal, and 8 x 8 mm MIPs axial images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9 mGy-cm. 2) Stationary Acquisition 17.6 s, 0.2 cm; CTDIvol = 300.2 mGy (Body) DLP = 60.0 mGy-cm. 3) Spiral Acquisition 6.2 s, 68.6 cm; CTDIvol = 4.1 mGy (Body) DLP = 275.5 mGy-cm. Total DLP (Body) = 337 mGy-cm. ** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND PELVIS WITH CONTRAST) COMPARISON: CT Chest dated ___. FINDINGS: There is conventional 3 vessel aortic arch anatomy. The thoracic aorta is normal in caliber with minimal atherosclerotic calcifications. The main, left, and right pulmonary arteries are normal in caliber without evidence of a filling defect to suggest an incidental central pulmonary embolus on this non-dedicated exam. The heart is top-normal in size, unchanged. Coronary artery calcifications are mild, unchanged. No pericardial effusion. The right Port-A-Cath tip ends in the right atrium. No pathologically enlarged axillary, supraclavicular, mediastinal, or hilar lymph nodes. The top-normal size retrocrural lymph node on the prior exam is not clearly appreciated today. Asymmetric mild hypertrophy of the right thyroid lobe is unchanged without evidence of a discrete nodule. The airways are patent to at least the subsegmental level. Mild peribronchiolar thickening persists, suggesting chronic small airways disease. No focal consolidation, edema, effusion, or pneumothorax. Segmental atelectasis on the prior exam has resolved. A small subpleural cyst in the left lower lobe is unchanged (series 5, image 28). A small 2-mm left lower lobe pulmonary micronodule is less conspicuous from the prior exam (series 5, image 39). No suspicious pulmonary nodules are identified. No osseous lesion suspicious for infection or malignancy in the thoracic cage. Please refer to the dedicated CT abdomen and pelvis report from the same day for description of sub- diaphragm findings. IMPRESSION: 1. 2-mm left lower lobe opacity is less conspicuous from the prior exam. 2. Persistent mild diffuse peribronchiolar thickening suggests chronic small airway disease. 3. Please refer to the dedicated CT abdomen and pelvis report from the same day for description of sub- diaphragm findings. Radiology Report EXAMINATION: US, OTHER SOFT TISSUE AREA INDICATION: ___ year old woman with history of HTN, depression, DM2, asthma, SVT with now diagnosis of intravascular lymphoma s/p 6 cycles of R-CHOP who is admitted with fever and hypotension. Now having persistent pain around Port site // Please ultrasound Port site and area around it to look for possible sources of pain such as swelling, collection, retained object TECHNIQUE: Grayscale ultrasound images were obtained of the superficial tissues of the right upper chest. COMPARISON: CT chest from ___ FINDINGS: Transverse and sagittal images were obtained of the superficial tissues of the right upper chest. No retained foreign body. Small amount of soft tissue swelling is noted. No abscess or fluid collection IMPRESSION: Small amount of soft tissue swelling seen surrounding the port. No abscess or fluid collection. No foreign body. Gender: F Race: HISPANIC/LATINO - PUERTO RICAN Arrive by AMBULANCE Chief complaint: Fever, Hypotension Diagnosed with Fever, unspecified temperature: 97.1 heartrate: 79.0 resprate: 18.0 o2sat: 98.0 sbp: 103.0 dbp: 82.0 level of pain: 0 level of acuity: 3.0

Ms. ___ is a ___ year old woman with history of intravascular lymphoma who is being admitted with fever and hypotension. # Fungal cystitis: increased risk for infection given immunocompromised status and diabetes mellitus with glycosuria. CT torso showed evidence of cystitis which would fit with her clinical symptoms and prior culture. Fever workup otherwise with no localizing sources (port considered by evaluated multiple times without significant findings), negative culture data and negative CT Torso (other than previously described). No further hypotension after admission with persistent SBP >110s. Initially started on cefepime which was discontinued after ID consulted. Started on fluconazole 400mg daily, then dose adjusted to 200mg daily to complete at 4 week course Urology consulted and agreed with ID recommendations with additional recommendations to send viral studies which were pending at time of discharge. Given lack of gross hematuria (15 RBCs on U/A), there was no need for acute management of this did indeed represent hemorrhagic cystitis- they recommended outpatient follow-up with Dr. ___ cystoscopy and urodynamic testing. # Intravascular B-cell lymphoma: confirmed by bone marrow biopsy, s/p recent R-CHOP, has required transfusion support after most recent cycle. Continued on VZV prophylaxis with acyclovir. Patient evaluated by Port team for a sensation of a "needle" sensation at port site. No change of sensation with accessing vs. deaccessing. Physical exam and CT failed to show any specific abnormality. Ultrasound showed some nonspecific surrounding soft tissue swelling but no contained fluid collection or foreign body. Discussed possible removal of port but after discussion with primary oncologist this was deferred given her high risk for disease relapse and possible need for additional treatment. Patient will follow-up with Dr. ___ as an outpatient for further care. # Anemia: chronic normocytic anemia slightly patient's baseline on presentation (baseline ___ in the setting of recent chemotherapy. Hemolysis labs negative. No evidence of active bleed with the exception of microscopic hematuria. Received 1U pRBCs with good response and stable counts thereafter. # Diabetes mellitus, type II: home metformin held, titrated ISS and glargine for target blood glucose <180. Early in admission, she had labile blood sugars with occasional symptomatic episodes of hypoglycemia (50s) prompting a more conservative sliding scale with no further events. # History SVT (AVNRT): continued on sotalol and monitored QTc while on fluoconazole (and home quetiapine) with daily EKGs (460s). Transitional Issues =================== [ ] continue fluconazole 200mg daily until ___ per ID, f/u yeast speciation [ ] f/u urine infectious studies (BK, culture, histoplasma) [ ] check magnesium at next visit (discharge Mg 1.4 and received 4g IV), discontinued home magnesium oxide due to patient complaint of loose stools since starting [ ] monitor QTc with EKG while on fluconazole and sotalol, recommend avoiding additional QT-prolonging agents (discharge QTc 460s) [ ] patient discontinued on Pyridium given absence of relief and risks associated with medication after discussion with Pharmacy [ ] obtain nonemergent pelvic ultrasound to characterize findings on CT Torso

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Cipro / Quinolones / Reglan / Compazine / Percocet Attending: ___. Chief Complaint: Nausea, vomiting, abdominal pain Major Surgical or Invasive Procedure: NGT placement and d/c History of Present Illness: Ms. ___ is a ___ year old woman with a PMH of cystic fibrosis c/b chronic pancreatitis s/p pancreatectomy, islet cell transplant, J tube (removed), splenectomy, multiple episodesof E. coli bacteremia and recurrent C diff, presenting with fevers, nausea/vomiting, abdominal pain since this morning. Patient has history of multiple episodes of E coli bacteremia and was recently admitted from ___ for fevers, epigastric pain, hypotension, leukocytosis (WBC ___, and was treated with 3 days C/F resulting in resolution of her leukocytosis, and she was transitioned to PO augmentin for ___long with PO vanco, although she had negative blood cultures and unclear infectious source per ID. Two days after her discharge, beginning last evening into this morning, patient began having sharp upper abdominal pain occasionally radiating to the back, fevers at home (measuring 101), and nausea/vomiting (2 episodes of bilious emesis). She states that her abdominal pain is similar in quality to that during her prior admission, though her pain today is slightly worse. She does note a history of a small bowel obstruction several years ago which was treated non-surgically. She had a bowel movement yesterday evening (diarrhea), and notes that she has been passing flatus, though when asked if she has passed flatus since this AM she is unsure. She has been taking her medications as prescribed. Denies hematochezia, melena. Her current ED course was notable for a tachycardia responsive to fluid boluses from HR 133 to 100s, WBC of 25.1 (from 9.5 on ___, Tmax 99.3, ALT 81 (from 92), AST 166 (from 49), AP 128 (from ___, T bili <0.2, CT scan showing multiple dilated fluid and air-filled loops of small bowel with transition point in LLQ suggestive of partial SBO. ACS surgery was consulted to evaluate for SBO. ROS: Negative except as noted in HPI Past Medical History: - Gastroparesis - Hospitalized almost every month with vomiting. Has had a J tube in past. No change in frequency of admissions for this since pancreatectomy which was done in ___. - Chronic pancreatitis s/p pancreatectomy with auto-islet cell transplant ___ - Jejunostomy - Splenectomy - Thrombocytosis - Eating disorder - J-tube placement (removed ___ - Thymoma - Chronic pain - Anxiety - Depression - Urinary retention - Hypoglycemia - Hypothyroidism - Insomnia - GERD - Chronic abdominal pain - Iron deficiency anemia - DVT of RUE - Fungemia - Restless leg syndrome - Microangiopathic hemolytic anemia - Cystic Fibrosis Carrier Social History: ___ Family History: Brother - DM Mother - colon cancer, gallstone pancreatitis and hypothyroid Father - HTN Physical ___: ADMISSION PHYSICAL EXAM PE: Vitals - Tmax 99.3; Tcurrent 98.7; GEN - Tired appearing HEENT - NCAT, EOMI, sclera anicteric CV - Mildly tachycardic PULM - No signs of respiratory distress. ABD - soft, mild to moderate focal tenderness at epigastrium, mildly distended, no rebound or guarding. EXT - Warm, well-perfused NEURO - A&Ox3, no focal neurologic deficits DISCHARGE PHYSICAL EXAM Vitals: 24 HR Data (last updated ___ @ 751) Temp: 98.1 (Tm 98.7), BP: 113/75 (107-125/67-78), HR: 79 (75-91), RR: 18 (___), O2 sat: ra% (91-96) General: Thin, fatigued appearing, pale, female in no acute distress HEENT: Moist mucous membranes, PERRL, EOMI, tolerating clears. CV: Regular rate and rhythm, no murmurs. RESP: Clear to auscultation bilaterally, normal work of breathing GI: Soft, non-tender, normal bowel sounds, no hepatosplenomegaly GU: Voiding independently MSK: no joint swelling, no edema Skin: no rash; pale; warm and dry Neuro: Moving all extremities, alert, and oriented. Speech is clear. No sensory deficits. No weakness noted. Access: PIV Pertinent Results: ___ 04:07AM BLOOD WBC-25.1* RBC-3.10* Hgb-7.6* Hct-25.1* MCV-81* MCH-24.5* MCHC-30.3* RDW-18.6* RDWSD-54.4* Plt ___ ___ 11:05PM BLOOD WBC-39.1* RBC-2.86* Hgb-7.0* Hct-23.2* MCV-81* MCH-24.5* MCHC-30.2* RDW-18.7* RDWSD-55.5* Plt ___ ___ 04:25AM BLOOD WBC-35.4* RBC-2.77* Hgb-6.9* Hct-22.2* MCV-80* MCH-24.9* MCHC-31.1* RDW-18.6* RDWSD-53.6* Plt ___ ___ 06:00AM BLOOD WBC-16.8* RBC-2.81* Hgb-6.9* Hct-22.4* MCV-80* MCH-24.6* MCHC-30.8* RDW-18.9* RDWSD-54.4* Plt ___ ___ 06:15AM BLOOD WBC-12.4* RBC-3.00* Hgb-7.4* Hct-24.0* MCV-80* MCH-24.7* MCHC-30.8* RDW-18.8* RDWSD-54.5* Plt ___ ___ 05:07AM BLOOD WBC-10.0 RBC-3.07* Hgb-7.4* Hct-24.5* MCV-80* MCH-24.1* MCHC-30.2* RDW-19.1* RDWSD-55.0* Plt ___ ___ 04:07AM BLOOD Neuts-94.9* Lymphs-1.6* Monos-1.1* Eos-1.3 Baso-0.3 NRBC-0.9* Im ___ AbsNeut-23.76* AbsLymp-0.41* AbsMono-0.28 AbsEos-0.33 AbsBaso-0.08 ___ 04:07AM BLOOD ___ PTT-33.1 ___ ___ 04:07AM BLOOD Glucose-92 UreaN-6 Creat-1.0 Na-139 K-4.1 Cl-106 HCO3-17* AnGap-16 ___ 05:07AM BLOOD Glucose-107* UreaN-6 Creat-0.8 Na-138 K-3.9 Cl-106 HCO3-22 AnGap-10 ___ 04:07AM BLOOD ALT-81* AST-166* AlkPhos-128* TotBili-<0.2 ___ 05:07AM BLOOD ALT-28 AST-21 ___ 11:05PM BLOOD Calcium-8.4 Phos-2.9 Mg-1.6 ___ 11:30PM BLOOD Type-MIX pO2-56* pCO2-43 pH-7.35 calTCO2-25 Base XS--1 Comment-GREEN TOP Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H 2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 3. Buprenorphine-Naloxone Film (8mg-2mg) 1 FILM SL QID 4. Vancomycin Oral Liquid ___ mg PO BID 5. Topiramate (Topamax) 100 mg PO BID 6. Prochlorperazine 10 mg IV Q6H:PRN Nausea/Vomiting - First Line 7. Prazosin 5 mg PO QHS night terrors 8. PARoxetine 40 mg PO QHS 9. Pantoprazole 40 mg PO Q24H 10. Multivitamins W/minerals 1 TAB PO DAILY 11. Mirtazapine 15 mg PO QHS 12. Levothyroxine Sodium 100 mcg PO 1X/WEEK (___) 13. Levothyroxine Sodium 50 mcg PO 6X/WEEK (___) 14. DiphenhydrAMINE 50 mg IV Q6H:PRN allergy to compazine 15. DICYCLOMine 10 mg PO QID 16. BuPROPion (Sustained Release) 150 mg PO QAM 17. Zenpep (lipase-protease-amylase) 25,000-79,000- 105,000 unit oral TID W/MEALS pancreatic insufficiency 18. Vitamin D ___ UNIT PO 3X/WEEK (___) Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 2. Buprenorphine-Naloxone Film (8mg-2mg) 1 FILM SL QID Consider prescribing naloxone at discharge 3. BuPROPion (Sustained Release) 150 mg PO QAM 4. DICYCLOMine 10 mg PO QID 5. DiphenhydrAMINE 50 mg IV Q6H:PRN allergy to compazine 6. Levothyroxine Sodium 100 mcg PO 1X/WEEK (___) 7. Levothyroxine Sodium 50 mcg PO 6X/WEEK (___) 8. Mirtazapine 15 mg PO QHS 9. Multivitamins W/minerals 1 TAB PO DAILY 10. Pantoprazole 40 mg PO Q24H 11. PARoxetine 40 mg PO QHS 12. Prazosin 5 mg PO QHS night terrors 13. Prochlorperazine 10 mg IV Q6H:PRN Nausea/Vomiting - First Line 14. Topiramate (Topamax) 100 mg PO BID 15. Vitamin D ___ UNIT PO 3X/WEEK (___) 16. Zenpep (lipase-protease-amylase) 25,000-79,000- 105,000 unit oral TID W/MEALS pancreatic insufficiency Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis Small bowel obstruction Secondary Diagnosis c. diff colitis 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: NO_PO contrast; History: ___ with significant abdominal surgery, sepsis, re-presents with abdominal pain.NO_PO contrast// Intra-abdominal abscess? TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.3 s, 56.7 cm; CTDIvol = 15.0 mGy (Body) DLP = 849.3 mGy-cm. 2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7 mGy-cm. 3) Stationary Acquisition 14.4 s, 0.5 cm; CTDIvol = 80.5 mGy (Body) DLP = 40.3 mGy-cm. Total DLP (Body) = 891 mGy-cm. COMPARISON: CT abdomen pelvis dated ___. FINDINGS: LOWER CHEST: There is mild right basilar atelectasis. Otherwise, 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 surgically absent. Punctate foci of pneumobilia are due to hepaticojejunostomy. PANCREAS: The pancreas is surgically absent. SPLEEN: The spleen is surgically absent. Subcentimeter accessory spleens are again noted. 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 patient is status post gastrojejunostomy. There are multiple dilated fluid and air-filled loops of small bowel measuring up to 3.5 cm (601:24, 601:17) with approach tapering in the left lower quadrant (02:59), and collapse of small-bowel distally. The biliary limb is decompressed. The large bowel contains large amount of stool and appears normal in caliber. There is redemonstration of a left upper quadrant omental infarct (02:33). 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. Small-bowel obstruction with dilatation of the gastrojejunal limb and transition point in the left lower quadrant, new since exam from 5 days ago. Biliary limb is decompressed. 2. Status post pancreatectomy Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with NGTube// eval NGT placement TECHNIQUE: Upright AP view of the chest COMPARISON: Chest radiograph ___ FINDINGS: Enteric tube is looped in the stomach with tip off of the inferior borders of the film. Left-sided Port-A-Cath tip terminates at the SVC/right atrial junction. Mild cardiac silhouette size enlargement is unchanged. Mediastinal and hilar contours are similar. There is mild pulmonary vascular congestion without pulmonary edema. Patchy atelectasis is seen in the lung bases, but no focal consolidation. No pleural effusion or pneumothorax. Dextroscoliosis of the thoracic spine is re-demonstrated along with multiple clips in the right upper quadrant of the abdomen. IMPRESSION: Enteric tube is looped in the stomach with tip off of the inferior borders of the film. Mild atelectasis in the lung bases and minimal pulmonary vascular congestion. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with NGT- pulled back 15cm from prior.// assess NGT placement TECHNIQUE: Semi-upright AP view of the chest COMPARISON: None. FINDINGS: Enteric tube tip is now within the stomach. Left subclavian central venous catheter tip terminates at the cavoatrial junction. Heart size is borderline normal, unchanged. The mediastinal and hilar contours are normal. The pulmonary vasculature is now within normal limits. Mild patchy atelectasis in the lung bases. No pleural effusion or pneumothorax is seen. There are no acute osseous abnormalities. Multiple clips are seen in the right upper quadrant of the abdomen. Mild dextroscoliosis of the thoracic spine. IMPRESSION: Enteric tube tip within the stomach. Mild atelectasis in the lung bases. Radiology Report INDICATION: ___ year old woman total pancreatectomy, splenectomy, islet cell tsp, CCY, multiple episodes bacteremia/recurrent C diff, p/w n/v, abdominal pain, WBC 25, CT c/f partial SBO, given PO contrast.// ?progression of PO contrast. Please obtain ___ at 00:30 TECHNIQUE: Abdomen portable one view COMPARISON: CT abdomen ___ FINDINGS: There are no abnormally dilated loops of large or small bowel. Oral contrast is seen diffusely within large bowel and rectum. 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 small-bowel obstruction. There is contrast throughout a nondilated colon. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Fever, Nausea, Transfer Diagnosed with Fever, unspecified temperature: 99.3 heartrate: 122.0 resprate: 18.0 o2sat: 99.0 sbp: 113.0 dbp: 80.0 level of pain: 6 level of acuity: 2.0

Ms. ___ is an ___ F with PMH of cystic fibrosis c/b by chronic pancreatitis s/p pancreatectomy in ___, and islet cell transplant, jejunostomy, splenectomy, eating disorder and multiple episodes of E coli bacteremia and recurrent C diff infection, recent discharge for fever with presumed transient bacteremia from gut translocation (discharged on Augmentin), now presenting with fever, leukocytosis, and partial SBO obstruction (relieved with NPO and NGT decompression).Infectious disease was consulted to help manage her presumed chronic c.diff infection. Her WBC count continued to rise to 39.0. Her abdominal exam remained benign. ___ Transferred to medicine for continued management of possible sepsis on IV Flagyl and for advancement of diet. Clinically stabilized, Flagyl d/c'd per ID, diet advanced. Discharged on extended vancomycin taper. ACUTE ISSUES: =============== # Partial SBO: Unclear trigger although patient does have risk factors of prior abdominal surgery including pancreatectomy and jejunostomy. She was admitted to ___ for serial monitoring, resolved with NPO and NGT. KUB on ___ showed no evidence of small bowel obstruction. NGT removed, diet advanced and tolerated. Home nausea medications continued. # Leukocytosis: suspected to be secondary to SBO # Sepsis, unclear source: History of transient sepsis (during most recent admission) from gut translocation, prior E. coli bacteremia on the admission before that. Improved with antibiotics now HD stable, initially on Flagyl which was discontinued per ID recs after clinical improvement, afebrile with improving WBC. Continued on vancomycin with extended taper per below. Blood cultures pending. # Chronic diarrhea # C. diff colitis C diff toxin pending but notably patient has been on po vancomycin for over a month and continued her po vancomycin prophylactic dosing at most recent discharge, multiple stool studies sent and pending upon discharge. ID consulted and recommended d/c Flagyl given clinical improvement and extended PO vancomycin taper given incomplete resolution of her symptoms. c.diff toxin pending on d/c. Vanc taper recs per ID as follows and outpatient ID f/u in ___ weeks. 125mg po q6h x 14 days 125mg po BID x 7 days 125mg po daily x 7 days 125mg po every other day x 8 days (4 doses) 125mg po every third day x 15 days (5 doses) # Elevated LFTs: initially elevated, normalized on d/c. CHRONIC ISSUES: =============== #Chronic microcytic anemia Hb b/l ___. Hb at baseline on admission. Receives IV iron q2 weeks. Will defer transfusions unless absolutely necessary given frequent history of transfusions. No evidence of bleed while admitted. #Chronic pain: Continue suboxone 1 film QID and Continue Tylenol PRN. Patient has history of gastritis on EGD in ___, avoided NSAIDs #Chronic nausea/vomiting. Continued home IV prochlorperazine 10mg q6h prn, continued home dicyclomine 10mg PO QID #Hypothyroidism. Continued home levothyroxine 50mcg PO 6x/week, 100mcg PO 1x/wk #Nutrition #H/o eating disorder #H/o J tube Previously had J-tube placed at ___, couldn't tolerate and removed in ___, followed by TPN c/b fungemia and discontinued in ___. Difficulty maintaining adequate PO intake and had port placed in ___ for IV fluids to maintain hydration. Tolerating PO intake and diet here. #H/o splenectomy. Ensure patient has augmentin on discharge, plan to f/u with PCP to ensure up to date on appropriate vaccines #H/o pancreatectomy on creon as inpatient, restarted zenpep on discharge #Anxiety and depression -Continued home mirtazapine -Continued home paroxetine -Briefly held prazosin in setting of hypotension, restarted prior to discharge. #migraine headache - Continued home topiramate - Did not require sumatriptan PRN for migraine #GERD - Continued home pantoprazole # Health maintenance - Continued home vit D, multivitamins TRANSITIONAL ISSUES =================== [] f/u with PCP: need to f/u to ensure vaccines are up-to-date [] f/u pending blood cultures, c.diff toxin. [] f/u with ID ___ weeks NEW MEDICATIONS None CHANGED MEDICATIONS

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Gadolinium-Containing Agents Attending: ___. Chief Complaint: cough and confusion Major Surgical or Invasive Procedure: None. History of Present Illness: ___ with hx of HL, AS, DMII, mild "short term memory problems" per son who presents with cough and confusion. Per the patient he has had a nonproductive cough for about the last week, but has worsened over the last 2 days, without chest pain or difficulty breathing. Today he was noted to be confused by his son and did not know what month he was in (he typically would know this). He has had no fevers or chills. He has had no sick contacts, not recently hospitalized, and no recent travel. He has not had his flu shot yet this season. In the ED intial vitals were: 100.2 90 144/69 16 96% though T reached a max of 103. Exam showed an erythematous throat, diminished breath sounds on right, with no meningimus and no focal neurologic findings. Labs were significant for HCT 35.5, lactate 2.4, and troponin 0.01. CXR showed no acute findings. EKG demonstrated 1-2mm STD in I, II, v2-v6 and TWI in III, which is similar to prior but just more pronounced. Patient was given: 1g acetaminophen, 325mg aspirin, and 750mg levofloxacin. Vitals on transfer: 99.0 83 113/48 16 96% RA. Upon arrival to the floor, he has no complaints and is alert-oriented x3. Review of Systems: (+) per HPI (-) fever, chills, sore throat, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: Anemia - documented by PCP, though pt denies Abnormal EKG - Nonspecific ST-T wave abnormalities increasing over years likely secondary to LVH ___.. RBBB ___ Dermatitis DM II HL GERD Hx syncope B/l knee arthroscopies 1980s by history Hx Bilateral achilles tendonitis Hx L rotator cuff tear s/p surgery by Dr ___ at ___ ___ Social History: ___ Family History: Per OMR: Father died in his ___ of CVA. Paternal grandmother with DM. Mother died at ___. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION EXAM: Vitals-97.7 112/47 70 20 97 RA General- Alert, oriented, no acute distress HEENT- Sclera anicteric, MMM, oropharynx clear and not particularly erythematous. tonsils not enlarged. Neck- supple Lungs- Clear to auscultation bilaterally with minimal rhonchi at the RLL, no wheezes, rales CV- Regular rate and rhythm, with SEM at the LUSB, normal S1 + S2 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: VS: 97.9, 56, 123/56, 18, 100 on RA GENERAL: asleep, comfortable, pleasant when aroused HEENT: NC/AT, no head/neck lymphadenopathy, sclerae anicteric, no conjunctival injection or pallor; oropharynx clear without erythema or exudate; MMM LUNGS: Clear to auscultation except minor crackles at b/l bases, otherwise no w/r/r HEART: RRR; III/VI SEM ABDOMEN: NABS, soft/NT/ND. EXTREMITIES: WWP NEURO: awake, A&Ox3 Pertinent Results: ============= ADMISSION LABS: ============= ___ 06:00PM BLOOD WBC-8.1 RBC-3.97* Hgb-12.4* Hct-35.5* MCV-90 MCH-31.3 MCHC-35.0 RDW-12.8 Plt ___ ___ 06:00PM BLOOD Neuts-82.4* Lymphs-8.8* Monos-6.4 Eos-1.9 Baso-0.7 ___ 06:00PM BLOOD Glucose-120* UreaN-13 Creat-1.1 Na-139 K-3.7 Cl-102 HCO3-26 AnGap-15 ___ 06:00PM BLOOD CK(CPK)-123 ___ 06:00PM BLOOD CK-MB-2 ___ 06:00PM BLOOD cTropnT-0.01 ___ 06:00PM BLOOD Calcium-9.0 Phos-2.3* Mg-1.8 ___ 06:22PM BLOOD Lactate-2.4* ============= DISCHARGE LABS: ============= ___ 07:05AM BLOOD WBC-6.4 RBC-3.69* Hgb-11.4* Hct-33.7* MCV-92 MCH-31.0 MCHC-33.9 RDW-13.5 Plt ___ ___ 07:05AM BLOOD WBC-6.4 RBC-3.69* Hgb-11.4* Hct-33.7* MCV-92 MCH-31.0 MCHC-33.9 RDW-13.5 Plt ___ ___ 07:05AM BLOOD Glucose-88 UreaN-14 Creat-1.1 Na-139 K-4.4 Cl-103 HCO3-28 AnGap-12 ___ 07:05AM BLOOD Calcium-8.9 Phos-2.9 Mg-1.9 ============= OTHER RESULTS: ============= ___ 07:20AM BLOOD CK(CPK)-352* ___ 07:20AM BLOOD CK-MB-3 cTropnT-<0.01 ___ 08:43AM BLOOD Lactate-1.6 ___ 08:15PM URINE Blood-TR Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG ___ 08:15PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE Epi-0 ___ 1:15 am Influenza A/B by ___ Source: Nasopharyngeal swab. **FINAL REPORT ___ DIRECT INFLUENZA A ANTIGEN TEST (Final ___: Negative for Influenza A. DIRECT INFLUENZA B ANTIGEN TEST (Final ___: Negative for Influenza B. ` Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 20 mg PO DAILY 2. GlyBURIDE 7.5 mg PO DAILY Discharge Medications: 1. Atorvastatin 20 mg PO DAILY 2. Levofloxacin 750 mg PO Q48H End date ___. RX *levofloxacin 750 mg 1 tablet(s) by mouth every other day Disp #*2 Tablet Refills:*0 3. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing RX *albuterol sulfate 90 mcg ___ puffs every 4 hours Disp #*1 Inhaler Refills:*2 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Presumed community acquired pneumonia Secondary diagnosis: Diabetes mellitus, type 2 Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report CHEST RADIOGRAPH PERFORMED ON ___ ___. CLINICAL HISTORY: Cough, confusion, question pneumonia. FINDINGS: PA and lateral views of the chest were provided. Lung volumes are low, though given this, there is no definite evidence of pneumonia or CHF. There is likely bibasilar atelectasis and bronchovascular crowding. No large effusion or pneumothorax is seen. The cardiomediastinal silhouette appears normal. Imaged osseous structures are intact. Anchors are noted in the left humeral head. No free air below the right hemidiaphragm. IMPRESSION: No acute findings in the chest. Gender: M Race: WHITE - OTHER EUROPEAN Arrive by AMBULANCE Chief complaint: COUGH/WEAKNESS Diagnosed with FEVER, UNSPECIFIED, COUGH temperature: 100.2 heartrate: 90.0 resprate: 16.0 o2sat: 96.0 sbp: 144.0 dbp: 69.0 level of pain: 0 level of acuity: 3.0

___ year old gentleman with type 2 diabetes not on insulin who presents with worsening nonproductive cough and confusion found to be febrile to 103 in the emergency department. # Presumed community-acquired pneumonia: Fever and increased neutrophils on differential suggest bacterial source of symptoms. Non-productive cough and clear chest xray are more suggestive of viral URI. Influenza swab negative. Blood cultures negative. UA benign. Patient was started on levofloxacin for presumed community-acquired pneumonia. His confusion resolved and he remained afebrile. His cough remained unchanged. He was discharged the following day to complete a five-day course of antibiotics. He declined home ___ services. He will follow-up with his PCP in two days. # EKG changes: On admission, EKG demonstarted more pronounced ST segment depression in leads I, II, v2-v6 when compared with prior EKG in ___. There was unchanged right bundle branch block and t wave inversion in lead III. Patient denied any chest pain or dyspnea. He had two negative troponins, ad EKG changes resolved in the morning without intervention. # Diabetes mellitus, type 2: Patient's glyburide was held on admission. Overnight he had an episode of hypoglycemia that resolved with administration of juice. In discussion with the PCP, it was decided to discontinue the glyburide permanently. # HL: Patient continued on home statin.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fall Major Surgical or Invasive Procedure: left hemiarthroplasty History of Present Illness: ___ F w dementia who presents from ALF/HD after a witnessed mechanical fall. The patient was walking in the dining room and tripped her a dustpan, landing on her R side. This was a witnessed fall with no apparent loss of consciousness, however the patient has dementia and does not recall the event and is unable to give further history. Pt initially presented to ___ where she had a CT that showed a ___ R femoral neck fracture. She was originally to be transferred to ___, but were concered about her medical comorbidities and therefore transferred to ___. Vitals in ___ ED: 97.2 85 121/61 16 95% ra. Initial labs in the ED, chemistries, CBC were unremarkable. UA appars contaminated. Pt was given morphine for pain control in the ED and admitted to the floor for further treatment. Ortho evaluated in the ED, unable to view the CT scan from OSH so obtained plain films, fracture now appears . Ortho also recommended ceftriaxone for UTI which she received in ED. Admitted to medicine for pain control. added on for hemiarthroplasty partial hip replacement, would be able to walk after, now displaced. At baseline patient is walking on flat ground with a walker, but not noted to be limited by dyspnea or discomfort, can walk long hallways with no problem. She has not climbed stairs in awhile. On the floor, pt is repeating "oh my god" and is unable to answer questions. She thinks she is in a forest and is not aware of her name or the year. REVIEW OF SYSTEMS: (+): (-): Chest pain, shortness of breath, cough, sputum production, nausea, vomiting, diarrhea, abdominal pain, dysuria, urinary urgency, urinary frequency, hematochezia, melena, visual changes, numbness, weakness. Past Medical History: - Dementia, independent in getting dressed. AOx1 at baseline to self. usually can recognize family, but usually not able to engage in conversation - Recurrent falls - GERD - Depression - Chronic vertebral compression fractures (L2, T11) - Recurrent UTIs - rheumatic heart disease as a child - breast cancer s/p mastectomy Social History: ___ Family History: ___ Physical Exam: Admission Physical: GEN: sleeping comfortably in bed, AxOxself only. "brick building" "not sure of year" HEENT: NCAT, PERRL NECK: supple, no lymphadenopathy COR: RRR, nl s1, s2 no m/r/g PULM: ctab auscultated anteriorly ___: soft, nt, nd +bs EXT: no c/c/e, RLE shortened compared to left and ext rotated NEURO: unable to cooperate with exam, cranial nerves grossly intact. AOx1 Discharge Physical: Afebrile, normotensive GEN: calm, oriented to person HEENT: MMM, OP clear COR: RRR, nl s1, s2 no m/r/g PULM: CTAB ___: soft, nt, nd +bs EXT: bandage to R hip, staples intact, warm, dry, 2+ DP pulses NEURO: unable to cooperate with exam, cranial nerves grossly intact. AOx1 (pt's baseline oriented to self only) Pertinent Results: Admission Labs: ___ 10:20PM BLOOD ___ ___ Plt ___ ___ 10:20PM BLOOD ___ ___ ___ 10:20PM BLOOD ___ ___ ___ 07:47AM BLOOD ___ ___ 10:20PM BLOOD ___ ___ Plt ___ Hgb/Hct trend: ___ 07:47AM BLOOD ___ ___ Plt ___ ___ 06:00AM BLOOD ___ ___ Plt ___ ___ 06:05AM BLOOD ___ ___ Plt ___ ___ 06:05AM BLOOD ___ ___ Plt ___ ___ 03:35PM BLOOD ___ ___ 06:10AM BLOOD ___ ___ Plt ___ ___ 06:10AM BLOOD ___ Pertinent labs: ___ 06:05AM BLOOD ___ ___ ___ 06:05AM BLOOD ___ Discharge Labs: ___ 06:10AM BLOOD ___ ___ Plt ___ ___ 06:10AM BLOOD ___ ___ ___ 06:10AM BLOOD ___ Imaging: CXR ___: FINDINGS: There are no old films available for comparison. Right upper quadrant clips are present. The right humerus is superiorly subluxed. There is some increased opacity in the right inferior hilum that could represent a calcified node. The right paratracheal stripe is also prominent that could be due to vascular changes or adenopathy. There are increased lung markings at the right base, but no definite infiltrate. A lateral film would be helpful when the patient is able. Hip films ___: IMPRESSION: Persistent right subcapital femoral neck fracture. If further evaluation is needed, recommend comparison to the outside hospital CT. Hip film ___ done in OR: HISTORY: Hemiarthroplasty. SINGLE AP PORTABLE VIEW OF THE RIGHT HIP. The patient is status post right hip hemiarthroplasty with femoral cerclage wire, in overall anatomic alignment on this single view. Relative lucency of the greater tuberosity is noted, but is likely accentuated due to overlying postoperative air. On current film, the possibility of a nondisplaced greater tuberosity fracture cannot be excluded, but the greater tuberosity is secured at its base by the cerclage wire. Attention to this area on followup films is requested. Microdata: ___ 3:48 am URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. PROBABLE ENTEROCOCCUS. ~1000/ML STRAIN 2. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ <=0.5 S Repeat UCx ___: ___ 4:11 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: ENTEROCOCCUS SP.. ___ ORGANISMS/ML.. SENSITIVITIES PERFORMED ON CULTURE # ___ ___. Pathology femur ___: DIAGNOSIS: Femoral head, arthroplasty: Consistent with fracture Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Calcium Carbonate 500 mg PO TID RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 2. Multivitamins 1 TAB PO DAILY RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Vitamin D 800 UNIT PO DAILY RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 4. Acetaminophen 1000 mg PO Q8H RX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day Disp #*84 Tablet Refills:*0 5. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 6. Polyethylene Glycol 17 g PO DAILY HOLD if loose stools RX *polyethylene glycol 3350 17 gram 17 gm by mouth daily Disp #*30 Packet Refills:*0 7. Senna 2 TAB PO HS constipation HOLD if loose stools RX *sennosides [senna] 8.6 mg 2 tablets by mouth at bedtime Disp #*60 Tablet Refills:*0 8. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain HOLD for sedation, RR<10 RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every six (6) hours Disp #*56 Tablet Refills:*0 9. Enoxaparin Sodium 40 mg SC DAILY continue for at least 2 weeks until you see orthopedics in ___ RX *enoxaparin 40 mg/0.4 mL 40mg subcutaneously daily Disp #*20 Syringe Refills:*0 10. Quetiapine Fumarate 6.25 mg PO HS HOLD for sedation please give at 1800 RX *quetiapine 25 mg 0.25 tablet(s) by mouth at bedtime Disp #*10 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Hip fracture s/p hemiarthroplasty Urinary tract infection, uncomplicated Delirium Anemia Secondary: Dementia 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 STUDY: AP pelvis and two views of the right hip ___. Note, images were provided for review on ___. COMPARISON: None available for review. INDICATION: Right hip pain status post mechanical fall. Outside hospital CT demonstrated non-displaced femoral neck fracture. FINDINGS: Non-obstructed bowel gas pattern which obscures the bony detail of the sacrum. Mild degenerative changes of the SI joints. Unremarkable pubic symphysis. Incompletely evaluated severe degenerative changes of the lower lumbar spine. The single AP view of the left hip is unremarkable. The right hip is unremarkable. Again seen is a subtle linear lucency through the subcapital region of the femoral neck, consistent with the known fracture. No new fracture. No dislocation. IMPRESSION: Persistent right subcapital femoral neck fracture. If further evaluation is needed, recommend comparison to the outside hospital CT. Radiology Report CHEST ON ___ HISTORY: Hip fracture pre-op. FINDINGS: There are no old films available for comparison. Right upper quadrant clips are present. The right humerus is superiorly subluxed. There is some increased opacity in the right inferior hilum that could represent a calcified node. The right paratracheal stripe is also prominent that could be due to vascular changes or adenopathy. There are increased lung markings at the right base, but no definite infiltrate. A lateral film would be helpful when the patient is able. Radiology Report HISTORY: Hemiarthroplasty. SINGLE AP PORTABLE VIEW OF THE RIGHT HIP. The patient is status post right hip hemiarthroplasty with femoral cerclage wire, in overall anatomic alignment on this single view. Relative lucency of the greater tuberosity is noted, but is likely accentuated due to overlying postoperative air. On current film, the possibility of a nondisplaced greater tuberosity fracture cannot be excluded, but the greater tuberosity is secured at its base by the cerclage wire. Attention to this area on followup films is requested. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: HIP FX Diagnosed with FX NECK OF FEMUR NOS-CL, FALL FROM OTHER SLIPPING,TRIPPING,STUMBLING, DEMENTIA, UNSPECIFIED, WITHOUT BEHAVIORAL DISTURBANCE temperature: 97.2 heartrate: 85.0 resprate: 16.0 o2sat: 95.0 sbp: 121.0 dbp: 61.0 level of pain: 13 level of acuity: 3.0

Brief Course: Ms. ___ is a ___ F with dementia presents from NH after a witnessed fall that resulted in a ___ R femoral head fracture, s/p left hemiarthroplasty. Her course was complicated by enterococcal UTI and delirium. She was discharged back to her assisted living with ___ and ___ services.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Penicillins / skale fish Attending: ___. Chief Complaint: Incarcerated incisional hernia w/ small bowel obstruction Major Surgical or Invasive Procedure: ___: Exploratory laparotomy, extensive lysis of adhesions taking over 90 minutes Incisional hernia repair with component separation and mesh placement. Anterior Gastric nodule resection History of Present Illness: ___ M w/ hx of bilateral TKA, complicated diverticulitis (s/p sigmoid colectomy w/ diverting colostomy, s/p reversal ___, ___), c/b large ventral incisional hernia, who presents to ___ with nausea, vomiting, watery diarrhea, and poor PO intake. The patient states that he ate a large meal last ___ and later that evening experienced his first episode of emesis. The patient continued to experience symptoms throughout the week and noted multiple episodes of watery diarrhea and found himself incontinent at night. The patient denies any episodes of obstipation of distention during this time. The patient denies any prior similar episodes or any significant abdominal pain associated with his current presentation. He denies any fevers, chills, or recent sick contacts. On ___, the patient underwent CT scan at the recommendation of a close friend ___ gastroenterologist)and was found to have imaging concerning for partial SBO. Past Medical History: PMH: TIA (___) no residual neurologic deficits, diverticulitis, BPH PSH: diveriticulitis s/p ___ and reversal (___), osteoarthritis s/p bilateral total knee replacements Social History: ___ Family History: Family hx: noncontributory Physical Exam: P/E: Vital Signs GEN: WD, WN in NAD HEENT: NCAT, EOMI, anicteric CV: RRR, PULM: no respiratory distress BACK: no vertebral tenderness, no CVAT ABD: soft, appropriate incisional tenderness, nondistended EXT: WWP, no CCE, no tenderness, 2+ B/L ___ NEURO: A&Ox3, no focal neurologic deficits Pertinent Results: ___ 03:30PM ___ PTT-26.0 ___ ___ 03:06PM LACTATE-1.4 ___ 02:55PM GLUCOSE-88 UREA N-15 CREAT-0.9 SODIUM-134 POTASSIUM-4.5 CHLORIDE-95* TOTAL CO2-24 ANION GAP-20 ___ 02:55PM estGFR-Using this ___ 02:55PM ALT(SGPT)-20 AST(SGOT)-39 ALK PHOS-69 TOT BILI-0.6 ___ 02:55PM LIPASE-19 ___ 02:55PM ALBUMIN-3.8 ___ 02:55PM WBC-7.5 RBC-4.65 HGB-13.6* HCT-42.0 MCV-90 MCH-29.2 MCHC-32.4 RDW-13.0 RDWSD-43.1 ___ 02:55PM NEUTS-63.2 LYMPHS-18.8* MONOS-15.6* EOS-1.6 BASOS-0.4 IM ___ AbsNeut-4.74 AbsLymp-1.41 AbsMono-1.17* AbsEos-0.12 AbsBaso-0.03 ___ 02:55PM PLT COUNT-251 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Terazosin 4 mg PO QHS 3. Pravastatin 40 mg PO QPM Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills:*0 3. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule(s) by mouth Daily Disp #*30 Capsule Refills:*0 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) to six (6) hours Disp #*50 Tablet Refills:*0 5. Aspirin 81 mg PO DAILY 6. Pravastatin 40 mg PO QPM 7. Terazosin 4 mg PO QHS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Incarcerated incisional hernia with obstruction. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM INDICATION: ___ year old man intubated // ETT and NGT positioning ETT and NGT positioning IMPRESSION: COMPARED TO CHEST RADIOGRAPHS ___. ET tube in standard placement. Nasogastric drainage tube passes below the diaphragm and out of view. Borderline cardiomegaly unchanged. Borderline vascular engorgement is chronic, exaggerated by even low lung volumes, but I see no pulmonary edema. Pleural effusion is mild if any. Opacification in the left lower lobe is most likely atelectasis. An apparent left upper lobe lung nodule on one view clears on the second view, when an overlying device most laterally indicating that it is instead an external artifact. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: N/V Diagnosed with Unspecified intestinal obstruction temperature: 97.4 heartrate: 89.0 resprate: 18.0 o2sat: 98.0 sbp: 177.0 dbp: 84.0 level of pain: 0 level of acuity: 2.0

The patient presented on ___ for a symptoms of a small bowel obstruction secondary to an incisional hernia. Thereafter, he was admitted to the ___ surgery service for bowel rest, resuscitation, and optimization. The patient underwent exploratory laparotomy, lysis of adhesions, ventral hernia repair with mesh, component separation, and gastric mass biopsy on ___. Please see the full operative report for further details. Thereafter, the patient was mildly hypotensive postoperative and was left intubated and would be admitted to the SICU for close clinical monitoring of his hemodynamics and extubation. The patient was extubated uneventfully on ___. The patient would transfer to the floor on ___. #NEURO: The patient was alert and oriented throughout hospitalization; pain was initially managed with PCA at low-dose setting. Once the patient had return of bowel function he was transitioned to an oral pain regimen. #CV: The patient was initially hypotensive after his operation and was taken to the SICU for close clinical monitoring. His pressures improved with IVF resuscitation postoperatively. The patient was noted to have ST depression on telemetry during his SICU admission, but remained asymptomatic and hemodynamically stable. The remainder of the ___ hospital course was uneventful. #PULMONARY: The patient remained stable from a pulmonary standpoint after his extubation on ___ vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. #GI/GU/FEN: The patient had a foley placed intra-operatively for close urine output monitoring. During his SICU course he received IVF boluses for marginal UOP and responded appropriately. The patient's foley catheter was removed on ___ and he would void without issue. The patient had an NGT placed intraoperatively given his significant abdominal operation. The NGT was clamped on ___ once the patient had flatus. The patient would tolerate a clear liquid diet on ___. The patient was tolerating a regular diet prior to discharge. #ID: The patient's fever curves were closely watched for signs of infection, of which there were none. #HEME: Patient received BID SQH for DVT prophylaxis, in addition to encouraging early ambulation and Venodyne compression devices. At the time of discharge, the patient's pain was well controlled on oral pain medications, his mental status was at his baseline, he was tolerating a regular diet and having bowel function.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: UROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: malaise, hematuria Major Surgical or Invasive Procedure: cystoscopy and transurethral resection of bladder tumor History of Present Illness: Mr. ___ was admitted to the urology service with malaise one day prior to his scheduled cystoscopy/TURBT. He was started on fluids and antibiotics and prepped for his scheduled procedure in the OR. Past Medical History: Problem list: 1. gross hematuria 2. ___, CT a/p and cystoscopy --> right ureteral lesion 3. ___, TURBT Dr ___: HG, TCC Ta, attempted retrograde, right sided-obstruction. 4. CT a/p from ___ showed a 4 cm right distal ureteral lesion suspicious for malignancy. 5. ___, TURBT showed papillary urothelial, Ta (muscle present) 6. In ED 3x post surgery, last on ___, for obstructed catheter. 7. ___, TURBT large-sized bladder tumors. Right robotic nephroureterectomy, instillation of Gemcytobine intravesical chemotherapy. 8. Pathology: Bladder - high grade Papillary TCC, Ta (muscle present). Right ureter - High grade, invasive papillary urothelial carcinoma, T3, node and margin negative. ABDOMINAL AORTIC ANEURYSM CORONARY ARTERY DISEASE DIABETES TYPE II DIABETIC NEPHROPATHY GASTRITIS HYPERLIPIDEMIA HYPERTENSION OBESITY OSTEOARTHRITIS SKIN CANCERS COLONIC POLYPS DIABETIC RETINOPATHY CHRONIC OBSTRUCTIVE PULMONARY DISEASE No history of MI, stroke, cardiac stents, DVT, or PE. He is not on any long term anticoagulation. He had a negative stress test in ___. APPENDECTOMY ___ CYSTOSCOPY TRANSURETHRAL RESECTION BLADDER TUMOR WITH BIPOLAR, LEFT URETERAL STENT PLACEMENT. ___ ___ CYSTOSCOPY TURBT; LAPAROSCOPIC ROBOTIC RIGHT NEPHROURETERECTOMY ___ ___ CYSTOSCOPY TRANSURETHRAL RESECTION OF A BLADDER TUMOR WITH BIPOLAR ___ ___ CYSTOSCOPY, CLOT EVACUATION, resection bladder tumor ~ 3cm and 2.5 cm. Bilateral retrogrades ___ ___ ENDOVASCULAR ABDOMINAL AORTIC ANEURYSM REPAIR Social History: Country of Origin: ___ Marital status: Married Children: Yes: 4 Lives with: ___ Lives in: House Work: ___ Tobacco use: Former smoker Year Quit: ___ Years Since ___ Quit: Pack Years: 60 Alcohol use: Present drinks per week: 12 Alcohol use beer comments: Depression: Based on a PHQ-2 evaluation, the patient does not report symptoms of depression Exercise: None Seat belt/vehicle Always restraint use: Family History: Mother ___ CANCER unsure what ___ cancer Father ___ MYOCARDIAL INFARCTION Other Deceased DIABETES MELLITUS diabetis paternanal grandfather Physical Exam: Gen: resting in bed Resp: conversing easily Abd: soft nontender GU: foley in place draining pyridium orange colored urine, no clots Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Bacitracin Ointment 1 Appl TP QID 3. Docusate Sodium 100 mg PO BID 4. Senna 17.2 mg PO QHS 5. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath 6. CARVedilol 25 mg PO BID 7. Furosemide 40 mg PO DAILY 8. Losartan Potassium 100 mg PO DAILY 9. MetFORMIN (Glucophage) 850 mg PO TID 10. Omeprazole 20 mg PO BID 11. Tiotropium Bromide 1 CAP IH DAILY 12. Atorvastatin 40 mg PO QPM 13. walker 1 ROLLING WALKER miscellaneous DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath 3. Atorvastatin 40 mg PO QPM 4. Bacitracin Ointment 1 Appl TP QID 5. CARVedilol 25 mg PO BID 6. Docusate Sodium 100 mg PO BID 7. Furosemide 40 mg PO DAILY 8. Losartan Potassium 100 mg PO DAILY 9. MetFORMIN (Glucophage) 850 mg PO TID 10. Omeprazole 20 mg PO BID 11. Senna 17.2 mg PO QHS 12. Tiotropium Bromide 1 CAP IH DAILY 13. walker 1 ROLLING WALKER miscellaneous DAILY Discharge Disposition: Home Discharge Diagnosis: bladder tumor 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 DoE. Eval acute process TECHNIQUE: Chest PA and lateral COMPARISON: Radiograph dated ___ FINDINGS: Lungs are fully expanded. Previously seen hazy opacity at the left lung base has resolved. No evidence for pneumothorax. No pleural effusion. No consolidation to suggest pneumonia. IMPRESSION: No acute intrathoracic abnormality. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Hematuria Diagnosed with Hematuria, unspecified, Anemia, unspecified temperature: 98.0 heartrate: 74.0 resprate: 14.0 o2sat: 99.0 sbp: 111.0 dbp: 42.0 level of pain: 0 level of acuity: 3.0

Mr. ___ was admitted to the urology service the day prior to his scheduled cystoscopy/TURBT. He was started on fluids and antibiotics. He was then taken to the OR for his TURBT; please see the operative note for further details. He recovered well from the procedure and had no further hematuria. He did have some bladder spasms overnight but otherwise recovered well. He was discharged home with foley in place and will return to clinic for a void trial in a week.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: lactose Attending: ___. Chief Complaint: Fevers, Myalgias and Malaise Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old female with no significant past medical history is coming in with ___ days of fevers and myalgias. Patient said she had recently returned from a trip to ___ where she travelled to ___, ___ and ___. She returned ___ days prior to admission. 5 days prior to admission she developed fatigue, but thought it was jet lag. ___ days prior to admission, she developed fevers to 102, chills, sweats, and agonizing back and hip pain that she described as feeling like she was in a "vice grip". She also reported headache at the time. ___ days prior to admission she also had elbow and hand pain as well. She went to the ED 2 days prior to admission and infectious work up was negative including smear for malaria and there was plan for follow up in ___ clinic. She went home and the day prior woke up feeling a little improved, but then later that day, her symptoms came on with full force and so she called her stepfather who brought her back to the ED. Of note, prior to her travel she received a typhoid vaccine in ___. She was immune to measles, mumps, rubella. While in ___, she did not take malaria prophylaxis. She used tap water to brush her teeth, but did not drink large amounts of it. She also swam in the ocean and she felt it was very dirty (she said she saw someone cleaning his behind near where she was swimming) and she swallowed a lot of the water. She was also on a pig farm and walked around barefoot. She had a few mosquito bites while she was in ___. She has 2 cats at home. She has not travelled anywhere else except maybe ___. She denies any tick bites. She has not had any rashes during this acute illness or in the recent past. No IV drug use. No recent incarcerations, not sexually active for over a year and last HIV test prior to that was negative. No recent sick contacts that she is aware of. Works in an office. On review of systems was positive as per HPI. In addition had one episode of loose stools 2 days prior to admission as well as some mild nausea. She denies vomiting, urinary sx, edema, hematochezia, photophobia, visual changes, rash or bruising. In the ED, initial vitals: 103 89 117/62 18 100%. No physical exam findings for meningitis. CXR negative. Initial labs concerning for WBC 1.5 (N:73.5 L:20.8 M:4.8 E:0.2 Bas:0.7), ANC 1100. plt 104-->77, ALT 29-->60, AST 75-->114, LDH 366-->314. Rpt U/A negative, Rpt smear negative, Blood cultures pending. According to the ED note, they spoke with ___ (no note from ID and could not find ___ in pager system) from Infectious disease. Patient's symptoms are suspicious for Salmonella infection and recommended 3g ceftriaxone one time dose. Given patient's neutropenia from repeat CBC and high fevers she will be admitted to the medicine service. Other medications given were: zofran for nausea, toradol for fever and myalgia. Vitals prior to transfer were: 98.3 73 ___ 100%. 10 point ros is otherwise negative, except per above Past Medical History: Anxiety Social History: ___ Family History: Mother past away from Multiple Myeloma in her ___. denies family history of HTN, DM, HLD, CAD Physical Exam: Admission Exam: VS - Temp 98.7F, BP: 115/85 , HR: 53, RR: 18, O2-sat 99% RA GENERAL - NAD, comfortable, appropriate HEENT - EOMI, sclerae anicteric, MMM, OP clear, no lesions NECK - supple, no thyromegaly, no JVD HEART - PMI non-displaced, RRR, nl S1-S2, no MRG LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) LYMPH Node: No axillary, cervical, supra/infraclavicular adenopathy, shotty inguinal adenopathy on the right. SKIN - no rashes or lesions NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait . Discharge Exam: Afebrile GENERAL - NAD, comfortable, appropriate HEENT - EOMI, sclerae anicteric, MMM, OP clear, no lesions NECK - supple, no thyromegaly, no JVD HEART - PMI non-displaced, RRR, nl S1-S2, no MRG LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) LYMPH Node: No axillary, cervical, supra/infraclavicular adenopathy, shotty inguinal adenopathy on the right. SKIN - no rashes or lesions NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait Pertinent Results: CBC: ___ 02:40PM BLOOD WBC-1.5*# RBC-4.48 Hgb-14.3 Hct-40.5 MCV-90 MCH-31.9 MCHC-35.3* RDW-13.1 Plt ___ ___ 04:20AM BLOOD WBC-3.6* RBC-4.15* Hgb-13.1 Hct-37.6 MCV-91 MCH-31.6 MCHC-34.9 RDW-12.8 Plt ___ ___ 04:35AM BLOOD WBC-4.9 RBC-3.93* Hgb-12.3 Hct-35.8* MCV-91 MCH-31.2 MCHC-34.3 RDW-12.9 Plt ___ DIFF: ___ 02:40PM BLOOD Neuts-73.5* ___ Monos-4.8 Eos-0.2 Baso-0.7 ___ 04:35AM BLOOD Neuts-32* Bands-0 Lymphs-50* Monos-15* Eos-0 Baso-0 ___ Myelos-0 Plasma-3* BMP: ___ 02:40PM BLOOD Glucose-93 UreaN-5* Creat-0.8 Na-136 K-3.5 Cl-99 HCO3-24 AnGap-17 ___ 04:35AM BLOOD Glucose-83 UreaN-7 Creat-0.7 Na-142 K-4.2 Cl-107 HCO3-29 AnGap-10 LFT: ___ 02:40PM BLOOD ALT-29 AST-75* LD(LDH)-366* AlkPhos-55 TotBili-0.3 ___ 04:15AM BLOOD ALT-87* AST-84* AlkPhos-47 TotBili-0.4 ELECTROLYTES: ___ 04:20AM BLOOD Calcium-8.9 Phos-2.9 Mg-2.0 ___ 04:35AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.2 MISC: ___ 04:15AM BLOOD HAV Ab-POSITIVE ___ 09:40AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE ___ 04:20AM BLOOD HIV Ab-NEGATIVE ___ 09:40AM BLOOD HCV Ab-NEGATIVE MICRO: CHIKUNGUNYA IGG SCREEN NEGATIVE CHIKUNGUNYA IGM SCREEN NEGATIVE LEPTOSPIRA AB SCREEN NEGATIVE W/REFLEX TO TITER Test Result Reference Range/Units A. PHAGOCYTOPHILUM IGG <1:64 <1:64 A. PHAGOCYTOPHILUM IGM <1:20 <1:20 ___ VIRUS VCA-IgG AB (Final ___: POSITIVE BY EIA. ___ VIRUS EBNA IgG AB (Final ___: POSITIVE BY EIA. ___ VIRUS VCA-IgM AB (Final ___: NEGATIVE <1:10 BY IFA. INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION. In most populations, 90% of adults have been infected at sometime with EBV and will have measurable VCA IgG and EBNA antibodies. Antibodies to EBNA develop ___ weeks after primary infection and remain present for life. Presence of VCA IgM antibodies indicates recent primary infection. ___ 8:15 pm SEROLOGY/BLOOD **FINAL REPORT ___ LYME SEROLOGY (Final ___: NO ANTIBODY TO B. BURG___ DETECTED BY EIA. Reference Range: No antibody detected. Negative results do not rule out B. burg___ infection. Patients in early stages of infection or on antibiotic therapy may not produce detectable levels of antibody. Patients with clinical history and/or symptoms suggestive of lyme disease should be retested in ___ weeks. ___ 5:36 pm Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. **FINAL REPORT ___ Respiratory Viral Culture (Final ___: No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at ___ within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final ___: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture for further information. ___ 5:32 am STOOL CONSISTENCY: FORMED Source: Stool. **FINAL REPORT ___ FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. . FEW POLYMORPHONUCLEAR LEUKOCYTES. ___ 4:20 am IMMUNOLOGY **FINAL REPORT ___ HIV-1 Viral Load/Ultrasensitive (Final ___: HIV-1 RNA is not detected. ___ 4:15 am Immunology (CMV) **FINAL REPORT ___ CMV Viral Load (Final ___: CMV DNA not detected. Time Taken Not Noted Log-In Date/Time: ___ 9:38 am Blood (CMV AB) CHEM # ___ ___. **FINAL REPORT ___ CMV IgG ANTIBODY (Final ___: POSITIVE FOR CMV IgG ANTIBODY BY EIA. 37 AU/ML. Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml. CMV IgM ANTIBODY (Final ___: NEGATIVE FOR CMV IgM ANTIBODY BY EIA. INTERPRETATION: INFECTION AT UNDETERMINED TIME. IMAGING: ___ CXR: FINDINGS: PA and lateral views of the chest. No prior. The lungs are clear. Cardiomediastinal silhouette is within normal limits. Osseous and soft tissue structures are unremarkable. IMPRESSION: No acute cardiopulmonary process. ___ RUQ U/S: FINDINGS: The liver does not show any focal lesions or structural abnormality. There is no intrahepatic or extrahepatic biliary dilatation. The gallbladder appears normal with no wall thickening and no stones. The pancreas appears unremarkable with no focal lesions or ductal dilatation. Common bile duct measures 0.54 cm and the main portal vein is patent with hepatopetal flow. The right kidney measures 10.7 cm and the left kidney measures 10.3 cm. There is no hydronephrosis. The spleen is 10.9 cm and has homogeneous echotexture. The visualized portions of the aorta and inferior vena cava are unremarkable. . ___ 04:20 DENGUE FEVER ANTIBODIES (IGG, IGM) Test Name In Range Out of Range Reference Range --------- -------- ------------ --------------- Dengue Fever Antibodies (IgG, IgM) Dengue Fever IgG 3.13 H <0.90 Dengue Fever IgM 4.90 H <0.90 Interpretation: These assays detect both IgG and IgM class antibodies against all four Dengue fever virus types. Except for very early IgM responses, the immune response to Dengue fever is not type specific. Therefore, type specific reactions are not reported. As with most serological assays, paired testing of acute and convalescent samples is preferred. This is especially important when the acute phase sample is taken within the first six days following onset. In most patients, Dengue antibodies are detectable after the sixth day following the onset of symptoms. Crossreactivity with other flaviviruses is known to occur. The extent and degree of crossreaction varies. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Propranolol LA 60 mg PO DAILY 2. Lorazepam 0.5 mg PO Q4H:PRN anxiety 3. EpiPen *NF* (EPINEPHrine) 0.3 mg/0.3 mL Injection PRN Anaphylaxis Discharge Medications: 1. Lorazepam 0.5 mg PO Q4H:PRN anxiety 2. EpiPen *NF* (EPINEPHrine) 0.3 mg/0.3 mL Injection PRN Anaphylaxis 3. Propranolol LA 60 mg PO DAILY 4. Meclizine 12.5 mg PO TID RX *meclizine [Antivert] 12.5 mg 1 tablet(s) by mouth three times a day Disp #*60 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Viral Illness, likely dengue fever Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report CHEST, TWO VIEWS: ___ HISTORY: ___ female with fever to 103. FINDINGS: PA and lateral views of the chest. No prior. The lungs are clear. Cardiomediastinal silhouette is within normal limits. Osseous and soft tissue structures are unremarkable. IMPRESSION: No acute cardiopulmonary process. Radiology Report INDICATION: ___ woman with fevers, myalgias, abdominal pain and abnormal LFTs with neutropenia and thrombocytopenia and recent travel to ___. Rule out pyogenic liver abscess. COMPARISON: None available. TECHNIQUE: Gray-scale and color Doppler ultrasound images of the abdomen were obtained. FINDINGS: The liver does not show any focal lesions or structural abnormality. There is no intrahepatic or extrahepatic biliary dilatation. The gallbladder appears normal with no wall thickening and no stones. The pancreas appears unremarkable with no focal lesions or ductal dilatation. Common bile duct measures 0.54 cm and the main portal vein is patent with hepatopetal flow. The right kidney measures 10.7 cm and the left kidney measures 10.3 cm. There is no hydronephrosis. The spleen is 10.9 cm and has homogeneous echotexture. The visualized portions of the aorta and inferior vena cava are unremarkable. IMPRESSION: No focal liver lesions identified. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: PAIN Diagnosed with FEVER, UNSPECIFIED temperature: 103.0 heartrate: 89.0 resprate: 18.0 o2sat: 100.0 sbp: 117.0 dbp: 62.0 level of pain: 4 level of acuity: 3.0

___ year old female with no significant past medical history and recent trip to ___ presenting from home with 4 days of fever and myalgias with and new neutropenia and thrombocytopenia concerning for an acute viral process, with positive dengue serology. # Fevers, myalgias, hematologic abnormalities likely due to dengue fever: Concerning for acute viral process. Differential diagnosis includes Influenza, EBV, HIV, Chikungunya (although tends to involve joints and with rash), Dengue fever, rickettsial diseases, leptospirosis and Typhoid and paratyphoid infection. We considered a malignant process although much less likely given her recent history. Given acute febrile illness, recent travel, headache, myalgias, leukopenia, thrombocytopenia, elevated AST concerning most for dengue fever(in addition to positive serology). We sent off an array of labs and consulted ID for any further work up that may be necessary. She was placed on cefepime on day 1 and then her ANC was increasing and so it was discontinued. She then had a blood culture bottle positive with GPC and vancomycin was added and then stopped when the culture speciated coag negative staph. RUQ U/S was also unremarkable. Her ANC increased to 1590, her thrombocytopenia resolved and her LFT abnormalities also trended towards normal. In terms of diagnostic work up, at the time of discharge, nothing was positive but several days after, dengue serology came back positive. At the time of writing this summary her HIV ab and VL were negative. EBV IgG was positive, but IgM was negative. CMV IgG was positive, but VL and IgM was negative, Chikungunya IgM/IgG was negative, anaplasma - negative, lyme - negative, hepatitis serologies negative. Babesia smear was negative and malaria smear was negative. The patient showed no active signs of bleeding during her course at ___. . # LFT abnormalities: AST>ALT with close to 2:1 ration. Patient denies alcohol intake. No new medications. Could also see this in muscle injury and cirrhosis. RUQ U/S was normal and GGT and CK were unrevealing. Her LFT were trending down at the time of discharge. # Neutropenia and thrombocytopenia: Likely ___ viral infection (dengue fever). Bandemia 6%, and other thing to consider is hematologic malignancy, but given her HPI, infectious process in more likely etiology. She does have a family history of hematologic malignancy so must keep it in the differential at this time. No anemia so HUS or DIC much less likely. See above for management. # Dizziness: On HD 4, the patient was complaining of intermittent light headedness and difficulty reading. Neuro exam with without focal abnormalities. ___ negative. Orthostatics was negative as well. Her symptoms were not severe and she was given a script of meclizine to take on a PRN basis. She was not that interested in taking this medication, but I told her she did not have to take it, but if she wanted to try it she could.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: aspirin / celecoxib / ketorolac / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: fatigue / weakness Major Surgical or Invasive Procedure: esophagogastroduodenoscopy (EGD) ___ History of Present Illness: I have read and agree with the MICU admission note as documented, and agree with transfer of patient to the medicine service. In brief, this is a ___ woman with PMHx notable for COPD, atrial fibrillation (not on home anti-coagulation), hypertension, and hyperlipidemia who initially presented to ___ ___ for weakness and transferred to ___ for acute liver and renal failure. Initially presented to OSH for fatigue and weakness and was diagnosed with a UTI for which she received an antibiotic. Given persistence of symptoms she returned to the OSH where she was discovered to have severe lab abnormalities prompting transfer to ___. Upon arrival to ED patient had single episode of coffee ground emesis prompting urgent endoscopy which revealed gastric and esophageal erosions. Evaluated by hepatology and liver transplant who recommended monitoring in the MICU. Past Medical History: epilepsy hypertension hyperlipidemia arthritis depression stroke asthma atrial fibrillation COPD "enlargement of neck" Past Surgical History: laparoscopic cholecystectomy C-section shoulder replacement orthopedic procedures on back, knee, hip (unspecified) colonoscopy Social History: ___ Family History: No history of liver or GI disease per family Physical Exam: ADMISSION EXAM ============================= GEN: A&O, appears tired, +asterixis HEENT: No scleral icterus, mucus membranes moist, +repetitive lip smacking CV: irregularly irregular per ED monitor, rate controlled PULM: nonlabored respirations ABD: Soft, nondistended, nontender, no rebound or guarding, no palpable masses, no liver edge palpated Ext: No ___ edema, ___ warm and well perfused DISCHARGE EXAM ============================= Vital signs stable General: Thin, elderly appearing woman in no acute distress. Comfortable. Neuro: AAOx3. Dysarthric speech (baseline) HEENT: Normocephalic, atraumatic. MMM. Cardiac: Regular rate & rhythm. Normal S1/S2. II/VI holosystolic murmur present. Pulmonary: Fine crackles at the inferior and mid-lung fields bilaterally. Abdomen: Soft, non-tender, non-distended. no rebound/guarding Extremities: Warm, well perfused, non-edematous. Pertinent Results: ADMISSION LABS ============================ ___ 09:03PM BLOOD WBC-10.4* RBC-3.28* Hgb-11.0* Hct-32.6* MCV-99* MCH-33.5* MCHC-33.7 RDW-16.2* RDWSD-59.2* Plt ___ ___ 09:03PM BLOOD Neuts-95.1* Lymphs-1.7* Monos-2.6* Eos-0.0* Baso-0.1 Im ___ AbsNeut-9.90* AbsLymp-0.18* AbsMono-0.27 AbsEos-0.00* AbsBaso-0.01 ___ 09:03PM BLOOD ___ PTT-35.3 ___ ___ 09:03PM BLOOD Plt ___ ___ 09:03PM BLOOD Glucose-70 UreaN-48* Creat-2.5* Na-141 K-4.6 Cl-100 HCO3-19* AnGap-22* ___ 09:03PM BLOOD ALT-4191* AST-8226* LD(LDH)-4825* CK(CPK)-154 AlkPhos-201* TotBili-1.6* ___ 09:03PM BLOOD Albumin-4.0 Iron-97 ___ 09:03PM BLOOD calTIBC-202* ___ TRF-155* ___ 09:03PM BLOOD TSH-0.25* ___ 09:03PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-5* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 07:36AM URINE Color-Yellow Appear-Hazy* Sp ___ ___ 07:36AM URINE Blood-SM* Nitrite-NEG Protein-30* Glucose-NEG Ketone-TR* Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR* ___ 07:36AM URINE RBC-2 WBC-9* Bacteri-FEW* Yeast-NONE Epi-1 TransE-1 ___ 07:36AM URINE CastHy-38* ___ 07:36AM URINE AmorphX-OCC* ___ 07:36AM URINE WBC Clm-FEW* Mucous-RARE* ___ 01:38AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG PERTINENT LABS ============================ ___ 06:20AM BLOOD WBC-4.7 RBC-2.67* Hgb-8.9* Hct-27.1* MCV-102* MCH-33.3* MCHC-32.8 RDW-16.5* RDWSD-59.4* Plt ___ ___ 04:50PM BLOOD ___ ___ 06:30AM BLOOD ___ PTT-32.6 ___ ___ 06:20AM BLOOD ___ PTT-32.6 ___ ___ 06:20AM BLOOD ___ PTT-33.5 ___ ___ 09:03PM BLOOD Glucose-70 UreaN-48* Creat-2.5* Na-141 K-4.6 Cl-100 HCO3-19* AnGap-22* ___ 06:20AM BLOOD Glucose-76 UreaN-9 Creat-0.4 Na-144 K-4.0 Cl-107 HCO3-27 AnGap-10 ___ 09:03PM BLOOD ALT-4191* AST-8226* LD(___)-4825* CK(CPK)-154 AlkPhos-201* TotBili-1.6* ___ 07:40AM BLOOD ALT-2956* AST-4465* LD(LDH)-1519* AlkPhos-169* TotBili-1.3 ___ 03:19PM BLOOD ALT-2398* AST-2870* LD(___)-513* AlkPhos-166* TotBili-1.7* ___ 06:45AM BLOOD ALT-1652* AST-1112* LD(LDH)-258* AlkPhos-147* TotBili-2.1* ___ 06:30AM BLOOD ALT-1202* AST-364* LD(LDH)-215 AlkPhos-145* TotBili-2.6* ___ 06:20AM BLOOD ALT-882* AST-156* LD(___)-210 AlkPhos-149* TotBili-2.1* ___ 06:20AM BLOOD ALT-637* AST-78* LD(LDH)-216 AlkPhos-142* TotBili-1.7* ___ 06:20AM BLOOD Albumin-3.2* Calcium-8.8 Phos-3.0 Mg-1.6 ___ 04:50PM BLOOD VitB12-1885* Folate-20 ___ 09:03PM BLOOD calTIBC-202* ___ TRF-155* ___ 07:40AM BLOOD Hapto-55 ___ 09:03PM BLOOD TSH-0.25* ___ 06:45AM BLOOD T3-39* Free T4-1.2 ___ 04:50PM BLOOD HBsAg-NEG HBcAb-NEG ___ 07:40AM BLOOD IgM HAV-NEG ___ 09:03PM BLOOD HBsAb-NEG HAV Ab-POS* ___ 09:03PM BLOOD AMA-NEGATIVE Smooth-POSITIVE* ___ 09:03PM BLOOD ___ ___ 09:03PM BLOOD IgG-441* IgA-90 IgM-37* ___ 09:03PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-5* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 09:03PM BLOOD HCV Ab-NEG ___ 09:03PM BLOOD HERPES SIMPLEX VIRUS 1 AND 2 (IGG)-Test ___ 01:38AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG DISCHARGE LABS ============================ ___ 06:20AM BLOOD WBC-4.7 RBC-2.67* Hgb-8.9* Hct-27.1* MCV-102* MCH-33.3* MCHC-32.8 RDW-16.5* RDWSD-59.4* Plt ___ ___ 06:20AM BLOOD Plt ___ ___ 06:20AM BLOOD ___ PTT-33.5 ___ ___ 06:20AM BLOOD Glucose-76 UreaN-9 Creat-0.4 Na-144 K-4.0 Cl-107 HCO3-27 AnGap-10 ___ 06:20AM BLOOD ALT-637* AST-78* LD(LDH)-216 AlkPhos-142* TotBili-1.7* ___ 06:20AM BLOOD Albumin-3.2* Calcium-8.8 Phos-3.0 Mg-1.6 PERTINENT STUDIES ============================ RUQUS (___) 1. Patient is status post cholecystectomy with mild intrahepatic biliary ductal dilation. The common hepatic duct measures 10 mm and there is a 4 mm echogenic shadowing structure in the distal common bile duct likely representing choledocholithiasis. Recommend further evaluation with MRCP. 2. 2.2 cm echogenic lesion in the right hepatic lobe likely represents hemangioma. Further evaluation can be obtained during follow-up MRCP. 3. The main portal and right portal vein branches are patent with hepatopetal flow. The left portal vein is patent with hepatofugal flow. MRCP (___) Mild intrahepatic ductal dilatation and dilatation of the common bile duct measuring up to 10 mm. There is a 3-4 mm stone in the distal common bile duct, confirmatory of the recent ultrasound. 2 cm lesion right lobe liver with imaging characteristics most compatible with a hemangioma. MICRO ============================ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ VIRUS VCA-IgG AB (Final ___: POSITIVE BY EIA. ___ VIRUS EBNA IgG AB (Final ___: POSITIVE BY EIA. ___ VIRUS VCA-IgM AB (Final ___: NEGATIVE <1:10 BY IFA. INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION. In most populations, 90% of adults have been infected at sometime with EBV and will have measurable VCA IgG and EBNA antibodies. Antibodies to EBNA develop ___ weeks after primary infection and remain present for life. Presence of VCA IgM antibodies indicates recent primary infection. CMV IgG ANTIBODY (Final ___: NEGATIVE FOR CMV IgG ANTIBODY BY EIA. <4 AU/ML. Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml. If acute infection is suspected request IgM antibody testing and/or submit convalescent serum in ___ weeks. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Clopidogrel 75 mg PO DAILY 2. Pravastatin 80 mg PO QPM 3. LamoTRIgine 50 mg PO BID 4. LevETIRAcetam 750 mg PO BID 5. Ondansetron 4 mg PO Q8H:PRN nausea 6. FoLIC Acid 1 mg PO DAILY 7. Losartan Potassium 50 mg PO DAILY 8. Metoprolol Succinate XL 12.5 mg PO DAILY 9. Oxazepam 10 mg PO DAILY 10. Gabapentin 300 mg PO QID 11. carisoprodol 350 mg oral TID:PRN 12. Ferrous Sulfate 325 mg PO DAILY 13. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 14. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN 15. Sertraline 50 mg PO DAILY 16. TraMADol 50 mg PO Q8H:PRN Pain - Moderate 17. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID:PRN 15MLS TO THE MOUTH OR THROAT TWICE A DAY FOR 14 DAYS Discharge Medications: 1. Pantoprazole 40 mg PO Q12H 2. Sucralfate 1 gm PO QID 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 4. carisoprodol 350 mg oral TID:PRN muscle spasm RX *carisoprodol 350 mg 1 tablet(s) by mouth three times daily Disp #*10 Tablet Refills:*0 5. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID:PRN 15MLS TO THE MOUTH OR THROAT TWICE A DAY FOR 14 DAYS 6. Clopidogrel 75 mg PO DAILY 7. Ferrous Sulfate 325 mg PO DAILY 8. FoLIC Acid 1 mg PO DAILY 9. Gabapentin 300 mg PO QID 10. LamoTRIgine 50 mg PO BID 11. LevETIRAcetam 750 mg PO BID 12. Metoprolol Succinate XL 12.5 mg PO DAILY 13. Ondansetron 4 mg PO Q8H:PRN nausea 14. Oxazepam 10 mg PO DAILY RX *oxazepam 10 mg 1 capsule(s) by mouth daily Disp #*3 Capsule Refills:*0 15. Pravastatin 80 mg PO QPM 16. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN 17. Sertraline 50 mg PO DAILY 18. TraMADol 50 mg PO Q8H:PRN Pain - Moderate RX *tramadol 50 mg 1 tablet(s) by mouth q8 hours Disp #*10 Tablet Refills:*0 19. HELD- Losartan Potassium 50 mg PO DAILY This medication was held. Do not restart Losartan Potassium until you discuss with your regular doctor Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS acute liver failure SECONDARY DIAGNOSES acute renal failure esophagitis acute upper GI bleed choledocholithiasis anemia 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 EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: History: ___ with acute liver failure// Liver pathology? TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: None. FINDINGS: LIVER: The hepatic parenchyma appears within normal limits. There is a 2.2 cm echogenic lesion in the right hepatic lobe, with no mass clarity within it. The main portal and right portal vein branches are patent with hepatopetal flow. The left portal vein is patent with hepatofugal flow. There is no ascites. BILE DUCTS: There is mild intrahepatic biliary dilation. The CHD measures 10 mm and there is a 4 mm echogenic foci with posterior shadowing in the distal common bile duct. GALLBLADDER: The patient is status post cholecystectomy. PANCREAS: The imaged portion of the pancreas appears within normal limits, without masses or pancreatic ductal dilation, with portions of the pancreatic tail obscured by overlying bowel gas. SPLEEN: Normal echogenicity, measuring 9.2 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. Patient is status post cholecystectomy with mild intrahepatic biliary ductal dilation. The common hepatic duct measures 10 mm and there is a 4 mm echogenic shadowing structure in the distal common bile duct likely representing choledocholithiasis. Recommend further evaluation with MRCP. 2. 2.2 cm echogenic lesion in the right hepatic lobe likely represents hemangioma. Further evaluation can be obtained during follow-up MRCP. 3. The main portal and right portal vein branches are patent with hepatopetal flow. The left portal vein is patent with hepatofugal flow. RECOMMENDATION(S): MRCP. The right lobe 2.2 cm echogenic lesion will also be better characterized on the MRI. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 10:09 am, 15 minutes after discovery of the findings. Radiology Report EXAMINATION: Chest: Frontal and lateral views INDICATION: History: ___ with weakness// Pneumonia, effusions? TECHNIQUE: Chest: Frontal and Lateral COMPARISON: None. FINDINGS: The lungs are clear without focal consolidation. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are unremarkable. Right shoulder arthroplasty noted. Mid thoracic level vertebroplasty changes noted. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: MRCP INDICATION: ___ PMHx COPD, atrial fibrillation (not on home anti-coagulation), hypertension, and hyperlipidemia who initially presented to OSH for weakness and transferred to ___ for acute liver and renal failure. Course complicated by single episode hematemesis but otherwise hemodynamically stable with improving liver and renal function. RUQ U/S showing "patient is status post cholecystectomy with mild intrahepatic biliary ductal dilation. The common hepatic duct measures 10 mm and there is a 4 mm echogenic shadowing structure in the distal common bile duct likely representing choledocholithiasis. TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were acquired in a 1.5 T magnet. Intravenous contrast: 5 mL Gadavist. Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered for oral contrast. COMPARISON: Ultrasound of the abdomen ___ FINDINGS: Lower Thorax: The heart is normal in size. The lung bases are not adequately visualized secondary to motion degradation. Liver: There is a 2 cm subcapsular lesion in the right lobe of the liver which is hyperechoic on ultrasound and demonstrates peripheral nodular enhancement on today's study. Findings are most compatible with a hemangioma. There is a 2 x 2.6 cm subcapsular area enhancement in the dome of the liver, likely a vascular shunt. Biliary: There is mild intrahepatic ductal dilatation. The common bile duct is dilated measuring 10 mm. There is a 3-4 mm stone in the distal common bile duct, confirmatory of the recent ultrasound. This is seen best on series 4, image 24 and on coronal 3D series 5, image 43. Pancreas: The pancreas is not adequately evaluated secondary to misregistration artifact due to respiratory motion. The common bile duct is not dilated. Spleen: The spleen is normal in size. Adrenal Glands: No adrenal masses are evident Kidneys: The kidneys are symmetric in size; there is no hydronephrosis. Gastrointestinal Tract: There is no gross small bowel dilatation however evaluation is compromised by motion degradation. Lymph Nodes: There is no bulky para-aortic adenopathy. Vasculature: The aorta maintains normal caliber. Osseous and Soft Tissue Structures: Degenerative changes are noted in the spine. IMPRESSION: Mild intrahepatic ductal dilatation and dilatation of the common bile duct measuring up to 10 mm. There is a 3-4 mm stone in the distal common bile duct, confirmatory of the recent ultrasound. 2 cm lesion right lobe liver with imaging characteristics most compatible with a hemangioma. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Abnormal labs, Weakness, Transfer Diagnosed with Weakness temperature: 96.8 heartrate: 90.0 resprate: 15.0 o2sat: 98.0 sbp: 110.0 dbp: 69.0 level of pain: 0 level of acuity: 2.0

___ woman with PMHx notable for COPD, atrial fibrillation (not on home anti-coagulation), hypertension, and hyperlipidemia who initially presented to ___ for weakness and transferred to ___ for acute liver and renal failure. Course complicated by single episode hematemesis s/p EGD but otherwise remained hemodynamically stable. Liver and kidney function rapidly improved with fluids and supportive care. Evaluated by physical therapy who recommended discharge to rehab. # ACUTE LIVER FAILURE / SHOCK LIVER Initially presented to outside hospital for fatigue in setting of outpatient treatment for UTI where was discovered to have markedly abnormal LFTs (AST/ALT in thousands). Transferred to ___ where imaging and laboratory workup was negative for thrombosis, acute viral hepatitis, auto-immune hepatitis, or other acute cause other than likely shock liver from hypotension from urosepsis. Admitted to the ICU where tox-screen notable for low-level Tylenol and so received N-acetylcysteine gtt, however this was not felt to be significant contributor to acute liver failure. LFTs rapidly improved with treatment of UTI and fluids. RUQUS and MRCP without evidence of cirrhosis, though did note 4mm stone in distal bile duct. Per ERCP service this was also unlikely to be a major cause of acute liver failure and so was discharged with plan for outpatient follow up for ERCP at a later date. LFTs rapidly improved and were approach normal range by time of discharge. # HEMATEMESIS Upon arrival to ___ had single episode of coffee ground emesis. Underwent EGD notable for esophagitis though no evidence of varices or active bleeding. Started octreotide (later discontinued) and PPI (to be continued at discharge). Did not have any recurrent episodes of hemoptysis. CBC stable. # ACUTE RENAL FAILURE Presented with acutely elevated Cr to 2.5. Improved to 0.4 by time of discharge with fluids and PO intake. Likely pre-renal in setting of shock liver. # UTI UA notable for bacteria and pyuria. Also with increased urinary frequency, no dysuria. Urine culture with mixed flora. Completed course of ceftriaxone ___ - ___. # FATIGUE / WEAKNESS In setting of acute hepatitis, UTI, uremia due to ___. CK normal. ___ recommended discharge to rehab. # COAGULOPATHY Elevated INR in setting of acute liver failure. Received IV vitamin K and FFP. INR approaching normal with resolution of acute liver failure. CHRONIC / STABLE ISSUES ============================ # ATRIAL FIBRILLATION Reported history though currently in sinus rhythm. Not on home anti-coagulation. Continued home metoprolol. # ASTHMA - albuterol prn # SEIZURE DISORDER - continued home levatiracetam - continued home lamotrigine # HYPERTENSION Held losartan in setting of GI bleed. Blood pressure remained normotensive for remainder of hospitalization and so held at discharge. # HYPERLIPIDEMIA - continued home pravastatin # DEPRESSION - continued home sertraline # Hx STROKE Dysarthric at baseline. No other focal deficits. - Holding ASA and Plavix in setting of GI bleed. Continue statin. TRANSITIONAL ISSUES =================================

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left leg pain Major Surgical or Invasive Procedure: 1. Irrigation debridement of traumatic lacerations, left lower extremity skin to muscle with excision of dead tissue and foreign bodies. 2. Open primary repair of tibialis anterior tendon, left lower extremity. 3. Open repair of peroneus brevis tendon, left lower extremity. 4. Open repair of left peroneus longus tendon, left lower extremity. 5. Closure of complex wound, left lower extremity. History of Present Illness: ___ with ___ notable for motorcycle injury s/p pelvic, ulna, clavicle, radius fracture, & bilateral lung collapse, with new motorcycle injury to LLE c/w 3 deep lacerations on lower left fibula. Patient reports he was pulling out on his motorcycle of a gas station when a car driving ___ mph hit him. His leg was pushed between his motorcycle and the bumper of the car. He deeply lacerated his left leg in 3 locations and superficially scratched his left arm. He rates his leg pain as ___. He denies falling on any additional body parts. He was wearing a helmet at the time. He denies alcohol or drug use. He denies back pain, hip pain, tingling, numbness, dizziness, fatigue. He was taken to ___ where he had CXR, Pelvis, and FAST done reported as negative; no fracture reported of left lower extremity. He was transferred to ___ for further management of deep lacerations with possible foreign body. Past Medical History: Motorcycle Crash - ___ years ago, multiple surgeries Past Surgical History: -Pelvic Fracture s/p metal plate: ___ years ago motorcycle injury -Ulna and Radius Fracture: ___ years ago motorcycle injury -Clavicle Fracture: ___ years ago motorcycle injury -Bilateral Lung Collapse: ___ years ago motorcycle injury -Reported Open heart surgery without intervention: ___ years ago motorcycle injury Social History: ___ Family History: non-contributory Physical Exam: Admission Physical Exam: Temp: 97.0 HR: 115 BP: 121/92 Resp: 18 O(2)Sat: 99 Normal Constitutional: Comfortable HEENT: Normocephalic, atraumatic, Pupils equal, round and reactive to light Oropharynx within normal limits Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm Abdominal: Soft Extr/Back: LLE with splint, large lacerations x 3 into muscle Skin: No rash Neuro: Speech fluent Psych: Normal mood Discharge Phsycial Exam: VS: 98.3, 89, 124/82, 16, 99 RA Gen: Awake, alert, sitting up in bed. HEENT: No deformity. PERRL, EOMI. neck supple, trachea midline. Mucus membranes pink moist. CV: RRR Pulm: Clear bilaterally Abd: Soft, non-tender, non-distended. Active Bowel sounds x 4 quadrants. Ext: Warm and dry. LLE with ace wrap. sensation intact. 2+ ___ pulses. Hard boot to LLE. Neuro: A&Ox3. Follows commands and moves all extremities equal and strong. Speech is clear and fluent. Pertinent Results: ___ 01:22PM BLOOD WBC-10.0 RBC-3.01* Hgb-9.4* Hct-27.7* MCV-92 MCH-31.2 MCHC-33.9 RDW-12.6 RDWSD-41.4 Plt ___ ___ 04:10AM BLOOD WBC-11.4* RBC-3.10*# Hgb-9.4*# Hct-28.8* MCV-93 MCH-30.3 MCHC-32.6 RDW-12.8 RDWSD-43.3 Plt ___ ___ 10:05PM BLOOD WBC-19.9* RBC-4.16* Hgb-12.8* Hct-38.3* MCV-92 MCH-30.8 MCHC-33.4 RDW-12.6 RDWSD-42.4 Plt ___ ___ 10:05PM BLOOD ___ PTT-25.2 ___ ___ 10:05PM BLOOD Glucose-186* UreaN-16 Creat-0.9 Na-141 K-3.8 Cl-105 HCO3-24 AnGap-16 ___ Left Foot: 1. No acute fracture or malalignment. 2. Mild degenerative changes of first MTP joint. ___ Pelvis: 1. Severe lateral left lower leg laceration with locules of gas and punctate radiopacities consistent with foreign bodies. 2. No acute fracture or acute malalignment. 3. Status post pubic symphysis plate and surgical screws with right surgical screw projecting over the right obturator foramen. Medications on Admission: none Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Docusate Sodium 100 mg PO BID hold for diarrhea RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Severe Take lowest effective dose. RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*80 Tablet Refills:*0 4. Senna 8.6 mg PO BID:PRN constipation RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp #*30 Tablet Refills:*0 5. 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 6.Crutches Dx: Left lower extremity laceration and tendon injury Px: Good ___: 13 months Discharge Disposition: Home Discharge Diagnosis: 1. Traumatic laceration, left lower extremity x3. 2. Traumatic laceration, left tibialis anterior tendon. 3. Traumatic laceration, left peroneus brevis tendon. 4. Traumatic laceration, peroneus longus tendon. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: DX PELVIS, FEMUR AND TIB/FIB INDICATION: ___ with left leg pain and lacerations. Assess for fracture. TECHNIQUE: Single AP view of pelvis, two views of left femur, two views of left knee, two views of left ankle. COMPARISON: None. FINDINGS: Pelvis: No acute fracture or malalignment. Mild multilevel degenerative changes are noted throughout the lower lumbar spine with osteophyte formation and endplate sclerosis. The femoral heads are well seated within the acetabulum. Visualized bowel gas pattern is nonobstructive. Plate and surgical screws are seen along the pubic symphysis. A right surgical screw projects into the right obturator foramen. Left femur: No acute fracture. Left knee: No acute fracture or acute malalignment. No joint effusion. Multiple punctate radiopacities and locules of gas along the left lateral leg is consistent with known laceration and foreign bodies. Left ankle: No acute fracture or acute malalignment. An os trigonum is present. No joint effusion. IMPRESSION: 1. Severe lateral left lower leg laceration with locules of gas and punctate radiopacities consistent with foreign bodies. 2. No acute fracture or acute malalignment. 3. Status post pubic symphysis plate and surgical screws with right surgical screw projecting over the right obturator foramen. Radiology Report EXAMINATION: FOOT AP,LAT AND OBL LEFT INDICATION: ___ with left leg pain and lacerations. Assess for fracture TECHNIQUE: Non-weightbearing frontal, oblique, and lateral view radiographs of left foot COMPARISON: None. FINDINGS: A bipartite sesamoid bone is present. Mild degenerative changes of the first MTP joint with subchondral sclerosis and small osteophyte formation. No fracture, or dislocation. No erosion or lytic or sclerotic lesion is identified. No soft tissue calcification or radio-opaque foreign body is detected. Os trigonum is noted. IMPRESSION: 1. No acute fracture or malalignment. 2. Mild degenerative changes of first MTP joint. Gender: M Race: UNKNOWN Arrive by UNKNOWN Chief complaint: Transfer, Motorcycle accident Diagnosed with Laceration without foreign body, left lower leg, init encntr, Mtrcy driver injured pick-up truck, pk-up/van in traf, init temperature: 97.0 heartrate: 115.0 resprate: 18.0 o2sat: 99.0 sbp: 121.0 dbp: 92.0 level of pain: 7 level of acuity: 2.0

Mr. ___ is a ___ yo M ___ who was struck on the left leg by a car admitted to the Acute Care Surgery Service on ___. He was noted to have 3 deep lacerations to the left lower leg and X-ray showed no fracture. Informed consent was obtained and he was taken to the operating room for a lower extremity wash out. Intraoperatively he was found to have multiple deep wounds involving lacerations of the anterior and lateral compartment tendons and orthopedic surgery was was contacted to provide assistance. He underwent operative repair of the tibias anterior tendon, preens braves tendon, left preens longs tendon, and closure of complex wounds. Please see operative report for details. He was admitted to the surgical floor for post operative management. On HD1 he remained afebrile and pain was well controlled on oral pain medications. He remained stable from a hemodynamic standpoint. His diet was advanced to regular which he tolerated well. He voided adequate urine without difficulty. His left lower extremity remained warm and well perfused with good capillary refill. He received wound care teaching and a CAM boot. He was seen and evaluated by physical therapy who determined safe discharge to home. The patient was discharged to home on HD1 in stable condition. 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: Vicodin / Risperidone / Meropenem / Codeine / Demerol / Dilaudid / Percocet / aspirin / Primaxin IV Attending: ___. Chief Complaint: Abdominal Pain, Chest Pain Major Surgical or Invasive Procedure: NONE History of Present Illness: Ms. ___ is a ___ yof with history of necrotizing pancreatitis, schizoaffective disorder, fibromyalgia, chronic back pain, chronic abdominal pain, DMII, and HTN who presents with abdominal pain and chest pain for past week. She reports pain started yesterday in lower abdomen and migrated up to include chest and flanks bilaterally. Patient has radiation of pain to neck and scapula. The pain is a sharp, pressure is diffusely throughout abdomen with some radiation to chest. Pain improved from ___ to ___ with morphine. She also reports "torturing" pain today in her abdomen and chest that felt like she did when she was raped by a family member. ___ pain does not occur with exertion and is not associated with shortness of breath. She was seen at ___ late last night and found to have neg CXR, WBC 12, and cardiac enzymes neg x1. She reports temperatures up to 99.9 at home for past month and says she has long standing history of heat intolerance. She denies any vomiting, diarrhea, or dysuria but does report some intermittent nausa and baseline dyspnea. Last BM yesterday and was normal. ED Course - Initial Vitals/Trigger: ___ 74 143/74 18 98% - EKG: nonischemic - ASA 325 -> pt reufsed - Morphine, Zofran - Admit for pain control, trop x2 - Guaic negative - Additional CP at 1200hr, repeat ECG non-ischemic - Hx VRE - BMP wnl, WBC 11.5, Hgb 12.9, Alk Phos 140, Lipase 15, Lact 1.5 - U/A negative ROS: Negative except for above. Past Medical History: schizoaffective disorder OSA asthma transverse myelitis HTN venous insufficiency DMT2 chronic pain chronic constipation ovarian cyst LUE DVT s/p pancreatic pseudocyst gastrostomy ___ ___ drainage pseudocyst and splenic abscess ___ cholecystectomy Social History: ___ Family History: No family history of pancreatitis. Father died in his ___ of COPD and "heart condition." Mother with HTN and asthma. Physical Exam: ADMISSION PHYSICAL EXAM: VS - AF 98.2 172/84 HR69 sat 92% on RA Gen: NAD, lying in bed, cushinoid appearing, obese, patient is tender almost everywhere she is touched HEENT: moist mucosa Neck: thick neck with cervical lordosis CV: NR, RR, no murmur Pulm: CTAB, no wheeze Abd: diffuse tenderness to very light palpation, obese but nondistended, soft, no rebound Ext: no peripheral edema Skin: some acne on upper back, no other skin lesions noted Neuro: moves all 4 extremities, ambulates, no focal deficit, EOMI DISCHARGE PHYSICAL EXAM: AF 98.3 137/68 HR 70 sat 99% on RA Gen: NAD, sitting in chair, obese, patient is tender almost everywhere she is touched. HEENT: moist mucosa Neck: thick neck with cervical lordosis CV: NR, RR, no murmur Pulm: CTAB, no wheeze Abd: diffuse tenderness to very light palpation, obese but nondistended, soft, no rebound Ext: no peripheral edema Skin: some acne on upper back, no other skin lesions noted Neuro: moves all 4 extremities, ambulates, no focal deficit, EOMI Pertinent Results: ___ 07:54AM BLOOD WBC-11.5* RBC-4.53 Hgb-12.9 Hct-39.5 MCV-87 MCH-28.5# MCHC-32.7 RDW-15.0 Plt ___ ___ 07:54AM BLOOD Glucose-78 UreaN-19 Creat-0.7 Na-143 K-4.2 Cl-103 HCO3-31 AnGap-13 ___ 06:55PM BLOOD CK(CPK)-57 ___ 07:54AM BLOOD ALT-16 AST-18 AlkPhos-140* TotBili-0.2 ___ 03:10AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 06:55PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 07:54AM BLOOD TSH-6.4* ___ 08:23AM BLOOD Lactate-1.5 ___ CT Abd/Pelv with Contrast: ABDOMEN: The liver is hypodense diffusely suggestive of fatty infiltration. No focal mass is present. The gallbladder has been removed and metallic clips remain in the gallbladder fossa. The intra- and extra-hepatic bile ducts are unremarkable. The pancreas demonstrates mild fatty infiltration within the head. No peripancreatic stranding or fluid collection is present and the pancreatic duct is not enlarged. A 2.9 x 2.0 cm (2:21) hypodense lesion along the lateral aspect of the spleen is stable since the prior exam of ___, and compatible with a subcapsular collection likely related to prior trauma or infarct. Adrenal glands are normal. Kidneys enhance symmetrically and excrete contrast promptly. The ureters are normal in course and caliber. Suture material along the lesser curvature of the stomach is compatible with prior pseudocyst gastrostomy. The stomach is otherwise unremarkable. The small and large bowel enhance homogeneously and have a normal course and caliber. The appendix is normal (601B:35). No retroperitoneal or mesenteric lymphadenopathy. The portal and systemic intra-abdominal vasculature is unremarkable. No free abdominal fluid or pneumoperitoneum. The stoma of a fat-containing ventral wall hernia (2:41) measures 17 mm. Small fat-containing periumbilical hernia is also present. PELVIS: The bladder is unremarkable. The uterus and ovaries are unremarkable. No free pelvic fluid or inguinal hernia. No pelvic or inguinal lymphadenopathy. OSSEOUS STRUCTURES: Multilevel thoracolumbar spine degenerative changes. No focal lytic or sclerotic lesion concerning for malignancy. IMPRESSION: 1. No acute intra-abdominal process. No evidence of pancreatitis or pseudocyst. 2. Stable size of 2.9-cm splenic subcapsular fluid collection. 3. Hepatic steatosis. CXR Portable ___: FINDINGS: Single frontal portable view of the chest was obtained. The patient is rotated with respect to the film. The heart is of normal size with normal cardiomediastinal contours. Lungs are clear without focal or diffuse abnormality. No large pleural effusion or pneumothorax. No radiopaque foreign body. Osseous structures are unremarkable. IMPRESSION: No acute cardiopulmonary process. Radiology Report HISTORY: Chest pain. Evaluate for pneumonia, pneumothorax, or pneumoperitoneum. COMPARISON: Multiple prior chest radiographs, most recently ___. FINDINGS: Single frontal portable view of the chest was obtained. The patient is rotated with respect to the film. The heart is of normal size with normal cardiomediastinal contours. Lungs are clear without focal or diffuse abnormality. No large pleural effusion or pneumothorax. No radiopaque foreign body. Osseous structures are unremarkable. IMPRESSION: No acute cardiopulmonary process. Radiology Report INDICATION: ___ female with diffuse abdominal pain. Evaluate for pancreatic pseudocyst. COMPARISONS: Multiple prior abdominal CTs, most recently CTU of ___. TECHNIQUE: MDCT sections were obtained from the lung bases to the pubic symphysis after administration of 130 cc of IV Omnipaque contrast. Axial images were interpreted in conjunction with coronal and sagittal reformats. FINDINGS: The visualized portion of the heart is unremarkable. The lung bases are clear. No pericardial or pleural effusion is visualized. ABDOMEN: The liver is hypodense diffusely suggestive of fatty infiltration. No focal mass is present. The gallbladder has been removed and metallic clips remain in the gallbladder fossa. The intra- and extra-hepatic bile ducts are unremarkable. The pancreas demonstrates mild fatty infiltration within the head. No peripancreatic stranding or fluid collection is present and the pancreatic duct is not enlarged. A 2.9 x 2.0 cm (2:21) hypodense lesion along the lateral aspect of the spleen is stable since the prior exam of ___, and compatible with a subcapsular collection likely related to prior trauma or infarct. Adrenal glands are normal. Kidneys enhance symmetrically and excrete contrast promptly. The ureters are normal in course and caliber. Suture material along the lesser curvature of the stomach is compatible with prior pseudocyst gastrostomy. The stomach is otherwise unremarkable. The small and large bowel enhance homogeneously and have a normal course and caliber. The appendix is normal (601B:35). No retroperitoneal or mesenteric lymphadenopathy. The portal and systemic intra-abdominal vasculature is unremarkable. No free abdominal fluid or pneumoperitoneum. The stoma of a fat-containing ventral wall hernia (2:41) measures 17 mm. Small fat-containing periumbilical hernia is also present. PELVIS: The bladder is unremarkable. The uterus and ovaries are unremarkable. No free pelvic fluid or inguinal hernia. No pelvic or inguinal lymphadenopathy. OSSEOUS STRUCTURES: Multilevel thoracolumbar spine degenerative changes. No focal lytic or sclerotic lesion concerning for malignancy. IMPRESSION: 1. No acute intra-abdominal process. No evidence of pancreatitis or pseudocyst. 2. Stable size of 2.9-cm splenic subcapsular fluid collection. 3. Hepatic steatosis. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: ABDO PAIN Diagnosed with ABDOMINAL PAIN OTHER SPECIED, CHEST PAIN NOS temperature: 98.3 heartrate: 74.0 resprate: 18.0 o2sat: 98.0 sbp: 143.0 dbp: 74.0 level of pain: 5 level of acuity: 3.0

Ms. ___ is a ___ yo f with history of necrotizing pancreatitis, schizoaffective disorder, fibromyalgia, chronic back pain, chronic abdominal pain, DMII, and HTN who presented with abdominal pain and chest pain for past week. # Abdominal Pain, generalized: Patient's abdominal pain is relatively inconsistent on exam and appears to be superficial. Her CT abd/pelv with contrast did not show any sources of pain. DDx somatoform disorder, GI process, GU process, or GYN process. Patient's only lab abnormalities was mild WBC elevation of 11.5. Afebrile, normal lactate, negative CT abd/pelv with contrast, lipase wnl, Hgb and vital signs stable. - continued home omeprazole and ranitidine - given po morphine PRN plus home pain medication # Chest Pain, Intermittent: She was diffusely tender to palpation and not currently suffering from pain. Very unlikely ACS, could be due to her fibromyalgia. Pneumonia or PE was unlikely based on history, vitals, EKG and neg OSH CXR. Her trop on admission was negative. EKG negative x2 in ED. CP overnight with normal EKG and cardiac enzymes. Patient monitored on telemetry. # DM - insulin SS while inpatient # HTN: Stable - continued home antihypertensives # CODE STATUS: DNR/DNI- confirmed with patient on admission # CONTACT: ___ (sister)- ___ # PCP: ___ MD # DISPO: Medicine to home. # Transitional Issues: - Will follow up with Primary Care Provider

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Taxol Attending: ___. Chief Complaint: anemia Major Surgical or Invasive Procedure: ___: Repositioned a new 8 ___ pigtail drainage catheter in the left upper quadrant adjacent to the G-tube. Exchanged the G-tube with a new 20 ___ Ponsky PEG tube. ___: EGD ___: PICC line placement ___: G-tube exchange/replacement History of Present Illness: ___ yo F with stage IV serous adenocarcinoma of the fallopian tube with widespread abd mets and peritoneal tumors p/w anemia. Pt recently admitted ___ for a clogged G tube, nausea, and vomiting. She had a para during that admission which showed gross purulence. JP drain placed. G tube found to be leaking into peritoneum and was replaced ___. Regarding antibiosis, initially pt placed on vanc/cefepime/flagyl, later narrowed to unasyn. GNRs/GPCs on gram. Cxs grew mixed bacterial flora: coag +staph only organism speciated out. She was discharged on a course of ertapenem. Pt seen in clinic for routine chemo and was found to have hct 20.2, down from last hct 27.9 on discharge. She was sent in to the ED for eval. . In the ED: 96.8 109 135/69 18 98% RA. On hx, pt denied blood in the stool, melena or abdominal pain. She denied vaginal bleeding or hematuria. Her only complaints were chronic fatigue and chronic nighttime nausea with non-bloody vomiting. Exam was benign. Admitted to OMED. . ROS: as above; otherwise complete ROS negative Past Medical History: Onc history: - early ___: abdominal cramping, bloating and early satiety - ___ CT abd/pelvis with omental caking, peritoneal implants, ascites - ___ CT chest with pleural nodularity, trace effusions - ___ CA125 59 - ___ ex lap, TAH/BSO, transverse colectomy with primary side-to-side functional end-to-end anastomosis, total omentectomy, appendectomy, optimal tumor debulking, IP port placement - ___: 6 cycles of IV/IP cis/taxol, required taxol desensitization after second cycle for taxol reaction - ___ CA125 19 - ___ CT chest/abd/pelvis: residual nodularity on sigmoid colon, soft tissue mass associated with distal ileum, soft tissue on anterior abdominal wall, 2-3mm pleural-based nodular densities - ___ PET-CT: FDG-avid lesions in the sigmoid, above the bladder, RUQ peritoneal surface, abdominal small bowel, and T9 sclerotic lesion - ___: started ___ for recurrent disease - ___ - ___: admitted for vomiting due to partial SBO - ___: started gemcitabine ___ CT Torso: No significant change from ___. Mild distension of a loop of proximal jejunum, transition left mid-abdomen. Unchanged peritoneal thickening and ascites with loculated appearance. Bilat pleural effusions, R > L. ___ 1,Day 15 Gemzar Past Medical History: - fallopian tube cancer - HTN - Hypothyroidism Obstetric History: G2P2, LTCS x 2 Gynecologic History: - fallopian tube cancer as above - no abnormal Paps or STIs Past Surgical History: - Removal of IP port ___ - Exploratory lapaparotomy, TAH/BSO, transverse colectomy with primary side-to-side functional end-to-end anastomosis, total omentectomy, appendectomy, optimal tumor debulking, IP port placement (___) - LTCS x 2 (___) - knee arthroscopy - cervical polypectomy Social History: ___ Family History: She denies gyn, colon or breast cancer. Her grandfather was a smoker and died of lung cancer. Her grandmother had hypertension. She otherwise denies family history of cardiovascular disease, diabetes or venous thromboembolic events. Physical Exam: ADMISSION PHYSICAL EXAM Vitals: T97.9 HR102 (99-108) BP118/72 RR20 95%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops Abdomen: G-tube in place with overlying wet dressing; JP bulb on left side of abdomen with minimal draining yellow output, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding; mild ttp over G tube and JP drain sites BACK: no hematoma of posterior back GU: no foley Ext: warm, well perfused, 2+ pulses, 3+ pitting edema of bilateral ___. Left sided PICC line in place. DISCHARGE PHYSICAL EXAM Tm/c 98.2 140/84 102 20 96% RA I/O: 1824/ 3200 O + 805 (G) + 800 (J) + 0 (JP) GEN: Alert, oriented x3, NAD HEENT: Sclera anicteric Neck: supple, no LAD Lungs: Clear to auscultation bilaterally with diminished breath sounds at bases L sl worse than right. Dull to percussion at bases, no wheezes or rales CV: Tachycardic, normal S1 + S2, systolic flow murmur appreciated Abdomen: G-tube in place; JP bulb with very minimal drainage. ___ tube draining light green fluid with no overt blood, abdomen non-tender, non-distended, bowel sounds present, some firmness to palpation periumbilica, no rebound tenderness or guarding; not ttp over G tube and JP drain sites GU: no foley Ext: warm, well perfused, 2+ pulses, 1+ pitting edema of bilateral ___. no evidence of line infection Pertinent Results: ADMISSION LABS ___ 09:15PM BLOOD WBC-8.4 RBC-2.16*# Hgb-6.6*# Hct-20.2*# MCV-93 MCH-30.3 MCHC-32.5 RDW-20.1* Plt ___ ___ 09:15PM BLOOD Neuts-88.0* Lymphs-7.7* Monos-4.1 Eos-0 Baso-0.1 ___ 09:15PM BLOOD ___ PTT-25.2 ___ ___ 09:15PM BLOOD Glucose-114* UreaN-22* Creat-0.8 Na-137 K-3.8 Cl-95* HCO3-35* AnGap-11 ___ 06:34AM BLOOD ALT-28 AST-22 LD(LDH)-182 AlkPhos-133* TotBili-1.3 ___ 09:15PM BLOOD Calcium-7.4* Phos-4.6* Mg-2.0 ___ 06:34AM BLOOD Albumin-2.1* Calcium-7.8* Phos-4.6* Mg-2.1 Iron-167* ___ 06:34AM BLOOD calTIBC-191* VitB12-488 Folate-11.0 Hapto-356* Ferritn-702* TRF-147* ___ 10:55PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 10:55PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG ___ 10:55PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-15 PERTINENT LABS (hgb/hct trend) ___ 12:42AM Hgb-7.1* Hct-22.5* ___ 06:34AM Hgb-6.7* Hct-20.2* ___ 06:01PM Hgb-8.5*# Hct-25.1* ___ 05:49AM Hgb-7.8* Hct-23.8* ___ 04:00PM Hgb-9.1* Hct-26.8* ___ 05:54AM Hgb-8.7* Hct-26.9* ___ 06:00AM Hgb-8.2* Hct-25.0* ___ 04:11PM Hgb-9.0* Hct-26.7* ___ 11:11PM Hct-26.1* ___ 06:00AM Hgb-8.3* Hct-24.8* ___ 04:29PM Hgb-8.8* Hct-26.5* ___ 05:10AM Hgb-8.2* Hct-23.9* ___ 12:00PM Hgb-8.5* Hct-25.9* ___ 06:23AM Hgb-9.2* Hct-27.9* ___ 06:16AM Hgb-7.3* Hct-22.3* ___ 11:05AM Hgb-7.4* Hct-22.2* ___ 02:33PM Hgb-7.9* Hct-23.9* ASCITES FLUID ___ 12:22PM ASCITES WBC-3875* RBC-975* Polys-97* Lymphs-2* ___ Macroph-1* MICROBIOLOGY ___ 12:22 pm PERITONEAL FLUID PERITONEAL FLUID. **FINAL REPORT ___ GRAM STAIN (Final ___: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final ___: Reported to and read back by ___ ___ 3:30PM. ENTEROCOCCUS SP.. RARE GROWTH. Daptomycin SENSITIVITY REQUESTED BY ___. ___ ___ ___. Daptomycin 3.0 MCG/ML Sensitivity testing performed by Etest. STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. RARE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. 1 COLONY ON 1 PLATE. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | STENOTROPHOMONAS (XANTHOMONAS) MALTOPH | | AMPICILLIN------------ =>32 R DAPTOMYCIN------------ S LINEZOLID------------- 2 S PENICILLIN G---------- =>64 R TRIMETHOPRIM/SULFA---- <=1 S VANCOMYCIN------------ =>32 R ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. ___ Blood cx pending PERTINENT IMAGING ___ CXR In comparison with the study of ___, the tip of the PICC line extends to the mid portion of the SVC. The left pleural effusion appears less prominent, though this may merely reflect a more upright position of the patient. Cardiac silhouette is within normal limits and there is no appreciable pulmonary vascular congestion. ___ CT a/p 1. Reaccumulation of fluid within the peritoneal cavity, particularly on the right side of the abdomen. There is little fluid in the left flank along the existing catheter as well as in the pelvis. There is diffuse thickening of the peritoneum and superinfection cannot be excluded. 2. Bilateral pleural effusions, left greater than right are stable. 3. Gastrostomy tube in adequate position. 4. Peritoneal nodules are again noted and are stable. ___ CXR Lungs are clear. Bilateral pleural effusions, left greater than right. Right PICC terminates in the low SVC. ___ KUB No evidence of pneumoperitoneum. Non-obstructive bowel gas pattern. ___ CT Abd/Pelvis with contrast IMPRESSION: 1. Ascites, unchanged with resolution of prior air inclusions. 2. Lack of oral contrast limits evaluation of known peritoneal implants. 3. Duodenal and small bowel dilatation with transition point in left mid abdomen. A partial small bowel obstruction cannot be excluded. 4. Gastric tube with tip terminating in lumen but coiled tubing and disc seen outside the lumen wall. ___ portable CXR The PICC line is unchanged. The NG tube is been removed. There are moderate bilateral pleural effusions which have increased slightly compared to the study from 6 days prior. There is minimal pulmonary vascular redistribution. Cardiac size is upper limits of normal. PROCEDURES ___ G-TUBE CHECK/REPLACE 1. 8 ___ biliary drainage catheter successfully repositioned into the left upper quadrant. 2. Successful exchange of a 14 ___ mic gastrostomy tube for a new 20 ___ Ponsky gastrostomy tube. Intraluminal location was confirmed with a contrast injection that showed gastric rugae. IMPRESSION: Successful exchange of a 14 ___ mic gastrostomy tube for a new 20 ___ Ponsky gastrostomy tube. RECOMMENDATION: Please place the 8 ___ biliary drainage catheter to a large JP bulb for suction for at least 48 hr to ensure adequate drainage from the left upper quadrant. Please use the gastrostomy as needed for venting. EGD ___: Large hiatal hernia Reflux esophagitis PEG was not visualized Ulcers in the hernia sac Esophagus and the stomach were completely full of fluid No evidence of tumor within the stomach ___ G-tube replacement FINDINGS: 1. Malpositioned percutaneous gastrostomy tube. 2. Successful repositioning of a catheter into the stomach from a percutaneous approach. 3. Successful placement of a shortened 18 ___ MIC gastrojejunostomy tube. IMPRESSION: Successful repositioning of a 18 ___ MIC gastrojejunostomy tube. Radiology Report HISTORY: PICC placement. FINDINGS: In comparison with the study of ___, the tip of the PICC line extends to the mid portion of the SVC. The left pleural effusion appears less prominent, though this may merely reflect a more upright position of the patient. Cardiac silhouette is within normal limits and there is no appreciable pulmonary vascular congestion. Radiology Report CT OF THE ABDOMEN AND PELVIS WITH IV CONTRAST INDICATION: ___ woman with new anemia and recent paracentesis. Rule out retroperitoneal bleed. CT OF THE ABDOMEN AND PELVIS WITH IV CONTRAST TECHNIQUE: Multidetector scanning is performed from the diaphragm through the symphysis during dynamic injection of Omnipaque. Comparison is made to ___. CT OF THE ABDOMEN WITH IV CONTRAST: There are bilateral pleural effusions, left greater than right. These are not significantly changed. There is mild atelectasis at the lung bases bilaterally. The liver enhances homogeneously. A moderate hiatal hernia is noted. The spleen is normal in size. The pancreas enhances normally. The adrenal glands are unremarkable. The kidneys enhance homogeneously. There is no retroperitoneal lymphadenopathy. The aorta is normal in caliber. There is no free fluid throughout the abdomen and enhancement of the peritoneum is seen. The fluid contains some air inclusions on the right (series 4, ___ 35). CT OF THE PELVIS WITH IV CONTRAST: A catheter is identified in the fluid collection that was introduced from the left. There is little fluid around the catheter in the pelvis and in the left flank; however, more fluid is seen anteriorly to the small bowel. This fluid has newly accumulated compared to ___. The bladder is unremarkable. There is no pelvic lymphadenopathy. There is no inguinal lymphadenopathy. Peritoneal nodules as noted on PET-CT from ___ are again noted and are stable. On bone windows, there is a small sclerotic focus in the vertebral body of L5. IMPRESSION: 1. Reaccumulation of fluid within the peritoneal cavity, particularly on the right side of the abdomen. There is little fluid in the left flank along the existing catheter as well as in the pelvis. There is diffuse thickening of the peritoneum and superinfection cannot be excluded. 2. Bilateral pleural effusions, left greater than right are stable. 3. Gastrostomy tube in adequate position. 4. Peritoneal nodules are again noted and are stable. Radiology Report INDICATION: ___ year old woman with g tube malpositioned // Attention : ___ G TUBE REPOSITION REQUEST COMPARISON: CT of the abdomen and pelvis from ___. TECHNIQUE: OPERATORS: Dr. ___ radiology fellow) and Dr. ___ radiology attending) performed the procedure. The attending, Dr. ___ was present and supervising throughout the procedure. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 250 mcg of fentanyl and 3 mg of midazolam throughout the total intra-service time of 2 hr. 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: 20 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 15 min, 250 mGy PROCEDURE: 1. Replacement and repositioning of an 8 ___ peritoneal drain into the left upper quadrant. 2. Exchange of an existing 14 ___ MIC G tube for a new 20 ___ Ponsky G-tube. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The right gastrostomy tube and peritoneal drainage catheter were prepped and draped in the usual sterile fashion. Following injection of 1% lidocaine, the paracentesis catheter was cut and a ___ wire was advanced through the catheter into the peritoneal cavity. Over the wire an 8 ___ sheath was advanced and a second wire, a ___ wire, was advanced into the peritoneum. The sheath was then withdrawn over both wires and advanced over the ___ wire. Using a Kumpe catheter the ___ wire was directed towards the left upper quadrant into the vicinity of the stomach. The sheath was then removed and an 8 ___ biliary catheter was advanced over the wire into the left upper quadrant. The wire and inner stiffener were removed, the catheter was locked, secured with stay sutures and a Flexitrack device and sterile dressings were applied. The catheter was attached to a large ___ bulb for suction. Next attention was turned towards exchanging the existing G-tube. Dr. ___ joined the procedure. The glidewire was advanced through the gastrostomy tube into the stomach. Before an endoscope could be advanced into the oral cavity, the wire was noted to enter the esophagus under fluoroscopy. The wire was pushed through the mouth and secured. At this point further involvement from the gastroenterologists was not required. A 5 ___ angled glide catheter was advanced over the wire and through and through access was obtained. The wire was then removed and the introducer wire from a Ponsky G-tube kit was advanced through the wire and secured through the oral cavity. The G-tube was then pulled through the oral cavity into the stomach. The existing G-tube was removed after its balloon was deflated. The gastrostomy catheter was cut and a clamp and hub was placed. Contrast injection confirmed appropriate location of the new catheter. The catheter was secured with 0 silk sutures and sterile dressings were applied. The patient tolerated the procedure well. FINDINGS: 1. 8 ___ biliary drainage catheter successfully repositioned into the left upper quadrant. 2. Successful exchange of a 14 ___ mic gastrostomy tube for a new 20 ___ Ponsky gastrostomy tube. Intraluminal location was confirmed with a contrast injection that showed gastric rugae. IMPRESSION: Successful exchange of a 14 ___ mic gastrostomy tube for a new 20 ___ Ponsky gastrostomy tube. RECOMMENDATION: Please place the 8 ___ biliary drainage catheter to a large JP bulb for suction for at least 48 hr to ensure adequate drainage from the left upper quadrant. Please use the gastrostomy as needed for venting. Radiology Report INDICATION: ___ year old woman with venting G tube, peritonitis, vomiting, and 75cc bloody emesis, evaluate for perforation. TECHNIQUE: Upright and supine radiographs of the abdomen and pelvis were obtained. COMPARISON: CT abdomen and pelvis from ___. FINDINGS: There is air and contrast material seen within the ascending colon, descending colon and the rectum. Overall bowel gas pattern is nonobstructive. There is no intraperitoneal free air. There are likely small bilateral pleural effusions, left greater than right. A pigtail catheter projects over the left hemi-abdomen. Surgical clips are seen over the right mid abdomen. IMPRESSION: No evidence of pneumoperitoneum. Non-obstructive bowel gas pattern. Radiology Report INDICATION: ___ year old woman with venting G tube, peritonitis, vomiting, and 75cc bloody emesis. // to eval pna? TECHNIQUE: Chest PA and lateral COMPARISON: ___ FINDINGS: A right PICC ens in the low SVC. The moderate left pleural effusion is likely unchanged allowing for differences in technique with associated atelectasis. Pulmonary vascular congestion has improved. A small right pleural effusion is unchanged. Heart size and mediastinal contours are normal. No pneumothorax. IMPRESSION: Stable moderate left and small right pleural effusions with associated atelectasis. Interval improvement in pulmonary vascular congestion. No focal consolidation. Radiology Report INDICATION: Patient with fallopian cancer status post brief intubation for EGD this morning now with tachypnea, hypoxia and abnormal breath sounds left base. Question aspiration pneumothorax. COMPARISON: ___. FINDINGS: A right PICC ends in the mid SVC. Compared to the prior study there are new patchy bibasilar opacities with increase in left pleural effusion. The heart size and mediastinal contours are stable. No right pleural effusion or pneumothorax. IMPRESSION: New bibasilar patchy opacities could reflect aspiration, infection or edema. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 3:22 ___, 15 minutes after discovery of the findings. Radiology Report INDICATION: New intubation. Assess ETT placement. COMPARISON: ___ at 14:12. FINDINGS: Portable frontal radiograph of the chest demonstrates the ET tube ending 2.5 cm above the carina. A esophageal probe is noted in the upper esophagus. The right PICC is in unchanged position. An NG tube within the stomach. There is overall worsening of lower lobe opacities which are now becoming more confluent and involving the left upper lobe. Small bilateral pleural effusions are possible. Stable heart size and mediastinal contours. No pneumothorax. IMPRESSION: Tubes and lines in satisfactory position. Overall worsening of lower lobe opacities with new upper lobe opacities could reflect aspiration or superimposed edema. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 3:22 ___, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman, intubated with new NG tube // NG tube placement? COMPARISON: ___ IMPRESSION: As compared to the previous image, a new nasogastric tube has been inserted. The course of the tube is unremarkable, the tip projects within 2 cm of the old tube. No evidence of complications, notably no pneumothorax. The other monitoring and support devices are constant. Constant is severe bilateral parenchymal opacities, notably at the lung bases. Retrocardiac atelectasis and mild left pleural effusion are unchanged. Radiology Report INDICATION: ___ year old woman with metastatic fallopian tube CA s/p NG tube placement // NG tube placement. TECHNIQUE: Portable AP radiograph of the chest. COMPARISON: Chest radiograph from ___. FINDINGS: The nasogastric tube terminates within the body of the stomach however the side port is immediately distal to the gastroesophageal junction. Right-sided PICC line terminates in the mid SVC. Severe bilateral parenchymal opacities, notably at the lung bases, right greater than left are persistent. Small bilateral pleural effusions and retrocardiac atelectasis is unchanged. There is no evidence of a pneumothorax. The visualized osseous structures are unremarkable. IMPRESSION: 1. Nasogastric tube extends below the diaphragm however the side port is immediately distal to the gastroesophageal junction. This tube must be advanced if the patient is to be fed. 2. Persistent severe bilateral parenchymal opacities at the lung bases. Persistent mild left pleural effusion. NOTIFICATION: These findings were discussed with Dr. ___ by Dr. ___ by phone at 11:00 on the day of the exam. Radiology Report EXAMINATION: PORTABLE ABDOMEN INDICATION: ___ year old woman with obstruction secondary metastatic fallopian tube cancer. Please evaluate position of NGT, Gtube and JP drain. TECHNIQUE: Portable abdominal radiograph. COMPARISON: ___ FINDINGS: The tip of the nasogastric tube is in the stomach with the proximal side hole past the gastroesophageal junction. The previous pigtail catheter in the left upper quadrant is in an unchanged position, likely the JP drain. The additional catheter in the left upper quadrant, the tip of which terminates near the nasogastric tube, is likely the G-tube. There is a relative paucity of bowel gas with air noted in the rectum. IMPRESSION: 1. Left upper quadrant pigtail catheter in unchanged position since ___. 2. Nasogastric tube terminates in the stomach. 3. New left upper quadrant catheter, presumably the G-tube, terminates in the area of the NG tube tip. Radiology Report EXAMINATION: PORTABLE ABDOMEN INDICATION: ___ year old woman with G-tube recently revised, please evaluate placement. TECHNIQUE: Portable abdominal radiograph COMPARISON: 1 day prior FINDINGS: The left upper quadrant JP drain is in an unchanged position. The G-tube appears to terminate in the area of the stomach. There has been interval removal of the nasogastric tube. Continued relative paucity of bowel gas with visualization of loops of small bowel in the left upper quadrant. IMPRESSION: Unchanged position of the JP drain. Tip of the G tube appears to terminate in the area of the stomach. Radiology Report INDICATION: ___ year old woman with stage IV adenocarcinoma of the fallopian tube with peritoneal deposits. Evaluate ascites and known peritoneal metastasis. TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis following intravenous administration of 130cc of Omnipaque. Coronal and sagittal reformations were performed. DOSE: DLP: 1859 mGy-cm. COMPARISON: CT dated ___. FINDINGS: Chest: When compared to examination dated ___, there has been minimal change in bilateral pleural effusions, the left greater than right. There is mild associated atelectasis. The heart and pericardium are unremarkable. The liver enhances homogeneously without focal lesions identified. The gallbladder pancreas spleen and adrenal glands are unremarkable. The kidneys enhance contrast symmetric freely without focal lesion identified. There is no hydronephrosis. There is a dilated esophagus. A G-tube is seen with just the tip identified within the lumen of the stomach. The disc and more proximal tubing is coiled outside the lumen. The duodenum appears mildly dilated and the proximal small bowel distended to approx 3 cms. A transition level is seen within the left mid abdomen with collapsed loops of bowel distally. A partial obstruction cannot be excluded. When compared to prior examination. There has been no change in the amount of free fluid within the abdominal cavity. Since prior examination, there has been resolution of prior identified air inclusions. The abdominal aorta is patent and normal in caliber without aneurysmal dilatation. Pelvic CT: Since prior examination, the previously identified catheter within the left flank has been replaced with a drain terminating more superiorly in the left upper quadrant. Lack of oral contrast and collapsed loops of disyal small bowel makes separation from and identification of peritoneal implants difficult. The bladder is unremarkable. There is no pelvic free fluid. Osseous structures: Redemonstration of stable appearing sclerotic lesion within T9 vertebral body. No new suspicious lytic or blastic lesion is identified. IMPRESSION: 1. Ascites, unchanged with resolution of prior air inclusions. 2. Lack of oral contrast limits evaluation of known peritoneal implants. 3. Duodenal and small bowel dilatation with transition point in left mid abdomen. A partial small bowel obstruction cannot be excluded. 4. Gastric tube with tip terminating in lumen but coiled tubing and disc seen outside the lumen wall. NOTIFICATION: These findings regarding the G tube were discussed with the ___ Radiologist ___ at 11:00 on ___ by Dr. ___ at the time of the findings. Radiology Report INDICATION: ___ year old woman with peritoneal mets complicated by bowel obstruction // please exchange/reposition displaced g tube COMPARISON: CT of the abdomen from ___. TECHNIQUE: OPERATORS: Dr. ___ radiology fellow), Dr. ___ Dr. ___ radiology ___ performed the procedure. The attending, Dr. ___ was present and supervising throughout the procedure. ANESTHESIA: General anesthesia was administered by the anesthesiology department. Please refer to anesthesiology notes for details. MEDICATIONS: None. CONTRAST: 60 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 40 min, 370 mGy PROCEDURE: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The tube site was prepped and draped in the usual sterile fashion. Under fluoroscopic guidance, a Glidewire was introduced into the gastrostomy tube. A second wire was introduced through the nasogastric tube and the nasogastric tube was removed. A 6 ___ renal double curve guiding catheter was advanced over the wire into the stomach through the nares. The wire was then removed and a ensnare was advanced into the stomach. The glidewire through the gastrostomy tube was advanced in the stomach and snared. The wire that was pulled out through the nose. A ___ catheter was advanced over the Glidewire and was used to exchanged the Glidewire for an Amplatz wire. The existing gastrostomy tube and biliary catheter were removed over the wire. A peel-away sheath was advanced over the Amplatz wires through the percutaneous gastrostomy site. Through the peel-away sheath, a Kumpe catheter and Glidewire were advanced and attempts were made to position the Kumpe catheter in a post-pyloric location. After multiple unsuccsesful attempts, the Kumpe catheter was removed. A 18 ___ MIC GJ tube was advanced. After initial difficulty, the jejunal portion of the tube was cut and the shortened tube was advanced into the stomach. Contrast injection confirmed appropriate position. The tube was then secured to the skin using sutures. Sterile dressings were applied. The nasogastric tube was removed. The patient tolerated the procedure well. FINDINGS: 1. Malpositioned percutaneous gastrostomy tube. 2. Successful repositioning of a catheter into the stomach from a percutaneous approach. 3. Successful placement of a shortened 18 ___ MIC gastrojejunostomy tube. IMPRESSION: Successful repositioning of a 18 ___ MIC gastrojejunostomy tube. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with metastatic ovarian carcinoma p/w with anemia and G-tube dysfunction // please evaluate for worsening L effusion v consolidation TECHNIQUE: Portable chest COMPARISON: ___. FINDINGS: The PICC line is unchanged. The NG tube is been removed. There are moderate bilateral pleural effusions which have increased slightly compared to the study from 6 days prior. There is minimal pulmonary vascular redistribution. Cardiac size is upper limits of normal. IMPRESSION: Increased bilateral pleural effusions. No focal infiltrate Gender: F Race: WHITE - OTHER EUROPEAN Arrive by WALK IN Chief complaint: Anemia Diagnosed with ANEMIA NOS, HYPERTENSION NOS temperature: 96.8 heartrate: 109.0 resprate: 18.0 o2sat: 98.0 sbp: 135.0 dbp: 69.0 level of pain: 0 level of acuity: 2.0

Ms. ___ is a ___ yo F with stage IV serous adenocarcinoma of the fallopian tube with widespread abd mets peritoneal carcinomatosis s/p venting G tube placement and JP drain placement for recurrent SBO/malignant ascites, who was admitted for asymptomatic anemia (HCT ___ with hospital course complicated by recurrent peritonitis and hematemesis. # Hematemesis: On initial presentation, patient was asymptomatic with no evidence of active bleeding. Labs had no evidence of hemolysis with normal Tbili and LDH. Etiology of anemia was thought to be multifactorial including secondary to chemotherapy, anemia of chronic disease, and malignancy. Patient was transfused with improvement in hct. She was maintained on max dose PPI. Hospital course was complicated by hematemesis of 50cc (dark red blood) initially thought to be secondary to a ___ tear or ulceration from the tubing. Patient remained hemodynamically stable and did not require further pRBC tranfusion, so EGD was not performed at that time. However, on the afternoon of ___, the patient had nearly continuous drainage of dark blood out of her G-tube followed by 300cc of hematemesis. She remained hemodynamically stable but hematocrit had dropped from 27.9 to 22.3 so she was transfused 2 units pRBCs. She was transferred to the MICU for closer monitoring as well as EGD. The EGD was performed on ___ and revealed ulcers in the stomach and esophagitis. No active bleeding was seen. She was continued on BID PPI. Her hematocrit did continue to trend downwards and she required multiple blood transfusions thought to be related to small ___ tears in the setting of emesis. # Nausea and vomiting: Initially felt to be secondary to malpositioned peritoneal drain, G-tube, and recurrent ascites. There was no evidence of obstruction on imaging and patient was having bowel movements and passing gas. 8 ___ biliary drainage catheter was successfully repositioned into the left upper quadrant by ___ on ___. In addition, the patient's 14 ___ mic gastrostomy tube was exchanged for a new 20 ___ Ponsky gastrostomy tube also on ___. She was treated with standing ondansetron, PRN lorazepam, and she was started on olanzapine 2.5mg BID which was uptitrated to 5mg BID due to persistent emesis. An NGT was placed while the patient was in the ICU and drained ~600ml/24-hours. The G tube was exchanged for a G-J tube on ___ with successful drainage and control of nausea vomiting. She was discharged on standing zyprexa, IV octreotide and prn zofran/ativan. # PNA: Aspiration event during EGD on ___ requiring reintubation. She was successfully extubated on ___ and weaned to room air on the floor. Daptomycin was changed to linezolid and zosyn was started. The patient defervesced. Bactrim, linezolid and zosyn were continued through ___. # Recurrent malignant ascites: Patient has hx of secondary peritonitis. Patient had been recently discharged on a 10 day course of ertapenem at last admission and completed course (on unasyn on ___. CT a/p had incidental findings of reaccumulation of fluid on the right side of the abdomen. On ___, patient underwent repositioning of a new 8 ___ pigtail drainage catheter in the left upper quadrant adjacent to the G-tube and exchange of the G-tube with a new 20 ___ Ponsky PEG tube. Peritoneal fluid from JP drain with leukocytosis, 97% polys, and fluid culture grew stenotrophomonas (sensitive to Bactrim) and VRE (sensitive to daptomycin). Bactrim and daptomycin were ultimately changed to bactrim, linezolid, zosyn secondary to aspiration pneumonia as above, and then spillage of large amounts of gastric contents in the peritoneum secndary to displaced G-tube. She completed antibiotics on ___. She has a JP drain in place to continue to drain ascites which was straw colored on day of discharge. # Tachycardia: The patient had persistent sinus tachycardia since last hospital stay, likely in the setting of decreased intake, anemia and stress of advanced malignancy. Patient denied any associated shortness of breath and remained hemodynamically stable. #. Serous Adenocarcinoma of the Fallopian Tube: Recurrent cancer s/p ex lap, TAH/BSO, transverse colectomy, total omentectomy, tumor debulking, 6 cycles of IV/IP cis/taxol, and ___, now on gemcitabine (last dose ___. Chemotherapy on ___ was held in the setting of acute illness. With improvement of the above issues, she received gemcitabine on ___ which she tolerated well. Further outpatient chemotherapy per Dr. ___. # Pain control: Initially on home fentanyl patch, which was discontinued when acutely ill in the ICU. She had no ongoing pain and was discharged off of pain medications. # Nutrition: She was continued on TPN. She tolerated clear liquid diet at the time of discharge which may be advanced as an outpatient

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: lisinopril / Feraheme / atenolol Attending: ___ Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Foley catheter (___) History of Present Illness: ___ with history of HTN, HLD, polyvalvular disease, and anemia who presents with one week of shortness of breath. She was in her usual state of health until one week ago when she started developing nausea and shortness of breath with acute worsening on the morning of admission. She has noticed difficulty walking up stairs and around the block, activities she was able to do without getting short of breath prior to last week. She endorses PND and orthopnea (using 2 pillows in past week compared to 1 pillow prior to that). Furthermore, she has noticed increased swelling in her legs and has felt fatigued. She did have a cough this prior ___ but it resolved the same day. She denies any fever, chills, vomiting, diarrhea, chest pain, lightheadedness, or diaphoresis. Of note, she has been reported to have exertional shortness of breath in the past, which has been attributed to her worsened anemia from chronic GI blood loss. She receives iron sucrose infusions every 4 weeks. She has had an extensive evaluation for her low-grade chronic Gi bleeding and only vessel ectasia has been found. In the ED, initial vitals: 98.0 102 177/66 20 98% 4L. Labs were notable for Cr 1.6 (baseline past ___ years), BNP 1887, and Hgb 6.1 Hct 19.8. Exam was notable for diminished lung sounds in R base without wheezes or crackles and trace foot edema. Rectal exam was negative. She received IV Zofran 4 mg for nausea and IV Ceftriaxone 1 gm and IV Azithromycin 500 mg for possible pneumonia. Vitals prior to transfer: 98.8 82 151/53 26 94% 1L NC. Currently, she is on 1L NC without any respiratory distress, resting comfortably in bed. Although her O2 sat remains stable on RA, she subjectively becomes short of breath. Past Medical History: -Anemia secondary to iron deficiency with question of myelodysplastic syndrome. Patient had endoscopoies and capsule studies ___ years ago that showed no source of bleeding. On monthly iron infusions -s/p total abdominal hysterectomy with oophorectomy. -lung cancer in ___ with surgery and removal of part of her left lung. She had no chemo. She smoked one pack per day for ___ years, but not now. -sickle cell trait -benign breast lesions -polyvalvular disease (2+ MR/2+ TR) Social History: ___ Family History: Both parents are deceased, one sister, one brother alive and well. She had a total of six brothers and four sisters, a nephew died of sickle cell disease, it is her sister's son. She has three children. Her daughter had cancer of the breast. She has five grandchildren alive and well. Physical Exam: At admission: VS: 98.8 150/64 94 18 94% 1L NC 93% RA GENERAL: Alert, oriented, no acute distress, pleasant and well-appearing HEENT: Sclerae anicteric, MMM, oropharynx clear NECK: supple, JVP elevated, no LAD RESP: diminshed breath sounds with absent sounds in R base, crackles heard at bases, no wheezes or rhonchi CV: RRR, Nl S1, S2, +S4, ___ systolic murmur heard at apex ABD: 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, motor function grossly normal SKIN: No excoriations or rash. At discharge: VS: 100.3 98.6 70-100s 130-160s/40-70s 18 94%RA Wt: 64.7 kg (65.2 kg yesterday, admission 69 kg) I/O's: incomplete but at least p24H ___ pMN NR/350 GENERAL: Alert, oriented, no acute distress, pleasant and well-appearing HEENT: Sclerae anicteric, MMM, oropharynx clear NECK: stiff to flexion and rotation, JVP not elevated, no LAD RESP: Diminshed breath sounds at bilateral bases, no crackles, wheezes, or rhonchi CV: RRR, Nl S1, S2, ___ holosystolic murmur heard at apex ABD: Soft, NT/ND bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema; mild L knee pain now improving, able to passively flex and extend, no erythema/swelling/effusion noted NEURO: CNs2-12 intact, motor function grossly normal SKIN: No excoriations or rash Pertinent Results: Labs at admission: ___ 11:25AM ___ PTT-27.3 ___ ___ 11:25AM PLT COUNT-266 ___ 11:25AM NEUTS-72.0* ___ MONOS-5.7 EOS-2.1 BASOS-0.4 ___ 11:25AM WBC-4.0 RBC-2.49* HGB-6.1* HCT-19.8* MCV-80* MCH-24.3* MCHC-30.5* RDW-17.8* ___ 11:25AM ALBUMIN-3.6 CALCIUM-9.2 PHOSPHATE-3.2 MAGNESIUM-2.2 ___ 11:25AM proBNP-1887* ___ 11:25AM LIPASE-34 ___ 11:25AM ALT(SGPT)-10 AST(SGOT)-32 ALK PHOS-64 TOT BILI-0.3 ___ 11:25AM estGFR-Using this ___ 11:25AM GLUCOSE-90 UREA N-19 CREAT-1.6* SODIUM-141 POTASSIUM-4.9 CHLORIDE-108 TOTAL CO2-23 ANION GAP-15 ___ 11:42AM LACTATE-1.9 Labs at discharge: ___ 05:37AM BLOOD WBC-7.8 RBC-2.83* Hgb-7.0* Hct-23.5* MCV-83 MCH-24.7* MCHC-29.8* RDW-16.8* RDWSD-51.4* Plt ___ ___ 05:37AM BLOOD Plt ___ ___ 05:37AM BLOOD Glucose-100 UreaN-46* Creat-1.7* Na-136 K-4.3 Cl-102 HCO3-25 AnGap-13 ___ 05:37AM BLOOD Calcium-9.4 Phos-4.1 Mg-2.9* Micro: BLOOD CULTURE (___): NO GROWTH. BLOOD CULTURE (___): pending BLOOD CULTURE (___): pending BLOOD CULTURE (___): pending BLOOD CULTURE (___): pending BLOOD CULTURE (___): pending URINE CULTURE (Final ___: NO GROWTH. C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. Imaging: CXR (___): 1. Findings consistent with moderate congestive heart failure including pleural effusions with suspected left basilar atelectasis. Pneumonia is not excluded, however. 2. Possible developing opacity at the right lung base versus regional edema. In addition to that, right hilum appears enlarged. Although these findings may be congestive in nature, re-evaluation in follow-up radiographs is recommended after treatment. TTE (___): Moderate to severe mitral regurgitation. Moderate pulmonary artery hypertension. Normal left ventricular cavity size with preserved regional and global systolic function. Mild right ventricular cavity dilation with preserved free wall motion. Moderate tricuspid regurgitation. Compared with the report of the prior study (images unavailable for review) of ___, the severity of mitral regurgitation and the estimated PA systolic pressure have both increased. The right ventricle is now mildly dilated. CXR (___): No relevant change as compared to the previous image. Known left postoperative changes with missing left rib. Elevation of the left hemidiaphragm with small left pleural effusion. Mild pulmonary edema. Mild cardiomegaly. Atelectasis at both the left and the right lung bases. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amitriptyline 10 mg PO QHS 2. Omeprazole 20 mg PO DAILY 3. Pravastatin 40 mg PO QPM 4. NIFEdipine CR 30 mg PO DAILY 5. Venofer (iron sucrose) 200 mg/10 mL iron injection q4week Discharge Medications: 1. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every 6 hours as needed Disp #*10 Tablet Refills:*0 2. Acetaminophen 500 mg PO Q6H:PRN pain 3. Amitriptyline 10 mg PO QHS 4. Omeprazole 20 mg PO DAILY 5. Pravastatin 40 mg PO QPM 6. Venofer (iron sucrose) 200 mg/10 mL iron INJECTION Q4WEEK 7. Lidocaine 5% Patch 1 PTCH TD QPM knee pain 8. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN stomach discomfort Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES: Congestive Heart Failure Polyvalvular Heart Disease Acute on Chronic Kidney Disease Chronic Anemia Mechanical Left Knee Pain Neck Muscle Stiffness SECONDARY DIAGNOSES: Hypertension Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CHEST RADIOGRAPHS INDICATION: Shortness of breath. TECHNIQUE: Chest, AP upright and lateral. COMPARISON: ___ and ___. FINDINGS: There again surgical clips in the mediastinum. The heart appears mildly enlarged. There is increased prominence in the aortopulmonary window which is suggestive of enlarged left atrial appendage. On the right there is probably a trace pleural effusion. On the left, there is a small to moderate pleural effusion with associated opacity probably due to atelectasis in the posterior left lower lobe. More generally, a moderate interstitial abnormality is most suggestive of congestive heart failure. Fissures are thickened. The right hilum appears more prominent than before and in addition there is the possibility of developing focal opacity at the right lung base. Streaky opacities in the lingula appear unchanged suggesting background scarring and mild volume loss, as depicted on prior studies. IMPRESSION: 1. Findings consistent with moderate congestive heart failure including pleural effusions with suspected left basilar atelectasis. Pneumonia is not excluded, however. 2. Possible developing opacity at the right lung base versus regional edema. In addition to that, right hilum appears enlarged. Although these findings may be congestive in nature, re-evaluation in follow-up radiographs is recommended after treatment. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with clinically volume overloaded undergoing diuresis, now with acute hypoxia to 79%on room air // eval pleural effusions, pulm edema COMPARISON: ___ IMPRESSION: No relevant change as compared to the previous image. Known left postoperative changes with missing left rib. Elevation of the left hemidiaphragm with small left pleural effusion. Mild pulmonary edema. Mild cardiomegaly. Atelectasis at both the left and the right lung bases. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ former smoker with history of HTN, HLD, and anemia presenting with dyspnea. Now with fever // please eval for pneumonia COMPARISON: ___. IMPRESSION: As compared to the previous image, there is evidence of increasing radiodensity in the right lung apex. Part of this observation might be caused by rotation of the patient. However, coexisting developing pneumonia might also be present. Short term radiographic followup is recommended. Otherwise, the radiograph is unchanged. Mild cardiomegaly and postoperative appearance of the left lung base is constant. Radiology Report INDICATION: Evaluate for fracture or other abnormality in a patient with acute knee pain. COMPARISON: None available. FINDINGS: AP and lateral left knee radiographs demonstrate no acute fracture, dislocation, or joint effusion. There are mild degenerative changes in the lateral and patellofemoral compartments, without significant loss of joint space. Chondrocalcinosis in the lateral compartment is noted, as are vascular calcifications. There is no focal lytic or sclerotic lesion. IMPRESSION: 1. No acute fracture or dislocation. 2. Mild degenerative changes of the lateral and patellofemoral compartments, with chondrocalcinosis in the lateral compartment as well as vascular calcifications. Radiology Report EXAMINATION: RENAL U.S. INDICATION: ___ year old woman with acute on chronic renal failure in setting of diuresis. Please evaluate for hydronephrosis or other abnormalities. TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: CT from ___. FINDINGS: The right kidney measures 9.2 cm. The left kidney measures 10.0 cm. There is no hydronephrosis, stones, or masses bilaterally. The kidneys are echogenic bilaterally, consistent with medical renal disease. There are multiple small bilateral cysts similar to the prior study. The cyst in the upper pole of the right kidney appears minimally complex with internal echoes and/or septations. The bladder is moderately well distended and normal in appearance. IMPRESSION: Echogenic kidneys consistent with medical renal disease. No evidence of urinary obstruction. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with new fevers to 101.9 and previous x-rays suggesting pneumonia // Please eval for interval change COMPARISON: ___ IMPRESSION: As compared to the previous radiograph, a pre-existing right basal parenchymal opacity has completely cleared. The left hemi thorax is unchanged, the postoperative lesions at the level of the hilus and the costophrenic sinus are constant. No new focal parenchymal opacities suggesting pneumonia. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Dyspnea Diagnosed with ANEMIA NOS, SHORTNESS OF BREATH temperature: 98.0 heartrate: 102.0 resprate: 20.0 o2sat: 98.0 sbp: 177.0 dbp: 66.0 level of pain: 0 level of acuity: 2.0

Ms. ___ is a previously highly functional ___ year old female with history of HTN, HLD, polyvalvular heart disease, and chronic anemia who presented with worsening dyspnea over the past week.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Keflex / Bactrim Attending: ___. Chief Complaint: Fevers, Rash Major Surgical or Invasive Procedure: None History of Present Illness: HPI: ___ male, previously healthy, presenting with high fever, and pruritic erythematous rash. Patient reported that several weeks ago, he developed a boil on his right chest, which he subsequently popped. Approximately 1 week ago, the boil continued to drain pus, increased in size, "appear infected." Patient initially presented to his PCP ___ ___, and was prescribed Bactrim. During that time, the patient reported a temperature to 104, which improved within a few days. 3 days prior to presentation, the patient reported that he "felt sick," and presented to an outside hospital, where he was prescribed Keflex for left middle ear infection. Patient began to have a pruritic generalized erythematous rash initially over his chest and torso. On the morning of admission, patient noted that after he took a shower, the rash spread across his whole body and he "looked like a tomato". In the ED, initial vital signs were 99.1 102 167/97 16 100% on RA. Labs were notable for a CBC with a WBC of 3.7 (70% neutrophils, 19% lymphocytes, 3% monocytes, 6.8% eosinophils), BMP WNL, LFTs with ALT 207, AST 191 146, T bili 0.3, lactate elevated at 2.5. ProBNP 44. UA notable for protein and ketones. Physical exam was notable for mild erythematous eruption over bilateral upper extremities, chest, back, and a healing skin lesion on his right upper chest, with inferior auricular lymphadenopathy. Patient was evaluated by dermatology who felt that his syndrome was overall consistent with DRESS. She received IV Zofran, IV Benadryl, 100 mg doxy, 1000 mg of acetaminophen, normal saline, prednisone 80 mg ×1. Upon arrival to the floor, the patient tells the story as above. He reports that he first became ill approximately ___ weeks ago. During that time, he was noted to have high fevers, up to 104, and he went to a clinic. Reportedly, the doctor told him "his spleen was enlarged" which was assessed via physical exam, without radiographic evidence. He took antibiotics at that time, but he does not know which one. He also reports that he was told he had a viral infection. Reportedly, he was tested for mono during that time, and he believes this came back negative. At that visit, he was also told that his liver enzymes were abnormal, but reports no further testing. Review of pharmacy records show that in early ___, he took a course of penicillin and most likely dexamethasone, so it is unclear if this is the episode he is mentioning. He did not have a rash at that time. He reports that in the last month, he has had increasing fatigue and lack of energy. He tells a story as above, beginning with a boil, with antibiotic history as above. However he notes, that whenever he has high fevers, he feels extremely unwell, associated with headaches, chills, rigors. She reports that the lymph nodes in his neck swell to the point that is extremely painful, and seems to be associated both with this incident as well as his incident of fevers approximately ___ months ago. He reports some nausea without vomiting that occurs with these episodes. On the day of admission, the patient was taking both Bactrim and Keflex as prescribed. He otherwise denies chest pain, abdominal pain, dysuria, diarrhea, bloody bowel movements. She otherwise denies sick contacts, recent travel, recent hiking or outdoor activity, or recent tick bites. He reports that his family recently traveled to ___, but he "stayed in hotel" and did not participate in outdoor activities. Past Medical History: Denies ___ Social History: ___ Family History: + DM, Parkinsons, +CAD requiring heart surgery in his father. He denies FH of cancers. Physical Exam: ADMISSION PHYSICAL EXAM VITALS: 98.6 PO ___ 20 97 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 Mucous membranes dry, with no obvious mucous membranes lesions Significant postauricular lymphadenopathy, standing down the anterior cervical chain, lymphadenopathy tender to palpation Lymph: Cervical lymphadenopathy as well, no axillary or inguinal lymphadenopathy CV: Heart regular, no murmur RESP: Lungs clear to auscultation with good air movement bilaterally GI: Abdomen soft, non-distended, non-tender to palpation, no appreciable hepatosplenomegaly MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: Faint erythematous confluent rash on the upper extremities and anterior torso, < 1 cm ulceration on right upper chest without fluctuance NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs PSYCH: pleasant, appropriate affect DISCHARGE PHYSICAL EXAM GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Improving but still painful post-auricular lymphadenopathy, also with anterior cervical chain, lymphadenopathy tender to palpation, particularly on L Lymph: Cervical lymphadenopathy as well, no axillary or inguinal lymphadenopathy CV: RRR, no mrg RESP: CTAB GI: Abdomen soft, non-distended, non-tender to palpation, no appreciable hepatosplenomegaly MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: Faint erythematous confluent rash on the upper extremities and anterior torso, < 1 cm ulceration on right upper chest without fluctuance, UE non pitting edema b/l NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs PSYCH: pleasant, appropriate affect Pertinent Results: LABS ___ 03:04PM BLOOD WBC:3.7* RBC:5.28 Hgb:14.5 Hct:44.4 MCV:84 MCH:27.5 MCHC:32.7 RDW:14.6 RDWSD:45.0 Plt Ct:155 ___ 08:10AM BLOOD WBC:3.8*# RBC:5.28 Hgb:14.5 Hct:44.7 MCV:85 MCH:27.5 MCHC:32.4 RDW:14.8 RDWSD:45.5 Plt Ct:184 ___ 03:04PM BLOOD Neuts:70.4 ___ Monos:3.0* Eos:6.8 Baso:0.0 Im ___ AbsNeut:2.58 AbsLymp:0.71* AbsMono:0.11* AbsEos:0.25 AbsBaso:0.00* ___ 08:10AM BLOOD Neuts:34.3 ___ Monos:8.0 Eos:5.3 Baso:0.3 Im ___ AbsNeut:1.29*# AbsLymp:1.94 AbsMono:0.30 AbsEos:0.20 AbsBaso:0.01 ___ 07:35AM BLOOD ___ PTT:36.4 ___ ___ 08:10AM BLOOD Glucose:93 UreaN:10 Creat:0.8 Na:146* K:4.5 Cl:103 HCO3:26 AnGap:17* ___ 08:10AM BLOOD ALT:184* AST:74* LD(LDH):303* AlkPhos:155* TotBili:0.3 DirBili:<0.2 IndBili:0.3 ___ 03:04PM BLOOD ALT:207* AST:191* LD(LDH):502* AlkPhos:146* TotBili:0.3 ___ 07:35AM BLOOD Albumin:4.1 Calcium:8.0* Phos:4.0 Mg:1.9 ___ 08:10AM BLOOD Ferritn:2324* ___ 07:35AM BLOOD HBsAg:NEG HBsAb:NEG HBcAb:NEG ___ 08:10AM BLOOD ANCA:PND ___ 08:10AM BLOOD RheuFac:<10 ___ CRP:36.8* ___ 07:35AM BLOOD HIV Ab:NEG ___ 07:35AM BLOOD HCV Ab:NEG ___ 07:35AM BLOOD CMV VL:NOT DETECT ___ 04:53PM BLOOD Lactate:2.5* ___ 07:59AM BLOOD Lactate:1.4 ___ 02:50PM URINE Blood:NEG Nitrite:NEG Protein:30* Glucose:NEG Ketone:40* Bilirub:SM* Urobiln:2* pH:6.5 Leuks:NEG ___ 02:50PM URINE RBC:<1 WBC:5 Bacteri:NONE Yeast:NONE Epi:0 DISHCARGE LABS WBC 3.8 HB 14.5 Plt 184 Na 146/K 4.5/CL 103/BUN 10/Cr 0.8 AST 74/ALT 184/LDH 303 Alk P ___ Tbili 0.5 Ca 8.7/Phos ___ 2.1 Hep B: negative, HIV negative CMV pending EBV: negative CRP 36.8 Ferritin 2324 UA: small bili, small protein, neg leuk esterase, neg bacteria Imaging: CT Chest: 1. Mildly enlarged, bilateral axillary lymph nodes up to 1.1 cm on the right and 1.0 cm in the left. No supraclavicular, mediastinal or hilar lymphadenopathy. 2. 2 mm solid nodule at the left lung apex. 3. Please refer to separate report for same day CT abdomen pelvis study for discussion of findings below the diaphragm. CT NECK 1. Increased number and prominence of cervical lymph nodes bilaterally which are nonspecific. Involvement of level V lymph nodes can still be reactive although there are no other signs of ongoing infection. Clinically correlate. CT ABD/PELVIS No lymphadenopathy by strict size criteria. Nonspecific subcentimeter mesenteric lymph nodes may be reactive. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 2. Cephalexin 500 mg PO Q6H 3. Sulfameth/Trimethoprim DS 1 TAB PO BID 4. Ondansetron 4 mg PO Q8H:PRN nausea 5. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild 6. Ibuprofen 200-600 mg PO Q6H:PRN Pain - Mild Discharge Medications: 1. Doxycycline Hyclate 100 mg PO Q12H RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth every 12 hours Disp #*16 Capsule Refills:*0 2. Mupirocin Ointment 2% 1 Appl TP BID to drained absecess on right chest RX *mupirocin [Centany] 2 % 1 application every day Refills:*0 3. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild 4. Ibuprofen 200-600 mg PO Q6H:PRN Pain - Mild 5. Ondansetron 4 mg PO Q8H:PRN nausea Discharge Disposition: Home Discharge Diagnosis: Fevers Skin Infection Inflammatory/Infectious or Autoimmune condition Elevated liver function tests Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ year old man with significant anterior cervical lymphadenopathy, fevers, transaminitis, which of note, the transaminitis/fevers occurred at least one month ago, now presenting with rash (?DRESS), would like to further r/o lymphoma due to need to treat with empiric steroids// evidence of lymphoma, mediastinal mass, other lymphadenopathy TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9 mGy-cm. 2) Stationary Acquisition 1.9 s, 0.2 cm; CTDIvol = 31.6 mGy (Body) DLP = 6.3 mGy-cm. 3) Spiral Acquisition 10.2 s, 66.4 cm; CTDIvol = 9.9 mGy (Body) DLP = 648.2 mGy-cm. Total DLP (Body) = 656 mGy-cm. COMPARISON: None. FINDINGS: LOWER CHEST: Please refer to separate report of CT chest performed on the same day for description of the thoracic findings. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. Normal appendix. No ascites. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: Prostate gland is not enlarged. LYMPH NODES: There is no retroperitoneal lymphadenopathy. Several scattered mesenteric lymph nodes are noted predominantly on the left, the largest measuring up to 0.6 cm (07:20, 4:63). Small bilateral pelvic sidewall nodes, the largest measuring up to 0.6 cm on the right (4:99). No inguinal adenopathy. VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease is noted. Likely a replaced right hepatic artery (04:54). BONES: There is a 0.5 cm sclerotic lesion in the posterior inferior pubic ramus/ischial tuberosity on the left (4:111), which may represent a bone island. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: No lymphadenopathy by strict size criteria. Nonspecific subcentimeter mesenteric lymph nodes may be reactive. Radiology Report EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK INDICATION: ___ year old man with significant anterior cervical lymphadenopathy, fevers, transaminitis, which of note, the transaminitis/fevers occurred at least one month ago, now presenting with rash (?DRESS), would like to further r/o lymphoma due to need to treat with empiric steroids// eval lymphadenopathy for reactive lymphadenopathy and/or evidence of mass/lymphoma TECHNIQUE: Imaging was performed after administration of 170 ml of Omnipaque intravenous contrast material. MDCT acquired helical axial images were obtained from the thoracic inlet through the skull base. Coronal and sagittal multiplanar reformats were then produced and reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.8 s, 31.4 cm; CTDIvol = 7.1 mGy (Body) DLP = 217.0 mGy-cm. Total DLP (Body) = 217 mGy-cm. COMPARISON: None. FINDINGS: Evaluation of the aerodigestive tract demonstrates no mass and no areas of focal mass effect. There are increased number and prominence of cervical lymph nodes bilaterally in level Ia, Ib, IIa, IIb, III, IV, and V. A lymph node in the left level V appears hypodense and measures 1.4 cm (3; 36). The salivary glands enhance normally and are without mass or adjacent fat stranding. The thyroid gland appears normal. The neck vessels are patent. The imaged portion of the lung apices are clear and there are no concerning pulmonary nodules. There are no osseous lesions. IMPRESSION: 1. Increased number and prominence of cervical lymph nodes bilaterally which are nonspecific. Involvement of level V lymph nodes can still be reactive although there are no other signs of ongoing infection. Clinically correlate. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ man with significant anterior cervical lymphadenopathy, fevers, transaminitis, now presenting with rash. Evaluate for lymphoma. TECHNIQUE: Multi-detector helical scanning of the chest was performed with intravenous iodinated contrast agent and reconstructed as 5 and 1.25 mm thick axial, 2.5 mm thick coronal and sagittal, and 8 mm MIP axial images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9 mGy-cm. 2) Stationary Acquisition 1.9 s, 0.2 cm; CTDIvol = 31.6 mGy (Body) DLP = 6.3 mGy-cm. 3) Spiral Acquisition 10.2 s, 66.4 cm; CTDIvol = 9.9 mGy (Body) DLP = 648.2 mGy-cm. Total DLP (Body) = 656 mGy-cm. ** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND PELVIS WITH CONTRAST) COMPARISON: Same day CT abdomen pelvis and CT neck. FINDINGS: NECK, THORACIC INLET, AXILLAE, CHEST WALL: The imaged thyroid is unremarkable. Prominent axillary lymph nodes measure up to 1.1 cm on the right (04:12) and 1.0 cm on the left (04:11). There is no supraclavicular lymphadenopathy. The esophagus is unremarkable. UPPER ABDOMEN: Please refer to separate report for same day CT abdomen pelvis study for discussion of findings below the diaphragm. MEDIASTINUM: Several mediastinal lymph nodes measure up to 9 mm in the lower right anterior paratracheal station (4:20). No mediastinal mass is seen. HILA: There is no hilar mass or lymphadenopathy. HEART and PERICARDIUM: Heart size is normal. The thoracic aorta is normal in caliber. There is no pericardial effusion. PLEURA: No pleural effusion or pneumothorax. LUNG: 1. PARENCHYMA: Minimal dependent atelectasis is noted. A 2 mm solid nodule is noted in the left lung apex (5:71). No suspicious masses, nodules or focal consolidations are seen. 2. AIRWAYS: The airways are patent to the level of the segmental bronchi bilaterally. 3. VESSELS: Main pulmonary artery diameter is within normal limits. Suboptimal evaluation of the pulmonary vasculature demonstrates no evidence of central pulmonary embolism. CHEST CAGE: No worrisome osseous lesions are identified. There is no acute fracture. IMPRESSION: 1. Mildly enlarged, bilateral axillary lymph nodes up to 1.1 cm on the right and 1.0 cm in the left. No supraclavicular, mediastinal or hilar lymphadenopathy. 2. 2 mm solid nodule at the left lung apex. 3. Please refer to separate report for same day CT abdomen pelvis study for discussion of findings below the diaphragm. Gender: M Race: ASIAN Arrive by WALK IN Chief complaint: Fever, Malaise, Rash Diagnosed with Rash and other nonspecific skin eruption, Adverse effect of cephalospor/oth beta-lactm antibiot, init, Oth places as the place of occurrence of the external cause temperature: 99.1 heartrate: 102.0 resprate: 16.0 o2sat: 100.0 sbp: 167.0 dbp: 97.0 level of pain: 10 level of acuity: 2.0

Summary: ___ otherwise healthy presenting with erythroderma, fevers, and lymphadenopathy with recent outpatient treatment with Bactrim and Keflex, found to have transaminitis, with clinical presentation concerning for possible DRESS, however, with over 1 month of fevers and lymphadenopathy at home.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: cisplatin Attending: ___. Chief Complaint: Bilateral Nephrostomy Tube Leakage Major Surgical or Invasive Procedure: Replacement of Bilateral nephrostomy tubes with ___ ___ Repeat Right nephrostomy tube exchange ___ with ___ History of Present Illness: Mr. ___ is s a ___ female with history of recurrent metastatic cervical cancer complicated by bilateral ureteral narrowing and rectovaginal fistulas, requiring diverting colostomy and bilateral nephrostomy tubes who presents for nephrostomy tube evaluation. She reports that there has been drainage around all of the tubes for the past few days and the bandages have fallen off. She has decreased output in left nephrostomy tube. The color of the drainage has been more brown but without blood. She has pain at her tube sites that is worse with movement. After the last nephrostomy change things had been working well. She notes her mother help with tube management and dressing changes. She does not currently have a ___. She also reports mild abdominal pain for the past few days associated with skin breakdown. She ran out of ostomy supplies so has not changed her ostomy bag in some time so believes the surrounding skin has become irritate. Also with right leg swelling for the past 2 days without pain. She notes chills without fever. She is currently wheelchair bound due to leg weakness. Of note, she has duplicated collecting system on left with a PCN in low pole and PCNU in upper moeity, last exchanged ___. On arrival to the ED, initial vitals were 98.5 118 111/68 20 100% RA. Exam was notable for ill-appearing with poor hygiene, ostomy bag in place with skin breakdown and erythema around the navel, 2+ right lower extremity unilateral edema, and 3 nephrostomy tubes in place draining clear urine without clots and bandages in disrepair and dirty with mild erythema at access sites. Per RN "upon exam dressings over nephrostomies noted to be saturated in brown foul smelling drainage with redness noted around umbilicus and multiple areas of stage 2 ulcers around groin". Labs were notable for WBC 3.9, H/H 8.6/27.6, Plt 151, Na 143, K 3.9, BUN/Cr ___, and lactate 1.3. Blood cultures were sent. Urine cultures from the nephrostomy tubes were ordered but not sent. ___ was consulted and recommended placing new clean dressings on tubes, obtaining abdominal x-ray to assess tube positioning, and NPO at midnight for possible drain exchange. Right leg ultrasound was negative for DVT. Abdominal x-ray showed tubes in place. Patient was given oxycodone 5mg PO x 2 and Zosyn 4.5g IV. Prior to transfer vitals were 98.8 114 114/73 14 99% RA. On arrival to the floor, patient reports ___ pain around her nephrostomy tubes. She denies fevers, headache, vision changes, dizziness/lightheadedness, weakness/numbness, shortness of breath, cough, hemoptysis, chest pain, palpitations, nausea/vomiting, diarrhea, hematemesis, hematochezia/melena, dysuria, hematuria, and new rashes. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: Stage ___ cancer (Diagnosed in ___: s/p chemoradiation (cisplatin course limited ___ ototoxicity) c/b radiation proctitis and rectovaginal fistulas s/p diverting ostomy, and ureteral obstruction s/p bilateral nephrostomy tubes PAST ONCOLOGIC HISTORY: - ___: Initial evaluation of postpartum menorrhagia, diagnosed with cervical cancer. Had prior history of abnormal Pap tests that normalized on follow-up. - ___: Received RT + cisplatin (truncated due to tinnitus) at ___, ? switch to carboplatin. - ___: Developed rectal bleeding, ultimately had colonoscopy ___ showing RT proctitis and rectovaginal fistula. - ___: Underwent lap diverting colostomy due to persistent rectal bleeding. Later developed urine leakage and blood from vagina, diagnosed with vesicovaginal fistula. Underwent bilateral PCNs due to worsening hydronephrosis. Hospitalized at ___ for 2 months, providers recommended palliative exenteration. - ___: First admission at ___, presenting with abdominal pain and decreased ostomy output, found to have left hydronephrosis and pyelonephritis, as well as pelvic fluid collections that appeared chronic, uninfected. Second left PCN was placed and pt was treated for pan-sensitive enterococcus bacteremia/urosepsis. Planned for outpatient evaluation for pelvic exenteration. - ___: Admitted to ___ for back pain, chills, vomiting, blood from ostomy site. Repositioned PCNs, no evidence of UTI. - ___: Admitted to ___ with N/V/abd pain, now found to have UTI and possible pyelonephritis on CT, treated for fungal UTI. - ___: Initial evaluation by Dr. ___ with Drs. ___ for consideration of pelvic exenteration. Felt to be a poor candidate due to nutritional status. - ___: Admitted to ___ for fevers, found to have severe left hydronephrosis and pyelonephritis, as well as left upper lung cavitary lesion. Underwent PCN replacement followed by EBUS and transbronchial biopsy on ___, path showing well-differentiated squamous cell carcinoma. - ___: C1 ___ AUC 4 & Taxol 140 mg/m2 - ___: C2 Cabo/Taxol Social History: ___ Family History: - ___ disease in father and uncles - melanoma in grandmother Physical Exam: ADMISSION PHYSICAL EXAM: VS: Temp 97.9, BP 116/76, HR 117, RR 16, O2 sat 99% RA. GENERAL: Pleasant woman, in no distress, lying in bed comfortably. HEENT: Anicteric, PERLL, OP clear. CARDIAC: Tachycardic, regular rhythm, normal s1/s2, no m/r/g. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: Soft, diffuse tenderness to palpation, non-distended, positive bowel sounds. LLQ ostomy (patient declined ostomy change overnight so unable to visualize stoma or underlying skin). Periumbilical erythema and dryness. GU: 2 left nephrostomy tubes and 1 right nephrostomy tubes with surrounding erythema at insertion site. Dressings soaked through and soiled. Minimal urine in bags. Partial thickness skin loss in bilateral groin folds. Foul-smelling brown vaginal discharge. EXT: Warm, well perfused, 2+ right lower extremity edema. NEURO: A&Ox3, good attention and linear thought, CN II-XII intact. Strength full throughout. Sensation to light touch intact. Discharge physical exam ======================== T 97.8 HR ___ BP 96 / 62 RR 14 GENERAL: Appears comfortable, sitting in chair. NAD HEENT: Anicteric, PERLL, OP clear. no LAD CARDIAC: Tachycardic, regular rhythm, normal s1/s2, no m/r/g. LUNG: clear to auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: Soft, tender to palpation in LLQ around ostomy site, non-distended, positive bowel sounds. LLQ ostomy with red healthy-appearing stoma. Periumbilical erythema and dryness, with skin under abdominal folds dry and less erythematous than yesterday. GU: Left nephrostomy upper and lower tube sites clean and dry, with no induration, redness or swelling, Right nephrostomy tube with dressing c/d/I and no urine leakage visualized EXT: Warm, well perfused, 2+ right lower extremity edema. NEURO: A&Ox3, good attention and linear thought, CN II-XII intact. Strength full throughout. Sensation to light touch intact. Pertinent Results: Admission Labs ================== ___ 05:37PM BLOOD WBC-3.9* RBC-2.75* Hgb-8.6* Hct-27.6* MCV-100* MCH-31.3 MCHC-31.2* RDW-16.0* RDWSD-58.4* Plt ___ ___ 05:37PM BLOOD Neuts-74.2* Lymphs-13.8* Monos-9.7 Eos-1.5 Baso-0.3 Im ___ AbsNeut-2.89 AbsLymp-0.54* AbsMono-0.38 AbsEos-0.06 AbsBaso-0.01 ___ 05:37PM BLOOD Plt ___ ___ 06:33AM BLOOD ___ PTT-25.8 ___ ___ 05:37PM BLOOD Glucose-103* UreaN-19 Creat-1.0 Na-143 K-3.9 Cl-102 HCO3-24 AnGap-17 ___ 05:37PM BLOOD Calcium-9.2 Phos-4.2 Mg-1.7 ___ 05:50PM BLOOD Lactate-1.3 Micro ===== ___ URINE URINE CULTURE-FINAL INPATIENT ___ URINE URINE CULTURE-FINAL {PROBABLE ENTEROCOCCUS} INPATIENT ___ MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS} INPATIENT ___ URINE URINE CULTURE-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, NGTD ___ BLOOD CULTURE Blood Culture, NGTD Imaging ======== ___ ___ IMPRESSION: No evidence of deep venous thrombosis in the right lower extremity veins. ___ Abd xray IMPRESSION: Bilateral percutaneous nephrostomy tubes, left percutaneous nephroureterostomy, and right ureteral stent in place. Discharge Labs =============== ___ 07:30AM BLOOD WBC-4.0 RBC-2.74* Hgb-8.4* Hct-26.3* MCV-96 MCH-30.7 MCHC-31.9* RDW-17.9* RDWSD-62.3* Plt ___ ___ 07:30AM BLOOD Glucose-106* UreaN-15 Creat-0.9 Na-139 K-4.6 Cl-104 HCO3-22 AnGap-13 ___ 06:33AM BLOOD ALT-10 AST-13 LD(LDH)-244 AlkPhos-55 TotBili-0.4 ___ 07:30AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.0 ___ 07:44AM BLOOD calTIBC-213* Hapto-677* Ferritn-640* TRF-164* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Megestrol Acetate 800 mg PO DAILY 2. Mirtazapine 7.5 mg PO QHS 3. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 4. Oxybutynin 5 mg PO TID 5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 6. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortnes of breath/wheezing 7. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting 8. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 9. Polyethylene Glycol 17 g PO DAILY:PRN constipation Discharge Medications: 1. Miconazole Powder 2% 1 Appl TP TID to rash in skin folds under ostomy apply to areas of moist, irritated skin under ostomy and lower stomach RX *miconazole nitrate [Anti-Fungal] 2 % apply to irritated moist skin twice per day Disp #*1 Bottle Refills:*0 2. Naloxone Nasal Spray 4 mg IH ONCE MR1 opiate overdose Duration: 1 Dose RX *naloxone [Narcan] 4 mg/actuation 1 spray nasal PRN Disp #*1 Spray Refills:*3 3. OxyCODONE SR (OxyconTIN) 10 mg PO QHS:PRN moderate-severe pain Duration: 14 Days RX *oxycodone [OxyContin] 10 mg 1 tablet(s) by mouth every evening as needed Disp #*14 Tablet Refills:*0 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg ___ tablet(s) by mouth Q4H:PRN Disp #*36 Tablet Refills:*0 5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 6. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortnes of breath/wheezing 7. Megestrol Acetate 800 mg PO DAILY 8. Mirtazapine 7.5 mg PO QHS 9. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 10. Oxybutynin 5 mg PO TID 11. Polyethylene Glycol 17 g PO DAILY:PRN constipation 12. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis =================== Nephrostomy tube Hydronephrosis Pyelonephritis Metastatic Cervical Squamous Cell Carcinoma Secondary Diagnosis ==================== Fatigue Sinus Tachycardia Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: UNILAT LOWER EXT VEINS RIGHT INDICATION: ___ yo F with stage 4 cervical cancer, unilateral swelling of right leg// ?DVT TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the right lower extremity veins. COMPARISON: No relevant comparison identified. FINDINGS: There is normal compressibility, flow, and augmentation of the right 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: No evidence of deep venous thrombosis in the right lower extremity veins. Radiology Report INDICATION: ___ year old woman with nephrostomy tubes concern for malplacement// ?malplacement of nephrostomy tubes COMPARISON: Prior CT of the abdomen pelvis from ___ FINDINGS: AP supine views of the abdomen pelvis provided. Bilateral percutaneous nephrostomy tubes are in place. There is a right ureteral stent which appears well positioned. There is also a left percutaneous nephroureterostomy the catheters appear well positioned. Bowel gas pattern is unremarkable. Bony structures are intact. IMPRESSION: Bilateral percutaneous nephrostomy tubes, left percutaneous nephroureterostomy, and right ureteral stent in place. Radiology Report INDICATION: ___ year old woman with ___ PCNU and L PCN (duplicated system) with leakage and probable kink on xray// ___ PCNU and L PCN exchange COMPARISON: Multiple prior exchanges TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ performed the procedure. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 200 mcg of fentanyl and 4.5 Mg of midazolam throughout the total intra-service time of 40 mins during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: CONTRAST: 10 ml of Optiray contrast FLUOROSCOPY TIME AND DOSE: PROCEDURE: 1. Bilateral diagnostic antegrade nephrostogram. 2. Bilateral 8 ___ nephrostomy to 12 ___ upsize. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient.The patient was then brought to the angiography suite and placed prone on the exam table. A pre-procedure time-out was performed per ___ protocol. The right and left flank were prepped and draped in the usual sterile fashion. Diluted contrast was injected into the left nephrostomy to confirm catheter position. The image was stored on PACS. Local anesthesia was administered with instillation of lidocaine jelly and 1% subcutaneous lidocaine injection. The catheter was cut. A ___ wire was advanced into the left nephrostomy tube and advanced into the distal ureter. The stay sutures were cut and the catheter was removed over the wire. A new 12 ___ nephrostomy catheter was flushed and advanced with its plastic stiffener over the wire into appropriate position. The wire and stiffener were removed and the pigtail was formed. Contrast injection confirmed appropriate positioning. The final image was saved. The catheter was then flushed and the catheter was secured with a Stayfix and sterile dressings. The catheter was attached to a bag for drainage. On the left side, the upper pole PCNU was also interrogated, however this was patent without evidence of obstruction so this was not changed. Diluted contrast was injected into the right nephrostomy to confirm catheter position. The image was stored on PACS. Local anesthesia was administered with instillation of lidocaine jelly and 1% subcutaneous lidocaine injection. The catheter was cut. A ___ wire was advanced into the right nephrostomy tube and advanced into the distal ureter. The stay sutures were cut and the catheter was removed over the wire. A new 12 ___ nephrostomy catheter was flushed and advanced with its plastic stiffener over the wire into appropriate position. The wire and stiffener were removed and the pigtail was formed. Contrast injection confirmed appropriate positioning. The final image was saved. The catheter was then flushed and the catheter was secured with a Stayfix and sterile dressings. The catheter was attached to a bag for drainage. The patient tolerated the procedure well and there were no immediate post-procedure complications. FINDINGS: 1. Both nephrostomy tubes were clogged 2. PCNU on the left was patent 3. Appropriate final position of bilateral ___ F nephrostomy tubes. IMPRESSION: Technically successful upsizing of bilateral nephrostomy tubes to ___ given frequent clogging. PCNU to upper pole of left kidney was not exchanged. Radiology Report INDICATION: ___ year old woman with post radiation obstruction. // Right PCN leaking; Right PCN check/reposition/ exchange COMPARISON: ___ Upsizing of bilateral nephrostomy tubes TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and Dr. ___. ___, interventional Radiology resident performed the procedure. Dr. ___ supervised the trainee during any key components of the procedure where applicable and reviewed and agrees with the findings as reported below. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 150mcg of fentanyl and 3 mg of midazolam throughout the total intra-service time of 20 during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: 1 g Cefazolin IV CONTRAST: 10 ml of Optiray contrast FLUOROSCOPY TIME AND DOSE: 2.0 minutes, 12 mGy PROCEDURE: 1. Right side diagnostic antegrade nephrostogram. 2. Right 12 ___ modified nephrostomy exchange. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient.The patient was then brought to the angiography suite and placed prone on the exam table. A pre-procedure time-out was performed per ___ protocol. The right flank was prepped and draped in the usual sterile fashion. Diluted contrast was injected into the right nephrostomy to confirm catheter position. The image was stored on PACS. Local anesthesia was administered with instillation of lidocaine jelly and 1% subcutaneous lidocaine injection. The catheter was cut. A ___ wire was advanced into the right nephrostomy tube and advanced into the renal pelvis. The stay sutures were cut and the catheter was removed over the wire. A new 12 ___ nephrostomy catheter was then modified with two additional side holes cut proximal to the pigtail. The catheter was flushed and advanced with its plastic stiffener over the wire into appropriate position. The wire and stiffener were removed and the pigtail was formed. Contrast injection confirmed appropriate positioning. The final image was saved. The catheter was then flushed, stay sutures applied and the catheter was secured with a Stat Lock device and sterile dressings. The catheter was attached to a bag for drainage. The patient tolerated the procedure well and there were no immediate post-procedure complications. FINDINGS: 1. Right side antegrade nephrostogram shows appropriate positioning of the percutaneous nephrostomy tube.. 2. Appropriate final position of 12 ___ modified nephrostomy tube. IMPRESSION: Technically successful Right 12 ___ modified nephrostomy exchange. Gender: F Race: OTHER Arrive by WALK IN Chief complaint: NEPHROSTOMY TUBE EVAL Diagnosed with Cellulitis of right lower limb temperature: 98.5 heartrate: 118.0 resprate: 20.0 o2sat: 100.0 sbp: 111.0 dbp: 68.0 level of pain: 9 level of acuity: 3.0

Summary ========= Ms. ___ is s a ___ female with history of recurrent metastatic cervical cancer complicated by bilateral ureteral narrowing and rectovaginal fistulas, requiring diverting colostomy and bilateral nephrostomy tubes who presents for nephrostomy tube evaluation. There was initial concern for UTI given WBCs in UA on admission, and she was treated with ___bx, until infection was r/o. She underwent bilateral nephrostomy tube replacement ___, with leakage of the R PCN requiring repeat exchange on ___. Active Issues ============== # Nephrostomy Tube Malfunction: # Hydronephrosis ___ Malignancy: # Concern for Cellulitis: # Pyelonephritis: Patient with a history of bilateral nephrostomy tubes secondary to ureteral narrowing due to malignancy presented with leaking around nephrostomy tubes. The patient is poor nephrostomy tube care at home he does not currently have ___ home services. Leaking around the tube was initially concerning for malposition but abdominal x-ray obtained on admission demonstrated good position of all tubes. Given this it is likely that the nephrostomy tubes had occluded. On ___ the patient's nephrostomy tubes were replaced by interventional radiology. The patient's urine was also examined and demonstrated signs of infection. Given that the source of the patient's urine was at the nephrostomy tube this was considered pyelonephritis. After receiving a dose of Zosyn in the ED, The patient was switched to Unasyn and vancomycin, which was discontinued ___ d/t negative urine and blood cx, lack of symptoms, and remaining afebrile. The patient was seen by social work and case management. SW will continue to follow up with patient through outpatient oncology office. #Skin breakdown with possible cellulitis #Rectovaginal fistula Patient has a history of a recto-vaginal fistula who presented with a white and brown foul-smelling vaginal discharge. Additionally the patient had erythema surrounding her ostomy site as well as skin breakdown surrounding the nephrostomy sites likely from continuous urine leakage. Given the above there was initial concern for skin and soft tissue infections as well as some concern for intra-abdominal process. Given that the patient was afebrile with mild leukopenia and pyelonephritis on admission did not initially undergo CT scan of the abdomen. She was treated with 3 day course of vancomycin and Unasyn, which was discontinued after urine and blood cx were negative and clinical status improved. Wound ostomy nurse was consulted for breakdown under pannus and around ostomy. Skin breakdown and irritation was treated with miconazole powder. # Metastatic Cervical Squamous Cell Carcinoma: She is s/p chemoradiation with curative intent at ___ in ___ though recent biopsy of LUL lesion unfortunately showed evidence of squamous cell carcinoma consistent with recurrent metastatic disease. She is currently being treated with palliative Carboplatin/Paclitaxel (s/p 2 cycles) with plan for 6 cycles, if tolerated. The patient is to her third cycle on ___ but skipped his not feeling well. The primary team reached out to the patient's oncologist Dr. ___ direction on chemotherapy regimen. # Cancer-Related Debility/Fatigue: Patient reports she is now wheelchair dependent due to lower extremity weakness. She states this is a chronic issue as she has not been utilizing her lower extremities for some time. Exam demonstrated ___ strength in bilateral lower extremities. The patient was seen by ___ who recommended that she be discharged to a rehabilitation facility due to the fact that she will need 24-hour assistance for mobility and ADLs. Patient refused ___ rehabilitation and was able to vocalize the risks of not going. Her mother is available to assist her on a 24-hour basis at home. She is also being discharged with ___ services and at-home ___. # Cancer-Related Pain: The patient's pain was attributed to her bilateral nephrostomy tubes and was treated with p.o. oxycodone and IV Dilaudid for breakthrough pain. Palliative care was consulted, who recommended oxycontin every night for longer-lasting pain control in addition to her oxycodone PRN. # Sinus Tachycardia: Patient notes that her baseline is tachycardia in the 120s. An ECG done here shows sinus tachycardia at a rate in the 110s. Chronic Issues ================= # Malnutrition: Continued home Megestrol and Mirtazipine # GU Symptoms: Continued home Oxybutynin 5mg TID # Nausea: Continued home Zofran PRN # Anemia Hgb trended downward to 6.6 today from baseline Hgb ___. Likely due to mixed anemia (chronic disease, iron deficiency d/t poor nutritional intake). Hgb responded appropriately and was stable at 8.4 on discharge. Transitional Issues ==================== [] will need monitoring of anemia as outpatient in the event that Hgb drops again and patient requires additional future transfusion [] nephrostomy drains are high risk of becoming clogged or dislodged; placed by ___ here and will need an evaluation if they become dislodged or fail to function [] patient needs more ostomy bags than her insurance currently covers [] initiated oxycontin QHS 10mg but did not assess how well she tolerates this in the hospital, titrate as needed outpatient Code: full Contact: ___ (sister) ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Increasing size of liver lesions Major Surgical or Invasive Procedure: Liver biopsy ___ History of Present Illness: ___ PMH of PE (lovenox), Anxiety, AML (in complete remission, undergoing consolidation with high dose ara-C), who was recently admitted for neutropenic fever found to have hepatic microabscesses, now admitttd with increased size of hepatic lesions despite ___s per review of discharge summary from 1 week ago, patient was admitted for febrile neutropenia, for which ID was consulted and felt that patient likely had transient bacteremia from mucositis, as she was found to have hepatic microabscesses. She was discharged on 14 day course of ertapenem (planned to end ___ and was supposed to have a CT scan following completion of therapy. CT was completed on ___ and was found to have increased size of hypodense lesions with hyperemia so was referred to ED for admission. In the ED, initial vitals: 97.2 103 142/87 18 100% RA. WBC 2.5, Hgb 9.0, plt 218, CHEM wnl, Lactate wnl, UA with few bact, sm Bld, Tr prot, lactate 0.6. CT A/P revealed: 1. The previously noted hypodense hepatic lesions are increased in size compared to prior imaging now measuring up to 14 mm (previously 4-5 mm). There is still geographic enhancement/hyperemia surrounding some of these lesions. These lesions are nonspecific and may be infective/inflammatory in nature or may be neoplastic/metastatic. Correlation with blood cultures with or without histology is recommended. 2. No other findings of note. Patient was given vancomycin, zosyn, voriconazole, lovenox, acyclovir and admitted to oncology for further care. VS prior to transfer were pain 0, T 98, HR 76, BP 114/65, RR 18, O2 100%RA. On arrival to the floor, patient has no acute complaints. She denies any recent fevers, chills, or rigors. She has no nausea or RUQ pain. No headaches or visual change. No URTI symptoms. No CP, SOB or cough. No N/V/D. No dysuria. Her only focal symptom is increased fatigue over the last few days. She also notes some intermittent vaginal spotting since last ___ she does receive Lupron for ovarian suppression and received her last injection on ___ (about a week late); she also had an IUD in place. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: PAST ONCOLOGIC HISTORY: As per last discharge summary: ___ with one month hx bruising and progressive fatigue. At the time of presentation she was found with WBC count of 61.9K, hemoglobin of 9.9, platelets of 28K with 22% blasts on the differential. Previous WBC on ___ was 6.9, with baseline hemoglobin of 13.2 and platelets of 248. Other labs notable for ESR of 45, INR of 1.1, PTT of 28, ALT of 27 from 10 previously, AST elevated to 50 from 16 previously, BUN/Cr of ___, uric acid 4.7, LDH 1470, negative U/A. She was transferred here where she was initially started on Hydroxyurea from ___ given concerns for APML however further information from bone marrow reveled AML vs APML. She then moved forward with . induction chemotherapy cytarabine and daunorubicin ___. Her course was complicated by febrile neutropenia, Right IJ thrombus and acute kidney injury. The patient developed fever on ___. She had minor mucositis and some diarrhea with possible colitis noted on CT A/P, other workup unrevealing. Initially on vanc/cefepime, vanc d/c in setting of ___, cefepime changed to zosyn for increased anaerobic coverage in light of evidence of colitis on CT. This was later changed to meropenem after rash developed. TTE (___) showed no evidence of endocarditis. All cultures negative. Patient remained afebrile until ___ when spiked fever, at that time no localizing symptoms, again started on vancomyin. Both vancomycin and mereopenem were d/c ___ and ___, respectively) as patient remained afebrile and ANC > 500. G6PD normal. Repeat BM Bx on ___ showed hypocellular marrow with no morphologic evidence of disease however ___ metaphase cells showing t(8,21). FISH was RUNX1/RUNX1T1 positive in 15% of the uncultured interphase cells examined. ___: BMBX consistent with morphologic and cytogenetic remission. ___: New PE started on therapeutic Lovenox ___: C1D1 HiDAC ___: C2D1 HiDAC ___: C2D1 HIDAC PAST MEDICAL HISTORY: - AML as above - Pulmonary embolism on lovenox (___) - lyme disease - mononucleosis - IUD - PICC associated RIJ and brachial vein thrombi (resolved) - anxiety - Headache/migraines - Febrile Neutropenia, thought to be ___ bacteremia in light of liver microabscesses, discharged on 2 week course of ertapenem (planned to end ___ Social History: ___ Family History: No known family history of leukemia or hematologic malignancy Physical Exam: ADMISSION PHYSICAL EXAM: VS: T 97.9 HR 71 BP 110/76 RR 16 SAT 100% O2 on RA GENERAL: Pleasant well appearing young woman with recovering alopecia, sitting up in bed in no distress EYES: Anicteric sclerea, PERLL, EOMI; ENT: Oropharynx clear without lesion, JVD not elevated CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops; 2+ radial pulses RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: Normal bowel sounds; nondistended; soft, nontender without rebound or guarding; no hepatomegaly, no splenomegaly MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema; Normal bulk NEURO: Alert, oriented, CN III-XII intact, motor and sensory function grossly intact SKIN: No significant rashes LYMPHATIC: No cervical, supraclavicular, submandibular lymphadenopathy. Bruising over lower abdomen PHYSICAL EXAM: ___ 0507 Temp: 98.1 PO BP: 101/69 HR: 73 RR: 16 O2 sat: 97% O2 delivery: RA GENERAL: Pleasant and well appearing young woman sitting up in bed in no distress EYES: Anicteric sclerea, PERLL, EOMI; ENT: Oropharynx clear without lesion, JVD not elevated CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: Normal bowel sounds; nondistended; soft, mildly tender to deep palpation in RUQ. No rebound or guarding. No ___ sign. No hepatomegaly, no splenomegaly. Right sided biopsy site dressed with occlusive dressing is c/d/I. Small bruising just inferior to site. No pain around biopsy site. MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema; Normal bulk NEURO: Alert, oriented, motor and sensory function grossly intact SKIN: No significant rashes LYMPHATIC: No cervical, supraclavicular, submandibular lymphadenopathy. Bruising over lower abdomen Pertinent Results: ADMISSION LABS: =============== ___ 08:30PM BLOOD WBC-2.5* RBC-2.80* Hgb-9.0* Hct-27.1* MCV-97 MCH-32.1* MCHC-33.2 RDW-17.7* RDWSD-49.9* Plt ___ ___ 08:30PM BLOOD Neuts-54.0 ___ Monos-23.0* Eos-0.0* Baso-0.8 Im ___ AbsNeut-1.34* AbsLymp-0.54* AbsMono-0.57 AbsEos-0.00* AbsBaso-0.02 ___ 08:30PM BLOOD ___ PTT-43.0* ___ ___ 08:30PM BLOOD Glucose-98 UreaN-7 Creat-0.6 Na-143 K-4.1 Cl-102 HCO3-25 AnGap-16 ___ 08:30PM BLOOD ALT-18 AST-18 AlkPhos-87 TotBili-0.3 ___ 10:33AM BLOOD Calcium-9.4 Phos-4.4 Mg-2.0 DISCHARGE LABS: =============== ___ 12:00AM BLOOD WBC-3.5* RBC-2.88* Hgb-9.6* Hct-28.0* MCV-97 MCH-33.3* MCHC-34.3 RDW-19.6* RDWSD-67.7* Plt ___ ___ 12:00AM BLOOD Neuts-56 Bands-0 ___ Monos-21* Eos-0 Baso-1 ___ Myelos-0 AbsNeut-1.96 AbsLymp-0.77* AbsMono-0.74 AbsEos-0.00* AbsBaso-0.04 ___ 12:00AM BLOOD Glucose-84 UreaN-10 Creat-1.0 Na-142 K-3.6 Cl-102 HCO3-26 AnGap-14 ___ 12:00AM BLOOD ALT-10 AST-13 LD(LDH)-202 AlkPhos-83 TotBili-0.4 ___ 12:00AM BLOOD Calcium-9.6 Phos-4.1 Mg-1.9 MICROBIOLOGY: ============= ___: Liver bx: Gram stain 1+ PMN; no micro-organism Culture - No growth ___ prep - No fungal elements Fungal culture - PND Nocardia - PND Viral Cx - Negative CMV Antigen - PND AFB smear - Negative AFB Cx - PND ___: EBV Serology - IgG positive; IgM Negative ___: CMV Serology - Negative ___: Cryptococcal antigen - Negative ___: Mycolytic blood cultures - PND ___: Urine Culture x1 - <10K CFU ___: Blood Culture x2 - Negative ___: CMV VL - Negative ___: EBV VL - PND ___: Aspergillus Galactomannan - Negative ___: B-Glucan - 161 (Positive) ___: Urine histoplasmosis antigen - Negative ___: Aspergillus Galactomannan - Negative ___: B-Glucan - Negative ___: Urine Culture - Vanc sensitive enterococcus ___ CFU PATHOLOGY ========= ___: Liver Bx - C/w resolving abscess ___: Liver Bx Flow Cytometry - PND Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q12H 2. Escitalopram Oxalate 5 mg PO DAILY 3. LORazepam 0.5-1 mg PO Q4H:PRN nausea/vomiting/anxiety/insomnia 4. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN mouth pain 5. OxyCODONE (Immediate Release) 2.5-5 mg PO Q6H:PRN Pain - Moderate 6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line 7. Enoxaparin Sodium 60 mg SC Q12H Discharge Medications: 1. Fluconazole 400 mg PO Q24H RX *fluconazole 100 mg 4 tablet(s) by mouth daily Disp #*56 Tablet Refills:*0 2. Piperacillin-Tazobactam 4.5 g IV Q8H RX *piperacillin-tazobactam 4.5 gram 4.5 g IV q8 hours Disp #*42 Vial Refills:*0 3. Acyclovir 400 mg PO Q12H 4. Enoxaparin Sodium 60 mg SC Q12H 5. Escitalopram Oxalate 5 mg PO DAILY 6. LORazepam 0.5-1 mg PO Q4H:PRN nausea/vomiting/anxiety/insomnia 7. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN mouth pain 8. OxyCODONE (Immediate Release) 2.5-5 mg PO Q6H:PRN Pain - Moderate 9. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: # Hepatosplenic candidiasis # Liver abscess # AML, in remission Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ year old woman with AML in remission on consolidation HiDAC. Recent admission for febrile neutropenia with ? microabscess. Now growing liver lesion despite ertapenem.// ? aspiration/sampling of presumed liver abscess. COMPARISON: CT abdomen dated ___ PROCEDURE: Ultrasound-guided targeted liver biopsy. OPERATORS: Dr. ___ radiologist personally supervised the trainee during the key components of the procedure and reviewed and agrees with the trainee's findings. FINDINGS: Limited preprocedure grayscale and Doppler ultrasound imaging of the liver was performed. The lesion for biopsy was identified in the right hepatic lobe measuring 9 x 8 x 7 mm in size. A suitable approach for targeted liver biopsy was determined. TECHNIQUE: The risks, benefits, and alternatives of the procedure were explained to the patient. After a detailed discussion, informed written consent was obtained. A pre-procedure timeout using three patient identifiers was performed per ___ protocol. Based on the preprocedure imaging, an appropriate skin entry site for the biopsy was chosen. The site was marked. The skin was then prepped and draped in the usual sterile fashion. The superficial soft tissues to the liver capsule were anesthetized with 10 mL 1% lidocaine. Under real-time ultrasound guidance, 4- 18-gauge core biopsy sample was obtained. 1 sample was sent for microbiology and cultures in saline, while the other samples were sent in formalin for The skin was then cleaned and a dry sterile dressing was applied. There were no immediate complications. SEDATION: Moderate sedation was provided by administering divided doses of 2.5 mg Versed and 125 mcg fentanyl throughout the total intra-service time of 55 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. IMPRESSION: Uncomplicated 18-gauge targeted liver biopsy x 4, with specimen sent for microbiology and cultures as well as histopathology. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Abnormal CT Diagnosed with Hepatomegaly, not elsewhere classified temperature: 97.2 heartrate: 103.0 resprate: 18.0 o2sat: 100.0 sbp: 142.0 dbp: 87.0 level of pain: 0 level of acuity: 3.0

PRINCIPLE REASON FOR ADMISSION: ___ PMH of PE (lovenox), Anxiety, AML (in complete remission, undergoing consolidation with high dose ara-C), who was recently admitted for neutropenic fever found to have hepatic microabscesses, admitttd with increasing size of hepatic lesions despite ___ntibiosis initially changed to vancomycin, pip/tazo, micafungin; later changed micafungin to fluconazole. She underwent liver biopsy on ___. Surgical pathology is consistent with resolving abscess, although microbiologic studies to date have been negative aside from positive B-Glucan. Plan to continue empiric IV zosyn with po fluconazole was made and she will follow up with ID to determine final abx course. Etiology of her abscess is unclear, which will make determination of abx course difficult. Given imaging findings and positive glucan (and since it worsened despite ertapenem) favor possible hepato-splenic candidiasis. afebrile with normal LFTs, and appears to be healing. Favor continue broad GNR/anaerobic coverage with pip/tazo and fluconazole for candidiasis. Will need likely prolonged treatment of at least two weeks. Will arrange home services and ID follow up next week. Otherwise she had developed moderate neutropenia which improved after initiating treatment as above. Likely related to resolving abscess. # Hepatic microabscesses: Etiology of abscesses remains unclear. Grew in size despite 2 weeks of ertapenem as outpatient. No significant fevers and no liver test abnormalities. Antibiosis initially changed to vancomycin, pip/tazo, micafungin; later changed micafungin to fluconazole. She underwent liver biopsy on ___. Surgical pathology is consistent with resolving abscess, although microbiologic studies to date have been negative aside from positive B-Glucan. Plan to continue empiric IV zosyn with po fluconazole was made and she will follow up with ID to determine final abx course. - ___ remaining infectious studies - ___ flow cytometry on liver sample - Con't pip-tazo/fluconazole; D1 effectively ___. - ___ in ___ clinic next week for final abx course # Neutropenia: Admitted with mild neutropenia. ___ eventually dropped to 750 on ___ before recovering prior to discharge. Potentially medication induced vs effect of infectious abscess. #Hx of PE: Lovenox was held prior to liver biopsy. Of note, she was not maintained on heparin gtt due to patients firm desire to avoid PIV, lack of additional IV access, and asympomtatic nature after >3 months of anticoagulation. She was restarted on therapeutic following biopsy without incident. #Hx of AML in remission Continued acyclovir ppx. Flow cytometry was sent on liver biopsy specimen. Will need to follow up with Dr. ___ week (either ___ or ___ for further treatment planning. # Vaginal spotting: Noted on admission. Likely due to delayed Lupron dosing. Resolved. #Anxiety Continued escitalopram # Anemia in malignancy Stable to improving sp consolidation chemotherapy # Billing: >30 minutes spent coordinating and executing this discharge plan

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Anorexia Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. ___ is a ___ woman with history of anorexia nervosa, depression with recent serious suicide attempt, and anxiety who presents from ___ Facility on ___ for anorexia, severe malnutrition, and weight loss. She was recently admitted to a hospital in ___ for two weeks for a purposeful overdose of percocet requiring intubation and complicated by aspiration pneumonia. She was discharged from ___ and admitted to the ___ yesterday with weight of 67 pounds. Her weight this AM was 64.8 pounds and she was referred to the ED at ___. Vitals there were 90/59 and HR 116. By report from the ED, she had been refusing to follow the plan for treatment of her anorexia, declining NGT and supplements. She was placed on ___ for transportation to the ED. She is independent in her ADLs. She denies SI and HI at this time. She was admitted to the hospital in ___ approximately 2 weeks ago after an overdose attempt on percocet. She states she was suicidal in the context of learning she had exhaused her medical leave and would not be able to return to college ___) as previously planned. She has had anorexia nervosa for ___ years. She has previously been admitted to medical facilities (including ___ prior to her last ___ stay) for medically monitored weight gain/anorexia. She has had at least three previous stays in inpatient eating disorder hospitals, including ___, a place in ___, and a place in ___. She states her lowest weight was 57 lbs in ___ and her highest was in the high 80's at her last discharge from ___, although her mother contends she has been in the 100's previously. She has had an NG tube previously for one day, denies percutaneous G tubes or J tubes. She received TPN during her last hospitalization after the suicide attempt/intubation. She states her LMP was approximately ___ years ago, at which time she reports being in the low 80lb range. She and her mother deny binding, purging, laxitive use, diet pill use, diuretics, emetics, or excessive exercise. She was doing "light walking" prior to this last hospitalization, although she is unable to quantify for how many minutes or for what distance. She dislikes nuts, penutbutter. She reports not tolerating milk well. Otherwise no dietary restrictions. She does not currently have an outpatient psychiatrist. She previously had a good relationship from a therapist at ___, although recently has not been followed by them. - In the ED, initial vitals were: 97.7 58 80/48 16 95% RA. - Labs were notable for: WBC 3.1, H/H 10.9/30.4, Plt 441, Na 136, K 4.2, Cr 0.5. UA bland. Serum tox negative and urine tox negative. - Patient was given: D5NS + 20K @ 125cc/hr. - Patient ate full lunch tray in ED. On the floor, she has no further complaints, and endorses understanding of the eating disorder protocol. Review of systems: (+) Per HPI She denies shortness of breath, chest pain, lower extremity edema, rashes (aside from irritation at the site of her recent PICC on right arm), abdominal pain, or other complaints. She endorses amenorrhea. Past Medical History: - Anorexia Nervosa x ___ years - Depression - Anxiety - H/O wisdom teeth removal, uncomplicated. Social History: ___ Family History: Maternal grandfather had a stroke. Denies family history of depression, anxiety, eating disorders, cancers, diabetes, high blood pressure, or heart attack. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 30.4kg on admission (in ___ and ___, 98.2, 92/66 (orthostatics pending), 65, 16, 100% on RA General: Extremely emaciated. Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP not elevated CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Scaphoid. Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: mildly cool to touch, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, gait deferred. DISCHARGE PHYSICAL EXAM: Vitals: T 97.8 RR 16 O2 100%RA Orthostatics: Supine: BP: 98/54 P: 70 Standing: BP: 102/72 P: 110 Weights: ___ 36.0kg ___ 35.6kg ___ 35.5kg ___ 34.9kg ___ 34.7kg ___ 34.7kg ___ 33.9kg -- admit (___): 29.2 (AM after admit weight) GEN: Cachectic, emaciated. Diffuse wasting throughout. Frail ___: RRR, no murmurs, rubs, or gallops. pulse 2+ and regular Lungs: CTAB Abd: Scaphoid. Pertinent Results: ADMISSION LABS: ======================== ___ 02:50PM BLOOD WBC-3.1* RBC-3.35* Hgb-10.9* Hct-30.4* MCV-91 MCH-32.4* MCHC-35.7* RDW-14.3 Plt ___ ___ 02:50PM BLOOD Neuts-61.1 ___ Monos-9.2 Eos-2.1 Baso-0.5 ___ 07:28AM BLOOD ___ PTT-32.8 ___ ___ 02:50PM BLOOD Glucose-89 UreaN-13 Creat-0.5 Na-136 K-4.2 Cl-98 HCO3-25 AnGap-17 ___ 02:50PM BLOOD ALT-36 AST-33 AlkPhos-74 TotBili-0.4 ___ 02:50PM BLOOD Lipase-79* ___ 02:50PM BLOOD Albumin-4.6 Calcium-10.1 Phos-4.9* Mg-2.2 ___ 02:50PM BLOOD TSH-3.1 ___ 02:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG DISCHARGE LABS: ======================= ___ 07:18AM BLOOD Calcium-9.4 Phos-3.8 Mg-2.1 ___ 07:18AM BLOOD Glucose-75 UreaN-19 Creat-0.5 Na-143 K-4.2 Cl-106 HCO3-26 AnGap-15 STUIDES: ======================= ECG (___): Sinus bradycardia. Otherwise, normal tracaing. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT QTc (___) P QRS T 52 148 76 412 398 43 0 46 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Temazepam 30 mg PO QHS 2. ClonazePAM 0.5 mg PO TID:PRN anxiety 3. Gabapentin 100 mg PO BID Discharge Medications: 1. ClonazePAM 0.5 mg PO TID:PRN anxiety 2. Gabapentin 100 mg PO BID 3. Temazepam 30 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: Anorexia Nervosa Extreme Malnourishment Bradycardia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with a medically unstable eating disorder. // Please evaluate for signs of heart failure. Please evaluate for signs of heart failure. COMPARISON: Prior chest radiographs are not available. IMPRESSION: Normal heart, lungs, hila, mediastinum, and pleural surfaces. No evidence of intrathoracic malignancy or infection, including tuberculosis, or cardiac decompensation. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Anorexia Diagnosed with ANOREXIA NERVOSA, CARDIAC DYSRHYTHMIAS NEC, OTHER MALAISE AND FATIGUE temperature: 97.7 heartrate: 58.0 resprate: 16.0 o2sat: 95.0 sbp: 80.0 dbp: 48.0 level of pain: 0 level of acuity: 2.0

Ms. ___ is a ___ woman with history of anorexia nervosa (admit BMI 10.7, 51.2% IBW), depression with recent suicide attempt, and anxiety who presents from ___ ___ for anorexia, severe malnutrition, and weight loss. # Severe Malnutrition # Anorexia Nervosa: Patient was maintained on an eating disorder refeading protocol as below. Most recently, patient failed breakfast on ___, was informed after lunch, mother and patient upset that she was informed "late". Exam with stable hypotension and bradycardia. Orthostasis stable. -By discharge, we were checking Chem-10 QOD and they remained stable. Would recommend approximately weekly Chem-10 checks once at ___ EDU, to be determined by medical director there.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Bile leak s/p lap cholecystectomy Major Surgical or Invasive Procedure: ___: ERCP ___: Exploratory laparotomy and Roux-en-Y hepaticojejunostomy. History of Present Illness: Per surgery consult note: ___ with symptomatic cholelithiasis ___ s/p lap cholecystectomy (___), transferred from ___ on ___ with abdominal pain and CT scan demonstrating multi-loculated fluid collection in RUQ near liver, s/p ERCP with placement of 7cm ___ biliary stent into the common bile duct (although no leak identified from cystic duct remnant or hepatic bile ducts), followed by percutaneous, transhepatic gallbladder fossa drainage for ?intra-abdominal abscess with ___ ___ all purpose drain by interventional radiology, now returns with abdominal pain and persistent drainage (~300mL/day). When placed by ___, the drain immediately put out 450mL dark bilious fluid, with bilirubin = 27, which prompted subsequent diagnosis of "resolved cystic stump leak." Following these procedures (ERCP, ___ drain), she was discharged from the ___ service ___ - ___, then subsequently readmitted to ___ on ___ with persistent abdominal pain. Subsequent to readmission, an abdominal U/S demonstrated the percutaneous transhepatic drainage catheter to be in the correct location, and the fluid collection within the gallbladder fossa to be largely resolved with only trace fluid remaining. ERCP was then repeated on ___, during which the right lobe of the liver appeared to have an area of limited opacification, suggesting an excluded part, not connected to the right hepatic duct. The patient has continued drainage of bile from the percutaneous drain (430mL yesterday, approximately 300mL at home). Currently, c/o persistent RUQ abdominal pain, on dilaudid ___ po q3h prn, yet is tolerating a regular diet. Transplant surgery was consulted for evaluation and recommendations for management of persistent bile leak. Of note, no reported or known operative complications with the cholecystectomy. Past Medical History: Depression, Carpal tunnel syndrome s/p Right carpal tunnel release Social History: ___ Family History: --Mother perforated diverticulitis Physical Exam: Admission/consult PE: T 98.4 HR 98 BP 119/69 RR 19 O2sat 94%RA Drain: 170mL today, 430mL yesterday Gen: NAD, A+Ox3 CV: RRR Pulm: clear to auscultation, bilaterally Abd: well-healed incisions, abdomen soft, obese, tender RUQ, drain exit site c/d/i, bilious drainage in bag, no guarding, no rebound tenderness Ext: wwp, no c/c/e Pertinent Results: On Admission: ___ WBC-7.4 RBC-4.33# Hgb-12.9# Hct-39.2# MCV-91 MCH-29.9 MCHC-33.0 RDW-13.3 Plt ___ PTT-30.7 ___ Glucose-85 UreaN-14 Creat-0.8 Na-139 K-4.1 Cl-102 HCO3-24 AnGap-17 ALT-56* AST-43* AlkPhos-241* TotBili-0.5 Albumin-3.7 Calcium-9.1 Phos-3.9 ___: Amylase 182 At Discharge: WBC-8.8 RBC-3.51* Hgb-10.1* Hct-31.4* MCV-90 MCH-28.9 MCHC-32.3 RDW-14.1 Plt ___ PTT-36.2 ___ Glucose-96 UreaN-10 Creat-0.5 Na-136 K-4.0 Cl-99 HCO3-25 AnGap-16 ALT-8 AST-15 AlkPhos-141* TotBili-0.3 Calcium-8.1* Phos-3.8 Mg-1.8 ... Culture Data: ___ 7:44 pm BILE **FINAL REPORT ___ GRAM STAIN (Final ___: THIS IS A CORRECTED REPORT ___. NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). PREVIOUSLY REPORTED AS ( ___. NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: Reported to and read back by ___ ___ ___ 1245PM. 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.. Work-up of organism(s) listed below discontinued (excepted screened organisms) due to the presence of mixed bacterial flora detected after further incubation. GRAM NEGATIVE ROD(S). MODERATE GROWTH. STAPH AUREUS COAG +. QUANTITATION NOT AVAILABLE. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. .......... Imaging: CT abdomen (OSH, ___: Fluid collection noted in the gallbladder fosa tracking over the liver superiorly, density consistent with bile, fluid layering in the abdominal cavity and pelvis likely bile based on the density characteristics. ERCP ___, ___: Normal major papilla, cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique, limited pancreatography demonstrated a normal caliber pancreatic duct. Normal common bile duct and intrahepatic biliary tree. No leak identified from cystic duct remnant or hepatic bile ducts. Given the pretest probability of a bile leak, a 7cm ___ biliary stent was placed in the CBD. ___ drain (___): Successful percutaneous, transhepatic gallbladder fossa drainage with 450 cc, ___ drain in place. Abdominal U/S (___): A percutaneous transhepatic catheter is seen traversing the liver to the gallbladder fossa. There is a trace residual fluid. The fluid collection within the gallbladder fossa is largely resolved. No hepatic collection is seen. There is no intrahepatic biliary ductal dilatation. The portal vein is patent demonstrating a hepatopetal flow. The common bile duct is prominent measuring 7 mm. ERCP ___, ___: Plastic stent in the major papilla removed. The CBD, CHD, right and left hepatic ducts, biliary radicles and cystic duct stump were filled with contrast and visualized. The course and caliber of the structures are normal with no evidence of extrinsic compression, no ductal abnormalities, and no filling defects. The right lobe of the liver seemed to have an area of limited opacification, suggesting an excluded part, not connected to the right hepatic duct. Forcefull contrast injection did not elucidate contrast extravasation. Suspected bile leak from excluded liver segment. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lorazepam 0.5 mg PO QID:PRN anxiety 2. Duloxetine 60 mg PO DAILY 3. ZYRtec *NF* 10 mg Oral Daily Discharge Medications: 1. Duloxetine 60 mg PO DAILY 2. Lorazepam 0.5 mg PO QID:PRN anxiety 3. Acetaminophen 1000 mg PO Q8H 4. Docusate Sodium 100 mg PO BID 5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills:*0 6. Senna 1 TAB PO BID 7. ZYRtec *NF* 10 mg Oral Daily Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: bile duct injury s/p lap ccy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Patient is status post cholecystectomy with fluid collection in the gallbladder fossa, status post drain placement. Assess for interval change. COMPARISONS: Reference CT abdomen of ___ and ultrasound exam of ___. FINDINGS: A percutaneous transhepatic catheter is seen traversing the liver to the gallbladder fossa. There is a trace residual fluid. The fluid collection within the gallbladder fossa is largely resolved. The liver is normal in echotexture. No hepatic collection is seen. No suspicious hepatic lesion is noted. There is no intrahepatic biliary ductal dilatation. The portal vein is patent demonstrating a hepatopetal flow. The common bile duct is prominent measuring 7 mm, which likely relates to patient's history of cholecystectomy. The pancreatic head is unremarkable. The distal body and tail obscured by overlying bowel gas. There is no ascites. IMPRESSION: Percutaneous transhepatic drainage catheter is in place. Fluid collection within the gallbladder fossa is largely resolved, only trace fluid remaining. Radiology Report INDICATION: ___ woman with persistent drainage of bile status post lap chole, complicated by bile leak status post ___ drain placement. COMPARISON: Liver ultrasound ___, CT torso ___. FINDINGS: Pre-contrast spot fluoroscopic image of the right upper quadrant shows a percutaneous drainage catheter in the expected location of the gallbladder fossa along with adjacent cholecystectomy clips. 40 cc of ioversol waster-soluble contrast was gently hand injected through the percutaneous drainage tube while serial fluoroscopic spot images were taken in multiple projections. Contrast is seen filling and distending a contained space which lays inferior to the hepatic shadow and slightly right of the midline without evidence of contrast material entering the intra- or extra-hepatic biliary duct system. Surgical staples are seen along the periphery of the contrast-filled collection. A small amount of contrast is seen extravasating around the tube track. Additional imaging after 10 minutes post injection showed no migration of contrast. This fluid collection roughly corresponds to the collection seen on prior CT torso examination. At the end of examination, injected contrast material could not be withdrawn. IMPRESSION: Contained fluid collection in the peritoneum to the right of midline, which roughly corresponds to the previously seen fluid collection on CT. There is no contrast material seen leading into the intra- or extra-hepatic biliary system. Radiology Report This is an outside second opinion CT scan. INDICATION FOR STUDY: Evaluate for injury to main, right and/or left hepatic artery. Patient is status post laparoscopic cholecystectomy and bile leak. Note that no outside report by the radiologist is provided. TECHNIQUE: According to information provided on the images, the patient was administered 80 mL of Isovue at 2 cc/sec and a helical scan was obtained from the mid-chest through the abdomen and pelvis down to the level of the hip joints. Images were reformatted in the axial, coronal and sagittal planes. The timing of the study was in the mid phase and not acquired to optimize opacification of the hepatic arteries for that reason; full evaluation of the intrahepatic arterial patency cannot be performed. DOSE RESPONSE: No information about dose is provided in the images. ABDOMEN WITH CONTRAST: Subsegmental atelectasis is noted in both lung bases with collapse of both the posterior aspect of the left and right lower lobes. Ascitic fluid is noted around the liver with the largest quantities inferior to segment III and lateral and superior to segment II. This is causing perfusion abnormalities in the liver with enhanced perfusion in the left lobe and somewhat diminished perfusion in the high right lobe of the liver. No intra- or extra-hepatic bile duct dilatation is noted. Several clips are noted in the gallbladder fossa. A large fluid collection with layering high attenuation material is present in the porta hepatis presumably representing bile with some hemorrhage. The portal vein is widely patent. Careful evaluation of the hepatic arteries reveals that these are patent on the left side. The gastroduodenal artery is patent. The images do not convincingly show patency of the right hepatic artery. Spleen is unremarkable but is surrounded by ascitic fluid. Stomach is unremarkable. Head, body and tail of the pancreas are all unremarkable. Left and right adrenal glands and kidneys are all unremarkable. PELVIS WITH CONTRAST: Loops of large and small bowel in the abdomen and pelvis are all unremarkable. A large amount of free fluid is present within the pelvis. The Hounsfield attenuation of this fluid is approximately 20 suggesting that this is simple fluid. The bladder is well distended. The uterus and adnexa are unremarkable. No inguinal or deep pelvic adenopathy is identified. The ureters are unremarkable and not dilated. SOFT TISSUE WINDOWS: No abnormalities are noted in the subcutaneous tissues. BONE WINDOWS: No concerning lytic or blastic lesions identified within the skeleton. REFORMATTED SEQUENCES: The sagittal and coronal reformatted sequences confirm the presence of a large amount of fluid around the left lobe of the liver. IMPRESSION: 1. Please note that the study was not timed to optimize hepatic artery opacification; however, while the left hepatic artery appears widely patent, the depiction of satisfactory flow within the right is diminished and if concern persists Doppler ultrasound of the hepatic artery could be performed. Alternatively, a CT angiogram might be far more sensitive. 2. Large biloma around the left lobe of the liver with a large amount of fluid around the spleen throughout the peritoneal cavity and extending down into the pelvis. This is almost likely related to the recent laparoscopic cholecystectomy. Radiology Report PA AND LATERAL VIEWS OF THE CHEST REASON FOR EXAM: Fever. There are low lung volumes. Cardiac size is minimally enlarged. Bibasilar opacities, larger on the right side are consistent with atelectasis. There is no pneumothorax or large effusions. Radiology Report INDICATION: Persistent drainage of bile status post laparoscopic cholecystectomy complicated by bile leak with ERCP with stent and ___ drain placement. Daily drain output is greater than 300 cc , query hepatic bile leak. TECHNIQUE: Multiplanar T1- and T2-weighted imaging was performed on a 1.5 T magnet, including dynamic 3D imaging, prior to, during and subsequent to the intravenous administration of 9 mL of Eovist. Delayed imaging at two hours was also performed. FINDINGS: The liver parenchyma is of normal signal on T2-weighted imaging. There is an 8.9 x 8.3 cm fluid collection posterior to the left lobe of the liver, decreased in size when compared to the prior CT dated ___. This corresponds to the fluid collection on the recent tubogram dated ___. The drainage catheter traversing the liver does not appear to lie within the collection, however it does communicate with this collection (as indicated by the recent tubogram) and may lie within a decompressed portion of the collection. There is prominence of the intrahepatic bile ducts within segments V and VIII, with delayed excretion of gadolinium contrast compared to the remainder of the liver, indicating a degree of outflow obstruction from these segments. There is also leakage of contrast from the biliary system into the collection and the indwelling drain, consistent with a bile leak. There are 2 right anterior hepatic ducts with the posterior right hepatic duct draining into the more posterior of the anterior ducts. The point of biliary leak is from the right main hepatic duct just distal to the confluence of the anterior hepatic ducts. The segment of the right main hepatic duct adjacent to the collection is not visualized likely due to adjacent edema. The left hepatic duct and an abberrent right posterior hepatic duct join with the right main hepatic duct distal to the leak. There is normal biliary excretion of contrast from the remainder of the liver. No suspicious liver lesion. The portal and hepatic veins are patent. Unfortunately, assessment of the hepatic arterial anatomy is limited by motion artifact on the arterial phase imaging. The pancreas is of normal signal and morphology. No focal pancreatic lesion or pancreatic duct dilatation. The spleen is unremarkable. No adrenal lesion. The kidneys enhance symmetrically, no suspicious renal lesion or hydronephrosis. There is bibasal atelectasis with a small effusion on the right. No upper abdominal or retroperitoneal lymphadenopathy. The visualized small and large bowel are unremarkable. IMPRESSION: 1. Collection posterior to the left lobe of the liver, with evidence of a bile leak from the right main hepatic duct into this collection and into the indwelling drainage catheter. 2. Bibasal atelectasis, small right-sided effusion. Radiology Report INDICATION: ___ female status post lap cholecystectomy complicated by bile leak status post ERCP not showing a ductal leak, transhepatic gallbladder fossa drainage with bile aspirated. MRCP demonstrates bile leaking from anterior duct. Requesting PTC drainage of the right anterior duct. PHYSICIANS: Dr. ___ (radiology fellow), Dr. ___ ___ (radiology resident) and Dr. ___ (radiology attending) who was present throughout and supervised the procedure. RADIATION: 20.54 minutes of fluoroscopy time, 497 mGy. MEDICATION: The procedure was performed under general anesthesia. Please see the dedicated anesthesia note for further details. In addition, the patient received 1 g of ceftriaxone prior to procedure. PROCEDURE: 1. Exchange of an indwelling transhepatic 8 ___ drainage catheter with repositioning more centrally within the cavity. 2. PTC with placement of an 8 ___ modified nephrostomy tube through the right anterior duct into the perihepatic collection. PROCEDURE DETAILS: Following discussion of the risks, benefits and alternatives to the procedure, informed written patient consent was obtained. The patient was brought to the angiographic suite and placed supine on the table. A preprocedure timeout was performed using three patient identifiers. The skin of the right and anterior abdomen was prepped and draped in the usual sterile fashion including the indwelling 8 ___ drainage catheter in the right upper quadrant. An initial quadrant image demonstrated multiple surgical clips in the right upper quadrant and a pigtail drain also in the right upper quadrant. Initially, we injected a small amount of contrast via this drain which opacified the subhepatic collection; however, the pigtail was not well positioned within the cavity. The catheter was cut and ___ wire was advanced over the catheter which was gradually removed. The ___ wire coiled in the same place as the pigtail catheter so a Kumpe catheter was used to manipulate the wire into the bulk of the cavity. Once this had been achieved catheter was removed and a new 8 ___ drainage catheter was advanced over the wire and positioned centrally within the cavity without difficulty. This catheter was left on free drainage. We then proceeded to attempt access of the right anterior duct. Using a combination of ultrasound and fluoroscopic guidance with approximately four passes, we opacified the nondilated right anterior duct system. There was a single branch of the right anterior system which passed vertically and inferiorly and we selected this for access as a good site. Using a second Cook needle, we advanced this inferior branch of the right anterior biliary tree with subsequent placement of a Headliner wire within the duct. The AccuStick system did not pass readily over the Headliner wire so a Cook stiff micropuncture sheath was used initially to dilate the tract followed by the AccuStick system. This deflected superiorly into the intrahepatic right anterior duct. The wire and introducer were removed and injection of contrast demonstrated filling of the right anterior system as well as frank leakage of contrast into the subhepatic space. The AccuStick sheath was withdrawn so that it was positioned at the confluence of this right inferior duct with the right anterior biliary duct and using a combination of Omniflush catheter and a Glidewire, we gained access to the area of leaking and eventually to the subhepatic collection. The Omniflush catheter and wire were advanced into the collection. The wire was removed and exchanged for ___ wire. Both the AccuStick sheath and the Omniflush catheter were removed at this point and exchanged for a modified 8 ___ Uresil drain with additional side holes cut to allow intrahepatic drainage. The pigtail was pulled and the catheter was retracted so that it was positioned appropriately through the bile duct injury leak. The catheter was secured to the skin with an 0 silk suture and a StatLock device. The catheter was attached to a drainage bag. There were no immediate post-procedure complications. IMPRESSION: 1. Technically successful PTC access in the right anterior duct with placement of a modified Uresil drain through the opening in the bile duct into the intra-abdominal collection (white catheter). 2. Successful exchange of an 8 ___ drainage catheter with repositioning of the catheter in the subhepatic collection (blue catheter). Radiology Report REASON FOR EXAMINATION: Evaluation of the patient after right anterior duct injury and after transhepatic pigtail drainage placement. PA and lateral upright chest radiographs were reviewed in comparison to ___. Heart size and mediastinum are stable. There is still present but improved left basal atelectasis. There is right pleural effusion and potentially increased area of consolidation on the right that might suggest infectious process. Pigtail catheters have been placed in the interim. There is no evidence of appreciable pneumothorax. Radiology Report REASON FOR EXAMINATION: Evaluation of the patient after hepaticojejunostomy, now with desaturations. AP radiograph of the chest was compared to ___. The right pleural effusion is moderate with increased right lower lobe atelectasis or potentially consolidation. Aspiration is another possibility. Left lower lobe atelectasis is unchanged, moderate. There is interval development of mild interstitial pulmonary edema. No pneumothorax is seen. The epidural catheter is in place. The NG tube tip is in the stomach. Radiology Report REASON FOR EXAMINATION: Desaturations, assessment of atelectasis. COMPARISON: Prior study obtained on ___ at 7:43 p.m. The NG tube tip is in the stomach. The pig-tail catheter is in place. Heart size and mediastinum are stable. Slight interval improvement in the aeration of the right lower lung is demonstrated but still pleural effusion and atelectasis are seen as well as left lower lobe atelectasis, minimally improved in the interim. Radiology Report HISTORY: Increasing oxygen requirement postop. Please evaluate for interval change. TECHNIQUE: Portable AP chest. COMPARISON: Multiple prior radiographs of the chest most recent ___. FINDINGS: The NG tube terminates in the stomach and is coiled in the fundus. The cardiomediastinal silhouette is not appreciably changed. There is mild cardiomegaly. Worsening of low lung volumes results in vascular crowding and somewhat limits the evaluation, however small bilateral pleural effusions are likely present with adjacent bibasilar atelectasis. The hemidiaphragms are less well seen. There is no apical pneumothorax. Surgical sutures projected over the right mid to upper abdomen. IMPRESSION: 1. Low lung volumes are worse, and small bilateral pleural effusions are likely present with adjacent bibasilar atelectasis made more prominent by the low lung volumes. 2. Mild cardiomegaly is unchanged. Radiology Report GRAVITY CHOLANGIOGRAM INDICATION: ___ female status post laparoscopic cholecystectomy complicated by biliary leak, which was treated with a PTC drainage and subsequent hepaticojejunostomy. Today, patient comes in for evaluation of the anastomosis. PHYSICIANS: Dr. ___, ___ fellow, and Dr. ___, ___ attending who was present throughout and supervising. RADIATION: 2.2 minutes of fluoroscopy time, 57 mGy. MEDICATION: No medication was used to perform this procedure. PROCEDURE: 1. Gravity cholangiogram. PROCEDURE DETAILS: The patient was explained about the procedure. The patient was brought to the angiography suite and placed supine on the imaging table. Preprocedure timeout was performed as per ___ protocol. Initial scout of the upper abdomen was obtained, which demonstrated multiple surgical clips in the right upper quadrant and a pigtail drain in the right upper quadrant, across the hepaticojejunostomy. A contrast bottle was connected into the drain, and was left to drip on gravity force. Initial opacification of a nondilated intrahepatic biliary tree was obtained. The hepaticojejunostomy was documented to be patent, and no evidence of bile leak was identified. Oblique images were also obtained, which also did not demonstrate any evidence of a residual biliary leak. Based on these findings the contrast bottle was disconnected and the study was ended. IMPRESSION: 1. Nondilated intrahepatic biliary tree. 2. Patent hepaticojejunostomy, with no evidence of a biliary leak. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: ABDOMINAL PAIN Diagnosed with ABDOMINAL PAIN OTHER SPECIED temperature: 98.2 heartrate: 94.0 resprate: 16.0 o2sat: 100.0 sbp: 128.0 dbp: 79.0 level of pain: 6 level of acuity: 3.0

___ yo F with symptomatic cholelithiasis ___ s/p lap CCY, multi-loculated fluid collections in RUQ near liver, s/p ERCP with no cystic or hepatic duct leak & placement of 7cm ___ biliary stent into the common bile duct, followed by percutaneous transhepatic gallbladder fossa drainage with ___ ___ all purpose drain by ___, returned with abdominal pain and persistent drainage. Repeat ERCP was performed with limited opacification of right lobe of the liver concerning for bile leak from an excluded liver segment. Cipro/Flagyl were started after pan-culture for temp to 102.9. CT scan of abdomen revealed a large biloma around the left lobe of the liver with a large amount of fluid around the spleen throughout the peritoneal cavity and extending down into the pelvis. The left hepatic artery was widely patent. The right hepatic artery flow appeared diminished. An abdominal MRI was performed on ___ that demonstrated a collection posterior to the left lobe of the liver, with evidence of a bile leak from the right main hepatic duct into this collection and into the indwelling drainage catheter. Bibasal atelectasis with small right-sided effusion was noted. On ___, bile culture was sent with note of 2+ GNRs. On ___, she underwent ___ cholangiogram with placement of PTC access in the right anterior duct with placement of a modified Uresil drain through the opening in the bile duct into the intra-abdominal collection (white catheter). The transhepatic catheter in fluid collection was exchanged for an 8 ___ drainage catheter with repositioning of the catheter in the subhepatic collection (blue catheter). Post procedure she had a fever to 101 with tachycardia to 140's. EKG showed sinus tachycardia. Repeat cultures were sent. On ___, she desat'd to 89%. Nasal cannula was applied. A CXR was done which showed improved a right pleural effusion and increased opacity. The left lower lobe atelectasis was improved. Bile culture from ___ isolated Staph aureus coag + and GNRs. Blood cultures from ___ and ___ were negative. Cipro and Flagyl were stopped on ___. She remained afebrile after this time. She was taken to the OR on ___ for repair of right anterior bile duct disruption and underwent exploratory laparotomy and Roux-en-Y hepaticojejunostomy. Surgeon was Dr. ___. Intraop the PTC was left in place and was not exchanged. Two JP drains were placed. Please refer to operative note for details. Postop, O2 sat decreased to 77% on 5L face mask. She was asympotmatic. CXR showed significant atelectasis and small R. pleural effusion. She was transferred to the SICU for close respiratory monitoring. An Epidural was placed intraop for pain control. The epidural was split. Toradol and tylenol were added for better pain control. On ___, she was well enough to transfer out of the SICU. NG tube was removed on ___ and then she started on sips. Diet was slowly progressed. IV Lasix given for fluid retention. O2 was weaned. CXR demonstrated persistent low lung volumes, bilateral pleural effusions and atelectasis. On ___, epidural was removed and a Dilaudid PCA was used for pain control. She was assisted out of bed to ambulate. ___ evaluated and cleared her for home. LFTs improved. JP drain outputs decreased. PTC was left open to gravity drainage until ___ when cholangiogram demonstrated biliary patency without leak. PTC was capped. LFTs were the same the next day except for slight elevation of alk phos. 145 from 137. By postop day ___, she was tolerating solids fair. She was switched to po dilaudid, but experienced nausea with each dose. Dilaudid was switched to Oxycodone with prn Zofran with relief of nausea. Incision was intact with staples without redness or drainage. On ___, the medial JP was removed. She was ambulating and felt well enough to go home on ___. JP and PTC drain care education was provided. ___ was scheduled to follow her at home. She was discharged to home in stable condition.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Ancef / adhesive tape / Cymbalta / codeine / Iodinated Contrast Media - IV Dye / tramadol / lisinopril / Sulfa (Sulfonamide Antibiotics) / metformin / Dilaudid Attending: ___. Chief Complaint: LLQ abdominal pain, stool from vagina Major Surgical or Invasive Procedure: ___: 1. Takedown of colovesical vaginal fistula with ___ colectomy, descending left colostomy and closure of rectum. 2. Rigid sigmoidoscopy. 3. Placement of VAC sponge 300 cm2. 4. Rigid sigmoidoscopy and exam under anesthesia. 5. Release of splenic flexure for formation of colostomy. History of Present Illness: Ms. ___ is a ___ F who presents as a transfer from ___ ___ after presenting there with complaint of 1.5 weeks of worsening LLQ pain, subjective chills, and stool coming out of her vagina. CT AP done at ___ demonstrates active diverticulitis with pelvic abscess suggestive of perforation, in addition to air and heterogenous material suggestive of stool within the bladder and vagina. Of note the patient had an episode of diverticulitis 5 weeks ago at which time she was managed conservatively with IV antibiotics and was discharged home. Today she reports that her LLQ continues to worsen. She endorses nausea, increasing distention and one episode of vomiting yesterday. She denies diarrhea, fevers, or other systemic symptoms. She reports that she continues to pass stool from the vagina. Past Medical History: Diverticulosis DM not on insulin HTN Peripheral edema AFIB not on anticoagulation Hip replacement (Left) BTL Metatarsal surgery x 3 Right eye x 3 Left knee replacement Left rotator cup Neurostimulator (lumbar) Ortho Social History: ___ Family History: Non-contributory Physical Exam: At admission: Vitals: 98.1 106 129/69 18 100RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, obese, protuberant. Moderate distension with exquisite ttp in the LLQ. No rebound or involuntary guarding. No masses or hernias Ext: No ___ edema, ___ warm and well perfused At discharge: VS: 98.0, 113, 116/46, 18, 94%ra Gen: A&O x3, calm, cooperative, in no distress CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: soft, obese. Midline incision with pink granulating tissue. VAC taken down for tx to rehab. No induration or erythema. JP site CDI, scant tan output. Colostomy with formed stool. GU: Foley draining CYU. Known vesico-vaginal fistula, some leaking of urine. Ext: no edema Pertinent Results: Admission labs: ___ 08:04PM BLOOD WBC-23.9* RBC-3.63* Hgb-10.0* Hct-32.7* MCV-90 MCH-27.5 MCHC-30.6* RDW-15.7* RDWSD-51.8* Plt ___ Discharge labs: ___ 04:57PM BLOOD WBC-9.2 RBC-2.53* Hgb-7.2* Hct-24.4* MCV-96 MCH-28.5 MCHC-29.5* RDW-19.2* RDWSD-67.4* Plt ___ Imaging: CT Abdomen/Pelvis (___): 1. Patient is status post ___ procedure with colostomy in the left lower quadrant. 2. The stomach and proximal portion of the duodenum is all mildly dilated. There is also a loop of jejunum in the left upper quadrant that demonstrates fecalization of small bowel material. Findings could relate to focal ileus. However distal loops of small bowel are collapsed and small bowel obstruction remains a consideration. 3. Fecal material with pockets of air is noted in the vaginal vault, smaller compared to the prior exam. 4. Indeterminate left adrenal nodule, unchanged. 5. Stable 3 mm pulmonary nodule in the right lung base. 6. This preliminary report was reviewed with Dr. ___, ___ radiologist. KUB (___): Interval removal of the gastric tube. Increased gaseous distention of the stomach and small bowel loops in the left upper quadrant concerning for obstruction. The colon is largely decompressed. CT A/P (___), PO contrast: 1. Improvement in the previously described ileus within the small bowel with mild residual dilatation. No findings to suggest mechanical obstruction at this time. 2. Indeterminate left adrenal nodule, unchanged. 3. Stable 3 mm pulmonary nodule in the right lung base. KUB (___): Interval placement of enteric tube with decompressed stomach. Persistent dilated loops of small bowel in the left upper quadrant not significantly changed since prior exam. CT A/P (___): 1. Findings of a partial small bowel obstruction involving the proximal jejunum. It is difficult to identify the transition point although the bowel does change caliber in the pelvis. This may be related to extensive pelvic inflammatory changes. 2. Extensive soft tissue infiltration and inflammatory changes in the pelvis. There are foci of intraperitoneal free air adjacent to the tip of the ___ pouch. A dehiscence in this region cannot be completely excluded. Although no oral contrast is seen within the vagina, there is no clear fat plane between the vagina and the ___ pouch; a fistula in this region cannot be completely excluded. 3. Stable changes of the left hip joint from left femoral head resection and pseudoarthrosis. 4. Stable left adrenal nodule. CT Cystogram (___): 1. Persistent vesicovaginal fistula. Colonic fistulization is not visualized. 2. Tiny locules of intraperitoneal free air again visualized adjacent to the suture line of the ___ pouch, similar to slightly decreased in size. PATHOLOGIC DIAGNOSIS: Sigmoid colon, sigmoid colectomy: - Diverticular disease with perforation and fistula formation, associated acute inflammation, fat necrosis, and focal mucosal ulceration. - Resection margins with no significant pathologic change. - No malignancy is identified. Microbiology: ___ 7:17 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. Sensitivity testing per ___. ___ ON ___. COAG NEG STAPH does NOT require contact precautions, regardless of resistance. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ 1 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- 1 R RIFAMPIN-------------- <=0.5 S VANCOMYCIN------------ 1 S ___ 9:40 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 10:08 am URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: Culture workup discontinued. Further incubation showed contamination with mixed skin/genital flora. Clinical significance of isolate(s) uncertain. Interpret with caution. YEAST. >100,000 CFU/mL. ENTEROCOCCUS SP.. 10,000-100,000 CFU/mL. CIPROFLOXACIN SENSITIVITY REQUESTED BY ___ ___ (___) ___. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ 4 S CIPROFLOXACIN--------- =>8 R NITROFURANTOIN-------- 32 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ 2 S Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Tartrate 25 mg PO BID 2. Amitriptyline 25 mg PO QHS 3. Citalopram 60 mg PO DAILY 4. Pravastatin 20 mg PO QPM 5. rOPINIRole 1 mg oral QHS 6. Hydroxychloroquine Sulfate 200 mg PO BID 7. Multivitamins 1 TAB PO DAILY 8. FoLIC Acid 1 mg PO DAILY 9. LORazepam 1 mg PO BID 10. DiphenhydrAMINE 25 mg PO Q6H:PRN Anxiety 11. melatonin ___ mg oral QHS 12. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild 13. Furosemide 20 mg PO BID Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Heparin 5000 UNIT SC BID 3. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 4. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing, SOB 5. Miconazole Powder 2% 1 Appl TP TID:PRN Rash 6. OLANZapine (Disintegrating Tablet) 5 mg PO QPM 7. Oxybutynin 5 mg PO BID 8. Pantoprazole 40 mg PO Q12H 9. Senna 8.6 mg PO BID:PRN constipation 10. TraMADol 25 mg PO Q6H:PRN Pain - Moderate RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six (6) hours Disp #*10 Tablet Refills:*0 11. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 12. Amitriptyline 25 mg PO QHS 13. Citalopram 60 mg PO DAILY 14. DiphenhydrAMINE 25 mg PO Q6H:PRN Anxiety 15. FoLIC Acid 1 mg PO DAILY 16. Furosemide 20 mg PO BID 17. Hydroxychloroquine Sulfate 200 mg PO BID 18. melatonin ___ mg oral QHS 19. Metoprolol Tartrate 25 mg PO BID 20. Multivitamins 1 TAB PO DAILY 21. Pravastatin 20 mg PO QPM 22. rOPINIRole 1 mg oral QHS 23. HELD- LORazepam 1 mg PO BID This medication was held. Do not restart LORazepam until it is needed. may start PRN Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: 1. ___ fistula due to diverticular perforation. 2. Morbid obesity. BMI greater than 35. 3. Post-operative ileus. Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report INDICATION: ___ xfer ___ for perf diverticulitis, cologenital fistula, s/p hartmans' procedure // ?ileus ?obstruction TECHNIQUE: Portable supine abdominal radiographs COMPARISON: Outside facility CT abdomen/ pelvis ___ FINDINGS: The stomach is markedly distended with air. There are prominent loops of small bowel in the left abdomen measuring up to 3.7 cm in diameter, which can be seen in the setting of small bowel obstruction. However, in light of extensive inflammatory changes noted on the recent CT abdomen/pelvis dated ___, this likely represents secondary ileus. Residual oral contrast is seen throughout the ascending and transverse colon, with note of several diverticuli. Assessment for free intraperitoneal air is limited on supine radiographs. If there is clinical concern for pneumoperitoneum, advise upright or left lateral decubitus radiograph, or cross-sectional imaging. There are chronic changes related to prior resection of the left femoral head. Left femoral shaft is laterally displaced relative to the acetabulum. There are 2 catheters projecting over the pelvis. IMPRESSION: Prominent loops of small bowel in the left lower quadrant measuring up to 3.7 cm in diameter, most likely representing focal ileus. Radiology Report INDICATION: ___ year old woman with perforated diverticulitis, cologenital fistula, s/p ___ now with emesis, NGT placed // ? Obstruction ?Etiology for delayed return bowel function TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired without intravenous contrast. Non-contrast scan has several limitations in detecting vascular and parenchymal organ abnormalities, including tumor detection. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.0 s, 54.9 cm; CTDIvol = 17.0 mGy (Body) DLP = 931.6 mGy-cm. Total DLP (Body) = 932 mGy-cm. COMPARISON: CT from ___. FINDINGS: LOWER CHEST: Visualized lung bases demonstrate small bilateral pleural effusions. Linear opacities within the lung bases is consistent with atelectasis. 3 mm pulmonary nodule in the right lung base is stable (2:3). ABDOMEN: HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout. There is no evidence of focal lesions within the limitations of an unenhanced scan. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. Previously demonstrated stones within the gallbladder are not visualized. Small amount of perihepatic fluid. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions within the limitations of an unenhanced scan. There is no pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: 1.4 cm adrenal nodule is unchanged. Right adrenal gland is normal size and shape. URINARY: The kidneys are mildly atrophic bilaterally. 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: NG tube is noted in situ. The stomach is unremarkable. The patient is status post ___ procedure with a colostomy noted in the left lower quadrant which appears uncomplicated. Two JP drains are noted through a right frontal approach with tip in the right lower quadrant and through a left frontal approach with tip in the midline of the pelvis. The stomach is distended with air and contrast. The proximal portion of the third part of the duodenum is dilated measuring up to 4.7 cm. There is focal narrowing of the distal third portion of the duodenum at the level of the SMA. A loop of jejunum in the left upper quadrant demonstrates fecalization of material. Findings may relate to ileus. PELVIS: Bladder is collapsed with Foley catheter in situ. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: Uterus is absent. Pockets of air are again noted in the vaginal vault but is smaller compared to the prior exam (2:80). 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: Resection of the left femoral head with pseudoarthrosis is unchanged in appearance. Multilevel degenerative changes of the lumbar spine. SOFT TISSUES: Laparotomy wound. Spinal stimulator within the subcutaneous soft tissues of the left back. IMPRESSION: 1. Patient is status post ___ procedure with colostomy in the left lower quadrant. 2. The stomach and proximal portion of the duodenum is all mildly dilated. There is also a loop of jejunum in the left upper quadrant that demonstrates fecalization of small bowel material. Findings could relate to focal ileus. However distal loops of small bowel are collapsed and small bowel obstruction remains a consideration. 3. Fecal material with pockets of air is noted in the vaginal vault, smaller compared to the prior exam. 4. Indeterminate left adrenal nodule, unchanged. 5. Stable 3 mm pulmonary nodule in the right lung base. 6. This preliminary report was reviewed with Dr. ___ radiologist. NOTIFICATION: The concern for small bowel obstruction was discussed with ___ ___, M.D. by ___, M.D. on the telephone on ___ at 2:53 ___, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM INDICATION: ___ y/o F s/p NGT re-placement // eval to ensure NGT in gastrum eval to ensure NGT in gastrum IMPRESSION: The second of 2 images shows the nasogastric tube correctly positioned in the stomach, with the side hole approximately 5 cm be low the gastroesophageal junction. No complications, no pneumothorax. Radiology Report INDICATION: ___ y/o F ___ s/p hartmans with N/V // eval for dilated loops, ileus, sbo TECHNIQUE: Upright and supine views of the abdomen. COMPARISON: CT scan dated ___ and radiograph of ___ FINDINGS: The gastric tube has been removed. There is gaseous distension of the stomach as well as increased dilatation of small bowel loops projecting over the left upper quadrant. The colon is largely collapsed. Suboptimal upright radiograph does not include the entire abdomen and evaluation of air-fluid levels cannot be assessed. No free air under the diaphragms. A spinal stimulator with leads is present. Two surgical drains project over the pelvis. Unchanged degenerative changes of the hips, greater on the left. IMPRESSION: Interval removal of the gastric tube. Increased gaseous distention of the stomach and small bowel loops in the left upper quadrant concerning for obstruction. The colon is largely decompressed. Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old woman with new line // new left PICC 48 cm ___ ___ Contact name: ___: ___ new left PICC 48 cm ___ ___ IMPRESSION: Compared to chest radiographs ___. New left PIC line ends in the low SVC. Esophageal drainage tube passes into the stomach and out of view. Midline stimulator objects over the lower thoracic spine. Peribronchial opacification, both lower lungs improved on the left, worsened slightly on the right. This could be changes of aspiration. Upper lungs are clear. Heart is top-normal size. Pleural effusion minimal on the left if any. No pneumothorax. Radiology Report INDICATION: ___ year old woman w/ perf diverticulitis, colovaginal/vesical fistula, s/p ___, delayed return bowel function w/ NGT placement, continued WBC rise // ? Collection, ? Obstruction TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 14.6 s, 50.1 cm; CTDIvol = 18.0 mGy (Body) DLP = 877.7 mGy-cm. Total DLP (Body) = 891 mGy-cm. COMPARISON: CT abdomen pelvis ___ FINDINGS: LOWER CHEST: Visualized lung bases demonstrate small bilateral pleural with compressive atelectasis. Again visualized, a 3 mm nodule in the right lung base (2:3). ABDOMEN: HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout. There is no evidence of focal lesions within the limitations of an unenhanced scan. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. Cholelithiasis without cholecystitis. Small amount of perihepatic fluid is stable. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions within the limitations of an unenhanced scan. There is no pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: 1.5 cm adrenal nodule is grossly stable. Right adrenal gland is normal size and shape. URINARY: The kidneys are mildly atrophic bilaterally. There is no evidence of focal renal lesions within the limitations of an unenhanced scan. There is contrast within the renal collecting system, evidence of prior contrast administration. There is no hydronephrosis. There is no nephrolithiasis. There is no perinephric abnormality. GASTROINTESTINAL: NG tube tip is at the distal gastric body. The stomach is unremarkable. The patient is status post ___ procedure with a colostomy noted in the left lower quadrant which appears uncomplicated. Two JP drains are noted through a right frontal approach with tip in the right lower quadrant and through a left frontal approach with tip in the midline of the pelvis. The stomach is distended with air and contrast. The small bowel is dilated up to 4.2 cm in greatest dimension, which has decompressed compared to the prior exam. There is normal appearance of contrast within the jejunum which previously demonstrated fecalization of material. This represents interval improvement and resolution of ileus compared to the prior exam. PELVIS: Bladder is collapsed with Foley catheter in situ. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: Uterus is absent. The vaginal vault is without emphysematous foci. RETROPERITONEUM: Small volume ascites. 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: Resection of the left femoral head with pseudoarthrosis is unchanged in appearance. Multilevel moderate to severe degenerative changes of the thoracolumbar spine. SOFT TISSUES: Laparotomy wound. Spinal stimulator within the subcutaneous soft tissues of the left back. IMPRESSION: 1. Improvement in the previously described ileus within the small bowel with mild residual dilatation. No findings to suggest mechanical obstruction at this time. 2. Indeterminate left adrenal nodule, unchanged. 3. Stable 3 mm pulmonary nodule in the right lung base. Radiology Report INDICATION: ___ y/o F POD13 hartmans w/ ileus // eval for interval change TECHNIQUE: AP portable radiograph COMPARISON: Radiograph dated ___ FINDINGS: AP portable radiograph of the abdomen demonstrates interval placement of an enteric tube, its tip in the anticipated location of the stomach. Again seen is a spinal stimulator. Partially imaged surgical drains project over the pelvis. The stomach is decreased in gasseous distention relative to radiograph dated ___. There is persistent increased dilation of small bowel loops projecting over the left upper quadrant. The colon is persistently collapsed. No appreciable free air is present. IMPRESSION: Interval placement of enteric tube with decompressed stomach. Persistent dilated loops of small bowel in the left upper quadrant not significantly changed since prior exam. Radiology Report EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM INDICATION: ___ y/o F POD 13 in need of enteral nutrition // 1 of 2 CXRs to confirm placement DOBHOFF PLACEMENT; 1 OF 2 CXRS TO CONFIRM PLACEMENT IMPRESSION: Only one radiographic image is submitted. Compared to chest radiographs ___. Esophageal feeding tube, wire stylet in place ends in the mid esophagus, no less than 17 cm above appropriate position. Left lower lobe atelectasis is mild. Pleural effusions small on the left if any. No pneumothorax. NOTIFICATION: The findings were discussed with Dr ___ by ___, M.D. on the telephone on ___ at 4:14 ___, 2 minutes after discovery of the findings. Radiology Report INDICATION: ___ y/o F in need of enteral nutrition // pls advance dobhoff post pyloric DOSE: Acc air kerma: 24 mGy; Accum DAP: 378.9 UGym2; Fluoro time: 2:19 COMPARISON: Portable abdominal radiograph dated ___ FINDINGS: Patient arrived to the department with an enteric tube in the left nares. Under intermittent fluoroscopic guidance, the feeding tube was advanced into the stomach and then post-pylorically using a guidewire. 10 cc of thin barium contrast were used to confirm post pyloric placement. Final fluoroscopic spot images demonstrated the type of the feeding tube in the third portion of the duodenum. The feeding tube was affixed to the patient's nose using tape. IMPRESSION: Successful post-pyloric feeding tube placement. The tube is ready to use. Radiology Report INDICATION: ___ y/o F POD15 hartmans w/ ? fecal drainage from vagina // ? enterovaginal fistula originating in small bowel TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired without intravenous contrast. Non-contrast scan has several limitations in detecting vascular and parenchymal organ abnormalities, including tumor detection. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.9 s, 53.9 cm; CTDIvol = 16.8 mGy (Body) DLP = 907.3 mGy-cm. Total DLP (Body) = 907 mGy-cm. COMPARISON: CT ___. FINDINGS: LOWER CHEST: There are small bilateral pleural effusions with bibasilar atelectasis. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions within the limitations of an unenhanced scan. There is no pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right adrenal gland appears within normal limits. There is a stable 1.6 cm left adrenal nodule. 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. GASTROINTESTINAL: There is an enteric tube with the distal tip in the third portion of the duodenum. Loops of the proximal jejunum in the left side of the abdomen appear dilated up to 5 cm in diameter. However, contrast is seen in the colon at the level of the right lower quadrant colostomy suggestive of a partial small bowel obstruction. The patient has a ___ pouch. Adjacent to the ___ pouch there are small foci of extraluminal air. There is extensive soft tissue stranding and infiltration throughout the pelvis. There is no fat plane seen between this region and the vagina. PELVIS: There are 2 surgical drains extending into the pelvis. The urinary bladder is decompressed by Foley catheter. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus is not visualized. There is a small amount of air in the vagina. No definite oral contrast is seen in the vagina. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. BONES: Stable changes at the left hip joint with resection of the left femoral head and pseudoarthrosis. SOFT TISSUES: A neurostimulator device is noted in the left lower back. IMPRESSION: 1. Findings of a partial small bowel obstruction involving the proximal jejunum. It is difficult to identify the transition point although the bowel does change caliber in the pelvis. This may be related to extensive pelvic inflammatory changes. 2. Extensive soft tissue infiltration and inflammatory changes in the pelvis. There are foci of intraperitoneal free air adjacent to the tip of the ___ pouch. A dehiscence in this region cannot be completely excluded. Although no oral contrast is seen within the vagina, there is no clear fat plane between the vagina and the ___ pouch; a fistula in this region cannot be completely excluded. 3. Stable changes of the left hip joint from left femoral head resection and pseudoarthrosis. 4. Stable left adrenal nodule. NOTIFICATION: The findings were discussed with ___, N.P. by ___ ___, M.D. on the telephone on ___ at 4:35 ___, 10 minutes after discovery of the findings. Radiology Report INDICATION: ?Enterovaginal fistula TECHNIQUE: One view pelvis. COMPARISON: CT ___. FINDINGS: Again seen is chronic changes of the left femoral acetabular joint with resection of the femoral head and neck and chronic remodeling. There is superior lateral subluxation of the femur with regard to the acetabulum. Drainage tubes overlie the pelvis. There is no contrast within the rectum. No definite contrast within the region of the vagina. A lateral radiograph would be helpful for further evaluation. Radiology Report INDICATION: ___ y/o F w/ post-pyloric dobhoff, now w/ dobhoff dislodgement // eval for post-pyloric/gastric placement TECHNIQUE: Supine portable abdominal radiographs COMPARISON: ___ intestinal tube placement with fluoro dated ___ and CT abdomen and pelvis dated ___ FINDINGS: An enteric tube is partially imaged, its terminal tip projecting over the midline in the anticipated location of the mid to distal esophagus. The stomach is distended with gas. Air-filled loops of small bowel are distended up to 4.5 cm. This is not changed relative to prior study. There is a colostomy in the low left hemiabdomen. High density material within loops of decompressed colon project over the right lower quadrant. 2 surgical drains are seen projecting over the pelvis. A spinal stimulator is noted projecting over the left hemiabdomen. Lung bases appear clear. IMPRESSION: Malpositioned enteric tube, its tip in the mid to distal esophagus. Persistently dilated loops of small bowel and air distended gastric lumen concerning for obstruction. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 8:16 AM, 1 minutes after discovery of the findings. Radiology Report INDICATION: ___ y/o F s/p dobhoff advancement // eval for placement in gastrum TECHNIQUE: Portable supine abdominal radiographs COMPARISON: Radiograph performed ___ approximately 4 hours prior FINDINGS: AP supine portable radiograph demonstrates an enteric tube within the gastric lumen which is gas-filled and distended. Loops of small bowel are gas-filled and dilated up to 4.6 cm, similar to prior examination. Patient has a colostomy. High density material within loops of decompressed colon overlies the right hemi abdomen. A spinal stimulator is noted projecting over the left hemi abdomen. Two surgical drains project over the pelvis. There is no evidence to suggest intra-abdominal free air although technique is suboptimal in its detection. IMPRESSION: Interval advancement of enteric tube now terminating in the gas distended gastric lumen. Multiple dilated loops of small bowel is concerning for obstruction. Radiology Report INDICATION: ___ xfer ___ for perf diverticulitis, cologenital fistula, s/p hartmans' procedure post-op course c/b delirium and ileus // evaluate interval change, ?persistent colovesical fistula 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. Approximately 150 cc of Cysto-Conray were administered through the Foley catheter into the bladder. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 2.9 s, 31.4 cm; CTDIvol = 16.6 mGy (Body) DLP = 520.1 mGy-cm. 2) Spiral Acquisition 2.9 s, 31.4 cm; CTDIvol = 16.6 mGy (Body) DLP = 520.2 mGy-cm. Total DLP (Body) = 1,040 mGy-cm. COMPARISON: Noncontrast CT abdomen/pelvis from ___. FINDINGS: The patient is status post hysterectomy and ___ colectomy. A right lower quadrant colostomy and suture lines in the right pelvis are unchanged, as are bilateral approach drains terminating in the midline to right upper pelvis. A Foley catheter is in place. After administration of contrast into the bladder, a persistent vesicovaginal fistula is identified (05:29). Superior extension of the contrast is similar in morphology as previously seen stool within the vagina on CT from ___, compatible with superior extension of the vaginal cuff. Fistulization into the colon is not visualized. Tiny locules of intraperitoneal free air are again visualized adjacent to the suture line of the ___ pouch, similar to slightly decreased in size. LYMPH NODES: Prominent lymph nodes are noted, without pathologic enlargement by CT size criteria. VASCULAR: Heavy atherosclerotic disease is noted. BONES: Resection of the left femoral head with pseudoarthrosis is unchanged in appearance. No focal lytic or sclerotic osseous lesion is identified. SOFT TISSUES: A neurostimulator device is noted in the left lower back. IMPRESSION: 1. Persistent vesicovaginal fistula. Colonic fistulization is not visualized. 2. Tiny locules of intraperitoneal free air again visualized adjacent to the suture line of the ___ pouch, similar to slightly decreased in size. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Abd pain, Transfer Diagnosed with Left lower quadrant pain temperature: 97.6 heartrate: 109.0 resprate: 13.0 o2sat: 94.0 sbp: 124.0 dbp: 75.0 level of pain: 7 level of acuity: 3.0

Ms. ___ presented to ___ as a transfer from ___ with diagnosis with active diverticulitis with pelvic abscess concerning for perforation and likely stool within the bladder and vagina. She was started on vancomycin, ciprofloxacin, and Flagyl. A Foley was placed and was subsequently upsized after feculent material was noted in bag. She was taken to the operating room on ___ where she underwent takedown of ___ fistula and ___ procedure. The fascia of the midline incision was sutured closed and a VAC was placed over the incision. Two JP drains were left sewn in, one anterior in the pelvis and the other posterior. She was extubated and returned to the PACU in stable condition. Upon satisfactory recovery from anesthesia, she was transferred to the surgical floor. She remained tachycardic despite adequate fluid resuscitation and metoprolol was titrated to achieve normal heart rate. She had several episodes of agitation and delirium for which Geriatrics was consulted and recommended nightly Zyprexa and avoidance of opiates, benzodiazepines, and antihistamines. On POD4, she began having large bilious emesis. She initially refused NGT, but agreed to placement on POD5 after continued emesis. WBC increased on POD6 and CT abdomen/pelvis showed no collections and suggested ileus. She was maintained on bowel rest with NG tube. She had ostomy output on POD7 and NGT was removed after successful clamp trial. Diet was advanced to clear liquids which she tolerated until POD8 when she once again had emesis. KUB was concerning for ileus. Patient was made NPO once again. She initially refused NGT, but after persistent bilious emesis, NGT was replaced on POD9. Ostomy output slowed and then stopped on POD 9. Repeat CT abdomen/pelvis on POD11 showed improving ileus, no small bowel obstruction or collections. On POD 13, NGT was removed and replaced with Dobhoff and tube feeds were started. She initially tolerated this well, but feeds were held after small bilious emesis. On POD14 ostomy output was once again noted and tube feeds were resumed. However the patient did not tolerate tube feeds so TPN was briefly given (___) until she was able to take food orally. The wound VAC was changed every 3 days post-operatively. On POD8, patient was noted to have urinary tract infection with culture growing enterococcus for which she was started on a 5 day course of Macrobid. On POD9, NGT was replaced and made NPO, thus she was switched to IV Vancomycin. A PICC was placed on ___ and she completed antibiotic course on ___. On ___, a CT cystogram was obtained which showed a vesicovaginal fistula. Therefore the Foley catheter was left in place and will remain in place for another 3 weeks until the patient has a repeat cystogram. Prior to discharge, the right drain which was scant serosanguinous drainage, was removed. The left drain remained. Pain was well controlled. Diet was progressively advanced as tolerated to a regular diet with good tolerability. During this hospitalization, the patient was out of bed to the chair daily but does not ambulate at baseline. She was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. . At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet and having colostomy output, out of bed with assist, voiding via the Foley, and pain was well controlled. The patient was discharged to rehab. 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: MEDICINE Allergies: iodine / shellfish derived / oxycodone / Vicodin / Percocet Attending: ___ Chief Complaint: Fever Major Surgical or Invasive Procedure: None History of Present Illness: This patient is a ___ male with pancreatic cancer metastatic to liver s/p partial pancratectomy and neoadjuvant FOLFIRINOX x2, currently on gem/abraxane last dose ___ presents for fever and generalized malaise that began approximately 1 week ago. Over past week has noted low grade fevers which had been controlled with Tylenol until today he spiked temp to 102.7 and came to ED. also has slight cough. Reported that he felt winded at home but primary complaint generalized malaise. Patient feels similar to his last experience with pneumonia. No chest pain, hemoptysis. Also endorsing left lower extremity pitting edema just been progressively worsening over the last 2 weeks. Extremities are nonpainful Vitals:102.7 102 145/88 18 96% RA CXR showed new infiltrate ___ negative for DVT in ED received 1L NS, cefepime 2g, Tylenol 1g and levofloxacin 750mg on arrival to floor reports feeling better. no recurrence fever thus far. currently denies any SOB. did have sick contact 2 days ago with a cold. Past Medical History: -___: Presented to ED with above symptoms as well as ___ lb weight loss. He was anemia and had guaiac-positive stools. EGD/Colonoscopy showed a stricture in the second portion of the duodenum. -___: MRI Abdomen showed 3.7 cm pancreatic head mass causing duodenal obstruction and gastric distention. -___: C1D1 neoadjuvant FOLFIRINOX. -___: Initiated tube feeds to improve nutritional status in anticipation for resection. -___: Pylorus-preserving pancreaticoduodenectomy (Whipple) and open cholecystectomy, uncomplicated. Pathology showed pT3N0, moderately differentiated, ___ lymph nodes involved, margins negative to 6 mm, positive large vessel/angiolymphatic invasion, positive perineural invasion. -___: C1D1 gemcitabine 1000 mg/m2/abraxane --hepatic mets discovered - ___ - C2D1 Gem/Abraxane - ___ - C3D1 Gem/Abraxane PAST MEDICAL HISTORY: 1. GERD 2. PUD c/b UGIB 3. Pancreatic cancer (s/p chemo, has bile duct stent) 4. R cerebral aneurysm (at junction of R ACA and common carotid) Social History: ___ Family History: HTN, mother with lung CA, grandmother with COPD Physical Exam: General: NAD VITAL SIGNS: 98.2 129/86 85 18 98%RA HEENT: OMM Neck: supple, no JVD CV: RR, NL S1S2 no S3S4 or MRG PULM: CTAB nonlabored ABD: BS+, soft, NTND, no masses, prior tube feed site well healed EXT: warm well perfused, no edema SKIN: No rashes or skin breakdown NEURO: alert and oriented x 4, face symmetric, moves all ext against resistance bilateral, sensation intact to light touch Pertinent Results: ___ 05:18AM BLOOD WBC-4.7 RBC-3.06* Hgb-8.1* Hct-27.2* MCV-89 MCH-26.5 MCHC-29.8* RDW-18.2* RDWSD-59.3* Plt ___ ___ 05:18AM BLOOD Glucose-103* UreaN-11 Creat-0.8 Na-135 K-4.4 Cl-101 HCO3-26 AnGap-12 ___ 09:20PM BLOOD ALT-16 AST-23 AlkPhos-177* TotBili-0.4 ___ 05:18AM BLOOD Calcium-7.9* Phos-3.4 Mg-2.0 ___ 09:42PM BLOOD Lactate-1.3 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Creon 12 2 CAP PO TID W/MEALS 2. LORazepam 0.5-1 mg PO Q12H:PRN anxiety 3. Neomycin-Polymyxin-Bacitracin 1 Appl TP BID 4. Ondansetron 8 mg PO Q8H:PRN nausea 5. Pantoprazole 40 mg PO Q24H 6. Prochlorperazine 10 mg PO Q6H:PRN nausea 7. Nystatin Oral Suspension 5 mL PO QID:PRN thrush Discharge Medications: 1. Creon 12 2 CAP PO TID W/MEALS 2. LORazepam 0.5-1 mg PO Q12H:PRN anxiety 3. Nystatin Oral Suspension 5 mL PO QID:PRN thrush 4. Ondansetron 8 mg PO Q8H:PRN nausea 5. Pantoprazole 40 mg PO Q24H 6. Prochlorperazine 10 mg PO Q6H:PRN nausea 7. Neomycin-Polymyxin-Bacitracin 1 Appl TP BID 8. Vancomycin Oral Liquid ___ mg PO BID c.diff prevention RX *vancomycin 125 mg 1 capsule(s) by mouth twice a day Disp #*31 Capsule Refills:*0 9. Cefpodoxime Proxetil 200 mg PO Q12H RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #*16 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Health Care Associated Pneumonia Pancreatic Cancer History of Severe Clostridium Dificile Colitis 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 fever, cough TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph ___, CT chest ___ FINDINGS: Left-sided Port-A-Cath tip terminates at the junction of the SVC and right atrium. Cardiac silhouette size is normal. Mediastinal and hilar contours are normal. Pulmonary vasculature is not engorged. Ill-defined hazy and patchy opacity is noted within the left lung base, as well as faint patchy opacity within the periphery of the right mid lung field, new in the interval. Small bilateral pleural effusions are demonstrated. No pneumothorax is present. There are no acute osseous abnormalities. Mild degenerative changes are noted within the imaged thoracic spine with slight loss of height anteriorly of the T11 vertebral body, unchanged. Clips are seen within the right upper quadrant of the abdomen as well as overlying the epigastric region. IMPRESSION: Patchy and ill-defined hazy opacities within the left lung base and right peripheral mid lung field concerning for infection. Small bilateral pleural effusions. Radiology Report EXAMINATION: UNILAT LOWER EXT VEINS LEFT INDICATION: History: ___ with ___ pitting edema // 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. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Fever, Cough Diagnosed with Pneumonia, unspecified organism temperature: 102.7 heartrate: 102.0 resprate: 18.0 o2sat: 96.0 sbp: 145.0 dbp: 88.0 level of pain: 2 level of acuity: 2.0

Mr ___ is a ___ w/ pancreatic cancer mets to liver s/p pancreatectomy and adjuvant FOLFIRINOX currently C3D22 Gemcitabine/Abraxane who is admitted with fevers and cough. CXR confirmed PNA. Due to exposure to sick contacts, and his rapid improvement on admission, his PNA is most likely viral process. Since he defervesced quickly, he was treated with 2gm Ceftriaxone. His cultures were NGTD and since he improved so quickly, was discharged home on oral cefpodoxime. He was discharged to complete a 10 day course with vancomycin BID dosing to extend 7 days afterwards for c.diff prophylaxis. He was encouraged to continue protein supplementation.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Codeine / morphine / Amoxicillin / Augmentin Attending: ___. Chief Complaint: headache Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a ___ year old RH woman with a history of low back pain and migraine headaches who was sent in by Dr. ___ ___ status ___ x6 weeks to control headache and rule out secondary causes of headache. The patient reports she had her first migraine ___ years ago after the birth of her second son. Her typical migraine is always L sided (never R sided) and associated with a visual aura of "squiggly lines" and "difficulty with depth perception" which improves when she covers one eye (?diplopia). HAs are throbbing, with nausea, vomiting, and photophobia. She was started on verapamil as a prophylactic medication which was effective: her migraine frequency decreased to once every ___ months. When she got a headache she took hydrocodone which was effective in aborting the headache. She previously tried triptans which gave her nausea. She still intermittently required ED visits to "break" a bad migraine. She states she had an MRI of her brain a long time ago which was reportedly normal. On ___ the patient was at her ___ house in ___ and was woken up from sleep at 6 AM by what she describes as her typical migraine headache. No preceding illnesses or head injuries. She started vomiting later that morning and went to a local ED, which give her Compazine and another medication IV. This temporarily resolved her HA, and she went home, but later that day had recurrence of her headache and went back to a different ED where she got tramadol and a nausea medication. Again the next 2 days she continues to have migraine headches. Her PCP then prescribed her a 20 day prednisone taper, which improved her headache so that she could function better, but she continued to have now a daily headache. She is now off the prednisone and continues to have daily headache. She feels her daily functioning is impaired. She reports difficulty with concentration and recently ordered 11 garlic breads by mistake from Peapod, and paid her bills to the wrong amount (last months amount instead of this months). She was also started on Depakote for her headaches, and since then feels that her balance is a little off and she is stumbling more, and also notes a postural tremor which impairs her handwriting. She is also taking Fiorcet TID, indomethacin TID, tramadol TID, but has not noted a big improvement with any of them. Out of everything, the very first dose of steroids seemed to help the most, but she continued to have headaches daily during the long 20 day taper. She describes her current headache as L sided, throbbing, associated with L ear tinnitus and photophobia. No nausea or vomiting. She did get a NCHCT as part of her work up which was reportedly normal although neither the imaging nor the records are in our system. She was seen by Dr. ___ in Neurology clinic today who sent her in for admission to Neurology to "break" her headache as well as exclude underlying brain lesion or temporal arteritis as causes of secondary headache. She received IV Mg, Compazine, and dilaudid in the ED. On neurologic review of systems, the patient endorses headache, confusion. Denies jaw claudication, PMR symptoms. 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 loss of sensation. Denies bowel or bladder incontinence or retention. Endorses difficulty with gait. On general review of systems, the patient denies fevers, rigors, night sweats, or noticeable weight loss. Denies chest pain, palpitations, dyspnea, or cough. Denies nausea, vomiting, diarrhea. Past Medical History: - low back pain: MRI with L5/S1 disc degeneration and collapse with no stenosis or neural compression - multinodular goiter - depression/anxiety - s/p surgery for rotator cuff tear - s/p hysterectomy - s/p RT thumb surgery - s/p tonsillectomy Social History: ___ Family History: Daughter has migraines. Son with epilepsy s/p surgery. Mother with rheumatic fever, valve replacement, and subsequent strokes. Physical Exam: Admission Exam: Physical Examination: VS 97.8 96 129/85 18 98% RA General: NAD, lying in bed comfortably. Head: NC/AT, + tenderness of the L occiput and L temporal region. Unable to palpate temporal artery pulses bilaterally. Neck: Supple, no nuchal rigidity, no meningismus Neurologic Examination: - Mental Status - Awake, alert, oriented x 3. Attention to examiner easily attained and maintained. Concentration maintained when recalling months backwards. Recalls a coherent history. Structure of speech demonstrates fluency with full sentences, intact repetition, and intact verbal comprehension. Content of speech demonstrates intact naming (high and low frequency) and no paraphasias. Normal prosody. No dysarthria. No evidence of hemineglect. No left-right agnosia. - Cranial Nerves - I. not tested II. Equal and reactive pupils (3mm to 2 mm). On fundoscopic exam, optic disc margins were sharp. Visual fields were full to finger counting. III, IV, VI. smooth and full extraocular movements without diplopia or nystagmus. The patient is mildly uncomfortable with testing. 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. Postural tremor. no asterixis. Infra Delt Bic Tri ECR Fext Fflex IP Quad Ham TA Gas EDB L 4 5 ___ 5 5 5 5 4+ 5 5 4 R 4 5 ___ 5 5 5 5 4+ 5 5 4 - Sensation - Intact to light touch, pinprick. Mildly decreased proprioception at the little toes bilaterally. - DTRs - Bic Tri ___ Quad Gastroc L 2 3 3 2 2 R 2 3 3 2 2 Plantar response equivocal on the R, extensor on the L. - Cerebellar - No dysmetria with finger to nose or HTS testing bilaterally. Good speed and intact cadence with rapid alternating movements. - Gait - Normal initiation. Narrow base. Normal stride length and arm swing. Difficulty with tandem gait, + sway with Rhomberg testing. = = = = = = ================================================================ Discharge Exam: Same as above, except Postural tremor improved. Pertinent Results: ___ 03:15PM BLOOD WBC-5.5 RBC-3.84* Hgb-11.9 Hct-36.4 MCV-95 MCH-31.0 MCHC-32.7 RDW-13.7 RDWSD-47.5* Plt ___ ___ 03:15PM BLOOD Plt ___ ___ 03:15PM BLOOD Glucose-81 UreaN-21* Creat-0.7 Na-140 K-4.0 Cl-104 HCO3-27 AnGap-13 ___ 04:55AM BLOOD ALT-11 AST-21 AlkPhos-68 TotBili-0.2 ___ 04:55AM BLOOD Calcium-8.7 Phos-3.9 Mg-2.2 ___ 03:15PM BLOOD Mg-2.0 ___ 03:15PM BLOOD CRP-6.5* ___ 04:55AM BLOOD Phenoba-<1.2* Valproa-22* ___ 03:15PM BLOOD Phenoba-<1.2* Valproa-12* ___ 03:15PM BLOOD SED RATE-Test ___ 03:15PM URINE Color-Straw Appear-Clear Sp ___ ___ 03:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR ___ 03:15PM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE Epi-<1 IMAGING: MRI/MRA/MRV ___ 1. No acute intracranial abnormality. 2. Unremarkable MRA of the brain. 3. Unremarkable MRV of the brain without evidence of dural venous sinus thrombosis. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Divalproex (EXTended Release) 500 mg PO DAILY 2. Acetaminophen-Caff-Butalbital 1 TAB PO Q8H:PRN headache 3. Famotidine 20 mg PO DAILY 4. Paroxetine 40 mg PO DAILY 5. Pravastatin 20 mg PO QPM 6. TraMADOL (Ultram) 50 mg PO TID 7. Verapamil SR 180 mg PO Q24H 8. Multivitamins W/minerals 1 TAB PO DAILY Discharge Medications: 1. Famotidine 20 mg PO DAILY 2. Pravastatin 20 mg PO QPM 3. Multivitamins W/minerals 1 TAB PO DAILY 4. Verapamil SR 240 mg PO Q24H RX *verapamil [Calan SR] 240 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*2 5. Paroxetine 40 mg PO DAILY 6. Topiramate (Topamax) 50 mg PO BID RX *topiramate [Topamax] 50 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*2 7. Tizanidine 2 mg PO BID RX *tizanidine 2 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*2 8. Acetaminophen 1000 mg PO TID:PRN pain 9. DiphenhydrAMINE ___ mg PO QHS Discharge Disposition: Home Discharge Diagnosis: Headache Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: MRI AND MRA BRAIN PT12 MR HEAD INDICATION: ___ year old woman with headache x 6 weeks, Evaluate for secondary causes of headache. TECHNIQUE: 3 dimensional time-of-flight MRA was performed through the brain. Sagittal and axial T1 weighted imaging were performed along with diffusion imaging. After administration of 7 mL of Gadavist intravenous contrast, axial imaging was performed with gradient echo, FLAIR, T2, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. Phase contrast MRV of the brain was also performed. Three dimensional maximum intensity projection and segmented images were generated. This report is based on interpretation of all of these images. COMPARISON: None. FINDINGS: MRI BRAIN: There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. The ventricles and sulci are normal in caliber and configuration. There is no abnormal enhancement after contrast administration. There are few scattered foci of T2/FLAIR hyperintensity in the subcortical, periventricular and deep white matter, nonspecific, likely secondary to small vessel ischemic disease. There is a punctate focus of susceptibility in the left frontal centrum semiovale on image 8:17, either secondary to prior microhemorrhage or mineralization. Incidentally seen is a developmental venous anomaly in the left frontal lobe on image 12:16. The orbits are unremarkable. Mild mucosal thickening in bilateral ethmoid air cells. The remaining visualized paranasal sinuses are clear. Bilateral mastoid air cells are clear. Intracranial flow voids are maintained. MRA brain: The intracranial vertebral and internal carotid arteries and their major branches appear normal without evidence of stenosis, occlusion, or aneurysm formation. Incidentally seen is hypoplastic right A1 segment of anterior cerebral artery. Also seen is hypoplastic right vertebral artery. MRV brain: The dural venous sinuses are patent. The vein ___ is patent. Bilateral internal jugular veins are patent IMPRESSION: 1. No acute intracranial abnormality. 2. Unremarkable MRA of the brain. 3. Unremarkable MRV of the brain without evidence of dural venous sinus thrombosis. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Headache Diagnosed with Headache temperature: 97.8 heartrate: 96.0 resprate: 18.0 o2sat: 98.0 sbp: 129.0 dbp: 85.0 level of pain: 7 level of acuity: 3.0

Ms. ___ is a ___ yo female admitted to Neurology Service for status migranosus x7 weeks in setting of multiple medications. Her fiorecet was tapered off; Her Tramadol, indomethacin, Percocet, and Depakote were stopped (Depakote not helpful and causing tremor). Her Verapamil was uptitrated to 240 mg daily. She was given a standing regimen of IVF, toradol and Zofran q6 hours. Nortryptyline was considered, but it would interact with her paxil. Topamax was started and titrated up to 50mg BID. She had significant neck muscle spasm and so was also given tizanidine which did seem to improve headache somewhat. Pain was consulted and performed several nerve blocks after which her headache was much improved. She was then discharged home with follow up with pain medicine and with neurology. Transitional Issues: - Can consider nortryptyline as needed, but would need to taper off paxil. - Pain clinic follow up, they will likely do botox as outpatient since nerve blocks worked well, she needs follow up in one week in case headache returns and she requires repeat nerve block (short-term solution). - Neurology clinic follow up

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: shortness of breath, cough Major Surgical or Invasive Procedure: Right anterior mediastinotomy and biopsy History of Present Illness: Healthy ___ y.o. female presents from ___ after CXR performed for evaluation of cough and fevers demonstrated large anterior mediastinal mass. Patient reports night sweats x 6 months, SOB at rest while speaking x 2 months. Night sweats are severe enough that sheets are soaked. Cough onset was 9 days ago, followed by fevers to 100.4 three days ago. Cough is productive but she denies hemoptysis. No rhinorrhea, sore throat. No abdominal pain, changes in bowel or bladder habits. Denies any history of asthma. Smokes a few cigarettes a month, is a ___ and occasionally visits prisons to interview inmates. During these visits she is in the same room as her clients. She was born in the ___ and has lived here her whole life. She has never worked in a healthcare setting apart from briefly working in a nursing home during high school. She denies any contacts with TB. She has never had a PPD as an adult. In the ED, initial vitals were: 99.3 94 139/75 18 97% RA - Labs were significant for leukocytosis to 15.7, Hg 11.1, platelets 494 - Imaging revealed: CT chest notable for large anterior mediastinal mass, pericardial effusion vs. thickening without evidence of tamponade, and RUL and RML consolidation - The patient was given 2g IV cefepime Past Medical History: OB History: G0, P0. GYN History: Menarche age ___. Regular menses every 28 days, seven days of heavy flow (cyclic menorrhagia), moderate dysmenorrhea but no significant pelvic pain. Denies any dyspareunia, pain with full bladder or bowel movement. - Denies history of abnormal Pap. Last Pap ___ reportedly negative. Last mammogram reportedly ___ yr ago also negative. - currently in a same sex relationship, but is bisexual and was in heterosexual relationship in the past. reports roughly 15 sexual partners throughout life. Does not currently require any contraception currently. Denies history of STDs. PMH: 1. Uterine fibroids (cyclic menorrhagia/dysmenorrhea) PSH: Negative. Social History: ___ Family History: Denies any GYN cancers or any cancers in the family. She reports the mother with hypertension and hypercholesterolemia and no other family medical conditions. Physical Exam: ADMISSION EXAM: ================= Vitals: 98.2 128/60 90 20 97% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, 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-tender, non-distended GU: No foley Ext: Warm, well perfused, no clubbing, cyanosis or edema Neuro: CNII-XII grossly intact DISCHARGE EXAM: ================= Vitals: Temp 98.8 HR 70-80s BP 100-120/60-70s RR 18 SpO2 95% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, 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-tender, non-distended GU: No foley Ext: Warm, well perfused, no clubbing, cyanosis or edema Neuro: CNII-XII grossly intact Pertinent Results: ADMISSION LABS: ================= ___ 04:35PM BLOOD WBC-15.7* RBC-4.54# Hgb-11.1*# Hct-36.5# MCV-80* MCH-24.4* MCHC-30.4* RDW-16.0* RDWSD-46.3 Plt ___ ___ 04:35PM BLOOD Neuts-80.1* Lymphs-10.2* Monos-6.9 Eos-1.8 Baso-0.6 Im ___ AbsNeut-12.58* AbsLymp-1.60 AbsMono-1.09* AbsEos-0.29 AbsBaso-0.10* ___ 08:00AM BLOOD ___ PTT-29.1 ___ ___ 04:35PM BLOOD Glucose-82 UreaN-9 Creat-0.7 Na-138 K-4.4 Cl-102 HCO3-24 AnGap-16 ___ 04:35PM BLOOD Calcium-9.7 Phos-4.0 Mg-2.1 ___ 04:35PM BLOOD HCG-<5 ___ 04:38PM BLOOD Lactate-1.5 IMAGING: =============== ___ - TTE The estimated right atrial pressure is ___ mmHg. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a trivial circumferential echolucent pericardial effusion. There is a moderately thick (~2 cm) echodense, fixed mass encasing the heart seen in multiple views, both anteriorly to the right ventricle and adjacent to the left ventricle. No right atrial or right ventricular diastolic collapse is seen. Trivial pericardial effusion. Mass seen external to the pericardial space which appears to surround the heart without apparent hemodynamic compromise. Normal biventricular systolic function. ___ - CXR Small right apical pneumothorax. No pneumomediastinum. Large mediastinal mass unchanged. No definite change in the lungs. Possible small right fissural pleural fluid collection. ___ - CT Chest contrast 1. Very large relatively homogeneous soft tissue density mass occupying nearly half of the anterior hemithorax centered in the right mediastinum encasing the major vessels and airways. Multiple round relatively hyperdense lesions in the right upper mediastinum likely reflecting lymph nodes. Given the appearance of the mass would favor lymphoma as the top differential diagnosis, less likely of thymic origin. 2. Large amount of intermediate density fluid or soft tissue thickening of the pericardium. No radiographic evidence of tamponade. 3. Consolidation in the right upper and middle lobes with air bronchograms. While this may reflect atelectasis, a postobstructive pneumonia is possible. MICROBIOLOGY: =============== Urinary legionella ag - negative ___ - Blood cultures x3 - NGTD ___ 4:25 pm TISSUE MEDIASTINAL MASS. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. TISSUE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. PATHOLOGY: ============= Pleural fluid - ___ - Negative for malignant cells. - Mesothelial cells and macrophages. Cytogenetics of LN ___ - Pending Tissue: MEDIASTINUM, MASS, RESECTION ___ - Pending DISCHARGE LABS: ================ ___ 07:45AM BLOOD WBC-14.4* RBC-4.43 Hgb-10.7* Hct-35.3 MCV-80* MCH-24.2* MCHC-30.3* RDW-15.9* RDWSD-45.8 Plt ___ Medications on Admission: 1. ___ FE ___ (28) (norethindrone-e.estradiol-iron) 1.5 mg-30 mcg (21)/75 mg (7) oral DAILY 2. Multivitamins 1 TAB PO DAILY 3. Ibuprofen 400 mg PO Q8H:PRN pain Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN pain 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 8 Days RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1 tablet(s) by mouth every 12 hours Disp #*18 Tablet Refills:*0 3. Benzonatate 100 mg PO TID:PRN cough RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day Disp #*21 Capsule Refills:*0 4. Ibuprofen 400 mg PO Q8H:PRN pain 5. ___ FE ___ (28) (norethindrone-e.estradiol-iron) 1.5 mg-30 mcg (21)/75 mg (7) oral DAILY 6. Multivitamins 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY: Anterior mediastinal mass Post-obstructive pneumonia 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 s/p mediastinotomy and bx of anterior mediastinal mass // please assess for PTX or other interval change please assess for PTX or other interval change COMPARISON: Chest radiograph ___. IMPRESSION: Small right apical pneumothorax. No pneumomediastinum. Large mediastinal mass unchanged. No definite change in the lungs. Possible small right fissural pleural fluid collection. Gender: F Race: OTHER Arrive by WALK IN Chief complaint: Cough, Dyspnea, Fever Diagnosed with Cough temperature: 99.3 heartrate: 94.0 resprate: 18.0 o2sat: 97.0 sbp: 139.0 dbp: 75.0 level of pain: 0 level of acuity: 2.0

SUMMARY: Otherwise healthy ___ y.o. female presents from ___ after CXR performed for evaluation of cough and fevers demonstrated large anterior mediastinal mass. She reported 6 months of night sweats and shortness of breath/shallow breathing as reported by her wife (pt denies dyspnea), 9 days of productive cough. # Pneumonia: Likely post-obstructive given anterior mediastinal mass. She did well clinically without fever and had improved leukocytosis. She will complete a 7 day course of augmentin with final day = ___. Negative urinary legionella ag. Blood cultures were NGTD at time of this summary. # Mediastinal mass: differential includes lymphoma, thymoma, thyroid, and teratoma. Per radiology report imaging most suggestive of lymphoma, and she also endorses B symptoms. Negative micro on biopsy specimen. - s/p mediasteinotomy ___ - pathology pending at discharge # Pericardial effusion: intermediate density fluid vs. soft tissue thickening of pericardium on CT without evidence of tamponade. TTE without significant pericardial effusion - no intervention

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Hydrocodone Attending: ___ Chief Complaint: Chest pain/ left arm pain Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is an ___ with dementia, coronary artery disease s/p CABG ___, atrial fibrillation on coumadin, AVR s/p bioprosthetic valve who presented to the ED with intermittent chest pain radiating down the left arm occurring over the past several days. She described it as a burning sensation extending down the entirety of the arm occurring principally with exertion but also occasionally at rest, and lasting typically about 5min. It would improve slightly with rest but incompletely. She had accompanying dyspnea at the same time and does complain of a cough. She denies chest pain or heaviness. She does not recall similar symptoms in the past though her last cardiology clinic note suggested similar symptoms. She sees Dr. ___ management of her multifacetted cardiac disease, most recently in ___ at which point she was complaining of left arm pain with exertion that improved with rest. She had mild heart failure as well, all of which was attributed to inadequately controlled hypertension. She was felt to have stable angina. In the ED, her initial vitals were 96.3 90 175/91 18 96% ra. Her initial EKG revealed atrial fibrillation with 1mm ST depressions in the lateral leads which were new, though occurred in the context of LVH. Her labs were generally unremarkable aside from an elevated BNP. CXR showed some fluid in the minor fissure and central venous engorgement without overt pulmonary edema. Her symptoms were felt to be related to hypertension, and they responded both clinically and numerically to 0.4mg of SL NTG with a resultant pressure of 120 systolic. She was admitted with stable troponins to the cardiology service. On arrival to the floor, her initial vitals were: T97.3BP129/59 P65 RR18 Sat94RA. She is comfortable. She has some aching in the right shoulder that she says is always present, but does not have the full arm pain that ushered her ED visit. She has no chest pain or shortness of breath currently, and feels well. She has no current orthopnea or PND and is laying flat in bed. She does carry a diagnosis of advancing dementia, and appears to be dependent on her son/daughter in law for all IADLs. Despite her extensive cardiac history, she could not remember any of her diagnoses or prior treatments. She is oriented to ___, name, ___, and ___, but she seems to struggle recollecting this information. On review of systems, she denies fevers, chills, naunsea, vomiting, claudication, dysuria, hematuria, muscle pains, arthralgias,visiion changes, weakness, fatigue, shortness of breath, hemoptysis, swelling Past Medical History: 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: ___ at ___ LIMA to the LAD; SVG to OMB; SVG to PDA) - atrial fibrillation on warfarin - Aortic Stenosis, s/p bioprosthetic Aortic Valve Replacement 3. OTHER PAST MEDICAL HISTORY: -Pulmonary HTN -Sleep apnea, unable to tolerate CPAP -Stage III renal insufficiency -Hypothyroid -Cancer-skin of face -Difficulty swallowing -Anxiety -Depression -Mild dementia -Rhinitis -Tinnitus -Spinal stenosis -S/P gallstone -GERD PAST SURGICAL HISTORY -S/P C-section x4 -Right Knee replacement -CABG -bioprosthetic AVR Social History: ___ Family History: Mother had CAD in her ___ per OMR Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS- T97.3BP129/59 P65 RR18 Sat94RA. Wt74.8 GENERAL- well appearing female, sleeping, in no acute distress. HEENT- PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK- Supple with JVP up to the mandibular angle CARDIAC- irregularly irregular, variable intensity S1, S2. ___ SEM at the ___ right ICS without radiation. No S3 or S4. LUNGS- crackle in the right base but moving good air and generally clear ABDOMEN- Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES- No c/c/e. SKIN- No stasis dermatitis, ulcers, scars, or xanthomas. PULSES- Right: Carotid 2+ DP 2+ ___ 2+ Left: Carotid 2+ DP 2+ ___ 2+ NEURO: A&O x 2, CN2-12 intact grossly, ___ strength throughout, normal sensation throughout. No focal deficits. DISCHARGE PHYSICAL EXAMINATION: VS- T97.6F, BP 130/66 (123-133/59-74), HR 62, RR 18, 97%RA Weight 72.4kg GENERAL- well appearing female, sleeping flat on back, in no acute distress, easily rousable HEENT- PERRL, EOMI. Conjunctiva pink, no pallor or cyanosis of the oral mucosa, OP clear NECK- Supple with JVP 7cm CARDIAC- irregularly irregular, normal S1, S2. ___ systolic murmur heard best at RUSB. LUNGS- good air movement, bibasilar crackles R>L ABDOMEN- Soft, NTND. No HSM or tenderness. +BS EXTREMITIES- No edema NEURO: A&Ox2 (not to date or to specific hospital), CN2-12 intact grossly Pertinent Results: ADMISSION LABS: ___ 09:20PM BLOOD WBC-5.5 RBC-5.09 Hgb-13.0 Hct-40.8 MCV-80* MCH-25.5* MCHC-31.8 RDW-17.3* Plt ___ ___ 09:20PM BLOOD Neuts-75.9* Lymphs-15.2* Monos-7.5 Eos-1.0 Baso-0.4 ___ 09:20PM BLOOD ___ PTT-32.8 ___ ___ 09:20PM BLOOD Glucose-107* UreaN-20 Creat-1.0 Na-140 K-4.3 Cl-107 HCO3-21* AnGap-16 ___ 09:20PM BLOOD proBNP-2637* ___ 09:20PM BLOOD cTropnT-<0.01 ___ 07:30AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 07:30AM BLOOD Calcium-8.6 Phos-4.0 Mg-1.9 PERTINENT LABS: ___ 05:30PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 05:30PM URINE Blood-MOD Nitrite-POS Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG ___ 05:30PM URINE RBC-2 WBC-70* Bacteri-MANY Yeast-NONE Epi-2 ___ 09:20PM BLOOD ___ PTT-32.8 ___ ___ 07:30AM BLOOD ___ PTT-31.6 ___ ___ 07:55AM BLOOD ___ ___ 07:30AM BLOOD ___ DISCHARGE LABS: ___ 07:55AM BLOOD WBC-5.8 RBC-4.73 Hgb-11.7* Hct-37.9 MCV-80* MCH-24.7* MCHC-30.9* RDW-17.2* Plt ___ ___ 07:30AM BLOOD ___ ___ 07:30AM BLOOD Glucose-86 UreaN-19 Creat-0.9 Na-141 K-3.7 Cl-108 HCO3-23 AnGap-14 ___ 07:30AM BLOOD Calcium-8.6 Phos-4.0 Mg-1.9 MICRO: 10:45 ___. CLOSTRIDIUM DIFFICILE. Positive for toxigenic C. difficile by the Illumigene DNA amplification. (Reference Range-Negative). ___: Urine cultre pending at discharge CXR ___ FINDINGS: Frontal and lateral views of the chest were obtained. The patient is status post median sternotomy and CABG. There is thickening/fluid along the minor fissure. There is elevation and eventration of the right hemidiaphragm with overlying right base atelectasis. The cardiac and mediastinal silhouettes are stable with the aorta calcified and tortuous and the cardiac silhouette mildly enlarged. Slight prominence of the hila is stable, which may relate to pulmonary vascular engorgement. No focal consolidation or evidence of pneumothorax is seen. There are degenerative changes at the partially imaged left shoulder. IMPRESSION: Persistent enlargement of the cardiac silhouette and central pulmonary vascular engorgement without overt pulmonary edema. Thickening/fluid along the minor fissure. No focal consolidation. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Donepezil 5 mg PO HS 3. Aspirin 81 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Rosuvastatin Calcium 5 mg PO DAILY 6. Digoxin 0.125 mg PO EVERY OTHER DAY 7. Diltiazem Extended-Release 120 mg PO DAILY 8. Fluoxetine 40 mg PO DAILY 9. Fluticasone Propionate NASAL 1 SPRY NU DAILY 10. Levothyroxine Sodium 100 mcg PO DAILY 11. Nitroglycerin SL 0.3 mg SL PRN CP 12. Omeprazole 20 mg PO DAILY 13. Metoprolol Succinate XL 150 mg PO HS 14. Vitamin D 50,000 UNIT PO 1X/WEEK (WE) 15. Warfarin 2 mg PO DAYS (___) 16. Warfarin 3 mg PO DAYS (___) 17. Potassium Chloride 20 mEq PO DAILY 18. lisinopril-hydrochlorothiazide *NF* ___ mg Oral daily Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Digoxin 0.125 mg PO EVERY OTHER DAY 3. Diltiazem Extended-Release 120 mg PO DAILY hold for SBP <100 or HR <55 4. Donepezil 5 mg PO HS 5. Fluoxetine 40 mg PO DAILY 6. Levothyroxine Sodium 100 mcg PO DAILY 7. Metoprolol Succinate XL 150 mg PO HS Hold for SBP< 100 or HR<55 8. Vitamin D 50,000 UNIT PO 1X/WEEK (WE) 9. Rosuvastatin Calcium 5 mg PO DAILY 10. Omeprazole 40 mg PO DAILY 11. Multivitamins 1 TAB PO DAILY 12. Acetaminophen 650 mg PO Q6H:PRN pain fever 13. Fluticasone Propionate NASAL 1 SPRY NU DAILY 14. Potassium Chloride 20 mEq PO DAILY 15. Furosemide 20 mg PO DAILY hold for SBP <100 16. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 17. Lisinopril 10 mg PO DAILY hold for SBP <100 18. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 3 Days Last day ___ 19. Nitroglycerin SL 0.3 mg SL PRN CP take 1 tab for chest pain. If no relief after 5 minutes, repeat dose. If no relief 5 minutes after 2nd dose, take a third dose and call ___. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Last day ___ Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: hypertension, clostridium difficile diarrhea, urinary tract infection Secondary: coronary artery disease 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 EXAM: Chest frontal and lateral views. CLINICAL INFORMATION: Left-sided chest pain, history of coronary disease, question pneumothorax, question pulmonary edema. ___. FINDINGS: Frontal and lateral views of the chest were obtained. The patient is status post median sternotomy and CABG. There is thickening/fluid along the minor fissure. There is elevation and eventration of the right hemidiaphragm with overlying right base atelectasis. The cardiac and mediastinal silhouettes are stable with the aorta calcified and tortuous and the cardiac silhouette mildly enlarged. Slight prominence of the hila is stable, which may relate to pulmonary vascular engorgement. No focal consolidation or evidence of pneumothorax is seen. There are degenerative changes at the partially imaged left shoulder. IMPRESSION: Persistent enlargement of the cardiac silhouette and central pulmonary vascular engorgement without overt pulmonary edema. Thickening/fluid along the minor fissure. No focal consolidation. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: CHEST AND ARM PAIN Diagnosed with CHEST PAIN NOS temperature: 96.3 heartrate: 90.0 resprate: 18.0 o2sat: 96.0 sbp: 175.0 dbp: 91.0 level of pain: 13 level of acuity: 2.0

Mrs. ___ is a pleasant ___ F with dementia, coronary artery disease, atrial fibrillation, and aortic valve replacement who presented with arm pain and dyspnea concerning for ischemia in the setting of lateral ST depressions. Symptoms felt to be anginal equivalent that may have been related to inadequately controlled blood pressures due to poor medication compliance in setting of recent social stressors, change in home situation. Found to have urinary tract infection and Clostridium difficile diarrhea. # STABLE ANGINA: Patient presenting with left arm pain. Though history clouded by dementia, her symptoms and EKGs were consistent with angina in patient with known coronary artery disease, improved with SL NTG and blood pressure control. No ST elevations or cardiac enzyme elevation to suggest an acute coronary syndrome, and her pain was easily managed. Isosorbide mononitrate was added to her regimen for long term antiangina management, and she was continued on medical management of her coronary artery disease as below. # CORONARY ARTERY DISEASE: status post CABG in ___. Current presentation was consistent with prior stable angina per cardiology clinic notes, and without persistent EKG changes or enzyme elevations. Symptoms improved with blood pressure control (presented with pressures in the 180s). Continued aspirin, statin, beta blockade, ACE inhibitor, sublingual nitroglycerin prn. Added isosorbid mononitrate as above. # ACUTE ON CHRONIC DIASTOLIC/SYSTOLIC HEART FAILURE: EF 45-50%. Presented with dyspnea on exertion and some central engorgement and fluid in fissure on admission CXR. Appeared volume overloaded but improved with 40mg PO furosemide x1, then daily 20mg PO thereafter. Exacerbation occurred in setting of discontinuation of furosemide as outpatient due to urinary incontinence. Of note, per documentation, patient was also hospitalized in ___ for overload when furosemide was stopped for urinary incontinence as well. This patient may need long term loop diuretic therapy, and urinary incontinence and its effect on her quality of life will need to be balanced with desire to avoid recurrent hospitalizations. # HYPERTENSION: Management as above with metoprolol, diltiazem, lisinopril # Urinary tract infection: Patient asymptomatic but poor historian, with positive UA. Started on 3 day course of Bactrim DS, urine culture pending at time of discharge. Last day of bactrim ___. # Clostridium difficile diarrhea: patient presented with diarrhea, noted to have ___ loose bowel movements daily, no new ingestions or sick contacts, no abdominal pain or leukocytosis. C. diff assay was positive, started metronidazole ___ for two week course, last day of metronidazole ___. # GERD: Felt to be contributing to this patient's vague chest pain complaints as symptoms worse with eating, laying flat. Increased omeprazole to 40mg daily.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: GIB Major Surgical or Invasive Procedure: Upper Endoscopy Capsule endoscopy History of Present Illness: ___ male with a past medical history of AVMs of GI tract, T1DM, CAD w/ 3vd, COPD, PVD, and aortic stenosis, revision of a left femoral-popliteal bypass on apixiban, recently hospitalized at ___ for BRBRPR and NSTEMI, presenting nausea, abdominal pain as well as increasing lightheadness, and DOE. Patient himself is a poor historian and denies having any black or bloody stools nor any other symptoms. Of note, patient underwent a revision of a left femoral-popliteal bypass about 2 months ago, now on xarelto. He was recently admitted from ___ to ___ with melena and acute on chronic anemia found to have AVMs in small intestine as source, and new ST depressions in lateral precordial leads c/w demand (Type II) NSTEMI. His blood counts stabilized on heparin drip and he was transitioned to apixaban for its lower rates of GI bleed. Patient went to his PCP today given these symptoms for 1 week and was found to have a drop in Hgb from 8.2 to 6.7. He was transferred to the ED for further care. In the ED, Initial Vitals: 98.0 100 111/55 18 100% RA Exam: General: Well appearing, no acute distress Cardiac: RRR no rgm Pulmonary: Clear to auscultation bilaterally, no crackles/wheezes Abdominal/GI: No tenderness or masses Renal: No CVA tenderness MSK: No deformities or signs of trauma Derm: No rashes or signs of trauma Psych: Normal judgment, mood appropriate for situation Guaic positive stools with visualized melena. Labs: Hgb 6.6, INR 2.1, trop 2.51 -> 1.71, MBI 8.1 Imaging: Consults: Atrius cardiology - transfuse PRN, continue to monitor GI- Keep on PPI 40 mg twice daily - Monitor H/H serially; maintain 2 large bore peripheral IV's - Maintain active type & screen - Will determine need and timing of EGD based on clinical trajectory - Call/page for unstable bleeding Interventions: IV PPI, 1u pRBC VS Prior to Transfer: 97.9 96 107/61 20 100% RA On arrival to the ICU, patient feels fine without any complaints. His daughters are at bedside who report patient has just had abdominal discomfort for the past week with ___ episodes of vomiting. Patient also felt short of breath with minimal exertion which is different than his baseline. This is primarily what prompted them to see their PCP. Past Medical History: prostate CA Type 1 DM diabetic retinopathy Acute on chronic combined systolic and diastolic congestive heart failure CAD w/ 3vd COPD PVD aortic valve stenosis Social History: ___ Family History: Father - deceased ___ lung cancer, smoker Mother - ___ Physical ___: ADMISSION PHYSICAL EXAM ========================= VS: Reviewed in metavision GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. oropharynx clear. NECK: No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. ___ systolic murmur at the LLSB. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. BACK: No spinous process tenderness. No CVA tenderness. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. EXTREMITIES: 2+ edema L shin and 1+ edema on the right. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill less than 2s. No rash. NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal sensation. Gait is normal, assisted by ___. AOx3. DISCHARGE PHYSICAL EXAM ========================== 24 HR Data (last updated ___ @ 1708) Temp: 97.8 (Tm 98.4), BP: 115/75 (104-115/64-75), HR: 93 (58-100), RR: 16 (___), O2 sat: 96% (93-99), O2 delivery: Ra GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. Pale conjunctiva. MMM. Oropharynx clear. NECK: No cervical lymphadenopathy. No JVD CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. ___ systolic murmur at the LLSB. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. BACK: No spinous process tenderness. No CVA tenderness. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. EXTREMITIES: No edema bilaterally. Pulses DP/Radial bilaterally SKIN: Warm. Cap refill less than 2s. No rash. NEUROLOGIC: CN grossly intact. Normal spontaneous movement. sensation grossly intact. Gait not assessed Pertinent Results: ADMISSION LABS ==================== ___ 01:51PM BLOOD Anisocy-1+* Poiklo-1+* Polychr-1+* Ovalocy-1+* Schisto-1+* Echino-1+* RBC Mor-SLIDE REVI ___ 01:51PM BLOOD ___ PTT-34.0 ___ ___ 01:51PM BLOOD Glucose-289* UreaN-24* Creat-0.9 Na-137 K-4.6 Cl-95* HCO3-24 AnGap-18 ___ 01:51PM BLOOD ALT-33 AST-47* CK(CPK)-505* AlkPhos-163* TotBili-0.3 ___ 01:51PM BLOOD CK-MB-41* MB Indx-8.1* ___ 01:51PM BLOOD cTropnT-2.51* ___ 01:51PM BLOOD Albumin-2.9* ___ 01:51PM BLOOD WBC-7.5 RBC-2.44* Hgb-6.6* Hct-21.9* MCV-90 MCH-27.0 MCHC-30.1* RDW-18.6* RDWSD-58.9* Plt ___ ___ 01:51PM BLOOD Neuts-79* Lymphs-9* Monos-11 Eos-1 Baso-0 AbsNeut-5.93 AbsLymp-0.68* AbsMono-0.83* AbsEos-0.08 AbsBaso-0.00* PERTINENT LABS ==================== ___ 05:31PM BLOOD cTropnT-1.71* ___ 02:58AM BLOOD CK-MB-12* MB Indx-5.3 cTropnT-1.49* ___ 01:51PM BLOOD WBC-7.5 RBC-2.44* Hgb-6.6* Hct-21.9* MCV-90 MCH-27.0 MCHC-30.1* RDW-18.6* RDWSD-58.9* Plt ___ ___ 02:58AM BLOOD WBC-5.6 RBC-2.58* Hgb-7.1* Hct-22.7* MCV-88 MCH-27.5 MCHC-31.3* RDW-17.7* RDWSD-54.0* Plt ___ ___ 05:14AM BLOOD WBC-4.2 RBC-3.19* Hgb-8.9* Hct-28.0* MCV-88 MCH-27.9 MCHC-31.8* RDW-17.3* RDWSD-54.4* Plt ___ ___ 01:51PM BLOOD ALT-33 AST-47* CK(CPK)-505* AlkPhos-163* TotBili-0.3 ___ 01:51PM BLOOD cTropnT-2.51* DISCHARGE LABS ==================== ___ 05:14AM BLOOD WBC-4.2 RBC-3.19* Hgb-8.9* Hct-28.0* MCV-88 MCH-27.9 MCHC-31.8* RDW-17.3* RDWSD-54.4* Plt ___ ___ 05:14AM BLOOD Plt ___ ___ 05:14AM BLOOD Glucose-52* UreaN-11 Creat-0.7 Na-140 K-4.3 Cl-104 HCO3-24 AnGap-12 ___ 05:14AM BLOOD Albumin-2.2* Calcium-8.0* Phos-3.9 Mg-1.9 MICROBIOLOGY ==================== None IMAGING ==================== EGD ___: IMPRESSION: - Irregular z-line of the mucosa was noted in the gastroesophageal junction. Biopsies were not taken in order to prevent distortion of capsule images - Normal mucosa in the whole stomach - A few small non-bleeding angioectasias were seen in the duodenal bulb and second part of the duodenum. Cautery was not performed since AVMs were not actively bleeding and to prevent distortion on images of subsequently placed capsule - A separate consent was obtained for capsule endoscopy. The capsule was placed endoscopically and released in the duodenum without complications. Study arterial duplex lower extremity ___: - Reason femoropopliteal bypass. - Duplex evaluations formed the left lower extremity bypass graft. Peak velocities from proximal to distal starting in the common femoral artery are 190, 90, 44, 30, 42, 66, 92. There is a seroma in the distal thigh. - Impression widely patent left femoral to popliteal artery bypass graft. Small seroma Portable abdominal x-ray (___): IMPRESSION: Endoscopic capsule in the distal colon. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN wheeze 2. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25 mcg/actuation inhalation DAILY 3. Felodipine 5 mg PO DAILY 4. Metoprolol Succinate XL 25 mg PO DAILY 5. Polyethylene Glycol 17 g PO DAILY 6. Ramelteon 8 mg PO QHS 7. Senna 8.6 mg PO BID:PRN Constipation - First Line 8. Lidocaine 5% Patch 1 PTCH TD QAM lumbar lower back pain 9. Acetaminophen 650 mg PO Q6H 10. Aspirin EC 81 mg PO DAILY 11. Atorvastatin 80 mg PO QPM 12. Furosemide 40 mg PO DAILY 13. Gabapentin 100 mg PO TID 14. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS 15. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain 16. Pantoprazole 40 mg PO Q24H 17. Spironolactone 25 mg PO DAILY 18. Apixaban 5 mg PO BID 19. Ferrous Sulfate 325 mg PO EVERY OTHER DAY 20. Glargine 30 Units Bedtime Humalog 5 Units Breakfast Humalog 5 Units Lunch Humalog 5 Units Dinner Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth daily at night Disp #*30 Tablet Refills:*0 2. needle (disp) 32 gauge 32 gauge x ___ miscellaneous Other RX *needle (disp) 32 gauge [Easy Touch Hypodermic Needle] 32 gauge X ___ To use with Kwikpen As directed Disp #*1 Package Refills:*0 3. Glargine 8 Units Breakfast Glargine 7 Units Bedtime Humalog 5 Units Breakfast Humalog 5 Units Lunch Humalog 5 Units Dinner Insulin SC Sliding Scale using HUM Insulin 4. Acetaminophen 650 mg PO Q6H 5. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN wheeze 6. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25 mcg/actuation inhalation DAILY 7. Aspirin EC 81 mg PO DAILY 8. Atorvastatin 80 mg PO QPM 9. Ferrous Sulfate 325 mg PO EVERY OTHER DAY 10. Furosemide 40 mg PO DAILY 11. Gabapentin 100 mg PO TID 12. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS 13. Lidocaine 5% Patch 1 PTCH TD QAM lumbar lower back pain 14. Metoprolol Succinate XL 25 mg PO DAILY 15. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain 16. Pantoprazole 40 mg PO Q24H 17. Polyethylene Glycol 17 g PO DAILY 18. Ramelteon 8 mg PO QHS Should be given 30 minutes before bedtime 19. Senna 8.6 mg PO BID:PRN Constipation - First Line 20. HELD- Spironolactone 25 mg PO DAILY This medication was held. Do not restart Spironolactone until you see your cardiologist Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: Primary diagnosis: Acute on chronic anemia Secondary diagnosis: Chronic arteriovenous malformations NSTEMI CAD Type 1 diabetes Peripheral vascular disease HFrEF Aortic stenosis COPD Hypertension 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 Study arterial duplex lower extremity Reason femoropopliteal bypass. Duplex evaluations formed the left lower extremity bypass graft. Peak velocities from proximal to distal starting in the common femoral artery are 190, 90, 44, 30, 42, 66, 92. There is a seroma in the distal thigh. Impression widely patent left femoral to popliteal artery bypass graft. Small seroma Radiology Report EXAMINATION: Abdominal radiograph, portable AP supine view. INDICATION: Status post capsule study. COMPARISON: ___. FINDINGS: Endoscopic capsule projects over the left upper quadrant, very likely in the lower descending or upper sigmoid portion of the colon. Bowel gas pattern is unremarkable. No indications of free air. Partly visualized brachytherapy seeds in the prostate. Moderate vascular calcification. Degenerative changes of the L4-L5 facet joints. IMPRESSION: Endoscopic capsule in the distal colon. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abd pain, Anemia Diagnosed with Anemia, unspecified temperature: 98.0 heartrate: 100.0 resprate: 18.0 o2sat: 100.0 sbp: 111.0 dbp: 55.0 level of pain: 0 level of acuity: 2.0

Key Information for Outpatient ___ male with a past medical history of AVMs of GI tract with recent admission for UGIB needing transfusions, T1DM, CAD w/ 3vd, COPD, PVD, and aortic stenosis, revision of a left femoral-popliteal bypass on apixiban presenting with abdominal pain and DOE, found to have acute blood loss anemia ___ recurrent GIB and NSTEMI, likely type II. His course was complicated by difficulty controlling her blood glucoses. #Acute on chronic anemia: Initial HgB on presentation was 6.6. He received 3u of pRBCs during his exam and his hemoglobin stabilized between 8.1 and 8.9 (8.9 on discharge). He has had multiple hospitalizations for anemia d/t presumed GI source. Upper EGD demonstrated irregular z-line of the mucosa at the GE junction, normal mucosa of the stomach, and a few small non-bleeding angioectasias. Interventions were not performed to preserve the capsule endoscopy, but the capsule endoscopy also did not reveal obvious sources of bleeding. He presented on apixaban and had previously been on Xarelto at the last hospitalization. We held an informed discussion with the patient's daughter regarding the risks of bleeding vs. clotting. Having failed two anticoagulation regimens, the decision was made to transition to Plavix rather than restarting anticoagulation. The family was informed that there was a higher risk of clotting on Plavix vs. anticoagulation, but there was also a lower risk of bleeding. Family expressed significant concerns about his continued hospitalizations for anemia, and thus, the decision was made to start him on dual antiplatelet therapy. He was instructed to get a repeat CBC next week, ___ with his PCP, his gastroenterologist and his vascular surgeon to continue the discussion of anticoagulation vs. DAPT. #NSTEMI: Patient with significant troponin leak to 2.51 that improved to 1.49. ECG did not reveal new ischemic changes. The troponin leak was felt to be d/t anemia. Patient has known history of significant CAD with 3vd (LAD 90%, LCx 90% and 100% RCA lesion on ___, but family and his cardiologist at ___ had elected for conservative management. After discussions with ___ cardiology, the decision was made to defer TTE and continue conservative management. #Type 1 diabetes: Patient seen by ___ for management of his diabetes. His insulin dosing was changed to 15U of lantus in the AM, 5U Humalog fixed for each meal and corrective dosing of 200/50/1/1. Patient has a continuous glucose monitor at home, which his daughter helps manage. #PVD s/p L femoral-popliteal bypass revision (___): Patient had previously been on rivaroxaban before transitioning to apixaban during recent hospitalization for anemia. Based upon recurrent GI bleeds, the decision was made to start DAPT and hold anticoagulation. As stated above, the family agreed with this plan. He was encouraged to ___ with his PCP. #HFrEF: Patient's last known EF was 40%. His furosemide, spironolactone and metoprolol were initially held. He was restarted on furosemide 40mg PO/NG daily and metoprolol succinate XL 25mg PO daily with instructions to followup with his cardiologist regarding his spironolactone. =================================

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: ___ y/o female w/ PMHx HTN, DM, CKD stage IV, anemia thought ___ renal failure on epo as an outpatient who presents with headache and shortness of breath x10 days. Was in her usual state of health when headache started, intermittent, squeezing sensation. SOB started few days ago, mildly worse than her baseline SOB, worsening with exertion. No chest pain. No fevers, chills, sweats, cough. In ___, she was seen in the ___ clinic for fatigue and shortness of breath and found to acute drop in H/H to 7.6/23.0. She did not want a transfusion at that time and was treated with aransep injections. Her repeat H/H 2 weeks later was 8.3/26.0. In the ED, initial VS were:98.2 75 152/44 20. Labs showed K of 5.7, Cr of 2.1, BNP of 808, H/H 8.4/27.0 (10.0/32.1 in ___. UA showed mod bacteria and 14 WBC. EKG showed NSR ___hanges or peaked Ts. CXR showed low lung volumes with mild pulmonary vascular congestion. She was given cipro 500mg PO to cover for a UTI and furosemide 40mg IV. Patient refused transfusion. VS on transfer: 99.1 68 ___ 24 96%. Overnight, her headache has resolved and she had no SOB at rest. Stated that if she were to walk around, she would become dyspneic. No chest pain ever. No urinary symptoms. States her leg swelling is at baseline. Has not noted any blood in stool or elsewhere. In the AM, her fatigue and dyspnea have resolved. She is able to walk to the bathroom without difficulty. Please see nightfloat admission note for home medications, allergies, FH, and SH, which I have confirmed with the patient. Past Medical History: Hypertension. Chronic kidney disease. Hypothyroidism. Depression Anemia Osteoarthritis Urinary incontinence Chronic tremor Cataracts Glaucoma Obesity History of carpal tunnel syndrome History of rotator cuff tear Status post of scapulolunate tear Social History: ___ Family History: Diabetes in her sister. The patient lost multiple family members when she came from ___. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 147/53 68 18 100%RA GENERAL: well appearing female in NAD HEENT: NC/AT, PERRL, EOMI, sclerae anicteric, MMM, poor dentition NECK: supple, no LAD, JVD difficult to appreciate but 2 cm above clavicle at 30 degrees LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART: RRR, no MRG, nl S1-S2 ABDOMEN: normal bowel sounds, obese, soft, non-tender, non-distended, no rebound or guarding, declined rectal exam EXTREMITIES: 2+ edema, 2+ pulses radial and dp, small bruises throughout arms NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ and symmetric DISCHARGE PHYSICAL EXAM: VS: 98.1 62 147/58 18 95%RA GENERAL: well appearing female in NAD HEENT: NC/AT, PERRL, EOMI, sclerae anicteric, MMM, poor dentition NECK: supple, no LAD, JVD difficult to appreciate but 2 cm above clavicle at 30 degrees LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART: RRR, no MRG, nl S1-S2 ABDOMEN: normal bowel sounds, obese, soft, non-tender, non-distended, no rebound or guarding, declined rectal exam EXTREMITIES: 2+ edema, 2+ pulses radial and dp, small bruises throughout arms NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ and symmetric Pertinent Results: ___ 08:40PM URINE HOURS-RANDOM ___ 08:40PM URINE UHOLD-HOLD ___ 08:40PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 08:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD ___ 08:40PM URINE RBC-0 WBC-14* BACTERIA-FEW YEAST-NONE EPI-1 ___ 08:40PM URINE MUCOUS-RARE ___ 07:37PM LACTATE-0.7 ___ 07:25PM GLUCOSE-182* UREA N-68* CREAT-2.1* SODIUM-141 POTASSIUM-5.7* CHLORIDE-108 TOTAL CO2-25 ANION GAP-14 ___ 07:25PM LD(LDH)-193 ___ 07:25PM proBNP-808* ___ 07:25PM IRON-38 ___ 07:25PM calTIBC-269 FERRITIN-205* TRF-207 ___ 07:25PM WBC-4.9 RBC-2.77* HGB-8.4* HCT-27.0* MCV-98 MCH-30.4 MCHC-31.2 RDW-13.2 ___ 07:25PM NEUTS-67.5 ___ MONOS-5.0 EOS-2.7 BASOS-0.3 ___ 07:25PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL ___ 07:25PM PLT COUNT-145* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aliskiren 300 mg PO DAILY hold for SBP < 90 2. Atorvastatin 40 mg PO DAILY 3. Calcitriol 0.25 mcg PO MWF 4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES DAILY 5. Multivitamins 1 TAB PO DAILY 6. Calcium Carbonate 1250 mg PO DAILY 7. Doxazosin 4 mg PO BID hold for SBP < 90 8. Furosemide 80 mg PO QAM 9. Furosemide 40 mg PO QPM 10. Travatan Z *NF* (travoprost) 0.004 % ___ 1 drop daily 11. Acetaminophen 650 mg PO Q8H 12. Vitamin D ___ UNIT PO DAILY 13. 70/30 23 Units Breakfast Glargine 26 Units Bedtime 14. Aranesp (in polysorbate) *NF* (darbepoetin alfa in polysorbat) 100 mcg/mL Injection q4weeks 15. Metoprolol Succinate XL 200 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q8H 2. Aliskiren 300 mg PO DAILY 3. Atorvastatin 40 mg PO DAILY 4. Calcitriol 0.25 mcg PO MWF 5. Calcium Carbonate 1250 mg PO DAILY 6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES DAILY 7. Doxazosin 4 mg PO BID 8. Furosemide 80 mg PO QAM 9. Furosemide 40 mg PO QPM 10. 70/30 23 Units Breakfast Glargine 26 Units Bedtime 11. Multivitamins 1 TAB PO DAILY 12. Vitamin D ___ UNIT PO DAILY 13. Aranesp (in polysorbate) *NF* (darbepoetin alfa in polysorbat) 100 mcg/mL Injection q4weeks 14. Metoprolol Succinate XL 200 mg PO DAILY 15. Travatan Z *NF* (travoprost) 0.004 % ___ 1 drop daily Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: pulmonary edema chronic anemia chronic kidney disease - stage IV hyperkalemia Secondary diagnoses: Hypertension Diabetes Mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Weakness. TECHNIQUE: PA and lateral views of the chest. COMPARISON: ___. FINDINGS: Lung volumes are low. The cardiac, mediastinal and hilar contours are unchanged, with mild enlargement of cardiac silhouette noted. Crowding of the bronchovascular structures is present as a result of the low lung volumes, with possible mild pulmonary vascular congestion, but no overt pulmonary edema. No focal consolidation, pleural effusion or pneumothorax is present. There are no acute osseous abnormalities. IMPRESSION: Low lung volumes with possible mild pulmonary vascular congestion. Gender: F Race: OTHER Arrive by AMBULANCE Chief complaint: PALE/SOB/WEAK Diagnosed with ANEMIA NOS, HYPERKALEMIA temperature: 98.2 heartrate: 75.0 resprate: 20.0 o2sat: nan sbp: 152.0 dbp: 44.0 level of pain: nan level of acuity: 2.0

___ y/o female w/ PMHx HTN, DM, CKD stage IV, anemia thought ___ renal failure on epo as an outpatient who presents with shortness of breath x 10 days, worsening anemia, and headache. # Shortness of breath - Feels better on discharge. Most likely mild volume overload based on CXR findings, vs worsening anemia. After a one-time dose of 40mg IV lasix overnight, her shortness of breath resolved in the morning. She no longer was dyspneic with exertion, and her ambulatory sat was 94-96% on RA. We held off on transfusion at this time as patient was sating well, and did not have profound anemia. Pt refused guiac exam multiple times. # Acute on chronic normocytic anemia - Related to worsening of her anemia of chronic disease, consistent with repeat iron studies sent. Patient continued to decline rectal exam in the ED and on floor. No signs of gross bleeding on exam otherwise and no history of blood loss. Her blood smear was unremarkable and her LDH did not show signs of hemolysis. # Hyperkalemia - Resolved. Initially K of 5.7 with no signs of instability on EKG. Received lasix in the ED with a repeat K of 5.1. She will need to discuss with her PCP the continuation of aliskiren given its side effect of hyperkalemia. # Headache - Resolved. No concerning signs/symptoms at this time. History sounded like a tension headache, treated with acetaminophen. # Asymptomatic bacteriuria - Received ciprofloxacin in the ED. However, she was asymptomatic and antibiotics were not continued.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Back pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ with h/o HTN, CAD s/p MI and stent in RCA here with acute onset of mid-back and abdominal pain that started a few hours prior to admission. C/O difficulties breathing ___ pain. Seen at ___ ED and CT scan showed Type B dissection. BP was elevated at 180's and pt given labetolol. Also given full dose ___. Patient currently stable on arrival to ___. Recieved morphine in ED and currently denies back or abdominal pain. No extremity pain. No headaches. Past Medical History: PMhx: Breast cancer, Ulcerative colitis (last C-scope ___ years ago and was per pt WNL), HTN, OA, ^lipid, CAD (2 vessel disease) with MI (inferior STEMI ___, SCC of lip PShx: Left Mx with XRT, lap tubal ligation, RCA stent, excision of lip SCC Social History: ___ Family History: No family history of early MI, otherwise non-contributory. Her sister has CAD with stents in place. Her mother died at age ___ from ___, and her father at age ___ from ___. There is also a family history of CVA's. Physical Exam: Afebrile, vital signs stable MMM, no scleral icterus, tongue and trachea midline, no palpable lymphadenopathy RRR CTAB Soft, NT/ND, no masses felt R: P/P/P/P L: P/P/P/P Left radial pulse palp and equal to right Pertinent Results: CT: Type B dissection originating from left subclavian extending to renals. Celiac supplied by both true and false lumen whereas both SMA and renals supplied by true lumen. Medications on Admission: Atenolol 12.5', crestor 10', ___ 325' Discharge Medications: 1. Aspirin 325 mg PO DAILY RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 2. Labetalol 100 mg PO BID RX *labetalol 100 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*1 3. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp #*20 Tablet Refills:*0 4. Rosuvastatin Calcium 10 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Type B aortic dissection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Aortic dissection. TECHNIQUE: Contiguous axial MDCT images were taken through the chest, abdomen, and pelvis after the administration of 130 cc of Omnipaque intravenous contrast material. Coronal and sagittal reformats as well as 3D reformats were also examined. DLP: 1000.62 mGy-cm. COMPARISON: CT ___. FINDINGS: An approximately 5 mm hypodense lesion is noted within the left lobe of the thyroid. The airways are patent to the subsegmental level. There is no mediastinal, hilar, or axillary lymphadenopathy. The heart and pericardium are unremarkable. Note is made of new bilateral pleural effusions, left greater than right with associated atelectasis. Again seen is the aortic dissection starting just distal to the left subclavian extending to just above the renal arteries. The celiac trunk arises from the false lumen, and the superior mesenteric artery arises from the true lumen. The appearance of the dissection is stable compared to the prior study. Again seen is a hypodense lesion in the right lobe of the liver, measuring 12 x 20 mm, stable since the prior study. There is no intra or extrahepatic biliary ductal dilatation. There is a small amount of fluid around the gallbladder, which is new since the prior study. Gallstones are again visualized within the gallbladder, but there is no adjacent fat stranding. The spleen is homogeneous and normal in size. The pancreas is unremarkable without any focal lesions, peripancreatic stranding, or fluid collection. The bilateral adrenal glands are unremarkable. Multiple bilateral renal hypodensities are seen, the largest measuring 1.2 cm in the interpolar region of the right kidney, too small to characterize. The stomach and small bowel are unremarkable with no evidence of thickening or obstruction. The colon is unremarkable. There is no ascites, free air, or abdominal wall hernias. There is no retroperitoneal or mesenteric lymphadenopathy. The bladder and terminal ureters are unremarkable. Note is made of a fibroid uterus. There is no pelvic sidewall or inguinal lymphadenopathy. There is no pelvic free fluid. No suspicious lesion is seen is visualized osseous structures. IMPRESSION: 1. Stable appearance of type B aortic dissection. 2. Pericholecystic fluid, which is new since the prior study but nonspecific. There are no definite signs of cholecystitis. 3. Hypodense nodule in the left lobe of the thyroid, which may be investigated further with ultrasound if clinically indicated. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: AORTIC DISSECTION Diagnosed with DISS THORACOABD AORTIC ANEURYSM temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: nan

The patient was admitted to the vascular surgery service at the ___ on ___. CT scan revealed the patient was experiencing a type B aortic dissection, and she was admitted to the CVICU. She was put on an esmolol drip for strict blood pressure control. The patient's vital signs and clinical status were monitored closely. After a period of observation in the CVICU, it was determined that the patient was stable for transfer to the floor. She was weaned off of antihypertensive drips, and transitioned to an oral antihypertensive regimen. While on the floor, she remained hemodynamically stable. Her blood pressure was optimized on oral pain medications, and while the oral regimen was being titrated, she received hydralazine PRN for blood pressure control. A cardiology consult was obtained regarding management of her blood pressure. They recommended she be started on labetalol 100mg BID. She will follow-up with her primary care physician ___ 3 days. She was able to ambulate independently, void independently, she was able to tolerate a PO diet. The patient received aspirin and heparin subcutaneously. Prior to discharge, the patient received a CTA of the torso to monitor any interval change of the aortic dissection, which was stable. At the time of discharge, the patient was on a stable oral antihypertensive regimen, tolerating PO, voiding and ambulating indepdnently, and able to verbalize understanding with the discharge plan/instructions.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ y/o male with a history of BPH (with chronic foley) and Mechanical AVR/MVR (on coumadin) who was sent to the ED from his cardiologist's office for anorexia, generalized weakness, and BP 80/40. Mr. ___ reports that he was in his usual state of health living indepdenetly at his house, and had no acute complaints, but went in to see his cardiologist today for a "check-up" and was referred here because "my blood pressure was low." He denied lightheadedness, syncope, fevers, chills at home. He has had poor intake "since my wife died ___ years ago." Mr. ___ reports he has had poor PO intake for years, but it is usually worse during this time of year since his wife died in the ___, and he is still grieving. He denies SI - "I'm a churchgoing man." The patient has been followed closely by PCP for anorexia (BMI stable ~18 for past ___ years). Mr. ___ lives in his own home and reports that he is able to cook, clean, and take care of himself at home. He usually eats frozen dinners, or has his son bring him food, or eats at restaurants. Yesterday evening, his son brought him ___ food, and he reports eating "a little bit." He denies N/V/D/constipation, abdominal pain. He usually has one formed bowel movement daily. Given his hypotension, he was referred to the ___ ED for further evaluation. In the ED, initial vitals were T 98 BP 88/48 HR 58 RR 14 SaO2 99% on RA. EKG revealed AFL @ 77bpm. U/A not performed due to anuria. He was given 2L NS with improvement in blood pressure. He was also given vancomycin/pipercillin-tazobactam emprically. VS prior to transfer where HR 89 BP 127/64 RR 18 SaO2 100% On the floor, vs were T 97.6 BP 139/87 HR 96 RR 18 SaO2 100% on RA. Currently, Mr. ___ denies acute complaints. He reports minimal discomfort "not pain" at foley insertion site. He states he was scheduled to have his foley taken out this ___ after having it put in for months "for my prostate." Review of sytems: (+) Per HPI (-) Denies fever, chills, HA, URI sx, cough, SOB, CP, palpitations, lightheadedness, weakness, tingling, numbness, vision changes, N/V/D/constipation, abdominal pain, melena, hematochezia, arthralgias, myalgias, rashes. Past Medical History: - Myxomatous valve disease: Mechanical replacement of the aortic and mitral valves in ___. - Hemolytic Anemia, thought to be related to mechanical valves - Atrial fibrillation - Atrial Flutter - COPD (PFTs ___: FEV1/FVC 44%, FEV1 67% predicted - Cachexia - BPH - Ulcer surgery in the past - does not recall details - Small CVA in ___ without residual deficits - CKD stage III - Gallstone disease: s/p ERCP ___ - CAD: abnormal stress, managed medically Social History: ___ Family History: - No history of malignancy - No history of heart valve problems Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T 97.6 BP 139/87 HR 96 RR 18 SaO2 100% 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, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Nonedematous. Dry scaling, dark skin on RLE ankle patient states is chronic from venous stasis Neuro: A&Ox3. Remarkably cognitively intact for ___ year old. Knows children's phone numbers by memory. Knows medication names and doses by memory. Intact strength and sensation in upper and lower extremities. CN II-XII grossly intact. Follows commands. DISCHARGE PHYSICAL EXAM: Vitals: T 98.8 BP 146/82 HR 74 RR 16 SaO2 100% on RA Telemetry: Atrial flutter, HR in ___ I/O: Voiding well in BR, PVR 160 this AM. General: Alert, oriented. NAD. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: JVP flat Lungs: CTAB CV: RRR, loud click heard on S1 and S2. Visible sternotomy wires through chest wall. Abdomen: Soft, nontender, nondistended. Bladder nonpalpable. Ext: Nonedematous. Dry scaling, dark skin on RLE ankle patient states is chronic from venous stasis Neuro: A&Ox3. Moving all four extremities spontaneously. Follows commands. CN II-XII grossly intact. Follows commands. Pertinent Results: ___ 12:50PM BLOOD Glucose-112* UreaN-16 Creat-1.8* Na-142 K-4.3 Cl-107 HCO3-23 AnGap-16 ___ 05:53AM BLOOD Glucose-107* UreaN-16 Creat-1.4* Na-143 K-4.3 Cl-116* HCO3-21* AnGap-10 ___ 05:49AM BLOOD Glucose-79 UreaN-13 Creat-1.3* Na-140 K-4.3 Cl-116* HCO3-21* AnGap-7* ___ 12:50PM BLOOD cTropnT-0.04* ___ 07:45PM BLOOD CK-MB-4 cTropnT-0.02* ___ 12:50PM BLOOD TSH-4.3* ___ 01:13PM BLOOD Lactate-4.0* ___ 07:58PM BLOOD Lactate-2.3* ___ 05:53AM BLOOD Albumin-2.8* Calcium-7.5* Phos-3.1 Mg-1.8 Iron-27* ___ 06:42PM URINE Blood-MOD Nitrite-POS Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG ___ 06:42PM URINE RBC-86* WBC->182* Bacteri-MANY Yeast-NONE Epi-0 ___ 06:42PM URINE Color-Yellow Appear-Cloudy Sp ___ ___ 05:49AM BLOOD WBC-3.5* RBC-3.38* Hgb-8.3* Hct-28.8* MCV-85 MCH-24.6* MCHC-28.9* RDW-19.3* Plt ___ ___ 05:51AM BLOOD WBC-3.2* RBC-3.08* Hgb-7.7* Hct-25.4* MCV-83 MCH-25.2* MCHC-30.5* RDW-19.7* Plt ___ ___ 05:53AM BLOOD ___ PTT-104.1* ___ ___ 05:49AM BLOOD ___ PTT-66.5* ___ ___ 05:51AM BLOOD ___ PTT-58.0* ___ ___ 05:51AM BLOOD Glucose-74 UreaN-15 Creat-1.2 Na-141 K-4.1 Cl-115* HCO3-20* AnGap-10 EKG (___) Atrial flutter with slow ventricular response. Voltage criteria for left ventricular hypertrophy with secondary repolarization abnormalities. T wave inversions in the anterior leads are new suggestive of possible anterior ischemia/infarction. Compared to the previous tracing of ___ the rhythm is more regular suggesting flutter as opposed to fibrillation and the anterior T wave inversions are new. Clinical correlation is suggested. CHEST X-RAY (___) FINDINGS: PA and lateral views of the chest were provided. Midline sternotomy wires and cardiac valve replacements are again noted. Clips are also noted at the level of the GE junction. The lungs are clear and well expanded. No focal consolidation, effusion, or pneumothorax is seen. The cardiomediastinal silhouette is normal. A dextroscoliosis is noted with the apex at the TL junction. Bony structures are intact. IMPRESSION: No acute intrathoracic process. ___ 6:42 pm URINE Source: Catheter. **FINAL REPORT ___ 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.. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ 8 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Finasteride 5 mg PO DAILY 2. Losartan Potassium 50 mg PO DAILY 3. Mirtazapine 45 mg PO HS 4. Diltiazem Extended-Release 360 mg PO DAILY 5. Amiodarone 200 mg PO DAILY 6. Warfarin 1.5 mg PO DAYS (___) 7. Warfarin 3 mg PO DAYS (___) 8. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 9. Tamsulosin 0.4 mg PO DAILY 10. Albuterol Inhaler ___ PUFF IH QID 11. Sertraline 100 mg PO DAILY Discharge Medications: 1. Finasteride 5 mg PO DAILY 2. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 3. Losartan Potassium 25 mg PO DAILY 4. Mirtazapine 45 mg PO HS 5. Sertraline 100 mg PO DAILY 6. Tamsulosin 0.4 mg PO DAILY 7. Warfarin 3 mg PO DAYS (___) 8. Warfarin 1.5 mg PO DAYS (___) 9. Albuterol Inhaler ___ PUFF IH QID 10. Cyanocobalamin 100 mcg PO DAILY 11. Diltiazem 60 mg PO QID Atrial flutter/fibrillation rate control 12. Docusate Sodium 100 mg PO BID 13. Ferrous Sulfate 325 mg PO DAILY Iron deficiency 14. FoLIC Acid 1 mg PO DAILY 15. Heparin IV per Weight-Based Dosing Guidelines 16. Multivitamins 1 TAB PO DAILY 17. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush 18. Sulfameth/Trimethoprim DS 1 TAB PO BID UTI Duration: 4 Days Last dose ___. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Hypovolemia Urinary tract infection Failure to thrive Atrial flutter Anemia Mechanical valve replacement Chronic kidney disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report CHEST RADIOGRAPH PERFORMED ON ___ ___. CLINICAL HISTORY: Weakness, question pneumonia. FINDINGS: PA and lateral views of the chest were provided. Midline sternotomy wires and cardiac valve replacements are again noted. Clips are also noted at the level of the GE junction. The lungs are clear and well expanded. No focal consolidation, effusion, or pneumothorax is seen. The cardiomediastinal silhouette is normal. A dextroscoliosis is noted with the apex at the TL junction. Bony structures are intact. IMPRESSION: No acute intrathoracic process. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: ANOREXIA Diagnosed with HYPOTENSION NOS, DEHYDRATION, LONG TERM USE ANTIGOAGULANT temperature: 98.0 heartrate: 58.0 resprate: 14.0 o2sat: 99.0 sbp: 88.0 dbp: 48.0 level of pain: 0 level of acuity: 1.0

NARRATIVE SUMMARY ================= Regarding his hypotension and bradycardia with Atrial flutter, Mr. ___ was initially hypotensive in the ED to 88/48 with HR 58 but patient was asymptomatic and appeared hypovolemic. He responded to 2 L NS with recovery of BPs to 100-120/50-70s with HRs in the ___. His medications were reconciled, and he was given his home dose of diltiazem XR (360mg) since he reported he had not taken it that day. On the morning of HD#2, he triggered for hypotension to ___ and marked bradycardia to the high ___. He denied lightheadedness and was mentating well. EKG showed atrial flutter with 5:1 AV block with rate of 44. Likely due to calcium channel blocker overdose. Suspect patient was not taking home diltiazem. IV calcium gluconate was given with recovery of HR and BP. No atropine given. Cardiology consulted and recommended decreasing CCB dose and discontinuing amiodarone. His hemodynamics were subsequently stable. Regarding his BPH with obstruction, his foley was discontinued and he had good UOPs subsequently with PVRs consistently < 180ml. He was continued on tamsulosin QHS and finasteride QD. We coordinated with his outpatient urologist Dr. ___ should follow-up with urology as an outpatient. Regarding his acute on chronic anemia, hemolytic, he was found to be anemic on CBC, with positive hemolysis labs. He was transfused 1 U pRBC with appropriate bump and started on iron, folate, and B12. On the day of discharge he had a drop in his hematocrit without apparent bleeding. Theorized to be due to mechanical valve hemolysis versus hypoproliferative bone marrow due to malnutrition. Nevertheless, a CBC should be checked at rehab and he should be transfused there if hct < 21%. SUMMARY BY PROBLEM ================== #) HEMODYNAMICS: His blood pressures and heart rates normalized after volume resuscitation and decreasing his calcium channel blocker to 60mg QID. He may need further titration of his CCB tailored to his heart rate. #) WEAKNESS: Major barrier seems to be food preparation. He has demonstrated good appetite while in house. Would like to get meals on wheels at home, but apparently unable to do so since son lives with him. - TSH mildly elevated, likely related to amiodarone. Repeat TFTs in ___ weeks. #) NSTEMI: Troponin mildly elevated at 0.04 and decreased to 0.02 with hydration. Repeat EKG without ischemic changes. #) ACUTE KIDNEY INJURY: Resolved. Creatinine 1.8 on presentation improved back to baseline of 1.4 with fluids. Continued to down-trend after removal of foley to 1.2. #) CATHETER-ASSOCIATED UTI: With frankly cloudy urine output, highly suspect CAUTI. UCx grew pansensitive E.coli > 10^5. Treated with ciprofloxacin for ___nding ___. #) BPH/Urinary Retention: Did well after weaning foley with low PVRs, robust UOP, and persistently baseline creatinine. Continued on tamsulosin and finasteride. #) MECHANICAL VALVE, MVR/AVR: Subtherapeutic INR and ___. Started on a heparin gtt with goal PTT ___ and goal INR 2.5-3.5. Will need cardiology follow-up. TRANSITIONAL ISSUES =================== [] Re-check CBC within 3 days. Transfuse 1 U pRBCs if hematocrit < 21% [] Titrate diltiazem to HR goal 55-100 and BP >100/60. Currently on diltiazem 60mg QID. Once equilibrium dose is achieved with stable hemodynamics for ___ days, can change to equivalent long acting diltiazem XR. [] Continue heparin gtt with goal PTT 60-100 with transition to warfarin until INR is 2.5-3.5 for 48 hours, then heparin can be discontinued. PTTs can be checked daily since they have been consistently at goal here on his current rate of 750 U/hr. [] Continue ___ [] Encourage PO intake [] Please help arrange for home-care after discharge. Would benefit hugely from meals preparation at home. FOLLOW-UP APPOINTMENTS NEEDED BUT NOT SCHEDULED =============================================== [] Follow-up with urology within two weeks with Dr. ___ ___ ___ [] Follow-up with cardiology within two weeks with Dr. ___ ___ ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine / Flaxseed Attending: ___. Chief Complaint: OUTPATIENT CARDIOLOGIST: ___ MD, MPH PCP: ___. CHIEF COMPLAINT: Weakness Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is an ___ F with AFib, HTN, HLD who presents two recent falls with weakness, ___, TWI's, and mild trop leak in the setting of UTI. Patient fell 4 days prior to admission in what she describes as a mechanical fall including a head strike. No LOC or post-ictal features. She then fell again the night prior to admission with a similar story. Her last fall prior to these was over a year ago. She does report weakness for the past year without clear worsening to her. Patient reports subjective fevers and rigors for past few days. She did have some nocturia, but denies dysuria. Decreased po intake for past few days. Patient said she also felt weak prompting her last admission in ___ when found to have UTI per pt. In ED: - initial vitals were 97.3 82 149/55 16 98% - documented as regular rhythm - no sx head trauma, neg CT head - CXR no obvious infiltrate - Cr 1.4 w/ baseline 1.0 - EKG shows NEW TWI in v2/v3 which are stable on repeat EKG. - given aspirin 325mg and admitted to ___. ROS: Detailed 8 pt review of systems negative except for above in HPI. Of note, denies nausea, vomiting, dyspnea, chest pain, cough. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: -CABG: N/A -PERCUTANEOUS CORONARY INTERVENTIONS: N/A -PACING/ICD: N/A 3. OTHER PAST MEDICAL HISTORY: -Atrial Fibrillation (off anticoagulation due to hx SAH) -Hypothyroidism -s/p L4/5 laminectomy -b/l corneal transplants Social History: ___ Family History: Mother - HTN, rheumatoid arthritis Father - unknown 3 children - all healthy Physical Exam: ADMISSION: VS: afebrile 97.8 172/75 HR 84 sat 98% on RA General: NAD HEENT: clear OP Neck: no JVD CV: irregular, normal rate, no murmur Lungs: CTAB, nonlabored Abdomen: NT, ND, soft GU: no Foley Ext: no lower ext edema Neuro: CNs intact, ___ strength, A&Ox3 Skin: no lesions Psych: appropriate DISCHARGE: VS: afebrile 98.4 146/55 64 sat 100% on RA General: NAD HEENT: clear OP Neck: no JVD CV: regular, normal rate, no murmur Lungs: CTAB, nonlabored Abdomen: NT, ND, soft GU: no Foley Ext: no lower ext edema Neuro: CNs intact, ___ strength, A&Ox3 Skin: no lesions Psych: appropriate Pertinent Results: LABS: ___ 02:10AM BLOOD WBC-13.2*# RBC-3.81* Hgb-11.5* Hct-34.3* MCV-90 MCH-30.2 MCHC-33.5 RDW-14.2 Plt ___ ___ 05:44AM BLOOD WBC-9.3 RBC-3.10* Hgb-9.3* Hct-27.6* MCV-89 MCH-30.1 MCHC-33.8 RDW-14.3 Plt ___ ___ 12:35PM BLOOD Hct-30.9* ___ 06:25AM BLOOD WBC-8.1 RBC-3.01* Hgb-8.9* Hct-27.0* MCV-90 MCH-29.6 MCHC-33.1 RDW-14.2 Plt ___ ___ 06:30AM BLOOD WBC-7.2 RBC-2.85* Hgb-8.6* Hct-25.3* MCV-89 MCH-30.0 MCHC-33.8 RDW-14.1 Plt ___ ___ 03:00PM BLOOD Hct-27.2* ___ 05:34AM BLOOD WBC-8.9 RBC-3.07* Hgb-9.3* Hct-27.5* MCV-90 MCH-30.4 MCHC-34.0 RDW-14.2 Plt ___ ___ 02:10AM BLOOD ___ PTT-33.3 ___ ___ 06:30AM BLOOD Ret Aut-1.9 ___ 02:10AM BLOOD Glucose-139* UreaN-27* Creat-1.4* Na-139 K-3.6 Cl-101 HCO3-25 AnGap-17 ___ 05:44AM BLOOD Glucose-95 UreaN-30* Creat-1.5* Na-139 K-4.0 Cl-108 HCO3-26 AnGap-9 ___ 06:30AM BLOOD Glucose-92 UreaN-26* Creat-1.3* Na-144 K-3.7 Cl-111* HCO3-25 AnGap-12 ___ 05:34AM BLOOD Glucose-92 UreaN-22* Creat-1.2* Na-141 K-4.1 Cl-108 HCO3-27 AnGap-10 ___ 02:10AM BLOOD ALT-13 AST-30 AlkPhos-74 TotBili-0.9 ___ 02:10AM BLOOD cTropnT-0.03* ___ 10:45AM BLOOD CK-MB-3 cTropnT-0.01 ___ 06:50PM BLOOD cTropnT-0.02* ___ 10:45AM BLOOD Calcium-8.3* Phos-2.3* Mg-2.1 ___ 06:25AM BLOOD calTIBC-160* Hapto-310* Ferritn-249* TRF-123* ___ 05:44AM BLOOD TSH-0.57 ___ 05:44AM BLOOD T4-4.9 ================================ CXR PA/Lat ___: IMPRESSION: No evidence of acute cardiopulmonary process. Blunting of the left costophrenic angle may represent a small left-sided pleural effusion. . CT HEAD noncontrast ___: IMPRESSION: 1. No evidence of acute intracranial abnormality. 2. Small sclerotic lesion in the left frontal bone, remodeling the internal table is unchanged from prior and likely a non-aggressive process such as an osteoma. 3. Chronic changes, as detailed. . EKG on admission: HR 82, sinus, normal axis, TWI in V2-V4 EKG ___ ___: QTc~450. EKG ___: unchanged TWI in V2&V3; QTc ~457 . ECHO ___ The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). No mid-cavitary gradient is identified. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. Moderate to severe [3+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion. IMPRESSION: Severe pulmonary artery hypertension. Relatively small left ventricular cavity with normal regional and hyperdynamic global systolic function. Moderate to severe tricuspid regurgitation. Is there a history to suggest high output syndrome (thiamine deficiency, anemia, thyrotoxicosis, peripheral shunt, etc.). MICRO: -___ CDIFF STOOL NEGATIVE -___ 5:30 am URINE URINE CULTURE (Final ___: GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 25 mg PO DAILY 2. Atorvastatin 20 mg PO DAILY 3. Levothyroxine Sodium 50 mcg PO DAILY 4. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES BID 5. Aspirin 81 mg PO DAILY Discharge Medications: 1. Sotalol 40 mg PO DAILY RX *sotalol 80 mg one half tablet(s) by mouth once a day Disp #*15 Tablet Refills:*2 2. Amlodipine 5 mg PO DAILY to treat your blood pressure. RX *amlodipine 5 mg 1 tablet(s) by mouth once daily Disp #*30 Tablet Refills:*0 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO DAILY RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Levothyroxine Sodium 50 mcg PO DAILY 6. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES BID 7. Metoprolol Succinate XL 100 mg PO DAILY to treat your AFib RX *metoprolol succinate 100 mg 1 tablet extended release 24 hr(s) by mouth once daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: UTI Atrial Fibrillation with RVR Anemia, normocytic Secondary: Hypothyroidisim Hypertension Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ female with generalized weakness and near syncope. Evaluate for infiltrate. COMPARISON: ___. TECHNIQUE: PA and lateral chest radiograph. FINDINGS: The lungs are well expanded and clear. Cardiomediastinal and hilar contours are unremarkable. Mild calcification is noted in the right lower paratracheal station, likely representing a calcified lymph node. The aorta is tortuous. There is no pleural effusion. There is blunting of the left costophrenic angle which may represent a small pleural effusion. IMPRESSION: No evidence of acute cardiopulmonary process. Blunting of the left costophrenic angle may represent a small left-sided pleural effusion. Radiology Report INDICATION: ___ female with generalized weakness and syncope. Evaluate for evidence of acute intracranial process. COMPARISON: ___. TECHNIQUE: Contiguous axial MDCT images were obtained through the head without administration of IV contrast. Coronal, sagittal, and thin sliced bone reformats were generated. DLP: 897.50 mGy-cm. CTDI: 63.81 mGy. FINDINGS: There is no hemorrhage, edema, mass, mass effect, or large territorial infarction. The ventricles and sulci are prominent, compatible with age-related atrophy. Periventricular white matter changes suggest chronic small vessel ischemic disease. A small hypodensity in the left frontal lobe (2:15) is likely a focus of encephalomalacia from prior infarct. Otherwise, there is preservation of gray-white matter differentiation in the unaffected parts of the brain and the basal cisterns are patent. Mineralization of the bilateral basal ganglia is also present. No fracture is identified. A 9-mm sclerotic lesion, centered in the right lateral aspect of the frontal bone with slight convex bowing of the internal table (3:27) is unchanged from ___. The visualized paranasal sinuses, mastoid air cells and middle ear cavities are clear. Atherosclerotic calcification of the carotid siphons is present. IMPRESSION: 1. No evidence of acute intracranial abnormality. 2. Small sclerotic lesion in the left frontal bone, remodeling the internal table is unchanged from prior and likely a non-aggressive process such as an osteoma. 3. Chronic changes, as detailed. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: WEAKNESS Diagnosed with OTHER MALAISE AND FATIGUE, URIN TRACT INFECTION NOS temperature: 97.3 heartrate: 82.0 resprate: 16.0 o2sat: 98.0 sbp: 149.0 dbp: 55.0 level of pain: 0 level of acuity: 3.0

Ms. ___ is an ___ F with AFib, HTN, HLD who presents two recent falls with weakness, ___, TWI's, and mild trop leak in the setting of UTI. . # AFib: CHADS score at least 2. Possible hx of TIA. Admitted off anticoagulation due to hx of spontaneous subarachnoid hemorrhage. Stroke team consulted ___ help decide risk of systemic anticoagulation, and since appears has Amyloid Angiopathy, will defer anticoagulation. Pt followed by Dr. ___ with ___ cardiology. Admitted in sinus, then went to AFib RVR to 140's on floor then converted from AFib RVR to sinus on ___ at 1600 with extra dose of Metoprolol tartrate 50mg po x1. Previously on amiodarone, but stopped in early ___ due to hypothyroidism, bradycardia, and abscence of AFib. Patient appears to have COPD on CXR and was found to have pulmonary HTN on echo ___ w/ 3+ TR. GFR is also borderline. TSH & T4 wnl. Deferred anticoagulation as above. Metoprolol succinate 100mg daily. Sotalol 40mg daily (started ___: dose reduced due to GFR <40. Discussed w/ pharmacy re: dose. EKG ___ QTc ~450. . # Anemia, Normocytic: Hct 34 on admission, most recent baseline from ___ ~31. Hct 34 --> 27 w/ fluids then up to 30. Continued to downtrend to 25.3 on ___. Labs suggest not hemolysis or iron deficiency. Last colonoscopy ___ per pt. Retic 1.8% on ___. Guaiac stools: neg x1 on ___. Consider outpatient colonoscopy and anemia work-up. . # Pulmonary Hypertension: Dx as severe on TTE ___ w/ 3+ TR. No prior dx of this. No sx of RV strain, suggesting is chronic. EF was hyperdynamic. CXR appears hyperinflated, so may be due to baseline lung dz. Could be pulmonary arterial. Less likely due to left heart failure or chronic thromboembolic dz. Recommend outpatient PFTs and outpatient Pulm f/u. . # T-Wave Inversions: She was found to have new t-wave inversion in V2-V4 when compared to previous EKG's. She was also noted to have a mildly elevated troponin of 0.03 in the setting of ___. Second trop was <0.01. Unlikely ACS since trop negative x3, no chest pain. Repeat EKG ___ showed unchanged TWI in V2&V3. ASA 81mg daily. Atorvastatin 40mg daily (increased from 20mg on ___. Discontinued Atenolol due to ___. Metoprolol succinate 100mg daily (started on admission). . # UTI: Positive U/A with recent rigors and subjective fevers at home. Ceftriaxone 1g q24 daily x5 day course (D1 = ___. ___ cx growing GPCs: alpha strep. . # Diarrhea: Had loose stools ___ AM x4. Resolved ___. CDiff negative. Guaiac neg x1 ___. . # ___: Pt admitted w/ creat 1.4 with baseline ~1.0. Discharge creat 1.2. FENA 1.1%. D/c Atenolol as above . #CODE: Full- confirmed #CONTACT: ___ (Son/HCP) ___ #DISPO: ___ cardiology service to home w/ ___ ___ . ### TRANSITIONAL ISSUES ### - please check EKG at next visit to ensure QTc is not prolonged with sotalol - please check Creat and Hct next visit - please discuss colonoscopy (last was ___ and her normocytic anemia (Hct 27 on discharge) - recommend outpatient PFTs and Pulm f/u for severe Pulmonary HTN seen on echo

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: L TKA prosthetic joint infection Major Surgical or Invasive Procedure: Left knee irrigation and debridement, spacer and wound VAC placement ___ (Dr. ___ Left knee irrigation and debridement, spacer, gastrocnemius flap and wound VAC placement ___ (Drs. ___ History of Present Illness: ___ PMH type II DM, AS, HTN, left TKA in ___ at ___, then left TKA explant, placement antibiotic spacer by Dr. ___ at ___ in ___ for septic TKA growing MSSA and serratia, now s/p 6 weeks cefazolin and levaquin. Patient had been doing well at rehab, recently discharged home. Today he was taking off his knee immobilizer and noticed purulent drainage from the knee the inferior aspect of the wound. No recent falls, no recent fevers or chills, no numbness or tingling. Past Medical History: Type 2 diabetes Aortic stenosis Hypertension Osteoarthritis Social History: ___ Family History: Non-contributory Physical Exam: VS: AFVSS GENL: NAD CARD: RRR, systolic murmur PULM: clear to auscultation bilaterally ABDM: non-distended; non tender EXTR: warm and well perfused, no edema on the right, 2+ edema L decreased sensation to light touch left foot NPWT in place, drains serosang, clear Pertinent Results: ___ 06:24AM BLOOD WBC-8.6 RBC-3.07* Hgb-8.2* Hct-26.0* MCV-85 MCH-26.7 MCHC-31.5* RDW-18.2* RDWSD-55.8* Plt ___ ___ 06:35AM BLOOD WBC-9.7 RBC-3.01* Hgb-8.1* Hct-25.8* MCV-86 MCH-26.9 MCHC-31.4* RDW-18.1* RDWSD-56.1* Plt ___ ___ 04:19AM BLOOD WBC-12.6* RBC-3.37* Hgb-9.0* Hct-29.2* MCV-87 MCH-26.7 MCHC-30.8* RDW-17.7* RDWSD-55.4* Plt ___ ___ 06:24AM BLOOD Glucose-81 UreaN-28* Creat-1.1 Na-134* K-4.4 Cl-99 HCO3-21* AnGap-14 ___ 06:35AM BLOOD Glucose-79 UreaN-29* Creat-1.2 Na-135 K-4.7 Cl-100 HCO3-20* AnGap-15 ___ 06:35AM BLOOD ALT-<5 AST-33 LD(LDH)-174 AlkPhos-101 TotBili-0.3 ___ 06:24AM BLOOD Calcium-8.1* Phos-3.9 Mg-2.1 ___ 06:35AM BLOOD Vanco-20.2* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 25 mg PO DAILY 2. Tizanidine 4 mg PO TID 3. Oxybutynin 10 mg PO DAILY 4. Triamcinolone Acetonide 0.025% Cream 1 Appl TP PRN itching 5. Furosemide 20 mg PO DAILY 6. irbesartan 150 mg oral BREAKFAST 7. Verapamil 200 mg PO QHS Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Apixaban 2.5 mg PO BID 3. Ascorbic Acid ___ mg PO BID 4. Bisacodyl 10 mg PR QHS:PRN constipation 5. DiphenhydrAMINE 25 mg PO Q6H:PRN itching 6. Docusate Sodium 100 mg PO BID 7. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Moderate RX *hydromorphone 2 mg ___ tablet(s) by mouth q3h Disp #*84 Tablet Refills:*0 8. Glargine 28 Units Bedtime Humalog 8 Units Breakfast Humalog 8 Units Lunch Humalog 6 Units Dinner Insulin SC Sliding Scale using HUM Insulin 9. Metoprolol Tartrate 12.5 mg PO BID 10. Milk of Magnesia 30 mL PO Q6H:PRN constipation 11. Multivitamins W/minerals 1 TAB PO DAILY 12. Senna 8.6 mg PO BID 13. Tamsulosin 0.4 mg PO QHS 14. Vancomycin 1000 mg IV Q48H RX *vancomycin 1 gram 1000 mg IV q48h Disp #*25 Vial Refills:*0 15. Zinc Sulfate 220 mg PO DAILY 16. Furosemide 40 mg PO BID 17. Tizanidine 4 mg PO TID RX *tizanidine 4 mg 1 tablet(s) by mouth three times a day Disp #*42 Tablet Refills:*0 18. Triamcinolone Acetonide 0.025% Cream 1 Appl TP PRN itching 19. HELD- Oxybutynin 10 mg PO DAILY This medication was held. Do not restart Oxybutynin until Foley out and voiding spontaneously 20.Outpatient Lab Work WEEKLY: CBC with differential, BUN, Cr, Vancomycin trough, crp Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: L TKA prosthetic joint infection Discharge Condition: VS: AFVSS GENL: NAD CARD: RRR, systolic murmur PULM: clear to auscultation bilaterally ABDM: non-distended; non tender EXTR: warm and well perfused, no edema on the right, 2+ edema L decreased sensation to light touch left foot NPWT in place, drains serosang, clear Followup Instructions: ___ Radiology Report INDICATION: ___ year old man with new numbness s/p knee spacer placement// new a-fib...fluid overload? TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: The size of the cardiac silhouette is enlarged in comparison to prior. Small bilateral pleural effusions are present with subjacent atelectasis. There is no evidence of pulmonary edema. No pneumothorax. IMPRESSION: Enlarged cardiac silhouette in comparison to prior. Small bilateral pleural effusions with subjacent atelectasis. No evidence of pulmonary edema. Radiology Report EXAMINATION: KNEE (2 VIEWS) LEFT INDICATION: ___ year old man with new numbness s/p knee spacer placement// Nerve compression from spacer Nerve compression from spacer TECHNIQUE: Frontal, lateral, and sunrise view radiographs of the left knee. COMPARISON: ___. IMPRESSION: Interval placement of new antibiotic spacer of the tibiofemoral joint. Screws are again seen through the distal femur and proximal tibia. Alignment appears relatively well maintained. Surgical drains are seen surrounding the knee as well as skin staples anteriorly. Wound VAC is seen anteriorly. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year old man with low albumin TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: None. FINDINGS: LIVER: The hepatic parenchyma appears within normal limits. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is trace perihepatic ascites. There are small bilateral pleural effusions. BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 10 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 14.7 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. Normal sonographic appearance of liver. 2. Mildly dilated common bile duct measuring up to 10 mm. No cholelithiasis or choledocholithiasis. Consider correlation with LFTs and if there is concern for biliary obstruction, further assessment with MRCP can be obtained. 3. Small bilateral pleural effusions and trace perihepatic ascites. 4. Mild splenomegaly. RECOMMENDATION(S): Mildly dilated common bile duct measuring up to 10 mm. No cholelithiasis or choledocholithiasis. Consider correlation with LFTs and if there is concern for biliary obstruction, further assessment with MRCP can be obtained. Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old man with new R PICC// 48 cm R brachial SL PICC- ___ ___ Contact name: ___: ___ cm R brachial SL PICC- ___ ___ IMPRESSION: Compared to chest radiographs since ___ most recently ___. New right PIC line ends at the level of the superior cavoatrial junction. Small bilateral pleural effusions, severe left lower lobe atelectasis and moderate enlargement of cardiac silhouette are stable. No pulmonary edema. No pneumonia. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: L Knee pain, L Knee swelling, Transfer Diagnosed with Other specified soft tissue disorders temperature: 98.1 heartrate: 80.0 resprate: 18.0 o2sat: 99.0 sbp: 125.0 dbp: 76.0 level of pain: 5 level of acuity: 2.0

SURGICAL COURSE: The patient was transferred with a worsening of his L knee infection and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for L knee I&D, spacer placement and VAC placement and on ___ for L knee I&D, spacer placement, coverage with a gastrocnemius flap and VAC placement, both of which the patient tolerated well. For full details of the procedures please see the separately dictated operative report. 3 JP drains were placed during the latter case, as well as an HVAC. One JP was pulled on ___ and another on ___ the HVAC and JP will stay until follow-up. The wound VAC was changed at bedside on ___ at which time there was noted to be 100% take of the graft, with plan for another graft assessment/VAC change in clinic on ___. He was transfused 2u on ___ for Hct 24 and 1u on ___ for Hct 24. Hct on discharge was 26. INFECTIOUS DISEASE COURSE: Cultures x6 from the initial washout on ___ grew out MSSA. Cultures from the ___ case grew out MSSA as well as coagulase-negative staph, which was methicillin-resistant. Given this finding, antibiotics were transitioned from cefazolin to vancomycin, with a plan for ongoing vancomycin therapy until ___. Infectious Disease follow-up plans are in the Discharge Worksheet. To summarize his antibiotic course: -Cefazolin/Levofloxacin ___ -Vanc/Cefepime ___ -Cefazolin 2 g q8h ___ - ___ -Vanc ___ The patient was also noted to have a new reduction in sensation in the LLE which was felt to be likely due to a neuropraxia and which was beginning to improve at the time of discharge. MEDICAL COURSE: The patient was noted to be in atrial fibrillation on ___ with ventricular response to the 130s. This was easily rate controlled with metoprolol and he converted back to sinus rhythm that afternoon and did not go back into fibrillation for the rest of his stay. Medicine was consulted and felt that discharge on metoprolol 12.5mb BID was appropriate. He was started on apixaban for anticoagulation; currently at 2.5mg BID with plans to increase to 5mg BID once his risk of graft loss from a hematoma is decreased. He was also noted to be fluid overloaded and was given 80mg IV Lasix on both ___ and ___ with some improvement. His standing PO dose was increased from 20mg qd to 40mg qd to 40mg BID on discharge, with a plan for continued net fluid goal of negative 0.5-1L daily. The patient also developed ___ of unclear etiology (to Cr 1.3 from baseline 0.6; 1.1 on discharge); for which his home irbesartan was held. Verapamil was also held and continues to be so. Other home medications continued throughout his stay. Patient had elevated LFTs with unclear etiology; RUQUS showed a dilated CBD with no evidence of stone disease; this warrants follow-up on an outpatient basis; MRCP could be considered for further work-up. DIABETES COURSE: The ___ Diabetes service was consulted for assistance in managing his diabetes; his blood glucose well controlled by the time of discharge and he was discharged on a stable insulin regimen. OTHER COURSE: The patient worked with ___ who determined that discharge to rehab was appropriate. At the time of discharge the patient's pain was well controlled with oral medications. The patient is non-weight bearing in the left lower extremity, and will be discharged on apixaban for anticoagulation. The patient will follow up with Dr. ___. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Hematuria Major Surgical or Invasive Procedure: Renal transplant graft biopsy History of Present Illness: HISTORY OF PRESENTING ILLNESS: ___ gentleman with a past medical history of ESRD secondary to fibrillary glomerulonephritis status post SCD kidney ___ on tacrolimus and mycophenolate presents with hematuria for 3 days. The patient notes that he started having clear dark red urine starting on ___ that has since progressed to become lighter in color. he reports some increased cough and mild shortness of breath, but otherwise, he denies any associated symptoms with the hematuria, such as fevers, chills, nausea, vomiting, abdominal pain, diarrhea, or dysuria. In the ED, initial vitals were: 97.2 88 ___ 97% RA. Labs were notable for Cr 1.7 with baseline of ___. UA showed 41 WBC, >182 RBC, Lg Bld, Sm Leuk, and Neg Neg. Renal graft ultrasound showed "1. Normal arterial waveforms in the transplanted kidney. 2. Unchanged 7 mm nonobstructing stone. New 5 mm nonobstructing stone in the upper pole. No hydronephrosis." He was started on maintenance IV fluid per Renal fellow and admitted. On the floor, the patient reports feeling ok. He does mention that with palpation over his surgical scar from his transplant, he does have pain. Past Medical History: - ESRD ___ fibrillary GN, IgA immune complex GN - Acute humoral graft rejection ___ - h/o Hepatitis A and B - Chronic Hepatitis C, genotype 1B, treated in ___ without response - Hypertension - Depression - Obstructive sleep apnea on CPAP - h/o CVA ___ w/ mild residual weakness - h/o EtOH abuse, sober ___ years PSH: - renal transplant ___ - thrombectomy of LUE AV graft ___ - attempted thrombectomy of LUE AV graft ___ - placement of LUE AV graft ___ Social History: ___ Family History: No family hx of kidney disease, several members with DM II and heart disease Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: T 98.1, BP 160/74, HR 84, RR 24, SAT 99%RA General: Elderly gentleman lying comfortably in bed, in no acute distress HEENT: EOMI, PERRL, sclerae anicteric Neck: supple, no JVD CV: RRR, no M/R/G Lungs: Significantly diminished breath sounds throughout, no wheezes Abdomen: tenderness over graft site, no flank pain, soft, nondistended, +BS Ext: 2+ lower extremity pulses with no edema Neuro: grossly nonfocal and moving all extremities symmetrically Skin: no rashes DISCHARGE EXAM: VS: 97.4 ___ 18 100% RA I/O: 360/550 (8); 1320/900+ x4 (24) Wt: 95.2 <- 96.7 <- 97.2 <- 97.3 <- 97.7 BS: ___ General: Elderly gentleman lying comfortably in bed, in no acute distress HEENT: NCAT, sclerae anicteric, wears dentures Neck: supple, no JVD CV: RRR, no M/R/G noted but exam limited by body habitus Lungs: CTAB. Abdomen: No tenderness over graft site, soft, nondistended, tympanitic, obese Ext: no edema Neuro: grossly nonfocal and moving all extremities symmetrically Skin: no rashes Psych: Pleasant & energetic Pertinent Results: ADMISSION LABS: ___ 05:40PM BLOOD ___ ___ Plt ___ ___ 05:40PM BLOOD ___ ___ Im ___ ___ ___ 11:03PM BLOOD ___ ___ ___ 05:40PM BLOOD ___ ___ ___ 05:20AM BLOOD ___ ___ 05:40PM BLOOD ___ ___ 05:47AM BLOOD ___ ___ 06:02PM BLOOD ___ DISCHARGE LABS: ___ 05:30AM BLOOD ___ ___ Plt ___ ___ 04:41AM BLOOD ___ ___ ___ 05:30AM BLOOD ___ ___ ___ 05:30AM BLOOD ___ ___ 04:41AM BLOOD ___ ___ 05:30AM BLOOD ___ ___ 04:41AM BLOOD ___ ___ 05:27AM BLOOD ___ ___ 05:30AM BLOOD ___ ___ 04:41AM BLOOD ___ ___ 01:23PM BLOOD ___ MICRO: ___ 5:27 am IMMUNOLOGY **FINAL REPORT ___ HBV Viral Load (Final ___: HBV DNA not detected. Performed using the Cobas Ampliprep / Cobas Taqman HBV Test v2.0. Linear range of quantification: 20 IU/mL - 170 million IU/mL. Limit of detection: 20 IU/mL. __________________________________________________________ ___ 11:05 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 5:40 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. IMAGING: RUQ ___: IMPRESSION: No concerning focal liver lesions. No biliary obstruction. Heterogeneous appearance of the liver parenchyma may be artifactual in the setting of poor acoustic windows, or less likely could reflect new development of steatosis since MR of ___. GU MRI ___: IMPRESSION: 1. Mild hydronephrosis of the renal transplant kidney. No focal mass. A small stone seen on prior ultrasound examinations is not visualized on MRI. There is no hydroureter, or ureteral or bladder stone. 2. Nonspecific diffuse minimal thickening of the renal transplant urothelium, possibly the sequela of prior inflammation or infection. No fluid collection or perinephric edema to suggest acute or active inflammation. 3. Markedly atrophic native kidneys, without focal mass. Abd US ___: IMPRESSION: 1. No bladder stone or suspicious bladder mass visualized. 2. The native kidneys cannot be identified. Renal Graft Ultrasound ___: IMPRESSION: 1. Normal arterial waveforms in the transplanted kidney. 2. Unchanged 7 mm nonobstructing stone. New 5 mm nonobstructing stone in the upper pole. No hydronephrosis. PATHOLOGY: RENAL ALLOGRAFT, CORE BIOPSY ___: 1. BORDERLINE ACUTE ___ MEDIATED REJECTION, SEE NOTE. 2. ___ REJECTION, (NEGATIVE C4D), SEE NOTE. 3. NO SIGNIFICANT CHRONIC CHANGES. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year old man with HCV, renal transplant, rising LFTs in the setting of pred for rejection // ?biliary obstruction or other acute process TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: MRI abdomen and pelvis ___ and the prior abdominal ultrasound dated ___. FINDINGS: Note is made that the patient was not in the fasting state for this exam therefore views of the midline are extremely limited. LIVER: Portions of the liver is appear diffusely echogenic with areas of patchy heterogeneity, however it is noted that the exam was limited by poor acoustic windows and these findings could very well be artifactual. No steatosis was noted on the recent MRI of ___. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 5 mm. GALLBLADDER: There is no evidence of stones or gallbladder wall thickening. PANCREAS: The pancreas is not well visualized, largely obscured by overlying bowel gas. SPLEEN: Normal echogenicity, measuring 8.8 cm. IMPRESSION: No concerning focal liver lesions. No biliary obstruction. Heterogeneous appearance of the liver parenchyma may be artifactual in the setting of poor acoustic windows, or less likely could reflect new development of steatosis since MR of ___. Radiology Report EXAMINATION: Chest: Frontal and lateral views INDICATION: History: ___ with hx renal xplant now rfank hematuria x 5 days, SOB // eval ? edema TECHNIQUE: Chest: Frontal and Lateral COMPARISON: ___ FINDINGS: Platelike atelectasis is seen at the left lung base. A adjacent area of lingular airspace opacity may relate to atelectasis however, consolidation due to pneumonia is not excluded in the appropriate clinical setting. The right lung is clear. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are unremarkable. No pulmonary edema is seen. IMPRESSION: Left basilar platelike atelectasis. Adjacent airspace opacity may relate to atelectasis however, consolidation due to pneumonia is not excluded in the appropriate clinical setting. No pulmonary edema. Radiology Report EXAMINATION: RENAL TRANSPLANT U.S. INDICATION: ___ year old man s/p RLQ kidney allograft w/ 5 days frank hematuria, evaluate right lower quadrant transplant kidney. TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images of the renal transplant were obtained. COMPARISON: Transplant renal ultrasound from ___ FINDINGS: The right iliac fossa transplant renal morphology is normal. Specifically, the cortex is of normal thickness and echogenicity, pyramids are normal, there is no urothelial thickening, and renal sinus fat is normal. There is no hydronephrosis and no perinephric fluid collection. A 7 mm stone is again identified in interpolar region. In addition, there is a 5 mm echogenic focus in the upper pole, likely another stone. The resistive index of intrarenal arteries ranges from 0.63 to 0.9, within the normal range. The main renal artery shows a normal waveform, with prompt systolic upstroke and continuous antegrade diastolic flow. Vascularity is symmetric throughout transplant. The transplant renal vein is patent and shows normal waveform. IMPRESSION: 1. Normal arterial waveforms in the transplanted kidney. 2. Unchanged 7 mm nonobstructing stone. New 5 mm nonobstructing stone in the upper pole. No hydronephrosis. Radiology Report EXAMINATION: COMPLETE GU U.S. (BLADDER AND RENAL) INDICATION: ___ year old man s/p DDRT ___ presenting with hematuria and ___ // Please evaluate for clots in bladder, stones in native kidney, other lesions in bladder or native kidneys. TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: None. FINDINGS: Despite effort the atrophic native kidneys cannot be identified. The bladder is minimally distended and normal in appearance. No bladder stone or suspicious bladder mass is visualized. The patient was not willing to attempt to void. IMPRESSION: 1. No bladder stone or suspicious bladder mass visualized. 2. The native kidneys cannot be identified. Radiology Report INDICATION: ___ year old man s/p renal transplant, with hematuria and ___, low tacro levels // Needs renal bx to r/o rejection COMPARISON: Complete GU ultrasound ___. PROCEDURE: Sonographic guidance for transplant renal biopsy by nephrologist. OPERATORS: Dr. ___ Dr. ___ sonographic guidance for biopsy that was performed by the Nephrology team. Dr. ___ radiologist, was present and supervising throughout the guidance and reviewed and agrees with the trainee's findings. TECHNIQUE: Ultrasound guidance by the radiologist was provided to nephrologist for biopsy of the lower pole of the the transplanted kidney located in the right lower quadrant. Two passes were made. Please refer to nephrologist note for details of the procedure. SEDATION: No moderate sedation was administered. FINDINGS: Survey view of the transplanted kidney shows no hydronephrosis or perinephric collection. IMPRESSION: Sonographic guidance for biopsy of the rightlower quadrant transplant kidney by nephrologist. Radiology Report EXAMINATION: MRI of the abdomen and pelvis. INDICATION: ___ year old man s/p renal transplant, here w/ hematuria // Pls evaluate native and transplanted kidneys for masses or other parenchymal abnormalities TECHNIQUE: T1 and T2 weighted multiplanar images of the abdomen and pelvis were acquired within a 1.5 Tesla magnet without the use of IV contrast. COMPARISON: Ultrasound examinations from ___ through ___. FINDINGS: MRI OF THE ABDOMEN AND PELVIS WITHOUT IV CONTRAST: Included views of the lung bases are clear. There is no pericardial pleural effusion. The heart size is normal. The hepatic parenchyma demonstrates normal signal intensity on T1 and T2 weighted sequences. No focal hepatic lesion is detected. There is no intra or extrahepatic bile duct dilation. The gallbladder is normal. No ductal stone is detected. The pancreas demonstrates normal signal intensity and bulk. The main pancreatic duct is normal in caliber. The spleen size is normal. No focal splenic lesion is seen. The adrenal glands are normal. The stomach and intra-abdominal and intrapelvic loops of small and large bowel are normal in caliber. No focal gastrointestinal mass is seen. The adrenal glands are normal. The native kidneys are markedly atrophic (series 3, image 16), without hydronephrosis or focal mass. A right lower quadrant renal transplant demonstrates mild hydronephrosis (series 17, image 17). The urothelium appears slightly thickened diffusely (series 17, image 18, 19). Previously-seen stone on the prior ultrasound examinations from ___ and ___ is not visualized with MR. ___ flow voids are demonstrated within the transplanted renal artery and vein and segmental branches on T2 weighted sequences (series 15, image 25). No focal mass is seen. There is no perinephric fluid collection or edema. No ureteral mass or stone is detected. The bladder is under distended, but appears normal. No focal bladder mass or bladder stone is seen. Trace intrapelvic free fluid is incidentally noted (series 15, image 30). Multiple pelvic sidewall lymph nodes remain well under cross-sectional criteria for adenopathy (series 15, image 27, 23). There are no osseous lesions concerning for malignancy or infection. IMPRESSION: 1. Mild hydronephrosis of the renal transplant kidney. No focal mass. A small stone seen on prior ultrasound examinations is not visualized on MRI. There is no hydroureter, or ureteral or bladder stone. 2. Nonspecific diffuse minimal thickening of the renal transplant urothelium, possibly the sequela of prior inflammation or infection. No fluid collection or perinephric edema to suggest acute or active inflammation. 3. Markedly atrophic native kidneys, without focal mass. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the ___ ___ at 4:10 ___, 5 minutes after discovery of the findings. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Hematuria Diagnosed with Right lower quadrant pain, Acute kidney failure, unspecified temperature: 97.2 heartrate: 88.0 resprate: 16.0 o2sat: 97.0 sbp: 112.0 dbp: 80.0 level of pain: 8 level of acuity: 2.0

Mr. ___ is a ___ gentleman with a past medical history of Hepatitis C, ESRD secondary to fibrillary glomerulonephritis status post SCD kidney ___ on tacrolimus and mycophenolate who presented with hematuria and was found to have ___ with graft biopsy positive for acute humoral rejection, possible cellular rejection as well. # ESRD s/p Kidney Transplant c/b acute rejection (___): s/p DDRT in ___ for fibrillary GN. Patient has baseline Cr ___ with presentation elevation to 1.7. Tacrolimus level was low on admission (goal ___, concern for missed doses at home. Biopsy c/w humoral with features of cellular rejection. He was continued on tacro (goal ___ and Cellcept. He received a steroid pulse and IVIG for four days and is now on a prednisone taper. He was also started on nystatin x 1 mo and Valgancyclovir x 6 weeks. He was also prophylaxed with Bactrim and a PPI. His acidosis was managed with PO bicarbonate. His mental status was monitored as prednisone can cause changes, but he tolerated it well. Patient will use pill box to help ensure med compliance. A ___ may be helpful with medication organization. # Hematuria: Differential given the hematuria includes rejection, kidney stones, and recurrence of previous glomerulonephritis. BK virus was negative and he had no evidence of infection. Kidney stones were seen on transplant US. Renal US of native kidneys and bladder was unable to locate kidneys and otherwise showed no concerning lesions. Mild hydronephrosis of the renal transplant kidney was seen on GU MRI. Hematuria slowly improved during his hospitalization. His lisinopril was held. # Transaminitis: Uptrend in liver panel after initiation of ___ meds. Concern for worsening of Hep C vs medication effect. RUQ US showed no concerning lesions. He will need labs + tacro trough checked weekly and sent to renal transplant clinic # Hyperkalemia: Likely ___ Bactrim and type IV RTA. He was treated with a ___ diet and Bicarbonate supplementation. # Leukocytosis: ___ steroids most likely as has no signs/sx of infection. Downtrended as steroid dose decreased. # Hepatitis C: Will see outpatient hepatologist to eval for tx # Hepatitis B exposure: Previously positive HBsAb and Hbcore Ab. HBsAg negative and HBV viral load not detectable. A course of lamivudine was not indicated as he was not treated with Rituximab. # Depression: Continued Seroquel 400 mg QHS, sertraline 100 mg daily, clonazepam 0.5 mg PRN # Chronic Pain: Reduced gabapentin to 100 mg TID given ___. He was on tapentadol [Nucynta] at home (nonformulary) and was monitored for withdrawal, restarted on discharge # HTN: Held home lisinopril given renal injury. Started amlodipine for BP control. # COPD: Albuterol, tiotropium # Diabetes: He was on metformin at home, which has been discontinued given renal impairment. He will start glipizide on discharge # Dispo: Patient has stuggled with showing up to appointments, does not have strong understanding of medications although appears to be filling them. He now lives alone with his wife in a nursing home. Also has probation officer, and needs to check in while inpatient. ================================

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Celebrex Attending: ___. Chief Complaint: hyponatremia Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ yo woman with hx HTN, MR ___ repair, low back pain who was recently diagnosed with nephrolithiasis (small bilateral, nonobstructing) and hyponatremia Na 122 earlier this month at ___. During that hospitalization ___, she presented with left flank pain, nausea, episodes of vomiting, poor po intake. Prior to that presentation she had also been seen as an outpt for microscopic hematuria and possible UTI, was briefly on Cipro prior to being admitted. We do not have full records from this ___, but she reportedly had normalized Na when discharged (per ___ clinic notes) She was admitted again to ___ ___ for recurrent hyponatremia (Na 121) and ongoing flank pain from known kidney stones. She was felt to have SIADH, ?suspected secondary to meds? Oxycodone was d/c. Appears losartan was also changed to amlodipine. She was maintained on 1200 ml fluid restriction. Her Na remained essentially unchanged at 122 when she was discharged on ___ with instructions to have f/u labs from PCP. She is now readmitted after her outpt labs returned with Na 120. She is generally feeling 'ok.' Some fatigue and nausea. Denies vomiting. She still has intermittent flank pain, this morning it was the right side and now left side. She has been drinking plenty of fluids, in fact it appears she misinterpreted her discharge instructions as advising her that she should drink *at least* 2 L/day. (she had been home only a day and half before being intructed to return to ED) ROS otherwise negative for fever, chills, chest pain, shortness of breath, abdominal pain, diarrhea, rashes, tremors, motor weakness +constipation Past Medical History: NEPHROLITHIASIS - dx at ___ ___, small bilateral nonobstructing by CT MITRAL REGURGITATION ___ mitral repair in ___, normal coronaries, systolic murmur c/w mitral ___ ___ LOW BACK PAIN - L sciatica,herniated discs,steroid injectons at ___ treatment APPENDECTOMY TAH/BSO w/bladder susupension___ ___ at ___ OSTEOPOROSIS COLONIC ADENOMA ___ in ___ - NL ,repeat ___ y previuosly adenomatous ___ PYELONEPHRITIS ___ BLEPHAROPLASTY Social History: ___ Family History: denies any significant family hx of cardiac, DM, malignancy Physical Exam: 97.4 BP 160/101 HR 67 RR 18 100%RA well nourished appearing woman, no distress, fatigued appearing but easily engages in conversation MMM, neck supple, sclera, anicteric irregularly irregular Lungs clear bilaterally Abd soft, nontender Flank - very mild tenderness to palpation bilaterally Extrem - no edema Neuro: oriented x 3, nonfocal, face symmetric, moving all extremities well Psych: pleasant, fluent speech Pertinent Results: ___ 04:56PM UREA N-17 CREAT-0.6 SODIUM-120* POTASSIUM-3.6 CHLORIDE-85* TOTAL CO2-23 ANION GAP-16 ___ 04:56PM OSMOLAL-251* ___ 01:01AM ALBUMIN-4.4 ___ 01:01AM WBC-7.5 RBC-3.73* HGB-12.1 HCT-32.9* MCV-88 MCH-32.4* proBNP-430 LIPASE-33 TSH 1.1 ___ 01:01AM GLUCOSE-119* UREA N-18 CREAT-0.5 SODIUM-121* POTASSIUM-3.7 CHLORIDE-85* TOTAL CO2-24 ANION GAP-16 ___ 01:01AM ALT(SGPT)-23 AST(SGOT)-24 ALK PHOS-90 TOT BILI-0.6 ___ 05:00AM TSH-1.1 ___ 05:00AM OSMOLAL-251* ___ 05:00AM GLUCOSE-127* UREA N-14 CREAT-0.5 SODIUM-121* POTASSIUM-3.6 CHLORIDE-84* TOTAL CO2-24 ANION GAP-17 ___ 04:45AM URINE HOURS-RANDOM CREAT-109 SODIUM-40 POTASSIUM-42 CHLORIDE-43 ___ 04:45AM URINE OSMOLAL-606 ___ 04:45AM URINE COLOR-Yellow APPEAR-Cloudy SP ___ ___ 04:45AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-LG ___ 04:45AM URINE RBC-6* WBC-14* BACTERIA-FEW YEAST-NONE EPI-1 EKG: Afib rates 70, no sign of acute ___ CT scan ___ - small nonobstructing calculi in both kidneys 2 mm in the right mid kidney and two 3-4 mm calculi in the mid-to-lower left kidney; no hydronephrosis or perinephric stranding ___ 05:00AM ___ CT scan ___ Small nonobstructing renal calculi No evidence of acute urinary tract obstruction. CT head noncontrast ___ IMPRESSION: 1. No acute intracranial process. 2. Please note MRI of the brain is more sensitive for the detection of acute infarct. 3. Paranasal sinus disease as described. CXR ___ IMPRESSION: No acute cardiopulmonary process. Discharge Labs: ___ 06:11AM BLOOD WBC-9.6 RBC-3.24* Hgb-10.5* Hct-30.1* MCV-93 MCH-32.4* MCHC-34.9 RDW-12.8 RDWSD-43.7 Plt ___ ___ 03:30PM BLOOD Na-128* K-3.7 Cl-93* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q4-6H: PRN wheeze 2. Amlodipine 5 mg PO DAILY 3. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia 4. Aspirin EC 81 mg PO DAILY 5. Calcium 500 + D (calcium carbonate-vitamin D3) unknown oral DAILY 6. Vitamin D ___ UNIT PO DAILY 7. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain Discharge Medications: 1. Amlodipine 5 mg PO DAILY 2. Aspirin EC 81 mg PO DAILY 3. Calcium 500 + D (calcium carbonate-vitamin D3) 1 tab ORAL DAILY 4. Multivitamins 1 TAB PO DAILY 5. Vitamin D ___ UNIT PO DAILY 6. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia 7. Bisacodyl 10 mg PO/PR DAILY constipation 8. Furosemide 10 mg PO BID RX *furosemide 20 mg 0.5 (One half) tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 9. Gabapentin 300 mg PO QHS RX *gabapentin 300 mg 1 capsule(s) by mouth at bedtime Disp #*30 Capsule Refills:*0 10. Senna 8.6 mg PO BID:PRN constipation 11. Sodium Chloride 1 gm PO TID RX *sodium chloride 1 gram 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 12. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 13. Outpatient Lab Work Please check sodium ___ 14. Outpatient Physical Therapy Thoracolumbar strain Please assess and treat Discharge Disposition: Home Discharge Diagnosis: Hyponatremia Nephrolithiasis Thoraco-lumbar pain Atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ female with weakness, headache, and hypernatremia. Evaluate for subdural hemorrhage or mass. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: This study involved 3 CT acquisition phases with dose indices as follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced Acquisition 16.0 s, 16.2 cm; CTDIvol = 55.2 mGy (Head) DLP = 891.9 mGy-cm. Total DLP (Head) = 892 mGy-cm. COMPARISON: None. FINDINGS: There is no evidence of no evidence of infarction, hemorrhage, edema, or mass. Prominent ventricles and sulci suggest age related involutional changes. Periventricular white matter hypodensities are consistent with chronic small vessel ischemic disease. Atherosclerotic vascular calcifications are noted of bilateral cavernous portions of internal carotid arteries. There is no evidence of fracture. A mucous retention cyst and mucosal thickening are seen in the right maxillary sinus. Otherwise, the visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. No acute intracranial process. 2. Please note MRI of the brain is more sensitive for the detection of acute infarct. 3. Paranasal sinus disease as described. Radiology Report EXAMINATION: Chest radiographs INDICATION: History: ___ with sob, hx of chf // chf? TECHNIQUE: Upright PA and lateral images of the chest. COMPARISON: Comparison is made with chest radiographs from ___ and ___. FINDINGS: Lungs well expanded and clear. There is no pleural effusion or pneumothorax. The cardiomediastinal silhouette is top normal in size. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: RENAL U.S. INDICATION: ___ year old woman with hx bilateral small nephrolithiasis (nonobstructing) at OSH CT scan ___, presenting with persistent flank pain, also noted to have pyuria, ?firm bladder on palpation despite being straight-cathed. // Please assess for possible bladder mass/wall thickening. Also rule out hydronephrosis TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: None. FINDINGS: The right kidney measures 12.2 cm. The left kidney measures 10.9 cm. Multiple tiny echogenic foci are noted bilaterally, measuring up to 2- 3 mm in the lower pole of the left kidney, which may represent nonobstructing renal calculi. There is no hydronephrosis or masses bilaterally. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. The bladder is moderately well distended and normal in appearance. A small amount of debris is noted within the bladder. IMPRESSION: 1. Multiple punctate bilateral nonobstructing renal calculi without hydronephrosis. 2. No bladder mass detected. Radiology Report EXAMINATION: CT L-SPINE W/O CONTRAST INDICATION: ___ year old woman with recent diagnosis nonobstructing bilateral kidney stones at OSH, with persistent bandlike pain in lower thoracic/lumbar region. Assess lower thoracic T10 through lumbar spine. r/o compression fracture TECHNIQUE: Ataxial, helical, MDCT images were acquired through the lumbar spine without the administration of intravenous contrast. Coronal, sagittal, and bone algorithm thin section reformatted images were generated. DOSE: This study involved 4 CT acquisition phases with dose indices as follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) CT Localizer Radiograph 4) Spiral Acquisition 10.5 s, 38.1 cm; CTDIvol = 40.2 mGy (Body) DLP = 1,340.5 mGy-cm. Total DLP (Body) = 1,341 mGy-cm. COMPARISON: None available. FINDINGS: For the purposes of numbering, the lowest rib was designated T12. This implies that there is a lumbarized first sacral segment Intervertebral disc space was designated the There is mild anterolisthesis of L5 on S1. Alignment is otherwise normal There is no evidence of fracture. The prevertebral and paraspinal soft tissues are unremarkable. Multilevel degenerative changes are seen throughout the thoracolumbar spine with subchondral sclerosis and disc space narrowing most prominent at T11-T12. T10-11: Possible small left left-sided disc protrusion (4:7) with mild left neural foraminal narrowing. No spinal canal narrowing. T11-T12: Mild degenerative disc disease with loss of height of the disc and endplate sclerosis. No encroachment on the thecal sac or neural foramina. T12-L4: Mild degenerative disc disease with loss of height of the disc and endplate sclerosis. No encroachment on the thecal sac or neural foramina. L4-L5: Mild thickening of the ligamentum flavum with small disc bulge is seen causing mild canal narrowing. No neural foraminal narrowing. L5-S1: Disc bulge in combination with spondylolisthesis and thickening of the ligamentum flavum produces mild spinal canal narrowing. The disc bulges into the neural foramina bilaterally, greater on the left than right. In these locations, it appears to contact and compresses the exiting left L5 nerve root and contact the right L5 nerve root without compression. There is severe narrowing of the left lateral recess with compression of the traversing left S1 nerve root by a a superior facet osteophyte. Mild degenerative disease of bilateral sacroiliac joints with subchondral sclerosis an ex vacuo phenomenon. Limited assessment of the intra-abdominal structures demonstrates a 2 mm nonobstructing stone within the left collecting system. There are several high intensity lesions in the left kidney, incompletely evaluated on this study. If further characterization is indicated, an ultrasound may be helpful. IMPRESSION: 1. Mild anterolisthesis of L5 on S1. 2. No evidence of fracture. 3. Degenerative disc disease at multiple levels with nerve root compression at L5-S1. 4. Partially lumbarized first sacral segment. 5. Nonobstructing 2 mm stone within left collecting system. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Abnormal sodium level Diagnosed with HYPOSMOLALITY/HYPONATREMIA temperature: 97.4 heartrate: 88.0 resprate: 17.0 o2sat: 99.0 sbp: 127.0 dbp: 85.0 level of pain: 4 level of acuity: 2.0

___ yo woman with hx HTN, MR ___ repair, low back pain who was recently diagnosed with nephrolithiasis (small bilateral, nonobstructing) and hyponatremia, with two hospitalizations at OSH, thought likely due to SIADH who now presents with persistent hyponatremia Na 120 #Hyponatremia - Due to SIADH and pain was thought to be the stimulus. She required hypertonic saline for a sodium of 119. Nephrology consulted and she was ultimately treated with fluid restriction, furosemide, and salt tabs. Her sodium was stable at 126-130 for the last 4 days of admission and 128 on discharge. She will follow-up on ___ for a sodium check. #Bilateral flank pain and nephrolithiasis - Her pain was multifactorial and included renal colic, MSK reproducible pain with thoracolumbar strain. She also had CT which demonstrated nerve compression of the L5-S1 nerve root. Over the past several days of her admission her pain was not severe, though it was would wake her from sleep as an annoying pain that would make for a difficult night of rest. She had tenderness to palpation over the paraspinal muscles which reproduced her pain. She was treated with gabapentin, lidocaine patch, heating pad and oxycodone. Flexeril was tried x1, but it made her drowsy and she was slightly confused on waking up. She was discharged with a script for outpatient ___. She will need to follow-up with Urology for her nephrolithiasis. #Pyuria - suspect due to stone. Denied dysuria and her culture was mixed flora. #Atrial fibrillation - newly noted on this admission, though her EKG looks to be an ectopic atrial focus vs. very prolonged PR (1st degree block). She should be re-evaluated with EKG in the office in follow-up. Appears CHADS2 score is 2 and CHA2DS2-VASc score of 4. If true afib, her cumulative risk over time will warrant anticoagulation. For now, she was increased to a full dose ASA. #HTN - continued amlodipine

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Ambien Attending: ___. Chief Complaint: chest pain Major Surgical or Invasive Procedure: intercostal nerve block History of Present Illness: CC: Right-sided chest pain HPI: Ms. ___ is a ___ y/o woman with a pmhx. of tobacco abuse (40 pack/yr,) and chronic pain syndrome, with recent diagnosis of stage IV NSCL, now C2D5 of ___, presenting with acute on chronic right-sided chest pain consistent with previous cancer pain. Ms. ___ first presented in the ___ with right-sided mid-back and shoulder discomfort, with imaging in ___ revealing right lung mass. As per outpatient oncology notes, Ms. ___ underwent bronchoscopy at ___ in early ___, with biopsy of right hilar mass positive for malignant cells consistent with non-small cell; IHC showed CK7 positive, TTF-1 cositive, napsin A, EPCAM, and focal positivity for CD56. Tumor cells were negative for P63, CD45, and synaptophysin and chromogranin. It was felt that the staining favored adenocarcinoma, although focal CD56 positivity raised question of neuroendocrine differentiation. There were insufficient material for mutation studies. She had a PET CT on ___, which showed a large FDG-avid right hilar mass, with several avid lymph nodes on the right. There was a moderate right pleural effusion and several areas of increased avidity along the posterior right pleura. Multiple additional lung nodules were noted on the right that were not avid, but borderline size. In the abdomen and pelvis, multiple foci of avidity including along the right liver capsule, right retrocrural area. Multiple foci of FDG avidity were seen throughout the skeleton including T12, L2, S1, left iliac, right acetabulum, right sacrum, left sacrum, and right ribs (none with evidence of spinal invasion). There was a mixed lytic and sclerotic lesion in the left aspect of L2. An MRI of her brain to complete staging showed the severe motion artifact with no definite mets. Ms. ___ was admitted with acute pain on ___ and had confirmatory biopsies of malignant right pleural effusion at that time as well (demonstrated adenocarcinoma). She underwent her first cycle of ___ on ___ during admission. Then she underwent intercostal nerve block on ___ with minimal relief. Mr. ___ received her second cycle of ___ as an outpatient on ___. She states that last night she developed acute pain, consistent with prior cancer-associated pain, not responsive to home pain regimen. However, Ms. ___ states that she is not entirely clear about what medications she is taking at home; her daughter fills her pill box. She thinks she may be running out of her medication a bit too quickly. She denies any chest pressure, worsening shortness of breath, current nausea, vomiting, diarrhea, fevers, or chills. A complete 12-point review of systems is negative aside from what is described above. Past Medical History: PAST MEDICAL HISTORY: --Ankle fracture --Depression --Fibromyalgia --GERD --Hyperlipidemia --Insomnia --OSA --H.Pylori --RLS --Tobacco abuse --Stage IV NSCLC AST ONCOLOGIC HISTORY: She presented several times in the late ___ with right-sided and mid back discomfort and right shoulder pain and SOB. At the end of ___, chest x-ray showed right-sided lung mass and pulmonary nodules for which she was sent to ___ ___. She underwent bronchoscopy at ___ in early ___. Bronch of the right upper lobe showed atypical cells and FNA of her right hilar mass was felt positive for malignant cells consistent with non-small cell, the impact showed the CK7 positive, TTF-1 positive, napsin A, EPCAM, and focal positivity for CD56. Tumor cells were negative for P63, CD45, and synaptophysin and chromogranin. It was felt that the staining favored adenocarcinoma, although focal CD56 positivity raised question of neuroendocrine differentiation. There were insufficient material for mutation studies. She had a PET CT on ___, which showed a large FDG-avid right hilar mass, several avid lymph nodes were noted on right. There was a moderate right pleural effusion and several areas of increased avidity along the posterior right pleura. Multiple additional lung nodules were noted on the right that were not avid, but borderline size. In the abdomen and pelvis, multiple foci of avidity including along the right liver capsule, right retrocrural area. Multiple foci of FDG avidity were seen throughout the skeleton including T12, L2, S1, left iliac, right acetabulum, right sacrum, left sacrum, and right ribs (none with evidence of spinal invasion). There was a mixed lytic and sclerotic lesion in the left aspect of L2. An MRI of her brain to complete staging showed the severe motion artifact with no definite mets. PAST MEDICAL HISTORY: COPD (not on home O2), fibromyalgia, depression Social History: ___ Family History: No family history of lung cancer. Cirrhosis in her father. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.3, 107/76, 116, 18, 95% RA ECOG: 2 GENERAL: Chronically ill appearing, no acute distress, lying in bed HEENT: Mucous membranes dry, no oral lesions, poor dentition CHEST: Decreased breath sounds at bases, no wheezes, rales, or rhonchi CARDIAC: Tachycardic, no murmurs, rubs, or gallops ABDOMEN: +BS, soft, non-tender, non-distended EXTREMITIES: No edema bilaterally SKIN: Very dry, no obvious rash NEURO: Pupils miotic but reactive, appropriate DISCHARGE Exam: VITALS: 98.2 114/57 ___ R18 Gen: breathing comfortably, mild distress due to pain, sleeping soundly, appears comfortable this morning Eyes: EOMI, sclerae anicteric ENT: MMM, OP clear Cardiovasc: RRR, no MRG, full pulses, no edema Resp: normal effort, no accessory muscle use, decreased breath sounds on the R GI: ab is nondistended, soft, NT, ND, BS+ Neuro: AAOx3. Psych: Full range of affect Pertinent Results: LABS: 132 92 12 140 AGap=21 ------------------ 4.0 23 0.6 Comments: Glucose: If Fasting, 70-100 Normal, >125 Provisional Diabetes ALT: 16 AP: 79 Tbili: 0.8 Alb: 4.0 AST: 15 LDH: Dbili: TProt: ___: Lip: 14 WBC: 9.6 Hgb: 11.7 Hct: 34.9 Plt: 340 MCV: 83 N:88.3 L:8.9 M:1.2 E:1.0 Bas:0.3 ___: 0.3 Absneut: 8.50 ___ Abslymp: 0.86 Absmono: 0.12 Abseos: 0.10 Absbaso: 0.03 PATHOLOGY: ___: Pleural Biopsy Right parietal pleural, biopsy: Positive for adenocarcinoma, consistent with lung o rigin. Note: The tumor is moderately to poorly differentia ___. Tumor cells are diffusely and strongly positive for CK7, Napsin and TTF1. There is also cytoplasmic positivity for WT1. Cells are negative for calretinin, CK20 and CDX2. The findings are consistent with an adenocarcinoma of lung origin ___: Pleural Fluid CYTOLOGY REPORT Final SPECIMEN(S) SUBMITTED: PLEURAL FLUID, right pleural effusion DIAGNOSIS: PLEURAL FLUID, RIGHT: POSITIVE FOR MALIGNANT CELLS. Metastatic lung adenocarcinoma. Note: By immunohistochemistry, tumor cells are positive for TTF-1 and Napsin A. No staining is seen for p63. The cellblock shows high tumor cellularity. ___: EBUS FNA 4R Metastatic Lung Adenocarcinoma CXR ___: PA and lateral views of the chest provided. Multiple known lung nodules are better visualized on prior CT chest. There is no convincing evidence of pneumonia or edema. Cardiomediastinal silhouette appears similar with mediastinal prominence reflecting known right hilar and suprahilar mass. Aortic calcifications again noted. Bony structures appear grossly intact. EKG: Sinus tachycardia with rate of 128, motion artifact, no concerning ST abnormalities NERVE BLOCK PROCEDURE NOTE ___: Chief Complaint: Right sided chest/ chest wall pain History/Statement of Medical Necessity: ___ year old female with metastatic non-small cell lung cancer, who was recently re-admitted for intractable pain at the right chest wall radiating to her back and to the anterior chest. She is on high doses of opioids with significant breakthrough pain, exacerbated with movement. She received a diagnostic intercostal block of the ___ to ___ intercostal nerves on the right side on ___ with minimal relief of her symptoms. She is currently admitted for pain and has been transported to clinic in order to recieve paravertebral blocks on the right at the level of the ___ and ___ level as well as neurolysis of the ___ and ___ intercostal nerves on the right in an effort to improve pain control and decrease the need for opioid use. Interval changes in history/medications/system review: Unchanged since last seen as inpatient this morning. Allergies: reviewed and updated as needed in OMR Medications: reconciled in OMR Pertinent Labs: 139/3.8 ___ <101 Ca: 8.6 Mg: 1.6 P: 3.1 4.3 > 10.3/32.6 < 217 ___: 12.1 INR: 1.1 Anticoagulants: Reviewed with patient, notable for xSubQ Heparin as an inpatient that was held this am. Focused Examination: Ax3 Mood and affect are normal Vital Signs sheet entries for ___: BP: 103/56. Heart Rate: 70. Weight: 185 (With Clothes) (___ Plan of Care: Education). Height: 60 (With Shoes). BMI: 36.1. Temperature: 96.8. Resp. Rate: 18. Pain Score: 7. O2 Saturation%: 100. Pre Procedure Diagnosis: Right chest wall pain Post Procedure Diagnosis: Right chest wall pain, intercostal neuralgia Procedure Performed by: ___ ___ Physician: ___ ___: Verbal and written informed consent was obtained/reviewed with the patient. Risks, benefits, alternatives discussed in detail. All questions were answered. Site was then marked. Position: prone Anesthesia: Monitored Anesthesia Care Monitoring: NIBP, Pulse oximetry Antibiotics: None The skin was prepped with chloraprep (chlorhexidine and alcohol) and then draped in a sterile fashion Time out was then performed as per protocol Procedure - Thoracic Paravertebral Block The patient was prepped with aseptic technique and was prepped with a sterile ultrasound sleeve in aseptic technique. Needle used: 22 GA 3.5 in Spinal Contrast: Omnipaque Injectate: Dexamethasone 14mg 2ml and Bupivicaine 0.5% 14 ml total 16ml divided into 4 levels Technique: Under live ultrasound guidance, a 25 G needle was introduced in-plane to the area of the right paraverterbral space by locating the spinous process at the ___ thoracic vertebral level and moving lateral past the transverse process. The needle was advanced to the praravertebral space just before the pleura. The tip of the needle was visualized at all times and during injection. After negative aspiration, the above mentioned injectate was administered 4 mL was injected. There was no evidence of intravascular or intraneural or intra-arterial injection. 1 ml of omnipaque was then administered with confirmation of appropriate spread consistent with intercostal nerve block and without evidence for intravascular uptake The needle was then withdrawn. The patient tolerated the procedure well and there were no complications. The same procedure was done at the level of ___ and ___ paravertebral levels. EBL: less than 1 ml Complications: None Specimen: None Fluids: None Procedure - Intercostal Neurolysis Needle entry site was then infiltrated with lidocaine 1% using 25G 1.5 inch needle 1ml Needle used: 22 GA 3.5 in Spinal Contrast: Omnipaque Injectate: Lidocaine 2% 15 ml total Phenol 6% 6 ml total Technique: The posterior angle of the ribs was identified, in line vertically with the lateral aspect of the scapula on right side. The needle was then advanced until it contacted the 5th rib. The needle was then carefully walked off the inferior margin of the rib and into the intercostalis groove, at a distance no greater than 3 mm. 1 ml of omnipaque was then administered with confirmation of appropriate spread consistent with intercostal nerve block and without evidence for intravascular uptake After negative aspiration for air or blood, 5 ml of the 2% lidocaine was administered and allowed to take effect for 60 sec at which time the administration of phenol 6% 2ml was adminstered into each level. No paresthesias were produced. The needle was withdrawn. The same procedure was done at the level of ___ and 7th rib. EBL: less than 1 ml Complications: None Specimen: None Fluids: None Post Procedure: see OMR. Patient was taken to the recovery and monitored. Patient was stable upon transfer back to the hospital. Detailed post procedure instructions were provided. Patient was asked to call in the event of worsening pain, shortnrss of breath, fever, weakness or numbness. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO TID 2. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 3. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN abdominal discomfort 4. BuPROPion (Sustained Release) 150 mg PO QAM 5. Docusate Sodium 200 mg PO BID 6. FoLIC Acid 1 mg PO DAILY 7. Escitalopram Oxalate 20 mg PO DAILY 8. Gabapentin 1200 mg PO TID 9. Nicotine Patch 21 mg TD DAILY 10. OxyCODONE SR (OxyconTIN) 80 mg PO Q8H 11. Polyethylene Glycol 17 g PO DAILY for no bowel movement 12. Senna 17.2 mg PO BID 13. Dexamethasone 4 mg PO BID 14. Cyanocobalamin 1000 mcg IM/SC EVERY 9 WEEKS 15. Lactulose 30 mL PO DAILY 16. Lidocaine 5% Patch 1 PTCH TD QAM 17. Lorazepam 0.5 mg PO Q4H:PRN anxiety/agitation 18. Naproxen 500 mg PO Q12H 19. OxycoDONE (Immediate Release) 20 mg PO Q6H:PRN Pain Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 2. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN abdominal discomfort 3. BuPROPion (Sustained Release) 150 mg PO QAM 4. Docusate Sodium 200 mg PO BID 5. Escitalopram Oxalate 20 mg PO DAILY 6. FoLIC Acid 1 mg PO DAILY 7. Gabapentin 1200 mg PO TID 8. Lactulose 30 mL PO DAILY 9. Lidocaine 5% Patch 1 PTCH TD QAM 10. Lorazepam 0.5 mg PO Q4H:PRN anxiety/agitation 11. Nicotine Patch 21 mg TD DAILY 12. OxycoDONE (Immediate Release) 20 mg PO Q6H:PRN Pain 13. OxyCODONE SR (OxyconTIN) 80 mg PO Q8H 14. Polyethylene Glycol 17 g PO DAILY for no bowel movement 15. Senna 17.2 mg PO BID 16. Acetaminophen 650 mg PO TID 17. Cyanocobalamin 1000 mcg IM/SC EVERY 9 WEEKS Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Cancer-related chest pain Discharge Condition: stable Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ with metastatic lung cancer, nausea/vomiting, on chemo // Eval for infection COMPARISON: CTA chest from ___ and chest radiograph from ___. FINDINGS: PA and lateral views of the chest provided. Multiple known lung nodules are better visualized on prior CT chest. There is no convincing evidence of pneumonia or edema. Cardiomediastinal silhouette appears similar with mediastinal prominence reflecting known right hilar and suprahilar mass. Aortic calcifications again noted. Bony structures appear grossly intact. IMPRESSION: Findings as stated above. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Nausea, Body aches Diagnosed with Other chronic pain temperature: 96.8 heartrate: 114.0 resprate: 18.0 o2sat: 97.0 sbp: 119.0 dbp: 79.0 level of pain: 8 level of acuity: 3.0

Ms ___ is a pleasant ___ y/o woman with a pmhx. significant for stage IV NSCLC with large R sided hilar mass c/b malignant pleural effusion, recently started on chemo s/p C2D5 of ___ most recently on ___, with significant cancer-associated chest pain (including recent admission ___ s/p intercostal nerve block done on ___ without much effect), admitted for management of acute on chronic right-sided chest pain. Symptoms were most consistent with continued cancer-related pain. No concerning features for ACS or PE. She was sating well on room air. Pain management consulted and she underwent a right sided ___, ___ and ___ intercostal neurolysis and right sided paravertebral block at the ___ and ___ levels on the right side with benzocaine and dexamethasone injections on ___ with improvement in her pain (particularly in the area towards her back) but with some residual anterior pain was noted. She developed with post-procedure nausea so remained inpatient an additional overnight for monitoring. She felt much better the following day and was discharged home with services. #Nausea: I discussed with the pain management team whether any of the injected drugs may have contributed to her nausea and they couldn't think of any identifiable causes relating to the procedure. Perhaps she was nauseated in response to the sedation she was given prior to the procedure? the Dexamethasone would be thought to have improved her nausea. Regardless, she was feeling much better the following morning and tolerated good pO intake before going home. #RIGHT-SIDED CHEST PAIN: Patient stated that pain was worsening of her chronic cancer-associated pain with no changes in the character or quality of the pain. She is usually on oxycontin 80mg tid and oxycodone 20mg Q6 at home however, she admits that she was unclear to her exactly what she is taking (since someone else fills her pill box). Initially there was a concern that her daughter may be handling her narcotics but it was confirmed with case management that the ___ service is in charge of this aspect of her care. -We continued her home oxycontin 80mg tid + oxycodone 20mg Q6 unchanged -she was also given Toradol 15mg Q6 x3 days -notably CT angiogram done when she had the same type of pain on ___ that showed no PE. CXR ___ showed known multiple metastases but no significant recurrence of effusion. No e/o pneumonia or edema were seen. The previously seen R sided hilar mass was still present. -Consider Radiation Oncology consult in the future to determine utility and feasibility of palliative radiation in case her pain continues -Pain management inpatient consult service was enlisted to help manage her pain and on ___, underwent Right sided ___ and ___ intercostal neurolysis and right sided paravertebral block at the ___ and ___ levels on the right side with benzocaine and dexamethasone injections. #TACHYCARDIA: up to 110s in ED in setting of discomfort, improved with IV morphine and IVF (rates of 130s in the ED, 110 on the floor). Now resolved, PE unlikely as above. She remained sating well on room air. #METASTATIC LUNG CANCER: C2D5 of ___. Further treatment as per outpatient physicians. Patient is receiving B12 and dex as an outpatient. She states that she only takes the dexamethasone right before her chemotherapy so this was held on her discharge and can be restarted by her outpatient oncology team as needed. She continues on folic acid. #Hyponatremia: Na 132 which is slightly reduced from her baseline around 137, now resolved. #CONSTIPATION: Continue miralax, senna, Colace, lactulose PRN #DEPRESSION: Continued home escitalopram and buproprion #FEN/GI/PPX: -Aggressive bowel regimen with large dose narcotics #CODE STATUS: FULL CODE (confirmed by me with the patient however she seemed a little confused as to what Full code entails as she later wanted to "just be made comfortable" in case she were to decompensate). I tried to pursue this further but she said she would rather discuss this with her daughter first. She remained full code for this admission and will discuss with her daughter as an outpatient. #TRANSITIONAL ISSUES: -outpt ___ with her oncologist Dr. ___ and in pain management clinic. -PCP ___ appointment for goals of care planning -if pain continues, can consider Radiation Oncology consult to determine utility and feasibility of palliative radiation if pain continues

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Flagyl / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: dyspnea x 2 days lower leg swelling x 3 weeks Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old female with COPD, HFpEF (TTE ___, EF>65%, dry weight: 135lbs), mild-moderate AR, mild-moderate TR, thoracic + abd aortic aneurysm with h/o Type A thoracic dissection s/p repair (___), Crohn's disease s/p colostomy + subsequent reversal ___, not on any medications), Bell's palsy w/ R facial droop, HTN, and hypothyroidism who is being admitted from ___ clinic on ___ for worsening dyspnea. The pt was recently hospitalized from ___ for concomitant COPD and CHF exacerbation. For her COPD exacerbation, she received a 5-day course of prednisone/AZT with plans to f/u with Pulm as outpatient, although never did. Regarding her acute HFpEF exacerbation, on admission her BNP was ~11,000 (baseline 3000) with mild interstitial edema on CXR. At the time of discharge, she had 1+ edema above the ankles and demanded to be discharged home despite recommendation for further diuresis (d/c weight: 142.8lbs, above dry weight: 135lbs). Her home Lasix was increased to 40mg bid prior to discharge. She did not keep her f/u PCP apt after leaving the hospital. However since discharge, the pt said she felt better than before, but never returned to baseline. Over the next several weeks she complained of progressive shortness of breath with exertion. Also w/ increasing ___ edema. Orthopnea at baseline without PND. Otherwise she also continued to have chronic cough productive of small amounts of white sputum. No fevers, chills, chest pain, n/v or abdominal pain. Says that her scale at home is broken, so could not comment on possible weight gain. Notably, the pt does admit to occasionally missing doses of Lasix bc of the inconvenience of frequent urination. She presented to clinic on ___ after calling the clinic with complaints of the above symptoms. Her weight there was recorded 143lbs, 8lbs above presumed dry weight. She was seen by Dr. ___ at referred her to the ED due to concern for concurrent CHF/COPD exacerbation. Past Medical History: CHF (dx ___, EF 35-40%, mild LVH, mod AR, mod TR; TTE ___ with EF 65% Mild-mod AR, Mild-mod) Hypertension Hypothyroid Crohn's disease, not on any maintenance medications Diverticulosis Bell's palsy-R facial droop Thoracic Type A aortic dissection s/p repair Thoracic and abdominal aortic aneurysm Colostomy and reversal for Crohn's Open cholecystectomy C-Section Hysterectomy Social History: ___ Family History: Mother: Died at age ___ in her sleep. She had colon cancer s/p resection and heart disease Father: Died at age ___, DM and heart disease Brother: Died at age ___, he had CHF, DM, and aneurysms Physical Exam: ADMISSION PHYSICAL EXAM: =========================== VITALS: T 97.7, BP 118/71, HR 89, RR 20, O2 93% on RA GENERAL: Alert and interactive, eating dinner, NAD HEENT: NCAT. Sclera anicteric and without injection. NECK: Supple, JVD 13cm, +HJR CARDIAC: RRR, no m/r/g LUNGS: Decreased breath sounds, diffuse wheezes and rhonchi ABDOMEN: Soft, non tender, non distended BS+ EXTREMITIES: 2+ ___ edema to knees bilaterally SKIN: Warm and well perfused NEUROLOGIC: CN2-12 grossly intact, AOx3 DISCHARGE PHYSICAL EXAM: ========================== VITALS: ___ 1140 Temp: 97.5 PO BP: 120/70 HR: 78 RR: 18 O2 sat: 93% O2 delivery: Ra GENERAL: Alert and interactive, sitting in bed in NAD HEENT: NCAT. Sclera anicteric and without injection. CARDIAC: RRR, no m/r/g LUNGS: Wheezes audible without stethoscope. Air movement poor, with diffuse wheezes in all lung fields and delayed expiration ABDOMEN: Soft, non tender, non distended BS+ EXTREMITIES: 2+ ___ edema to thighs, L>R SKIN: Warm and well perfused; mild venous stasis changes at ankles; poor toenail hygeine NEUROLOGIC: Mild right upper and lower facial droop (chronic); otherwise CN2-12 grossly intact, AAOx3 Pertinent Results: ADMISSION LABS: =================== ___ 12:05PM BLOOD WBC-8.6 RBC-4.68 Hgb-12.0 Hct-39.3 MCV-84 MCH-25.6* MCHC-30.5* RDW-16.5* RDWSD-50.9* Plt ___ ___ 12:05PM BLOOD Neuts-77.6* Lymphs-13.1* Monos-4.9* Eos-3.4 Baso-0.7 Im ___ AbsNeut-6.70* AbsLymp-1.13* AbsMono-0.42 AbsEos-0.29 AbsBaso-0.06 ___ 12:05PM BLOOD Glucose-143* UreaN-36* Creat-1.7* Na-145 K-4.6 Cl-103 HCO3-24 AnGap-18 ___ 12:05PM BLOOD CK-MB-7 cTropnT-0.02* proBNP-7739* ___ 12:05PM BLOOD cTropnT-0.02* ___ 04:50PM BLOOD cTropnT-0.01 ___ 07:00AM BLOOD Calcium-8.9 Phos-4.1 Mg-2.1 ___ 07:00AM BLOOD TSH-6.5* ___ 12:25PM BLOOD ___ pO2-34* pCO2-51* pH-7.33* calTCO2-28 Base XS-0 DISCHARGE LABS: ================== ___ 07:54AM BLOOD WBC-11.4* RBC-4.66 Hgb-11.9 Hct-38.4 MCV-82 MCH-25.5* MCHC-31.0* RDW-16.7* RDWSD-49.3* Plt ___ ___ 07:54AM BLOOD Glucose-102* UreaN-66* Creat-2.0* Na-142 K-4.2 Cl-97 HCO3-27 AnGap-18 ___ 07:54AM BLOOD Calcium-9.7 Phos-3.6 Mg-2.3 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Budesonide 0.25 mg/2 mL inhalation BID 2. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25 mcg/actuation inhalation DAILY 3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 4. Furosemide 40 mg PO BID 5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing 6. amLODIPine 5 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES QHS 9. Rosuvastatin Calcium 5 mg PO QPM 10. Carvedilol 12.5 mg PO BID 11. Levothyroxine Sodium 75 mcg PO DAILY Discharge Medications: 1. Azithromycin 250 mg PO DAILY Duration: 3 Doses RX *azithromycin 250 mg 1 tablet(s) by mouth Daily Disp #*1 Tablet Refills:*0 2. Ipratropium-Albuterol Neb 1 NEB NEB Q4H RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1 nebulizer inhaled Every 4 horus Disp #*1 Ampule Refills:*0 3. PredniSONE 10 mg PO DAILY Duration: 3 Doses RX *prednisone 10 mg 4 tablet(s) by mouth Daily Disp #*16 Tablet Refills:*0 4. Torsemide 60 mg PO DAILY RX *torsemide 20 mg 3 tablet(s) by mouth Daily Disp #*21 Tablet Refills:*0 5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing 6. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 7. amLODIPine 5 mg PO DAILY 8. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25 mcg/actuation inhalation DAILY 9. Aspirin 81 mg PO DAILY 10. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES QHS 11. Budesonide 0.25 mg/2 mL inhalation BID Start once finish the prednisone 12. CARVedilol 12.5 mg PO BID 13. Levothyroxine Sodium 75 mcg PO DAILY 14. HELD- Furosemide 40 mg PO BID This medication was held. Do not restart Furosemide until you finish the torsemide. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: ---------- Chronic pulmonary obstructive disease exacerbation Diastolic Heart Failure exacerbation Secondary: ---------- Tobacco dependence 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 sob// r/o infection r/o infection IMPRESSION: Compared to chest radiographs ___ most recently one ___. Moderate cardiomegaly is stable. Severe upper mediastinal widening due to generalized aortic ectasia and arterial enlargement has not progressed. Lungs are grossly clear and there is no pleural abnormality. Gender: F Race: OTHER Arrive by AMBULANCE Chief complaint: Dyspnea Diagnosed with Dyspnea, unspecified temperature: 98.9 heartrate: 88.0 resprate: 28.0 o2sat: 100.0 sbp: 131.0 dbp: 70.0 level of pain: 0 level of acuity: 2.0

PATIENT SUMMARY: Ms. ___ is a ___ year old female with COPD, HFpEF (TTE ___, EF>65%, dry weight: 135lbs), mild-moderate AR, mild-moderate TR, thoracic + abd aortic aneurysm with h/o Type A thoracic dissection s/p repair (___), Crohn's disease s/p colostomy + subsequent reversal ___, not on any medications), Bell's palsy w/ R facial droop, HTN, and hypothyroidism who was admitted ___ from ___ clinic for dyspnea x 2 days and ___ edema 2 weeks.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ___ Allergies: Levaquin / Sulfa (Sulfonamide Antibiotics) / Ceftriaxone / Dilaudid / Aspirin Attending: ___. Chief Complaint: presyncope Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo w/ovarian cyst, SLE, prior PE on coumadin presents as transfer from ___ with presyncope. Today pt felt cold and dizzy for several minutes and then nearly lost consciousness. She was helped to the floor. She did not hit her head. She sat for about 30min and felt better until she stood up again. Denies CP, palp, SOB. She has had vaginal bleeding, one pad per day over the past week. One week ago she was admitted to the hospital for a ruptured ovarian cyst. She has not had any chest pain, SOB, palpitations. In ___ pt had US which showed hemoperitoneum, found to have INR of 4.6. BP 95/50. Given 2L ns, 1u FFP, 10mg IV VitK. Seen by OB who recommended transfer to BID for further work up. Upon arrival to BID ___ pt BP improved to 114/70, repeat INR 1.7. Past Medical History: SLE: followed by Dr. ___ at ___. Ovarian cyst PE, on coumadin Social History: ___ Family History: no history of SLE Physical Exam: Admission Exam VS: 97.9 127/83 72 18 100%ra Pain: 0 Gen: nad, lying in bed Heent: mmm Skin: multiple ecchymosis Resp: ctab CV: rrr Abd: nabs, soft, nt/nd Ext: no e/c/c Neuro: alert, follows commands, answering questions approrpriately Discharge Exam: VS: 98.2 ___ 16 96% RA Pain: 0 Gen: NAD, sitting in chair Resp: CTAB CV: RR, nl rate, no r/g/m Abd: soft, nt/nd Ext: No edema Pertinent Results: ___: Transvaginal US Impression: 1. Large amount of hypoechoic somewhat well-organized complex material in the right adnexal area adjacent to a remnant of ovarian tissue medially. Most likely blood clot related to a ruptured/rupture rain ovarian cyst. Echogenic debris is seen around this and dependently in the pelvis consistent with blood. No free fluid is seen in the upper abdomen. MCV: 75.0*, HGB: 11.1 (Delta), WBC: 13.8*, PLT: 297 (Delta), HCT: 35.5 (Delta) ___ URINE PREGNANCY TEST (QUAL): Neg URINALYSIS W/REFLEX MIC CUL, information as of ___, 12:04 pm Color: DK YELLOW Clarity: CLOUDY SpecGr: 1.024 pH: 6.5 Urobil: 0.2 Bili: NEGATIVE Leuk: NEGATIVE Bld: LARGE Nitr: NEGATIVE Prot: TRACE Glu: NEGATIVE Ket: NEGATIVE BID Results: ___ 06:20PM WBC-11.9*# RBC-4.26 HGB-9.9* HCT-31.7* MCV-74* MCH-23.2* MCHC-31.1 RDW-16.5* ___ 06:20PM ___ PTT-58.7* ___ ___ 06:20PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 06:20PM GLUCOSE-83 UREA N-7 CREAT-0.3* SODIUM-139 POTASSIUM-3.6 CHLORIDE-108 TOTAL CO2-23 ANION GAP-12 ___ 06:30AM BLOOD WBC-19.1* RBC-4.44 Hgb-10.5* Hct-33.2* MCV-75* MCH-23.6* MCHC-31.6 RDW-17.0* Plt ___ ___ 03:30PM BLOOD Neuts-89* Bands-2 Lymphs-3* Monos-2 Eos-0 Baso-0 ___ Metas-4* Myelos-0 ___ 06:20PM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG ___ 06:20PM URINE RBC-11* WBC-0 Bacteri-NONE Yeast-NONE Epi-1 Pelvic u/s: Impression: 6.4 cm right ovarian hemorrhagic cyst, with mild complex free fluid suggesting rupture. Arterial and venous waveforms seen in the right ovary, although given enlarged size of the ovary (with hemorrhagic cyst), intermittent torsion can not be excluded. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Warfarin 3 mg PO 2X/WEEK (MO,TH) 2. Warfarin 4 mg PO 5X/WEEK (___) 3. Hydroxychloroquine Sulfate 100 mg PO BID 4. Methylprednisolone 30 mg PO DAILY 5. Calcium Carbonate 500 mg PO BID Discharge Medications: 1. Enoxaparin Sodium 70 mg SC Q12H RX *enoxaparin 80 mg/0.8 mL please take 70 mg twice per day Disp #*20 Syringe Refills:*0 2. Calcium Carbonate 500 mg PO BID 3. Hydroxychloroquine Sulfate 100 mg PO BID 4. Methylprednisolone 30 mg PO DAILY 5. Warfarin 4 mg PO DAILY16 this will need to be adjusted with your ___ clinic. Do not get pregnant while on this medication. 6. Acetaminophen 325-650 mg PO Q4H:PRN Pain Discharge Disposition: Home Discharge Diagnosis: ruptured hemorrhagic ovarian cyst acute blood loss anemia presyncope/hypotension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Coumadin with INR of 4.6, near syncope and known persistently bleeding ovarian cyst. No prior examinations for comparison. LMP: ___. PELVIC ULTRASOUND: Transabdominal and transvaginal images were acquired, the latter for further characterization of the uterus and adnexa. The uterus measures 6.3 x 6 x 2.8 cm. Endometrial stripe measures 3 mm, and there is a small amount of fluid in the endometrial cavity. No detectable endometrial flow. There is a large hemorrhagic cyst within the right ovary measuring 6.4 x 4.6 x 3.3 cm. This has a heterogeneously hypoechoic appearance, with multiple internal reticulations and no internal vascularity. Surrounding right ovarian tissue has normal arterial and venous Doppler waveforms. Left ovary is normal in size, with preserved vascular waveforms. There is mild complex free fluid in the pelvis. IMPRESSION: 6.4 cm right ovarian hemorrhagic cyst, with mild complex free fluid suggesting rupture. Arterial and venous waveforms seen in the right ovary, although given enlarged size of the ovary (with hemorrhagic cyst), intermittent torsion can not be excluded. Gender: F Race: OTHER Arrive by AMBULANCE Chief complaint: SYNCOPE/PRESYNCOPE Diagnosed with OVARIAN CYST NEC/NOS temperature: 97.7 heartrate: 71.0 resprate: 16.0 o2sat: 100.0 sbp: 107.0 dbp: 57.0 level of pain: 3 level of acuity: 2.0

___ with ovarian cyst, SLE, prior PE on warfarin p/w presyncope, hypotension and anemia. She was treated with fluids without further decrease in hematocrit. Her pain improved and her hypotension/presyncope resolved. She was restarted on anticoagulation (lovenox and warfarin) without evidence of further bleed. She was discharged with close follow up. # Ruptured ovarian hemorrhagic cysts: Her hct was trended and was stable. Gynecology consulted and felt there was no need for surgical intervention or need for lupron at this time. She did not require blood transfusion. She was restarted on lovenox and warfarin and monitored for 24 to make sure her hematocrit and hemodynamics were stable. She was discharged with a hematocrit of 33.2. She will have follow up early next week including INR draw and hematocrit. She will follow up with gynecology next week for further assessment of the cyst. # Prior PE: She was admitted with supratherapeutic INR. She was given s/p FFP and vitamin K. Her warfarin was restarted along with a lovenox bridge (she was monitored to make sure she did not have any bleeding prior to discharge. She will have close follow up. # SLE: her home medications were continued. # Leukocytosis: This was thought to be due to a stress response. However, she will need follow up to make sure this, along with the atypical cells in her blood resolve. This was discussed with her PCP. # Hematuria: Likely secondary from vaginal bleeding. Will need follow up to ensure resolution. # Anemia: acute blood loss and Fe deficiency. Will be followed by PCP. # Routine health care: due for pap smear.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Major Surgical or Invasive Procedure: T9 bone biopsy attach Pertinent Results: NOTABLE LABS: ___ 07:14AM BLOOD WBC-6.6 RBC-4.57 Hgb-10.8* Hct-36.0 MCV-79* MCH-23.6* MCHC-30.0* RDW-16.5* RDWSD-47.2* Plt ___ ___ 04:20AM BLOOD Glucose-93 UreaN-10 Creat-0.8 Na-140 K-4.1 Cl-104 HCO3-24 AnGap-12 ___ 07:14AM BLOOD ALT-14 AST-18 AlkPhos-96 TotBili-0.4 ___ 07:14AM BLOOD Albumin-3.3* Calcium-9.4 Phos-3.7 Mg-2.3 IMAGING: MRI Mediastinum IMPRESSION: 1. A slightly heterogenous T2 hyperintense lesion in the pre-vascular mediastinum corresponds to recent CT findings, and shows no evidence of associated contrast enhancement. Findings are suggestive of a benign etiology, likely related to a congenital cyst rather than transformation. 2. Nonocclusive filling defect in the left brachiocephalic vein confluence is concerning for thrombus. 3. Enhancing lesion in likely the T9 vertebral body correlates with a rim sclerotic lesion on recent CT and is concerning for metastatic disease. 4. Partially visualized right breast tissue shows non circumscribed cystic areas with associated ill-defined enhancement. RECOMMENDATION(S): 1. CTV neck is recommended for further evaluation of vascular findings. 2. Clinical correlation and possible biopsy is suggested for enhancing lesion in thoracic vertebral body. 3. Breast followup as planned for further evaluation of right breast findings. CTV Neck IMPRESSION: 1. Thrombus within the left superior intercostal vein with partial extension into the left brachiocephalic vein. 2. Heterogeneous sclerosis of the C2 through C6 vertebrae, which may represent metastatic disease. 3. Periapical lucencies involving several right mandibular and maxillary teeth, which is concerning for periodontal and periapical infection. OTHER DATA: Imaging at ___ ___ Chest: IMPRESSION: 1. No PE. 2. 3.5 cm near water density cystic mass in the left superior mediastinum. Limited differential diagnosis includes patulous pericardial recess, pericardial cyst and cystic neoplasm. CT A/P: IMPRESSION: 1. Slight fullness of the right pelvicalyceal system. No obstructing stone or obvious lesion. Otherwise, no acute intra-abdominal/pelvic pathology identified. 2. Uterine fibroid. Right breast US CONCLUSION: 4.5 x 4.1 x 1.7 cm thin-walled simple benign cyst. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Apixaban 5 mg PO BID Take 2tabs (10mg) for the next 8 doses followed by 1tab (5mg) twice daily RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Superior intercostal vein thrombus Periapical lucencies concern for periodontal disease Discharge Condition: Discharge condition: stable Mental status: ANOX3 Ambulatory Followup Instructions: ___ Radiology Report INDICATION: ___ year old woman with mediastinal mass noted, per ___ would need mediastinal MRI before any procedural planning // assess mediastinal mass TECHNIQUE: Multiplanar multisequence MRI of the mediastinum/lung performed before and after intravenous administration of 9 mL of Gadavist contrast medium. Motion artifact degrades quality of the examination. COMPARISON: Correlated with outside CT examination of ___ FINDINGS: LUNGS: No gross abnormality is identified within the lungs. No evidence of an enhancing pulmonary mass or nodule. There is no evidence of a significant pneumothorax. Trace left pleural effusion is noted. VASCULATURE: The thoracic aorta and pulmonary vessels show normal configuration and contrast an 8 mm filling defect is identified at the left brachiocephalic vein confluence (___), demonstrating STIR hyperintensity. Apparent enhancement within the lesion is questionable, and may be artifactual. HEART AND MEDIASTINUM: The heart is normal in size. There is no pericardial effusion. The recently described cystic lesion in the upper mediastinum correlates with a slightly heterogenous T2 hyperintense 1.9 cm region in the pre-vascular space (3: 13), without evidence of associated enhancement. UPPER ABDOMEN: No gross abnormalities identified. Valuation once markedly limited by motion artifact. OSSEOUS STRUCTURES: 1.6 cm ill-defined T2 hyperintense lesion is identified in the left aspect of likely the T9 vertebral body (8:26), demonstrating enhancement on post-contrast images. There is no evidence of macroscopic fat to suggest a hemangioma. This lesion corresponds to a sclerotic rim lesion on recent CT of ___. No other focus of enhancement is identified in the included osseous structures. SOFT TISSUES: Ill-defined geographic areas of T2 hyperintensity are identified in the partially visualized right breast tissues, demonstrating associated enhancement. Few prominent right axillary lymph nodes are identified, the largest measuring up to 1 cm in short axis. IMPRESSION: 1. Cystic structure in the mediastinum without worrisome features corresponds to recent CT findings, favoring congenital cyst rather than transformation. 2. Nonocclusive filling defect in the left brachiocephalic vein confluence, concerning for thrombus. 3. Enhancing lesion in likely the T9 vertebral body correlates with a rim sclerotic lesion on recent CT, concerning for metastatic disease. 4. Partially visualized right breast tissue shows non circumscribed cystic areas with associated ill-defined enhancement. Further evaluation with dedicated breast imaging is recommended. RECOMMENDATION(S): 1. CTV neck is recommended for further evaluation of vascular findings. 2. Clinical correlation and possible biopsy is suggested for enhancing lesion in thoracic vertebral body. 3. Breast followup as planned for further evaluation of right breast findings. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 12:30 pm, 20 minutes after discovery of the findings. Radiology Report EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK INDICATION: ___ year old woman with unremarkable PMHx who p/w right sided back pain and new breast lesion, found to have cystic lesion in R breast a/w abnormal enhancement, as well as MRI mediastinum showing left brachiocephalic vein confluence concerning for thrombus. CTV for further assessment of thrombus. Note finding in L brachiocephalic vein on MRI. Please go down to aortic arch. // CTV neck for assessment of left brachiocephalic vein thrombus. TECHNIQUE: Imaging was performed after administration of Omnipaque350 intravenous contrast material. MDCT acquired helical axial images were obtained from the thoracic inlet through the skull base. Coronal and sagittal multiplanar reformats were then produced and reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.5 s, 29.2 cm; CTDIvol = 17.2 mGy (Body) DLP = 491.8 mGy-cm. Total DLP (Body) = 492 mGy-cm. COMPARISON: MR ___ ___. Outside reference CT chest ___. FINDINGS: Evaluation of the aerodigestive tract demonstrates no mass and no areas of focal mass effect. The salivary glands enhance normally and are without mass or adjacent fat stranding. The thyroid gland appears normal.There are several prominent lymph nodes within the bilateral submandibular space but no cervical lymphadenopathy by size criteria.The bilateral carotid arteries and internal jugular veins are patent. Of note, the right internal jugular vein is diminutive. Periapical lucencies are seen involving ___ teeth 3, 5, 28, and 30 (3:28, 21, 30, 31). There are small retention cysts in the bilateral maxillary sinuses. There is a well delineated rounded a centrally located filling defect within the left brachiocephalic vein (3:66), which does not appear to extend into the left subclavian vein, left internal jugular vein, or to the superior vena cava. Contrast is seen within the left subclavian vein and refluxing to the left internal jugular vein, however, there is a lack of reflux into the left superior intercostal vein (3:68), suspicious for extension of thrombus. The imaged portion of the lung apices are clear and there are no concerning pulmonary nodules. There is a 1.8 cm nonenhancing rounded low-density structure within the superior mediastinum, anterior to the aortic arch (3:75), better characterized on prior MR. ___ is heterogeneous sclerosis of the C2 through C6 vertebrae, which may represent metastatic disease. No pathological fracture is identified. There are mild multilevel degenerative changes in the cervical spine. IMPRESSION: 1. Thrombus within the left superior intercostal vein with partial extension into the left brachiocephalic vein. 2. Heterogeneous sclerosis of the C2 through C6 vertebrae, which may represent metastatic disease. 3. Periapical lucencies involving several right mandibular and maxillary teeth, which is concerning for periodontal and periapical infection. Radiology Report EXAMINATION: CT-guided spine biopsy INDICATION: ___ year old woman with unremarkable PMHx who presents with right back pain and new right breast lesion, found to have cystic appearing breast lesion with some abnormal enhancement and a T9 lesion which is concerning for metastatic spread. Consult for biopsy of this lesion. // T4 lesion c/f met COMPARISON: CT ___, MRI ___, outside hospital CT ___ PROCEDURE: CT-guided core biopsy of T8 vertebral boy. OPERATORS: Dr. ___, radiology resident and Drs. ___ ___, attending radiologists performed the procedure. Dr. ___ ___ supervised the trainee during the key components of the procedure and reviewed and agrees with the trainee's findings. TECHNIQUE: The risks, benefits, and alternatives of the procedure were explained to the patient. After a detailed discussion, informed written consent was obtained. A pre-procedure timeout using three patient identifiers was performed per ___ protocol. The patient was placed in a supine position on the CT scan table. Limited preprocedure CT scan of the intended biopsy area was performed. There is redemonstration a right peripheral breast lesion (series 2, image 7). Based on the CT findings an appropriate position for the biopsy was chosen. The site was marked. The site was prepped and draped in the usual sterile fashion. 1% lidocaine were administered to the subcutaneous and deep tissues for local anesthetic effect. 5% bupivacaine was administered along the periosteum. Under CT guidance, using an Arrow OnControl bone access system, an 11 gauge access needle was introduced into the lesion. A 13 gauge bone biopsy needle was used to obtain 3 specimens of the left aspect of the vertebral body at the level of T8, through a transpedicular approach. The samples were sent for pathology. A postprocedure spiral CT was obtained, which demonstrated the tract site of the biopsy without evidence of large hematoma, pneumothorax or fracture. The procedure was tolerated well and there were no immediate post-procedural complications. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.0 s, 21.2 cm; CTDIvol = 29.1 mGy (Body) DLP = 624.8 mGy-cm. 2) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 3) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 4) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 5) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 6) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 7) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 8) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 9) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 10) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 11) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 12) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 13) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 14) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 15) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 16) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 17) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 18) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 19) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 20) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 21) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 22) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 23) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 24) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 25) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 26) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 27) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 28) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 29) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 30) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 31) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 32) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 33) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 34) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 35) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 36) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 37) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 38) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 39) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 40) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 41) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 42) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 43) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 44) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 45) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 46) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 47) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 48) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 49) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 50) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 51) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 52) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 53) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 54) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 55) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 56) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 57) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 58) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2 mGy-cm. 59) Spiral Acquisition 3.2 s, 16.7 cm; CTDIvol = 29.1 mGy (Body) DLP = 493.8 mGy-cm. Total DLP (Body) = 1,358 mGy-cm. SEDATION: Moderate sedation was provided by administering divided doses of 3 mg Versed and 150 mcg fentanyl throughout the total intra-service time of 45 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. FINDINGS: 1. Pre and postprocedural CT read demonstrated a sclerotic lesion within the left lateral aspect of the T8 vertebral body. Additionally, there is a soft tissue lesion and general nodularity of the right breast, which is incompletely characterized on this noncontrast CT and would be better evaluated mammographically. IMPRESSION: 1. Successful biopsy of the left sided sclerotic T8 vertebral body lesion. Samples were sent to pathology for review. 2. No immediate complications. 3. Soft tissue mass and nodularity of the right breast, which would be better characterized mammographically. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: R Breast pain, Transfer Diagnosed with Unspecified lump in the right breast, unspecified quadrant temperature: 97.9 heartrate: 96.0 resprate: 20.0 o2sat: 100.0 sbp: 139.0 dbp: 77.0 level of pain: 0 level of acuity: 3.0

SUMMARY: ___ yo healthy, obese female who presented with R breast pain and R stabbing back pain, found to have a cystic breast mass, enhancing sclerotic lesions at C3-C6 and T9 vertebral bodiesm and a left superior intercostal vein thrombus with extension into the L brachiocephalic vein. Findings were overall concerning for underlying malignancy. She underwent an ___ guided T9 spinal bone biopsy.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: BuSpar / amoxicillin / salsalate Attending: ___. Chief Complaint: chest pain Major Surgical or Invasive Procedure: cardiac catheterization with PCI ___ History of Present Illness: Ms. ___ is a ___ year old female with mild aortic stenosis ___ 1.2-1.9), hypertension, hyperlipidemia, GERD, and recent admission for chest pain with negative stress echo, who presents with substernal chest pain. She describes the chest pain as substernal, band-like, with some radiation to her back and teeth. The pain was ___ in severity, similar in character to that from her last admission but worse. The patient at Maalox at home with no relief of symptoms. The pain does not get worse with exertion. She denies shortness of breath and edema. In the ED, initial vitals were 98 70 160/90 16 99% RA. Labs were notable for WBC 11.1, Cr 0.8, trop 0.14 -> 0.29. EKG showed SR, LAD, Q waves in III, aVF, V1-V3 without ST changes. Due to persistent pain, the patient was given ASA 324mg, nitro SL and gtt, and heparin gtt. Her pressures dropped to SBP ___ after the admission of nitro SL. Given her persistent chest pain and rising troponins, the patient was taken directly to the C. Cath lab where 2 DES were placed in her RCA. She was loaded with ticagrelor 180 mg PO once. She tolerated the procedure well and was admitted to the general cardiology service. On the floor, the patient feels well. She has no further chest pain at present. She has no other complaints at present. Of note, the patient was recently admitted to ___ for chest pain from ___ to ___. Due to concern for ACS, she was started on a heparin gtt for 48 hours. TTE showed mild aortic stenosis with EF 65%. An exercise stress echo was done without evidence of inducible ischemia. It was felt her pain was non-cardiac in etiology. On review of systems, the patient complains of phlebitis on her right ankle. She denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, 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 dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: IBS-C GASTROESOPHAGEAL REFLUX HYPERTENSION ELEVATED CHOLESTEROL ASTHMA Aortic stenosis ___ 1.2-1.9cm2) Social History: ___ Family History: no family history of MI, sudden cardiac death Physical Exam: PHYSICAL EXAM: Vitals: T 98.3, BP 140-84, HR 75, RR 16, O2 98%RA General: Pleasant woman in bed in NAD. HEENT: NCAT, MMM, EOMI Neck: JVP not elevated CV: ___ systolic murmur strongest at the LUSB, RRR, normal S1S2 Lungs: CTAB, no crackles or wheezes appreciated Abdomen: soft, nontender, nondistended, +BS Extr: warm and well-perfused, no cyanosis, clubbing, or edema, 2+ DP pulses bilaterally. Swollen superficial vein near right ankle. Neuro: A&Ox3, no gross deficits. Pertinent Results: ADMISSION LABS: ___ 02:30AM WBC-11.1* RBC-5.66* HGB-15.7 HCT-47.3* MCV-84 MCH-27.7 MCHC-33.2 RDW-13.2 RDWSD-39.5 ___ 02:30AM GLUCOSE-96 UREA N-15 CREAT-0.8 SODIUM-136 POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-28 ANION GAP-14 ___ 02:30AM LIPASE-26 ___ 02:30AM cTropnT-0.14* TROPONIN TREND: ___ 02:30AM BLOOD cTropnT-0.14* ___ 08:35AM BLOOD cTropnT-0.29* DISCHARGE LABS: ___ 06:05AM BLOOD WBC-11.1* RBC-5.18 Hgb-14.4 Hct-44.0 MCV-85 MCH-27.8 MCHC-32.7 RDW-13.3 RDWSD-41.0 Plt ___ ___ 06:05AM BLOOD Plt ___ ___ 06:05AM BLOOD Glucose-72 UreaN-13 Creat-0.6 Na-139 K-3.8 Cl-101 HCO3-25 AnGap-17 ___ 06:05AM BLOOD cTropnT-0.17* ___ 06:05AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.5 MICROBIOLOGY: none IMAGING/PROCEDURES: Cardiac cath ___: The ___ had no angiographically apparent CAD. The LAD had mild calcification and luminal irregularities. The Cx and OM had mild luminal irregularities. The RCA was moderately calcified with irregular, hazy and calcific 60-70% stenoses in the mid and distal section. Successful PCI of the RCA with two overlapping stents. Final angiography revealed normal flow, no dissection, 0% residual stenosis. CXR ___: No acute cardiopulmonary process Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. Cetirizine 10 mg PO DAILY 3. Fluticasone Propionate NASAL 1 SPRY NU DAILY 4. linaclotide 290 mcg oral DAILY 5. Omeprazole 20 mg PO BID 6. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID 7. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY Discharge Medications: 1. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 2. Omeprazole 20 mg PO BID 3. Aspirin EC 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 4. Metoprolol Succinate XL 50 mg PO DAILY RX *metoprolol succinate 50 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 5. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID 6. Cetirizine 10 mg PO DAILY 7. Fluticasone Propionate NASAL 1 SPRY NU DAILY 8. linaclotide 290 mcg oral DAILY 9. TiCAGRELOR 90 mg PO BID RX *ticagrelor [BRILINTA] 90 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 10. Lisinopril 2.5 mg PO DAILY RX *lisinopril 2.5 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY: non-ST elevation myocardial infarction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: PA AND LATERAL CHEST RADIOGRAPH INDICATION: History: ___ with CP, concern for NSTEMI // evidence of pneumothorax or pneumonia TECHNIQUE: Chest PA and lateral COMPARISON: None FINDINGS: The cardiomediastinal and hilar contours are within normal limits. The lungs are clear without focal consolidation, pleural effusion or pneumothorax. No pulmonary edema. Linear opacity at the left costophrenic angle corresponds to scarring when correlated with recent chest CT. IMPRESSION: No acute cardiopulmonary process Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Epigastric pain Diagnosed with SUBENDOCARDIAL INFARCTION, INITIAL EPISODE OF CARE temperature: 98.0 heartrate: 70.0 resprate: 16.0 o2sat: 99.0 sbp: 160.0 dbp: 90.0 level of pain: 7 level of acuity: 2.0

___ year old female with mild aortic stenosis ___ 1.2-1.9), hypertension, and GERD who presents with substernal chest pain. Troponins elevated on admission and uptrending. EKG consistent with NSTEMI. # NSTEMI: The patient's troponins in the ED uptrended from 0.14 to 0.29. Serial EKGs on admission showed Q waves in III, AVR, and V1, with T-wave flattening/inversions in V4 and V5, no ST elevations or depressions. The patient's chest pain persisted and she patient did not tolerate SL nitro (blood pressures dropped in ED). The patient was taken to the Cath Lab where they found one-vessel disease and two overlapping DES were placed in her RCA. She was loaded with ticagrelor in the cath lab. The patient tolerated the procedure well and ger chest pain resolved after PCI. After her PCI, that patient had dual-antiplatelet therapy with aspirin and ticagrelor. We increased her home atorvastatin to 80mg. We also started metoprolol tartrate 12.5mg q6h. We avoided further nitros. After her cath, the patient's troponins were 0.17. The patient's post-cath course was uneventful and she was discharged in stable condition on ___. # HTN: chronic. We started metoprolol as above. We held the patient's home Triamterene/HCTZ on admission # GERD: chronic. We continued the patient's home home omeprazole 20mg BID. # HLD: chronic. We increased the patient;s home atorvastatin from 40mg to 80mg as above. # Asthma: chronic - Home Symbicort not on the formulary, giving Advair during this admission. Discharged back on home Symbicort. ***Transitional Issues*** [ ] follow up with your PCP [ ] follow up with your cardiologiest

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: ___ Celiac plexus neurolysis History of Present Illness: ___ with Stage IIB pancreatic adenocarcinoma s/p surgery, chemoXRT, adjuvant SBRT, and gemcitabine, presenting again with acute on chronic abdominal pain. Patient states since his cancer diagnosis, he has chronic LUQ, LLQ, and RLQ pain. He takes oxycodone and oxycontin for this pain. He has had multiple hospitalizations for this pain. On ___, he was found to have intussusception of his small bowel. He was treated conservatively and his symptoms improved. He was again admitted from ___ to ___ for acute on chronic abdominal pain. CT showed no acute findings. Bowel regimen was increased and he was discharged home. Today, he reports epigastric pain and nausea which has progressively worsened last several days. No vomiting or fevers. His last bowel movement was reportedly normal. In the ED, initial vitals were T99.1 59 135/69 18 100RA. Labs were at baseline except for mild transaminitis, normal AP, TB, lipase. CT showed stable appearance of pancreatic head mass and ill-defined soft tissue. No evidence of small-bowel obstruction. Intact jejunal anastomosis. He was given 1L NS, morphine 5mg IV x4, Zofran 4mg IV x3, fluoxetine 10mg. Past Medical History: ============================================== PAST ONCOLOGIC HISTORY ============================================== Mr ___ underwent resection in ___ for stage IIB (pT3, pN1, cM0) 1.5 cm, grade 1 pancreatic ductal adenocarcinoma with LVI and perineural invasion and positive margins 1 of 3 lymph nodes positive s/p central pancreatectomy. Received adjuvant therapy on study ___, a phase 3 study of chemotherapy and chemoradiotherapy with or without hyperacute-pancreas immunotherapy in subjects with resected pancreatic cancer. Randomized to standard of care arm and completed adjuvant therapy in ___. . Surveillance scans in ___ were concerning for local recurrence which was biopsy proven. Mark started chemotherapy for local recurrence ___ with gemcitabine, with plan for ___ cycles. Received adjuvant SBRT to the pancreas in ___. Course complicated by need for dose adjustment due to counts as well as hospitalization for abdominal pain in ___. Resumed chemotherapy ___ to finish planned adjuvant course. - S/p Gemcitabine Cycle 6. ============================================== PAST MEDICAL HISTORY ============================================== --CELIAC PLEXUS NEUROLYSIS ___ --GERD --Chronic back pain --Cholecystecomy with intraoperative cholangiogram (___) --Appendectomy --Tonsillectomy Social History: ___ Family History: adopted, family hx unknown Physical Exam: =================== ADMISSION PHYSICAL: =================== GENERAL: NAD HEENT: NC/AT, EOMI, PERRL, MMM CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4 LUNG: clear to auscultation, no wheezes or rhonchi ABD: +BS, soft, NT/ND, no rebound or guarding EXT: No lower extremity pitting edema PULSES: 2+DP pulses bilaterally NEURO: A&O x 3, CN II-XII intact SKIN: Warm and dry, without rashes =================== DISCHARGE PHYSICAL: =================== VS: 98.4 106/56 57 20 98%RA GENERAL: NAD HEENT: NC/AT, EOMI, PERRL, MMM CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4 LUNG: clear to auscultation, no wheezes or rhonchi ABD: +BS, soft, NT/ND, no rebound or guarding EXT: No lower extremity pitting edema PULSES: 2+DP pulses bilaterally NEURO: A&O x 3, CN II-XII intact SKIN: Warm and dry, without rashes Pertinent Results: ================ ADMISSION LABS: ================ ___ 03:55AM BLOOD WBC-9.1 RBC-3.76* Hgb-11.6* Hct-36.8* MCV-98 MCH-30.9 MCHC-31.5* RDW-15.2 RDWSD-55.1* Plt ___ ___ 03:55AM BLOOD Neuts-72.5* Lymphs-15.7* Monos-6.9 Eos-4.3 Baso-0.3 Im ___ AbsNeut-6.57* AbsLymp-1.43 AbsMono-0.63 AbsEos-0.39 AbsBaso-0.03 ___ 03:55AM BLOOD ___ PTT-30.9 ___ ___ 03:55AM BLOOD Glucose-100 UreaN-12 Creat-0.5 Na-138 K-4.2 Cl-104 HCO3-23 AnGap-15 ___ 03:55AM BLOOD ALT-64* AST-41* AlkPhos-124 TotBili-0.2 ___ 03:55AM BLOOD Lipase-10 ___ 03:55AM BLOOD Albumin-3.6 Calcium-8.5 Phos-4.1 Mg-2.1 ================ DISCHARGE LABS: ================ ___ 04:53AM BLOOD WBC-6.7 RBC-3.66* Hgb-11.4* Hct-35.9* MCV-98 MCH-31.1 MCHC-31.8* RDW-14.9 RDWSD-53.8* Plt ___ ___ 04:53AM BLOOD Plt ___ ___ 04:53AM BLOOD Glucose-99 UreaN-12 Creat-0.5 Na-139 K-4.3 Cl-105 HCO3-27 AnGap-11 ___ 04:53AM BLOOD ALT-91* AST-28 AlkPhos-218* TotBili-0.2 ___ 04:53AM BLOOD Calcium-8.3* Phos-3.9 Mg-2.1 ========= IMAGING: ========= ___ CT ABD/PELVIS: 1. Stable appearance of pancreatic head mass and ill-defined soft tissue. 2. No evidence of small-bowel obstruction. Intact jejunal anastomosis. Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: +PO contrast; History: ___ with diffuse abdominal pain history of pancreatic cancer+PO contrast // eval for sbo, worsening cancer 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: Total DLP (Body) = 600 mGy-cm. COMPARISON: ___ a 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. Hypodensity at the liver dome has not changed since the recent examinations. No other focal hepatic lesions are seen. Minimal intrahepatic biliary ductal dilatation with focal dilatation of the dome is unchanged since the 2 prior examinations. The common bile duct measures approximately 9 mm, which is unchanged since prior examinations. The gallbladder is absent. PANCREAS: The patient is status post central pancreatectomy and pancreaticojejunostomy. The pancreatic tail is atrophic. Again seen is a hypodense lesion in the pancreatic head, not significantly changed since the prior. Ill-defined soft tissue adjacent to the fiducial markers is also unchanged (02:23), and is difficult to measure. 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 is a simple cyst in the upper pole of the right kidney. There is no hydronephrosis or perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. The patient has undergone prior pancreaticojejunostomy. Right upper quadrant anastomosis is intact, with contrast material passing past this region, through the entire small bowel, into the colon. The small bowel is largely unremarkable. A prominent loop of small bowel in the right upper quadrant measures approximately 3.7 cm in diameter, and is nonspecific. A decompressed loop of small bowel is seen in the left lower quadrant (601b:20). The this may be related to peristalsis. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The prostate is enlarged. LYMPH NODES: No definite lymphadenopathy is present. VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic disease is noted. BONES: Degenerative changes are seen throughout the thoracolumbar spine, particularly at L4 and 5. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Stable appearance of pancreatic head mass and ill-defined soft tissue. 2. No evidence of small-bowel obstruction. Intact jejunal anastomosis. Radiology Report INDICATION: ___ year old man with pancreatic cancer and acutely worsening abdominal pain with guarding and rebound evaluate for perforation or obstruction. TECHNIQUE: Supine and upright abdominal radiographs were obtained. COMPARISON: ___ CT of the abdomen and pelvis with contrast. FINDINGS: There are no abnormally dilated loops of large or small bowel. There is no free intraperitoneal air. The clips overlie the right upper quadrant and upper abdomen. There are mild degenerative changes of the lumbar spine. IMPRESSION: No obstruction or pneumoperitoneum. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abd pain, Nausea Diagnosed with Lower abdominal pain, unspecified, Malignant neoplasm of pancreas, unspecified temperature: 99.1 heartrate: 59.0 resprate: nan o2sat: 100.0 sbp: 135.0 dbp: 69.0 level of pain: 8 level of acuity: 2.0

___ with Stage IIB (pT3, pN1, cM0) pancreatic adenocarcinoma s/p central pancreatectomy, pancreaticojejunostomy w/ adjuvant chemoradiation with biopsy confirmed local recurrence in ___ s/p adjuvant CK ___ and 6 cycles of Gemcitabine (last dose ___ c/b recent dx of jejunal intussusception presenting with acute on chronic abdominal pain. =============

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Keflex / Sulfa(Sulfonamide Antibiotics) / Xanax / Prozac / vancomycin / lisinopril Attending: ___. Chief Complaint: CC: ___, flank pain and abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: HPI: Ms. ___ is a ___ female with the past medical history notable for CHF (LVEF 50%), breast cancer in remission since ___ s/p chemotherapy/mastectomy/radiation c/b pulmonary fibrosis and pulmonary hypertension who presented with complaints of 1 day of diarrhea, nausea, flank pain and abdominal pain. Patient reports she has been having symptoms of diarrhea since ___. She was first admitted on ___ and treated for UTI, eosinophilia and thrush with unintentional weight loss. She was recently readmitted from ___ in the setting of nausea, vomiting and diarrhea after another admission on ___ for similar symptoms. On her most recent admission CT scan was negative, MRCP had showed intra and extrahepatic bile duct dilation which was felt due to prior cholecystectomy as EUS and MRCP were reassuring and workup for PBC was negative. She then saw her PCP ___ ___ who had planned to check stool for cultures, ova and parasites, cdiff giardia, strongyloides antibodies, schistosoma antibodies, unfortunately stool studies weren't obtained yet. Patient was found to have H.Pylori IgG Antibody positive and started on pylera (Bismuth/ Metronidazole / Tetracycline with omeprazole for 10 days. She has currently taken 3 days of the pills. On ___ she presented again with 1 day of diarrhea overnight (~5 episodes of watery diarrhea), abdominal pain and bilateral flank pain. She reports chills but denies fevers. Denies any recent travel. Reports unintentional weight loss of ~11 pounds for the past few months. She denies urinary symptoms. She reports diarrhea has improved however she took loperamide on morning prior to coming to the ED. In the ED - Initial vitals: 97.0 74 127/78 18 95% RA - Exam notable for: minimal epigastric tenderness with no rebound or guarding - Labs: + CBC: WBC 8.2 H/H 10.9/33.6 Plt 320 + Chem 10: Na 132 Creat 1.4, HCO3 24 + LFTs: ALT 17 AST 60 Alkphos 109, T bili 0.4 + UA was normal - Imaging: Cxray showed: No evidence of acute pneumonia or vascular congestion - Patient was given: Haldol PO 1.5mg, Erythromycin 250mg and 2L NS. - Transfer vitals: 98.0 57 108/38 18 100% RA On the floor patient reports improvement in symptoms. She reports abdominal cramps but denies overt abdominal tenderness. Rest of history as above. She had half of her dinner and relatively tolerated it well. She denies any recent travel or exposure to sick contacts. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: PAST MEDICAL/SURGICAL HISTORY: - Congestive Heart Failure: unclear etiology thought to be due to Adriamycin vs. ischemic cardiomyopathy - CAD s/p DES placed to RCA in ___ (reports recently being on 1 month of clopidogrel due to a procedure she had, ended ___ - Abnormal lung parenchyma, post-radiation changes and COPD - Cath demonstrated elevated PAsp and elevated PCWP - GERD - Depression - COPD - Hypertension - LUE DVT in ___ s/p 3 month Lovenox - Hx of breast cancer s/p mastectomy/chemo/radiation in remission - Cataract surgery - Hyperlipidemia - Cholecystectomy in ___ - Hysterectomy age ___ - Multiple thyroid nodules - Osteoporosis Social History: ___ Family History: Reviewed and found to be not relevant to this illness/reason for hospitalization. Mother had CHF. Sister who was diagnosed with breast cancer at ___. Physical Exam: Admission EXAM VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx dry without visible lesion, erythema or exudate CV: Heart regular, ___ murmur loudest in ___ RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation in all quadrants, though reports lower quadrant cramps. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs Back: Reports CVA tenderness ___ 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: 98.1 105 / 60 65 18 96 Ra GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx dry without visible lesion, erythema or exudate CV: Heart regular, ___ murmur loudest in ___ RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation in all quadrants. No cramps reported today. 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 Back: No CVA tenderness SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Pertinent Results: Relevant historical labs: ========================== Strongyloides (___) negative IgE ___ High at 4426 Atrius records from ___ - H. Pylori IgG Antibody Positive Imaging: ======== Chest xray showed: No evidence of acute pneumonia or vascular congestion Abdominal xray: ___ IMPRESSION: No evidence of bowel obstruction Discharge labs: =============== ___ 07:35AM BLOOD Glucose-77 UreaN-19 Creat-0.9 Na-144 K-4.7 Cl-105 HCO3-25 AnGap-14 ___ 07:35AM BLOOD Calcium-9.1 Phos-3.3 Mg-2.3 Microbiology: ============= ___ 1:58 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: < 10,000 CFU/mL. ___ 11:00 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: < 10,000 CFU/mL. ___ 8:25 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay.. (Reference Range-Negative). ___ 8:25 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA FOUND. Cryptosporidium/Giardia (DFA) (Final ___: NO CRYPTOSPORIDIUM OR GIARDIA SEEN. ___ 8:19 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. ___ 8:17 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. OVA + PARASITES (Pending): Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of breath 3. LORazepam 0.5 mg PO Q8H:PRN anxiety 4. Metoprolol Succinate XL 12.5 mg PO DAILY 5. Pravastatin 40 mg PO QPM 6. Multivitamins W/minerals 1 TAB PO DAILY 7. Omeprazole 20 mg PO BID 8. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild 9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shorteness of breath 10. Clobetasol Propionate 0.05% Cream 1 Appl TP BID eczema 11. Docusate Sodium 100 mg PO BID:PRN constipation 12. Hydrocortisone Cream 1% 1 Appl TP TID vaginal pruritis 13. ipratropium bromide 0.06 % nasal BID 14. Ondansetron 4 mg PO BID:PRN nausea/vomiting 15. Spironolactone 25 mg PO EVERY OTHER DAY 16. Torsemide 20 mg PO EVERY OTHER DAY 17. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID to all pruritic areas 18. LOPERamide 2 mg PO QID:PRN diarrhea 19. Pylera (bismuth subcit K-metronidz-tcn) ___ mg oral QID Discharge Medications: 1. Simethicone 40-80 mg PO QID:PRN gas pains RX *simethicone 80 mg 1 tablet by mouth four times a day Disp #*60 Tablet Refills:*0 2. Omeprazole 40 mg PO BID RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*3 3. Ondansetron 4 mg PO BID:PRN nausea/vomiting 4. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild 5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shorteness of breath 6. Aspirin 81 mg PO DAILY 7. Clobetasol Propionate 0.05% Cream 1 Appl TP BID eczema 8. Hydrocortisone Cream 1% 1 Appl TP TID vaginal pruritis 9. ipratropium bromide 0.06 % nasal BID 10. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of breath 11. LOPERamide 2 mg PO QID:PRN diarrhea 12. LORazepam 0.5 mg PO Q8H:PRN anxiety 13. Metoprolol Succinate XL 12.5 mg PO DAILY 14. Multivitamins W/minerals 1 TAB PO DAILY 15. Pravastatin 40 mg PO QPM 16. Pylera (bismuth subcit K-metronidz-tcn) ___ mg oral QID 17. Spironolactone 25 mg PO EVERY OTHER DAY 18. Torsemide 20 mg PO EVERY OTHER DAY 19. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID to all pruritic areas Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Intolerance of Fermentable Oligo-, Di-, Mono-saccharides And Polyols H. Pylori ___ 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 low BP, infectious work-up// evaluate for infectious process IMPRESSION: In comparison with the study ___, the cardiomediastinal silhouette is stable. No substantial change in the postoperative appearance of the left upper lung. No evidence of acute pneumonia or vascular congestion. Radiology Report INDICATION: ___ year old woman with diarrhea, abd distension// assess for dilated loops of bowel, any signs of obstruction TECHNIQUE: Abdomen supine COMPARISON: ___ FINDINGS: There are no abnormally dilated loops of large or small bowel. There is no free intraperitoneal air. Osseous structures are unremarkable. The patient is status post cholecystectomy. IMPRESSION: No evidence of bowel obstruction Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Abd pain, N/V Diagnosed with Unspecified abdominal pain temperature: 97.0 heartrate: 74.0 resprate: 18.0 o2sat: 95.0 sbp: 127.0 dbp: 78.0 level of pain: 6 level of acuity: 3.0

___ w/ CAD s/p DES ___, HTN/HLD, dCHF, breast CA s/p mastectomy/chemo/XRT, GERD admitted with diarrhea, nausea, abdominal pain and bloating. Her symptoms have been intermittent for the past 2 months, during which time she has had 3 hospitalizations for this problem. She has also had an 11 lb weight loss over the past 2 months due mainly to decreased PO intake due to nausea. She also had some ___ on admission that resolved with PO intake and hydration; her diuretics were held during this admission. This improved with increasing her omeprazole to 40 mg PO BID. Her diarrhea resolved with one dose of immodium, and she was started on a FODMAP elimination diet. Her case was discussed with gastroenterology, who felt that since she will undergo a repeat EGD in 4 weeks to assess for H. pylori resolution, it would be preferable to assess her colon with a colonoscopy at that time. She was discharged with gastroenterology follow-up.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: L sided weakness Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ right-handed man with PMH significant for a heart murmur for which he takes ASA 81mg who was transferred from ___ for right basal ganglia IPH. As per the pt's wife, the pt was in his usual state of health when he awoke this morning, had breakfast and then went to the bathroom to get cleaned up and start his day. When he returned from the bathroom he was slipping as he walked toward the bed. His wife initially thought he was goofing off, so she told him to go get dressed, but when he went over to the dresser he continued to have difficulty standing and was slipping almost pulling the dresser down on himself. As he turned to try to walk back towards the bed, he told his wife that his left-side felt funny and then he became unable to walk and started crawling towards the bed. His wife called ___ and she noticed that he had a left facial droop and started to slur his words. He was taken by EMS to ___ where a ___ showed a right BG IPH and he was transferred to ___ for further evaluation. At the OSH, BP 183/87. OSH Labs: Chem 142/3.3 ___ Glc 140 Ca 9.5 CBC: 14>13.9/41.7<246 Trop <0.01 He was transferred to ___ for further evaluation. Upon arrival a CODE STROKE was called. NIHSS 8* and he was taken for CT/CTA H/N. BP on arrival 172/88. As per wife, no reported headache, loss of vision, blurred vision, diplopia, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. No bowel or bladder incontinence or retention. As per wife, no 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: heart murmur (unspecified valvular disease) Social History: ___ Family History: Mother: DM. Maternal side: Strokes with old age Physical Exam: ADMISSION EXAM: Vitals: T:98.6 P: 53 R: 14 BP: 172/88 SaO2:99% RA General: Awake, right-gaze preference. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple Pulmonary: Normal work of breathing Cardiac: RRR, warm, well-perfused Abdomen: soft, non-distended Extremities: No ___ edema. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented to self, hospital and date. +Dysarthric speech. Right gaze preference with left-sided neglect. +Inattention requiring repetition and reorientation. -Cranial Nerves: PERRL 3 to 2mm and brisk. EOM full horizontal gaze without nystagmus. Normal saccades. +LNLFF at rest and left droop with activation. Tongue midline -Motor: Normal bulk, tone throughout. Delt Bic Tri IP Quad Ham TA ___ ___ L 5- 4+ ___- 5- 4+ 5- 4+ R 5 5 ___ 5 5 5 5 -Sensory: No deficits to light touch throughout. -DTRs: ___ Pat +crossed adductors b/l L 2 2 3 R 2 2 3 L toe mute, R toe up -Coordination: No dysmetria to FNF on right, no gross ataxia on L FNF, but hard to assess due to LUE weakness -Gait: Deferred ======================== DISCHARGE EXAM: General: Awake, NAD, no gaze preference. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple Pulmonary: Normal work of breathing Cardiac: warm, well-perfused Abdomen: soft, non-distended Extremities: No ___ edema. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented. Language fluent. Dysarthria resolved. -Cranial Nerves: PERRL 3 to 2mm and brisk. EOM full horizontal gaze without nystagmus. Normal saccades. +LNLFF at rest, symmetric activation. Tongue midline -Motor: Normal bulk, tone throughout. Pronator drift LUE Delt Tri WrExtIP IP Quad Ham TA L 5 5- 5 5- 5- 5 5 R 5 5 5 ___ 5 -Sensory: decreased sensation on L compared to R for pinprick, temp, proprioception and vibration -DTRs: L toe mute, R toe up -Coordination: No dysmetria to FNF on right, L side dysmetria improving -Gait: wide based Pertinent Results: ___ 07:00AM BLOOD WBC-6.4 RBC-4.74 Hgb-12.5* Hct-39.6* MCV-84 MCH-26.4 MCHC-31.6* RDW-14.1 RDWSD-43.4 Plt ___ ___ 07:00AM BLOOD Glucose-100 UreaN-12 Creat-1.0 Na-144 K-4.3 Cl-104 HCO3-26 AnGap-14 ___ 05:05PM BLOOD ALT-17 AST-23 LD(LDH)-214 CK(CPK)-178 AlkPhos-95 TotBili-0.2 ___ 12:29AM BLOOD Calcium-9.1 Phos-3.4 Mg-1.7 ___ 05:05PM BLOOD Triglyc-73 HDL-64 CHOL/HD-4.5 LDLcalc-211* ___ 12:38PM BLOOD %HbA1c-5.7 eAG-117 ___ 05:05PM BLOOD TSH-0.93 =============== DIAGNOSTIC STUDIES: CTA ___ ___: 1. Right basal ganglia hemorrhage without mass effect, midline shift or significant surrounding edema. 2. Mild atherosclerotic disease both carotid bifurcations otherwise no significant abnormalities on CT angiography of the ___ and neck. CT ___ ___: Grossly unchanged 3.5 x 2.3 cm right basal ganglia intraparenchymal hematoma with surrounding edema. No evidence of new intracranial hemorrhage. MR ___ w/wo contrast ___: Right basal ganglia hemorrhage is again noted. No other hemorrhage. No acute infarct. No abnormal enhancement post-contrast. Imaging follow-up after resolution advised to exclude an underlying lesion, if clinically indicated. (Not indicated given etiology is hypertensive bleed) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY Discharge Medications: 1. Lisinopril 10 mg PO DAILY 2. HELD- Aspirin 81 mg PO DAILY This medication was held. Do not restart Aspirin until minimum 1 month after stroke. Should be restarted only if physician says it is necessary for treating an existing condition. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Acute hemorrhagic stroke Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CT ANGIOGRAPHY HEAD AND NECK INDICATION: History: ___ with L sided weakness, L hemineglect// R basal ganglia hemorrhage, midline shift, worsening, aneurism? TECHNIQUE: CT of the head was acquired. Following contrast administration and departmental protocol CT angiography of the head and neck was obtained. 3D and curved reformatted images were obtained on the independent workstation. DOSE: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 802.7 mGy-cm. 2) Stationary Acquisition 7.0 s, 0.5 cm; CTDIvol = 76.2 mGy (Head) DLP = 38.1 mGy-cm. 3) Spiral Acquisition 5.0 s, 39.7 cm; CTDIvol = 31.0 mGy (Head) DLP = 1,231.3 mGy-cm. Total DLP (Head) = 2,072 mGy-cm. COMPARISON: None FINDINGS: CT head shows a right basal gangliar intraparenchymal bleed that measures up to 2.1 x 3.6 cm (02:16). There is no shift of normally midline structures. The basal cisterns are patent. CT angiography of the neck shows normal appearance of the carotid and vertebral arteries without stenosis or occlusion or dissection. The distal right vertebral artery ends in posterior inferior cerebellar artery, a normal variation. CT angiography of the head shows normal appearance of the arteries of the anterior and posterior circulation without stenosis or occlusion or aneurysm greater than 3 mm in size. Mild atherosclerotic disease seen at both carotid bifurcations without stenosis. IMPRESSION: 1. Right basal ganglia hemorrhage without mass effect, midline shift or significant surrounding edema. 2. Mild atherosclerotic disease both carotid bifurcations otherwise no significant abnormalities on CT angiography of the head and neck. Radiology Report INDICATION: ___ with weakness// ?pna TECHNIQUE: Single portable view of the chest. COMPARISON: None FINDINGS: Lungs are clear. There is no focal consolidation. There is no effusion or edema. The cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD INDICATION: ___ year old man with hypertension and R BG IPH, eval for interval change and any underlying mass// interval scan and etiology of bleed TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: Prior CT brain done ___ FINDINGS: The right basal ganglia hemorrhage is again noted being T1 iso to hyperintense and T2 hyperintense with marked blooming on the gradient echo with surrounding edema on T2 and FLAIR. The bleed measures approximately 40 x 24 mm in the axial plane on T2 imaging. There is mass effect on the adjacent left lateral ventricle with midline shift by 1-2 mm. No abnormal enhancement postcontrast. No other areas of intracranial hemorrhage. No acute infarct. Partially empty sella. The craniocervical junction appears normal. The intracranial arteries demonstrate normal T2 flow voids. Mild mucosal thickening involving the paranasal sinuses. The orbits appear normal. IMPRESSION: Right basal ganglia hemorrhage is again noted. No other hemorrhage. No acute infarct. No abnormal enhancement postcontrast. Imaging follow-up after resolution advised to exclude an underlying lesion, if clinically indicated. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD. INDICATION: ___ year old man with R BG IPH// Repeat in 24hrs. 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: CTA head and neck dated ___. FINDINGS: Again seen is a 3.5 x 2.3 cm intraparenchymal hematoma in the right basal ganglia with surrounding edema, grossly unchanged compared to ___ given technique differences. No significant midline shift. There is no evidence ofnew hemorrhage,edema,or mass. Mild effacement of the right lateral ventricle is unchanged. The sulci are mildly effaced. There is no evidence of fracture. There is mild mucosal thickening of the right maxillary sinus. The remaining paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: Grossly unchanged 3.5 x 2.3 cm right basal ganglia intraparenchymal hematoma with surrounding edema. No evidence of new intracranial hemorrhage. Gender: M Race: OTHER Arrive by AMBULANCE Chief complaint: L Weakness, Transfer Diagnosed with Cerebral infarction, unspecified temperature: 98.6 heartrate: 60.0 resprate: 18.0 o2sat: 99.0 sbp: 148.0 dbp: 82.0 level of pain: 0 level of acuity: 2.0

Mr. ___ is a ___ right-handed man with PMH significant for a heart murmur (unspecified valvular disease) who was transferred from ___ for right basal ganglia IPH. Etiology likely hypertensive. Patient was briefly on nicardipine drip ~5 hours. SBPs was kept within goal 150mg with PRN antihypertensives. Patient started on lisinopril with blood pressures sustained systolics 100-150mmHg. MRI was obtained 24 hours after initial presentation and showed stable bleeding. No additional intracranial anomalies, signs of vessel abnormalities, or concerns for cerebral amyloid. ___ evaluated patient and recommended ___ rehabilitation. Patient passed bedside dysphagia screen and tolerated regular diet. ================================== AHA/ASA Core Measures for Intracerebral Hemorrhage 1. Dysphagia screening before any PO intake? (x) Yes - () No 2. DVT Prophylaxis administered? (x) Yes - () No 3. Smoking cessation counseling given? () Yes - (x) No [reason (x) ___ - () unable to participate] 4. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 5. Assessment for rehabilitation and/or rehab services considered? (x) Yes - () No ====================================

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: s/p fall Major Surgical or Invasive Procedure: None History of Present Illness: ___ w/ h/o stroke on aggrenox who is s/p fall from standing around 9:30 pm and transferred from OSH w/ CT findings of L parietal skull fracture, epidural hematoma, and SAH. He stated he slipped on ice on the sidewalk and had likely +LOC. He had friends who witnessed the fall and stated he hit the back of his head. He was alert and oriented at the scene and responding to questions appropriately. He was brought to OSH, where CT Head showed L parietal bone fracture and a 1.8 x 6 cm epidural hematoma, as well as frontal contusions and SAH. He was transferred to ___, hemodynamically stable. He is complaining of a mild headache as well as nausea, and he has had a few episodes of emesis. Past Medical History: DM2, s/p CVA, HTN, hyperlipidemia, thyroid nodule, erectile dysfunction PSH: none Social History: ___ Family History: NC Physical Exam: Upon admission: Gen: NAD, A&Ox3 CV: RRR Pulm: CTAB Neuro: CN: II: Pupils equally round and reactive to light III, IV, VI: EOMI V, VII: facial strength/sensation intact symmetric VIII: intact to voice IX, X: Palatal elevation symmetrical XI: intact ___ strength XII: Tongue midline Motor: Normal bulk and tone bilaterally. Strength full power ___ throughout. Sensation: Intact to light touch throughout Upon discharge: Awake, alert, oriented x3, MAE full. Pertinent Results: ___ EKG Sinus tachycardia. Late R wave progression. Minor lateral precordial ST segment depression. No previous tracing available for comparison. Clinical correlation is suggested. ___ CXR Left basilar opacity, which may represent atelectasis, aspiration or pneumonia. A dedicated PA and lateral view of the chest would be helpful for further evaluation. ___ CT head 1. Known left epidural hematoma appears slightly larger than on the prior examination. There is no evidence of midline shifting of the normally midline structures. 2. Small foci of bilateral subarachnoid hemorrhage, small left subdural hemorrhage, and right inferior frontal contusions are stable. ___ CT head 1. No appreciable change in left epidural hematoma and other small subdural and subarachnoid hemorrhages. 2. Tiny amount of hemorrhage layering dependently in the occipital horns is more conspicuous. 3. Left subgaleal hemorrhage is improving. ___ CT head: 1. No appreciable change in left epidural and small left subdural hematomas. 2. No significant change in small intraventricular hemorrhage. 3. Small bilateral subarachnoid hemorrhages are less conspicuous. ___ 06:52AM BLOOD WBC-13.8* RBC-5.14 Hgb-16.2 Hct-47.3 MCV-92 MCH-31.6 MCHC-34.3 RDW-13.4 Plt ___ ___ 04:50AM BLOOD WBC-15.4* RBC-4.86 Hgb-15.0 Hct-44.9 MCV-92 MCH-31.0 MCHC-33.5 RDW-13.9 Plt ___ ___ 04:24AM BLOOD WBC-16.1* RBC-4.84 Hgb-15.1 Hct-46.1 MCV-95 MCH-31.2 MCHC-32.8 RDW-13.5 Plt ___ ___ 07:26AM BLOOD WBC-17.7* RBC-4.87 Hgb-15.1 Hct-44.8 MCV-92 MCH-31.0 MCHC-33.7 RDW-14.0 Plt ___ ___ 01:33AM BLOOD WBC-19.4*# RBC-5.32 Hgb-16.3 Hct-48.6 MCV-91 MCH-30.6 MCHC-33.5 RDW-14.2 Plt ___ ___ 01:33AM BLOOD Neuts-85.1* Lymphs-8.9* Monos-5.0 Eos-0.7 Baso-0.5 ___ 06:52AM BLOOD ___ PTT-28.8 ___ ___ 01:33AM BLOOD ___ PTT-28.9 ___ ___ 06:52AM BLOOD Glucose-53* UreaN-21* Creat-1.0 Na-136 K-4.0 Cl-97 HCO3-29 AnGap-14 ___ 04:50AM BLOOD Glucose-175* UreaN-19 Creat-0.9 Na-138 K-4.4 Cl-100 HCO3-28 AnGap-14 ___ 04:24AM BLOOD Glucose-70 UreaN-16 Creat-0.9 Na-141 K-4.0 Cl-105 HCO3-23 AnGap-17 ___ 05:28PM BLOOD Glucose-167* UreaN-16 Creat-1.0 Na-140 K-4.1 Cl-102 HCO3-27 AnGap-15 ___ 07:26AM BLOOD Glucose-452* UreaN-19 Creat-1.2 Na-132* K-4.9 Cl-96 HCO3-24 AnGap-17 ___ 01:33AM BLOOD Glucose-251* UreaN-19 Creat-1.1 Na-137 K-4.1 Cl-100 HCO3-25 AnGap-16 ___ 06:52AM BLOOD Calcium-9.3 Phos-3.9 Mg-2.2 ___ 04:50AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.2 ___ 04:24AM BLOOD Calcium-8.1* Phos-3.3 Mg-2.0 ___ 05:28PM BLOOD Calcium-8.7 Phos-3.4 Mg-1.9 ___ 07:26AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.6 Medications on Admission: aggrenox ___ BID, atorvastatin 80mg daily, lantus 30u qAM 8u qpm, humalong SSI, irbesartan 300mg daily, metoprolol 100 BID, nifedipine ER 60mg daily, tadalafil 20mg q72h prn Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN headache 2. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills:*0 3. LeVETiracetam 1000 mg PO BID RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 4. Metoprolol Tartrate 100 mg PO BID 5. NIFEdipine CR 60 mg PO DAILY 6. Glargine 30 Units Breakfast Glargine 8 Units Bedtime 7. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills:*0 8. Outpatient Physical Therapy Dx: ___ s/p fall with epidural hematoma and skull fx Discharge Disposition: Home Discharge Diagnosis: Frontal Contusion Epidural Hematoma SAH L parietal skull fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Needs some intermittent supervision for medications and cooking. Followup Instructions: ___ Radiology Report INDICATION: ___ with fall, EDH, skull fx, oxygen requirement // ? pneumonia TECHNIQUE: AP upright view of the chest. COMPARISON: Chest radiograph ___, chest CT ___. FINDINGS: The cardiomediastinal and hilar contours are normal. There is no pneumothorax or large pleural effusion. Elevation of the right hemidiaphragm is again seen, with right basilar atelectasis. Heterogeneous left basilar opacities are noted, which may are present atelectasis, aspiration, or infectious process. Evidence of right rotator cuff repair is noted. The upper abdomen is unremarkable. IMPRESSION: Left basilar opacity, which may represent atelectasis, aspiration or pneumonia. A dedicated PA and lateral view of the chest would be helpful for further evaluation. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 10:14 AM. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old man s/p fall w/ L parietal skull fx epidural/subarachnoid hematoma, on aggrenox at home // eval progression of epidural hematoma / SAH. TECHNIQUE: Contiguous axial images images of the brain were obtained without contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed images were obtained. CTDIvol: 54.90 mGy DLP: 1003.42 mGy-cm COMPARISON: Outside hospital head CT ___. FINDINGS: A left frontoparietal epidural hematoma appears slightly larger in size compared to the prior exam allowing for differences in technique. This hematoma now has a maximum at 18 mm from the inner table. There is local mass effect, but no midline shift. Multiple small foci of subarachnoid hemorrhage in the left frontal and parietal lobes are similar compared to the prior exam. A small left subdural hematoma is similar, with maximum depth of 4 mm from the inner table (series 2, image 21). Right parietal subarachnoid hemorrhage is also now seen. Right frontal intraparenchymal hyperdensities, consistent with contusion, are slightly more conspicuous than on the prior examination. Ventricles and sulci are stable in size and configuration. Right frontal lobe encephalomalacia is stable compared to the prior exam. The basal cisterns are patent, and there is preservation gray-white matter differentiation. A nondisplaced left parietal bone fracture is present. No other fractures are visualized. The mastoid air cells and middle ear cavities are clear. Partial opacification of the right sphenoid sinus is noted, as well as patchy opacification of right ethmoid air cells. The visualized portions of the maxillary sinuses are clear. A left parietal subgaleal hematoma is similar to prior. The globes are unremarkable. IMPRESSION: 1. Known left epidural hematoma appears slightly larger than on the prior examination. There is no evidence of midline shifting of the normally midline structures. 2. Small foci of bilateral subarachnoid hemorrhage, small left subdural hemorrhage, and right inferior frontal contusions are stable. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ? enlargement epudral hematoma ___ year old man with Left parietal skull Fx and epidural hematoma // ? enlargement epudral hematoma TECHNIQUE: Contiguous axial images images of the brain were obtained without contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed images were obtained. DOSE CTDIvol: 533 mGy DLP: 1003 mGy-cm COMPARISON: CT head ___ at 04:15 and outside CT of the head ___. FINDINGS: Allowing for differences in slice selection and measurement technique left frontoparietal epidural hemorrhage is unchanged maximally measuring up to 18 mm (02:25). As on the prior study there is local mass effect but no shift of midline structures. Overlying subgaleal hemorrhage is smaller. Small left frontal subdural hematoma is unchanged. Tiny amount of hemorrhage layering the occipital horns is minimally more conspicuous. Multiple small subarachnoid hemorrhages bilaterally are unchanged. Small right frontal hemorrhagic contusions are re- demonstrated. Size and configuration of the lateral ventricles is unchanged. The basal cisterns are patent. Right frontal encephalomalacia is re- demonstrated. As before there is a nondisplaced left calvarial fracture involving the frontal and parietal skull. There is persistent mucosal thickening of the ethmoidal air cells. There is partial opacification of the right sphenoid sinus with aerosolized secretions as before. The mastoid air cells and middle ear cavities are clear. IMPRESSION: 1. No appreciable change in left epidural hematoma and other small subdural and subarachnoid hemorrhages. 2. Tiny amount of hemorrhage layering dependently in the occipital horns is more conspicuous. 3. Left subgaleal hemorrhage is improving. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: Last CT ___ pleae evaluate for evolution ___ year old man with epidural hematoma // Last CT ___ pleae evaluate for evolution TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed images were obtained. CTDIvol: 55.33 mGy DLP: 1003.42 mGy-cm COMPARISON: Head CT ___, FINDINGS: Multiple foci of intracranial hemorrhage are present. The largest of these is a left frontoparietal epidural hematoma measuring 5.5 x 1.7 cm, with local mass effect. This hemorrhage is not significantly changed in size since the prior examination. A small amount of left subdural frontal hemorrhage is also unchanged. Several small right inferior frontal hemorrhagic contusions appear similar to prior examination. Several foci of subarachnoid hemorrhage bilaterally are less conspicuous on the prior examination. A small amount of hemorrhage layering in the occipital horns of the lateral ventricles bilaterally is stable to slightly increased compared to the prior exam. The ventricles are stable in size and configuration since the prior examination. The basal cisterns remain patent. An area of right frontal encephalomalacia is redemonstrated. There is no fracture. Bubbly secretions in the right sphenoid sinus are noted. Patchy opacification bilateral ethmoid air cells is also present. The remainder of the paranasal sinuses, as well as the mastoid air cells and middle ear cavities, are clear. Carotid siphon calcifications are again noted. IMPRESSION: 1. No appreciable change in left epidural and small left subdural hematomas. 2. No significant change in small intraventricular hemorrhage. 3. Small bilateral subarachnoid hemorrhages are less conspicuous. Gender: M Race: WHITE Arrive by HELICOPTER Chief complaint: ICH Diagnosed with CL SKL FX NEC/MENING HEM, UNSPECIFIED FALL temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: 1.0

On ___ Mr. ___ was admitted to the neurosurgical service after sustaining a fall resulting in EDH, SAH, L parietal bone fracture. He was admitted to the ICU. He recieved 1 pack plt for hx of aggrenox. He was neurologically intact. On ___ Patient underwent repeat head CT which was stable. He remained in the ICU. Later in the day he reported increasing nausea, vomiting and headache. A Stat CT head was obtained which revealed stable hematoma. On ___ His neurological exam was stable. His blood pressure goal was liberalized SBP <160. Increased metoprolol to home dosing. Transfer orders were written to floor On ___ Patient was neurologically stable. He was awaiting transfer to the floor. He was evaluated by ___ who recommened ___ more visits prior to making final recommendations. Mr. ___ was evaluated by ___ and OT on ___. Both services felt that he would need at least one additional session with them before he was safely discharged home. Based on their evaluation, the patient had imbalance issues and slight difficulty, e.g. slowing, in performing certain mental tasks. The patient was re-evaluated by ___ and OT on ___ and discharged home with outpatient ___.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: codeine / Banana / Gleevec Attending: ___ Chief Complaint: Fever Major Surgical or Invasive Procedure: ___: L4-L5 maximal access surgery with posterior lumbar interbody fusion History of Present Illness: Mr. ___ is a ___ male with history of CML on ___ presented to ___ ED with primary complaint of fever. He is s/p max access posterior lumbar interbody fusion with Dr. ___ on ___ and was discharge home on ___. He represents with fever to 100.6 at home in addition to chills, sweats and cough. CXR obtained in ED with possible pneumonia. Past Medical History: Seizures (induced by gleevec) Reflux CML (dx ___ yrs ago) Social History: ___ Family History: Father with leukemia in ___ although unclear what type. Physical Exam: Exam at discharge: Afebrile Vital signs stable No apparent distress Heart rate regular Respirations non-labored Abdomen soft, non-tender, non-distended Back incision clean, dry, intact Motor ___ throughout Sensation intact to light touch throughout Pertinent Results: ___ 06:48AM BLOOD WBC-7.6 RBC-3.21* Hgb-10.3* Hct-30.9* MCV-96 MCH-32.1* MCHC-33.3 RDW-13.9 RDWSD-49.4* Plt ___ Medications on Admission: ___ Discharge Medications: 1. Diazepam ___ mg PO Q6H:PRN muscle spasm 2. Docusate Sodium 100 mg PO BID 3. Gabapentin 300 mg PO TID 4. Acetaminophen 1000 mg PO Q8H:PRN pain 5. Levofloxacin 750 mg PO Q24H Duration: 4 Doses RX *levofloxacin 750 mg 1 tablet(s) by mouth Daily Disp #*4 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Pneumonia Lumbar spondylolisthesis Discharge Condition: Stable Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ with CML, s/p L4/L5 fusion this week, p/w fever; pursuing infectious work-up. Please eval for PNA. TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph of ___ and ___. FINDINGS: Compared with the prior studies, new bibasilar opacities, left greater than right, are concerning for developing infection given the clinical history. The cardiomediastinal silhouette is within normal limits. No large focal consolidation, pleural effusion, or pneumothorax. IMPRESSION: New bibasilar opacities, left greater than right, are concerning for developing pneumonia, given the patient's clinical history. NOTIFICATION: The above findings were communicated via telephone by Dr. ___ to Dr. ___ at 10:35 pm on ___, at the time of his call. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Fever Diagnosed with Fever, unspecified temperature: 99.1 heartrate: 70.0 resprate: 16.0 o2sat: 96.0 sbp: 111.0 dbp: 60.0 level of pain: 10 level of acuity: 2.0

Mr. ___ is a ___ male with history of CML on Dastinib who underwent L4-L5 MAS PLIF with Dr. ___ on ___ and discharged home on ___. He presented to the ___ ED on ___ with primary complaint of fever at home to 100.6 in addition to sweats and chills. Labs were notable for WBC of 13.2. Chest XRAY could not rule out pneumonia and so the patient was admitted for treatment. The patient was evaluated by the Medicine service on ___ who recommended treatment with a five day course of Levaquin. The patient received his first dose of Levaquin on ___ and was discharged with a prescription for the remainder of the course. ___ had down-trended to 7.6 on ___. Per the patient's Oncologist, Dr. ___ was being held for one week before and after surgery. The patient was therefore instructed to restart ___ on ___. At the time of discharge on ___, the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient will follow up with Dr. ___ routine. The patient expressed readiness for discharge.