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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 distention Major Surgical or Invasive Procedure: ___ PROCEDURES: 1. Exploratory laparotomy. 2. Bilateral rectus abdominis component-separation repair of abdominal wall defect. 3. Small-bowel resection with primary anastomosis x1. 4. A 10 x 14 inch polypropylene mesh onlay performed in the manner of STOPPA. History of Present Illness: ___ M s/p exploratory laparotomy, small bowel decompression, rectosigmoid colectomy, appendectomy, colorectal anastomosis for obstructing colon adenocarcinoma (pT3N2b, stage IIIc) in ___ who presents to the ED with symptoms of bloating, abdominal pain and distention x6 days. He was seen by his PCP today who ordered a KUB demonstrating dilated loops of bowel and presented to the ED at his PCP's request for a CT scan given concern for a small bowel obstruction. He reports ___ pain currently which has been up to a ___, continued bloating and gas pains. No nausea, no emesis. He is tolerating PO, although his appetite is decreased and he is passing flatus and having bowel movements. Last BM this AM. Past Medical History: Past Medical History: Colon Cancer-pT3N2b, stage IIIc S/P resection, chemo x2 and cyberknife treatment (Met found in ___ in aortal caval LN). Last CT showed no evidence of recurrence in ___ of ___. HTN, HLD Past Surgical History: ___- exploratory laparotomy, small bowel decompression, rectosigmoid colectomy, on-table colonic lavage, appendectomy, colorectal anastomosis, and rigid sigmoidoscopy Repair of left inguinal hernia ___ Port-a-cath placement ___, removal ___ and replacement ___ Knee surgery as a teen Social History: ___ Family History: Father- prostate CA, DM, Heart Disease, Mother ___ CA & Kidney CA Physical Exam: ON ADMISSION ___: Vitals: T 97.9 HR 65 BP 144/100 RR 16 100% RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR PULM: Clear to auscultation b/l ABD: Soft, distended, nontender, no rebound or guarding, normoactive bowel sounds, large midline hernia- partially reducible EXT: No ___ edema, ___ warm and well perfused ON DISCHARGE ___: VS: T 98.4, HR 81, BP 136/71, RR 18, SaO2 99% RA Pertinent Results: CBC: ___ 03:15PM BLOOD WBC-8.6 RBC-4.90 Hgb-15.1 Hct-45.2 MCV-92 MCH-30.9 MCHC-33.5 RDW-13.4 Plt ___ ___ 10:00PM BLOOD WBC-9.0 RBC-4.48* Hgb-14.0 Hct-40.5 MCV-90 MCH-31.2 MCHC-34.6 RDW-14.3 Plt ___ ___ 10:10PM BLOOD WBC-9.3 RBC-4.44* Hgb-13.7* Hct-40.4 MCV-91 MCH-30.8 MCHC-33.9 RDW-13.7 Plt ___ ___ 08:00AM BLOOD WBC-11.4* RBC-4.15* Hgb-13.0* Hct-37.7* MCV-91 MCH-31.4 MCHC-34.5 RDW-13.6 Plt ___ ___ 03:31AM BLOOD WBC-10.6 RBC-3.55* Hgb-11.1* Hct-32.7* MCV-92 MCH-31.3 MCHC-34.0 RDW-13.8 Plt ___ ___ 05:17AM BLOOD WBC-12.1* RBC-3.80* Hgb-11.8* Hct-35.9* MCV-94 MCH-31.1 MCHC-33.0 RDW-13.7 Plt ___ ___ 01:26PM BLOOD WBC-7.2 RBC-3.44* Hgb-10.7* Hct-31.6* MCV-92 MCH-31.3 MCHC-34.0 RDW-13.8 Plt ___ ___ 04:59AM BLOOD WBC-8.8 RBC-3.57* Hgb-11.0* Hct-32.3* MCV-90 MCH-30.7 MCHC-34.0 RDW-13.9 Plt ___ ___ 07:49AM BLOOD WBC-10.4 RBC-3.70* Hgb-11.6* Hct-34.4* MCV-93 MCH-31.3 MCHC-33.7 RDW-14.1 Plt ___ ___ 07:03AM BLOOD WBC-9.8 RBC-3.70* Hgb-11.5* Hct-34.0* MCV-92 MCH-31.2 MCHC-33.9 RDW-13.8 Plt ___ ___ 07:56AM BLOOD WBC-8.8 RBC-3.89* Hgb-11.9* Hct-35.9* MCV-92 MCH-30.5 MCHC-33.0 RDW-13.8 Plt ___ CHEMISTRY: ___ 03:15PM BLOOD UreaN-12 Creat-1.1 ___ 10:00PM BLOOD Glucose-98 UreaN-14 Creat-1.0 Na-140 K-3.7 Cl-104 HCO3-27 AnGap-13 ___ 10:00PM BLOOD Albumin-4.4 ___ 10:10PM BLOOD Glucose-155* UreaN-12 Creat-1.1 Na-140 K-4.6 Cl-107 HCO3-25 AnGap-13 ___ 10:10PM BLOOD Calcium-6.9* Phos-4.3 Mg-1.3* ___ 08:00AM BLOOD Glucose-161* UreaN-16 Creat-1.2 Na-139 K-4.2 Cl-104 HCO3-27 AnGap-12 ___ 08:00AM BLOOD Calcium-8.6 Phos-4.5 Mg-2.5 ___ 03:31AM BLOOD Glucose-109* UreaN-20 Creat-1.1 Na-139 K-4.1 Cl-106 HCO3-27 AnGap-10 ___ 05:17AM BLOOD Glucose-112* UreaN-15 Creat-0.8 Na-137 K-4.2 Cl-102 HCO3-28 AnGap-11 ___ 05:17AM BLOOD Calcium-8.3* Phos-2.3*# Mg-2.1 ___ 01:26PM BLOOD Glucose-105* UreaN-9 Creat-0.7 Na-142 K-3.4 Cl-102 HCO3-26 AnGap-17 ___ 01:26PM BLOOD Calcium-8.2* Phos-2.0* Mg-1.9 ___ 12:08PM BLOOD Glucose-116* UreaN-7 Creat-0.6 Na-139 K-3.5 Cl-100 HCO3-28 AnGap-15 ___ 12:08PM BLOOD Calcium-8.3* Phos-2.5* Mg-1.9 ___ 04:59AM BLOOD Glucose-115* UreaN-6 Creat-0.6 Na-141 K-3.2* Cl-99 HCO3-28 AnGap-17 ___ 04:59AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.0 ___ 07:49AM BLOOD Glucose-116* UreaN-6 Creat-0.8 Na-143 K-4.3 Cl-99 HCO3-30 AnGap-18 ___ 07:49AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.2 ___ 07:03AM BLOOD Glucose-120* UreaN-6 Creat-0.7 Na-141 K-4.2 Cl-101 HCO3-30 AnGap-14 ___ 07:03AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.1 ___ 07:56AM BLOOD Glucose-112* UreaN-6 Creat-0.7 Na-142 K-4.3 Cl-101 HCO3-28 AnGap-17 ___ 07:56AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.2 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 25 mg PO DAILY 2. Valcyte (valGANciclovir) 500 mg oral DAILY Discharge Medications: 1. Atenolol 25 mg PO DAILY 2. Valcyte (valGANciclovir) 500 mg oral DAILY 3. Senna 8.6 mg PO DAILY RX *sennosides [senna] 8.6 mg 1 tablet by mouth at bedtime Disp #*60 Tablet Refills:*1 4. Polyethylene Glycol 17 g PO DAILY:PRN constipation RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 dose by mouth DAILY Refills:*1 5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain Do not drink or drive while taking narcotics. RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills:*0 6. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 7. Cephalexin 500 mg PO Q6H Duration: 4 Doses Take for 1 more day - 1 tab every 6 hours RX *cephalexin 500 mg 1 tablet(s) by mouth every six (6) hours Disp #*4 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Large ventral hernias Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Postoperative day 6 status post complex ventral hernia repair with mesh and small bowel resection. Patient now presenting with ileus. Evaluate for source of ileus, intra-abdominal fluid collection or obstruction. TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis after the uneventful administration of 130 ml of Omnipaque. Coronal and sagittal reformations were provided and reviewed. Gastrografin as oral contrast anterior abdomen. Cutaneous laparotomy staples are noted. A small fluid collection beneath the incision measuring 3.1 x 2.3 cm is likely a postoperative seroma. Administered. DOSE: DLP: 1073.52 mGy-cm COMPARISON: CT abdomen and pelvis ___. FINDINGS: Oral contrast has progressed to the proximal jejunum. Dilated loops of small bowel range in size up to the 4.6 cm. There is a transition in small bowel caliber seen in the left lower quadrant (602b:65). The distal loops of small bowel are decompressed. A small amount of contrast is seen in the colon from prior CT examination. Findings are consistent with a small bowel obstruction. This is thought to be from an adhesion given the adjacent narrowing and angulation without obstruction seen on the nearby and proximal jejunum (2:63). There is a trace amount of mesenteric edema, presumably from recent surgery. There is no bowel wall edema. There is no extraluminal contrast. The imaged lung bases show bibasilar atelectasis. There is no pleural effusion. The included portion of the heart is normal in size and there is no pericardial effusion. A small focus of air seen in the anterior abdomen is probably within the rectus sheath (02:58). There is no definite free air. 2 subcutaneous drains terminate in the subcutaneous fat of the anterior abdominal wall. The liver enhances homogeneously without focal lesions. The gallbladder is normal and there is no intra or extrahepatic biliary ductal dilation. The spleen, pancreas and adrenal glands are unremarkable. The kidneys enhance symmetrically and excrete contrast without hydronephrosis. The aorta is normal caliber. The portal vein, splenic vein and superior mesenteric vein are patent. The bladder, prostate and rectum are normal. There is no pelvic or inguinal sidewall lymphadenopathy. There are no lytic or blastic osseous lesions. IMPRESSION: 1. Complete obstruction with transition in the left lower quadrant. Given the adjacent narrowing and angulation without obstruction on the nearby the jejunum, this is felt to be secondary to an adhesion. No bowel wall edema or intra-abdominal free air. 2. Bilateral subcutaneous drains are well positioned. NOTIFICATION: The findings were discussed by Dr. ___ with ___ via telephone on ___ at 2:04 ___, 15 minutes after discovery of the findings. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abd pain, Abdominal distention Diagnosed with INTESTINAL OBSTRUCT NOS, HX OF COLONIC MALIGNANCY temperature: 98.6 heartrate: 80.0 resprate: 18.0 o2sat: 95.0 sbp: 143.0 dbp: 98.0 level of pain: 1 level of acuity: 3.0

Dear Mr. ___, It was a pleasure taking care of you here at ___ ___. You were admitted to our hospital after undergoing repair of your ventral hernia. You have recovered from surgery and are now ready to be discharged to home with services. Please follow the recommendations below to ensure a speedy and uneventful recovery. ACTIVITY: - Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. - You may climb stairs. - You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. - Don't lift more than 10 lbs for 6 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. - You may start some light exercise when you feel comfortable. - Heavy exercise may be started after 6 weeks, but use common sense and go slowly at first. - You may resume sexual activity unless your doctor has told you otherwise. HOW YOU MAY FEEL: - You may feel weak or "washed out" for 6 weeks. You might want to nap often. Simple tasks may exhaust you. - You may have a sore throat because of a tube that was in your throat during surgery. - You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. - You could have a poor appetite for a while. Food may seem unappealing. - All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your surgeon. YOUR INCISION: - Your incision may be slightly red around the edges. This is normal. - If you have steri strips, do not remove them for 2 weeks. (These are the thin paper strips that are on your incision.) But if they fall off before that that's okay). - You may gently wash away dried material around your incision. - It is normal to feel a firm ridge along the incision. This will go away. - Avoid direct sun exposure to the incision area. - Do not use any ointments on the incision unless you were told otherwise. - You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your surgeon. - You may shower, but do not bathe you are seen in clinic for follow-up. YOUR BOWELS: - Constipation is a common side effect of medicine such as Percocet or codeine. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. - If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. - After some operations, diarrhea can occur. If you get diarrhea, don't take anti-diarrhea medicines. Drink plenty of fluitds and see if it goes away. If it does not go away, or is severe and you feel ill, please call your surgeon. PAIN MANAGEMENT: - It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". - Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. -You will receive a prescription from your surgeon for pain medicine to take by mouth. It is important to take this medicine as directied. - Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. - Your pain medicine will work better if you take it before your pain gets too severe. - Talk with your surgeon about how long you will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your surgeon has said its okay. - If you are experiencing no pain, it is okay to skip a dose of pain medicine. - Remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the folloiwng, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: - Take all the medicines you were on before the operation just as you did before, unless you have been told differently. - If you have any questions about what medicine to take or not to take, please call your surgeon.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Ace Inhibitors / Bactrim / Hydrochlorothiazide / Aricept Attending: ___. Chief Complaint: Slammed into door, sustaining injuries including C4 vertebral fracture, retroperitoneal hematoma, retropharyngeal hematoma. Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old female with history of AFib (on warfarin), cognitive impairment with h/o recurrentfalls, CAD s/p remote CABG ___ ago), CKD (baseline Cr 1.5), diffuse esophageal spasm, HTN, and ?COPD here after slamming into door with active extravastation... retropharyngeal hematoma requiring intubation. Patient was walking in the dark and slammed into a door at home, hitting her face. She had a L eyelid laceration, paramedics came to see her, and she ultimately declined ED admission. 45min afterwards, she felt short of breath and felt like her "airway was closing" prompting arrival to ED. The patient then underwent emergent intubation for airway protection. Her INR was 1.8 and was given K centra and 10 IV vitamin K. Past Medical History: # CAD s/p CABG # HTN # Mitral Regurgitation # Chronic Afib: On warfarin # CKD # Hx.of UTIs (typically EColi, variable resistance, most recent pan-sensitive ___ # Osteopenia # Mild Peripheral Neuropathy: previously on gabapentin, did not tolerate ___ cognitive issues # Possible Cognitive Impairment (undergoing neuropsych evaluation ___ Social History: ___ Family History: Father died suddenly of a cerebral hemorrhage when pt. was ___. Otherwise, non-contributory Physical Exam: PHYSICAL EXAMINATION: upon admission ___ Temp: 97.6 HR: 87 BP: 158/94 Resp: 18 O(2)Sat: 94 Normal Constitutional: Comfortable Chest: neck with left sided ttp and fullness; OP clear and patent; no bruit on neck exam; from ; no c-spine TTP; ?some dysphonation but daughter says no different than usual voice Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Non-tender, Soft, Non-distended Skin: Warm and dry Neuro: right elbow hematoma with sts; from; nvi right hand Psych: Normal mood, Normal mentation; CN intact; PERRL 4 mm ___: No petechiae physical examination upon discharge: ___: GENERAL: NAD vital signs: 98.6, hr=97, bp=150/81, rr=18 98% room air HEENT: Ecchymosis left side face, left cheek bone, left neck CV: Irreg. LUNGS: clear ABDOMEN: hypoactive BS, soft, non-tender EXT: ecchymosis ant. aspect right lower leg, ecchymosis right thigh, no calf pain bil, + dp bil NEURO: alert and oriented x3, speech clear, no tremors Pertinent Results: CBC ___ 05:45AM BLOOD WBC-10.5* RBC-3.04* Hgb-9.3* Hct-28.7* MCV-94 MCH-30.6 MCHC-32.4 RDW-14.6 RDWSD-47.9* Plt ___ ___ 05:45AM BLOOD WBC-10.8* RBC-3.10* Hgb-9.4* Hct-28.5* MCV-92 MCH-30.3 MCHC-33.0 RDW-14.1 RDWSD-46.3 Plt ___ ___ 05:21AM BLOOD WBC-12.3* RBC-3.02* Hgb-9.2* Hct-28.1* MCV-93 MCH-30.5 MCHC-32.7 RDW-14.1 RDWSD-47.0* Plt ___ ___ 03:38AM BLOOD WBC-14.0* RBC-3.13* Hgb-9.5* Hct-28.2* MCV-90 MCH-30.4 MCHC-33.7 RDW-13.9 RDWSD-45.4 Plt ___ ___ 03:03AM BLOOD WBC-9.4 RBC-3.19* Hgb-9.6* Hct-29.5* MCV-93 MCH-30.1 MCHC-32.5 RDW-14.1 RDWSD-47.7* Plt ___ ___ 02:21AM BLOOD WBC-8.7 RBC-2.91* Hgb-8.9* Hct-27.1* MCV-93 MCH-30.6 MCHC-32.8 RDW-14.5 RDWSD-48.8* Plt ___ ___ 02:23AM BLOOD WBC-12.0* RBC-3.14* Hgb-9.6* Hct-28.6* MCV-91 MCH-30.6 MCHC-33.6 RDW-14.0 RDWSD-46.4* Plt ___ ___ 09:43PM BLOOD WBC-10.8* RBC-3.09* Hgb-9.6* Hct-28.1* MCV-91 MCH-31.1 MCHC-34.2 RDW-13.8 RDWSD-45.9 Plt ___ ___ 02:04AM BLOOD WBC-11.9* RBC-3.53* Hgb-10.8* Hct-31.6* MCV-90 MCH-30.6 MCHC-34.2 RDW-13.7 RDWSD-44.6 Plt ___ ___ 05:23PM BLOOD WBC-13.0* RBC-3.83* Hgb-11.9 Hct-34.5 MCV-90 MCH-31.1 MCHC-34.5 RDW-14.0 RDWSD-45.8 Plt ___ ___ 02:23AM BLOOD WBC-12.0* RBC-3.14* Hgb-9.6* Hct-28.6* MCV-91 MCH-30.6 MCHC-33.6 RDW-14.0 RDWSD-46.4* Plt ___ ___ 09:43PM BLOOD WBC-10.8* RBC-3.09* Hgb-9.6* Hct-28.1* MCV-91 MCH-31.1 MCHC-34.2 RDW-13.8 RDWSD-45.9 Plt ___ ___ 02:04AM BLOOD WBC-11.9* RBC-3.53* Hgb-10.8* Hct-31.6* MCV-90 MCH-30.6 MCHC-34.2 RDW-13.7 RDWSD-44.6 Plt ___ ___ 05:23PM BLOOD WBC-13.0* RBC-3.83* Hgb-11.9 Hct-34.5 MCV-90 MCH-31.1 MCHC-34.5 RDW-14.0 RDWSD-45.8 Plt ___ ___ 07:40AM BLOOD WBC-9.7 RBC-3.35* Hgb-10.3* Hct-30.7* MCV-92 MCH-30.7 MCHC-33.6 RDW-14.2 RDWSD-47.0* Plt ___ ___ 01:54AM BLOOD WBC-12.3* RBC-3.47* Hgb-10.7* Hct-32.1* MCV-93 MCH-30.8 MCHC-33.3 RDW-14.4 RDWSD-47.9* Plt ___ ___ 06:15PM BLOOD WBC-12.4* RBC-3.93 Hgb-12.1 Hct-36.1 MCV-92 MCH-30.8 MCHC-33.5 RDW-14.0 RDWSD-47.0* Plt ___ ___ 01:50PM BLOOD WBC-11.6* RBC-3.92 Hgb-12.1 Hct-35.8 MCV-91 MCH-30.9 MCHC-33.8 RDW-13.9 RDWSD-46.3 Plt ___ ___ 08:30AM BLOOD WBC-14.4*# RBC-4.80 Hgb-14.7 Hct-42.6 MCV-89 MCH-30.6 MCHC-34.5 RDW-13.8 RDWSD-44.8 Plt ___ CHEST (PORTABLE AP) Study Date of ___ 8:30 AM FINDINGS: AP portable upright view of the chest. Midline sternotomy wires and mediastinal clips again noted. Overlying EKG leads are present. The heart is stably mildly enlarged. Prominence of the superior mediastinum reflects known hematoma in the retropharyngeal space extending into the superior mediastinum as seen on same-day neck CT. Lungs are clear bilaterally. Bony structures appear intact. CT HEAD W/O CONTRAST Study Date of ___ 8:32 AM IMPRESSION: 1. No acute hemorrhage or fracture. 2. Chronic small vessel disease. 3. Small left ___ hematoma. CT NECK W/O CONTRAST (EG: PAROTIDS) Study Date of ___ 8:45 AM IMPRESSION: Massive pre-vertebral hematoma with associated hyper extension teardrop fracture at C4 without alignment abnormality or distraction. Recommend urgent CTA to assess active bleeding. CTA NECK W&W/OC & RECONS Study Date of ___ 9:21 AM IMPRESSION: 1. Extensive retropharyngeal hematoma spanning from C2 through T1, measuring 4.6 x 2.6 cm axially with active extravasation. Unclear whether this represents active extravasation from prevertebral artery versus retropharyngeal branch artery, although the associated vessel does appear to be likely prevertebral (series 2, image 144). Consultation with neurosurgery is recommended. 2. An additional linear focus of hyperdensity along the lateral aspect of the hematoma inferiorly (series 2, image 103) cannot be connected to a larger vessel. This could represent venous hemorrhage. Close attention on ___ is recommended. 3. Additional findings described above. CT CHEST W/O CONTRAST Study Date of ___ 4:25 ___ IMPRESSION: 1. A large retropharyngeal hematoma extends into the superior mediastinum, not appreciably changed compared to the earlier same day neck CTA. There is mild mass effect on the posterior wall of the trachea, but no significant luminal narrowing. 2. Somewhat nodular opacification focally within the anterior right lower lobe probably reflects atelectasis. However, recommend three-month ___ chest CT to assess stability. CT NECK W/O CONTRAST (EG: PAROTIDS) Study Date of ___ 4:25 ___ IMPRESSION: 1. Re-demonstration of retropharyngeal hematoma extending from C2 through the right aspect of the posterior mediastinum, slightly decreased in size from the prior study with non-visualized hematocrit levels previously seen, likely secondary to mass effect from endotracheal tubes and intubation. 2. The hematoma extends to the posterior mediastinum. The component in the mediastinum appears more prominent when compared to prior examination. This could represent redistribution, however the findings could represent continued active extravasation and close interval ___ is recommended to document stability/growth. Portable TTE (Complete) Done ___ at 12:00:00 ___ FINAL IMPRESSION: Borderline LV systolic function secondary to septal dyssynchrony. Bi-leaflet MVP with moderate mitral regurgitation. Mild pulmonary hypertension. CHEST (PORTABLE AP) Study Date of ___ 4:50 AM IMPRESSION: Compared to chest radiographs since ___, most recently ___. Lungs clear. Moderate cardiomegaly is chronic. No pulmonary edema or pleural effusion. MR CERVICAL SPINE W/O CONTRAST Study Date of ___ 9:19 ___ IMPRESSION: 1. Acute fracture involving the anterior C4 vertebral body with pre-vertebral soft tissue edema and probable injury to the anterior longitudinal ligament as well the as the inter-spinous ligament. 2. Edema within the C6-C7 intervertebral disc space with probable osseous edema of the superior C7 vertebral body. 3. Re-demonstration of retropharyngeal hematoma. 4. Retrolisthesis of C4 on C5 and anterolisthesis of C2 on C3. 5. Multilevel degenerative changes as detailed above, with moderate spinal canal stenosis at C4-C5 through C6-C7 levels with spinal cord remodeling, without definite cord edema. CHEST (PORTABLE AP) Study Date of ___ 4:54 AM IMPRESSION: In comparison with the study ___, the monitoring support devices are essentially unchanged. Cardiac silhouette remains mildly enlarged without evidence of vascular congestion, pleural effusion, or acute focal pneumonia. CHEST PORT. LINE PLACEMENT Study Date of ___ 10:53 ___ IMPRESSION: Compared to chest radiographs since ___, most recently ___ through ___ at 05:33. Combination of small to moderate pleural effusions and moderate bibasilar atelectasis has increased since earlier in the day. Moderate cardiomegaly is chronic. There is also very mild ___ edema. Indwelling cardiopulmonary support devices in standard placements. CHEST (PORTABLE AP) Study Date of ___ 5:31 AM IMPRESSION: Lines and tubes are in standard position. Bibasilar opacities have markedly improved. Bilateral effusions have improved. Cardiomegaly, tortuous aorta and prominent hila bilaterally are stable. There is no evident pneumothorax. Sternal wires are intact. VIDEO OROPHARYNGEAL SWALLOW Study Date of ___ 11:37 AM IMPRESSION: No aspiration. Penetration with thin and nectar consistencies. Please refer to the speech and swallow division note in OMR for full details, assessment, and recommendations. CT HEAD W/O CONTRAST Study Date of ___ 5:41 ___ IMPRESSION: 1. Findings most consistent with severe chronic small vessel ischemic changes in the absence of acute symptoms. No intracranial hemorrhage. 2. Para-nasal sinus disease, suggestive of acute sphenoid sinusitis in the absence of recent intubation. ___: CXR; In comparison with the study ___, the right IJ catheter has been removed. Continued enlargement of the cardiac silhouette in a patient with previous CABG procedure an intact midline sternal wires. Mild elevation of pulmonary venous pressure with small bilateral pleural effusions and compressive atelectasis at the bases. No definite acute focal pneumonia. ___ 5:24 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay.. (Reference Range-Negative Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Atorvastatin 10 mg PO QPM 3. irbesartan 300 mg oral DAILY 4. Metoprolol Succinate XL 50 mg PO DAILY 5. Warfarin 2.5 mg PO 2X/WEEK (WE,SA) 6. Aspirin 81 mg PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 9. Fish Oil (Omega 3) 1000 mg PO BID 10. Warfarin 5 mg PO 5X/WEEK (___) Discharge Medications: 1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity 2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 3. Docusate Sodium 100 mg PO BID 4. Donepezil 10 mg PO QHS 5. Heparin 5000 UNIT SC BID ___ d/c after ambulatory 6. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 7. Multivitamins W/minerals Liquid 15 mL PO DAILY 8. Nystatin Oral Suspension 5 mL PO QID:PRN swish may diconstinue when no signs or symptoms 9. OxycoDONE Liquid ___ mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg/5 mL ___ mg by mouth every four (4) hours Disp ___ Milliliter Refills:*0 10. Senna 8.6 mg PO BID:PRN constipation 11. Warfarin 2.5 mg PO 2X/WEEK (WE,SA) ON HOLD UNTIL ___ WITH ___. ___ 12. amLODIPine 5 mg PO DAILY 13. Aspirin 81 mg PO DAILY 14. Atorvastatin 10 mg PO QPM 15. Fish Oil (Omega 3) 1000 mg PO BID 16. irbesartan 300 mg oral DAILY 17. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 18. Metoprolol Succinate XL 50 mg PO DAILY 19. Omeprazole 20 mg PO DAILY 20. Warfarin 5 mg PO 5X/WEEK (___) ON HODL UNTIL FOLLOW UP WITH ___. ___ ___ Disposition: Extended Care Facility: ___ Discharge Diagnosis: retropharyngeal hematoma C4 vertebral body fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ s/p fall COMPARISON: Same-day neck CTA and chest radiograph from ___ FINDINGS: AP portable upright view of the chest. Midline sternotomy wires and mediastinal clips again noted. Overlying EKG leads are present. The heart is stably mildly enlarged. Prominence of the superior mediastinum reflects known hematoma in the retropharyngeal space extending into the superior mediastinum as seen on same-day neck CT. Lungs are clear bilaterally. Bony structures appear intact. IMPRESSION: As above. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ with history of headstrike on Coumadin// eval for intracranial hemorrhage TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Total DLP (Head) = 803 mGy-cm. COMPARISON: CT head ___. FINDINGS: There is no evidence of large vascular territory infarction,hemorrhage,edema,or mass effect. There is prominence of the ventricles and sulci suggestive of involutional changes. Again demonstrated, is severe periventricular and subcortical white matter hypodensities, consistent with chronic microvascular ischemic disease. Bilateral basal ganglia and thalamic hypodensities are also noted similar to prior. There is no fracture. Mild mucosal thickening of the sphenoid sinus. The visualized portion of the remaining paranasal sinuses, mastoid air cells, and middle ear cavities are clear. There is a small ___ and preseptal hematoma without underlying fracture or signs of globe injury. IMPRESSION: 1. No acute hemorrhage or fracture. 2. Chronic small vessel disease. 3. Small left ___ hematoma. Radiology Report EXAMINATION: CT NECK W/O CONTRAST INDICATION: ___ year old woman with history of neck fullness on Coumadin with concern for collection// eval for hematoma TECHNIQUE: Multidetector CT through the neck performed without contrast with multiplanar reformations DOSE: Total DLP (Body) = 310 mGy-cm. COMPARISON: None. FINDINGS: There is a massive midline prevertebral hematoma approximately 12.8 cm in craniocaudal dimension and 6.8 (TR) x 4.4 (AP) cm. Urgent CTA is required to assess active bleeding, ? carotid injury. There is associated mass-effect on the airway most pronounced at the level of the epiglottis. Consider urgent intubation for airway protection. An acute hyperextension fracture is noted at the anterior inferior corner of C4 without distraction or alignment abnormality. Fracture is best appreciated on the sagittal reformats, series 602b image 28 through 31. There is minimal anterolisthesis of C2 on C3 which is likely chronic/related to degeneration. Disc disease is most notable spanning C4 through C7 with loss of disc space, disc osteophyte complexes which result in mild to moderate central spinal canal narrowing. In addition, uncovertebral joint hypertrophy noted at multiple levels results in severe neural foraminal narrowing at C4-5 and C5-6 on the left. The lung apices notable for emphysema. Prevertebral hematoma extends to the level of the superior mediastinum. Thyroid is unremarkable. IMPRESSION: Massive prevertebral hematoma with associated hyper extension teardrop fracture at C4 without alignment abnormality or distraction. Recommend urgent CTA to assess active bleeding. RECOMMENDATION(S): -Intubation for airway protection. -C-spine collar placement given acute fracture at C4. Radiology Report EXAMINATION: CTA NECK WANDW/OC AND RECONS Q25 CT NECK INDICATION: History: ___ with head strike with prevertebral hematoma on CT// eval for dissection or active extravasation in the neck TECHNIQUE: Rapid axial imaging was performed from the aortic arch through the skull base during infusion of 70 mL of Omnipaque intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 65.3 mGy (Head) DLP = 32.7 mGy-cm. 2) Spiral Acquisition 4.3 s, 33.7 cm; CTDIvol = 35.2 mGy (Head) DLP = 1,186.8 mGy-cm. Total DLP (Head) = 1,219 mGy-cm. COMPARISON: CT neck of ___ FINDINGS: There is a retropharyngeal hematoma spanning from the level of C2 to T1, measuring 12.3 cm with max diameter measuring 4.6 x 2.9 cm on the axial dimension, overall similar in prior examination. Of note, there is a fluid fluid level within the ___ the hematoma (series 2, image 135). At the level C3-4 disc space, there is vigorous, active extravasation of intravenous contrast into the hematoma (2:150). The hematoma appears to be connected to a small prevertebral arterial vessel (series 2, image 144) although this region of enhancement cannot be definitively connected to a larger vessel. The expanded hematoma displaces the esophagus anteriorly and somewhat narrows the airways, though the central airways remain patent. The retroperitoneal hematoma extends into the mediastinum to the level of pulmonary artery bifurcation. There is trace linear hyperdensity, likely representing additional site of extravasation (series 2, image 103) at the level of the thyroid gland, without definitive source. There is layering fluid in the sphenoid sinus. Mild mucosal thickening is seen in the posterior ethmoid air cells. The visualized paranasal sinuses, mastoid air cells, middle ear cavities are otherwise patent. Moderate calcifications are seen at the bilateral carotid siphons. While this exam is not tailored for intracranial contents, the visualized circle of ___ appears patent. No territorial infarct is seen. Prominent left periorbital hematoma and soft tissue stranding is noted. By NASCET criteria, there is no significant stenosis of the ICA bilaterally. The left vertebral artery is diminutive throughout its course, likely congenital variation. Degenerative changes of the cervical spine with disc space and vertebral body height loss, most severe at C4 through C7 is noted. C4 anterior teardrop fracture is better visualized on prior examination. IMPRESSION: 1. Extensive retropharyngeal hematoma spanning from C2 through T1, measuring 4.6 x 2.6 cm axially with active extravasation. Unclear whether this represents active extravasation from prevertebral artery versus retropharyngeal branch artery, although the associated vessel does appear to be likely prevertebral (series 2, image 144). Consultation with neurosurgery is recommended. 2. An additional linear focus of hyperdensity along the lateral aspect of the hematoma inferiorly (series 2, image 103) cannot be connected to a larger vessel. This could represent venous hemorrhage. Close attention on followup is recommended. 3. Additional findings described above. NOTIFICATION: The findings were discussed with ___ resident by ___, M.D. on the telephone on ___ at 10:03 am, 5 minutes after discovery of the findings. The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 10:30 am, 30 minutes after discovery of the findings. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ with s/p intubation// Eval ETT COMPARISON: None FINDINGS: AP portable upright view of the chest. There has been interval placement of an endotracheal tube with its tip positioned 3.2 cm above the carina. An OG tube courses into the left upper abdomen with its tip excluded from view. Midline sternotomy wires and mediastinal clips are again noted. There is mediastinal widening which is reflective of known prevertebral/mediastinal hematoma, appears increased from prior. The heart remains stably enlarged. Lungs are clear. Bony structures are intact. IMPRESSION: Interval intubation with appropriately positioned ET tube. OG tube positioned appropriately. Expanding mediastinal hematoma. Radiology Report EXAMINATION: CT NECK W/O CONTRAST (EG: PAROTIDS) Q21 CT NECK INDICATION: ___ year old woman with retropharyngeal hematoma// ?interval change TECHNIQUE: Imaging was performed after administration of Omnipaque intravenous contrast material. MDCT acquired helical axial images were obtained from the thoracic inlet through the skull base. Coronal and sagittal multiplanar reformats were then produced and reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 3.5 s, 27.7 cm; CTDIvol = 5.4 mGy (Body) DLP = 148.6 mGy-cm. Total DLP (Body) = 149 mGy-cm. COMPARISON: CT neck ___ FINDINGS: In comparison with the recent CT neck, there is interval decrease in size of a retropharyngeal hematoma which now measures 4.2 x 1.7 cm, previously 4.6 x 2.9 cm. The previously seen hematocrit levels are not visualized on this study. This could be secondary to mass effect from intubation and the endotracheal tubes. The hematoma extends from C2 through visualized right aspect of the posterior mediastinum. However, the extent of hematoma within the mediastinum appears more prominent when compared to prior examination and findings remain concerning for active extravasation versus redistribution secondary to mass effect from the intubation. There is stranding within the soft tissues of the lower neck. There are subcentimeter cervical lymph nodes, possibly reactive. There are vascular calcifications of the aorta and origins of the great vessels. The thyroid gland appears unremarkable. There are multilevel degenerative changes of the cervical spine. There is dependent atelectasis within the visualized lung apices. IMPRESSION: 1. Redemonstration of retropharyngeal hematoma extending from C2 through the right aspect of the posterior mediastinum, slightly decreased in size from the prior study with nonvisualized hematocrit levels previously seen, likely secondary to mass effect from endotracheal tubes and intubation. 2. The hematoma extends to the posterior mediastinum. The component in the mediastinum appears more prominent when compared to prior examination. This could represent redistribution, however the findings could represent continued active extravasation and close interval followup is recommended to document stability/growth. Radiology Report EXAMINATION: Chest CT INDICATION: ___ year old woman with retropharyngeal hematoma. TECHNIQUE: Contiguous axial images were obtained through the chest without intravenous contrast. Coronal and sagittal reformats were obtained. COMPARISON: Same day neck CTA FINDINGS: HEART AND VASCULATURE: The there is severe cardiomegaly. Patient appears status-post CABG with median sternotomy wires and mediastinal clips. Native coronary calcifications are severe. The aorta is normal in caliber. Aortic arch and great vessel origin calcifications are moderate to severe. MEDIASTINUM: The mediastinal portion of a large retropharyngeal hematoma appears no larger than the earlier same day head and neck CTA. The hematoma is smaller at the level of thoracic inlet than it is either superiorly or inferiorly. Inferior to the level of thoracic inlet, the hematoma spans 6.2 x 3.7 cm, terminating approximately 1 cm superior to the carina (series 602, image 64). PLEURAL SPACES: No pleural effusion or pneumothorax. LUNGS/AIRWAYS: The mediastinal hematoma exerts mild mass effect on the posterior wall of the trachea, though no significant narrowing is noted. An endotracheal tube tip terminates approximately 2 cm above the level of the carina. There is a somewhat nodular area of probable atelectasis in the anterior right lower lobe abutting the major fissure (series 302, image 158). There is linear atelectasis or scarring elsewhere at lung bases. There is mild pleural thickening and punctate pleural calcifications. BASE OF NECK: Visualized portions of the base of the neck show no abnormality. ABDOMEN: There is a 1.6 cm cyst in hepatic segment VII. An enteric catheter courses below the diaphragm and outside the field of view, at least to the level of the gastric body. BONES: No thoracic spine rib fractures visualized. The known cervical spine fracture was not included within the field of view on this examination. IMPRESSION: 1. A large retropharyngeal hematoma extends into the superior mediastinum, not appreciably changed compared to the earlier same day neck CTA. There is mild mass effect on the posterior wall of the trachea, but no significant luminal narrowing. 2. Somewhat nodular opacification focally within the anterior right lower lobe probably reflects atelectasis. However, recommend three-month follow-up chest CT to assess stability. RECOMMENDATION(S): Somewhat nodular opacification focally within the anterior right lower lobe probably reflects atelectasis. However, recommend three-month follow-up chest CT to assess stability. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with intubation// Tube placement, evidence of atelectasis or pneumonia Tube placement, evidence of atelectasis or pneumonia IMPRESSION: Compared to chest radiographs since ___, most recently ___. Lungs clear. Moderate cardiomegaly is chronic. No pulmonary edema or pleural effusion. ET tube in standard placement. Nasogastric drainage tube ends in the upper stomach. Radiology Report EXAMINATION: MR CERVICAL SPINE W/O CONTRAST ___ MR ___ SPINE INDICATION: ___ year old woman with mechanical fall and retropharyngeal hematoma. Evaluate for fracture. TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique. Axial T2 and gradient echo imaging were next performed. COMPARISON: CT neck ___ FINDINGS: There is redemonstration of retropharyngeal hematoma (06:24). There is linear STIR hyperintensity extending through anterior C4 vertebral body through the anterior osteophyte extending into the intervertebral disc space, with mild intervertebral disc edema. There is mild prevertebral soft tissue edema with questionable injury to the anterior longitudinal ligament. There is also edema along the inter spinous process and ligamentum nuchae, more significant at C4/C5 level, there is fluid within the C6-C7 intervertebral disc space with STIR hyperintensity of the superior C7 vertebral body endplate without definite T1 hypointensity, possibly related to marrow edema. Patient is intubated with presence of an enteric tube. There is 5 mm retrolisthesis of C4 on C5 and 2 mm anterolisthesis of C 2 on C3. There is loss of intervertebral disc space at C4-C5 through C6-C7 levels with disc desiccation related to degenerative process. C2-C3: There is no spinal canal stenosis or neural foraminal narrowing. C3-C4: There is a disc bulge with facet and uncovertebral joint arthropathy resulting in moderate left and mild right neural foraminal narrowing without spinal canal stenosis or cord edema. C4-C5: There is a disc bulge with facet and uncovertebral joint arthropathy causing moderate spinal canal stenosis with remodeling of spinal cord without cord edema. There is moderate to severe right and mild left neural foraminal narrowing. C5-C6: There is a disc bulge with facet and uncovertebral joint arthropathy resulting in moderate spinal canal stenosis with remodeling of the ventral with remodeling and flattening of the spinal cord (07:27) with moderate bilateral neural foraminal narrowing. C6-C7: There is a disc bulge with facet and uncovertebral joint arthropathy resulting in moderate spinal canal stenosis with remodeling of the ventral spinal cord without cord edema. There is moderate left and no right neural foraminal narrowing. C7-T1: There is no spinal canal stenosis or neural foraminal narrowing. IMPRESSION: 1. Acute fracture involving the anterior C4 vertebral body with prevertebral soft tissue edema and probable injury to the anterior longitudinal ligament as well the as the interspinous ligament. 2. Edema within the C6-C7 intervertebral disc space with probable osseous edema of the superior C7 vertebral body. 3. Redemonstration of retropharyngeal hematoma. 4. Retrolisthesis of C4 on C5 and anterolisthesis of C2 on C3. 5. Multilevel degenerative changes as detailed above, with moderate spinal canal stenosis at C4-C5 through C6-C7 levels with spinal cord remodeling, without definite cord edema. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with interval change// interval change IMPRESSION: In comparison with the study ___, the monitoring support devices are essentially unchanged. Cardiac silhouette remains mildly enlarged without evidence of vascular congestion, pleural effusion, or acute focal pneumonia. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old woman with new R IJ CVL// assess for CVL location Contact name: ___: ___ assess for CVL location IMPRESSION: Compared to chest radiographs since ___, most recently ___ through ___ at 05:33. Combination of small to moderate pleural effusions and moderate bibasilar atelectasis has increased since earlier in the day. Moderate cardiomegaly is chronic. There is also very mild perihilar edema. Indwelling cardiopulmonary support devices in standard placements. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with retropharyngeal hematoma, intubated// eval for interval change TECHNIQUE: Single frontal view of the chest COMPARISON: ___ IMPRESSION: Lines and tubes are in standard position. Bibasilar opacities have markedly improved. Bilateral effusions have improved. Cardiomegaly, tortuous aorta and prominent hila bilaterally are stable. There is no evident pneumothorax. Sternal wires are intact. Radiology Report EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS INDICATION: ___ year old woman with feeding needs// eval dobhoff placement COMPARISON: Chest x-ray is ___ FINDINGS: Portable AP semi upright views of the chest were provided. Dobhoff tube is seen being advanced through the esophagus and ultimately coils at the GE junction. A enteric feeding tube courses below the diaphragm, but terminates beyond the field of view of the image. A right internal jugular central venous catheter terminates in the distal SVC. Endotracheal tube terminates 2.3 cm above level of carina. There is mild pulmonary vascular congestion. There is moderate cardiomegaly, stable. There is bibasilar atelectasis. IMPRESSION: Interval placement of Dobhoff feeding tube which coils at the GE junction and should be repositioned. No other significant interval change. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with retropharyngeal hematoma// Assess for interval change Assess for interval change IMPRESSION: Compared to chest radiographs ___ through ___. Mild cardiomegaly improved, lungs grossly clear, small bilateral pleural effusions new or newly apparent. No pneumothorax. Right jugular line ends in the low SVC.. Radiology Report EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS INDICATION: ___ year old woman with dobhoff placement// dobhoff placement TECHNIQUE: Chest single view COMPARISON: ___ 12:23 FINDINGS: Under radiograph taken at 19:24 feeding tube tip is coiled in the proximal stomach. On the radiograph taken at 19:32, feeding tube has been pulled back, with tip in the distal esophagus. Heart size, mild pulmonary vascular congestion are stable. Mild basilar opacities have increased, consider worsening edema or atelectasis. Small bilateral pleural effusions are likely. No pneumothorax. IMPRESSION: On the second radiograph, feeding tube tip is in distal esophagus, should be advanced. Radiology Report EXAMINATION: VIDEO OROPHARYNGEAL SWALLOW INDICATION: ___ year old woman with retropharyngeal hematoma// ability to eat TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in conjunction with the speech and swallow division. Multiple consistencies of barium were administered. DOSE: Fluoro time: 02:16 min. COMPARISON: None. FINDINGS: Barium passes freely through the oropharynx and esophagus without evidence of obstruction. There was no gross aspiration. Penetration is seen thin and nectar consistencies, which cleared with subsequent swallow. IMPRESSION: No aspiration. Penetration with thin and nectar consistencies. Please refer to the speech and swallow division note in OMR for full details, assessment, and recommendations. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman with RP bleed with C4 VB fx., now with increased neck pain and post. head pain// evaluate for 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 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 747.3 mGy-cm. Total DLP (Head) = 747 mGy-cm. COMPARISON: ___ FINDINGS: There is no evidence of acute infarction,hemorrhage,edema, or mass. There is prominence of the ventricles and sulci suggestive of involutional changes. Again seen is confluent periventricular and subcortical, brainstem white matter hypodensities, nonspecific, however likely sequela of severe chronic small vessel ischemic disease in the absence of acute symptoms, similar.. Bilateral basal ganglia and thalamic hypodensities are also unchanged, thought to represent a combination of prominent perivascular spaces and chronic lacunar infarcts. Tiny chronic right cerebellar infarct, stable. There is no evidence of acute fracture. There is moderate opacification with fluid in the sphenoid sinus. Submucosal retention cyst in the left maxillary sinus is. Trace fluid in the inferior left mastoid 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. Dense calcifications in the carotid siphons are noted. IMPRESSION: 1. Findings most consistent with severe chronic small vessel ischemic changes in the absence of acute symptoms. No intracranial hemorrhage. 2. Paranasal sinus disease, suggestive of acute sphenoid sinusitis in the absence of recent intubation. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with recent trauma to neck now w/ low-grade fevers and leukocytosis// rule out pneumonia IMPRESSION: In comparison with the study ___, the right IJ catheter has been removed. Continued enlargement of the cardiac silhouette in a patient with previous CABG procedure an intact midline sternal wires. Mild elevation of pulmonary venous pressure with small bilateral pleural effusions and compressive atelectasis at the bases. No definite acute focal pneumonia. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: L Eyelid laceration Diagnosed with Unsp disp fx of fourth cervical vertebra, init for clos fx, Walked into furniture, initial encounter temperature: 97.6 heartrate: 87.0 resprate: 18.0 o2sat: 94.0 sbp: 158.0 dbp: 94.0 level of pain: 5 level of acuity: 3.0

You were admitted to the hospital after walking into a door and hitting your face. You sustained a left eyelid injury. You were seen by the paramedics and declined admission to the emergency room. Shortly afterward, you felt short of breath and felt like your "airway was closing" prompting arrival to emergency room. You had an airway placed for airway protection. You had an elevated INR of 1.8 and was given medication to lower the level. You underwent imaging and you were reported to have a retro-pharyngeal hematoma and an isolated fracture to your neck. You were evaluated by Neurosurgery and no surgery was indicated. Your vital signs have been stable and you are preparing for discharge to a rehabilitation center to further regain your strength and mobility. You are being discharged with the following instructions: return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please return to the emergency room if you have a recurrence of neck pain, headache, and throat pain. If you begin to have difficulty swallowing it is important to return here. You will see Dr. ___ prior to resuming your coumadin

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Ciprofloxacin / Paxil Attending: ___. Chief Complaint: hematochezia Major Surgical or Invasive Procedure: endoscopic ultrasound with biopsy History of Present Illness: ___ yo M with PMH of DM2, CAD s/p CABG, ischemic cardiomyopathy with LVEF 20%, atrial fibrillation on Coumadin, and a recent history of pancreatitis, cholecystitis, and c. diff colities at ___ who presents from rehab with 2 day history of bloody bowel movements and an E. coli UTI. With respect to his stools, patient has been having large-volume frankly bloody bowel movements. Records do not report melanotic or black stool. With respect to his UTI, patient has also been having increased frequency for the last 2 days for which UA and urine culture was sent yesterday. UCx returned positive for E. coli today. Patient spiked to 101.5 today at rehab. Notably, patient has been on vancomycin PO for recurrent C. diff. In the ED, initial vitals signs were 97.4, 85, 101/48, 18, 96% RA. Labs were remarkable for H/H 9.6/29.8, Na 126, INR 2.8, lactate 3.2 initially which downtrended to 1.6 with IVF. UA grossly positive. CT abdomen/pelvis showed no obvious source of GI bleed. During CT scan, patient became hypotensive to 86/40 for which he received 2 L IVF and 1 unit pRBCs given continued BRBPR in the ED. This resulted in increase in blood pressures. Patient also received ceftriaxone and Flagyl as well as vitamin K and FFP for INR. Decision was made to admit to the FICU given concern for continued hemodynamic instability. Review of systems: (+) Per HPI, (+) weight loss 30 lbs since ___. (+) diarrhea. (-) Denies fever, chills, night sweats. Denies sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain, palpitation. Denies nausea, vomiting. Past Medical History: - Hypertension - Hyperlipidemia - Type 2 diabetes - CAD s/p NSTEMI in ___. CABG in ___ (SVG to LAD and Cx to PDA). PCI in ___ with 90% stenosis of SVG to LAD and OM2 patent with moderate diffuse disease. Stented proximal ramus. - VFib arrest in ___ s/p ICD and upgrade to BiV in ___ - Ischemic cardiomyopathy with LVEF of 20% - Atrial fibrillation on Coumadin - Stable infrarenal AAA - Irritable bowel syndrome - ___ esophagus/esophagitis - Recent pancreatitis - Current C. diff colitis - BPH s/p TURP - Depression Social History: ___ Family History: No history of bleeding. No known family history of heart disease, CA, DM or HTN. Physical Exam: Admission Physical Exam: Vitals- afebrile, 81, 102/43, 98% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM Lungs: Clear to auscultation bilaterally, no wheezes CV: Distant heart sounds; Regular rate and rhythm Abdomen: soft, (+) LLQ tenderness, non-distended, hypoactive bowel sounds GU: foley draining faintly bloody urine; (+) blood around urethral meatus Ext: warm, well perfused, no edema Rectal: maroon stool; no hemorrhoids appreciated Pertinent Results: PATHOLOGIC DIAGNOSIS: Esophageal biopsy: Squamous epithelium with active esophagitis and foreign pigmented material associated with an inflammatory exudate. The foreign material stains strongly for iron and could represent part of an iron pill. A rare yeast form is seen in the exudate on GMS and PAS stain. Final Report INDICATION: Patient with history of C. diff. colitis and abdominal pain and bloody bowel movements. COMPARISONS: ___. TECHNIQUE: MDCT-acquired images through the abdomen and pelvis was obtained. Coronally and sagittally reformatted images are provided. 30 cc of IV contrast was administered when primary team requested mesenteric CTA. Therefore, no true pre-contrast sequence is available. Arterial and venous phases were subsequently obtained. FINDINGS: CT OF THE ABDOMEN: Imaged lung bases are clear. The liver demonstrates homogeneous enhancement. There is a 12 mm hyperenhancing lesion in segment VII/VIII (5b:80), most likely flash-filling hemangioma, unchanged since ___ exam. There is no evidence of intrahepatic biliary ductal dilatation. Biliary stent is unchanged in position. There is expected pneumobilia predominantly in the left hepatic lobe. The portal vein is patent. The gallbladder is surgically absent. There is a small hiatal hernia. The spleen is normal in size. The pancreas enhances homogeneously without main pancreatic ductal dilatation. Focal fatty deposition within the pancreatic head is unchanged (5b:215). There is a 1.7 x 1.6 cm hypodensity in the uncinate process of the pancreas, which is more conspicuous since priors. The adrenal glands are unremarkable. The kidneys enhance and excrete contrast symmetrically without hydronephrosis or suspicious renal masses. Subcentimeter renal hypodensities are too small to characterize and are most likely cysts. There is small amount of ascites, increased since prior study. There is no mesenteric or retroperitoneal lymphadenopathy. Aorta demonstrates extensive calcified atherosclerotic disease with multiple infrarenal fusiform aneurysms, the largest measuring 3.3 cm, unchanged (604b:59). Aneurysmal changes extend to the bilateral iliac vessels, the left measuring 1.6 and the right measuring 2.2 cm. The right external iliac artery measures 11 mm, and appears ectatic. There is moderate narrowing at the origin of the celiac axis. The SMA is patent. There is marked bowel wall edema involving nearly entire colon, which most likely relates to patient's known Clostridium difficile infection. There are multiple colonic diverticula. There are focal areas of hyperintensity within the descending and sigmoid colon (5b:244, 288), which appear hyperdense on the arterial phase. However, no significant progression of hypodensities is seen within the bowel. The evaluation is limited given lack of pre-contrast sequence. CT OF THE PELVIS: A foley catheter is within the bladder. Small amount of air within the bladder likely relates to Foley placement. The rectum, prostate gland and seminal vesicles are unremarkable. There is small amount of free fluid. There is no free air. No pelvic or inguinal lymphadenopathy. OSSEOUS STRUCTURES: No suspicious lytic or sclerotic bony lesion. Prior right eigth rib fracture is noted. IMPRESSION: 1. Limited evaluation due to lack of pre-contrast sequence. Focal areas of hyperdensity within the descending and sigmoid colon without definite progression, are felt to be hight density intraluminal contents unlikely to represent GI bleed; however, this cannot be definitely excluded due to limitation of the study. 2. Diffuse colonic edema, compatible with patient's known history of Clostridium difficile infection. 3. Small amount of ascites and anasarca, increased since prior. 4. Biliary drain is in place with expected pneumobilia. 5. A 12 mm arterial enhancing hepatic lesion, likely flash-filling hemangioma, unchanged since ___ exam. 6. A 17 x 15 mm hypodensity in the uncinate process of the pancreas, more conspicuous since prior studies, which can be further assessed with MRCP, if patient's pacemaker is MR compatible. Otherwise, consider EUS. 7. Extensive calcified atherosclerotic disease of the aorta with associated aneurysmal changes, stable. 8. Small hiatal hernia. The study and the report were reviewed by the staff radiologist. =========================== LABS ON ADMISSION: =========================== ___ 04:45PM BLOOD WBC-4.5 RBC-2.88* Hgb-9.6* Hct-29.8* MCV-104* MCH-33.5* MCHC-32.3 RDW-17.3* Plt ___ ___ 04:45PM BLOOD Neuts-86.8* Lymphs-7.9* Monos-4.6 Eos-0.4 Baso-0.3 ___ 04:45PM BLOOD ___ PTT-28.2 ___ ___ 04:45PM BLOOD Glucose-160* UreaN-22* Creat-1.0 Na-126* K-4.3 Cl-85* HCO3-31 AnGap-14 ___ 11:05PM BLOOD Calcium-8.2* Phos-3.3 Mg-1.7 ___ 04:45PM BLOOD Albumin-2.7* ___ 04:45PM BLOOD ALT-16 AST-30 AlkPhos-139* TotBili-0.7 ___ 04:45PM BLOOD Lipase-32 ___ 05:01PM BLOOD Lactate-3.2* ___ 07:11PM BLOOD Lactate-1.6 K-3.6 =========================== LABS ON DISCHARGE: =========================== =========================== OTHER RESULTS: =========================== ___ CT Ab/Pelvis IMPRESSION: PRELIM READ 1. Limited evaluation due to lack of pre-contrast sequence. Focal areas of hyperdensity within the descending and sigmoid colon without definite progression, are felt unlikely to represent GI bleed; however, this cannot be definitely excluded due to limitation of the study. 2. Diffuse colonic edema, compatible with patient's known history of Clostridium difficile infection. 3. Small amount of ascites and anasarca, increased since prior. 4. Biliary drain is in place with expected pneumobilia. 5. A 12 mm arterial enhancing hepatic lesion, likely flash-filling hemangioma, unchanged since ___ exam. 6. A 17 x 15 mm hypodensity in the uncinate process of the pancreas, more conspicuous since prior studies, which can be further assessed with MRCP, if patient's pacemaker is MR compatible. Otherwise, consider EUS. 7. Extensive calcified atherosclerotic disease of the aorta with associated aneurysmal changes, stable. 8. Small hiatal hernia. PRIOR GI PROCEDURES: ___ Colonoscopy - Diverticulosis of the sigmoid colon Grade 2 internal hemorrhoids Polyps in the colon There was a blue lesion at 60cm which may have been trauma or an old scar. ___ EGD - Normal mucosa in the whole examined duodenum Normal mucosa in the whole stomach Small hiatal hernia There was a ''pocket'' in the distal esophagus where the lumen took a sharp turn. There was a presbyesophagus more proximally.The Z-line was slightly irregular, but there was no definite ___ esophagus. No biopsies were done due to the anticoagulation. Otherwise normal EGD to third part of the duodenum ___ 06:50AM BLOOD WBC-7.9 RBC-2.97* Hgb-9.9* Hct-29.8* MCV-100* MCH-33.2* MCHC-33.1 RDW-17.8* Plt ___ ___ 06:50AM BLOOD ___ ___ 06:50AM BLOOD Glucose-79 UreaN-11 Creat-0.6 Na-131* K-3.9 Cl-95* HCO3-29 AnGap-11 ___ 05:09AM BLOOD CA ___ -Test Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Pravastatin 40 mg PO DAILY 2. Finasteride 5 mg PO DAILY 3. Ferrous Sulfate 325 mg PO DAILY 4. Gabapentin 300 mg PO QPM 5. Allopurinol ___ mg PO QPM 6. Torsemide 20 mg PO BID 7. PredniSONE 10 mg PO DAILY 8. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain 9. Acetaminophen 650 mg PO Q4H:PRN pain 10. Aspirin 81 mg PO DAILY 11. Digoxin 0.125 mg PO DAILY 12. Metoprolol Tartrate 50 mg PO BID 13. Vancomycin Oral Liquid ___ mg PO Q6H 14. Insulin SC Sliding Scale Insulin SC Sliding Scale using REG Insulin 15. Warfarin 5 mg PO DAILY16 16. Gabapentin 600 mg PO BID 17. Docusate Sodium 100 mg PO BID 18. Omeprazole 40 mg PO DAILY 19. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal dryness Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN pain 2. Allopurinol ___ mg PO QPM 3. Aspirin 81 mg PO DAILY 4. Digoxin 0.125 mg PO DAILY 5. Insulin SC Sliding Scale Insulin SC Sliding Scale using REG Insulin 6. Metoprolol Tartrate 50 mg PO BID 7. PredniSONE 10 mg PO DAILY 8. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal dryness 9. Torsemide 20 mg PO DAILY 10. Vancomycin Oral Liquid ___ mg PO Q6H 11. Warfarin 3 mg PO DAILY16 12. Docusate Sodium 100 mg PO BID 13. Ferrous Sulfate 325 mg PO DAILY 14. Finasteride 5 mg PO DAILY 15. Gabapentin 300 mg PO QPM 16. Gabapentin 600 mg PO BID 17. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain 18. Pravastatin 40 mg PO DAILY 19. Omeprazole 40 mg PO BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: e. coli septicemia e coli uti gi bleeding ischemic colitis acute blood loss anemia chronic systolic chf 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: Patient with history of C. diff. colitis and abdominal pain and bloody bowel movements. COMPARISONS: ___. TECHNIQUE: MDCT-acquired images through the abdomen and pelvis was obtained. Coronally and sagittally reformatted images are provided. 30 cc of IV contrast was administered when primary team requested mesenteric CTA. Therefore, no true pre-contrast sequence is available. Arterial and venous phases were subsequently obtained. FINDINGS: CT OF THE ABDOMEN: Imaged lung bases are clear. The liver demonstrates homogeneous enhancement. There is a 12 mm hyperenhancing lesion in segment VII/VIII (5b:80), most likely flash-filling hemangioma, unchanged since ___ exam. There is no evidence of intrahepatic biliary ductal dilatation. Biliary stent is unchanged in position. There is expected pneumobilia predominantly in the left hepatic lobe. The portal vein is patent. The gallbladder is surgically absent. There is a small hiatal hernia. The spleen is normal in size. The pancreas enhances homogeneously without main pancreatic ductal dilatation. Focal fatty deposition within the pancreatic head is unchanged (5b:215). There is a 1.7 x 1.6 cm hypodensity in the uncinate process of the pancreas, which is more conspicuous since priors. The adrenal glands are unremarkable. The kidneys enhance and excrete contrast symmetrically without hydronephrosis or suspicious renal masses. Subcentimeter renal hypodensities are too small to characterize and are most likely cysts. There is small amount of ascites, increased since prior study. There is no mesenteric or retroperitoneal lymphadenopathy. Aorta demonstrates extensive calcified atherosclerotic disease with multiple infrarenal fusiform aneurysms, the largest measuring 3.3 cm, unchanged (604b:59). Aneurysmal changes extend to the bilateral iliac vessels, the left measuring 1.6 and the right measuring 2.2 cm. The right external iliac artery measures 11 mm, and appears ectatic. There is moderate narrowing at the origin of the celiac axis. The SMA is patent. There is marked bowel wall edema involving nearly entire colon, which most likely relates to patient's known Clostridium difficile infection. There are multiple colonic diverticula. There are focal areas of hyperintensity within the descending and sigmoid colon (5b:244, 288), which appear hyperdense on the arterial phase. However, no significant progression of hypodensities is seen within the bowel. The evaluation is limited given lack of pre-contrast sequence. CT OF THE PELVIS: A foley catheter is within the bladder. Small amount of air within the bladder likely relates to Foley placement. The rectum, prostate gland and seminal vesicles are unremarkable. There is small amount of free fluid. There is no free air. No pelvic or inguinal lymphadenopathy. OSSEOUS STRUCTURES: No suspicious lytic or sclerotic bony lesion. Prior right eigth rib fracture is noted. IMPRESSION: 1. Limited evaluation due to lack of pre-contrast sequence. Focal areas of hyperdensity within the descending and sigmoid colon without definite progression, are felt to be hight density intraluminal contents unlikely to represent GI bleed; however, this cannot be definitely excluded due to limitation of the study. 2. Diffuse colonic edema, compatible with patient's known history of Clostridium difficile infection. 3. Small amount of ascites and anasarca, increased since prior. 4. Biliary drain is in place with expected pneumobilia. 5. A 12 mm arterial enhancing hepatic lesion, likely flash-filling hemangioma, unchanged since ___ exam. 6. A 17 x 15 mm hypodensity in the uncinate process of the pancreas, more conspicuous since prior studies, which can be further assessed with MRCP, if patient's pacemaker is MR compatible. Otherwise, consider EUS. 7. Extensive calcified atherosclerotic disease of the aorta with associated aneurysmal changes, stable. 8. Small hiatal hernia. Gender: M Race: WHITE - OTHER EUROPEAN Arrive by AMBULANCE Chief complaint: Abd pain Diagnosed with GASTROINTEST HEMORR NOS temperature: 97.4 heartrate: 85.0 resprate: 18.0 o2sat: 96.0 sbp: 101.0 dbp: 48.0 level of pain: 8 level of acuity: 2.0

you were hospitalized for gi bleeding that was from ischemic colitis. you underwent biopsy of your pancreas that did not show cancer. you received transfusion of blood. blood thinner was resumed. you were treated for bacterial infection and are undergoing treatment for C. diff infection. You will need a repeat ERCP in 6 weeks and repeat CT scan of your pancreas in 4 weeks to follow up findings in your pancreas.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Epigastric pain Major Surgical or Invasive Procedure: Supraventricular tachycardia ablation (___) History of Present Illness: ___ man, past medical history of hypertrophic cardiomyopathy status post alcohol septal ablation, presents with epigastric gas-like pain. He states he usually goes away with antacids. States that it "feels like gas-like pain" but when further asked, agreed that it felt like palpitations. No lightheadedness or dizziness. Some mild increased fatigue recently. No chest pain, chest pressure, SOB, DOE, ___ edema, orthopnea, dizziness, lightheadedness, syncope, or falls. Had an episode two months prior where he woke up trying to catch his breath. He was seen by his PCP in office for a routine follow-up regarding this discomfort. They did an EKG and it showed that he was in a rapid supraventricular rhythm. Therefore he was transferred here. The patient states he has had these sensations on and off for over a month and a half at this time. Patient last saw his EP specialist, Dr. ___, in clinic in ___. Per note: "At present, he appears to be asymptomatic to his LVOT obstruction and does not have exertional symptoms. However, given his occasional indigestion with activity, I will have him undergo stress testing. I will also have him repeat a Holter monitor. Holter/stress showed SR as underlying rhythm, rare APDs, frequent multiform VPDs and 3-beat run of VT is noted. He reported feeling well during monitoring period. No changes were made to his management. In the ED, EKG interpreted as supraventricular tachyarrhythmia, likely atrial flutter. Given IV diltiazem 15 mg. Immediately converted into sinus rhythm. Past Medical History: ___ s/p colectomy w/ ileoanal anastomosis, asthma, anxiety, hypertrophic cardiomyopathy, recurrent GI bleeds in ___ (source never identified despite extensive workup, including Spirus enteroscopy, Meckel's scan, multiple CTAs and routine standard upper and lower endoscopy; ultimately thought to be a SB AVM) PSH: colectomy w/ileoanal anastomosis, ileostomy takedown Social History: ___ Family History: Notable for a brother with ulcerative colitis who died of an MI at age of ___, uncle with colon cancer, Brother with prostate and gastric cancer, and sister with breast cancer. Physical Exam: ADMISSION EXAM: VITALS: T 97.6 BP 145/90 HR 59 RR 18 96%Ra GENERAL: well developed, well nourished in NAD HEENT: sclera anicteric, MMM NECK: JVP at at level of clavicle, no LAD CARDIAC: RRR, no mrg, heart sounds soft LUNGS: CTABL, no wheezes, rales, or rhonchi, normal WOB on room air ABDOMEN: soft, non-tender, non-distended, bowel sounds present GU: No foley EXTREMITIES: warm, well perfused, no cyanosis or edema NEURO: AOx3, face symmetric, MAE anti-gravity DISCHARGE EXAM: GENERAL: well developed, well nourished in NAD HEENT: sclera anicteric, MMM NECK: JVP flat while lying at 30 degrees, no LAD CARDIAC: RRR, heart sounds soft. No HCOM murmur with valsava. LUNGS: CTABL, no wheezes, rales, or rhonchi, normal WOB on room air ABDOMEN: soft, non-tender, non-distended, bowel sounds present GU: After EP study, bilateral femoral access points evaluated. There is no underlying hematoma, no bruit auscultated bilaterally. Sites are covered with clean dry gauze. EXTREMITIES: warm, well perfused, no cyanosis or edema NEURO: AOx3, face symmetric, MAE anti-gravity Pertinent Results: ADMISSION LABS: ___ 06:50PM BLOOD WBC-11.9* RBC-5.04 Hgb-15.4 Hct-49.4 MCV-98 MCH-30.6 MCHC-31.2* RDW-12.9 RDWSD-46.4* Plt ___ ___ 06:50PM BLOOD Glucose-120* UreaN-12 Creat-1.1 Na-146 K-4.2 Cl-109* HCO3-26 AnGap-11 ___ 06:50PM BLOOD CK-MB-17* MB Indx-6.0 cTropnT-0.03* PERTINENT RESULTS: TTE: ___ Mild symmetric left ventricular hypertrophy with normal cavity size and regional systolic function. Global systolic function is hyperdynamic. No valvular ___ or resting/inducible intracavitary gradient. Mildly dilated aortic arch DISCHARGE LABS: ___ 07:51AM BLOOD WBC-7.6 RBC-5.21 Hgb-16.2 Hct-49.4 MCV-95 MCH-31.1 MCHC-32.8 RDW-12.7 RDWSD-44.3 Plt ___ ___ 07:51AM BLOOD Glucose-96 UreaN-15 Creat-0.9 Na-141 K-4.4 Cl-107 HCO3-23 AnGap-11 ___ 05:10AM BLOOD CK-MB-14* MB Indx-7.1* cTropnT-0.03* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Verapamil SR 120 mg PO Q24H 2. Amitriptyline 10 mg PO QHS Discharge Medications: 1. Aspirin 325 mg PO DAILY Duration: 30 Days 2. Amitriptyline 10 mg PO QHS 3. Verapamil SR 120 mg PO Q24H Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS/ES: ==================== -Supraventricular tachycardia due to atrioventricular node re-entrant tachycardia (AVNRT) SECONDARY DIAGNOSIS/ES: ======================== -Troponin elevation (demand myocardial infarction) -Hypertrophic cardiomyopathy -Hypertension -Ulcerative colitis -Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with tachycardia, palpitations// assess for pna TECHNIQUE: Upright AP view of the chest COMPARISON: Chest radiograph ___ FINDINGS: Lung volumes are lower compared to the previous exam. There is mild cardiac enlargement, slightly increased from the prior exam. The aorta is mildly tortuous. Mediastinal and hilar contours are otherwise unremarkable. Pulmonary vasculature is not engorged. Lungs appear clear. No pleural effusion or pneumothorax. No acute osseous abnormality. IMPRESSION: No acute cardiopulmonary abnormality. Gender: M Race: WHITE - OTHER EUROPEAN Arrive by WALK IN Chief complaint: Palpitations Diagnosed with Unspecified atrial flutter temperature: 96.0 heartrate: 161.0 resprate: 18.0 o2sat: 99.0 sbp: 141.0 dbp: 112.0 level of pain: 0 level of acuity: 1.0

Dear Mr. ___, WHY WERE YOU ADMITTED TO THE HOSPITAL: -You were having burning and palpitations in your chest -You had an abnormal, fast rhythm of the heart. This is called supraventricular tachycardia (SVT) WHAT WAS DONE FOR YOU WHILE IN THE HOSPITAL: -You were given medications to slow your heart rate down -You were monitored closely on a heart rhythm monitor -You were seen by the electrophysiologists (electrical doctors of the ___ -Your medications were adjusted to help prevent further episodes of SVT WHAT SHOULD YOU DO AFTER LEAVING THE HOSPITAL: -Please continue taking your medications as prescribed -Please follow-up with your outpatient doctors as ___ Thank you for allowing us to participate your care. We wish you the best of luck! Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: Sulfa (Sulfonamide Antibiotics) Attending: ___ Chief Complaint: intraparenchymal hemorrhage with intraventricular hemorrhage Major Surgical or Invasive Procedure: none History of Present Illness: ___ y/o male on Coumadin who lives in assisted living who suffered a witnessed fall today. He was being transferred from his wheelchair to bed when he fell onto his left side and struck his head this morning at 8:45am. It is unclear whether the patient had loss of consciousness at the time of the fall. A cranial CT was done at 1pm that revealed a hemorrhage into an old stroke bed. Patient's INR was 3.0 at presentation. He was given Kcentra and vitamin K. Patient's son endorses a seizure history and states that he had a seizure last week. Past Medical History: 1. CARDIAC RISK FACTORS: + Hypertension 2. CARDIAC HISTORY: -CABG: ___ -PERCUTANEOUS CORONARY INTERVENTIONS: ___ - embolic stroke in ___ after PCI c/b hemorrhagic conversion after receiving TPA - psoriasis - hypothyroid - afib Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. His son does have CAD and is s/p MI with stent placement in his ___. Physical Exam: On Admission: O: T:38.4 BP:100 /65 HR:72 R18 O2Sats 95 Gen: WD/WN, comfortable, NAD. HEENT:Left eye ecchymosis Neck: Trauma collar Cardiac: Irregular Abd: Soft, Extrem: Warm and well-perfused. Neuro: Mental status: Lethargic, but arousable Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light,5 to 3mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Left upper and lower extremity contracture from previous stroke, right side full strength. C/o left hip pain with palpation On Discharge: Left periorbital ecchymosis, Alert and oriented x3, left side contracted and plegic, R side 4+/5 throughout Pertinent Results: ___ 09:06AM PLT COUNT-189 ___ 09:06AM ___ PTT-31.5 ___ ___ 02:06PM WBC-10.9# RBC-4.46* HGB-12.9* HCT-41.8 MCV-94 MCH-28.9 MCHC-30.8* RDW-15.6* ___ NCHCT 1. Right frontal intraparenchymal hemorrhage in the region of encephalomalacia related to prior right MCA infarct. Hemorrhage extending into the bilateral lateral ventricles and the third ventricle. Small left frontal contusion versus subarachnoid hemorrhage. 2. Segmental fracture of the left zygomatic arch. ___ CT Cspine No evidence of acute fracture or dislocation. ___ Chest Xray No definite acute cardiopulmonary process. ___ Hip Films 1. Apparent foreshortening of the right femoral neck, not well assessed on this study, although this does not appear to be the patient's site of concern. 2. No evidence of acute fracture or dislocation of the left hip. ___ Pelvis AP film 1. Apparent foreshortening of the right femoral neck, not well assessed on this study, although this does not appear to be the patient's site of concern. 2. No evidence of acute fracture or dislocation of the left hip. ___ CT SINUS/MANDIBLE/MAXIL Segmental fracture of the left zygomatic arch and possible nondisplaced fracture of the lateral wall of left orbit. ___ ___ Large parenchymal hemorrhage in the right MCA territory at the site of prior infarction with overall minimal change from prior exam. Intraventricular hemorrhage again noted without evidence of obstructive hydrocephalus or herniation. Left zygomatic arch fracture. HEAD CT ___: Final read pending at time of discharge: Stable IPH with improved IVH and stable ventricular size. Medications on Admission: Lisinopril 2.5mg', Keppra 500mg ___, wed, ___ and ___, Metoprolol succ ER 12.5 mg ', Aspirin 81mg',Levothyroxine 75mcg', fish oil, atorvastatin 80mg', Coumadin 2mg', metamucil ' Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN pain or fever > 101.4 2. Docusate Sodium 100 mg PO BID 3. Famotidine 20 mg PO DAILY 4. LeVETiracetam 500 mg PO BID 5. Lisinopril 2.5 mg PO DAILY 6. Metoprolol Tartrate 12.5 mg PO BID 7. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: intraparenchymal hemorrhage IVH 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 SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST INDICATION: ___ year old man with zygomatic arch fx // other fx? TECHNIQUE: Helical axial images were acquired through the paranasal sinuses. Coronal and sagittal reformatted images were obtained and reviewed. DOSE: DLP: 583.83 mGy-cm; CTDI: 25.94 mGy COMPARISON: Comparison is made with CT head from ___. FINDINGS: Segmental fracture of the left zygomatic arch is again seen, similar to prior head CT. There is also a possible nondisplaced fracture of the lateral wall of the left orbit. No other fracture or dislocation is seen. Mucosal thickening is seen in the bilateral maxillary sinuses and ethmoid air cells. Otherwise, the visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The ostiomeatal units are patent bilaterally. Limited views of the brain again demonstrate intracranial bleed, better characterized on recent head CT. IMPRESSION: Segmental fracture of the left zygomatic arch and possible nondisplaced fracture of the lateral wall of left orbit. Radiology Report INDICATION: ___ male with intracranial hemorrhage, evaluate for evolution. TECHNIQUE: Helical axial MDCT images were obtained through the brain without the administration of IV contrast. Reformatted images in coronal and sagittal axes were generated. DOSE: DLP: 1226 mGy-cm COMPARISON: Head CT ___. FINDINGS: Encephalomalacia in the right MCA territory again noted, compatible with a chronic infarction ,which can be seen extending back to ___. Acute hemorrhage within this region of encephalomalacia is again noted (in the right temporal and frontal lobes as well as the rt basal ganglia) extending into the right lateral ventricle. There has been minimal increase in overall volume of hemorrhage from previous study. Intraventricular hemorrhage extends into the lateral ventricles and third ventricle without significant change in ventricular size or evidence of obstructive hydrocephalus. Subarachnoid hemorrhage in the right temporal lobe is unchanged (2 a: 13). Ex vacuo dilation of the right ventricle is unchanged. Minimal hyperdensity previously seen adjacent to the left inferior frontal lobe, thought to represent a tiny component of subarachnoid hemorrhage is not clearly visualized on this exam. There remains no shift of midline structures. Basal cisterns remain patent. Again seen, is an acute segmental fracture through the left zygomatic arch. There is mild mucosal thickening of the maxillary sinuses. The remaining sinuses are clear. Postsurgical changes in the calvarium noted on the right side. IMPRESSION: Large parenchymal hemorrhage in the right MCA territory at the site of prior infarction with overall minimal change from prior exam. Intraventricular hemorrhage again noted without evidence of obstructive hydrocephalus or herniation. Left zygomatic arch fracture. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old man with IVH, IPH // Eval for interval change; assess for increase vent size; pls do ___ AM TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without the administration of IV contrast. Reformatted coronal, sagittal and thin section bone algorithm-reconstructed images were then generated. DOSE: CTDIvol: 55 mGy DLP: 1003.42 mGy-cm COMPARISON: CT head without contrast ___ FINDINGS: In comparison the previous examination, again seen is a large intraparenchymal hemorrhage on chronic encephalomalacia with interventricular hemorrhage unchanged from the previous examination with stable midline shift and mass effect. There is again demonstrated fractures the left zygomatic arch and patient is status post craniotomy. The basal cisterns appear patent and there is preservation of gray-white matter differentiation. The paranasal sinuses, mastoid air cells, and middle ear cavities are clear. Atherosclerotic mural calcification of the vertebral and internal carotid arteries is noted. The globes are unremarkable. IMPRESSION: Unchanged intraparenchymal hemorrhage and left zygomatic fractures from previous examination. No new areas of hemorrhage or infarction. Gender: M Race: ASIAN - CHINESE Arrive by AMBULANCE Chief complaint: s/p Fall, L Eye pain Diagnosed with BRAIN HEM NEC W/O COMA, FX MALAR/MAXILLARY-CLOSE, FALL RESULTING IN STRIKING AGAINST OTHER OBJECT, HYPERTENSION NOS, LONG TERM USE ANTIGOAGULANT temperature: 38.4 heartrate: 72.0 resprate: 18.0 o2sat: 95.0 sbp: 100.0 dbp: 65.0 level of pain: 0 level of acuity: 3.0

Take your pain medicine as prescribed. ¨ Exercise should be limited to walking; no lifting, straining, or excessive bending. ¨ Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ¨ Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ¨ If you were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin prior to your injury, you may not resume taking this until you have been seen in follow up by Dr. ___. ¨ You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ¨ New onset of tremors or seizures. ¨ Any confusion, lethargy or change in mental status. ¨ Any numbness, tingling, weakness in your extremities. ¨ Pain or headache that is continually increasing, or not relieved by pain medication. ¨ New onset of the loss of function, or decrease of function on one whole side of your body.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Penicillins Attending: ___. Chief Complaint: Non - healing left toe amp site with dry gangrene Major Surgical or Invasive Procedure: ___ LLE angiogram ___ LLE TMA History of Present Illness: Mr. ___ is a ___ gentleman with a complex vascular history who has undergone multiple bilateral lower extremity procedures. He has a history of end-stage renal disease and is currently being dialyzed through a right groin tunneled catheter. He presents with dry gangrene of his remaining three toes on his left foot. We have planned for left lower extremity angiogram via the right groin with further intervention to be dictated by our findings. Past Medical History: - ESRD for ___ years. Per medical records, ESRD was ___ severe HTN, though pt reports it followed a gunshot wound to the chest (with possible hypotension and ischemic ATN). He has since required HD, w/ multiple past IV access procedures. Currently undergoes dialysis MWF at ___ in ___ - Status post DDRT in ___ (at ___. ___ RRT in the interim, but graft failed ___ years later. - Hypertension - Parathyroid hyperactivity with "soft bones". Parathyroid was surgically removed ___ years ago. - Status post GSW to right chest ___ years ago. The apical portion of the right lung is removed. Social History: ___ Family History: Denies premature coronary artery disease Physical Exam: ON ADMISSION: Phys Ex: VS - 98.4 80 96/54 20 97% RA Gen - in mild distress ___ pain CV - RRR Pulm - non-labored breathing, no resp distress, satting adequately on RA MSK & extremities/skin - s/p R BKA, L ___ toe amp w/ dry eschar over wound (picture uploaded to ___), b/l palpable femoral pulses(faint), dopplerable L AT and ___ signals ON DISCHARGE: Pertinent Results: ___ 05:12AM BLOOD WBC-8.3 RBC-3.66* Hgb-10.5* Hct-34.5* MCV-94 MCH-28.7 MCHC-30.4* RDW-17.5* RDWSD-59.6* Plt ___ ___ 05:18AM BLOOD WBC-8.9 RBC-3.77* Hgb-10.9* Hct-35.6* MCV-94 MCH-28.9 MCHC-30.6* RDW-17.6* RDWSD-60.0* Plt ___ ___ 05:24PM BLOOD Neuts-70.5 Lymphs-15.8* Monos-7.9 Eos-3.3 Baso-0.6 NRBC-0.4* Im ___ AbsNeut-7.89* AbsLymp-1.77 AbsMono-0.89* AbsEos-0.37 AbsBaso-0.07 ___ 05:12AM BLOOD Plt ___ ___ 05:12AM BLOOD ___ PTT-33.7 ___ ___ 05:12AM BLOOD Glucose-76 UreaN-48* Creat-9.7*# Na-138 K-5.0 Cl-95* HCO3-24 AnGap-19* ___ 05:18AM BLOOD Glucose-90 UreaN-37* Creat-7.7*# Na-136 K-4.9 Cl-95* HCO3-26 AnGap-15 ___ 05:12AM BLOOD Calcium-9.0 Phos-7.8* Mg-2.0 ___ 05:18AM BLOOD Calcium-9.0 Phos-6.7* Mg-2.0 ___ 06:45AM BLOOD Vanco-22.8* ___ 05:03AM BLOOD Vanco-10.5 ___ 05:33PM BLOOD Creat-8.3* K-3.7 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 80 mg PO QPM 2. Gabapentin 100 mg PO TID:PRN pain 3. Omeprazole 20 mg PO DAILY 4. Percocet (oxyCODONE-acetaminophen) ___ mg oral TID:PRN pain 5. sevelamer HYDROCHLORIDE 1600 mg oral TID W/MEALS 6. Aspirin 81 mg PO DAILY 7. Senna 17.2 mg PO DAILY Discharge Medications: 1. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 2. Nephrocaps 1 CAP PO DAILY RX *B complex with C 20-folic acid [Mynephrocaps] 1 mg 1 capsule(s) by mouth once a day Disp #*30 Capsule Refills:*3 3. Percocet (oxyCODONE-acetaminophen) 1 tab mg oral TID:PRN pain 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 80 mg PO QPM 6. Gabapentin 100 mg PO TID:PRN pain 7. Omeprazole 20 mg PO DAILY 8. Senna 17.2 mg PO DAILY 9. sevelamer HYDROCHLORIDE 1600 mg oral TID W/MEALS Discharge Disposition: Home Discharge Diagnosis: PERIPHERAL VASCULAR DISEASE CHRONIC RENAL FAILURE GANGRENE, dry Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report INDICATION: ___ with pre-op // PNA TECHNIQUE: AP view of the chest. COMPARISON: Chest CT from ___ and chest x-ray from ___. FINDINGS: Surgical material projects over the right upper lung as seen previously. The lungs are clear without consolidation, effusion, or edema. Mild cardiomegaly is again noted. Old healed right-sided rib fractures are noted as well as a median sternotomy. Inferior approach central venous catheter tip projects over the right atrium. Resorption of the distal right clavicle is noted, chronic. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: FOOT AP,LAT AND OBL LEFT INDICATION: ___ male with left foot pain // osteo, fracture TECHNIQUE: 3 nonweightbearing views of the left foot. Please note COMPARISON: None FINDINGS: Status post resection of the first digit to the proximal aspect of the proximal phalanx. The osteotomy is irregular and uncorticated, consistent with recent resection. Apparent linear lucency extending toward the base of the medial aspect of the remaining proximal phalanx could be artifactual due to overlying skin defect, although fracture or osteomyelitis would be difficult to exclude. Soft tissue swelling and apparent skin defects are seen about the stump. No subcutaneous gas is identified. No dislocation is seen. There is mild osseous demineralization throughout. There are mild degenerative changes throughout the foot. Extensive vascular calcifications are seen. IMPRESSION: Status post resection of the first digit with expected postsurgical changes. Apparent linear lucency extending from the osteotomy toward the base of the remaining proximal phalanx could be artifactual due to overlying skin defect, although fracture or osteomyelitis would be difficult to exclude. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ HTN, ESRD on HD after failed renal transplant (___), and extensive vascular surgical history w/ open L toe amp wound, s/p L pop/AT stent // st depression st depression IMPRESSION: Comparison to ___. Stable postoperative right apical changes. Stable sternotomy wires and inferior vena cava device. Borderline size of the cardiac silhouette. Stable subtle ___ bronchial opacities, new as compared to the previous examination, and potentially reflecting mild interstitial edema. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: L Foot pain Diagnosed with Local infection of the skin and subcutaneous tissue, unsp temperature: 98.5 heartrate: 87.0 resprate: 16.0 o2sat: 98.0 sbp: 91.0 dbp: 47.0 level of pain: 9 level of acuity: 3.0

It was a pleasure taking care of you at ___ ___. During your hospitalization, you had surgery to remove unhealthy tissue on your lower extremity. You tolerated the procedure well and are now ready to be discharged from the hospital. Please follow the recommendations below to ensure a speedy and uneventful recovery. LOWER TRANSMETATARSAL AMPUTATION DISCHARGE INSTRUCTIONS ACTIVITY •You should keep your amputation site elevated and straight whenever possible. This will prevent swelling of the stump and maintain flexibility in your joint. •It is very important that you put no weight or pressure on your stump with activity or at rest to allow the wound to heal properly. •You may use the opposite foot for transfers and pivots, if applicable. It will take time to learn to use a walker and learn to transfer into and out of a wheelchair. MEDICATION •Before you leave the hospital, you will be given a list of all the medicine you should take at home. If a medication that you normally take is not on the list or a medication that you do not take is on the list please discuss it with the team! •You will likely be prescribed narcotic pain medication on discharge which can be very constipating. If you take narcotics, please also take a stool softener such as Colace. If constipation becomes a problem, your pharmacist can suggest an additional over the counter laxative. •You should take Tylenol ___ every 6 hours, as needed for pain. If this is not enough, take your prescription narcotic pain medication. You should require less pain medication each day. Do not take more than a daily total of 3000mg of Tylenol. Tylenol is used as an ingredient in some other over-the-counter and prescription medications. Be aware of how much Tylenol you are taking in a day. BATHING/SHOWERING: •You may shower when you feel strong enough but no tub baths or pools until you have permission from your surgeon and the incision is fully healed. •After your shower, gently dry the incision well. Do not rub the area. WOUND CARE: •Please keep the wound clean and dry. It is very important that there is no pressure on the stump. If there is no drainage, you may leave the incision open to air. •Your staples/sutures will remain in for at least 4 weeks. At your followup appointment, we will see if the incision has healed enough to remove the staples. •Before you can be fitted for prosthesis (a man-made limb to replace the limb that was removed) your incision needs to be fully healed. CALL THE OFFICE FOR: ___ •Opening, bleeding or drainage or odor from your stump incision •Redness, swelling or warmth in your stump. •Fever greater than 101 degrees, chills, or worsening incisional/stump pain NO OTHER PROVIDER, EXCEPT YOUR VASCULAR SURGEON, SHOULD DETERMINE IF YOUR STAPLES ARE READY TO BE REMOVED FROM YOUR SURGICAL SITE. IF THERE ARE ANY QUESTIONS, THE PROVIDER SHOULD CALL THE VASCULAR SURGERY OFFICE AT ___ TO DISCUSS. THE STAPLES/SUTURES WILL BE REMOVED IN THE OFFICE AT YOUR FOLLOWUP APPOINTMENT WHEN IT IS DETERMINED BY THE VASCULAR SURGEON THAT THE WOUND HAS SUFFICIENTLY HEALED.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: ciprofloxacin / Celexa / latex / morphine Attending: ___. Chief Complaint: Abdominal Pain due to Hemmorhagic Ovarian Cyst Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old Female who presents with a known hemorrhagic ovarian cyst with severe left lower quadrant pain which radiates to the back which began while in exercise class today while performing a pushup. She apparently felt a popping sensation in the LLQ and the severe pain shot to her left inguinal crease to her left labia. She felt the sensation of liquid there, but was dry. Since then she has had intermittant nausea and severe sharp shooting pain. She states that about 1 week prior to admission her stools became quite pale ___ like") and had one bout of diarhea. She states the pain did not worsen with eating. The stools have continued very pale. The patient is at the end of her mestrual period, and she notes that it was one day late. In the ED her initial vitals were 98.2, 85, 105/68, 20, 96%. She underwent an ultrasound (pelvic and transvaginal) along with a CT Abdoment/Pelvis without any explanation of the pain. In addition she was seen by OBGYN consult in the ED, although there is no consult note on the dashboard or OMR, it appears that they felt the cyst would not be explaining this. In the ED she was given fentanyl, dilaudid, ondansetron, ketorolac x2 and promethazine without relief. She arrives on the ward dry heaving in ___ pain. Past Medical History: Chronic Stable Asthma ADHD Peptic ulcer disease Appendectomy Tonsillectomy Social History: ___ Family History: Father: ___ Cancer Mother: DM, DVT Physical Exam: PHYSICAL EXAM: VSS: 98.2, 98/62, 80, 18, 100%RA GEN: NAD Pain: ___ HEENT: EOMI, MMM, - OP Lesions PUL: CTA B/L COR: RRR, S1/S2, - MRG ABD: Moderate LLQ TTP, + Left CVAT, - rebound, - guarding, +BS, - distension EXT: - CCE NEURO: CAOx3, Non-Focal DISCHARGE EXAM: Stable vitals Soft abdomen with volunatary guarding Pertinent Results: ___ 01:00AM BLOOD WBC-8.1 RBC-4.23 Hgb-13.3 Hct-39.1 MCV-92 MCH-31.4 MCHC-34.0 RDW-12.3 RDWSD-41.5 Plt ___ ___ 01:00AM BLOOD Neuts-42.0 ___ Monos-9.0 Eos-3.1 Baso-1.0 Im ___ AbsNeut-3.38 AbsLymp-3.61 AbsMono-0.73 AbsEos-0.25 AbsBaso-0.08 ___ 01:00AM BLOOD Glucose-105* UreaN-11 Creat-1.0 Na-140 K-3.8 Cl-103 HCO3-23 AnGap-18 ___ 01:00AM BLOOD ALT-19 AST-19 LD(LDH)-135 AlkPhos-61 TotBili-0.1 ___ 01:00AM BLOOD Albumin-4.5 ___ 01:17AM BLOOD Lactate-1.8 ___ 04:05AM URINE Color-Straw Appear-Clear Sp ___ ___ 04:05AM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 04:05AM URINE RBC-16* WBC-1 Bacteri-NONE Yeast-NONE Epi-1 ___ 04:05AM URINE UCG-NEGATIVE PELVIS U.S., TRANSVAGINAL Study Date of ___ 1:56 AM PELVIS, NON-OBSTETRIC Study Date of ___ 1:56 AM IMPRESSION: 1. 12 mm left ovarian dermoid. 2. Otherwise normal ovaries without evidence of torsion. 3. Millimetric anterior wall fibroid. CT ABD & PELVIS WITH CONTRAST Study Date of ___ 6:01 AM IMPRESSION: 1. No acute CT findings of the abdomen and pelvis. 2. 9 mm left ovarian dermoid as seen on same-day ultrasound. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing 2. Acetaminophen 325-650 mg PO/PR Q4H:PRN Pain RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours as needed for pain Disp #*50 Tablet Refills:*0 3. Lorazepam 0.5 mg PO Q4H:PRN anxiety RX *lorazepam 0.5 mg 1 tab by mouth once every 4 hours as needed for anxiety/pain Disp #*24 Tablet Refills:*0 4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours as needed for pain Disp #*28 Tablet Refills:*0 5. Tamsulosin 0.4 mg PO DAILY RX *tamsulosin 0.4 mg 1 capsule(s) by mouth once daily Disp #*5 Capsule Refills:*0 6. Metoclopramide 10 mg PO Q8H:PRN nausea RX *metoclopramide HCl 10 mg 1 tab by mouth every 8 hours as needed for nausea Disp #*21 Tablet Refills:*0 7. Ondansetron 4 mg PO Q8H:PRN nausea RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours as needed for nausea Disp #*21 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Renal colic Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: PELVIS U.S., TRANSVAGINAL INDICATION: History of ovarian cyst presenting with pelvic pain. TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with transabdominal approach followed by transvaginal approach for further delineation of uterine and ovarian anatomy. COMPARISON: Pelvic ultrasound ___. FINDINGS: The uterus is anteverted and measures 9.1 x 3.0 x 4.7 cm. The endometrium is homogenous and measures 4 mm. 5 mm anterior wall fibroid as seen previously. 12 mm left ovarian dermoid. The ovaries are otherwise normal. Ovarian vascularity is preserved. There is trace free fluid. IMPRESSION: 1. 12 mm left ovarian dermoid. 2. Otherwise normal ovaries without evidence of torsion. 3. Millimetric anterior wall fibroid. Radiology Report EXAMINATION: CT abdomen and pelvis with contrast INDICATION: Left lower quadrant pain and tenderness to palpation. 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 not administered. DOSE: DLP: 484.91 mGy cm COMPARISON: Same-day pelvic ultrasound. FINDINGS: Heart size is normal without significant pericardial fluid. Imaged lung bases are clear. CT abdomen with contrast: Millimetric hypodensity in hepatic segment 8 is too small to fully characterize but likely represents a biliary hamartoma. Liver otherwise enhances homogeneously without suspicious focal mass or biliary dilatation. Gallbladder is unremarkable. Portal vein is patent. Spleen, pancreas and adrenal glands are unremarkable. Kidneys present symmetric nephrograms and excretion of contrast without focal lesion or hydronephrosis. Stomach, duodenum and small bowel loops are unremarkable without evidence of obstruction. Large bowel is thin-walled and unremarkable without pericolonic fat stranding or fluid collection. Abdominal aorta is normal caliber. No mesenteric or retroperitoneal lymphadenopathy. No ascites, pneumoperitoneum or abdominal hernia. CT pelvis with contrast: Uterus, right ovary and rectum are unremarkable. Small free pelvic fluid. 9 mm fat density left ovarian lesion corresponding to dermoid seen on same-day ultrasound. No free pelvic air. No inguinal or pelvic sidewall lymphadenopathy by CT size criteria. Bones and soft tissues: No suspicious focal bone lesion. IMPRESSION: 1. No acute CT findings of the abdomen and pelvis. 2. 9 mm left ovarian dermoid as seen on same-day ultrasound. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Abd pain Diagnosed with ABDOMINAL PAIN OTHER SPECIED temperature: 98.2 heartrate: 85.0 resprate: 20.0 o2sat: 96.0 sbp: 105.0 dbp: 68.0 level of pain: 10 level of acuity: 2.0

Dear Ms. ___, It was a pleasure participating in your care at ___. You were admitted with severe abdominal pain that was most likely due to a small kidney stone, though it was not visualized on CAT scan and UA was negative. Your pain has improved, and as we discussed, you will be discharged with a short course of oxycodone, tylenol and ibuprofen, as well as Reglan and Zofran. Finally, you are given a prescription for a medicine to help the stone pass if it has not already. Please sip fluids to stay hydrated as you recover.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Headache Major Surgical or Invasive Procedure: ___ - Pipeline embolization for R ICA pseudoaneurysm History of Present Illness: ___ is a ___ year old female with PMH of PCOMM aneurysm s/p clipping on ___ with Dr. ___ unsecured left para-opthalmic artery aneurysm. She had been having headaches for one week prior to presentation that significantly worsened on day of presentation with associated nausea and vomiting. NCHCT at OSH showed acute SAH with IVH. She was transferred to ___ for further evaluation and treatment. Past Medical History: HTN high cholesterol SAH PCOMM aneurysm s/p coiling ___ 4mm L para ophthalmic artery aneurysm (unsecure) Social History: ___ Family History: Brother exp MI in his ___ Physical Exam: On Arrival: ----------- Gen: WD/WN, comfortable, NAD. HEENT: Pupils: ___ EOMs full Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: Lethargic but follows exam with redirection. ___ speaking but daughter at bedside translating. Orientation: Oriented to person, hospital, and month/year. Language: Speech fluent with good comprehension Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to 3-2 mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Intact to light touch Upon Discharge: --------------- She is awake, alert, and cooperative with the exam. She is ___ speaking. She's oriented to self, location, and date. PERRL, EOMI. Left nasolabial fold flattening. Tongue midline. No pronator drift. She moves all extremities with ___ strength. Groin site soft and nontender. Dorsalis pedis pulses palpable and equal bilaterally. Pertinent Results: Please see all pertinent results in OMR Medications on Admission: Alendronate 70 mg tablet. 1 (One) tablet(s) by mouth once a week ATORVASTATIN - Atorvastatin 20 mg tablet. 1 tablet(s) by mouth every night BUTALBITAL-Butalbital-acetaminophen-caffeine 50 mg-325 mg-40 mg tablet. 1 (One) tablet(s) by mouth every six (6) hours as needed for headache Cyclobenzaprine 5 mg tablet. 1 tablet(s) by mouth every 8 hours as needed for muscle spasms Fluticasone 50 mcg/actuation nasal spray,suspension. 2 (Two)sprays b/l nostrils once daily Anusol-HC 2.5 % topical cream with perineal applicator. apply to rectum 2 times daily as needed for hemorrhoids MELOXICAM - Dosage uncertain Ranitidine 150 mg capsule. 1 (One) capsule(s) by mouth 2 times daily Acetaminophen 500 mg tablet. 2 (Two) tablet(s) by mouth up to 3 times daily as needed Adult Low Dose Aspirin 81 mg tablet,delayed release. 1 tablet(s) by mouth once a day CALCIUM 600 + D(3) - Calcium 600 + D(3) 600 mg calcium-200 unit capsule. 1 (One) capsule(s) by mouth 2 times daily Cholecalciferol (vitamin D3) 2,000 unit capsule. 1 (One) capsule(s) by mouth once daily Loratadine 10 mg capsule. 1 (One) capsule(s) by mouth once daily as needed Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Dexamethasone 3 mg PO Q8H Duration: 6 Doses Taper 1 This is dose # 2 of 4 tapered doses 4. Dexamethasone 1 mg PO Q8H Duration: 6 Doses Taper #3 This is dose # 4 of 4 tapered doses 5. Dexamethasone 2 mg PO Q8H Duration: 6 Doses Taper #2 This is dose # 3 of 4 tapered doses 6. Docusate Sodium 100 mg PO BID:PRN constipation 7. Heparin 5000 UNIT SC BID 8. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate 9. Neutra-Phos 2 PKT PO BID 10. NiMODipine 60 mg PO Q4H 11. Senna 17.2 mg PO QHS:PRN constipation 12. TiCAGRELOR 90 mg PO BID 13. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN Pain - Moderate Reason for PRN duplicate override: switching tyelenol 14. Aspirin 81 mg PO DAILY 15. Atorvastatin 20 mg PO QPM 16. Calcium Carbonate 500 mg PO BID 17. Fluticasone Propionate NASAL 2 SPRY NU DAILY 18. Loratadine 10 mg PO DAILY 19. Vitamin D 400 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Subarachnoid hemorrhage Right ICA pseudoaneursym Hypertension Headache Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK INDICATION: History: ___ with subarachnoid hemorrhage, aneurysm clipping. Question of worsening hydrocephalus. 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 Omnipaque intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 14.0 s, 14.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 702.4 mGy-cm. 2) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 32.7 mGy (Head) DLP = 16.3 mGy-cm. 3) Spiral Acquisition 4.3 s, 33.5 cm; CTDIvol = 30.8 mGy (Head) DLP = 1,033.0 mGy-cm. Total DLP (Head) = 1,752 mGy-cm. COMPARISON: CT head done ___ Cerebral angiogram done ___ CTA done ___. FINDINGS: CT HEAD: Surgical clips and embolization coils in the area of the right suprasellar cistern results in a large amount of beam hardening artifact making evaluation of this area difficult. Hemorrhage is noted in the left lateral ventricle near the foramina ___ as well as in the third and fourth ventricles, similar to the earlier same-day CT. Subarachnoid hemorrhage in the suprasellar cistern, anterior interhemispheric fissure, left sylvian fissure, and left-sided sulci is stable compared to the earlier same-day CT. Mild hydrocephalus is stable compared to the earlier same-day CT but new compared to ___. Right frontotemporal extra-axial collection measuring 3 mm in diameter and postsurgical right frontotemporal craniotomy changes appear similar compared to most recent CT. There is mild mucosal thickening in the ethmoid air cells. CTA HEAD AND NECK: Hyperdense embolization coil and surgical clip is noted in the region of the right posterior communicating artery and M1 segment of the right middle cerebral artery which results in a large amount of beam hardening artifact, making the previously treated aneurysm arising from the communicating segment of the right ICA difficult to re-evaluate. The 2 mm medially projecting aneurysm measured rising from the clinoid segment of the left ICA appear similar compared to prior, image 3:198. Within the limitations of the study there is no acute arterial occlusion. No ICA stenosis by NASCET criteria. Mild calcific atherosclerotic changes of the carotid siphons bilateral. The vertebral arteries are patent without evidence for flow-limiting stenosis. OTHER: The visualized portion of the lungs are clear. 7 mm hypodense nodule in the left lobe of thyroid does not meet size criteria for further evaluation by ultrasound according to the ACR guidelines. There is no lymphadenopathy by CT size criteria. IMPRESSION: -Intraventricular and subarachnoid hemorrhage are stable compared to the earlier same-day noncontrast head CT. -Mild hydrocephalus, stable compared to the earlier same-day CT, but new compared to ___. -Revaluation of the previously treated right supraclinoid ICA aneurysm is limited by streak artifact from surgical clips and endovascular coils. Please refer to the subsequent cerebral angiography results for further detail. -Stable 2 mm left ICA clinoid segment aneurysm. NOTIFICATION: According to notes on OMR dated ___ at 17:22 the neurosurgery team was aware of the subarachnoid and intraventricular hemorrhage. Radiology Report EXAMINATION: Right common carotid artery angiogram. Left common carotid artery angiogram. Left vertebral artery angiogram. Right common femoral artery angiogram. INDICATION: ___ year old woman with SAH/IVH, hydrocephalus and known PCOMM aneurysm s/p coiling ___, also with Left para ophthalmic artery aneurysm (unsecure)// diagnostic with possible intervention ANESTHESIA: General endotracheal anesthesia was maintained by separate anesthesia provider throughout the entirety of the case. The anesthesia provider also monitored the patient's hemodynamic and respiratory parameters. TECHNIQUE: Patient was brought into the angio suite, ID was confirmed via wrist band.The patient was placed supine on fluoroscopy table and bilateral groins were prepped and draped in the usual sterile manner. Time-out procedure was performed per institutional guidelines. The location of the right mid femoral head was located using anatomic and radiographic landmarks. 10 +10 cc of subcutaneous lidocaine was infused into the tissue. Micropuncture kit was used to gain access to the right femoral artery, serial dilation was undertaken until a long 6 ___ groin sheath connected to a continuous heparinized saline flush could be inserted. ___ catheter was connected to the power injector and also to a continuous heparinized saline flush. This was advanced over the 0.038 glidewire brought up the aorta used to select the right common carotid artery. AP, oblique and lateral views of the anterior cerebral circulation were obtained. Subsequently, 3D rotational images were performed requiring post processing on an independent workstation under concurrent physician supervision and used in the interpretation and reporting of the procedure. Catheter was then pulled back in the aorta and used to select the left common carotid artery. AP, oblique and lateral views of the anterior cerebral circulation were obtained. The catheter was then pulled back in the aorta and the left subclavian artery was selected. AP and lateral road map imaging was undertaken. Next, the left vertebral artery was selected. AP and lateral views were taken from this vessel for the posterior cerebral circulation. All the Ace runs were medically necessary for management planning. 5000 units of heparin were given, and in collaboration with our colleagues in anesthesia subsequent doses were given to target ACT ___. Also 15 mg of IV Integrilin was given. An OG tube was inserted in verified via chest x-ray and used to gave 300 mg of aspirin and 180 mg of Birlinta. Diagnostic catheter was exchanged to 6 ___ Benchmark Delivery Catheter which was mounted over an angled exchange length wire slowly and carefully with continuous fluoro. Then it was positioned at a satisfactory position in the right internal carotid artery, new road maps were taken. Subsequently, Phenom micro catheter was advanced on a synchro 2 wire until it was parked in a satisfactory position in the middle cerebral artery (M1/M2 junction) carefully and slowly under direct fluoro. A new angio run was done at this point. Measurements were obtained for the pipeline, the synchro 2 wire was pulled out and the pipeline embolization device was advanced until the tip was visualized at the M1 segment of the MCA, the Phenom and the device were then slowly Re treated into the internal carotid artery an slow and careful deployment of the pipeline device was done across the pseudoaneurysm, once we reached the satisfactory apposition against the wall of the artery the pipeline device was completely deployed. A new angio run was done at this point confirming patency of the artery. The microcatheter was retrieved. New magnified and de-magnified angio runs were taken which confirmed the patency of the artery and the excellent positioning of the pipeline device and significant reduction of flow into the pseudoaneurysm. The catheter was then pulled back in the aorta fully removed from the body. A common femoral arteriogram was performed prior to use of a closure device, subsequently 6 ___ Angio-Seal was put in. At the conclusion of the procedure, there is no evidence of thromboembolic complication and the patient was at his neurologic baseline. COMPARISON: ___ PROCEDURE: Diagnostic cerebral angiogram +pipeline embolization of a right internal carotid artery communicating segment pseudoaneurysm. FINDINGS: Right common carotid artery: Carotid bifurcations well-visualized. There is no significant atherosclerosis or carotid stenosis. Right internal carotid artery: The distal right ICA, proximal and distal MCA and ACA branches are well-visualized. An ICA communicating segment pseudoaneurysm was identified, measuring around 4 mm in maximum diameter. Post pipeline embolization, successful deployment of the stent across the neck of the aneurysm with no InStent narrowing or stenosis. Significantly improved distal M1 vasospasm likely secondary to manipulation. Otherwise, vessel caliber smooth and tapering. Normal arterial, capillary, and venous phase. Left common carotid artery: Carotid bifurcations well-visualized. There is no significant atherosclerosis or carotid stenosis. Left internal carotid artery: Distal left ICA, proximal and distal MCA and ACA branches are well-visualized. Stable appearance of the previously noted 2-3 mm aneurysm in the pARA-CLINOIDAL segment of the ICA. Otherwise, vessel caliber smooth and tapering. Normal arterial, capillary, and venous phase . No vascular abnormalities identified . Left vertebral artery , left ___, basilar artery, bilateral AICA, bilateral SCA and bilateral PCAs are well-visualized. The right ___ is not well visualized as there was no cross-filling to the right vertebral artery. No vascular abnormalities identified, vessel caliber smooth and tapering. Arterial, capillary, venous phases were normal . Right common femoral artery: Well-visualized with a good caliber size for closure device. I, ___, participated in the procedure. I, ___, was present for the entirety of the procedure and supervised all critical steps. I, ___, have reviewed the report and agree with the fellow's findings. IMPRESSION: Right ICA communicating segment pseudoaneurysm was identified, measuring around 4 mm in maximum diameter. Post pipeline embolization, successful deployment of the stent across the neck of the aneurysm with no InStent narrowing or stenosis. Significantly improved distal M1 vasospasm likely secondary to manipulation. RECOMMENDATION(S): 1. Continue on dual antiplatelet. 2. Follow-up angiogram within 4 weeks. 3. Tight blood pressure control for the next few days. 4. Subarachnoid hemorrhage management as per usual protocol. Radiology Report INDICATION: ___ year old woman with SAH// Assess ETT position and OGT position and for any pulmonary congestion TECHNIQUE: AP portable chest radiograph COMPARISON: ___ IMPRESSION: The tip of the endotracheal tube projects 2.2 cm from the carina and the tip of the feeding tube projects over the stomach. There are low bilateral lung volumes. New streaky opacities in the left lower lung may reflect atelectasis or aspiration. The right lung is grossly clear. No pleural effusion or pneumothorax. The size of the cardiac silhouette is within normal limits. Radiology Report INDICATION: ___ year old woman with SAH// New NGT please assess position TECHNIQUE: AP portable chest radiograph COMPARISON: ___ from earlier in the day FINDINGS: The tip of the nasogastric tube the AA projects over the distal stomach. The tip of the endotracheal tube projects 2 cm from the carina. No focal consolidation, pleural effusion or pneumothorax. The size of the cardiac silhouette is within normal limits.. IMPRESSION: The tip of the nasogastric tube projects over the distal stomach. The tip of the endotracheal tube projects 2 cm from the carina. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old woman with Low grade SAH// POD 2 from pipline of R ICA pseudo-aneurysm. TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained without intravenous contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 747.5 mGy-cm. Total DLP (Head) = 747 mGy-cm. COMPARISON: CTA head and neck dated ___ and CT head from outside facility also dated ___. FINDINGS: Metallic clips and embolization coils with associated artifact are again noted adjacent to the right suprasellar cistern. Assessment of the posterior fossa and adjacent structures is limited. Since the prior examination, there is increased high-density layering hemorrhage within the occipital horns of both lateral ventricles (02:15) and the superior aspect of the third ventricle (02:16). There has been interval slight increased prominence of the bilateral frontal horns of the lateral ventricles and temporal horn of the right lateral ventricle. The temporal horn of the left lateral ventricle is likely stable from prior. Subarachnoid hemorrhage involving the bilateral parasagittal frontal lobes and right frontal lobe appears stable (02:12, 02:14). Previously described subarachnoid hemorrhage in the suprasellar cistern is less evident suggesting evolution. Right frontal temporal postsurgical changes are re-demonstrated with decreased prominence of the right frontotemporal extra-axial collection measuring 1-2 mm, previously 3 mm. No definite new hemorrhage or infarct. No midline shift. IMPRESSION: 1. Interval new intraventricular hemorrhage and slight worsening of hydrocephalus. 2. No midline shift or evidence of infarct. 3. Redemonstrated embolization coils and surgical clips limiting assessment of surrounding structures. NOTIFICATION: The findings were discussed with ___, N.P. by ___ ___, M.D. on the telephone on ___ at 4:02 pm, 2 minutes after discovery of the findings. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman with SAH/IVH s/p PCOMM aneurysm clipping// hemorrhage or infarct TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Total DLP: 752.1 mGy-cm. COMPARISON: ___ noncontrast head CT. FINDINGS: Surgical hardware streak artifact limits examination. Patient is status post metallic clips and embolization coil placement in the right suprasellar region, consistent with history of right communicating artery aneurysm clipping. The right internal carotid artery stent at the clinoid is also noted. While there is stable ventriculomegaly and near complete effacement of cerebral gyri and sulci, pre-existing layering intraventricular hyperdensity has resolved. There remains stable ovoid hyperdensity along the posterior midline of the interventricular septum measuring 1.4 x 1.0 cm. Patient is status post right temporal craniotomy with stable postsurgical changes. Bilateral mastoid air cells are underpneumatized. 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. Surgical hardware streak artifact limits examination. 2. Within limits of study, no evidence of new or enlarging hemorrhage and no definite evidence of territorial infarct. Please note MRI of the brain is more sensitive for the detection of acute infarct. 3. Interval resolution of layering intraventricular hemorrhage. 4. Grossly stable ventriculomegaly with near complete effacement of the sulci. 5. Grossly stable intraventricular septum 1.4 cm probable blood products compared to ___ prior exam, new compared to ___ prior. Radiology Report EXAMINATION: CTA HEAD WANDW/O C AND RECONSQ1213CTHEAD INDICATION: ___ s/p pipeline embo of R ICA pseudoaneurysm on ___ now with worsening HA, agitation and new R Ptosis. Eval for etiology of neurologic symtpoms.// Evaluate for etiology of neurologic symptoms and new R ptosis. TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Next, rapid axial imaging was performed through the brain during the uneventful infusion of Omnipaque intravenous contrast material. Three-dimensional angiographic volume rendered and segmented images were then generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 747.5 mGy-cm. 2) Spiral Acquisition 2.5 s, 19.6 cm; CTDIvol = 27.6 mGy (Head) DLP = 539.9 mGy-cm. 3) Sequenced Acquisition 0.5 s, 0.5 cm; CTDIvol = 5.7 mGy (Head) DLP = 2.8 mGy-cm. 4) Stationary Acquisition 4.6 s, 0.5 cm; CTDIvol = 51.1 mGy (Head) DLP = 25.6 mGy-cm. Total DLP (Head) = 1,316 mGy-cm. COMPARISON: CT head without contrast ___., CTA head neck ___ FINDINGS: CT HEAD WITHOUT CONTRAST: Status post right-sided craniotomy. Metallic clips and embolization coils with associated streak artifact are present adjacent to the right suprasellar cistern. The patient is status post right paraclinoid pipeline carotid artery stent placement. Right parasellar aneurysm clip. Otherwise, no significant change in the blood products (0.1 cm AP x 1.4 cm TV) in the interventricular septum since ___. There is no new intracranial hemorrhage. There is no large territorial infarct. Stable moderate hydrocephalus with mild periventricular low-attenuation changes may be from periventricular edema, with possible contribution from chronic small vessel ischemic changes. Trace intraventricular blood products within occipital horn, similar. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. CTA HEAD: There is within spasm at the bilateral M1, A1, proximal ACA segments,, bilateral PCA similar compared with ___, apparent compared with ___. There is mild parenchymal edema, without definite areas of ischemia. The vessels of the circle of ___ and their principal intracranial branches appear normal with no evidence of stenosis, occlusion, or aneurysm. The dural venous sinuses are patent. IMPRESSION: 1. No significant change in size of the interventricular hemorrhage. 2. Unchanged moderate hydrocephalus, suggestion of periventricular edema. 3. Intracranial arterial vasospasm, similar to ___ exam.. Suggestion of areas of parenchyma edema, without definite ischemia. Radiology Report EXAMINATION: Diagnostic cerebral angiogram for evaluation of previously ruptured right posterior communicating artery aneurysm in the setting of new right eye ptosis. During the procedure the following vessels were selectively catheterized angiograms performed: Right internal carotid artery Three-dimensional rotational angiography of the right internal carotid artery circulation requiring post processing on an independent workstation and concurrent attending physician interpretation and review Left common femoral artery Ultrasound-guided access to the left common femoral artery INDICATION: This ___ female who suffered a subarachnoid hemorrhage in posterior communicating artery aneurysm rupture several months ago. She underwent coiling at that time. Angiogram at follow-up in ___ showed residual aneurysm that underwent clipping. There is a drop to of rupture during the clipping. She presented several days after with a new headache. There is evidence of residual aneurysm near the clip versus dissection. She was treated with a pipeline embolization device. This morning she presented with new headache and additional right-sided ptosis. She underwent a CTA that was unrevealing but had significant artifact related to the coils and clips and pipeline. For that reason angiogram was undertaken. ANESTHESIA: The patient was somewhat somnolent at baseline and received 2 mg of Versed for the procedure. She did not received 2 agents. Her respiratory in hemodynamic parameters were continuously monitored by a trained an independent observer. TECHNIQUE: Diagnostic cerebral angiogram, single-vessel COMPARISON: Multiple previous angiograms. PROCEDURE: The patient was identified and brought to the neuro radiology suite. She was transferred to the fluoroscopic table supine. An interpreter was present for the duration of the procedure. Versed was administered. Bilateral groins were prepped and draped in standard sterile fashion. A time-out was performed. In light of her many recent procedure she has several palpable Angio-Seal device is in the right groin. For this reason the left groin was used for access. The left common femoral artery was identified using anatomic and radiographic landmarks. The left common femoral artery was accessed using standard micropuncture technique after infiltration of local anesthetic using ultrasound guidance. A long 5 ___ sheath was introduced, connected to continuous heparinized saline flush, and secured. Next a stiff ___ 2 catheter was introduced. It was advanced over 038 glidewire through the aorta into the aortic arch. It was used to select the right common carotid artery. The wire was removed. A roadmap was performed. The wire was introduced and used to select the right internal carotid artery. The catheter was positioned over the wire in the right internal carotid artery. The wire was removed. Vessel patency was confirmed via hand injection. Three-dimensional rotational images well as standard AP and lateral and high magnification oblique views were obtained. Next the diagnostic catheter was removed. Left t common femoral angiogram was performed via hand injection through the sheath. The sheath was removed and the arteriotomy was closed using a 6 ___ Angio-Seal evolution. The patient was removed from the fluoroscopy table remained at her neurologic baseline without any evidence of thromboembolic complications. OPERATORS: Dr. ___ Dr. ___ physician performed the procedure. Dr. ___ supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings. FINDINGS: Ultrasound the left common femoral artery: There is a single noncompressible, arterial, pulsatile lumen. There is evidence of access of the wire into the lumen Right internal carotid artery: Vessel caliber smooth and regular. There is opacification of the anterior and middle cerebral arteries and their distal territories. There is no evidence of a residual filling of the previous posterior communicating artery aneurysm. There is artifact related to the previous coil and clip. There is a pipeline device located across the neck of the previous aneurysm. There is no evidence of endoleak. There is no InStent stenosis. There is no residual filling on the three-dimensional image as well. Left common femoral artery: Arteriotomy is above the bifurcation. There is good distal runoff. There is no evidence of dissection. Vessel caliber appropriate for closure device. . IMPRESSION: ___ 1, no residual filling of previously ruptured, coiled, clipped, and pipelined right posterior communicating artery aneurysm. RECOMMENDATION(S): 1. Continue aspirin and relate to. Plans for remote treatment of contralateral ICA aneurysm on the left. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with subarachnoid hemorrhage S/P pipeline embolization of pseudoaneurysm with leukocytosis// rule out pneumonia rule out pneumonia IMPRESSION: Compared to chest radiographs since ___ most recently ___. Heart size top-normal. Lungs clear. No pleural abnormality. Radiology Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ year old woman with subarachnoid hemorrhage now S/P pipeline embolization of R ICA pseudoaneurysm with leukocytosis// rule out DVT TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, flow, and augmentation of the bilateral common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: No evidence of deep venous thrombosis in the right or left lower extremity veins. Gender: F Race: HISPANIC/LATINO - DOMINICAN Arrive by AMBULANCE Chief complaint: SAH, Transfer Diagnosed with Headache temperature: 97.0 heartrate: 75.0 resprate: 18.0 o2sat: 95.0 sbp: 123.0 dbp: 58.0 level of pain: 7 level of acuity: 2.0

Discharge Instructions Activity · You may gradually return to your normal activities, but we recommend you take it easy for the next ___ hours to avoid bleeding from your groin. · Heavy lifting, running, climbing, or other strenuous exercise should be avoided for ten (10) days. This is to prevent bleeding from your groin. · You make take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. · Do not go swimming or submerge yourself in water for five (5) days after your procedure. · You make take a shower. Medications · Resume your normal medications and begin new medications as directed. · It is very important to take the medication your doctor ___ prescribe for you to keep your blood thin and slippery. This will prevent clots from developing and sticking to the stent. · You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. · If you take Metformin (Glucophage) you may start it again three (3) days after your procedure. Care of the Puncture Site · The small bandage over the site was removed. · Keep the site clean with soap and water and dry it carefully. · You may use a band-aid if you wish. What You ___ Experience: · Mild tenderness and bruising at the puncture site (groin). · Soreness in your arms from the intravenous lines. · The medication may make you bleed or bruise easily. · Fatigue is very normal. When to Call Your Doctor at ___ for: · Severe pain, swelling, redness or drainage from the puncture site. · Fever greater than 101.5 degrees Fahrenheit · Constipation · Blood in your stool or urine · Nausea and/or vomiting Call ___ and go to the nearest Emergency Room if you experience any of the following: · Sudden numbness or weakness in the face, arm, or leg · Sudden confusion or trouble speaking or understanding · Sudden trouble walking, dizziness, or loss of balance or coordination · Sudden severe headaches with no known reason

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: seasonal Attending: ___ Chief Complaint: Shortness of breath and leg swelling Major Surgical or Invasive Procedure: None History of Present Illness: ___ male with PMHx new diagnosis CHF (EF 55%), hypertension, spinal stenosis, anxiety, depression, alcohol abuse, and chronic macrocytic anemia presenting with 1 week of worsening dyspena on exertion. He was seen in his PCP's office on ___, was started on furosemide and told to go to the ED for worsening anemia. He was not able to make it to the ED as recommended, and has had worsening DOE, leg, scrotal, and abomdinal edema despite diuretics. In the ED, he was afebrile, hypertensive to 142/68, and SaO2 96% on RA. Labs remarkable for Na+119, proBNP 9033, HCT 23 (MCV 99), INR 1.2, trop <0.01. Received 40mg IV furosemide, albuterol and ipratropium, nebs. On ROS, he notes progressive SOB and edema of his legs for the past 3 months. He reports 3 weeks of non-bloody diarrhea without sick contacts, recent abx use, no laxative use. He reports a chronic cough that he attributes to smoking, but has noted increased phlegm over several weeks. Reports slightly decreased appetite, weight gain of unknown amount over several months. Denies fevers, chills, night sweats, headache, sinus tenderness, rhinorrhea, congestion, chest pain, chest tightness, palpitations, nausea, vomiting, hematemesis, constipation, abdominal pain, dysuria, arthralgias, myalgias. On the floor patient reports trouble breathing mostly with transfers, and less so at rest. He denies a history of blood transfusions. No other complaints. States he feels very tired right now. Past Medical History: Alcohol abuse CHF Grand mal seizure (presumed d/t EtOH) several years ago Macrocytic anemia, likely due to ETOH use (normal B12, folate, iron studies, BM Bx) Mild proteinuria Mild bicuspid aortic stenosis Moderate mitral regurgitation Moderate tricuspid regurgitation Peripheral vascular disease Spinal stenosis c/b neurogenic claudication, s/p L2-5 Laminectomy with L3-5 fusion; C5-6 and C6-7 discetomy and fusion Chronic back pain (treated w regular injections) Fatty liver disease Chronic Hepatitis B Essential HTN Hiatal hernia with reflux Allergic rhinitis Psoriasis h/o Hyponatremia, possibly beer potomania Adjustment disorder with mixed anxiety/depression Erectile dysfunction Gastritis S/P closed scapula fracture Adenomatous and benign colonic polyps Social History: ___ Family History: No known history of CAD, HTN, DM. Father had alcohol abuse and subsequent cardiomyopathy. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.5, 156/80, 98, 20, 100% on 2L NC Weight: 88.6kg I/O: 2250 UOP since 10mg IV lasix (in 6 hours) GEN: NAD, alert, oriented, conversant and appropriate HEENT: NC/AT, PERRL, sclera anicteric, MM slightly dry, oropharynx clear, poor dentition without gum erythema or lesions NECK: supple, JVD mildly elevated, no LAD RESP: good effort, no accessory muscle use, rales ___ way up, no rhonchi, occasional expiratory wheeze CV: RRR, nl s1/s2, ___ holosystolic murmur at apex, ___ early systolic murmur at RUSB ABD: soft, distended, non-tender, 1+ abdominal pitting edema to umbillicus, organomegaly not appreciated, + BS EXT: warm, well-perfused, 2+ pitting edema b/l ___, dry and thickened skin on anterior tibia b/l NEURO: aaox3, CNII-XII intact, mild dysmetria, normal rapid alternating movements, gait deferred DISCHARGE PHYSICAL EXAM: VS: 98.3 132/71 81 20 96% on RA Weight: 87.0 I/O: 500+sips/3150 GEN: NAD, alert, oriented, conversant and appropriate HEENT: NC/AT, PERRL, sclera anicteric, conjunctival pale, MMM, oropharynx clear, poor dentition without gum erythema or lesions NECK: supple, no JVD elevation, no LAD RESP: good effort, no accessory muscle use, rales at bases, no rhonchi, bilateral short expiratory wheeze CV: RRR, nl s1/s2, ___ holosystolic murmur at apex, ___ early systolic murmur at RUSB ABD: soft, obese, non-tender, 1+ abdominal pitting edema at flanks to umbillicus, organomegaly not appreciated, + BS EXT: warm, well-perfused, 1+ pitting edema b/l ___, dry and thickened skin on anterior tibia b/l NEURO: aaox3, CNII-XII intact, moving all 4 extremities Pertinent Results: ADMISISON LABS: ======================= ___ 05:30PM BLOOD WBC-6.0 RBC-2.33* Hgb-7.5* Hct-23.0* MCV-99* MCH-32.4*# MCHC-32.8 RDW-18.2* Plt ___ ___ 05:30PM BLOOD Neuts-68.7 ___ Monos-6.9 Eos-3.9 Baso-0.7 ___ 05:30PM BLOOD ___ PTT-35.9 ___ ___ 05:30PM BLOOD Glucose-88 UreaN-10 Creat-0.7 Na-119* K-4.7 Cl-84* HCO3-25 AnGap-15 ___ 05:30PM BLOOD ALT-13 AST-19 AlkPhos-104 TotBili-0.3 ___ 05:30PM BLOOD Lipase-41 ___ 05:30PM BLOOD cTropnT-<0.01 proBNP-9033* ___ 05:30PM BLOOD Albumin-2.6* Calcium-8.3* Phos-3.9 Mg-1.0* ___ 05:30PM BLOOD VitB12-GREATER THAN ___ 05:30PM BLOOD TSH-2.0 ___ 05:38PM BLOOD Lactate-0.9 IMAGING/STUDIES: ======================== ___ CXR: Interval increase in pulmonary vascular congestions, interstitial edema, small bilateral pleural effusions R>L ___ ECG: Poor baseline, NSR at 75bpm, normal axis, IVCD, 1mm STE in V2 that is new from ___ ___ RUQ US: FINDINGS: The liver shows no evidence of focal lesions or textural abnormality. Doppler assessment of the main, right, and left portal vein show patency and hepatopetal flow. There is no ascites. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The common bile duct measures 0.6 cm. The gallbladder is normal without evidence of stones or gallbladder wall thickening. Pancreatic head and body are unremarkable; the pancreatic tail is not well visualized secondary to overlying bowel gas. The spleen measures 8.3 cm and has a homogeneous echotexture. The right and left kidneys are normal without mass, hydronephrosis or stones. The right kidney measures 12.9 cm in the left kidney measures 13.3 cm. The aorta is of normal caliber throughout, without evidence of atherosclerotic plaques. The visualized portions of the inferior vena cava appear normal. Incidental note is made of a right pleural effusion. IMPRESSION: 1. No focal liver masses. 2. Patent hepatic vasculature with hepatopetal flow. PERTINENT LABS ================================= ___ 06:10AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL Target-1+ ___ 06:10AM BLOOD Ret Aut-4.0* ___ 06:10AM BLOOD LD(LDH)-193 ___ 05:30PM BLOOD ALT-13 AST-19 AlkPhos-104 TotBili-0.3 ___ 05:30PM BLOOD Lipase-41 ___ 05:30PM BLOOD cTropnT-<0.01 proBNP-9033* ___ 06:10AM BLOOD calTIBC-273 Hapto-270* Ferritn-149 TRF-210 ___ 05:30PM BLOOD TSH-2.0 ___ 05:38PM BLOOD Lactate-0.9 DISCHARGE LABS ================================== ___ 06:25AM BLOOD WBC-7.2 RBC-2.54* Hgb-8.2* Hct-24.3* MCV-96 MCH-32.3* MCHC-33.7 RDW-16.9* Plt ___ ___ 06:25AM BLOOD Glucose-107* UreaN-20 Creat-0.7 Na-129* K-4.3 Cl-88* HCO3-33* AnGap-12 ___ 06:25AM BLOOD Calcium-8.3* Phos-3.7 Mg-1.5* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Betamethasone Dipro 0.05% Cream 1 Appl TP BID 2. ClonazePAM 1 mg PO TID 3. Loratadine 10 mg PO DAILY:PRN allergic rhinitis 4. Multivitamins 1 TAB PO DAILY 5. Omeprazole 20 mg PO DAILY 6. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H 7. Cyanocobalamin 1000 mcg PO DAILY 8. Baclofen 10 mg PO TID 9. Vitamin D 1000 UNIT PO DAILY 10. Citalopram 40 mg PO DAILY 11. Lisinopril 20 mg PO DAILY 12. Docusate Sodium 100 mg PO BID 13. Metoprolol Tartrate 50 mg PO BID 14. Zolpidem Tartrate 10 mg PO HS:PRN insomnia Discharge Medications: 1. Baclofen 10 mg PO TID 2. Betamethasone Dipro 0.05% Cream 1 Appl TP BID 3. Citalopram 40 mg PO DAILY 4. ClonazePAM 1 mg PO TID 5. Cyanocobalamin 1000 mcg PO DAILY 6. Docusate Sodium 100 mg PO BID 7. Lisinopril 20 mg PO DAILY 8. Loratadine 10 mg PO DAILY:PRN allergic rhinitis 9. Metoprolol Tartrate 50 mg PO BID 10. Multivitamins 1 TAB PO DAILY 11. Omeprazole 20 mg PO DAILY 12. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H 13. Vitamin D 1000 UNIT PO DAILY 14. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob, wheeze 15. Aspirin 81 mg PO DAILY 16. Ferrous Sulfate 325 mg PO DAILY 17. Nicotine Patch 21 mg TD DAILY 18. Torsemide 60 mg PO DAILY 19. Zolpidem Tartrate 10 mg PO HS:PRN insomnia Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: diastolic CHF exacerbation Secondary: peripheral edema, macrocytic anemia, alcohol abuse 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: Dyspnea on exertion, here to evaluate for fluid overload or pneumonia. COMPARISON: Prior chest radiograph dated ___ and ___. TECHNIQUE: Upright AP and lateral radiographs of the chest. FINDINGS: There is interval increased mild pulmonary vascular congestion/interstitial edema from the remote prior study. Small bilateral pleural effusions on the right greater than left are present. There is no pneumothorax. Mild biapical scarring appears symmetrical. Increased opacification at the right lung base is most likely reflective of atelectasis. The cardiac silhouette is moderately enlarged but stable. The mediastinum is prominent, likely related to a combination of tortuous vessels and technique. Anterior cervical spine fixation hardware is redemonstrated. There are multiple old fracture deformities of the bilateral clavicles and right posterior ribs. IMPRESSION: Mild pulmonary vascular congestion/interstitial edema and small bilateral pleural effusions. Radiology Report HISTORY: ___ year old man with chronic Hepatitis B, alcohol abuse, presenting ___ and abdominal edema, hyponatremia. Evaluate for evidence of cirrhosis and patency of hepatic vasculature. TECHNIQUE: Gray scale and Doppler ultrasound images of the abdomen were obtained. COMPARISON: Abdominal ultrasound from ___. FINDINGS: The liver shows no evidence of focal lesions or textural abnormality. Doppler assessment of the main, right, and left portal vein show patency and hepatopetal flow. There is no ascites. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The common bile duct measures 0.6 cm. The gallbladder is normal without evidence of stones or gallbladder wall thickening. Pancreatic head and body are unremarkable; the pancreatic tail is not well visualized secondary to overlying bowel gas. The spleen measures 8.3 cm and has a homogeneous echotexture. The right and left kidneys are normal without mass, hydronephrosis or stones. The right kidney measures 12.9 cm in the left kidney measures 13.3 cm. The aorta is of normal caliber throughout, without evidence of atherosclerotic plaques. The visualized portions of the inferior vena cava appear normal. Incidental note is made of a right pleural effusion. IMPRESSION: 1. No focal liver masses. 2. Patent hepatic vasculature with hepatopetal flow. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: DYSPNEA Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, HYPOSMOLALITY/HYPONATREMIA, HYPERTENSION NOS temperature: 97.3 heartrate: 78.0 resprate: 20.0 o2sat: 95.0 sbp: 147.0 dbp: 73.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, You were admitted to ___ for worsening leg and abdominal swelling, worsening shortness of breath, and low blood counts. We gave you medications to help you urinate out extra fluid. We were able to get fluid out of your lungs and you no longer requried oxygen to breathe. The fluid in your legs improved. You received blood to elevated your blood count to help your breathing and fatigue. Your blood counts remained stable. Please weigh yourself daily.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Tetracycline / Minocin / hydrocodone / nifedipine / ibuprofen Attending: ___. Chief Complaint: headache Major Surgical or Invasive Procedure: None History of Present Illness: ___ y/o female with a past medical history of T4N0M0 Stage IIIA poorly differentiated adenosquamouscarcinoma of the lung s/p right pneumonectomy ___, adjuvant cisplatin/gemcitabine ___ now on active surveillance, recent admission for CAP (D/C ___ on cefpodox/azithro through ___, on enoxaparin since ___ for PE, now presents with headache and gait imbalance. The history is obtained with pt and her son who lives with her. He states that ___ days ago his wife started noticing that the patient had her head tilted to the right side and they also noted over the past ___ days that things had to be repeated to her and she was having trouble understanding things though not overtly confused and disoriented otherwise. She also noted headaches starting about 2 days ago which are intermittent and mostly located over the left temple though some right sided neck pain is associated. She denies any visual changes/diplopia. Denies fever/nausea/vomiting. She has baseline dyspnea on exertion after her pneumonectomy, and cough at baseline, but these things have not worsened. She recalls no trauma or head strike. No report of syncope. She also denies diarrhea/dysuria/abd pain/chest pain. ED COURSE: v/s 97.8 94 130/96 18 100% RA . Exam was notable for left facial droop and head tilt to left. Labs were unremarkable, including LFTS, CBC, chem, coags, trop (in ED she reported having had chest pain at home), and UA. noncon CT had showed interval development of multiple intracranial mass lesions with associated vasogenic edema new from ___, rec MRI. Vasogenic edema from left temporal/parietal lobe mass results in effacement of temporal horn of left lateral ventricle. CXR no acute process. Neurosurgery was consulted and they felt that this was c/w brain mets of known lung cancer, no indication for neurosurgical intervention at this time. SHe received 1g apap, 2.5mg olanzapine, 120mg lovenox at 10 AM, 100mcg levothyroxine. Past Medical History: PAST ONCOLOGIC HISTORY: ___ woman who in started to experience non-productive cough in ___, and subsequently developed hemoptysis on ___ when she went to ___ too be evaluated. There she had a chest CT which showed a 4.4 x 4.2 cm right hilar/right middle lobe lung mass surrounding the right pulmonary artery and nearly collapsing the right bronchus intermedius; also, there was a 1.0 x 1.6 cm right lower lobe spiculated nodule and a 0.7 cm 4R lymph node and a 2.0 x 1.1 cm right adrenal nodule. She had a bronchoscopy ___ with biopsy of the right lower lobe lung mass which showed non-small cell carcinoma with CK5/6 positive, P63 positive, TTF-1 negative, napkin A negative, supporting squamous cell carcinoma. Washings from the RLL were positive for malignant cells compatible with carcinoma. On ___ a head CT was negative for metastases. PET-CT on ___ showed a 5 x 5.4 cm right parahilar mass with an SUV of 18.2 with partial collapse of the RML; there was extension of the mass to the right upper lobe bronchus and mild mass effect on the RLL bronchus; there was a 1.7 x 1.5 cm ground-glass opacity in the RLL with an SUV of 2.8, concerning for metastasis; there was a 2.1 x 1.7 cm right paratracheal lymph node with an SUV of 3.3; a prevascular lymph node measuring 1.8 x 1.1 cm with an SUV of 2.3; there was a 1.8 x 1.3 cm subcarinal lymph node with an SUV of 3.2; there were no abdominal, pelvic or bone metastases. On ___ she underwent an EBUS-guided of 11L, 7L, and 4R LNs that were negative for malignancy; biopsy of the RML lung mass showed invasive poorly differentiated non-small cell carcinoma with cytokeratin 7 positive and focal positivity for CK5/6 and TTF-1; napsin was negative and the differential diagnosis was felt to be adenosquamous carcinoma versus high-grade mucoepidermoid carcinoma; RLL FNA was positive for malignant cells compatible with nonsmall cell carcinoma. On ___ she had a cervical mediastinoscopy; biopsy from the 4R station showed four lymph nodes, which were negative and biopsy from the level 7 station also showed four lymph nodes, which were negative. On ___ he had a right pneumonectomy. Her tumor was 8.2 cm in greatest diameter. In addition, she did have a separate tumor nodule in the right lower lobe, which was a squamous cell carcinoma 1.5 cm unclear whether this represents a second primary or a satellite lesion. There was also adjacent lung parenchyma with atypical adenomatous hyperplasia, multiple lymph nodes were negative. All margins were negative. No LVI, no visceral pleural involvement. She recovered reasonably well from her surgery. Was started on Adjuvant Cisplatin and Gemcitabine on ___ and completed on ___. Her treatment was complicated by pulmonary embolism in ___ and she was started on enoxaparin. Past Medical History: 1. Bipolar disorder 2. Schizophrenia 3. Hypothyroidism 4. Vasculitis 5. GERD. 6. Lung cancer, as above. 7. Right adrenal nodule - not FDG avid 8. Pulmonary embolism on anticoagulation Social History: ___ Family History: - Father died at age ___ from heart disease. - Mother died at age ___ from complications of diabetes mellitus - Maternal aunt had throat cancer. Physical Exam: ADMISSION PHYSICAL EXAM: General: NAD HEENT: MMM, no OP lesions, no cervical, supraclavicular, or axillary adenopathy, no thyromegaly CV: RR, NL S1S2 no S3S4 MRG PULM: CTAB GI: BS+, soft, NTND, no masses or hepatosplenomegaly LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal adenopathy SKIN: No rashes or skin breakdown Neurological Examination: Her ___ Performance Score is 70. She is oriented to name and place. She does not know the year, month is ___ then ___ is summer. 6 quarters in $1.75. There is no right-left confusion, finger agnosia, no apraxia, clock drawing is normal, she can copy two intersecting pentagons. She is inattentive. She is dysarthric with nonfluent aphasia. She can name, repeats with mild paraphasic errors, comprehends, reads, writes. Her recent recall is fair. Cranial Nerve Examination: Her pupils are equal and reactive to light, 4 to 2 mm bilaterally. Extraocular movements are full; there is no nystagmus, no ptosis, no diplopia. Visual field are full. She has a mild left UMN facial. Facial sensation is intact bilaterally. Her hearing is intact bilaterally. Her tongue is midline. Palate goes up in the midline. Sternocleidomastoid and upper trapezius are strong. Motor Examination: She has left upper extremity pronation. Tone is increased in the left lower extremity. Her muscle strengths are ___ at all muscle groups except 4+/5 hip left knee flexion. Her reflexes are 1+ on the right upper and lower extremity and 2+ on the left upper and lower extremity. Ankle jerk are absent. Left toe up going and right down going. Sensory examination is intact in all modalities except proprioception in left great toe is not intact. She does not have a sensory level. Coordination examination does not reveal dysmetria but she is tremulous in left upper extremity on finger to nose. Her gait is steady but cautious. She cannot tandem. She does not have a Romberg. DISCHARGE PHYSCIAL EXAM: VITAL SIGNS: 97.7 122/80 77 18 95%RA General: NAD HEENT: MMM, no OP lesions CV: RRR, NL S1S2 PULM: decreased on R, L clear, nonlabored GI: Soft, NTND, no masses or hepatosplenomegaly LIMBS: No edema, clubbing, tremors, or asterixis SKIN: No rashes or skin breakdown NEURO: speech is slow w/ some dysarthria. Oriented to person and place, not to date. EOMI, sl left facial droop but raises bilat w/ smile, tongue midline. no nystagmus strength is ___ of the proximal and distal upper and lower extremities. sensation intact to light touch, mild dysmetria w/ finger-to-nose but only in R upper motion, gait slow and cautious but steady, cannot perform tandem gait. visual fields full to confrontation Pertinent Results: ADMISSION LABS: ___ 02:00AM BLOOD WBC-8.5 RBC-4.10 Hgb-11.5 Hct-36.5 MCV-89 MCH-28.0 MCHC-31.5* RDW-14.9 RDWSD-48.5* Plt ___ ___ 02:00AM BLOOD Neuts-54.2 ___ Monos-8.5 Eos-3.5 Baso-0.4 Im ___ AbsNeut-4.60 AbsLymp-2.79 AbsMono-0.72 AbsEos-0.30 AbsBaso-0.03 ___ 02:00AM BLOOD ___ PTT-24.5* ___ ___ 02:00AM BLOOD Glucose-108* UreaN-27* Creat-0.8 Na-137 K-3.6 Cl-99 HCO3-27 AnGap-15 ___ 02:00AM BLOOD ALT-36 AST-27 AlkPhos-93 TotBili-0.3 ___ 02:00AM BLOOD Albumin-4.2 Calcium-9.9 Phos-4.2 Mg-1.8 DISCHARGE LABS: ___ 05:37AM BLOOD WBC-21.9* RBC-4.58 Hgb-12.9 Hct-39.6 MCV-87 MCH-28.2 MCHC-32.6 RDW-15.6* RDWSD-49.4* Plt ___ ___ 05:37AM BLOOD Glucose-134* UreaN-41* Creat-0.7 Na-135 K-4.3 Cl-97 HCO3-27 AnGap-15 ___ 05:37AM BLOOD ALT-41* AST-23 AlkPhos-53 TotBili-0.3 ___ 05:37AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.1 PERTINENT IMAGING: BRAIN MRI W/ & W/O CONSTRAST ___ There is a 1.3 AP by 2.2 TV by 1.4 SI cm enhancing mass within the right superior cerebellar cortex which demonstrates adjacent vasogenic edema and mild mass effect on the fourth ventricle (see900:52). . There is an adjacent ventral small 5 mm enhancing nodule (see900:50). There is a 2.0 AP by 3.3 TV by 2.8 SI cm enhancing mass at the posterior left mesial temporal cortex left forceps major with adjacent FLAIR signal hyperintense vasogenic edema extending into the posterior temporal and occipital lobes across the splenium. There is associated mass effect on the occipital horn left lateral ventricle (see900:69). There is a 2.4 AP by 2.3 TV by 2.1 cm SI cm peripherally enhancing mass at the lateral right precentral gyrus which demonstrates adjacent vasogenic edema and mass effect (see900:90). There is a small amount of central hemorrhage seen on the gradient echo sequence. There is a 1.7 AP by 2.2 TV by 1.7 SI cm cystic and solid enhancing mass at the posterior right superior frontal gyrus which demonstrates adjacent vasogenic edema which extends throughout the precentral gyrus. There is a subependymal focus of gradient echo hypointensity with petechial hemorrhage at the right lateral ventricular atria (see6:15). There is no evidence of acute infarct. There is stable prominence of the ventricles and cortical sulci. The extra-axial spaces are unremarkable. The orbits, calvarium, and soft tissues are unremarkable. The paranasal sinuses and mastoid air cells are clear. IMPRESSION: Enhancing masses within the right frontal, left temporal, and right cerebellar cortices with adjacent vasogenic edema and mass effect, consistent with metastatic disease. These are new in comparison to ___. CT chest w/ contrast ___ IMPRESSION: 1. Marked improvement of previous ground-glass opacities, consistent with resolving infectious/inflammatory etiology. There is no evidence for intrathoracic malignancy. CT ab/pelvis w/ contrast ___ IMPRESSION: 1. Interval decrease in the size of the right adrenal nodule. 2. Colonic diverticulosis without diverticulitis. MRI C/T/L spine ___ IMPRESSION: 1. No evidence of metastases to the cervical, thoracic or lumbar spine. 2. No abscess, osteomyelitis/discitis or cord signal abnormalities. 3. Mild degenerative changes without significant spinal canal narrowing. Mild right neural foraminal narrowing at C5-C6 and C6-C7 as described above. 4. Benign appearing superior endplate compression deformities at T12 and L1. CXR ___ FINDINGS: Post pneumonectomy appearance of the right hemi thorax is stable compared to the prior radiograph. Left lung remains hyperexpanded but grossly clear, and there is no evidence of left pleural effusion. Cardiomediastinal contours remain shifted to the right and are unchanged in appearance. . IMPRESSION: No acute cardiopulmonary abnormality. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Enoxaparin Sodium 120 mg SC DAILY Start: ___, First Dose: First Routine Administration Time 2. Levothyroxine Sodium 100 mcg PO DAILY 3. OLANZapine 2.5 mg PO QAM 4. OLANZapine 5 mg PO QPM 5. Loratadine 10 mg PO DAILY:PRN allergies 6. Senna 8.6 mg PO DAILY 7. Docusate Sodium 100 mg PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO DAILY 2. Enoxaparin Sodium 120 mg SC QDAY Start: ___, First Dose: Next Routine Administration Time 3. Levothyroxine Sodium 100 mcg PO DAILY 4. Loratadine 10 mg PO DAILY:PRN allergies 5. OLANZapine 2.5 mg PO QAM 6. OLANZapine 2.5 mg PO QPM 7. Senna 8.6 mg PO DAILY 8. Acetaminophen 500 mg PO Q6H:PRN headache 9. Dexamethasone 4 mg PO Q12H 10. Pantoprazole 40 mg PO Q24H 11. Polyethylene Glycol 17 g PO DAILY:PRN constipation 12. Omeprazole 40 mg PO QAM Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Brain metastases Cerebral edema History of lung cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: History: ___ with hx lung ca, PE on lovenox, here w/ CP, HA x2days // ? pneumonia, acute cardiopulm process TECHNIQUE: Chest PA and lateral COMPARISON: CT chest dated ___ and chest radiograph dated ___. FINDINGS: Patient is status post total right pneumonectomy, with expected postoperative changes, including rightward shift of the mediastinal structures. Right-sided Port-A-Cath ends in the low SVC. Cardiac and mediastinal contours are unchanged. No left-sided consolidation, pneumothorax, or pleural effusion. IMPRESSION: No pneumonia. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: History: ___ with hx lung ca, PE on lovenox, here w/ CP, HA x2days // ? pneumonia, acute cardiopulm process 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, 16.4 cm; CTDIvol = 54.5 mGy (Head) DLP = 891.9 mGy-cm. Total DLP (Head) = 892 mGy-cm. COMPARISON: MR head dated ___. FINDINGS: There has been interval development of multiple intracranial mass lesions, including 2 in the right frontal lobe measuring 2.6 x 2 cm (2:21) and 2.1 x 1.8 cm (603b:41), as well as a second in the left temporoparietal lobe, which measures 2.5 x 2 cm. These areas are surrounded by a large amount of vasogenic edema. An additional area vasogenic edema is seen in the right cerebellum. There is no evidence of intracranial hemorrhage. Vasogenic edema on the left temporoparietal lobe results in effacement of the temporal horn of the left lateral ventricle. The basal cisterns appear patent. No fracture is identified. Visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The globes are unremarkable. IMPRESSION: 1. Interval development of multiple intracranial mass lesions with associated vasogenic edema, new from ___. Recommend further evaluation with contrast enhanced MRI of the head. 2. Vasogenic edema from the left temporal parietal lobe mass results in effacement of the temporal horn of the left lateral ventricle. RECOMMENDATION(S): 1. Interval development of multiple intracranial mass lesions with associated vasogenic edema, new from ___. Recommend further evaluation with contrast enhanced MRI of the head. NOTIFICATION: Wet read was discussed with Dr. ___ by Dr. ___ telephone at 3:32 am on ___, approximately 10 min after discovery. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD INDICATION: ___ female with newly diagnosed lung cancer found to have metastasis on prior head CT now experiencing a new neurological deficits. Evaluate intracranial disease. TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of 7 mL of Gadavist intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: ___ noncontrast head CT. ___ contrast-enhanced head MRI. ___ noncontrast head CT. FINDINGS: There is a 1.3 AP by 2.2 TV by 1.4 SI cm enhancing mass within the right superior cerebellar cortex which demonstrates adjacent vasogenic edema and mild mass effect on the fourth ventricle (see900:52). . There is an adjacent ventral small 5 mm enhancing nodule (see900:50). There is a 2.0 AP by 3.3 TV by 2.8 SI cm enhancing mass at the posterior left mesial temporal cortex left forceps major with adjacent FLAIR signal hyperintense vasogenic edema extending into the posterior temporal and occipital lobes across the splenium. There is associated mass effect on the occipital horn left lateral ventricle (see900:69). There is a 2.4 AP by 2.3 TV by 2.1 cm SI cm peripherally enhancing mass at the lateral right precentral gyrus which demonstrates adjacent vasogenic edema and mass effect (see900:90). There is a small amount of central hemorrhage seen on the gradient echo sequence. There is a 1.7 AP by 2.2 TV by 1.7 SI cm cystic and solid enhancing mass at the posterior right superior frontal gyrus which demonstrates adjacent vasogenic edema which extends throughout the precentral gyrus. There is a subependymal focus of gradient echo hypointensity with petechial hemorrhage at the right lateral ventricular atria (see6:15). There is no evidence of acute infarct. There is stable prominence of the ventricles and cortical sulci. The extra-axial spaces are unremarkable. The orbits, calvarium, and soft tissues are unremarkable. The paranasal sinuses and mastoid air cells are clear. IMPRESSION: Enhancing masses within the right frontal, left temporal, and right cerebellar cortices with adjacent vasogenic edema and mass effect, consistent with metastatic disease. These are new in comparison to ___. Radiology Report EXAMINATION: MR ___ AND W/O CONTRAST T___ MR SPINE INDICATION: ___ year old woman with metastatic nsclc and new brain mets, hoping to obtain MRI spine to evaluate for mets // ****please obtain MRI of whole spine to evaluate for mets along spine ****please obtain MRI of whole spine to evaluate for mets al TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique, followed by axial T2 imaging. 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 7 mL of Gadavist contrast agent. COMPARISON: ___ chest radiograph. CT Torso ___. FINDINGS: Cervical spine: Alignment of the cervical spine is normal. Intervertebral disc and marrow signal intensity is normal. No cord signal abnormalities are identified. There is no evidence of infection or neoplasm. Notable degenerative changes within the cervical spine include: At C3-C4, there is a tiny midline disc protrusion that does not result in significant spinal canal or neural foraminal narrowing. At C5-C6, there is a right intervertebral osteophyte that results in mild narrowing of the right neural foramen. No spinal canal narrowing at this level. At C6-C7, there is also mild narrowing of the right neural foramen which may be due to a combination of a right intervertebral osteophyte and a small right paracentral disc protrusion. Thoracic spine: Alignment of the thoracic spine is normal. Intervertebral disc and marrow signal intensity are normal. No cord signal abnormalities are identified. Conus medullaris terminates at T12. There is no infection or neoplasm within thoracic spine. No spinal canal or neuroforaminal narrowing. Incidental note is made of a tiny syrinx (4:11). Lumbar spine: Alignment of the lumbar spine is normal. Superior endplate compression deformities are noted at T12 and L1 (901: 10), without marrow signal abnormalities throughout the lumbar spine. Notable degenerative changes in the lumbar spine including mild disc bulge at L4-L5 and L5-S1, without spinal canal or neural foraminal narrowing. No evidence of infection or neoplasm. OTHER: Limited images of the posterior fossa demonstrate no gross abnormalities. Right pneumonectomy changes are noted. There are several left renal cysts, one of which contains a fluid level. These findings are better characterized on the recent CT chest/abdomen/pelvis performed on the same date. IMPRESSION: 1. No evidence of metastases to the cervical, thoracic or lumbar spine. 2. No abscess, osteomyelitis/discitis or cord signal abnormalities. 3. Mild degenerative changes without significant spinal canal narrowing. Mild right neural foraminal narrowing at C5-C6 and C6-C7 as described above. 4. Benign appearing superior endplate compression deformities at T12 and L1. Radiology Report INDICATION: ___ year old woman with metastatic nsclc with new brain mets, hoping to evaluate for other mets // worsening mets? 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: This study involved 8 CT acquisition phases with dose indices as follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9 mGy-cm. 4) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9 mGy-cm. 5) Stationary Acquisition 6.3 s, 0.2 cm; CTDIvol = 106.6 mGy (Body) DLP = 21.3 mGy-cm. 6) Spiral Acquisition 6.4 s, 75.1 cm; CTDIvol = 7.3 mGy (Body) DLP = 516.7 mGy-cm. 7) Spiral Acquisition 2.8 s, 34.6 cm; CTDIvol = 5.3 mGy (Body) DLP = 158.1 mGy-cm. 8) Spiral Acquisition 1.5 s, 20.1 cm; CTDIvol = 5.9 mGy (Body) DLP = 89.8 mGy-cm. Total DLP (Body) = 790 mGy-cm. COMPARISON: Comparison is made to prior from ___. FINDINGS: LOWER CHEST: Please refer to dedicated chest CT for complete report. 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: There is interval decrease in the size of the right adrenal nodule, which measures 1.1 x 1.1 cm in the current study compared to prior measurement of 1.1 x 1.4 cm. The left adrenal is unremarkable. URINARY: Normal appearance of the right kidney. Multiple cysts are appreciated within the left kidney. No evidence of hydronephrosis on either side. The bladder is unremarkable. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. There is extensive colonic diverticulosis. No evidence of diverticulitis in the current study. The appendix is normal. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The reproductive organs are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. Prominent right external iliac lymph node, measuring up to 1.0 cm in short axis. VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic disease is noted. BONES AND SOFT TISSUES: Vertebral body compression at T12 and L1. Degenerative changes within the spine. Multiple subcutaneous soft tissue stranding in the anterior abdominal wall from injections. IMPRESSION: 1. Interval decrease in the size of the right adrenal nodule. 2. Colonic diverticulosis without diverticulitis. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ female with metastatic non small cell lung cancer with new brain metastases. Question intrathoracic metastases. The patient had ground-glass opacities on passed chest CT, questioning infectious or malignant etiology. 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 axial maximal intensity projection images were submitted to PACS and reviewed. DOSE: See abdomen/pelvic CT COMPARISON: CT chest dated ___. FINDINGS: Neck/cardiomediastinal: The thyroid is unremarkable. There is no axillary or supraclavicular lymphadenopathy. Subcentimeter mediastinal lymph nodes are unchanged in size. A right Port-A-Cath terminates in the superior cavoatrial junction. The heart is normal in size. The aorta is normal in caliber. The main pulmonary artery is normal in caliber without intraluminal filling defect. There is no pericardial effusion. Airway/lungs: The patient is post right pneumectomy. The right bronchial stump has a normal postoperative appearance. Postoperative change of right intercostal muscle flap remain. The pleural rind surrounding the contents of the pneumonectomy space is stable from prior. The ground-glass and nodular opacities throughout the left lung have markedly improved. A region of linear opacity in the left upper lobe remains (05:18), likely atelectasis. A calcified granuloma in the left lower lobe is stable (05:20). Abdomen: Infra-diaphragmatic structures will be reported separately. Cardiac thoracic cage/soft tissues: There are no suspicious blastic or lytic lesions. IMPRESSION: 1. Marked improvement of previous ground-glass opacities, consistent with resolving infectious/inflammatory etiology. There is no evidence for intrathoracic malignancy. 2. Please see abdomen/ pelvic CT for additional findings. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with hx lung cancer new brain mets, SOB, leukocytosis // eval for effusion, pneumonia TECHNIQUE: Chest PA and lateral COMPARISON: ___. FINDINGS: Post pneumonectomy appearance of the right hemi thorax is stable compared to the prior radiograph. Left lung remains hyperexpanded but grossly clear, and there is no evidence of left pleural effusion. Cardiomediastinal contours remain shifted to the right and are unchanged in appearance. . IMPRESSION: No acute cardiopulmonary abnormality. Gender: F Race: WHITE - BRAZILIAN Arrive by WALK IN Chief complaint: L Weakness, Confusion, Chest pain Diagnosed with BRAIN CONDITION NOS temperature: 97.8 heartrate: 94.0 resprate: 18.0 o2sat: 100.0 sbp: 130.0 dbp: 96.0 level of pain: nan level of acuity: 2.0

Ms ___ it was a pleasure caring for you during your stay at ___. You were admitted with headache and difficulty with balance. You were found to have multiple brain tumors as well as swelling in the brain. You were started on radiation treatment which you have been tolerating well. We did not find any other areas where the cancer spread. Your steroid dose will be determined by the radiation oncologists. You also have a repeat brain MRI scheduled about one month after you complete radiation. You are discharged to ___ in ___ to continue rehabilitation. You will return to complete radiation this week. ___ at 10:30am. No treatment is scheduled on ___

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: ___ Cardiac Catheterization with no PCI History of Present Illness: ___ PMH HLD, HTN, DM, CAD s/p IMI and CABG in ___ followed by PCI of SVG-OM that same year, p/w atypical chest pain for 1.5 weeks. Patient reports one and a half weeks of crescendo chest pain that comes and goes. Prain pressure-like, in L isde of chest, occurring ___ times a day and lasting ___, no clear inciting or relieving factors. With associated flushing and mild headache, radiation to back and arm, facial numbness. Not exertional or pleuritic. Pain worse on ___ so took nitro with no/little relief. Different from reflux pain, but similar to the pain she felt prior to needing a stent in ___. No association with eating or BMs. She denies fevers, chills, shortness of breath, diaphoresis, abdominal pain, nausea, vomiting. Significantly, patient reports this chest pain pattern is very similar to that which she had prior to her last cath/stent in ___ In the ED initial vitals were: 98.6 164/55 66 14 100/RA EKG: TWI in III, aVF, STD in II similar to prior without new ischemic changes. Labs/studies notable for: 10.2>12.8/40.0<225 136 | 100 | 17 ---------------<246 4.6 | 25 | 0.7 Trop <0.01 x2 INR 0.9 UA benign CXR: no acute process Patient was given: Nitro SL .4 x 2, ASA 324, APAP 1g, MS 2mg x2, Insulin 40, metformin 1g, Plavix 75, asa 81, lisinopril 5, metop succinate 75, imdur 120 and 30, fluoxetine 40, omeprazole 40 On the floor, patient reports mild pressure but otherwise feeling well. ROS: Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Denies exertional buttock or calf pain. On further review of systems, denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. Denies recent fevers, chills or rigors. All of the other review of systems were negative. PAST MEDICAL HISTORY: 1. CAD, inferior wall MI ___, CABG: LIMA-LAD, SVG-OM, SVG-PDA in ___. Symptoms: chest pressure, LUE/jaw discomfort. SVG-OM DES 11.10. 2. Obesity. BMI 35.9 3. DLD: 12.15 TC108.TG136.H22.L59. atorva 80mg, fish oil. 4. Insulin-requiring diabetes, HbA1c 8.9, ___. Dx ___ 5. Family history of pCAD (father, brother) 6. ___ (metoprolol, isosorbide, lisinopril) Other Relevant Medical Issues: - Prior tobacco abuse. - Depression. - GERD. - Obstructive sleep apnea, intolerant of CPAP. HOME MEDS: The Preadmission Medication list is accurate and complete 1. Lisinopril 5 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Clopidogrel 75 mg PO DAILY 4. Estrogens Conjugated 1 gm VG 1X/WEEK (FR) 5. FLUoxetine 40 mg PO DAILY 6. econazole 1 % topical DAILY 7. Glargine 40 Units Breakfast Glargine 40 Units Dinner Insulin SC Sliding Scale using HUM Insulin 8. Isosorbide Mononitrate (Extended Release) 150 mg PO QAM 9. Isosorbide Mononitrate (Extended Release) 30 mg PO QPM 10. MetFORMIN (Glucophage) 500 mg PO QHS 11. Metoprolol Succinate XL 75 mg PO DAILY 12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 13. Lovaza (omega-3 acid ethyl esters) 1 gram oral BID 14. Omeprazole 40 mg PO BID 15. Aspirin 81 mg PO DAILY 16. Vitamin D Dose is Unknown PO DAILY 17. Cyanocobalamin 1000 mcg PO DAILY 18. Loratadine 10 mg PO DAILY 19. Multivitamins 1 TAB PO DAILY 20. Psyllium Powder 1 PKT PO Frequency is Unknown 21. Calcium Carbonate 1500 mg PO DAILY ALLERGIES: NKDA SOCIAL HISTORY: ___ FAMILY HISTORY: Dad- MI @___ Sister: MI in ___ Brother: sudden cardiac death from MI @___ Most family members with DM. PHYSICAL EXAM: VS: 97.6 132/63 57 16 96/RA; admission weight 96.6kg GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP of 8 cm. CARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops. No thrills, lifts. CHEST: No chest wall deformities, scoliosis or kyphosis; has sternotomy scar. Resp were unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Distal pulses palpable and symmetric Past Medical History: 1. CAD, inferior wall MI ___, CABG: LIMA-LAD, SVG-OM, SVG-PDA in ___. Symptoms: chest pressure, LUE/jaw discomfort. SVG-OM DES 11.10. 2. Obesity. BMI 35.9 3. DLD: 12.15 TC108.TG136.H22.L59. atorva 80mg, fish oil. 4. Insulin-requiring diabetes, HbA1c 8.9, 12.15. Dx ___ 5. Family history of pCAD (father, brother) 6. ___ (metoprolol, isosorbide, lisinopril) Other Relevant Medical Issues: - Prior tobacco abuse. - Depression. - GERD. - Obstructive sleep apnea, intolerant of CPAP. Social History: ___ Family History: Has son with unknown type of congenital heart disease-"hole in heart." Father with MI, age ___, CABG, PPM, deceased in ___ from melanoma. Three siblings, one brother with sudden cardiac death after MI age ___. Older sister with silent MI in her ___. Most family members with DM. Physical Exam: ADMISSION PHYSICAL EXAM: ========================== VS: 97.6 132/63 57 16 96/RA; admission weight 96.6kg GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP of 8 cm. CARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops. No thrills, lifts. CHEST: No chest wall deformities, scoliosis or kyphosis; has sternotomy scar. Resp were unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Distal pulses palpable and symmetric DISCHARGE PHYSICAL EXAM: ========================== VS: T 98.1 120-140/51-63 HR 56-63 RR 18 98% tele: sinus rhythm, sinus brady GENERAL: WDWN in NAD. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP of 8 cm. CARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops. No thrills, lifts. CHEST: No chest wall deformities, scoliosis or kyphosis; has sternotomy scar. Resp were unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Distal pulses palpable and symmetric NEURO: Oriented x3. PSYCH: Mood, affect appropriate. Pertinent Results: ADMISSION LABS: =============== ___ 09:03AM cTropnT-<0.01 ___ 06:44AM URINE HOURS-RANDOM ___ 06:44AM URINE UHOLD-HOLD ___ 06:44AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 06:44AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 06:44AM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-1 ___ 06:44AM URINE MUCOUS-RARE ___ 03:00AM GLUCOSE-246* UREA N-17 CREAT-0.7 SODIUM-136 POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-25 ANION GAP-16 ___:00AM estGFR-Using this ___ 03:00AM cTropnT-<0.01 ___ 03:00AM WBC-10.2* RBC-4.44 HGB-12.8 HCT-40.0 MCV-90 MCH-28.8 MCHC-32.0 RDW-12.5 RDWSD-41.2 ___ 03:00AM NEUTS-59.8 ___ MONOS-8.4 EOS-2.5 BASOS-0.3 IM ___ AbsNeut-6.08 AbsLymp-2.90 AbsMono-0.85* AbsEos-0.25 AbsBaso-0.03 ___ 03:00AM PLT COUNT-225 ___ 03:00AM ___ PTT-28.1 ___ INTERIM LABS: ============= ___ 07:00AM BLOOD WBC-8.7 RBC-4.58 Hgb-13.0 Hct-41.6 MCV-91 MCH-28.4 MCHC-31.3* RDW-12.3 RDWSD-40.6 Plt ___ ___ 07:10AM BLOOD WBC-7.9 RBC-4.72 Hgb-13.3 Hct-43.2 MCV-92 MCH-28.2 MCHC-30.8* RDW-12.3 RDWSD-41.2 Plt ___ ___ 07:00AM BLOOD Glucose-214* UreaN-16 Creat-0.7 Na-137 K-4.2 Cl-101 HCO3-24 AnGap-16 ___ 07:10AM BLOOD Glucose-185* UreaN-15 Creat-0.7 Na-139 K-4.4 Cl-105 HCO3-23 AnGap-15 ___ 09:03AM BLOOD cTropnT-<0.01 ___ 07:05AM BLOOD CK-MB-3 cTropnT-<0.01 ___ 07:10AM BLOOD Calcium-9.6 Phos-3.4 Mg-2.0 MICRO: ====== UCx negative STUDIES/IMAGING: ================ CXR ___: The lungs are well expanded and clear. There is no pleural abnormality. The moderate cardiomegaly is unchanged from prior exam. The mediastinal and hilar contours are stable. Median sternotomy wires and surgical clips are aligned and intact. The osseous structures are unremarkable. ETT ___: INTERPRETATION: ___ yo woman with HL, HTN and DM, s/p IMI and CABG in ___ followed by PCI of SVG-OM that same year was referred to evaluate an atypical chest discomfort. The patient completed 9.25 minutes of a modified ___ protocol representing an average exercise tolerance; ~ ___ METS. The exercise test was stopped due to fatigue. The patient denied any chest, back, neck or arm discomforts during the procedure. At peak exercise, 0.5-1 mm upsloping ST segment depressions were noted inferolaterally. Immediately post-exercise, a horizontal ST morphology was noted in these same leads. The ST segment changes resolved with rest and returned to standing baseline by 4 minutes post-exercise. The rhythm was sinus with rare isolated APBs. The blood pressure increased with exercise, however the response was blunted. In the presence of beta blocker therapy, the peak exercise heart rate was somewhat blunted. CATH ___: Coronary Anatomy Dominance: Right LMCA: The LMCA was calcified with mild plaquing proximally. LAD: The proximal and mid LAD were heavily calcified. The proximal LAD had diffuse mild plaquing to 40% mid vessel involving the origin of D1 mildly. The mid LAD had a 75% stenosis with competitive flow seen distally. LCX: The proximal CX was calcified. The proximal CX tapered to 40%. A small long (<2 mm in diameter) OM1 had a proximal 70% stenosis. The AV groove CX was occluded mid vessel. RCA: The RCA was heavily calcified. There was a proximal 70% stenosis and a mid vessel chronic total occlusion. There was faint filling of the mid-distal RCA via vasa and other right-to-right collaterals. SVG-RPDA: The SVG had a corkscrew turn near ostially. The SVG had mild plaquing and grafted onto a large RPDA with retrograde perfusion of the large distal RCA system into multiple RPLs. There was NO retrograde perfusion of the mid RCA. SVG-LPL: The SVG had mild plaquing, especially ostially. The grafted LPL (also <2 mm in diameter) had serial 70% and 75% stenoses. There was retrograde perfusion down the distal AV groove CX. LIMA-LAD: The LIMA-LAD was patent onto the mid LAD with competitive flow seen retrogradely in the mid LAD. The apical LAD had diffuse plaquing. Impressions: 1. Native three vessel coronary artery disease with chronic total occlusion of the CX and RCA, unrevascularized native OM1 disease and LPL disease downstream of the SVG (both of these in vessels <2 mm in diameter and thus too small for PCI). 2. Systemic systolic arterial hypertension. 3. Moderate-severe left ventricular diastolic heart failure. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 5 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Clopidogrel 75 mg PO DAILY 4. Estrogens Conjugated 1 gm VG 1X/WEEK (FR) 5. FLUoxetine 40 mg PO DAILY 6. econazole 1 % topical DAILY 7. Glargine 40 Units Breakfast Glargine 40 Units Dinner Insulin SC Sliding Scale using HUM Insulin 8. Isosorbide Mononitrate (Extended Release) 150 mg PO QAM 9. Isosorbide Mononitrate (Extended Release) 30 mg PO QPM 10. MetFORMIN (Glucophage) 500 mg PO QHS 11. Metoprolol Succinate XL 75 mg PO DAILY 12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 13. Lovaza (omega-3 acid ethyl esters) 1 gram oral BID 14. Omeprazole 40 mg PO BID 15. Aspirin 81 mg PO DAILY 16. Cyanocobalamin 1000 mcg PO DAILY 17. Loratadine 10 mg PO DAILY 18. Multivitamins 1 TAB PO DAILY 19. Psyllium Powder 1 PKT PO Frequency is Unknown 20. Calcium Carbonate 1500 mg PO DAILY Discharge Medications: 1. Lisinopril 10 mg PO DAILY RX *lisinopril 10 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 2. Glargine 40 Units Breakfast Glargine 40 Units Dinner Insulin SC Sliding Scale using HUM Insulin 3. Psyllium Powder 1 PKT PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 80 mg PO QPM 6. Calcium Carbonate 1500 mg PO DAILY 7. Clopidogrel 75 mg PO DAILY 8. Cyanocobalamin 1000 mcg PO DAILY 9. econazole 1 % topical DAILY 10. Estrogens Conjugated 1 gm VG 1X/WEEK (FR) 11. FLUoxetine 40 mg PO DAILY 12. Isosorbide Mononitrate (Extended Release) 150 mg PO QAM 13. Isosorbide Mononitrate (Extended Release) 30 mg PO QPM 14. Loratadine 10 mg PO DAILY 15. Lovaza (omega-3 acid ethyl esters) 1 gram oral BID 16. MetFORMIN (Glucophage) 500 mg PO QHS 17. Metoprolol Succinate XL 75 mg PO DAILY 18. Multivitamins 1 TAB PO DAILY 19. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 20. Omeprazole 40 mg PO BID Discharge Disposition: Home Discharge Diagnosis: PRIMARY: -Unstable Angina, s/p catheterization -Coronary Artery Disease s/p CABG Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: Chest: Frontal and lateral views INDICATION: History: ___ with chest pain // Evaluate for ACS TECHNIQUE: Chest: Frontal and Lateral COMPARISON: Chest radiograph from ___. FINDINGS: The lungs are well expanded and clear. There is no pleural abnormality. The moderate cardiomegaly is unchanged from prior exam. The mediastinal and hilar contours are stable. Median sternotomy wires and surgical clips are aligned and intact. The osseous structures are unremarkable. IMPRESSION: No acute cardiopulmonary process. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Chest pain Diagnosed with Other chest pain temperature: 98.6 heartrate: 66.0 resprate: 14.0 o2sat: 100.0 sbp: 164.0 dbp: 55.0 level of pain: 5 level of acuity: 2.0

Dear Ms. ___, You were admitted to the ___ Cardiology Team ___ after you had worsening chest pain. What was done? =============== -You had a cardiac catheterization which showed some narrowing and blockages, but none were suitable to have new stent placement. -We increased your lisinopril dose from 5 mg to 10 mg which may help with your pain. What to do next? ================== -Please follow up with your primary care ___ at 12P) and cardiologist ___ at 2P) for further medication titration as needed. These appointments have been scheduled for you. -We recommend no strict exercise limitations, walking is helpful for your heart, but avoid excessive stress. -Avoid fast food and fried foods as well as red meat. Eat food high in fiber such as fruits and vegetables. We wish you the best! - Your ___ cardiology team