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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

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Phenothiazines / Clozaril / Lactose Attending: ___ Chief Complaint: Jaw swelling/pain Major Surgical or Invasive Procedure: Periapical Incision & Drainage (___) Foley inserted ___ History of Present Illness: Ms. ___ is a ___ year old woman with history of diabetes and schizophrenia who presents with jaw swelling. Patient states that she started to develop pain and swelling in her jaw for the past 3 days, that first started on R lower chin/jaw, but then continued to involve the entire right side including her cheek. She reports pain when opening her mouth and eating, so she has not eaten since the pain started. She denies any drooling and is able to manage secretions. She has significant pain inside her mouth. Denies any recent dental work, or difficulty breathing. Denies fevers/chills, cough, N/V, chest pain, abdominal pain, constipation, diarrhea, dysuria, rash, sick contact. In the ED, initial vital signs were: 97.2 108 134/89 18 98% RA - Exam notable for: Tenderness under her tongue. - Labs were notable for WBC 7.4, bicarb 25, cr 0.7, lactate 0.9 - Studies performed include CT Neck which showed soft tissue stranding anterior to the mandible without definite abscess. - Patient was given 2L NS, 1G acetaminophen, 3G unasyn - Vitals on transfer: 99.6 99 ___ 100% RA Upon arrival to the floor, the patient was comfortable, but complaining of lower jaw pain Review of Systems: (+) per HPI (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: HTN HLD DM II Morbid Obesity Schizophrenia Hx of Carcinoid: carcinoid: colon - excised ___ ___ - colonoscopy ___ - BX neg in area of tumor, colonic polyp - hyperplasia - colonoscopy ___ - Dr. ___ all WNL, showing no more carcinoid tissue: ___: Re- referred to Dr. ___ s/p R total shoulder ___ GERD OSA on CPAP LV systolic dysfunction Hyperprolactinemia: ___ Endocrine f/u Social History: ___ Family History: N/A Physical Exam: ON ADMISSION: Vitals- 99.7 165/80 103 18 100% GENERAL: obese ___ woman laying in bed comfortably in NAD. Unable to enunciate words well. No muffled speech HEENT: poor dentition, tenderness across the anterior neck, mandible with increased involvement on the right side. Most tender on the anterior inferior periodontal region. PERRL. EOMI. Unable to open mouth wide to evaluate oropharynx. No peripheral LAD CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops. No JVD. LUNGS: Clear to auscultation bilaterally w/appropriate breath sounds appreciated in all fields. No wheezes, rhonchi or rales. BACK: Skin. no spinous process tenderness. no CVA tenderness. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. Tympanic to percussion. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema, no sign of atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally. SKIN: No evidence of ulcers, rash or lesions suspicious for malignancy NEUROLOGIC: CN2-12 intact. ___ strength througout. Normal sensation. No ataxia, dysmetria, disdiadochokinesia. Gait deferred ON DISCHARGE: PHYSICAL EXAM: Vitals- 98.6 ___-100% ra I/O: 540/1330mL. Bladder scan - 700cc GENERAL: obese ___ woman laying in bed comfortably in NAD. HEENT: poor dentition, mildly tender across the anterior chin, R cheek. Still tender in the mouth, but improved. PERRL. EOMI. Large tongue Unable to open mouth wide to evaluate oropharynx. No peripheral LAD CARDIAC: RR, normal rate, no murmurs/rubs/gallops. No JVD. LUNGS: CTAB w/appropriate breath sounds appreciated in all fields. No wheezes, rhonchi or rales. BACK: Skin. no spinous process tenderness. no CVA tenderness. ABDOMEN: Normal bowels sounds, nd nt to deep palpation in all four quadrants. Tympanic to percussion. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema, no sign of atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally. SKIN: No evidence of ulcers, rash or lesions suspicious for malignancy NEUROLOGIC: CN2-12 intact. ___ strength througout. Normal sensation. No ataxia, dysmetria, disdiadochokinesia. Gait deferred Rectal: good rectal tone. No external hemorrhoids. Brown stool GU: Foley in place Pertinent Results: ON ADMISSION ====================== ___ 09:00AM WBC-7.4# RBC-3.92 HGB-11.5 HCT-37.4 MCV-95 MCH-29.3 MCHC-30.7* RDW-14.1 RDWSD-49.2* ___ 09:00AM GLUCOSE-110* UREA N-19 CREAT-0.7 SODIUM-141 POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-25 ANION GAP-18 ___ 09:00AM NEUTS-74.6* LYMPHS-17.2* MONOS-7.3 EOS-0.4* BASOS-0.1 IM ___ AbsNeut-5.51# AbsLymp-1.27 AbsMono-0.54 AbsEos-0.03* AbsBaso-0.01 ___ 09:00AM PLT COUNT-255 ___ 10:35AM LACTATE-0.9 ON DISCHARGE ___ 07:50AM BLOOD WBC-3.5* RBC-4.07 Hgb-11.9 Hct-39.7 MCV-98 MCH-29.2 MCHC-30.0* RDW-13.5 RDWSD-48.4* Plt ___ ___ 07:50AM BLOOD Plt ___ ___ 07:50AM BLOOD Glucose-86 UreaN-24* Creat-0.7 Na-141 K-4.4 Cl-101 HCO3-30 AnGap-14 IMAGING: CT NECK W/ CONTRAST (___): FINDINGS: Evaluation of the aerodigestive tract demonstrates no mass, and no areas of focal mass effect. Soft tissue stranding is noted anterior to the mandible. This extends just to the level of the mental protrude , without extension to the subcutaneous fat adjacent to the mandibular body. Lucencies identified in the right incisor (2: 53) suggestive of periapical infection. No definite abscess is identified. Thyroid gland is diffusely enlarged. IMPRESSION: 1. Soft tissue stranding anterior to the mandible without definite abscess. 2. Right mandibular incisor. Apical infection. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amoxicillin 500 mg PO Frequency is Unknown 2. Benztropine Mesylate 2 mg PO QHS 3. BuPROPion (Sustained Release) 300 mg PO QAM 4. Docusate Sodium 100 mg PO BID 5. Fluticasone Propionate 110mcg 2 PUFF IH BID 6. Fluticasone Propionate NASAL 1 SPRY NU DAILY 7. Gabapentin 300 mg PO QHS 8. Lisinopril 40 mg PO DAILY 9. Loratadine 10 mg PO DAILY 10. OLANZapine 35 mg PO QHS 11. Omeprazole 20 mg PO BID 12. Polyethylene Glycol 17 g PO DAILY 13. Senna 17.2 mg PO DAILY 14. Sertraline 100 mg PO DAILY 15. TraZODone 100 mg PO QHS 16. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral DAILY 17. Mylanta 30 mL ORAL TID:PRN nausea/heartburn 18. Gabapentin 600 mg PO TID 19. Chlorthalidone 25 mg PO DAILY 20. Simvastatin 40 mg PO QPM 21. MetFORMIN (Glucophage) 500 mg PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Moderate RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) hours Disp #*20 Tablet Refills:*0 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet by mouth twice a day Disp #*8 Tablet Refills:*0 3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID Duration: 1 Week RX *chlorhexidine gluconate 20 % 15mL twice a day Refills:*0 4. Lisinopril 10 mg PO DAILY RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Benztropine Mesylate 2 mg PO QHS 6. BuPROPion (Sustained Release) 300 mg PO QAM 7. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral DAILY 8. Docusate Sodium 100 mg PO BID 9. Fluticasone Propionate 110mcg 2 PUFF IH BID 10. Fluticasone Propionate NASAL 1 SPRY NU DAILY 11. Gabapentin 300 mg PO QHS 12. Gabapentin 600 mg PO TID 13. Loratadine 10 mg PO DAILY 14. MetFORMIN (Glucophage) 500 mg PO BID 15. Mylanta 30 mL ORAL TID:PRN nausea/heartburn 16. OLANZapine 35 mg PO QHS 17. Omeprazole 20 mg PO BID 18. Polyethylene Glycol 17 g PO DAILY 19. Senna 17.2 mg PO DAILY 20. Sertraline 100 mg PO DAILY 21. Simvastatin 40 mg PO QPM 22. TraZODone 100 mg PO QHS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY: Periapical Abscess Multiple Dental Carries Urinary Retention SECONDARY: Schizophrenia Obstructive Sleep Apnea Hypertension Diabetes Gastroesphageal reflux Chronic Obstructive Pulmonary Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK INDICATION: History: ___ with pain, swelling of L lower chin, tender under tongue. // ___? TECHNIQUE: Imaging was performed after administration of 70 ml of Omnipaque intravenous contrast material. MDCT acquired helical axial images were obtained from the thoracic inlet through the skull base. Coronal and sagittal multiplanar reformats were then produced and reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.6 s, 36.1 cm; CTDIvol = 18.7 mGy (Body) DLP = 676.6 mGy-cm. Total DLP (Body) = 677 mGy-cm. COMPARISON: None. FINDINGS: Evaluation of the aerodigestive tract demonstrates no mass, and no areas of focal mass effect. The salivary glands enhance normally and are without mass or adjacent fat stranding. The thyroid gland appears normal. There is no lymphadenopathy by CT criteria. The neck vessels are patent. Soft tissue stranding is noted anterior to the mandible. This extends just to the level of the mental protrude , without extension to the subcutaneous fat adjacent to the mandibular body. Lucencies identified in the right incisor (2: 53) suggestive of periapical infection. No definite abscess is identified. The imaged portion of the lung apices are clear and there are no concerning pulmonary nodules. There are no osseous lesions. Thyroid gland is diffusely enlarged. IMPRESSION: 1. Soft tissue stranding anterior to the mandible without definite abscess. 2. Right mandibular incisor. Apical infection. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Jaw pain, Mouth pain Diagnosed with Cellulitis of face, Chronic apical periodontitis temperature: 97.2 heartrate: 108.0 resprate: 18.0 o2sat: 98.0 sbp: 134.0 dbp: 89.0 level of pain: 10 level of acuity: 3.0

Dear Ms. ___, It was a pleasure taking care of you Why you were here: -You were in the hospital because you were complaining of jaw pain and swelling from an infection around you tooth -You were not urinating well What we did for you: -You were given antibiotics for the treatment of your infection -The oral surgeons drained a pocket of infection around your tooth -A foley catheter was placed to drain the urine in the bladder What you should do after leaving the hospital: -Call the oral surgery clinic (___ Building at ___ - ___ at EXACTLY 7:00am any day ___ through ___ so you can have a same day clinic appointment to get your teeth removed. -Please continue taking your antibiotic (augmentin) twice a day to be completed for a 7 day course (last dose on ___ -please use the chlorhexadine to rinse your mouth twice a day -Please continue taking all your medicine and follow up with your primary care doctor and dentist We wish you the best, Your ___ team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Nsaids/Anti-Inflammatory Classifier / Sulfa (Sulfonamide Antibiotics) / Penicillins / E-Mycin / Aspirin / Azithromycin / Flagyl Attending: ___. Chief Complaint: slowed movements, unable to ambulate Major Surgical or Invasive Procedure: na History of Present Illness: Ms. ___ is an ___ F with h/o vascular parkinsonism and multifactorial gait disorder (frontal + parkinsonian features, on Levodopa/Carbidopa), AFib, CAD, spinal stenosis s/p lumbar surgery who presents with 3 days of worsened gait freezing, difficulty moving/getting out of bed and slowing of her speech. For the past ___ years or so, patient has had problems with gait, in particular increased slowness, freezing and shuffling (especially when trying to get around a small or cluttered area). She uses a cane or walker at baseline. Has also had some urinary incontinence and anxiety. She is followed by Dr. ___ as an outpatient for this, who diagnosed her with vascular Parkinsonism (head CT with generalized atrophy and small vessel disease) and a multifactorial gait disorder with frontal and parkinsonian components. She is being treated with Levodopa-Carbidopa for the gait symptoms which has helped slightly but not significantly. Has had a few falls over the past couple of years which seem to be related to attentional difficulties, often happening in the setting of having additional thoughts or external cues (e.g. fell recently when fire alarm went off in her building). Most recent clinic note from ___ documents ongoing gait freezing and slowed movements as well as pallilalia (stuttering/halting speech). Over the past 3 days, her slowness and gait problems acutely worsened. She has felt unable to get out of bed or even move much due to marked slowness and stiffness. When she tried to walk to the bathroom on ___ night, she noticed that she was freezing severely, perhaps more in the left leg which felt like it was heavy and dragging. It took her a long time to get to the bathroom. At baseline she ambulates with a walker, but has been unable to do so even with walker and assistance from visiting nurse ___ ___ 7 days per week). In this setting she has had increased incontinence due to trouble getting out of bed. Speech has also seemed slower and softer than usual. Her ___ that she may not have been taking all her meds, evidence of missed medication doses in the home (a new problem for her). Pt has also been acutely anxious over the past 3 days, and reports getting no sleep in the evening before the symptoms began. Yesterday she called PCP office reporting increased urge incontinence and was scheduled for outpt appt. Today, her son (present at bedside) was called by ___ who reported acute worsening of her gait problems. He came over and thought he also saw increased left facial droop (a baseline problem). He called ___ because he was concerned she had a UTI. She was brought to our ED, where labs including UA were unremarkable. Neurology was consulted for assistance with further workup. Pt denies missing any doses of Sinemet recently though when pressed she cannot remember. She denies any fluctuations in symptoms over past 3 days. Denies dyskinetic symptoms. On ROS, patient reports ___ pound weight loss over the past ___ months. She denies fevers, chills, cough, dysuria, nausea, vomiting, diarrhea or constipation. Neurologic and General ROS are otherwise negative. Past Medical History: - Vascular ___ Disease - Multifactorial gait disorder w frontal and Parkinsonian features - Paroxysmal AFib - CAD s/p CABG x 5 (___) - Depression - Diverticulosis - GERD - H/O L femoral hernia - Hyperlipidemia - Lymphocytic colitis (___) - Spinal stenosis, s/p L1-sacral decompression + fusion (___) - Thyroid nodule (___) - Osteoporosis - Sensorineural hearing loss Social History: ___ Family History: Her mother died in her ___ from heart failure, father died age ___ from a pneumonia. She had a sister who died in her ___ from a heart attack or stroke, and another sister who died from a heart attack, also in her ___. A brother also in her late ___ died from a stroke. Family history, in addition to cardiovascular disease and strokes is positive for diabetes, but negative for dementia and ___ disease. Physical Exam: GENERAL EXAM: - Vitals: 97.6 91 151/84 18 98% RA - General: thin, frail appearing elderly woman in NAD - HEENT: NC/AT - Neck: Supple, no carotid bruits appreciated. No nuchal rigidity - Pulmonary: CTABL - Cardiac: RRR, no murmurs - Abdomen: soft, nontender, nondistended - Extremities: no edema, pulses palpated - Skin: no rashes or lesions noted. NEURO EXAM: - Mental Status: Awake, alert, oriented x 3. +Masked facies, +marked hypomimia. +Grasp reflexes bilaterally. Able to relate a fairly accurate history though requires help with details from son. Marked inattention on ___ and ___ backward. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Able to register 3 objects and recall ___ at 5 minutes. Good knowledge of current events. No evidence of apraxia or neglect. - Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: Decreased upgaze, otherwise EOMI without nystagmus. +saccadic breakdown. V: Facial sensation intact to light touch. VII: +left NLF flattening (baseline), no facial droop with smile. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. - Motor: Decreased bulk throughout. Marked axial and appendicular rigidity and paratonia (present in upper and lower extremities). +Bradykinesia and decrement with fine finger movements bilaterally. No tremor. No asterixis. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___- ___ 5 5 5 4 5 4+ 5 R 5 ___ ___ 5 5 5 5 5 5 5 - Sensory: No deficits to light touch throughout. No extinction to DSS. - DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was EXTENSOR bilaterally. - Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. - Gait: marked retropulsion when standing. Significantly slowed movements when rising into a seated position or attempting to stand. Can only walk a couple of steps before she retropulses, but observed markedly decreased stride length and slowed speed. Unable to test Romberg. Pertinent Results: ___ 06:30AM BLOOD WBC-5.5 RBC-4.62 Hgb-13.1 Hct-41.7 MCV-90 MCH-28.3 MCHC-31.4 RDW-15.2 Plt ___ ___ 05:20PM BLOOD Neuts-70.2* ___ Monos-8.1 Eos-2.0 Baso-0.4 ___ 06:30AM BLOOD ___ PTT-44.7* ___ ___ 06:30AM BLOOD Glucose-85 UreaN-16 Creat-0.6 Na-140 K-4.0 Cl-104 HCO3-26 AnGap-14 ___ 05:20PM BLOOD ALT-3 AST-14 AlkPhos-71 TotBili-0.7 ___ 05:20PM BLOOD Albumin-4.1 Calcium-9.3 Phos-4.3 Mg-2.2 ___ 05:51AM BLOOD TSH-6.8* ___ 07:30PM BLOOD Free T4-1.3 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Carbidopa-Levodopa (___) 2 TAB PO TID 2. Furosemide 20 mg PO DAILY:PRN swelling 3. Zenpep (lipase-protease-amylase) 25,000-85,000- 136,000 unit oral 1 capsule by mouth three times daily 4. Losartan Potassium 25 mg PO BID 5. Metoprolol Succinate XL 100 mg PO DAILY 6. Oxybutynin 2.5 mg PO TID 7. Pravastatin 10 mg PO DAILY 8. Aspirin 325 mg PO DAILY 9. Omeprazole 20 mg PO DAILY 10. Fluticasone Propionate NASAL 2 SPRY NU DAILY Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. Carbidopa-Levodopa (___) 2 TAB PO TID 3. Fluticasone Propionate NASAL 2 SPRY NU DAILY 4. Losartan Potassium 25 mg PO BID 5. Metoprolol Succinate XL 100 mg PO DAILY 6. Omeprazole 20 mg PO DAILY 7. Acetaminophen 1000 mg PO Q8H:PRN headache/fever 8. Levothyroxine Sodium 12.5 mcg PO DAILY 9. Meclizine 12.5 mg PO TID standing through ___ - then PRN 10. Furosemide 20 mg PO DAILY:PRN swelling 11. Zenpep (lipase-protease-amylase) 25,000-85,000- 136,000 unit oral 1 capsule by mouth three times daily To be restarted after meclizine stopped. if needed 12. Oxybutynin 2.5 mg PO TID 13. Venlafaxine XR 37.5 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: peripheral vertigo vascular parkinsonism Gait instability Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ with movement d/o p/w worsening of underlying neuro status. COMPARISON: ___. FINDINGS: PA and lateral views of the chest provided. Midline sternotomy wires and mediastinal clips again noted as well as partially imaged lumbar spinal hardware. The heart remains moderately enlarged. The lungs appear clear though there is mild cephalization which may reflect increased pulmonary venous pressures. No large effusion or pneumothorax is seen. Cardiomegaly is stable. Tortuous thoracic aorta is noted with scoliotic lower T-spine. IMPRESSION: Cardiomegaly with mild pulmonary venous congestion. Radiology Report INDICATION: ___ with hx of cva with ?new L facial droop. Assess for intracranial hemorrhage. TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without administration of IV contrast. Reformatted coronal, sagittal, and thin section bone algorithm reconstructed images were generated. DOSE: DLP: 891.93 mGy-cm COMPARISON: Noncontrast head CT ___. FINDINGS: No evidence of hemorrhage, edema, mass effect, or acute large territorial infarction. Again seen is evidence of right frontotemporal chronic infarction, unchanged in size and appearance since ___. Prominence of the ventricles and sulci are related to age-related cortical volume loss. Periventricular subcortical and deep white matter hypodensities are likely sequelae of chronic small vessel ischemic disease. The basal cisterns are patent and there is preservation of gray-white matter differentiation. No fracture identified. Mild mucosal thickening of the ethmoidal air cells. The additional visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. Globes are notable for bilateral lens replacement. Dense vascular calcifications are again noted in the cavernous portions of the internal carotid arteries, bilateral middle cerebral arteries, basilar artery, and vertebral arteries. IMPRESSION: Chronic changes as described above. No intracranial hemorrhage. Of note MR is more sensitive to the detection of acute infarction. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Weakness Diagnosed with OTHER MALAISE AND FATIGUE, FAILURE TO THRIVE,ADULT temperature: 97.6 heartrate: 91.0 resprate: 18.0 o2sat: 98.0 sbp: 151.0 dbp: 84.0 level of pain: 0 level of acuity: 2.0

Dear ___, You were admitted to the neurology service because of you worsening gait. We restarted your home medications and this improved greatly. You were evaluated by ___ and will be going to acute rehab to work on your gait.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Dysphagia, odynophagia Major Surgical or Invasive Procedure: Rigid bronchoscopy and tracheal stent removal ___ History of Present Illness: As per admitting MD ___ is a ___ yo ___ man with high grade neuroendocrine mediastinal carcinoma on paclitaxel and RT to mediastinum, c/b malignant hemoptysis s/p tracheal stent ___, DVT on Xarelto, who presents with 2 days of worsening odynophagia and dysphagia. Mr ___ was recently admitted ___ with small volume hemoptysis. Bronchoscopy ___ showed multiple tracheal masses and scant blood. He received 16 x 60 mm covered stent to prevent further intrinsic and extrinsic malignant compression. CT that admission demonstrated rapid progression of disease; so he was urgently started on paclitaxel and RT to mediastinum ___. Of note, day prior to discharge, Mr ___ reported dysphagia (solids > liquids). He developed subjective fevers and tachycardia. A CT neck/chest was done which did not demonstrate any acute changes. His symptoms improved the next day and he was discharged with instructions to seek medical care if recurrent. Since discharge, Mr ___ says he has primarily had soup because of ongoing mild dysphagia. However, 2 days prior to admission, he noticed his dysphagia and odynophagia became worse and he was not even able to swallow his spit. He feels his inability to swallow was due to both pain and a sensation that the liquids didn't seem to pass through his throat. He states he was able to intermittently manage solids. He was able to take small pills, although he sometimes had to chew on larger pills. He was able to eat an apple in the ED prior to admission. He denies any pain in the chest with swallowing; just pain in the throat. He denies regurgitation. He does not have the sensation of food getting stuck in his chest. No heartburn. He denies shortness of breath, new chest pain (has ongoing L sided cancer associated pain), lightheadedness, dizziness, fevers, chills, hemoptysis, N/V/abdominal pain. In ED: T 99.2 | 95 | 108/76 | 98% RA. A CT chest was done which did not demonstrate any acute changes. IP was consulted and noted mild migration of tracheal stent that may warrant repeat bronchoscopy but was unlikely to be the source of his symptoms. Prior to admission, he received: ___ 13:19 NEB Acetylcysteine 20% 3 mL ___ 13:19 IV Morphine Sulfate 2 mg Past Medical History: As per admitting MD ___ pancreatitis ___ gall stones s/p ERCP Alcohol use disorder (12 beers a day; quit in ___ Tobacco use disorder ___ years; quit ___ Hyperglycemia Hemorrhoids S/p R knee meniscus repair Asthma in childhood RUE DVT (diagnosed ___, LUE DVT High-Grade NE Tumor ONCOLOGIC HISTORY ___ At Age ___, he presented to the ED with 3 days of constant right sided chest pain, had a CTA that found a large mediastinal mass with multiple pulmonary nodules compatible with metastasis. Retrospectively, he noticed a hoarse voice and some throat discomfort for last six months. In the previous month, he also reported progressive dysphagia to solids initially, but lately also to liquids and with some associated odynophagia. He was seen by ENT and 2 laryngoscopies were negative for masses. Patient endorses minimally nonproductive cough, chills with night sweats almost nightly for the last few weeks. ___ CT revealed a large superior mediastinal mass that may represent a conglomerated lymph nodal mass measuring up to 6.1 cm with bilateral hilar, subcarinal and paratracheal lymphadenopathy. Left supraclavicular lymphadenopathy is also noted. Innumerable bilateral pulmonary nodules consistent with metastases. Diffuse sclerosis involving the right posterior seventh and left posterior eighth ribs may reflect osseous metastasis. No pathologic fracture. 8 mm prominent porta hepatis lymph node is nonspecific. MRI brain without metastasis. PET confirmed metastatic disease at both lungs. ___ - ___: received 4 cycles of chemotherapy: .Cisplatin 75 mg/m2 on day 1 (-20% due to neutropenia) .Etoposide 80 mg/m2 on days 1, 2 and 3 (-20% due to neutropenia) .Atezolizumab 1200 mg on day 1 (started from cycle 2) ___ Start Atezolizumab maintenance every 21d (IMpower133) ___ Atezolizumab 1200 mg IV ___ - ___ Admitted for small volume hemoptysis, in s/o malignant tracheal tumors and therapeutic anticoagulation for DVT. Underwent bronchoscopy ___ with small amounts of blood seen coming from RUL. 16 mm x 60 mm covered stent placed for extrinsic and intrinsic tumoral compression. Imaging that admission also notable for rapid progression of disease for which he was started on paclitaxel and RT ___: C1D1 paclitaxel and RT Social History: ___ Family History: As per admitting MD ___ + Father with HTN, 7 siblings most with HTN. Reports no family history malignancy Physical Exam: Admit: General: Well appearing pleasant man sitting up at edge of bed Neuro: PERRL, EOMI, palate elevates symmetrically, tongue midline Handgrip ___ Alert, oriented, provides clear history HEENT: Oropharynx clear, moist membranes, no lesions. Sclera anicteric Cardiovascular: RRR no murmurs Chest/Pulmonary: Clear to auscultation bilaterally. nontender to palpation Abdomen: Soft, nontender, nondistended. Bowel sounds present Extr/MSK: WWP, no peripheral edema Skin: No obvious rashes + tattoos Access: POC Discharge: General: Well appearing pleasant man sitting up in bed in no acute distress, calm EYES: PERRLA, anicteric HEENT: Oropharynx clear, MMM. Firm nontender left sided cervical adenopathy CV: RRR no murmurs, normal distal perfusion without edema PULM: CTA b/l, no wheezes/rales/rhonchi, normal RR ABD: Soft, nontender, nondistended, normoactive BS LIMBS: No peripheral edema, WWP, no deformity, normal muscle bulk SKIN: No obvious rashes, warm/dry NEURO: Alert, oriented, PERRL PSYCH: Normal mood, insight, judgment, affect ACCESS: POC, dressing c/d/i Pertinent Results: Admit: ___ 10:37AM BLOOD WBC-2.0* RBC-3.91* Hgb-9.9* Hct-31.8* MCV-81* MCH-25.3* MCHC-31.1* RDW-14.1 RDWSD-41.1 Plt ___ ___ 10:37AM BLOOD Glucose-117* UreaN-10 Creat-0.8 Na-139 K-4.2 Cl-103 HCO3-26 AnGap-10 ___ 05:02AM BLOOD Calcium-9.1 Phos-4.0 Mg-1.7 Discharge: ___ 06:15AM BLOOD WBC-5.7 RBC-4.87 Hgb-12.2* Hct-38.4* MCV-79* MCH-25.1* MCHC-31.8* RDW-14.4 RDWSD-39.3 Plt ___ ___ 06:15AM BLOOD Glucose-103* UreaN-20 Creat-0.8 Na-140 K-3.9 Cl-97 HCO3-32 AnGap-11 ___ 06:15AM BLOOD Calcium-8.9 Phos-4.2 Mg-1.9 IMAGING ======= CT NECK ___ 1. Large central thoracic inlet, mediastinal mass, increasing since ___. 2. Tracheal deviation to the right, mild tracheal narrowing, tracheal stent. Loss of fat planes between tumor and esophagus, trachea, which may be invaded. 3. Left level ___ adenopathy, mildly increased since ___. 4. Lung nodules, right pleural effusion, refer to chest CT from yesterday CT CHEST ___ 1. Redemonstration of a large mediastinal mass/lymph node conglomerate within the anterior upper mediastinum, overall similar in size and appearance compared to prior CT chest from ___, with associated mass effect deviating the trachea and upper esophagus to the right. 2. Tracheal stent is widely patent, with trace dependent secretions, and slight (approximately 4 mm) inferior migration compared to the prior study. The inferior portion the stent protrudes into the carina. 3. Redemonstration of numerous solid and cavitating pulmonary lesions scattered throughout the bilateral lungs, some of which have slightly decreased in size. 4. Small right pleural effusion with adjacent compressive atelectasis, unchanged. Bronch ___ -Moderate granulation tissue at the proximal and distal end of stent, patent airway status post stent removal CXR ___: In comparison with the study of ___, there are lower lung volumes, which may account for the increased transverse diameter of the heart. Nevertheless, there is engorgement of indistinct pulmonary vessels, consistent with pulmonary vascular congestion. Blunting of the right costophrenic angle is again seen and the Port-A-Cath extends to the right atrium. No evidence of acute focal consolidation. Substantial displacement of the upper thoracic trachea to the right is consistent with thyroid mass. Micro: Blood Cx negative final Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetylcysteine 20% ___ mL NEB BID 2. GuaiFENesin ER 1200 mg PO Q12H 3. melatonin 3 mg oral QHS:PRN 4. Acetaminophen 1000 mg PO Q8H 5. Lidocaine 5% Patch 1 PTCH TD QPM R lateral chest wall 6. Morphine SR (MS ___ 15 mg PO Q12H 7. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 8. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN BREAKTHROUGH PAIN 9. Polyethylene Glycol 17 g PO DAILY 10. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second Line 11. Rivaroxaban 20 mg PO DAILY 12. Senna 8.6 mg PO BID:PRN Constipation - First Line 13. sodium chloride 0.9 % inhalation TID Discharge Medications: 1. Baclofen 5 mg PO TID:PRN hiccups RX *baclofen 5 mg 1 tablet(s) by mouth every eight (8) hours Disp #*90 Tablet Refills:*0 2. Lidocaine Viscous (lidocaine HCl) 2 % mucous membrane TID:PRN RX *lidocaine HCl [Lidocaine Viscous] 2 % 10mL three times a day Refills:*2 3. Maalox/Diphenhydramine/Lidocaine 5 mL PO QID mouth/throat pain RX *alum-mag hydroxide-simeth [Maalox Advanced] 200 mg-200 mg-20 mg/5 mL 5 ml by mouth four times a day Refills:*1 5. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 6. Acetaminophen 1000 mg PO Q8H 7. Lidocaine 5% Patch 1 PTCH TD QPM R lateral chest wall 8. melatonin 3 mg oral QHS:PRN 9. Morphine SR (MS ___ 15 mg PO Q12H 10. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 11. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN BREAKTHROUGH PAIN RX *oxycodone 5 mg/5 mL 5 ml by mouth every four (4) hours Refills:*0 12. Polyethylene Glycol 17 g PO DAILY 13. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second Line 14. Rivaroxaban 20 mg PO DAILY 15. Senna 8.6 mg PO BID:PRN Constipation - First Line Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: # Dysphagia (solids > liquids) ___ tumoral compression # Odynophagia ___ mucositis # Metastatic high-grade neuroendocrine carcinoma of the mediastinum # Cancer associated chest pain # Leukopenia, neutropenia # Acute on chronic anemia # Malignant hemoptysis and tracheal compression s/p stenting ___ s/p stent removal Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT CHEST WITH CONTRAST INDICATION: History: ___ with mediastinal neuroendocrine carcinoma s/p tracheal stent placement and radiation now with progressive dysphagia and odynophagia. Evaluation for evidence of stent migration, worsening lymphadenopathy, stricture, or other causes of dysphagia/odynophagia. TECHNIQUE: Contiguous axial images were obtained through the chest after administration of intravenous contrast. Coronal and sagittal reformats were obtained. COMPARISON: Comparison to CT chest with contrast from ___. FINDINGS: HEART AND VASCULATURE: The thoracic aorta and main pulmonary artery are normal in caliber. Though not specifically protocoled for assessment of the pulmonary arterial tree, there is no central pulmonary embolism through the lobar level. There is a port in the right chest wall with catheter terminating in the right atrium. Heart size is normal. There are moderate coronary calcifications, most pronounced in the LAD. Trace pericardial fluid is within physiologic limits. AXILLA, HILA, AND MEDIASTINUM: Large mediastinal mass/lymph node conglomerate within the anterior upper mediastinum is overall similar in size and appearance compared to prior CT chest from ___, measuring 7.7 x 5.7 cm in greatest axial dimension (04:48), unchanged from prior study when using similar measurement technique. The mass again deviates the trachea and upper esophagus to the right, and splays the brachiocephalic and left common carotid arteries. The degree of tracheal deviation is not significantly changed. The tracheal stent is widely patent, with trace dependent secretions, and slight (approximately 4 mm) inferior migration compared to the prior study. The inferior portion the stent protrudes into the carina. Additional smaller mediastinal lymph nodes are similar to the prior study. Left supraclavicular lymphadenopathy is also unchanged. Right hilar lymph nodes measuring up to 8 mm short axis have slightly increased in size, previously 6 mm. PLEURAL SPACES: No pneumothorax. Small right pleural effusion with adjacent compressive atelectasis, unchanged. LUNGS/AIRWAYS: Again seen are numerous solid and cavitating pulmonary lesions scattered throughout the bilateral lungs, some which have slightly decreased in size. The largest lesion in the right upper lobe measuring 1.1 cm (4:107), previously measuring 1.4 cm, with decreased surrounding ground-glass change. A 0.7 cm lesion in the left apex is now cavitary (04:42), previously solid and measuring 8 mm. Central airways are patent. There is mild diffuse bronchial wall thickening. BASE OF NECK: There is compression and possible invasion of the posterior left thyroid lobe by the mediastinal mass. ABDOMEN: This study is not tailored for subdiaphragmatic evaluation. There is moderate diffuse atrophy of the pancreas with scattered punctate calcifications, likely sequela of chronic pancreatitis. A coarse calcification is again demonstrated in the hepatic segment VIII. BONES: No suspicious osseous abnormality is seen.? There is no acute fracture. IMPRESSION: 1. Redemonstration of a large mediastinal mass/lymph node conglomerate within the anterior upper mediastinum, overall similar in size and appearance compared to prior CT chest from ___, with associated mass effect deviating the trachea and upper esophagus to the right. 2. Tracheal stent is widely patent, with trace dependent secretions, and slight (approximately 4 mm) inferior migration compared to the prior study. The inferior portion the stent protrudes into the carina. 3. Redemonstration of numerous solid and cavitating pulmonary lesions scattered throughout the bilateral lungs, some of which have slightly decreased in size. 4. Small right pleural effusion with adjacent compressive atelectasis, unchanged. Radiology Report EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT INDICATION: ___ year old man with high grade neuroendcrine carcinoma, presenting with worsening dysphagia and odynophagia. CT last ___ showing edema and compression of larynx, follow up exam// evaluate cause of odynophagia, dysphagia-- mass, edema, other lesion? TECHNIQUE: Imaging was performed after administration of Omnipaque intravenous contrast material. MDCT acquired helical axial images were obtained from the thoracic inlet through the skull base. Coronal and sagittal multiplanar reformats were then produced and reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.1 s, 26.9 cm; CTDIvol = 11.1 mGy (Body) DLP = 292.5 mGy-cm. Total DLP (Body) = 293 mGy-cm. COMPARISON: CT chest ___, CT chest ___. CT neck ___. FINDINGS: Thoracic inlet: Thoracic inlet mass, with supraclavicular, and upper mediastinal extension, measures 5.1 cm x 5.8 cm in cross-section, and at least 5.5 cm superior to inferior (inferior edge not completely seen on the CT neck. On ___, mass measured 6.1 cm x 5.5 cm in cross-section, the and 7.2 cm superior inferior. On ___, it measured 4.2 cm x 3.6 cm in cross-section. On ___ it measured 5.6 cm x 5.6 cm in cross-section. Mass effect on the trachea which is deviated to the right mildly narrowed. Tracheal stent in place. Tumor extends to the level of the left brachiocephalic vein, upper margin of the aortic arch, is situated between left common carotid and right brachiocephalic artery, anterior to the vertebral column, and to the left of the esophagus. Esophagus is deviated to the right. Fat planes between mass, trachea, esophagus, left tracheoesophageal groove are obliterated, there may be local invasion. Inferior margin of the left thyroid lobe is indistinct, may be involved by tumor. The Aero digestive tract: There is no mucosal based mass. Neck lymph nodes: Right neck: There is no right level ___ adenopathy. Few subcentimeter right level 7 lymph nodes. Left neck: Enlarged retro jugular level 2A, 3, 4, 5 B lymph nodes. Largest level 5B lymph node measures 1.7 x 1.4 cm today, compared with 1.5 cm x 1.4 cm ___ level ___ lymph nodes have enlarged. Central mediastinal mass situated at the level of the left 6 and 7 lymph nodes, described above, may represent conglomerate adenopathy or local extensive primary/metastatic tumor. There is no retropharyngeal adenopathy. Extra nodal tumor spread: Irregular contour of left level 5 B lymph node, and central mediastinal mass, suggestive of extranodal extension. Deep neck muscles, masticator space: There is no muscle invasion. Bones, skull base: There is no bone involvement. There are no findings suggestive of perineural tumor extension. Jugular foramen, carotid canal, pterygopalatine fossa, infraorbital foramen, other skull base foramina are not involved. Vessels: There is no vascular invasion. Brachial Plexus: There is no brachial plexus contact or invasion. Left level 5B lymph node is probably just anterior to the brachial plexus. Thyroid, salivary glands: There is no mass. Other findings: Multiple solid and cavitated lung nodules, for thoracic findings refer to chest CT from yesterday. Moderate free-flowing right pleural effusion. Probable secretions in the trachea. Potential intraluminal tumor extent is not definitely seen IMPRESSION: 1. Large central thoracic inlet, mediastinal mass, increasing since ___. 2. Tracheal deviation to the right, mild tracheal narrowing, tracheal stent. Loss of fat planes between tumor and esophagus, trachea, which may be invaded. 3. Left level ___ adenopathy, mildly increased since ___. 4. Lung nodules, right pleural effusion, refer to chest CT from yesterday. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man with neuroendocrine mediastinal cancer, s/p tracheal stent for tumor compression (now removed), here with dysphagia/odynophagia, new cough e/f aspiration// cough TECHNIQUE: Chest PA and lateral COMPARISON: Chest CT ___. Chest radiograph ___. FINDINGS: Right Port-A-Cath tip terminates in the low right atrium, similar to prior. Lung volumes are increased. No focal consolidation. Interval decrease in mild pulmonary edema. Minimal interval decrease in upper mediastinal mass and and severe rightward tracheal shift. Tracheal stent has been removed, but relatively mild tracheal narrowing is stable. The cardiomediastinal silhouette and hilar silhouette are normal. Small right pleural effusion persists. No significant left pleural effusion. No pneumothorax. IMPRESSION: Interval resolution of mild pulmonary edema with increased lung volumes. Minimal interval decrease in upper mediastinal widening with persistent right tracheal shift. No progression of mild tracheal narrowing following removal of previous tracheal stent. Small right pleural effusion persists. No pneumothorax. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man s/p tracheal stent removal with persistent secretions/cough, pls assess for pneumonia// ___ year old man s/p tracheal stent removal with persistent secretions/cough, pls assess for pneumonia IMPRESSION: In comparison with the study of ___, there are lower lung volumes, which may account for the increased transverse diameter of the heart. Nevertheless, there is engorgement of indistinct pulmonary vessels, consistent with pulmonary vascular congestion. Blunting of the right costophrenic angle is again seen and the Port-A-Cath extends to the right atrium. No evidence of acute focal consolidation. Substantial displacement of the upper thoracic trachea to the right is consistent with thyroid mass. Gender: M Race: BLACK/CAPE VERDEAN Arrive by WALK IN Chief complaint: Difficulty swallowing Diagnosed with Dysphagia, unspecified, Chest pain, unspecified temperature: 99.2 heartrate: 95.0 resprate: 18.0 o2sat: 98.0 sbp: 108.0 dbp: 76.0 level of pain: 8 level of acuity: 3.0

Mr ___ It was a pleasure taking care of you. As you know you were admitted due to difficulty swallowing which we found was due to irritated tissue. You were given a short course of steroids and medications to control the symptoms. Since you are now eating normally you don't need steroids but can continue the other meds to ensure pain relief. Please be sure to followup with Dr ___ and continue your remaining radiation treatments.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Codeine / acyclovir / Penicillins / aspirin / Tylenol / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) Attending: ___. Chief Complaint: AMS, GI bleed Major Surgical or Invasive Procedure: esophagogastricduodenoscopy with APC History of Present Illness: ___ w/___ vs. cryptogenic cirrhosis c/b esophageal variceal bleed (___), recurrent encephalopathy s/p TIPS (___), GAVE s/p APC treatments, and anemia who presents to ___ as a transfer from ___ with AMS and GI bleed (Hct 18). His wife called EMS when she discovered him urinating in the wrong place and he was found to have Hct 18 at ___. He was given 1U PRBC's and transferred to ___, where repeat Hct was 21.8. Other labs significant for INR 1.5, Tbili 2.5, AP 91, ALT 23, AST 35, Lip 27, and ammonia 120. At transfer, he was hemodynamically stable. Of note, he is initiating transplant work-up but is not currently listed. He receives most of his care at ___ ___ and has had multiple recent admissions for AMS since having TIPS in ___, averaging 2 admissions/month. Head CT in ___ was negative. His last EGD was in ___ and showed grade I nonbleeding esophageal varices, and severe gastric antral vascular ectasia with active bleeding throughout the antrum, treated extensively with argon plasma coagulation with some oozing at the end of the procedure. US in ___ showed patent TIPS. He is now being transferred to ___ for EGD here and consideration of TIPS reversal. Upon arrival in the ED, vitals: 98 91 120/75 17 97%. Patient was oriented x 1 and stool was guaiac positive. CT head was negative. In the ED, GI evaluated the patient. RUQ US showed patent TIPS. She was given ceftriaxone, lactulose, and plan was initiated for EGD in the AM. There was no pocket for diagnostic tap. Vitals prior to transfer were 97.5 86 114/59 11 98% RA. Labs were notable for HCT of 21.8 and INR 1.5 and bili 2.5. He was given 1U PRBCs in route. ROS: Otherwise negative in detail Past Medical History: #Cirrhosis NASH vs. cryptogenic c/b esophageal and gastric varices #encephalopathy s/p TIPS ___ #GI bleed (___) #GAVE s/p APC treatments #Anemia #Chronic thrombocytopenia #Chronic leukopenia #CAD s/p CABG ___ #LVH #Aortic stenosis s/p bovine aortic valve replacement #Bovine aortic valve replacement ___ #Morbid obesity #Depression #C-spine fracture s/p fusion ___ #Peripheral neuropathy #DM #PVD #Chronic ___ edema #Arthritis #HTN #Migraines #R shoulder arthroscopy x 3 Social History: ___ Family History: Mother died in ___ after a fall, father died of heart valve problems. no GI malignancies or cirrhosis Physical Exam: ADMISSION EXAM 97 140/63 90 16 99% RA General: NAD HEENT: EOMI, PERRL, MMM Neck: supple CV: RRR, ___ SM prominent at ___ Lungs: CTAB Abdomen: soft, nondistended, no ttp GU: no foley Ext: 2+ edema to sacrum Neuro: A&Ox3, slowed speech, otherwise nonfocal, no asterixis Skin: no rash DISCHARGE EXAM 98.9, 114/54, 78, 18, 95% RA, Wt 119.9kg, Fasting blood sugar: 128 I/O 1260/1080, 0 BMs General: NAD HEENT: EOMI, PERRL, anicteric, MMM Neck: supple, No JVD, No ___ CV: RRR, ___ SM prominent at ___ Lungs: CTAB, no w/r/r Abdomen: NABS, soft, nondistended, no ttp Ext: 2+ edema to sacrum Neuro: A&Ox3, no asterixis Skin: no rash Pertinent Results: ADMISSION LABS ___ 04:19PM BLOOD WBC-2.9* RBC-2.15* Hgb-6.7* Hct-21.8* MCV-101* MCH-31.1 MCHC-30.7* RDW-20.0* Plt Ct-61* ___ 04:19PM BLOOD Neuts-63.7 ___ Monos-5.3 Eos-2.1 Baso-0.4 ___ 04:19PM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+ Macrocy-1+ Microcy-OCCASIONAL Polychr-1+ Ovalocy-1+ Target-OCCASIONAL Schisto-OCCASIONAL Burr-OCCASIONAL Stipple-OCCASIONAL Tear Dr-OCCASIONAL ___ 04:19PM BLOOD ___ PTT-33.1 ___ ___ 04:19PM BLOOD Glucose-213* UreaN-25* Creat-1.2 Na-137 K-4.4 Cl-104 HCO3-26 AnGap-11 ___ 04:19PM BLOOD ALT-23 AST-35 AlkPhos-91 TotBili-2.5* ___ 04:19PM BLOOD Lipase-27 ___ 04:19PM BLOOD Albumin-2.4* PERTINENT LABS ___ 05:50AM BLOOD calTIBC-247* Ferritn-56 TRF-190* ___ 05:50AM BLOOD Albumin-2.2* Calcium-7.4* Phos-3.5 Mg-1.8 Iron-40* Cholest-75 ___ 05:50AM BLOOD Triglyc-63 HDL-29 CHOL/HD-2.6 LDLcalc-33 ___ 05:50AM BLOOD 25VitD-58 ___ 05:50AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE ___ 05:50AM BLOOD AMA-NEGATIVE ___ 05:50AM BLOOD ___ ___ 05:50AM BLOOD CEA-<1.0 PSA-<0.1 AFP-1.1 ___ 05:50AM BLOOD IgG-1203 IgA-378 IgM-56 ___ 05:50AM BLOOD HIV Ab-NEGATIVE ___ 05:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 05:50AM BLOOD HCV Ab-NEGATIVE Test Result Reference Range/Units CA ___ 15 <34 U/mL HCT TREND ___ 12:11AM BLOOD Hgb-6.8* Hct-21.6* ___ 09:00AM BLOOD Hgb-7.9* Hct-24.8* ___ 04:10PM BLOOD Hct-22.7* ___ 01:44AM BLOOD Hct-20.7* ___ 06:45AM BLOOD Hgb-7.6* Hct-22.9* ___ 03:41PM BLOOD Hgb-8.3* Hct-26.0* ___ 05:50AM BLOOD Hgb-7.7* Hct-24.8* ___ 03:20PM BLOOD Hct-23.9* ___ 11:23PM BLOOD Hct-23.6* ___ 06:50AM BLOOD Hgb-7.8* Hct-23.5* ___ 03:00PM BLOOD Hct-26.7* DISCHARGE LABS ___ 06:50AM BLOOD WBC-2.2* RBC-2.44* Hgb-7.8* Hct-23.5* MCV-97 MCH-31.8 MCHC-33.0 RDW-20.2* Plt Ct-50* ___ 03:00PM BLOOD Hct-26.7* ___ 06:50AM BLOOD ___ ___ 06:50AM BLOOD Glucose-107* UreaN-16 Creat-0.9 Na-135 K-3.9 Cl-102 HCO3-27 AnGap-10 ___ 06:50AM BLOOD ALT-20 AST-39 AlkPhos-72 TotBili-1.6* ___ 06:50AM BLOOD Calcium-7.7* Phos-3.0 Mg-1.8 MICRO ___ VIRUS VCA-IgG AB (Final ___: POSITIVE BY EIA. ___ VIRUS EBNA IgG AB (Final ___: POSITIVE BY EIA. ___ VIRUS VCA-IgM AB (Final ___: NEGATIVE <1:10 BY IFA. CMV IgG ANTIBODY (Final ___: EQUIVOCAL FOR CMV IgG ANTIBODY BY EIA. 4 AU/ML. Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml. VARICELLA-ZOSTER IgG SEROLOGY (Final ___: POSITIVE BY EIA. RUBELLA IgG SEROLOGY (Final ___: POSITIVE BY EIA. RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE. URINE CULTURE (Final ___: <10,000 organisms/ml Blood Culture, Routine (Final ___: NO GROWTH. IMAGING CT HEAD ___: Limited examination due to patient motion and streak artifact. No definite hemorrhage or acute large territorial infarction. LIVER U/S ___: 1. Patent TIPS shunt. Slightly elevated velocities as compared to recent prior. 2. Cirrhotic liver without definite lesion. 3. Trace perihepatic ascites and splenomegaly. 4. Gallbladder sludge. TTE ___: The left atrial volume is moderately increased. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. A bioprosthetic aortic valve prosthesis is present. The transaortic gradient is higher than expected for this type of prosthesis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Well seated aortic valve bioprosthesis, but with increasd gradient. Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. Compared with the prior study (images reviewed) of ___, the aortic valve gradient and the estimated PA systolic pressure have increased (as has the heart rate). If clinically indicated, a TEE would be better able to visualize the aortic valve leaflets. CLINICAL IMPLICATIONS: Based on ___ AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis IS recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Measurements, Normal Range Left Atrium - Long Axis Dimension: *5.3 cm <= 4.0 cm Left Atrium - Four Chamber Length: *5.8 cm <= 5.2 cm Left Atrium - Volume: *92 ml < 40 ml Left Atrium - LA Volume/BSA: *37 ml/m2 <= 28 ml/m2 Right Atrium - Four Chamber Length: *5.3 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.0 cm Left Ventricle - Fractional Shortening: 0.38 >= 0.29 Left Ventricle - Ejection Fraction: >= 65% >= 55% Left Ventricle - Lateral Peak E': 0.15 m/s > 0.08 m/s Left Ventricle - Septal Peak E': 0.14 m/s > 0.08 m/s Left Ventricle - Ratio E/E': *13 < 13 Aorta - Sinus Level: *4.3 cm <= 3.6 cm Aortic Valve - Peak Velocity: *4.3 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *74 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 46 mm Hg Aortic Valve - LVOT VTI: 39 Mitral Valve - E Wave: 1.9 m/sec Mitral Valve - A Wave: 1.8 m/sec Mitral Valve - E/A ratio: 1.06 Mitral Valve - E Wave deceleration time: 239 ms 140-250 ms TR Gradient (+ RA = PASP): *35 mm Hg <= 25 mm Hg EGD REPORT ___: Three ___ of grade two varices were noted in the lower third of the esophagus. There was no bleeding or high risk signs. 3 small venous blebs noted in the mid esophagus. Mild congestion and erythema with a mosiac apperance consistent with mild portal hypertensive gastropathy noted though out the stomach. Bright red blood was oozing from the antrum consistent with gastric antral vascular ectasia (GAVE). Hemostasis was successfuly achieved with argon plasma coagulation (APC) which was applied though out the antrum. No additional bleeding was noted after APC. There were no gastric or fundic varices. Mild amounts of patchy duodenitis was noted though segemnts one and two of the duodenum, otherwise normal deuodenum. Otherwise normal EGD to third part of the duodenum Recommendations: -Follow up with routine blood work to asses stability of hematocrit. - PPI 40mg PO daily - If pt continues to have a decline in hematocrit, we suggests a follow up EGD in ___ weeks with possible APC or RFA. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Rifaximin 550 mg PO BID 2. Lactulose 45 mL PO QID 3. Citalopram 10 mg PO DAILY 4. Furosemide 20 mg PO DAILY 5. Spironolactone 50 mg PO DAILY 6. Pantoprazole 40 mg PO Q12H 7. 70/30 16 Units Breakfast 70/30 10 Units Dinner Insulin SC Sliding Scale using HUM Insulin 8. alpha lipoic acid ___ unit oral qam 9. Multivitamins 1 TAB PO DAILY 10. Ferrous Sulfate 325 mg PO DAILY 11. Caltrate 600 (calcium carbonate) 600 mg (1,500 mg) oral BID 12. Magnesium Oxide 280 mg PO DAILY 13. Docusate Sodium 100 mg PO BID Discharge Medications: 1. Citalopram 10 mg PO DAILY RX *citalopram 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*1 2. Furosemide 20 mg PO DAILY RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*1 3. 70/30 16 Units Breakfast 70/30 10 Units Dinner Insulin SC Sliding Scale using HUM Insulin RX *insulin NPH and regular human [Humulin 70/30] 100 unit/mL (70-30) 16 Units before BKFT ; 10 Units before DINR daily Disp #*3 Vial Refills:*1 4. Lactulose 45 mL PO QID RX *lactulose 10 gram/15 mL (15 mL) 45 ml by mouth four times a day Disp #*5400 Milliliter Refills:*1 5. Multivitamins 1 TAB PO DAILY RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Capsule Refills:*1 6. Rifaximin 550 mg PO BID RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*3 7. Spironolactone 50 mg PO DAILY RX *spironolactone 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*1 8. Nadolol 20 mg PO DAILY RX *nadolol 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*1 9. alpha lipoic acid ___ unit oral qam 10. Caltrate 600 (calcium carbonate) 600 mg (1,500 mg) oral BID RX *calcium carbonate 600 mg (1,500 mg) 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 11. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*1 12. Ferrous Sulfate 325 mg PO DAILY RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*1 13. Magnesium Oxide 280 mg PO DAILY RX *magnesium oxide 250 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*1 14. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet,delayed release (___) by mouth twice a day Disp #*60 Tablet Refills:*1 15. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp #*6 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: gastric antral vascular ectasias decompensated cirrhosis acute toxic/metabolic encephalopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (___) Followup Instructions: ___ Radiology Report INDICATION: ___ male with history of NASH cirrhosis, now presenting with confusion and left facial droop. COMPARISON: Head CT from ___. TECHNIQUE: MDCT axial images of the brain were obtained without intravenous contrast. Bone and soft tissue algorithms were reviewed. Coronal and sagittal reformations were prepared. NON-CONTRAST HEAD CT: Examination is limited secondary to patient motion and streak artifact from cervical spinal fusion hardware. There is no definite hemorrhage, mass, mass effect, or acute large territorial infarction. Gray-white matter differentiation is preserved. The ventricles and sulci are mildly prominent compatible with age appropriate atrophy. There is no shift of the midline structures. Suprasellar and basilar cisterns are widely patent. No scalp abnormality is detected. The visualized paranasal sinuses and mastoid air cells appear clear. Cervical spinal fusion hardware is only partially imaged and incompletely evaluated. IMPRESSION: Limited examination due to patient motion and streak artifact. No definite hemorrhage or acute large territorial infarction. Radiology Report INDICATION: History of NASH cirrhosis and TIPS, now presenting with confusion. COMPARISON: Abdominal ultrasound from ___ and ___ FINDINGS: The coarse heterogeneous appearance of the liver is consistent with cirrhosis. No definite hepatic lesion is identified. There is no biliary ductal dilatation. The common bile duct measures 4 mm. There is splenomegaly measuring up to 21 cm. The gallbladder remains filled with sludge. There is no ascites within the lower abdomen. Trace perihepatic ascites is noted. DOPPLER EXAMINATION: Color Doppler and spectral waveform analysis was performed. The main portal vein is patent with hepatopetal flow with a velocity of 36 cm/sec. The TIPS stent is patent with wall-to-wall flow and velocities of 156, 206, 128 cm/sec in the proximal, mid and distal portions respectively. Helical flow is again seen within the anterior right portal vein. Flow towards the TIPS shunt is seen within the left portal vein. The velocities are slightly increased in the shunt, findings are overall similar compared to most recent prior examination. IMPRESSION: 1. Patent TIPS shunt. Slightly elevated velocities as compared to recent prior. 2. Cirrhotic liver without definite lesion. 3. Trace perihepatic ascites and splenomegaly. 4. Gallbladder sludge. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: LOW HCT Diagnosed with ALTERED MENTAL STATUS , GASTROINTEST HEMORR NOS temperature: 98.0 heartrate: 91.0 resprate: 17.0 o2sat: 97.0 sbp: 120.0 dbp: 75.0 level of pain: 0 level of acuity: 2.0

Mr. ___, You were admitted to the hospital with bleeding and confusion. Your confusion cleared quickly with lactulose. You underwent endoscopy that showed non-bleeding esophageal varices, and areas of bleeding in your stomach related to your cirrhosis. You underwent a procedure called APC during your endoscopy to stop the bleeding, and your blood counts stabilized. During your admission, you started the evaluation for liver transplant with laboratory testing and social work consultation. You should follow up with the transplant hepatologist on ___, as previously scheduled, for further evaluation. You also underwent an echocardiogram on admission that showed your aortic stenosis has worsened. You were evaluated by cardiology. You should follow up with your outpatient cardiologist for further management of your aortic stenosis. You may need a special echo called a "trans-esophageal echo" in the future, if you are to be further evaluated for liver transplantion.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: RUE weakness Major Surgical or Invasive Procedure: 1. Anterior cervical diskectomy and arthrodesis C4-5. 2. Application of interbody cage, machined allograft C4-5. 3. Arthrodesis C4-5. 4. Anterior instrumentation C4-5 with a plate. History of Present Illness: Patient is a ___ w four days of RUE weakness and neck pain. She has a 6 month history of intermittent neck pain, but it had recently become worse and the weakness is a new finding. She is otherwise well. She has no bowel or bladder sx, she does state she has had clumsiness in her RUE intermittently. Past Medical History: HTN Social History: No tobacoo, etoh, ___ speaking. Physical Exam: Physical Exam Per Ortho Spine Admission Note dated ___- NAD Normal chest rise Motor key 0 - Flaccid 1 - Voluntary twitch 2 - Voluntary mvmt cannot overcome gravity 3 - Can overcome gravity only 4 - Voluntary can overcome some resistance 5 - Normal strength Sensation key 0 - Insensate 1 - Altered sensation 2 - Normal sensation Upper Motor Upper Sensation R L R L C5 5 5 Elbow flexor ___ C6 3+ 5 Wrist extensor ___ C7 4- 5 Elbow extensor ___ C8 4+ 5 Finger flexor ___ T1 3+ 5 Finger abduction ___ Lower Motor Lower Sensation R L R L L2 5 5 Hip adductor L2 2 1 L3 5 5 Knee extensor L3 2 1 L4 5 5 Ankle DF L4 2 2 L5 5 5 ___ L5 2 2 S1 5 5 Ankle PF S1 2 2 Midline pain: TTP right side of cervical spine and shoulder Rectal sensation: intact Rectal tone: intact Babinski:equivocal ___: negative Clonus: none Quality of exam: excellent Upper extremity reflexes symmetric. Pertinent Results: ___ 05:00AM BLOOD WBC-13.8* RBC-4.01* Hgb-11.2* Hct-35.3* MCV-88 MCH-28.0 MCHC-31.8 RDW-12.9 Plt ___ ___ 05:00AM BLOOD Plt ___ ___ 05:00AM BLOOD Glucose-142* UreaN-9 Creat-0.7 Na-142 K-4.2 Cl-106 HCO3-26 AnGap-14 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 10 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain or fever RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6) hours Disp #*45 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills:*0 3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain Please do not operate heavy machinery, drink alcohol, or drive RX *oxycodone [Oxecta] 5 mg ___ tablet, oral only(s) by mouth every four (4) hours Disp #*75 Tablet Refills:*0 4. Amlodipine 10 mg PO DAILY 5. Sulfameth/Trimethoprim SS 1 TAB PO BID Duration: 3 Days RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by mouth twice a day Disp #*10 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: 1. Cervical disk herniation C4-5. 2. Cervical right upper extremity radicular symptoms with weakness. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Pre-operative evaluation for cervical fixation. COMPARISON: None available. TECHNIQUE: PA and lateral chest radiographs, two views. FINDINGS: Heart size is mildly enlarged. Mediastinal silhouette and hilar contours are unremarkable. Lungs are clear. Pleural surfaces are clear without effusion or pneumothorax. IMPRESSION: No acute cardiopulmonary abnormality. Radiology Report HISTORY: Right-sided neck pain and C4-5 disc herniation on MR. ___ evaluation of bones. COMPARISON: Same-day cervical spine MR of ___, cervical spine radiograph ___. TECHNIQUE: Axial helical MDCT images were obtained of the cervical spine without contrast. Multiplanar reformatted images were generated in the coronal and sagittal planes. DLP: 720.42 mGy-cm. CTDIvol: 36.76 mGy. FINDINGS: There is no cervical spine fracture or malalignment.A 7 mm sclerotic lesion in the left C1 posterior arch suggests a bone island. Vertebral body heights are maintained. Again seen are large disc herniations at C3-4, C4-5, and C5-6 with spinal canal narrowing and mass effect on the spinal cord, most severe at C4-5 where severe cord compression is demonstrated on the preceding MRI. There is also a smaller central disc herniation at C6-7. In addition, there are posterior endplate osteophytes from C3-4 through C6-7. There is moderate left facet arthropathy from C3-4 through C5-6, and milder facet arthropathy at other levels on the left and on the right. Uncovertebral osteophytes are also present bilaterally. The extent of neural foraminal narrowing is better assessed on MRI. The prevertebral soft tissues are unremarkable. The imaged lung apices are clear. The visualized portion of the thyroid is unremarkable. A 9 mm left level 5 lymph node on image 3:35 is top normal in size and unusual for age, but appears to contain a preserved fatty hilus. IMPRESSION: 1. No cervical spine fracture or malalignment. 2. Multilevel degenerative disease with severe cord compression at C4-5, better assessed on the preceding MR. Radiology Report SIX INTRAOPERATIVE RADIOGRAPHS OF THE CERVICAL SPINE CLINICAL INDICATION: ___ female with anterior cervical spine fusion. TECHNIQUE: Six intraoperative radiographs of the cervical spine were obtained. COMPARISON: CT cervical spine dated ___. FINDINGS: The initial radiograph demonstrates a marker within the C5-C6 intervertebral disc space. The final image demonstrates anterior cervical fusion from C4 through C5. No definite hardware complication is seen. IMPRESSION: Anterior cervical fusion at C4-C5 without definite hardware complication. Please refer to the intraoperative report for further details. Radiology Report HISTORY: Right-sided neck pain, PCP once ___. TECHNIQUE: AP, lateral, and open-mouth views of the cervical spine. COMPARISON: None. FINDINGS: On the lateral view, C1-C7 are included. The C7/T1 interval is not well seen although grossly, anatomic alignment is likely maintained. There is a small well corticated ossific structure measuring 2-3 mm just anterior to the inferior/anterior aspect of the C5 vertebral body, which appears old. Minimal disc space narrowing is seen at C4/C5. Vertebral body heights are maintained without findings to suggest acute fracture. Atlanto axial interval is maintained. No dislocation is seen. There is no prevertebral soft tissue swelling. The visualized lung apices are grossly clear. IMPRESSION: C7/T1 interval not optimally seen, although grossly, anatomic alignment is likely maintained. If there is high clinical concern at this location, suggest swimmer's view or CT. Otherwise, mild degenerative changes without definite acute fracture or dislocation. Radiology Report CERVICAL SPINE MRI WITHOUT CONTRAST, ___ INDICATION: Right-sided neck pain, weakness of right wrist flexion. Evaluate for cord impingement. COMPARISON: Cervical spine radiographs performed earlier today. TECHNIQUE: Sagittal T1-weighted, T2-weighted, and STIR images of the cervical spine, as well as sagittal diffusion-weighted images of the cervical spine, and axial gradient echo and T2-weighted images of the cervical spine. FINDINGS: Vertebral body heights are preserved. There is no subluxation. No concerning bone marrow signal abnormalities are seen. At C2-3, there is no significant spinal canal or neural foraminal narrowing. There is mild left facet arthropathy. At C3-4, there is a broad-based disc osteophyte complex moderately narrowing the spinal canal and flattening the ventral spinal cord. Cord signal appears preserved at this level. There is moderate bilateral neural foraminal narrowing by uncovertebral and facet osteophytes. At C4-5, there is a large central disc herniation, larger on the right than left, which severely narrows the spinal canal and compresses the spinal cord. There is high signal in the cord at this level on T2-weighted images, compatible with edema or myelomalacia. There is mild right and moderate left neural foraminal narrowing by uncovertebral osteophytes. At C5-6, there is a central disc protrusion moderately narrowing the spinal canal and flattening the ventral spinal cord. Cord signal appears preserved. There is moderate right and severe left neural foraminal narrowing by uncovertebral and facet osteophytes. At C6-7, there is a small central disc protrusion which abuts the ventral spinal cord without significant cord deformation. There is mild-to-moderate spinal canal narrowing. There is mild left neural foraminal narrowing by uncovertebral osteophytes. C7-T1 level demonstrates mild left neural foraminal narrowing by uncovertebral osteophytes. Sagittal images through the T1-2 level demonstrate a possible shallow disc herniation without significant spinal canal narrowing. Cerebellar tonsils are normally positioned. The imaged portion of the posterior fossa appears unremarkable. There is no diffusion abnormality in the spinal cord. IMPRESSION: 1. At C4-5, there is a large central disc herniation, larger on the right than left, which compresses the spinal cord and severely narrows the spinal canal. Abnormal cord signal at this level may indicate edema or myelomalacia. 2. At C3-4 and C5-6, there is moderate spinal canal stenosis with deformation of the spinal cord, but no abnormal cord signal. Cord compression and cord signal abnormality were documented in the ___ medical record and immediately transmitted to the ED dashboard by Dr. ___ on ___ at 9:11 p.m. At the time of final dictation, the patient had already been taken to the operating room. Gender: F Race: ASIAN - CHINESE Arrive by WALK IN Chief complaint: Weakness, Shoulder pain Diagnosed with CERVICAL DISC DISPLACMNT temperature: 97.4 heartrate: 58.0 resprate: 18.0 o2sat: 100.0 sbp: 111.0 dbp: 57.0 level of pain: 13 level of acuity: 3.0

ACDF: You have undergone the following operation: Anterior Cervical Decompression and Fusion Immediately after the operation: • Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit in a car or chair for more than ~45 minutes without getting up and walking around. • Rehabilitation/ Physical Therapy: ___ ___ times a day you should go for a walk for ___ minutes as part of your recovery. You can walk as much as you can tolerate. ___ Isometric Extension Exercise in the collar: 2x/day x ___xercises as instructed. • Swallowing: Difficulty swallowing is not uncommon after this type of surgery. This should resolve over time. Please take small bites and eat slowly. Removing the collar while eating can be helpful – however, please limit your movement of your neck if you remove your collar while eating. • Cervical Collar / Neck Brace: You have been given a soft collar for comfort. You may remove the collar to take a shower or eat. Limit your motion of your neck while the collar is off. You should wear the collar when walking, especially in public • Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually ___ days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Call the office at that time. If you have an incision on your hip please follow the same instructions in terms of wound care. • You should resume taking your normal home medications. • You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so plan ahead. You can either have them mailed to your home or pick them up at the clinic located on ___ 2. We are not allowed to call in narcotic (oxycontin, oxycodone, percocet) prescriptions to the pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. • Follow up: ___ Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. ___ At the 2-week visit we will check your incision, take baseline x rays and answer any questions. ___ We will then see you at 6 weeks from the day of the operation. At that time we will most likely obtain Flexion/Extension X-rays and often able to place you in a soft collar which you will wean out of over 1 week. Please call the office if you have a fever>101.5 degrees Fahrenheit, drainage from your wound, or have any questions.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Vasotec / Niaspan Starter Pack / Ibuprofen Attending: ___. Chief Complaint: R elbow pain and swelling Major Surgical or Invasive Procedure: none History of Present Illness: ___ yo M w/ h/o AF on coumadin p/w right arm redness and swelling since ___. Per wife, was watching TV, when pt noted pain with movement of his R arm. Went to ___'s office on ___ where plain films were obtained and sent to Dr. ___ (___), who felt that there may be hemarthrosis given elevated INR 5. Patient's wife noted redness was more extensive, arm more warm, tender on ___ so she brought pt to ___ for further evaluation. At ___, labs notable for INR 5.2, WBC 6.9, hct 34.9 (c/w baseline). He received ancef for possible cellulitis, was going to be admitted for further abx and monitoring but patient requested transfer to ___. In the ED, initial vs were: 98.5 70 149/73 18 94% RA. Labs were remarkable for INR 4.7, hct 36.1, creatinine 1.2 w/ BUN 27, lactate 1.0. Patient was given 1g IV vancomycin. Was seen by ortho who felt exam was not c/w septic arthritis and recommended admission to medicine for antibiotics and monitoring. Vitals on Transfer: 98.7 78 144/77 16 98%. On the floor, vs were: T 97.8 P 93 BP 144/77 R 16 O2 99% on RA. Patient was comfortable without any complaints except pain in his R arm with movement. Denied fevers, chills, any recent trauma or injury, no recent dietary changes or medication changes/antibiotics. Per patient has not had many difficulties keeping INR in therapeutic range and has only had one other episode of bleeding- lower GI bleed in ___. Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies myalgias. Ten point review of systems is otherwise negative. PAST MEDICAL HISTORY: Past Medical History: -Atrial fibrillation on warfarin -Chronic constipation -Pancolonic diverticuli -Colon polyps -BPH -Partial lung resection for suspicious nodule, ___ -TKRs bilaterally at ___ -open cholecystectomy -open appendectomy -Squamous cell carcinoma (skin) Social History: ___ Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 97.8 BP: 144/77 P: 93 R: 16 O2: 99% RA General: Alert, orient to person, place, and partially to time, no acute distress, pleasant HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Irregular, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly; well healed surgical scars Ext: R UE with extensive hematoma on medial aspect, marked, and tender to palpation; no other surrounding erythema; pt unable to actively move R arm ___ pain, but ROM on passive evaluation is intact; ___ are warm, well perfused, 2+ pulses, trace edema b/l; no clubbing, cyanosis Neuro: alert, oriented x3, CNII-XII grossly intact; motor and sensation grossly intact; normal gait Discharge Physical Exam: no significant difference from admission exam Pertinent Results: ============================================================= LABS: ___ 07:40PM BLOOD WBC-7.5 RBC-3.84* Hgb-12.3* Hct-36.1* MCV-94 MCH-31.9 MCHC-33.9 RDW-13.9 Plt ___ ___ 07:43AM BLOOD WBC-7.0 RBC-3.84* Hgb-11.7* Hct-35.0* MCV-91 MCH-30.5 MCHC-33.5 RDW-14.2 Plt ___ ___ 07:40PM BLOOD Neuts-63.5 ___ Monos-10.4 Eos-1.7 Baso-0.9 ___ 07:40PM BLOOD ___ PTT-63.2* ___ ___ 07:43AM BLOOD ___ PTT-57.0* ___ ___ 07:40PM BLOOD Glucose-119* UreaN-27* Creat-1.2 Na-138 K-3.7 Cl-102 HCO3-27 AnGap-13 ___ 07:43AM BLOOD Glucose-113* UreaN-23* Creat-1.0 Na-140 K-3.9 Cl-106 HCO3-25 AnGap-13 ___ 07:40PM BLOOD Calcium-8.9 Phos-2.1* Mg-2.0 ___ 07:43AM BLOOD Calcium-9.2 Phos-2.5* Mg-1.9 ___ 07:40PM BLOOD CRP-70.0* ___ 07:40PM BLOOD Digoxin-0.4* ============================================================= MICROBIOLOGY: ___ 7:40 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: BACILLUS SPECIES; NOT ANTHRACIS. Isolated from only one set in the previous five days. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE ROD(S). CONSISTENT WITH CLOSTRIDIUM OR BACILLUS SPECIES. Reported to and read back by ___ (___) ___ @1740. ___ 7:40 pm BLOOD CULTURE 2 OF 2. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH ============================================================= IMAGING: Upper Extremity Ultrasound ___: FINAL READ IMPRESSION: No evidence of pseudoaneurysm or drainable fluid collection. Small hematoma at the site of patient's echhymosis. ============================================================= Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ascorbic Acid ___ mg PO DAILY 2. Digoxin 0.25 mg PO DAILY 3. Finasteride 5 mg PO DAILY 4. Atorvastatin 10 mg PO DAILY 5. Tricor *NF* (fenofibrate nanocrystallized) 48 mg Oral daily 6. Warfarin 5 mg PO DAILY16 7. Losartan Potassium 80 mg PO DAILY 8. Zolpidem Tartrate 10 mg PO HS:PRN insomnia 9. Triamterene 32.5 mg PO DAILY ___ edema 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation Discharge Medications: 1. Ascorbic Acid ___ mg PO DAILY 2. Atorvastatin 10 mg PO DAILY 3. Digoxin 0.25 mg PO DAILY 4. Finasteride 5 mg PO DAILY 5. Losartan Potassium 80 mg PO DAILY 6. Polyethylene Glycol 17 g PO DAILY:PRN constipation 7. Zolpidem Tartrate 10 mg PO HS:PRN insomnia 8. Acetaminophen 650 mg PO Q6H:PRN pain 9. Triamterene 32.5 mg PO DAILY ___ edema 10. Tricor *NF* (fenofibrate nanocrystallized) 48 mg ORAL DAILY Discharge Disposition: Home Discharge Diagnosis: Ecchymosis Supratherapeutic INR Mild hemarthrosis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: ___ man with painful elbow and ecchymosis over right medial arm. COMPARISON: None. TECHNIQUE: Limited soft tissue ultrasound of the right arm. FINDINGS: Evaluation of the area of discoloration over the patient's right medial forearm demonstrates no evidence of vascular compromise or pseudoaneurysm. Soft tissue changes consistent with a small hematoma is noted below the area of the discoloration. IMPRESSION: No evidence of pseudoaneurysm or drainable fluid collection. Small hematoma at the site of patient's echhymosis. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: R ARM SWELLING Diagnosed with JOINT EFFUSION-UP/ARM, JOINT PAIN-UP/ARM, ABNORMAL COAGULATION PROFILE, ADV EFF ANTICOAGULANTS, HYPERCHOLESTEROLEMIA temperature: 98.5 heartrate: 70.0 resprate: 18.0 o2sat: 94.0 sbp: 149.0 dbp: 73.0 level of pain: 10 level of acuity: 3.0

Dear Mr. ___, It was a pleasure taking care of you while you were admitted to ___. You were admitted because of pain at your elbow and redness/bruising on your right arm. We checked your bloodwork and found you to have an elevated INR (Coumadin level) which has lead to ecchymosis or bleeding within the superficial skin layers. We evaluated your arm with ultrasound and the preliminary read confirmed that there was no hematoma or blood collection that would require further intervention. Also, we repeated your INR which was trending down. After serial examinations of your arm, we feel that the current area of redness is not expanding further. When you return home, it is important that you do not take Coumadin today. Tomorrow, you have an appointment with your PCP, ___, at 3pm for a check-up of your arm and repeat INR level. Dr. ___ will instruct you on further Coumadin dosing. Additionally, please call your cardiologist to arrange an appointment in the next ___ days.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: dizziness, slurred speech Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a very pleasant ___ w/ thalamic glioblastoma c/b hydrocephalus s/p VP shunt, s/p IMRT/TMZ ___, TMZ and Bevacizumab, c/b disease recurrence s/p SRS ___, now on TMZ/Beva q3 mo w/ recent dx of disease progression who p/w slurred speech. She went to have her MRI today prior to her brain tumor clinic appointment. There she noted she had dizziness so a code was called and she was referred to the ED. SHe states her symptoms are largely stable since she last presented to the hospital. Of note, I admitted her on ___ when she presented w/ sig nausea, vertigo, difficulty projecting voice, DOE, dysphagia, found to have disease progression, and started on dex. LP was done and cytology negative for malignant cells but MRI was c/f progression. She was discharged ___ on 4 mg dex BID. Since then, she noted no change in her dizziness. Dizziness is mainly when she moves her head or eyes, but does NOT have dizziness at rest looking straight. Her nausea improved on dex. She still has dysphagia and that seems to be slightly worse. Her speech is sometimes slurred as well, not always, but "feels like my tongue is swollen," or like "i'm speaking with a swollen tongue." Her HA improved on dex but still has them intermittently, not currently. She had sig relief w/ fioricet on last admission. In the ED, she was seen by neurology service who noted a baseline neurological exam w/ exception of mild dysarthria. They recommended admission to neuro-onc for brain MRI and further workup. Past Medical History: Positive PPD Depressive disorder Suicide threat or attempt Burn Social History: ___ Family History: NC Physical Exam: ADMISSION PHYSICAL EXAM: VITAL SIGNS:97.8 PO 160 / 111 R Lying 78 18 98 RA General: NAD, Resting in bed with fiance at bedside HEENT: MMM, no OP lesions, no nystagmus at rest, tongue is midline CV: RR, NL S1S2 no S3S4 No MRG PULM: CTAB, No C/W/R, No respiratory distress ABD: BS+, soft, NTND, no peritoneal signs LIMBS: WWP, no ___, no tremors SKIN: No notable rashes on trunk nor extremities NEURO: CN III-XII intact, strength b/l ___ intact, she has >10 sec nystagmus in both horizontal and vertical directions but much worse on end horizontal gaze and that reproduces her dizziness, unable to assess for fatigability as she became sig symptomatic holding her vision and had to abort, PEERL 3->2 mm, she has minimal to no dysarthria, speech is clear and fluent w/o word finding difficulty but slightly hypophonic, she has no dysmetria or dysdiadochokinesia, negative rhomberg, she sways ambulating in room, + subjective orthostatic dizziness PSYCH: Thought process logical, linear, future oriented ACCESS: PIV DISCHARGE PHYSICAL EXAM: Vitals: ___ 2308 Temp: 97.8 PO BP: 150/94 R Lying HR: 78 RR: 18 O2 sat: 97% O2 delivery: RA Pain Score: Sleeping General: NAD, Resting in bed HEENT: MMM, no OP lesions CV: RR, NL S1S2 no S3S4 No MRG PULM: CTAB, No C/W/R, No respiratory distress ABD: BS+, soft, NTND, no peritoneal signs LIMBS: WWP, no ___, no tremors SKIN: No notable rashes on trunk nor extremities NEURO: horizontal nystagmus present, tongue with left sided deviation. Remaining CNs intact. strength b/l ___ intact, PEERL, mild dysarthria, speech is fluent w/o word finding difficulty but slightly hypophonic, she has no dysmetria or dysdiadochokinesia, negative rhomberg, she sways ambulating in room, + subjective orthostatic dizziness PSYCH: Thought process logical, linear, future oriented ACCESS: PIV Pertinent Results: ADMISSION LABS ============== ___ 03:27PM BLOOD WBC-12.4* RBC-5.23* Hgb-16.8* Hct-47.8* MCV-91 MCH-32.1* MCHC-35.1 RDW-12.1 RDWSD-40.3 Plt ___ ___ 03:27PM BLOOD Neuts-84.0* Lymphs-8.1* Monos-5.9 Eos-0.1* Baso-0.1 Im ___ AbsNeut-10.41* AbsLymp-1.00* AbsMono-0.73 AbsEos-0.01* AbsBaso-0.01 ___ 03:52PM BLOOD ___ PTT-25.6 ___ ___ 03:27PM BLOOD Glucose-148* UreaN-10 Creat-0.7 Na-133* K-5.1 Cl-95* HCO3-21* AnGap-17 ___ 03:27PM BLOOD ALT-51* AST-53* AlkPhos-65 TotBili-0.4 ___ 03:27PM BLOOD Albumin-4.5 Calcium-9.6 Phos-3.5 Mg-2.4 ___ 03:27PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 03:53PM BLOOD Lactate-3.3* DISCHARGE LABS ============== ___ 01:10PM BLOOD WBC-26.6* RBC-5.13 Hgb-16.3* Hct-46.8* MCV-91 MCH-31.8 MCHC-34.8 RDW-12.1 RDWSD-40.3 Plt ___ ___ 01:10PM BLOOD Plt ___ ___ 07:50AM BLOOD Glucose-69* UreaN-11 Creat-0.5 Na-138 K-3.6 Cl-99 HCO3-24 AnGap-15 ___ 06:55AM BLOOD ALT-41* AST-22 LD(LDH)-181 AlkPhos-61 TotBili-0.5 ___ 07:50AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.3 MICRO ===== ___ 5:15 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING ======= CXR ___ The lungs are clear without focal consolidation. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are stable. No pulmonary edema is seen. Partially imaged right sided catheter, likely VP shunt. CT CHEST ___. Allowing for differences in modality, ill-defined hypodensity about the posterior midline pons, middle cerebellar peduncles, and upper cervical spine appears grossly similar. MRI is more sensitive. Nonspecific periventricular and subcortical white matter hypodensities appear similar as well. No evidence of acute large territory infarction or intracranial hemorrhage. 2. Stable appearance of ventricular system. MR HEAD ___. Slight interval decrease in leptomeningeal enhancement along the anteroinferior surface of the fourth ventricle. Otherwise, no interval change compared with the MRI of ___. 2. Specifically, FLAIR hyperintense signal and swelling of the brainstem primarily involving the pons as well as with extension into the medulla and cervicomedullary junction is re-demonstrated, with slight effacement of the inferior fourth ventricle, no associated parenchymal enhancement or restricted diffusion. 3. Appearance is nonspecific and differential is broad, including disease progression, atypical/central-variant hypertensive encephalopathy (PRES), radiation necrosis, as well as demyelinating or other inflammatory conditions, viral encephalitis. Correlate with CSF analysis, if not recently performed. Additionally, MR perfusion and spectroscopy could be performed for further evaluation. 4. Unchanged faint enhancement along the floor of the fourth ventricle. 5. No new abnormal enhancement or new acute intracranial process. No recent infarction or extra-axial collection. 6. Stable right thalamic post treatment changes. 7. Unchanged right frontal ventriculostomy, tip at the foramina of ___. Stable shunted ventricular caliber. 8. Stable nonspecific supratentorial white matter FLAIR hyperintensities. VIDEO SWALLOW ___ Penetration with thin liquids. No evidence of aspiration. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line 2. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild 3. Dexamethasone 4 mg PO BID 4. Omeprazole 40 mg PO DAILY 5. NIFEdipine (Extended Release) 30 mg PO DAILY Discharge Medications: 1. Acetaminophen-Caff-Butalbital ___ TAB PO Q4H:PRN Headache Do not exceed 6 tablets/day RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___ tablet(s) by mouth every 4 hours Disp #*20 Tablet Refills:*0 2. Meclizine 12.5 mg PO Q8H:PRN dizziness RX *meclizine 12.5 mg 1 tablet(s) by mouth every 8 hours Disp #*60 Tablet Refills:*0 3. NIFEdipine (Extended Release) 60 mg PO DAILY RX *nifedipine 60 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily Disp #*30 Packet Refills:*0 5. Senna 8.6 mg PO BID RX *sennosides [senna] 8.6 mg 1 by mouth two times per day Disp #*60 Tablet Refills:*0 6. Dexamethasone 4 mg PO BID 7. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild 8. Omeprazole 40 mg PO DAILY 9. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line 10.Outpatient Speech/Swallowing Therapy Clinical swallow evaluation and therapy for dysphagia ICD-10: R13.10 11.Outpatient Lab Work Please draw CBC on ___ Results should be faxed to Dr. ___ at ___. ICD-10: ___.___ Discharge Disposition: Home Discharge Diagnosis: Primary: Thalamic glioblastoma 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 rule out cardiopulmonary process// rule out cardiopulmonary process TECHNIQUE: Chest: Frontal and Lateral COMPARISON: ___ FINDINGS: The lungs are clear without focal consolidation. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are stable. No pulmonary edema is seen. Partially imaged right sided catheter, likely VP shunt. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: History: ___ with left face numbe, vertticla nystagmus// left face numbe, vertticla nystagmus TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 16.1 cm; CTDIvol = 49.9 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: MR head ___ and CT head ___ FINDINGS: Right frontal approach ventriculostomy catheter tip is seen near the foramina of ___, unchanged. Reservoir is again seen over the right frontal scalp. Shunted ventricular caliber is stable. Allowing for differences in modality, periventricular and subcortical white matter hypodensities, worst on the right, appear similar to prior. Streak artifact within the posterior fossa limits evaluation of the brainstem, although allowing for this, ill-defined hypodensity about the posterior midline pons, middle cerebellar peduncles, and upper cervical spine appears grossly similar to fuller hyperintensity seen on recent prior MRI from ___. Right thalamic hypodensity is again seen, possibly related to biopsy. There is no evidence of acute large territory infarction or hemorrhage. There is no evidence of acute fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. Allowing for differences in modality, ill-defined hypodensity about the posterior midline pons, middle cerebellar peduncles, and upper cervical spine appears grossly similar. MRI is more sensitive. Nonspecific periventricular and subcortical white matter hypodensities appear similar as well. No evidence of acute large territory infarction or intracranial hemorrhage. 2. Stable appearance of ventricular system. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD. INDICATION: ___ year old woman with GBM w/ recent dx of disease progression, started on dex, now p/w dysarthria// eval for disease progression. TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of 6 mL of Gadavist intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: 1. CT head ___. 2. MR head ___ and ___. FINDINGS: There are stable post treatment changes along the medial right thalamus. Infiltrative FLAIR hyperintensity seen centered symmetrically about the posterior brainstem involving primarily the pons but also extending to involve the middle as well as the cervicomedullary junction and upper cervical cord, as well as the very posteromedial aspects of the mid brain nearly to the level of the sylvian aqueduct. There is involvement as well the adjacent scratch posteromedial portions of the middle cerebellar peduncles. These signal abnormalities are so seated with swelling and of mass-effect of the involved areas of brainstem (03:12), with slight effacement of the inferior aspect of the fourth ventricle, new from ___, similar to ___. Linear enhancement along the inferior, ventral surface of the fourth ventricle posterior to the pons and midbrain (series 10 images ___ is minimally decreased from prior, particularly on the right, now with enhancement mostly confined to the left of the midline. The previously demonstrated focus of enhancement along the floor of the third ventricle is unchanged (900:82). Again seen is right frontal approach ventriculostomy catheter with tip terminating near the foramen of ___, unchanged. There is no new area of enhancement. No recent infarction, new hemorrhage, extra-axial collection, new parenchymal edema, mass, or mass effect. The ventricles and sulci are normal in caliber and configuration. Linear FLAIR hyperintensity along the right frontal approach ventriculostomy catheter is unchanged. A few scattered supratentorial deep white matter foci of FLAIR hyperintensity are also unchanged, nonspecific. The visualized paranasal sinuses and mastoids appear clear. The globes and orbits are unremarkable. Major intracranial vascular flow voids are preserved. Major dural venous sinuses are patent. IMPRESSION: 1. Slight interval decrease in leptomeningeal enhancement along the anteroinferior surface of the fourth ventricle. Otherwise, no interval change compared with the MRI of ___. 2. Specifically, FLAIR hyperintense signal and swelling of the brainstem primarily involving the pons as well as with extension into the medulla and cervicomedullary junction is re-demonstrated, with slight effacement of the inferior fourth ventricle, no associated parenchymal enhancement or restricted diffusion. 3. Appearance is nonspecific and differential is broad, including disease progression, atypical/central-variant hypertensive encephalopathy (PRES), radiation necrosis, as well as demyelinating or other inflammatory conditions, viral encephalitis. Correlate with CSF analysis, if not recently performed. Additionally, MR perfusion and spectroscopy could be performed for further evaluation. 4. Unchanged faint enhancement along the floor of the fourth ventricle. 5. No new abnormal enhancement or new acute intracranial process. No recent infarction or extra-axial collection. 6. Stable right thalamic post treatment changes. 7. Unchanged right frontal ventriculostomy, tip at the foramina of ___. Stable shunted ventricular caliber. 8. Stable nonspecific supratentorial white matter FLAIR hyperintensities. RECOMMENDATION(S): Correlation with CSF analysis, if not recently performed, as well as consideration of MR spectroscopy and perfusion for further evaluation of brainstem FLAIR abnormalities, as above. Radiology Report EXAMINATION: Video oropharyngeal swallow study. INDICATION: ___ year old woman with GBM and progressive dysphagia// eval for silent aspiration TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in conjunction with the Speech-Language Pathologist from the Voice, Speech & Swallowing Service. Multiple consistencies of barium were administered. DOSE: Fluoro time: 5 minutes 2 seconds FINDINGS: There was penetration with thin liquids. No evidence of aspiration. IMPRESSION: Penetration with thin liquids. No evidence of aspiration. Please note that a detailed description of dynamic swallowing as well as a summative assessment and recommendations are reported separately in a standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation Services). Gender: F Race: ASIAN - SOUTH EAST ASIAN Arrive by WALK IN Chief complaint: Dizziness Diagnosed with Secondary malignant neoplasm of brain, Dizziness and giddiness, Dysarthria and anarthria, Anesthesia of skin temperature: 97.1 heartrate: 100.0 resprate: 16.0 o2sat: 100.0 sbp: 170.0 dbp: 115.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, It was a pleasure taking care of you at ___ ___. Why was I admitted to the hospital? - You were dizzy and had difficulty speaking What was done while I was in the hospital? - You had an MRI that showed your cancer was stable - You had a swallow study that showed you are at risk for aspirating What should I do when I get home from the hospital? - Be sure to continue to take your medications as prescribed - Please go to all of your follow-up appointments, including with oncology and the speech and swallow team - If you have headache, nausea, vomiting, new weakness, numbness, tingling, problems speaking, worsening dizziness, or generally feel unwell, please call your doctor or go to the emergency room Sincerely, Your ___ Treatment Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: vancomycin Attending: ___. Chief Complaint: Shortness of breath and chest pain Major Surgical or Invasive Procedure: ___ 1. Redo sternotomy. 2. Coronary artery bypass grafting x2 with left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to the posterior descending artery. 3. Aortic valve replacement with a 29 ___ Ease pericardial tissue valve, model ___, TFX, serial number is ___. 4. Reconstruction of pericardium with CorMatrix History of Present Illness: ___ year old male with past medical history of hypertension, hyperlipidemia, and s/p ascending aortic aneurysm repair and single vessel bypass (SVG-PDA) in ___ at ___ who presented to OSH with shortness of breath. He was seen by Dr. ___ in ___ after CTA chest revealed saccular outpouching of contrast, 1.1 x 1.8 cm, at the site of his aortic root repair, not seen on prior imaging studies and concerning for pseudoaneurysm, no surgery indicated at that time and plan was to follow up with echo. CTA at ___ showed mural thrombus. Patient transferred to ___ on Heparin gtt for further evaluation. Cardiac surgery consulted. Past Medical History: Ascending Aortic Aneurysm repair with 26 mm gelweave graft/ CABG x1(SVG-PDA) in ___ at ___ w/ Dr. ___ c/b MRSA sternal wound infection (6 weeks of vancomycin) Coronary Artery Disease Bicuspid aortic valve Aortic stenosis GERD BPH Hypertension Hyperlipidemia Umbilical hernia Urosepsis Left spontaneous PTX requiring CT placement Bilateral Shoulder surgery x 5 -most recent ___ Umbilical Hernia repair C5-C6 fusion Social History: ___ Family History: Denies significant family history Physical Exam: ADMISSION PHYSICAL EXAM ============================ VS: T 98.7 HR 60 BP 150/58 RR 18 O2 Sat 98% RA GENERAL: NAD HEENT: AT/NC, anicteric sclera, MMM NECK: supple, no LAD CHEST: Sternal incision, well healed CV: ___ midsystolic murmur auscultated in upper sternal area PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles GI: abdomen soft, mildly distended, nontender, +umbilical hernia EXTREMITIES: no cyanosis, clubbing. Trace edema MSK: Bilateral shoulder incisions, well healed PULSES: 2+ radial pulses bilaterally NEURO: Alert, moving all 4 extremities with purpose, face symmetric DERM: Multiple tattoos covering chest and arms. Warm and well perfused, no excoriations or lesions, no rashes . DISCHARGE PHYSICAL EXAM: 98.6 125 / 67 70 18 97 Ra General: NAD [x] Neurological: A/O x3 [x] non-focal [x] HEENT: PEERL [x] Cardiovascular: RRR [x] Irregular [] Murmur [] Rub [x] Respiratory: CTA [x] No resp distress [] GI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] NT [x] Extremities: Right Upper extremity Warm [] Edema Left Upper extremity Warm [] Edema Right Lower extremity Warm [x] Edema 1+ Left Lower extremity Warm [x] Edema 1+ Pulses: DP Right: Left: ___ Right: Left: Radial Right: Left: Skin/Wounds: Dry [x] intact [x] Sternal: CDI [x] no erythema or drainage [x] Sternum stable [] Prevena [] Lower extremity: Right [] Left [x] CDI [x] Pertinent Results: ADMISSION LABS ======================== ___ 05:30PM BLOOD WBC-7.1 RBC-4.15* Hgb-13.1* Hct-37.6* MCV-91 MCH-31.6 MCHC-34.8 RDW-14.7 RDWSD-48.3* Plt ___ ___ 05:30PM BLOOD Neuts-88.6* Lymphs-9.5* Monos-1.3* Eos-0.1* Baso-0.1 Im ___ AbsNeut-6.24* AbsLymp-0.67* AbsMono-0.09* AbsEos-0.01* AbsBaso-0.01 ___ 05:30PM BLOOD ___ PTT-50.1* ___ ___ 05:30PM BLOOD Glucose-151* Creat-1.1 Na-140 K-5.4 Cl-104 HCO3-17* AnGap-19* ___ 05:30PM BLOOD ALT-23 AST-42* AlkPhos-62 TotBili-0.6 ___ 05:30PM BLOOD cTropnT-<0.01 ___ 10:24PM BLOOD cTropnT-<0.01 ___ 05:30PM BLOOD Lipase-20 ___ 05:30PM BLOOD Albumin-4.1 ___ 07:12PM BLOOD %HbA1c-5.5 eAG-111 IMAGING ========================== ___ TTE The left atrial volume index is moderately increased. The right atrium is mildly enlarged. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is ___ mmHg. There is moderate symmetric left ventricular hypertrophy with a normal cavity size. There is normal regional and global left ventricular systolic function. Overall left ventricular systolic function is low normal. Quantitative 3D volumetric left ventricular ejection fraction is 50 %. There is no resting left ventricular outflow tract gradient. Tissue Doppler suggests an increased left ventricular filling pressure (PCWP greater than 18mmHg). Mildly dilated right ventricular cavity with normal free wall motion. The aortic sinus is mildly dilated with mildly dilated ascending aorta. The aortic arch is mildly dilated. The aortic valve is bicuspid with moderately thickened leaflets with fusion of the right/left raphe. There is severe aortic valve stenosis (valve area less than 1.0 cm2). There is an eccentric, anterior mitral leaflet directed jet of moderate [2+] aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is mild to moderate [___] mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. There is moderate to severe pulmonary artery systolic hypertension. There is a trivial pericardial effusion. IMPRESSION: Moderate symmetric left ventricular hypertrophy with normal cavity size and lownormal global systolic function. Increased PCWP. Bicuspid aortic valve with fusion of the right and left commissures ___ 1A). Severe aortic valve stenosis. Moderate aortic regurgitation. Mild to moderate mitral regurgitation. Mild tricuspid regurgitation. Moderate to severe pulmonarya rtery systolic hypertension. Mild thoracic aortic enlargement. Compared with the prior TTE ___ , the aortic valve area is now smaller, the degree of aortic regurgitation has increased, and left ventricular systolic function is slightly worse. ___ CAROTID US No atherosclerotic plaque or hemodynamically significant stenosis of the bilateral carotid arteries. ___ CXR Small bilateral pleural effusions and mild atelectasis in the lung bases. . preliminary TEE report ___ PREBYPASS 1. Overall normal LVEF 2. Severe Aortic stenosis with bicuspid severely calcified Ao valve (valve area 0.8 cm2) 3. Moderate AI with eccentric jet towards AMVL No spontaneous echo contrast or thrombus is seen in the body of the right atrium or the right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). There is mild symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. with normal free wall contractility. The aortic root is mildly dilated at the sinus level. There are simple atheroma in the descending thoracic aorta. The aortic valve is bicuspid. The aortic valve leaflets are severely thickened/deformed. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. The mean LVOT gradient is 0.9 mmHg. There is severe aortic valve stenosis (valve area <1.0cm2). The aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. POSTBYPASS RHYTHM: A paced. INFUSIONS: Epi and neo Well seated bioprosthesis noted in the aortic position. Biventricular LV fuction remains unchanged. Interpretation assigned to ___, MD, Interpreting physician . ___ 04:14AM BLOOD WBC-6.1 RBC-2.54* Hgb-7.9* Hct-23.3* MCV-92 MCH-31.1 MCHC-33.9 RDW-15.0 RDWSD-50.4* Plt ___ ___ 04:14AM BLOOD ___ ___ 04:18AM BLOOD ___ PTT-26.6 ___ ___ 09:31AM BLOOD ___ PTT-28.2 ___ ___ 02:10AM BLOOD ___ PTT-27.3 ___ ___ 09:25PM BLOOD ___ PTT-34.7 ___ ___ 04:14AM BLOOD Glucose-113* UreaN-24* Creat-1.0 Na-137 K-4.1 Cl-101 HCO3-26 AnGap-10 ___ 04:01AM BLOOD Glucose-98 UreaN-30* Creat-0.9 Na-137 K-3.8 Cl-98 HCO3-24 AnGap-15 ___ 02:10AM BLOOD ALT-22 AST-107* LD(LDH)-509* AlkPhos-36* Amylase-50 TotBili-0.3 ___ 04:14AM BLOOD Mg-2.3 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Metoprolol Succinate XL 50 mg PO DAILY 3. Rosuvastatin Calcium 40 mg PO QPM 4. NIFEdipine (Extended Release) 30 mg PO DAILY 5. Ranitidine 150 mg PO DAILY 6. Finasteride 5 mg PO DAILY 7. Tamsulosin 0.4 mg PO QHS 8. krill oil 1,000-170-50-80 mg oral DAILY 9. Multivitamins 1 TAB PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES - Ascending aortic aneurysm pseudoaneurysm - Severe aortic stenosis - Moderate aortic regurgitation SECONDARY DIAGNOSES - Coronary artery disease - Hyperlipidemia - Hypertension - GERD - BPH Discharge Condition: Alert and oriented x3, non-focal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema 1+ Followup Instructions: ___ Radiology Report EXAMINATION: Carotid Doppler Ultrasound INDICATION: ___ year old male with a history of bicuspid aortic valve with mild-moderate AS/AR, ascending aortic aneurysm s/p graft repair (___), CABG x 1 to RCA ((SVG to PDA) ___, HTN, and BPH who presents as a transfer from ___ for new mural thrombosis in the setting of an ascending aortic aneurysm// pre-op, eval for stenosis TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound imaging of the carotid arteries was obtained. COMPARISON: None FINDINGS: RIGHT: The right carotid vasculature has no atherosclerotic plaque. The peak systolic velocity in the right common carotid artery is 64 cm/sec. The peak systolic velocities in the proximal, mid, and distal right internal carotid artery are 90, 85, and 73 cm/sec, respectively. The peak end diastolic velocity in the right internal carotid artery is 19 cm/sec. The ICA/CCA ratio is 1.4. The external carotid artery has peak systolic velocity of 73 cm/sec. The vertebral artery is patent with antegrade flow slightly diminished diastolic flow. LEFT: The left carotid vasculature has no atherosclerotic plaque. The peak systolic velocity in the left common carotid artery is 70 cm/sec. The peak systolic velocities in the proximal, mid, and distal left internal carotid artery are 45, 54, and 68 cm/sec, respectively. The peak end diastolic velocity in the left internal carotid artery is 16 cm/sec. The ICA/CCA ratio is 1.0. The external carotid artery has peak systolic velocity of 60 cm/sec. The vertebral artery is patent with antegrade flow. IMPRESSION: No atherosclerotic plaque or hemodynamically significant stenosis of the bilateral carotid arteries. Radiology Report INDICATION: ___ year old man with s/p Redo AVR// cardiac surgery fast track. eval for ptx, effusions. call ___ house officer at ___ if there is any concern with findings Contact name: ___ house officer, ___: ___ TECHNIQUE: Chest PA and lateral COMPARISON: Prior chest x-ray dated ___. FINDINGS: Sternotomy wires are intact. Aortic mechanical valve. Right-sided Swan-Ganz in right pulmonary artery. Esophageal feeding tube passes the GE junction. ET tube is 5.4 cm above the carina. Right chest tube lies in lung base. Mediastinal drains. Undefined radiopaque marker projecting over the mandible. Mild cardiomegaly. Mild bilateral pleural effusions. No pneumothorax. New left lower lobe atelectasis and milder in the right base. IMPRESSION: Normal postoperative appearance. Esophageal tube ends in stomach fundus, and could be pushed further down. Radiology Report INDICATION: ___ year old man with s/p avr cabg redo sternotomy// post op bleeding TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: The patient is post median sternotomy, aortic valve replacement and CABG. The supporting lines and tubes are unchanged in position. Unchanged retrocardiac opacities likely reflect atelectasis and pleural fluid. There is no pneumothorax identified. The right lung is clear. The size of the cardiomediastinal silhouette is enlarged. IMPRESSION: Expected postoperative changes. No pneumothorax. Further advancement of the gastric tube is recommended to ensure that it lies well beyond the GE junction. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with as above// s/p CABG/AVR w/increased chest tube output r/o effusion IMPRESSION: In comparison with the study of ___, there is no evidence of pneumothorax or increased pleural effusion. Indeed, the left hemidiaphragmatic contour is actually more sharply seen on the current study. Endotracheal tube and nasogastric tube have been removed. Radiology Report INDICATION: ___ year old man with s/p CABG, RIJ MAC changed to TLC// eval new line Contact name: ___: ___ TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: The Swan-Ganz catheter has been removed.A right IJ catheter tip projects over the mid to distal SVC. Mediastinal drains and left chest tubes are present. The size of the cardiac silhouette is enlarged, unchanged. There are small bilateral pleural effusions and subjacent atelectasis, left greater than right. Mild pulmonary edema is new since prior. No pneumothorax. IMPRESSION: The tip of a new right internal jugular central line projects over the mid to distal SVC. No pneumothorax. Small bilateral pleural effusions and subjacent atelectasis, left greater than right. Mild pulmonary edema. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with s/p AVR/repair of pseudoan// eval hemothorax eval hemothorax IMPRESSION: Comparison to ___. The left chest tubes are in stable position. Correct alignment of the sternal wires, correct position of the right internal jugular vein catheter. There is no pneumothorax. The right lung basis is slightly better ventilated than on the previous image. No pulmonary edema. Stable borderline size of the cardiac silhouette and retrocardiac atelectasis. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with cabg, AVR// s/p chest tube removal s/p chest tube removal IMPRESSION: Comparison to ___. Status post removal of the left chest tube. There now is a 2 cm left apical pneumothorax without evidence of tension. Bleeding along the tract of the tube is noted. Mild retrocardiac atelectasis. Stable normal appearance of the right lung. Radiology Report EXAMINATION: Chest radiograph PA and lateral INDICATION: ___ year old man s/p CABG, AVR// eval post op changes, effusions TECHNIQUE: Chest PA and lateral COMPARISON: Multiple prior chest x-rays, most recently ___. FINDINGS: Sternotomy wires are intact. Right IJ ends in upper SVC. Mild to moderate cardiomegaly. Left pneumothorax is slightly larger than in ___.. Stable appearance of mild retrocardiac atelectasis.. IMPRESSION: Slight increase in left pneumothorax. Overall unchanged appearance of remaining findings. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Dyspnea, Transfer Diagnosed with Dyspnea, unspecified temperature: 98.2 heartrate: 66.0 resprate: 18.0 o2sat: 97.0 sbp: 127.0 dbp: 64.0 level of pain: 0 level of acuity: 2.0

Please shower daily -wash incisions gently with mild soap, no baths or swimming, look at your incisions daily Please - NO lotion, cream, powder or ointment to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics Clearance to drive will be discussed at follow up appointment with surgeon No lifting more than 10 pounds for 10 weeks **Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours** **Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours**

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: lisinopril Attending: ___. Chief Complaint: fall, intoxication, left ___ rib fractures Major Surgical or Invasive Procedure: none History of Present Illness: ___ s/p fall 4 days ago. He states that he was in his home while standing on a stool and fell to the ground. He claims he was not intoxicated when he fell and has not had a drink since last ___, but his EtOH level on arrival was 45. He has had multiple admission in the past for alcohol withdrawal. After his recent fall, he states he presented to an OSH and was discharge with pain medications. Given persistent pain, he presented to the ___ ED for further evaluation. FAST exam was performed which showed no evidence of intra-abdominal free fluid. Past Medical History: PMH: HTN, HLD, Eczema, GERD, alcoholic steatosis, Alcohol abuse c/b withdrawal s/p hospitalization x2, MVA ___ c/b thoracic back pain PSH: None Social History: ___ Family History: Father is ___ with diabetes, mother passed at ___ for unknown cause (?stroke vs. head bleed); reports his siblings are all healthy; reports no one in family has alcohol-related issues Physical Exam: Physical Exam Vitals: 97.0 62 165/94 14 96%RA GEN: AOx3, ill-appearing, tremulous, diaphoretic HEENT: No scleral icterus Back: C7 and 79 tenderness to palpation CV: RRR, No M/G/R PULM: Clear to auscultation b/l ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses DRE: normal tone, no gross or occult blood Ext: No ___ edema, ___ warm and well perfused Pertinent Results: Imaging ___ CHEST (PA & LAT) IMPRESSION: No radiographic evidence of traumatic injury. Please note that this is not a dedicated exam for evaluation of the bones. Correlate with focal exam findings and obtain dedicated radiographs as needed CT TORSO W/CONTRAST IMPRESSION: 1. Nondisplaced left ___ and 10th rib fractures with small left chest wall hematoma and complex effusion likely representing a hemothorax. No pneumothorax. No other fractures identified. 2. No other acute intrathoracic or intra-abdominal injury. CT C-SPINE W/O CONTRAST IMPRESSION: 1. No acute fracture or malalignment. 2. Focal prevertebral soft tissue edema anterior to C4 which raises the possibility of ligamentous injury. If focally tender in this area, MRI could be obtained if clinically indicated. CT HEAD W/O CONTRAST IMPRESSION: No acute intracranial process Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. FoLIC Acid 1 mg PO DAILY 3. Hydrochlorothiazide 50 mg PO DAILY 4. Losartan Potassium 50 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Pravastatin 40 mg PO DAILY 7. Thiamine 100 mg PO DAILY 8. Metoprolol Succinate XL 100 mg PO DAILY 9. Furosemide 20 mg PO DAILY 10. Omeprazole 20 mg PO BID 11. Amlodipine 10 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Multivitamins 1 TAB PO DAILY 3. Omeprazole 20 mg PO BID 4. Pravastatin 40 mg PO DAILY 5. Amlodipine 10 mg PO DAILY 6. Docusate Sodium 100 mg PO BID discontinue if more that 7 loose stools per day 7. Senna 8.6 mg PO BID:PRN constipation discontinue use if more than 7 loose stools a day 8. FoLIC Acid 1 mg PO DAILY 9. Furosemide 20 mg PO DAILY 10. Hydrochlorothiazide 50 mg PO DAILY 11. Losartan Potassium 50 mg PO DAILY 12. Metoprolol Succinate XL 100 mg PO DAILY 13. Thiamine 100 mg PO DAILY 14. Acetaminophen 650 mg PO Q6H pain do not exceed more than 4gms a day Discharge Disposition: Home Discharge Diagnosis: Rib fractures secondary to Mechanical fall Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: Chest radiograph INDICATION: History: ___ with s/p fall, etoh // eval for acute injuries TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph dated ___. FINDINGS: No significant interval change. The lungs are clear. No focal consolidation, effusion, edema, or pneumothorax. The heart is top-normal in size, unchanged. No acute osseous abnormality. IMPRESSION: No radiographic evidence of traumatic injury. Please note that this is not a dedicated exam for evaluation of the bones. Correlate with focal exam findings and obtain dedicated radiographs as needed. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ with s/p fall, etoh // eval for acute injuries TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Total DLP (Head) = 803 mGy-cm. COMPARISON: None. FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles and sulci are normal in size and configuration. There is no evidence of fracture. The visualized portion of the mastoid air cells and middle ear cavities are clear. There is trace bilateral maxillary sinus and sphenoid sinus mucosal thickening. Incidentally noted is a left frontal sinus osteoma. The visualized portion of the orbits are unremarkable. IMPRESSION: No acute intracranial process. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: ___ with s/p fall, etoh // eval for acute injuries TECHNIQUE: Non-contrast helical multidetector CT was performed through the cervical spine. Soft tissue and bone algorithm images were generated. Coronal and sagittal reformations were then constructed. DOSE: Total DLP (Body) = 673 mGy-cm. COMPARISON: None. FINDINGS: Alignment is normal. No acute fractures are identified.There is subtle focal prevertebral soft tissue edema anterior to the vertebral body of C4. Degenerative changes are present most notable at C2-C3 and C3-C4 including osteophytosis and uncovertebral joint hypertrophy. Multilevel disc bulges result in mild spinal canal narrowing. Incidentally noted is a calcified right stylohyoid ligament. IMPRESSION: 1. No acute fracture or malalignment. 2. Focal prevertebral soft tissue edema anterior to C4 which raises the possibility of ligamentous injury. If focally tender in this area, MRI could be obtained if clinically indicated. NOTIFICATION: The updated findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 11:17 AM, 2 minutes after discovery of the findings. Radiology Report EXAMINATION: CT torso. INDICATION: ___ with s/p fall, etoh // eval for acute injuries TECHNIQUE: MDCT axial images were acquired through the chest, abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 560 mGy-cm. COMPARISON: MRI of the abdomen and pelvis from ___. Ultrasound of the liver from ___ FINDINGS: CHEST: HEART AND VASCULATURE: The thoracic aorta is normal in caliber without evidence of acute injury. The heart, pericardium, and great vessels are within normal limits. No pericardial effusion is seen. AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar lymphadenopathy is present. No mediastinal mass or hematoma. PLEURAL SPACES: No pneumothorax. There is a small left complex pleural effusion likely representing a hemothorax. LUNGS/AIRWAYS: Bibasilar atelectasis is present. The airways are patent to the level of the segmental bronchi bilaterally. Apical emphysematous changes are present. No mass or consolidation is seen. BASE OF NECK: Visualized portions of the base of the neck show no abnormality. CHEST WALL: A small left chest wall hematoma is present adjacent to the nondisplaced left ___, and 10th rib fractures. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous low attenuation throughout consistent with hepatic steatosis. There is no evidence of focal lesion or laceration. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesion or laceration. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is normal. There is no evidence of mesenteric injury. There is no free fluid or free air in the abdomen. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The prostate and seminal vesicles are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma. Moderate atherosclerotic disease is noted. Mild eccentric noncalcified plaque within the left common iliac artery is seen. BONES: There are nondisplaced left ___, and 10th rib fractures. No other fractures are identified. A sclerotic focus within the right ilium is most consistent with a bone island. SOFT TISSUES: Incidentally noted is a lipoma deep to the right gluteus maximus. Otherwise the abdominal and pelvic walls are within normal limits. IMPRESSION: 1. Nondisplaced left ___ and 10th rib fractures with small left chest wall hematoma and complex effusion likely representing a hemothorax. No pneumothorax. No other fractures identified. 2. No other acute intrathoracic or intra-abdominal injury. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old male with a history of HTN, multiple admissions for alcohol withdrawal, now with rib fractures and acute withdrawal: // Interval assessment Interval assessment IMPRESSION: Comparison to ___. New retrocardiac opacity with air bronchograms, likely reflecting pneumonia. No pleural effusions. No pulmonary edema. Borderline size of the cardiac silhouette. Radiology Report EXAMINATION: C-SPINE NON-TRAUMA ___ VIEWS INDICATION: ___ year old man with s/p fall from standing with mild ? ligamentous abnormality on CT // eval for dynamic instability TECHNIQUE: Neutral, flexion and extension lateral projections of the cervical spine. COMPARISON: CT cervical spine ___. FINDINGS: Multilevel mild degenerative changes with disc space narrowing and endplate spurring. Impression of mild prevertebral soft tissue swelling in the upper cervical spine. No dynamic instability is demonstrated on flexion extension views. IMPRESSION: Degenerative changes. No dynamic instability is identified. There is mild prevertebral soft tissue swelling in the upper cervical spine. RECOMMENDATION(S): As previously recommended, if concern for ligamentous injury, recommend MRI. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old male with a history of HTN, multiple admissions for alcohol withdrawal, now with rib fractures and acute withdrawal // Interval assessment Interval assessment IMPRESSION: Comparison to ___. Minimal improvement of the pre-existing retrocardiac atelectasis. No other relevant change. Borderline size of the cardiac silhouette. No pulmonary edema, no pleural effusions, no pneumonia. Known rib fractures are subtle and better appreciated on the CT examination from ___. Gender: M Race: BLACK/CAPE VERDEAN Arrive by WALK IN Chief complaint: s/p Fall, Chest pain, Back pain Diagnosed with Multiple fractures of ribs, left side, init for clos fx, Traumatic hemothorax, initial encounter, Other fall from one level to another, initial encounter, Alcohol dependence with withdrawal, unspecified, Blood alcohol level of 40-59 mg/100 ml temperature: 97.0 heartrate: 101.0 resprate: 17.0 o2sat: 96.0 sbp: 209.0 dbp: 114.0 level of pain: 10 level of acuity: 2.0

Thank you for choosing ___ for your care. You were seen in the emergency room by the Acute Care/Trauma Surgery team for a fall that happened a few days before you came in. You were admitted for pain control and was monitored for alcohol withdrawal since you had an elevated blood alcohol level. After evaluation from the Trauma service and Psychiatric service, you are now able to return home for further recovery. Rib Fractures: * Your injury caused 9 - 10th rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * If your doctor allows, non-steroidal ___ drugs are very effective in controlling pain ( ie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs (crepitus).

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Right-sided abdominal pain for 9 hours Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ female, s/p ___ gastric bypass surgery in ___ at ___. The patient was in her usual state of health until approximately 11:30 am ___, today, when she began having ___ non-radiating RUQ and middle right side abdominal pain. She went to ___ for lunch and before she started eating the pain worsened to ___. She has a history of kidney stones and thought this might be a recurrence so she tried to hydrate with PO fluids. She states that she urinated x 2, with simultaneous BM and flatus around 12 pm. She continued to hydrate with PO fluids and had more micturition and flatus. The patient's pain continued at ___ and at around 12 pm she called her PCP who directed her to the ___. She arrived at the ___ at approximately 2:15 pm where a CT scan wet read showed nephrolithiasis and possible partial SBO. The patient was given morphine which relieved her pain to a ___ level and she was sent via ambulance to the ___ ___. When she arrived at ___ she had more flatus and her pain has since been very well controlled. Ms. ___ had a ___ bypass surgery in ___ which was complicated on POD 1 with bleeding, possibly from a pre-existing duodenal ulcer. She was taken back to the OR that day and a repair was performed which remained laparoscopic, no records are available. The patient endorses a 40-lbs total weight loss sinc surgery and no other interval changes. On exam today, she denies fever, chills, nausea, vomiting, dyspnea, chest pain, dysuria, weakness or dizziness. She has had no changes in appetite, temperature intolerance or changes in hair or skin texture. Past Medical History: 1. Depression. 2. Ovarian cancer, cancer free since ___. PSH: 1. Total hysterectomy with BLSO ___ ovarian cancer (___). No chemotherapy or radiation at that time. 2. ___ gastric bypass (___). 3. Colonoscopy (___). Social History: ___ Family History: Non-contributory Physical Exam: On admission: Physical Exam: VS-T: 98.4, HR: 74, BP: 150/70, RR: 15, SpO2: 96% RA, Pain: ___. GEN: Lying in bed, NAD, pain well controlled, pleasant cooperative. HEENT: EOMI, PERRLA, trachea midline, mucous membranes moist, (-) LAD. CHEST: No cyanosis, no tachypnea or accessory muscle use. Lungs-CTA bilaterally, on anterior and posterior exams. Heart-RRR, (+) S1/S2, (-) S3/S4/m/c/r/g/h/t ABDOMEN: Soft, non-distended, mildly TTP RUQ/right mid-abdomen, no jaundice, not rigid, no guarding. EXTR/MSK: Pulses full and RRR x 4 extremities, moves all extremities against gravity. NEURO: CN II-XII grossly intact, no focal neurological deficits. Full and appropriate affect. On discharge: Tm 98.2 Tc98.2 BP 140/62 HR 72 RR 18 Sat 97% on RA GEN: alert, pleasant, NAD, nontoxic appearing HEENT: MMM sclera anicteric CV: RRR no m/r/g PULM: ctab nonlabored breathing ABD: soft, nontender, nondistended, normotympanitic to percussion, well healed lap scars no appreciable hernia, no masses EXT: no ___ Pertinent Results: --CBC/Chem10 Hct 32.3 stable; WBC 5.3 stable; Cr 0.7 --LFTs ALT 9 AST 16 AlkP 90 Amylase 52 TB 0.2 Lipase 32 ___ 49 Lactate 1.2 --Nutrition Labs -Iron 29 VitB12 329 Folate out of range >20 ----CT Abd/Pelvis WITH contrast ___-- The lung bases are clear. There is annular calcification of the mitral valve. The heart size is normal. Probable small hiatal hernia. Postsurgical changes related to gastric bypass are noted. There is no oral contrast seen in the excluded portion of the stomach and proximal small bowel. Oral contrast has passed through the stomach and the distal loops of small bowel. Contrast is also present within the ascending colon to the level of the hepatic flexure. The small bowel loops are normal in caliber with interval resolution of the obstruction. The adrenal glands, pancreas, spleen, and kidneys are normal. Of note, there is IV contrast within the bilateral collecting systems from previously performed contrast enhanced CT. There is no free fluid or free air. The urinary bladder is distended with contrast material. Osseous structures are intact with degenerative disc disease at L5-S1. ----OSH CT abd/pelvis WITHOUT contrast ___-- Wet read: possible pSBO Medications on Admission: Wellbutrin Protonix Discharge Medications: Protonix Wellbutrin Discharge Disposition: Home Discharge Diagnosis: Enteritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Abdominal pain status post gastric bypass with recent obstruction. Evaluate for obstruction. TECHNIQUE: Limited CT acquisition through the abdomen and pelvis was performed after the administration of oral contrast only. Post processing reconstruction was performed in the coronal and sagittal planes. DLP: 880.2 mGy-cm COMPARISON: CT abdomen and pelvis from ___. FINDINGS: The lung bases are clear. There is annular calcification of the mitral valve. The heart size is normal. Probable small hiatal hernia. Postsurgical changes related to gastric bypass are noted. There is no oral contrast seen in the excluded portion of the stomach and proximal small bowel. Oral contrast has passed through the stomach and the distal loops of small bowel. Contrast is also present within the ascending colon to the level of the hepatic flexure. The small bowel loops are normal in caliber with interval resolution of the obstruction. The adrenal glands, pancreas, spleen, and kidneys are normal. Of note, there is IV contrast within the bilateral collecting systems from previously performed contrast enhanced CT. There is no free fluid or free air. The urinary bladder is distended with contrast material. Osseous structures are intact with degenerative disc disease at L5-S1. IMPRESSION: 1. Interval resolution of previously seen obstruction. 2. Small hiatal hernia. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: ABD PAIN Diagnosed with ABDOMINAL PAIN OTHER SPECIED, HYPOTHYROIDISM NOS, BARIATRIC SURGERY STATUS , HX OF OVARIAN MALIGNANCY temperature: 98.4 heartrate: 74.0 resprate: 15.0 o2sat: 96.0 sbp: 150.0 dbp: 70.0 level of pain: 2 level of acuity: 3.0

You were admitted to the hospital with abdominal pain. A CT abdomen at an outside hospital raised the possibility of a partial small bowel obstruction and you were transferred here for further workup. We repeated the CT abdomen, this time with oral contrast which can provide more information, and there was no evidence of a small bowel obstruction. There was no evidence of an acute abdominal process to explain your abdominal pain. You have been tolerating a stage III bariatric diet and you are safe to be discharged. Please return to the ___ if you have any recurrent abdominal pain or have any difficulty taking food down. Please also stop taking any NSAIDs, including aleve aspirin or advil. We also drew nutrition las, and you are iron deficient. Please be sure to have close follow up with nutrition labs either by your PCP or ___ nutritionist. We called your PCP to ensure they also know this information. Please also continue to take any medications you were on prior to your arrival EXCEPT for any NSAIDs including aleve or advil; these should be stopped.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Pt found down Major Surgical or Invasive Procedure: none History of Present Illness: ___ female w/ PMH HTN, hypothyroidism, mood disorder with sleep issues, constipation, history of breast cancer who presents after she was found down. She was found down for an unknown time. She was found to have an elevated CK and was started on IV hydration for rhabdomyolysis. She had an episode of chest pain while in the ED with first troponin negative and normal EKG. Chest pain resolved without intervention. Second troponin was pending on transfer. She was given full dose aspirin. In the ED she received 1.5L IVF. CT head, C-spine were negative for pathology of fracture. Gleno-humeral shoulder X-ray showed no fracture of dislocation. CXR showed no acute process, hiatal hernia. On arrival to the floor, she is very tired and is upset that I have woken her. She asks if "we can do this tomorrow" and says she has bad heart burn. She told the nurse she knew she was in the hospital but she isn't answering my question now and goes back to sleep. She does respond that she doesn't remember any of the events of today's fall but does have a history of falls. She can't confirm her medications. Past Medical History: HTN Hypothyroidism Mood disorder with sleep issues Constipation History of breast cancer s/p surgery and radiation Social History: ___ Family History: Reviewed and found to be not relevant to this illness/reason for hospitalization. Physical Exam: ADMISSION EXAM: VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Sleeping, doesn't want to wake up EYES: Anicteric, pupils equally round CV: Heart regular, ___ systolic murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: unable to assess PSYCH: tired, not wanting to engage in interview Pertinent Results: Admission Data WBC 15.3, Hgb 13, Cr 0.9, bicarb 21, AST 80, CK 4960, CK-MB 29, trop negative x 1, lactate 2.6 EKG: sinus rhythm, normal axis, normal rate, normal QRS. T wave flat in V2, III, inverted T wave aVF. Telemetry: no events CTH No acute intracranial process. Chronic small vessel disease. CT C Spine No fracture or alignment abnormality. Degenerative changes as stated without critical stenosis. CXR: No acute intrathoracic process, hiatal hernia. Discharge labs: ___ 06:49AM BLOOD WBC-6.0 RBC-3.68* Hgb-11.4 Hct-35.7 MCV-97 MCH-31.0 MCHC-31.9* RDW-13.5 RDWSD-48.7* Plt ___ ___ 06:49AM BLOOD Glucose-79 UreaN-11 Creat-0.7 Na-140 K-5.8 (hemolyzed)* Cl-101 HCO3-25 AnGap-14 ___ 06:49AM BLOOD CK(CPK)-153 ___ 03:35PM BLOOD Lipase-15 ___ 07:50AM BLOOD CK-MB-5 cTropnT-<0.01 ___ 07:04AM BLOOD Phos-3.0 Mg-1.9 ___ 07:50AM BLOOD TSH-5.5* ___ 04:37PM BLOOD Lactate-2.6* K-4.3 Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Lisinopril 30 mg PO DAILY 2. Finasteride 2.5 mg PO DAILY 3. Vesicare (solifenacin) 10 mg oral DAILY 4. Doxepin HCl 10 mg PO HS 5. CARVedilol 3.125 mg PO BID 6. TraZODone 100 mg PO QHS:PRN insomnia 7. Levothyroxine Sodium 75 mcg PO DAILY 8. Divalproex (EXTended Release) 250 mg PO DAILY 9. Pantoprazole 40 mg PO Q24H 10. meloxicam 15 mg oral DAILY 11. Escitalopram Oxalate 20 mg PO DAILY 12. amLODIPine 2.5 mg PO DAILY Discharge Medications: 1. Ramelteon 8 mg PO QHS:PRN insomnia 2. amLODIPine 10 mg PO DAILY 3. Lisinopril 40 mg PO DAILY 4. Escitalopram Oxalate 20 mg PO DAILY 5. Levothyroxine Sodium 75 mcg PO DAILY 6. meloxicam 15 mg oral DAILY 7. Pantoprazole 40 mg PO Q24H Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Fall, altered mental status Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Mental Status: Confused - sometimes. Followup Instructions: ___ Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: ___ with altered mental status, fall, pain// Fracture, bleed TECHNIQUE: Noncontrast CT cervical spine with axial, coronal, sagittal reformations. DOSE: Total DLP (Body) = 351 mGy-cm. COMPARISON: None FINDINGS: There is no acute fracture or malalignment in the cervical spine. The visualized outline of the thecal sac is unremarkable. Degenerative disease is most pronounced at C4-5 and C5-6 with disc space narrowing and small endplate osteophytes. Facet and uncovertebral joint hypertrophy is noted at multiple levels with moderate neural foraminal stenosis noted on the left at C3-4 level. No critical central canal or neural foraminal stenosis. No prevertebral edema. The aerodigestive tract appears patent. Lung apices are clear. Thyroid gland appears normal. IMPRESSION: No fracture or alignment abnormality. Degenerative changes as stated without critical stenosis. Radiology Report EXAMINATION: CHEST (SINGLE VIEW) INDICATION: ___ with fall, chest pain, pneumothorax// Fracture COMPARISON: None FINDINGS: AP portable upright view of the chest. Retrocardiac opacity is noted most likely representing a hiatal hernia. The lungs are clear bilaterally. There is no focal consolidation, effusion, or pneumothorax. The cardiomediastinal silhouette is normal. Imaged osseous structures are intact. IMPRESSION: No acute intrathoracic process, hiatal hernia. Radiology Report INDICATION: History: ___ with left shoulder pain//Fracture COMPARISON: Three views of the left shoulder were provided. FINDINGS: A rounded ossific density is seen projecting over the left humeral neck along the medial cortex which could represent a loose body, measuring approximately 9 x 10 mm. No fracture or dislocation is seen. There is mild inferior spurring at the left glenohumeral joint. AC joint aligns normally without significant OA. The imaged left upper ribs appear intact. IMPRESSION: No fracture or dislocation. Possible loose body within the left glenohumeral joint space. Mild left glenohumeral OA. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ with altered mental status, fall, pain// Fracture, bleed TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain, intermediate and bone windows. Coronal and sagittal reformats were also performed. Repeated imaging due to patient motion. DOSE: Total DLP (Head) = 934 mGy-cm. COMPARISON: prior study is dated ___ FINDINGS: There is no intra-axial or extra-axial hemorrhage, edema, shift of normally midline structures, or evidence of acute major vascular territorial infarction. Periventricular white matter hypodensities are again noted reflecting chronic microvascular ischemic disease. A tiny right basal ganglia lacunar infarct noted. Age related involutional changes are noted. Ventricles appear normal in stable in size. Basal cisterns are patent. The imaged paranasal sinuses, mastoid air cells and middle ear cavities appear well aerated. The bony calvarium is intact. A sebaceous cyst is seen at the right parietal scalp. IMPRESSION: No acute intracranial process. Chronic small vessel disease. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Altered mental status, s/p Fall Diagnosed with Altered mental status, unspecified temperature: 97.4 heartrate: 78.0 resprate: 18.0 o2sat: 100.0 sbp: 166.0 dbp: 92.0 level of pain: 0 level of acuity: 2.0

You were admitted to the hospital after a fall and presumed loss of consciousness. We evaluated you for causes of your frequent falls, including arrhythmias, heart attacks, deconditioning, and low blood pressure. Ultimately we were not able to find a single unifying reason for your falls, however a condition called orthostatic hypotension may be contributing, as well as being on multiple sedating medications.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Nausea/vomiting/jaundice; mass causing duodenal and biliary obstruction Major Surgical or Invasive Procedure: Percutaneous transhepatic cholangiography/biliary decompression (___) Exploratory laparotomy with biopsy of periduodenal nodule, cholecystectomy, Roux-en-Y, choledochojejunostomy and gastrojejunostomy (___) History of Present Illness: Chief Complaint: nausea, vomiting, jaundice Reason for MICU transfer: hypotension after nausea ___ ___ who presented with a 2 month history of abdominal pain, nausea and vomiting. The patient and her family reported that she had not been able to eat well and had lost ___ lbs. Her family first noted that she became jaundiced 1 month prior. She denied fevers, chills, diarrhea and constipation. Her last formed bowel movement had been 2 days prior. She denied BRBPR. She denied pain radiating to her back. The patient resides in ___, ___ and came to ___ for medical care at the ___ "Benevolant Association" a non-medical care facility. It was there that she fell due to weakness and hit her head. She had no loss of consciousness and minor facial abrasions. She decided on ___ to pursue further medical care and arranged transport to the ___ ED. Past Medical History: None documented Social History: ___ Family History: No cancer in the family. Father died of heart disease at age of ___. Mother died of diabetes. Physical Exam: Admission Exam: General: AAOx3, NAD, grossly jaundiced HEENT: Sclera severely icteric, MM relatively dry, oropharynx clear, EOMI, PERRL CV: RRR, + S1/S2, ___ systolic murmur best heard at ___, no rubs or gallops Lungs: CTAB, no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. +1 edema b/l Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. Exam upon discharge: Vitals: General: AAOx3, NAD HEENT: CV: RRR, +S1/S2, systolic murmur Resp: CTAB Abdomen: Right subcostal incision open to air with steri strips and c/d/i. Ext: no cyanosis/clubbing/edema, warm, well-perfused bilaterally, 2+ distal pulses bilaterally Pertinent Results: Admission Labs: ___ 09:35AM BLOOD WBC-16.4* RBC-4.99 Hgb-15.2 Hct-43.9 MCV-88 MCH-30.4 MCHC-34.6 RDW-17.7* Plt ___ ___ 09:35AM BLOOD Neuts-85.6* Lymphs-9.1* Monos-4.9 Eos-0.1 Baso-0.2 ___ 09:35AM BLOOD ___ PTT-33.0 ___ ___ 09:35AM BLOOD Glucose-126* UreaN-52* Creat-1.6* Na-126* K-2.0* Cl-69* HCO3-39* AnGap-20 ___ 09:35AM BLOOD ALT-128* AST-174* AlkPhos-530* TotBili-42.4* DirBili-28.8* IndBili-13.6 ___ 09:35AM BLOOD Lipase-48 ___ 09:35AM BLOOD Albumin-3.4* Calcium-9.7 Phos-2.7 Mg-3.3* ___ 09:48AM BLOOD Lactate-2.7* ___ 02:55PM URINE Color-DkAmb Appear-Hazy Sp ___ ___ 02:55PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-LG Urobiln-NEG pH-6.0 Leuks-NEG ___ 02:55PM URINE RBC-<1 WBC-3 Bacteri-FEW Yeast-NONE Epi-0 ___ 02:55PM URINE CastHy-5* ___ 02:55PM URINE Mucous-RARE CT Head w/o contrast ___: There is no evidence of hemorrhage, edema, mass, mass effect, or infarction. The ventricles and sulci are normal in size and configuration for the patient's age. The basal cisterns are patent. There is preservation of gray-white matter differentiation. Atherosclerotic calcifications are noted in the internal carotid arteries. No fracture is identified. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The soft tissues are unremarkable. IMPRESSION: No acute intracranial abnormality. CT C-spine w/o contrast ___: 1. No fracture or malalignment. 2. Multilevel degenerative changes with multilevel neural foraminal narrowing due to facet arthrosis. 3. Multiple nodules in the thyroid gland. If clinically indicated, recommend further evaluation with a thyroid ultrasound. RUQ U/S ___: 1. Severely dilated intra- and extra-hepatic biliary ducts without definite associated mass. Recommend MRCP for further evaluation if there are no contraindications to MRI. Alternatively, a multiphasic CT of the abdomen should be performed. 2. Distended gallbladder with cholelithiasis and sludge, but no other findings to suggest evidence of acute cholecystitis. CXR ___: no intrathoracic process. CT Abdomen/Pelvis ___: There is a mass lesion involving the ampullary region which results in severe dilatation of the intra and extrahepatic biliary tree as well as mild main pancreatic ductal dilatation. Differential considerations include a cholangiocarcinoma versus a pancreatic neoplasm. There is no evidence of distant metastases. Trace ascites is seen. Incidental hepatic and renal hypodensities, likely cysts as described above. Incidental pancreatic cystic lesions, most compatible with IPMN. EGD ___: The duodenal bulb was dilated. There was a complete obstruction in the duodenal bulb preventing an ERCP from being performed. PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY ___: 1. Marked intra and extrahepatic biliary dilatation to the level of the distal CBD. 2.Successful placement of an 8 ___ percutaneous transhepatic biliary drain throught the obstruction which has been left on free drainage. OPERATIVE PATHOLOGY: (Periduodenal nodule): Metastatic well differentiated adenocarcinoma present in fibroadipose tissue. Discharge Labs: ___ 04:15AM BLOOD WBC-10.5 RBC-3.01* Hgb-9.3* Hct-29.1* MCV-97 MCH-31.0 MCHC-32.1 RDW-15.9* Plt ___ ___ 04:15AM BLOOD Plt ___ ___ 04:15AM BLOOD Glucose-107* UreaN-13 Creat-0.7 Na-137 K-3.7 Cl-106 HCO3-25 AnGap-10 ___ 04:15AM BLOOD ALT-71* AST-77* AlkPhos-245* TotBili-7.0* DirBili-4.7* IndBili-2.3 ___ 04:15AM BLOOD Calcium-7.3* Phos-3.4 Mg-2.1 ___ 04:20AM BLOOD Triglyc-278* Medications on Admission: None Discharge Medications: 1. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*30 Capsule Refills:*5 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*1 3. Senna 1 TAB PO BID:PRN constipation 4. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 5. Megestrol Acetate 400 mg PO DAILY RX *megestrol 400 mg/10 mL (40 mg/mL) 1 Suspension(s) by mouth once a day Disp #*30 Packet Refills:*0 6. Metoclopramide 10 mg PO QIDACHS RX *metoclopramide HCl 10 mg 1 by mouth QIDACHS Disp #*56 Tablet Refills:*0 7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*120 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: 1. Metastatic well differentiated adenocarcinoma. 2. Chronic cholecystitis and cholelithiasis. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: New jaundice and poor oral intake. Evaluate for metastatic disease. COMPARISONS: None. FINDINGS: The lungs are clear without consolidation or edema. No large nodules are identified. There is no pleural effusion or pneumothorax. The cardiomediastinal silhouette is normal. Probable small calcified lymph nodes are noted in the left hilum. IMPRESSION: No acute cardiopulmonary process. Radiology Report INDICATION: Fall with head strike. COMPARISONS: None. TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without the administration of IV contrast. Sagittal, coronal, and thin slice bone image reformats were obtained and reviewed. FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or infarction. The ventricles and sulci are normal in size and configuration for the patient's age. The basal cisterns are patent. There is preservation of gray-white matter differentiation. Atherosclerotic calcifications are noted in the internal carotid arteries. No fracture is identified. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The soft tissues are unremarkable. IMPRESSION: No acute intracranial abnormality. Radiology Report INDICATION: Fall with head strike. COMPARISONS: None. TECHNIQUE: Contiguous helical axial MDCT images were obtained from the base of the skull to the apices of the lungs without the administration of IV contrast. Sagittal and coronal reformatted images were obtained and reviewed. FINDINGS: The patient is diffusely osteopenic. There is no prevertebral soft tissue abnormality. No fracture is identified. There is no malalignment. Straightening of the normal cervical lordosis is likely due to patient positioning. There are multilevel degenerative changes with disc space narrowing, osteophyte formation, uncovertebral hypertrophy, and severe facet arthrosis. There is no significant spinal canal narrowing. Multilevel neural foraminal narrowing is present from the facet arthrosis, most severe at C3-4 on the left. The apices of the lungs are clear. Multiple nodules are noted in both lobes of the thyroid gland. The largest is in the right lobe and measures 7 mm (2, 56). There is no lymphadenopathy. The visualized portions of the brain are unremarkable. IMPRESSION: 1. No fracture or malalignment. 2. Multilevel degenerative changes with multilevel neural foraminal narrowing due to facet arthrosis. 3. Multiple nodules in the thyroid gland. If clinically indicated, recommend further evaluation with a thyroid ultrasound. Radiology Report INDICATION: Painless jaundice for one month. COMPARISONS: None. FINDINGS: The liver is normal in shape and contour. There is normal echogenicity. No focal hepatic lesions are identified. The portal vein is patent. There is severe intra- and extra-hepatic biliary duct dilation. The common hepatic duct measures 2 cm at its greatest width, and the common bile duct measures 1.8 cm at its greatest width. The common bile duct remains dilated as it enters the pancreatic head. There is no intraluminal lesion identified within the ducts. No definite extrinsic mass is identified. The visualized portions of the pancreas are unremarkable. There is no pancreatic duct dilation. The gallbladder is mildly distended. There are stones and sludge layering within the gallbladder. The largest stone measures 1.7 x 0.7 x 1.2 cm and is present within the neck of the gallbladder. There is no gallbladder wall thickening or pericholecystic fluid to suggest acute cholecystitis. There is no ascites. Limited views of the kidneys are unremarkable without evidence of hydronephrosis. The spleen is normal, and measures 10.2 cm. IMPRESSION: 1. Severely dilated intra- and extra-hepatic biliary ducts without definite associated mass. Recommend MRCP for further evaluation if there are no contraindications to MRI. Alternatively, a multiphasic CT of the abdomen should be performed. 2. Distended gallbladder with cholelithiasis and sludge, but no other findings to suggest evidence of acute cholecystitis. Radiology Report HISTORY: PICC placement. FINDINGS: PICC line extends into the right neck. This information has been telephoned to the IV nurse. The nasogastric tube extends to the uppermost portion of the stomach. However, the side hole is only in the lower esophagus. Radiology Report HISTORY: PICC placement. FINDINGS: In comparison with the earlier study of this date, the right subclavian PICC line has been re-positioned so that the tip lies in the mid-to-lower portion of the SVC. Radiology Report INDICATION: ___ woman with painless jaundice. High suspicion for pancreas cancer. COMPARISON: Ultrasound ___. TECHNIQUE: FINDINGS: There is an NG tube with its tip in the gastric body. There is severe dilatation of the intra and extra hepatic biliary tree extending to the level of the common bile duct. The common bile duct abruptly terminates as it enters the pancreas, where a hypoattenuating mass is seen in the region of the pancreatic ampulla. This region measures 1.5 x 2.9 cm. There is dilatation of the main pancreatic duct as well as the accessory pancreatic duct. There is a 7mm cystic lesion seen within the pancreatic head, most compatible with a focal intraductal papillary mucinous neoplasm. There is a fat containing lesion in the pancreatic groove, most in keeping with a lipoma. There is conventional hepatic arterial anatomy. The SMV, splenic vein and portal vein are patent and demonstrate no thrombus. There are no focal parenchymal hepatic mass lesions. There is a cystic lesion within hepatic segment VI, most compatible with a simple cyst measuring 1.9 cm. There is no intraperitoneal or retroperitoneal lymphadenopathy. The adrenals, spleen, right kidney and proximal ureters are unremarkable. There is a small hypodensity within the interpolar region of the left kidney, too small to characterize but most in keeping with a simple cyst. There is a small amount of free fluid within the small bowel mesentery as well as the right paracolic gutter. There is evidence of pancolonic diverticulosis. The small and large bowel are unremarkable otherwise with no evidence of obstruction. SKELETON/ LUNG BASES: Atelectasis is seen at the lung bases. There are bilateral pleural effusions. Discogenic degenerative changes are noted within the proximal thoracic spine. There are no suspicious bony lesions. IMPRESSION: There is a mass lesion involving the ampullary region which results in severe dilatation of the intra and extrahepatic biliary tree as well as mild main pancreatic ductal dilatation. Differential considerations include a cholangiocarcinoma versus a pancreatic neoplasm. There is no evidence of distant metastases. Trace ascites is seen. Incidental hepatic and renal hypodensities, likely cysts as described above. Incidental pancreatic cystic lesions, most compatible with IPMN. Radiology Report INDICATION: Painless jaundice with concern for malignancy. Acutely altered mental status. TECHNIQUE: Multidetector CT scan of the head was obtained without the administration of contrast. COMPARISON: CT examination dated ___. FINDINGS: There is no evidence of acute hemorrhage, edema, mass effect, or recent infarction. Prominence of the ventricles and sulci is compatible with age-related global atrophy. No concerning osseous lesion is seen. A mucosal retention cyst is partially imaged within the left maxillary sinus. The mastoid air cells are clear. IMPRESSION: No evidence of acute intracranial process. Radiology Report INDICATION: ___ woman with no past medical history, admitted with painless jaundice, altered mental status, evidence of infection? COMPARISON: ___ at 18:48. TECHNIQUE: Portable supine chest radiograph. FINDINGS: The right PICC line appears now to enter the right internal jugular vein and trend up into the neck where it loops on itself and turns back around, coming down to the level of the clavicle. This line is not properly placed and needs to be repositioned. NG tube is again noted but tip is not visualized. Cardiomediastinal contours are stable. Lung fields are clear. No significant pleural effusions and no pneumothorax. IMPRESSION: Left PICC line enters the right internal jugular vein and loops around, coming down to the level of the right clavicle. The line needs to be withdrawn and repositined. Radiology Report HISTORY: PICC placement. FINDINGS: The right subclavian PICC line again extends well into the neck. Otherwise, little change. Radiology Report PROCEDURE: PICC LINE REPOSITIONING. HISTORY: ___ female with painless jaundice with misplaced right PICC line. Request is to reposition. OPERATORS: Dr. ___ and Dr. ___ performed the procedure. PROCEDURE NOTE IN DETAIL: Informed verbal consent was obtained from the patient. The patient was then transferred to the ___ suite and placed supine on the imaging table. A limited fluoroscopic spot film of the chest demonstrates the right-sided PICC line extending into the right internal jugular vein. The area was prepped and draped in the usual sterile fashion. A preprocedure huddle and timeout were performed as per ___ protocol. Under real-time fluoroscopic guidance, the catheter was withdrawn and the tip positioned at the origin of the SVC. Using a pre-curved 018 nitinol wire, the wire was advanced into the SVC and the catheter then tracked along the wire. The tip was positioned at the cavoatrial junction. The wire was withdrawn. Satisfactory blood aspiration and flushing was noted from both lumens. Sterile dressing was applied. The patient was then transferred to the floor in stable condition for further post-procedure monitoring. IMPRESSION: Uncomplicated repositioning of a right-sided PICC line with the tip now positioned at the cavoatrial junction. The line may be used for infusion therapy immediately. Radiology Report INDICATION: ___ woman with painless jaundice, total bilirubin in the ___, cholangitis on Zosyn, needs decompression . PHYSICIANS: Dr. ___ (radiology fellow), Dr. ___ ___ (radiology attending)and Dr ___. MEDICATION: The procedure was performed under general anesthesia, please see the dedicated anesthesia note for further details. RADIATION: 21 minute 47 seconds of fluoroscopy time. CONTRAST: 50 cc Omnipaque 320. PROCEDURE: 1. Percutaneous transhepatic cholangiography. 2. Placement of an ___ internal-external percutaneous transhepatic biliary drain. PROCEDURE DETAILS: Following discussion of the risks, benefits and alternatives to the procedure, informed written patient consent was obtained. The patient was brought to the angiographic suite and a preprocedure timeout was performed using three patient identifiers. The procedure was performed under general anesthesia which was induced in the angiographic suite, please see relevant documentation. The patient received 2 g of cefazolin IV prior to commencing the procedure. The skin in the right anterior abdominal wall was prepped and draped in usual sterile fashion. Using ultrasound guidance, a peripheral dilated right posterior intrahepatic bile duct was targeted with a 21G Cook needle. Positioning within the bile duct was confirmed by a small injection of contrast to opacify the dilated intrahepatic biliary tree. A nitinol wire was advanced via the Cook needle, the needle was removed and the central portion of an AccuStick system was advanced over the wire to stabilize access to the biliary tree. The nitinol wire was removed and a Glidewire was advanced via the AccuStick into the dilated bile ducts, with some difficulty we manipulated the Glidewire into the common bile duct. The wire would not pass further than the mid portion of the common bile duct, therefore we removed at AccuStick system and advanced a 5 ___ sheath advanced over the wire. We then used a 5 ___ long Kumpe catheter also over the Glidewire which advanced into the proximal common bile duct and injected a small amount of contrast. This opacified a very dilated common bile duct, cystic duct and gallbladder, but no contrast was seen to pass distally through the CBD into the duodenum. We advanced the sheath into the dilated common bile duct, and we used a combination of the Kumpe catheter and Glidewire to locate the opening of the markedly narrowed distal common bile duct. The Kumpe catheter was advanced over the Glidewire and a small injection of contrast confirmed access to the duodenum. The Glidewire was exchanged for an Amplatz wire and advanced via the Kumpe into the duodenum and jejunum. The Kumpe catheter and sheath were removed, the tract was dilated with an 8 ___ dilator. An 8 ___ percutaneous transhepatic biliary drain was advanced over the Amplatz wire down to the level of the duodenum. A pigtail was formed and the catheter was confirmed to be in adequate position by injection of small amount of contrast. There were no immediate post-procedure complications, and the patient was returned to the ___ ICU. FINDINGS: 1. Marked intrahepatic biliary duct dilatation down to the level of the mid to distal common bile duct with a tight stenosis at that level. 2. Predominant opacification of the right-sided intrahepatic ducts; however, some contrast and at least one guidewire was seen to enter the left-sided ducts which are presumed to be in free communication. 3. Succesful traversal of the distal CBD obstruction with placement of an ___ Internal / External biliary drain. 4. Of note NG tube noted with its distal tip in the stomach. IMPRESSION: 1. Marked intra and extrahepatic biliary dilatation to the level of the distal CBD. 2.Successful placement of an 8 ___ percutaneous transhepatic biliary drain throught the obstruction which has been left on free drainage. Radiology Report INDICATION: Painless jaundice, confirm NG tube placement. COMPARISON: ___. TECHNIQUE: Single AP portable upright chest. FINDINGS: A nasogastric tube courses below the diaphragm, with tip below the borders of the radiograph, but likely located within the distal stomach. A right-sided PICC has been repositioned and now terminates in lower SVC. Mild left basilar atelectasis is persistent but slightly improved. Otherwise, no significant interval change. IMPRESSION: Nasogastric tube below the diaphragm, with tip likely located in distal stomach. Right-sided PICC with tip in lower SVC after repositioning. Left basilar atelectasis. Radiology Report HISTORY: Right IJ line placement. CHEST, SINGLE PORTABLE VIEW. Right IJ central line tip overlies the proximal/mid SVC and a right subclavian PICC line tip overlies the SVC/RA junction. NG tube tip extends beneath the diaphragm and overlies the stomach. No pneumothorax detected. Upper zone re-distribution, without overt CHF. Patchy retrocardiac opacity, similar or slightly improved compared with ___. No pneumothorax detected. Biapical pleural thickening again noted. Calcified left hilar lymph nodes again noted. Radiology Report INDICATION: ___ female status post ex lap Roux-en-Y choledochojejunostomy and gastrojejunostomy, now with recent removal of right IJ on the same side as the PICC line. COMPARISON: Comparison is made with chest radiograph from ___ and ___. FINDINGS: Two frontal images of the chest demonstrate a right PICC line terminates in the low SVC, unchanged from previous imaging. There is no pneumothorax or other complications. Interval removal of NG tube is also noted. There is a left pleural effusion and opacity in the left lower lobe associated with some volume loss. A catheter is seen overlying the liver. Calcified left hilar lymph nodes are again noted. Otherwise, the lungs appear clear and well expanded. Osseous structures are unremarkable. IMPRESSION: Right PICC line in unchanged position. No pneumothorax or other complications. Small left pleural effusion. Radiology Report CT CHEST WITH CONTRAST COMPARISON: None. Correlation is made with CTA abdomen of ___. TECHNIQUE: Multiple axial CT images were obtained through the chest following the administration of 75 cc of Omnipaque IV contrast. Sagittal and coronal reconstructions were obtained. No adverse reactions were reported. INDICATION: ___ female with pancreatic cancer, status post exploratory laparotomy with biopsy of ___ nodule, cholecystectomy, Roux-en-Y procedure, choledochojejunostomy, and gastrojejunostomy. Exam is done for oncology staging. FINDINGS: Right PICC terminates at the superior atriocaval junction. No supraclavicular, mediastinal, hilar, or retrocrural lymphadenopathy. Small right hilar lymph node measures 8 mm on short axis and does not meet criteria for pathologic enlargement by size. Scattered left hilar pulmonary calcified granulomas. Heart size is within normal limits without pericardial effusion. The thoracic aorta is normal in caliber without dissection or aneurysmal dilatation. Branches of the aortic arch are normal. Pulmonary trunk is within normal limits by size. No central pulmonary thromboembolic disease is identified. Thyroid gland demonstrates homogeneous attenuation without focal lesions. There is a 4-mm nodule in the middle lobe and a 3-mm nodule in the subpleural right lower lobe (2:36). No pulmonary mass is identified. Bilateral basilar subsegmental atelectasis. Small bilateral pleural effusions. No pneumothorax. ABDOMEN: Pneumobilia is likely related to recent changes of reported choledochojejunostomy. Hypodensity in the gallbladder fossa with intrinsic air is compatible with Surgicel packing although an abscess would have a similar appearance. Stable 0.9 x 1.3 cm hypodensity in the right hepatic lobe (segment VII). Small perihepatic and perisplenic ascites. Colonic diverticulosis without diverticulitis involving the visible splenic flexure. There is patchy fluid surrounding the splenic flexure, which may be due to post-surgical change. BONES AND SOFT TISSUES: No acute fracture or destructive osseous process. Multilevel degenerative disc disease. Advanced degenerative changes of the right and moderate degenerative changes of the left acromioclavicular joint. Degenerative arthrosis of both humeral heads. There is a calcific structure along the greater tuberosity of the left humerus which may relate to calcific tendinosis. No acute fracture or destructive osseous process. IMPRESSION: 1. Indeterminate right middle lobe and lower lobe pulmonary nodules. In a patient with history of prior malignancy, unenhanced CT chest is recommended in three months to monitor growth pattern and malignant potential. 2. No intrathoracic lymphadenopathy. 3. Pneumobilia, abdominal ascites and pericolonic fluid involving the splenic flexure are likely related to recent surgery. Hypoattenuation in gallbladder fossa with intrinsic air is compatible with Surgicel packing, however an abscess would have a similar appearance and cannot be excluded. 4. Scattered colonic diverticulosis. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: DIFFICULTY EATING Diagnosed with JAUNDICE NOS, OBSTRUCTION OF BILE DUCT temperature: 96.8 heartrate: 80.0 resprate: 12.0 o2sat: 100.0 sbp: 94.0 dbp: 63.0 level of pain: 0 level of acuity: 2.0

You were admitted to the surgery service at ___ for surgical evaluation of your biliary obstruction. You have done well in the post operative period and are now safe to return home to complete your recovery with the following instructions: Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips ___ days after surgery. Please call your doctor or nurse practitioner if you experience the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: EGD ___ History of Present Illness: ___ y.o male with significant Pmhx of bipolar diorder, depression, osteoarthritis, and DVT/PE s/p IVC filter, currently on coumadin, who presents from his nursing home s/p fall on his face/and right side after tripping on a table. Patient reports that he had recent increase in dose of his pscyhiatric medications and since then he has felt increased dizziness and a little more trouble ambulating. He is experiencing ___ headache located in the right temple without radiation, associated with no vision changes, recent nausea/vomiting, limb weakness, confusion. He reports that he has had increased SOB this morning at rest and with exertion over the past day. He denies any assoicated cough, fevers/chills, orthopnea, PND, ___ pitting edema, chest pain. He has had nausea and abdominal pain over the past week that is mild and diffuse in nature. He has been using Maalox for this which improves these symtoms. He has had 3 episodes of emesis on ___, one of which had dark "red blood" in it per patient report. He reports constipation, and his last BM was yesterday, which he reported was hard with no hematochezia or melena. He denies any recent fevers/chills/ malaise/motor/sensory neuro abnormalities/vision changes/diarrhea. In the ___ initial vitals were: 98.7 P 79 BP 108/71 RR 16 POx 94% RA. He was given IV 40mg Pantoprazole , and 2mg IV Zofran. The patient was noted to be less responsive this AM and repeat CT head was carried out which revealed no frank head bleed. Neurosurgery consult was obtained which concluded he is neurologically intact and no further neurological intervention needs to be done. BP holding around 90-100s SBP. DRE showed positive occult blood and pt had 3 episodes of bloody vomitus yesterday. IV 10mg Vitamin K. Started protonix bolus and drip. Consulted GI who recommended repeating hematocrit. Also CXR has some elements of CHF and he was admitted to MICU for further management. On arrival to the MICU, the patient looks well and his only complaint is headache. He currently denies nausea, vomiting, abdominal pain, chest pain, dyspnea. He denies vision changes, numbness or problems moving his arms and legs. He is "tired" but denies any confusion. Review of systems: Obtained from patient (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: ___ PE, left-sided DVT (___) s/p IVC filter on Coumadin Chronic pain ___ DJD disease, compression fractures of T11, L2 (wheelchair use) GERD Hiatal hernia (associated with prior chest pain) ___ of Osteomyelitis in R ___ toe Past Psychiatric History: Reported multiple past hospitalizations at ___, ___ ___, etc, typically for similar SI though no documented SA. Has received OP treatment through ___ and ___ in the past, currently without treaters. Has been on "multiple antidepressants" per record without specific names recalled, no overt side effects or adverse outcomes. Reportedly on lithium ___, stopped several months ago for noncompliance. No other known med trials. No record of assault, violence. Substance Use History: 1PPD tobacco. Denies EtOH, IVD, cocaine, THC abuse. No past withdrawal/seizure/DTs. Per PCP, has ___ heavy ETOH. Social History: ___ Family History: Father died of MI at ___ Mother died of MI at ___ Physical Exam: ADMISSION PHYSICAL EXAM: General: Alert, oriented X 3 , no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated though hard to assess given habitus, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: no wheezes, bibasilar insp. rales,no ronchi Abdomen: soft, tendernes in the epigastric region, non-distended, bowel sounds present, no organomegaly. No rebound tenderness, no guarding. GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Rectal: Dark brown guaiac positive stool DISCHARGE PHYSICAL EXAM: VS - 98.5, 126/88, 73, 18, 98% RA FSBG 121 GENERAL - awake, comfortable, in NAD HEENT - NC/AT, sclerae anicteric LUNGS - few crackles at the base of the lungs, bilaterally. Moving air well and symmetrically, resp unlabored, no accessory muscle use HEART - RRR, S1-S2 clear and of good quality without murmurs, rubs or gallops ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral DP pulses NEURO - awake, A&Ox3, CNs II-XII grossly intact Pertinent Results: Admission Labs ___ 11:30PM BLOOD WBC-11.1*# RBC-4.14* Hgb-12.4* Hct-37.5* MCV-91 MCH-29.9 MCHC-33.0 RDW-15.9* Plt ___ ___ 11:30PM BLOOD Neuts-72.3* ___ Monos-2.9 Eos-1.7 Baso-0.2 ___ 11:30PM BLOOD ___ PTT-38.9* ___ ___ 11:30PM BLOOD Glucose-94 UreaN-21* Creat-0.8 Na-138 K-4.6 Cl-105 HCO3-27 AnGap-11 ___ 11:30PM BLOOD ALT-19 AST-27 AlkPhos-56 TotBili-0.3 ___ 11:30PM BLOOD Lipase-12 ___ 11:30PM BLOOD Albumin-3.9 Calcium-8.6 Phos-3.3 Mg-2.5 ___ 11:30PM BLOOD VitB12-486 ___ 11:30PM BLOOD Valproa-79 DISCHARGE LABS: ___ 03:02AM BLOOD WBC-6.5 RBC-4.05* Hgb-11.9* Hct-36.9* MCV-91 MCH-29.5 MCHC-32.4 RDW-15.9* Plt ___ ___ 03:02AM BLOOD Plt ___ ___ 03:02AM BLOOD ___ PTT-34.3 ___ ___ 03:02AM BLOOD Glucose-120* UreaN-26* Creat-0.8 Na-139 K-4.4 Cl-106 HCO3-25 AnGap-12 IMAGING: - CT HEAD W/O CONTRAST ___: IMPRESSION: Mildly artifact-limited study. Previously seen focus of left frontal cortical hyperdensity is no longer present on the current examination. Apparent foci of hyperdensity now project over different portions of the frontal cortex bilaterally, almost certainly artifactual. The artifacts are in part related to the protective goggles over the patient's eyes. If additional imaging is desired, the patient should be rescanned with his neck flexed, so that the goggles would not project over the frontal lobes. - CXR ___: FINDINGS AND IMPRESSION: Lung volumes are low. As compared to the prior examination, previously seen bibasilar opacities are improved and right midlung pneumonia has cleared. There is mild bibasilar atelectasis, but no consolidation to suggest pneumonia. Moderate cardiomegaly, increased since ___, generalized systemic and pulmonary overcirculation and is incipient pulmonary edema indicate biventricular cardiac decompensation. I discussed these findings by telephone with Dr ___ in the ___ at 8:30AM. - CT HEAD W/O CONTRAST ___: IMPRESSION: Motion-limited study. Apparent hyperdensity projecting over the left anterior frontal cortex, subjacent to bone, is probably artifactual. However, given history of fall and anticoagulation, a small hemorrhage cannot be excluded. Close clinical follow-up and short-interval follow-up imaging should be considered. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from ___ home medication sheet. 1. Divalproex (DELayed Release) 500 mg PO QAM 2. Divalproex (DELayed Release) 750 mg PO HS 3. Ferrous Sulfate 325 mg PO DAILY 4. Quetiapine extended-release 500 mg PO DAILY 5. Doxepin HCl 100 mg PO HS 6. BuPROPion (Sustained Release) 450 mg PO HS 7. Warfarin Dose is Unknown PO DAYS (___) 8. Furosemide 40 mg PO DAILY 9. TraMADOL (Ultram) 25 mg PO BID 10. Clonazepam 2 mg PO BID 11. Omeprazole 20 mg PO DAILY 12. Paroxetine 30 mg PO DAILY Discharge Medications: 1. BuPROPion (Sustained Release) 450 mg PO HS 2. Clonazepam 2 mg PO BID 3. Divalproex (DELayed Release) 500 mg PO QAM 4. Divalproex (DELayed Release) 750 mg PO HS 5. Doxepin HCl 100 mg PO HS 6. Ferrous Sulfate 325 mg PO DAILY 7. Furosemide 40 mg PO DAILY 8. Paroxetine 30 mg PO DAILY 9. Quetiapine extended-release 500 mg PO DAILY 10. TraMADOL (Ultram) 25 mg PO BID 11. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 12. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN GI upset 13. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN shortness of breath or wheezing 14. Bisacodyl 10 mg PR HS:PRN constipation not responsive to milk of magensia 15. Fleet Enema ___AILY:PRN constipation not responsive to suppository 16. Guaifenesin 10 mL PO Q6H:PRN cough 17. Milk of Magnesia 30 mL PO QHS:PRN constipation 18. Prochlorperazine 10 mg PO Q6H:PRN nausea or vomiting 19. TraMADOL (Ultram) 25 mg PO BID for back pain 20. Acetaminophen 650 mg PO Q6H:PRN pain or fever 21. Miconazole Powder 2% 1 Appl TP BID:PRN rash 22. Polyethylene Glycol 17 g PO EVERY OTHER DAY hold for diarrhea 23. ___ MD to order daily dose PO DAYS (___) Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Mechanical Fall Erosive gastritis Secondary: Bipolar disorder Gastroesophageal reflux disorder History of deep venous thrombosis Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Mental Status: Confused - sometimes. Followup Instructions: ___ Radiology Report INDICATION: Status post fall. On Coumadin. Initial head CT with question of possible subarachnoid hemorrhage. TECHNIQUE: Multidetector CT scan of the head was obtained without the administration of contrast. Coronal and sagittal reformations were prepared. COMPARISON: Correlation with CT dated ___ obtained approximately 5.5 hours prior. Review of CT head examination dated ___. FINDINGS: The study is mildly limited by artifacts, less so than the prior study performed approximately 5.5 hours earlier. The location of the previously described hyperdensity appears normal on the current CT examination. Apparent hyperdensity now projects over the left anteromedial frontal cortex (___), in a different location than the questionable finding on the prior CT. There are bilateral apparent areas of hyperdensity along the inferomedial frontal cortex bilaterally (102A:36-37). These are almost certainly artifactual. No subdural or epidural collection is seen. Prominence of the ventricles and sulci is consistent with mild cerebral atrophy, unchanged. No concerning osseous lesion or fracture is identified. There is minimal mucosal thickening of the left maxillary sinus and bilateral anterior ethmoid air cells. IMPRESSION: Mildly artifact-limited study. Previously seen focus of left frontal cortical hyperdensity is no longer present on the current examination. Apparent foci of hyperdensity now project over different portions of the frontal cortex bilaterally, almost certainly artifactual. The artifacts are in part related to the protective goggles over the patient's eyes. If additional imaging is desired, the patient should be rescanned with his neck flexed, so that the goggles would not project over the frontal lobes. Gender: M Race: WHITE Arrive by UNKNOWN Chief complaint: UNWITNESSED FALL Diagnosed with HEAD INJURY UNSPECIFIED, NAUSEA WITH VOMITING, UNSPECIFIED FALL temperature: 98.7 heartrate: 79.0 resprate: 16.0 o2sat: 94.0 sbp: 108.0 dbp: 71.0 level of pain: 9 level of acuity: 3.0

Dear Mr. ___, It was a pleasure taking care of you at ___ ___. You were admitted after you had a fall, and were vomiting blood. While you were hospitalized, you underwent two head CT scans, both of which did not demonstrate evidence of acute bleed after your falls. Given your history of vomiting blood, you were initially admitted to the ICU. Here you were started on a new medication, called pantoprazole, to treat your GI bleed. You were monitored for evidence of bleeding, which you did not have. You improved, and you were transferred to the normal medicine floor. You undewent an EGD, where the GI doctors used ___ to look into your esophagus, stomach, and first part of your small intestine. During this procedure, it was discoverd that you have erosive gastritis, which is likley the cause of the blood in your vomit. Additionally, you were found to have a large amount of food in your stomach. The GI doctors who did this procedure recommend that you have a repeat EGD in 8 weeks to evaluate for healing, as well as an outpatient gastric emptyng study to evaluate the cause of the food retention in your stomach. Please note that the following changes were made to your medications: 1. Please start taking pantoprazole 40 mg by mouth twice a day Please discuss your medications with your PCP and psychiatrist. It is possible your medications are contributing to your unsteadiness, and you may benefit from having your medications adjusted.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Oxycodone / Percocet Attending: ___. Chief Complaint: Lethargy Major Surgical or Invasive Procedure: None. History of Present Illness: ___ w/CLL, pure red cell aplasia, dCHF and A-fib present presents with fatigue x 2 weeks. Pt admitted from ___ to medicine for fatigue and ___ and ___ ___ w/dyspnea, cough, increasing pleural effusion with pneumonia. Patient was discharged the first hosptial visit on Metalozone for increasing edema. Patient was readmitted with Cr 3.7 (baseline ~ 1.6 - 1.9), metalozone was held and Cr improved to 3.2 and patient was discharged. On repeat lab draw today, Cr still 3.2 so patient was referred to ED. Patient reports continued to feel fatigued. Reports 19lb weight loss since ___. No night sweats. Denies chest pain, SOB, cough, fever, chills, nausea, vomiting, diarhea. Leg swelling improved from baseline. No blood in stool. In the ED, initial vitals were: 97.5 75 100/48 18 100% 0 - Labs were significant for Na 127, Cr 2.7 (2.0 on ___, up to 3.7 on ___ , BUN 77, Hgb/Hct 8.___.1 (at baseline). Coags and UA were normal, however 21 casts noted. - Imaging revealed CXR - no fluid overload. Bilateral pleural effusions - The patient was not given medications, started on 75cc/hr IVF. Vitals prior to transfer were: 78 118/78 23 Nasal Cannula Upon arrival to the floor, patient reports fatigue no other complaints. Past Medical History: PAST MEDICAL HISTORY -CLL c/b immune thrombocytopenia, pure RBC aplasia, HSV stomatitis oral candidiasis therapy-related hypoplastic myelodysplastic syndrome, parvovirus B19 infection and CMV infection -Coronary artery disease (no h/o MI, stents, or CABG) -atrial fibrillation, not on anticoagulation -chronic diastolic CHF (EF 50%) -S/p hernia repair Social History: ___ Family History: - Mother: ___ cancer - Father: CAD, MI Physical Exam: ========================== ADMISSION PHYSICAL EXAM: ========================== Vitals: 98.8 106/60 104 18 99%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL CV: irregular rate normal S1 + S2, no murmurs Lungs: Clear to auscultation bilaterally, no wheezes Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding Ext: Warm, well perfused, 1+ edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. =========================== DISCHARGE PHYSICAL EXAM: =========================== Vitals: Tmax 99.2, Tc 98.9 BP 125/69 HR 114 RR 18 96%RA I/O: ___ (8H) 900/850 (24H) ***Discharge Weight***: 137.8 lbs. General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, JVP 9 cm at 45 degrees CV: Irregular rate and rhythm, normal S1 + S2, no murmurs Lungs: Clear to auscultation bilaterally, no wheezes Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding Ext: Warm, well perfused, trace peripheral edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. Pertinent Results: ================= ADMISSION LABS: ================= ___ WBC-7.0 RBC-2.46* Hgb-8.8* Hct-26.1* MCV-106* MCH-35.8* MCHC-33.7 RDW-13.8 RDWSD-53.9* Plt Ct-ERROR ___ Neuts-49 Bands-5 ___ Monos-2* Eos-0 Baso-0 ___ Myelos-0 AbsNeut-3.78 AbsLymp-3.08 AbsMono-0.14* AbsEos-0.00* AbsBaso-0.00* ___ Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-2+ Microcy-NORMAL Polychr-NORMAL ___ ___ PTT-39.6* ___ ___ Glucose-137* UreaN-77* Creat-2.7* Na-127* K-4.5 Cl-90* HCO3-24 AnGap-18 ==================== PERTINENT RESULTS: ==================== ___ TSH-1.6 == CXR ___: As compared to ___ chest radiograph, bilateral pleural effusions and adjacent basilar atelectasis have slightly worsened. The right pleural effusion is now moderate, in the left is small to moderate. No other relevant changes. == CXR ___: The right Port-A-Cath is in stable position. There unchanged appearance of the small right pleural effusion and small left pleural effusion. Adjacent atelectasis is seen. The heart size is stable. No overt pulmonary edema or pneumothorax is seen. No new focal consolidation is seen. ================== DISCHARGE LABS: ================== ___ WBC-5.9 RBC-2.18* Hgb-7.8* Hct-23.7* MCV-109* MCH-35.8* MCHC-32.9 RDW-13.9 RDWSD-55.4* Plt ___ ___ Glucose-128* UreaN-61* Creat-1.8* Na-130* K-4.1 Cl-94* HCO3-27 AnGap-13 ___ Calcium-8.5 Phos-2.8 Mg-1.7 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q12H 2. Aspirin 81 mg PO DAILY 3. Atovaquone Suspension 1500 mg PO DAILY 4. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H 5. Diltiazem Extended-Release 180 mg PO DAILY 6. FoLIC Acid 1 mg PO DAILY 7. Metoprolol Succinate XL 100 mg PO QPM 8. Metoprolol Succinate XL 200 mg PO QAM 9. PredniSONE 7.5 mg PO DAILY 10. Furosemide 80 mg PO BID 11. Potassium Chloride 10 mEq PO TID 12. Cyanocobalamin 1000 mcg PO DAILY 13. Magnesium (oxide/AA chelate) (magnesium oxide-Mg AA chelate) 133 mg oral BID Discharge Medications: 1. Acyclovir 400 mg PO Q12H 2. Aspirin 81 mg PO DAILY 3. Atovaquone Suspension 1500 mg PO DAILY 4. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H 5. Diltiazem Extended-Release 180 mg PO DAILY 6. FoLIC Acid 1 mg PO DAILY 7. Metoprolol Succinate XL 100 mg PO QPM 8. Metoprolol Succinate XL 200 mg PO QAM 9. PredniSONE 7.5 mg PO DAILY 10. Cyanocobalamin 1000 mcg PO DAILY 11. Magnesium (oxide/AA chelate) (magnesium oxide-Mg AA chelate) 133 mg oral BID 12. Potassium Chloride 10 mEq PO TID 13. Furosemide 40 mg PO EVERY OTHER DAY 14. Furosemide 80 mg PO EVERY OTHER DAY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: - Acute on Chronic Kidney Injury Secondary Diagnoses: - Acute on Chronic Diastolic Heart Failure - Atrial fibrillation - Coronary artery disease - Chronic Lymphocytic Leukemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ male with congestive heart failure and presents with fatigue and renal failure. Evaluate for CHF. TECHNIQUE: Frontal and lateral chest radiographs were obtained. COMPARISON: Chest radiograph from ___. FINDINGS: The right Port-A-Cath is in stable position. There unchanged appearance of the small right pleural effusion and small left pleural effusion. Adjacent atelectasis is seen. The heart size is stable. No overt pulmonary edema or pneumothorax is seen. No new focal consolidation is seen. IMPRESSION: Similar appearance of the bilateral small pleural effusions. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with CLL and new fever. // Signs of Pneumonia or infiltrate? IMPRESSION: As compared to ___ chest radiograph, bilateral pleural effusions and adjacent basilar atelectasis have slightly worsened. The right pleural effusion is now moderate, in the left is small to moderate. No other relevant changes. . Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abnormal labs, Lethargy Diagnosed with RENAL & URETERAL DIS NOS, OTHER MALAISE AND FATIGUE temperature: 97.5 heartrate: 75.0 resprate: 18.0 o2sat: 100.0 sbp: 100.0 dbp: 48.0 level of pain: 0 level of acuity: 3.0

Dear Mr. ___, It was a pleasure taking care of ___ during your recent admission to ___ came to use because your creatinine was increased. We gave ___ fluids and your creatinine improved. We also adjusted your diuretic regimen. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. We wish ___ a fast recovery. Sincerely, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ___ Attending: ___. Chief Complaint: Fever Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ man with history of CAD s/p CABG, HTN, HLD, DMII, multiple myeloma s/p auto SCT currently on pomalidomide/daratumumab presenting with weakness. The patient has a history of multiple myeloma s/p auto SCT (___). He was initially on Revlimid, then Ninlaro, and now initiated ___ on pomalidomide/daratumumab/dexamethasone. The patient and his wife report that he has progressively become weaker over the past several months, but it has been worse in the past several weeks. He also notes that he has had drenching sweats for over a year but this has also gotten worse recently. He reports that his blood sugars have been labile since initiating the dexamethasone, sometimes in the 300-400s, but also low in the ___. About 3 weeks ago, the patient got up in the night to urinate and feel extremely weak. His wife found him lying on the floor in the bathroom. He was taken to BID-M on ___. There, he was found to have febrile neutropenia and acute on chronic anemia. ID was consulted and he underwent extensive infectious evaluation including blood and urine cultures, sputum culture, Flu/RSV swab; Lyme, Anaplasma, Babesia, Erlichia negative; CT abdomen/pelvis; TTE without vegetations. The patient was given vancomycin/cefepime empirically for 10 days and defervesced. His hospital course was complicated by an acute gout flare for which he received prednisone and colchicine. He was discharged on ___. The patient saw his oncologist Dr. ___ on ___. The plan at that time was to hold Bactrim/acyclovir prophylaxis, hold aspirin given worsened thrombocytopenia, resume atenolol, and to hold pomalidomide. However, the patient took a dose on ___. At home, he continued to feel extremely weak. He denies any fevers at home, but noted ongoing drenching sweats. His wife reports that she went to the supermarket and returned 45 minutes later and found her husband on the floor. The patient reports that he was sitting in a recliner and attempted several times to stand but felt extremely weak and repeatedly fell back into the recline. On his final attempt to stand he rocked forward and fell out of the chair. He denies any loss of consciousness. He denies any antecedent symptoms such as chest pain, palpitations, dizziness or lightheadedness. He felt too weak to prop himself up, and when his wife returned she called EMS. He was taken to ___, where he was febrile to 100.5. He was give IV vancomycin, IV cefepime, oral vancomycin for potential C. diff, and 1 unit pRBCS. He was transferred to ___ for further care. The patient additionally notes that he developed a dry cough while at ___ but denies any shortness of breath. No abdominal pain, nausea, vomiting. He had a few loose stools several days prior to admission this has been ongoing related to chemotherapy. He has a rash on his forehead due to his use of ___ for his actinic keratosis but no other rashes or lesions. No dysuria. No known sick contacts. In the ED, vitals: Tmax 102.7 80 122/66 16 98% RA Exam notable for: CTAB no WRR, unlabored breathing Labs notable for: WBC 5.5, Hb 7.9, plt 94, INR 1.6; trop 0.07->0.04, MB 3->2; UA with glucosuria Imaging: CXR Patient given: Magnesium 2 gm IV, insulin 6 units, Tylenol 1 gm, erythromycin eye ointment In our ED, he was noted to have left eye lid with scant purulent appearing discharge. No pain or redness in the eye. Started on erythromycin ointment for presumed bacterial conjunctivitis On arrival to the floor, the patient reports that he feels fatigued but otherwise has no complaints. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: Hypertension Dyslipidemia Diabetes (type II with retinopathy) BPH Colon Polyps s/p polypectomy Lung Nodule (right side- stable) Basal cell CA Diverticulosis Multiple myeloma Social History: ___ Family History: Mother and father died of CAD in their ___ Physical Exam: ADMISSION VITALS: 99.7 125 / 80 67 18 94 RA GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: Rash on forehead NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: Very pleasant, appropriate affect GENERAL: Alert and in no apparent distress EYES: Anicteric sclera ENT: Oropharynx without visible lesion, erythema or exudate. CV: Heart regular, no murmur RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored. GI: Abdomen is soft, non-distended, non-tender to palpation. MSK: Neck supple, moves all extremities SKIN: Crusted rash on face extending across midline NEURO: Alert, oriented, speech fluent PSYCH: Pleasant, appropriate affect Pertinent Results: ADMISSION ___ 11:30PM BLOOD WBC-5.5 RBC-2.86* Hgb-7.9* Hct-25.5* MCV-89 MCH-27.6 MCHC-31.0* RDW-16.2* RDWSD-51.4* Plt Ct-94* ___ 11:30PM BLOOD Neuts-70.7 ___ Monos-7.7 Eos-0.2* Baso-0.2 Im ___ AbsNeut-3.89 AbsLymp-1.08* AbsMono-0.42 AbsEos-0.01* AbsBaso-0.01 ___ 11:30PM BLOOD ___ PTT-26.8 ___ ___ 11:30PM BLOOD Glucose-182* UreaN-13 Creat-0.9 Na-136 K-4.3 Cl-102 HCO3-23 AnGap-11 ___ 11:30PM BLOOD CK(CPK)-857* ___ 05:51AM BLOOD ALT-7 AST-19 LD(LDH)-96 CK(CPK)-109 AlkPhos-65 TotBili-0.9 ___ 11:30PM BLOOD CK-MB-3 cTropnT-0.07* ___ 11:30PM BLOOD Calcium-9.6 Phos-3.5 Mg-1.2* Iron-40* ___ 08:48AM BLOOD PEP-PND FreeKap-134.6* FreeLam-1.3* Fr K/L-103.5* ___ 11:30PM BLOOD calTIBC-120* Ferritn-1101* TRF-92* ___ 07:30AM BLOOD Cortsol-17.7 ___ 11:30PM BLOOD TSH-3.4 ___ 11:38PM BLOOD Glucose-178* Lactate-1.0 IMAGING - CT Head (___): CT head that did not show acute hemorrhage, mass, territorial infarct. - CT chest (___) 1. Multiple lucent lesions scattered throughout the axial skeleton are concerning for myelomatous involvement. Several of the lesions including dominant lesions in the T6 and T7 vertebral bodies, which were not FDG avid on the prior PET-CT appear grossly unchanged. A probable lesion in the medial aspect of the right clavicle, appears new from PET-CT ___ and is concerning for new or worsening myelomatous involvement. 2. Small pulmonary nodules measure up to 2 mm, not definitely seen on PET-CT ___, possibly due to poor resolution. Recommend ___ month interval follow-up to assess for stability. 3. Assessment is moderately limited by respiratory motion, but no definite evidence of pneumonia or bronchitis. - CT sinus (___) 1. There is moderate mucosal thickening of the bilateral ethmoid air cells and left maxillary sinus with partial opacification of the left maxillary sinus which may represent sinus disease in the appropriate clinical setting. 2. There is opacification of the left infundibulum. 3. Polypoid soft tissue in the left maxillary sinus may represent sinus polyposis. 4. The bilateral orbits are unremarkable. ___ 07:05AM BLOOD WBC-3.4* RBC-2.61* Hgb-7.3* Hct-23.2* MCV-89 MCH-28.0 MCHC-31.5* RDW-15.4 RDWSD-49.4* Plt Ct-87* ___ 07:05AM BLOOD Glucose-93 UreaN-12 Creat-1.1 Na-136 K-3.4* Cl-100 HCO3-29 AnGap-7* ___ 07:05AM BLOOD Mg-1.4* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Colchicine 0.6 mg PO DAILY 2. Nateglinide 120 mg PO TIDAC 3. pomalidomide 2 mg oral DAILY 4. Dexamethasone 20 mg PO 1X/WEEK (___) 5. fluorouracil 5 % topical DAILY 6. Omeprazole 20 mg PO DAILY 7. colestipol 5 gram oral DAILY 8. Cyanocobalamin 1000 mcg PO DAILY 9. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 10. Glargine 22 Units Bedtime 11. FoLIC Acid 1 mg PO DAILY 12. magnesium chloride 64 mg oral BID 13. Lisinopril 10 mg PO DAILY 14. Atenolol 25 mg PO DAILY 15. Atorvastatin 20 mg PO QPM 16. Aspirin 81 mg PO DAILY 17. Fish Oil (Omega 3) 1000 mg PO DAILY 18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN Chest pain Discharge Medications: 1. Benzonatate 200 mg PO TID Cough RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day Disp #*30 Capsule Refills:*1 2. GuaiFENesin ER 1200 mg PO Q12H RX *guaifenesin [Mucus-ER MAX] 1,200 mg 1 tablet(s) by mouth twice a day Disp #*28 Tablet Refills:*1 3. LevoFLOXacin 750 mg PO DAILY RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*8 Tablet Refills:*0 4. MetroNIDAZOLE 500 mg PO/NG Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*24 Tablet Refills:*0 5. Multivitamins W/minerals 1 TAB PO DAILY RX *multivitamin,tx-minerals 1 tablet(s) by mouth once a day Disp #*90 Tablet Refills:*3 6. Aspirin 81 mg PO DAILY 7. Atenolol 25 mg PO DAILY 8. Atorvastatin 20 mg PO QPM 9. colestipol 5 gram oral DAILY 10. Cyanocobalamin 1000 mcg PO DAILY 11. Dexamethasone 20 mg PO 1X/WEEK (___) 12. Fish Oil (Omega 3) 1000 mg PO DAILY 13. FoLIC Acid 1 mg PO DAILY 14. Glargine 22 Units Bedtime 15. Lisinopril 10 mg PO DAILY 16. magnesium chloride 64 mg oral BID 17. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 18. Nateglinide 120 mg PO TIDAC 19. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN Chest pain 20. Omeprazole 20 mg PO DAILY 21. HELD- fluorouracil 5 % topical DAILY This medication was held. Do not restart fluorouracil until your oncologist tells you to 22. HELD- pomalidomide 2 mg oral DAILY This medication was held. Do not restart pomalidomide until your oncologist tells you to Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Febrile illness Acute metabolic encephalopathy Multiple myeloma Anemia and thrombocytopenia CAD s/p CABG Demand ischemia Diabetes mellitus Weakness Fall Conjunctivitis Essential hypertension Hyperlipidemia Gout Actinic keratosis: Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: Chest: Frontal and lateral views INDICATION: History: ___ with multiple myeloma, low grade fevers and cough// pna? TECHNIQUE: Chest: Frontal and Lateral COMPARISON: ___ FINDINGS: Patient is status post median sternotomy and CABG.The lungs are clear without focal consolidation. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are unremarkable. Cardiac silhouette remains mildly enlarged. Mediastinal contours unremarkable. No pulmonary edema is seen. Osseous structures are not well assessed on this study. IMPRESSION: No focal consolidation to suggest pneumonia. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with History of multiple myeloma on immunotherapy presenting with recurrent fever of unclear etiology with cough// Possible encephalopathy evaluate cause of alter mental status TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: DLP 855 mGy cm COMPARISON: None. FINDINGS: There is no evidence of large territory acute infarction,hemorrhage,edema, or mass. The ventricles and sulci are age-appropriate. There is mild calcified atherosclerosis at the bilateral carotid siphons. There is no evidence of fracture. There is a moderate sized anterior nasal septal defect. There is moderate mucosal thickening of the left maxillary sinus and mild mucosal thickening of the ethmoid air cells and left sphenoid sinus. The visualized portion of the remaining paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: No acute intracranial process. If there is high clinical concern for encephalitis, further evaluation may be performed with MRI brain with contrast Radiology Report EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Q116 CT HEADSINUS INDICATION: ___ year old man with myeloma and recurrent febrile illness. Notable left eye edema and discharge with chronic rhinitis.// Evaluate for sinus infection. TECHNIQUE: Helically-acquired multidetector CT axial images were obtained through the maxillofacial bones and mandible. Intravenous contrast was not administered. Axial images reconstructed with soft tissue and bone algorithm to display images with 1.25 mm slice. Coronal and sagittal reformations were also constructed. All produced images were evaluated in production of this report. DOSE: Acquisition sequence: 1) Spiral Acquisition 2.7 s, 14.4 cm; CTDIvol = 27.9 mGy (Head) DLP = 408.8 mGy-cm. Total DLP (Head) = 409 mGy-cm. COMPARISON: CT head dated ___ FINDINGS: No fractures are identified. There is no evidence of facial swelling. There is moderate mucosal thickening of the bilateral ethmoid air cells and left maxillary sinus. There is aerosolized material and a polypoid soft tissue left maxillary sinus. There is opacification of the left infundibulum. The partially visualized bilateral mastoids appear normal. The globes, extraocular muscles, optic nerves, and retrobulbar fat appear normal. The visualized upper aerodigestive tract appears normal. The mandible and temporomandibular joints appear normal. IMPRESSION: 1. There is moderate mucosal thickening of the bilateral ethmoid air cells and left maxillary sinus with partial opacification of the left maxillary sinus which may represent sinus disease in the appropriate clinical setting. 2. There is opacification of the left infundibulum. 3. Polypoid soft tissue in the left maxillary sinus may represent sinus polyposis. 4. The bilateral orbits are unremarkable. Radiology Report EXAMINATION: CT CHEST W/O CONTRAST INDICATION: ___ year old man with multiple myeloma presenting with recurrent febrile illness and cough// Assess for lung pathology to explain symptoms such as pneumonia/bronchitis TECHNIQUE: Multidetector scanning of the chest was performed and reconstructed as contiguous 5- and 1.25-mm thick axial, 2.5-mm thick coronal and sagittal, and 8 x 8 mm MIPs axial images. No IV Contrast administered. DOSE: Acquisition sequence: 1) Spiral Acquisition 6.3 s, 33.4 cm; CTDIvol = 8.1 mGy (Body) DLP = 272.4 mGy-cm. Total DLP (Body) = 272 mGy-cm. COMPARISON: PET-CT ___ FINDINGS: NECK, THORACIC INLET, AXILLAE, CHEST WALL: The thyroid is unremarkable. No axillary or supraclavicular lymphadenopathy. UPPER ABDOMEN: Limited assessment of the upper abdomen is grossly unremarkable. MEDIASTINUM: No mediastinal lymphadenopathy. HILA: No hilar lymphadenopathy within the limitations of this noncontrast study. HEART and PERICARDIUM: Coronary calcifications are heavy. No pericardial effusion. PLEURA: No pleural effusion. LUNG: 1. PARENCHYMA: Assessment of the lungs is moderately limited by respiratory motion. Multiple granulomas are noted at the right lung apex. Small pulmonary nodules measure up to 2 mm (series 5, image 71, 84, 86). 2. AIRWAYS: Airways are patent to the subsegmental level. 3. VESSELS: Vascular calcifications are moderate. Aorta and main pulmonary artery are normal in size. CHEST CAGE: Superficial soft tissues are grossly unremarkable. The patient is status post median sternotomy. A large lytic lesion involving the T6 and T7 vertebral body (series 7, image 85, 81) and extending into the left seventh rib, as well as a lytic lesion in the spinous process and extending into the facets at T8 (series 7, image 39) allowing for technical differences are unchanged from PET-CT ___ and concerning for myelomatous involvement, although were not FDG avid on prior. Lucent lesion in the medial aspect of the right clavicle (series 5, image 49) was not definitely seen on prior PET-CT. Numerous additional subcentimeter lucent lesions scattered throughout the axial skeleton (Series 7, image 84, 81) are concerning for myelomatous involvement. DISH is noted throughout the visualized thoracic spine. IMPRESSION: 1. Multiple lucent lesions scattered throughout the axial skeleton are concerning for myelomatous involvement. Several of the lesions including dominant lesions in the T6 and T7 vertebral bodies, which were not FDG avid on the prior PET-CT appear grossly unchanged. A probable lesion in the medial aspect of the right clavicle, appears new from PET-CT ___ and is concerning for new or worsening myelomatous involvement. 2. Small pulmonary nodules measure up to 2 mm, not definitely seen on PET-CT ___, possibly due to poor resolution. Recommend ___ month interval follow-up to assess for stability. 3. Assessment is moderately limited by respiratory motion, but no definite evidence of pneumonia or bronchitis. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Syncope, Transfer Diagnosed with Weakness temperature: 98.7 heartrate: 63.0 resprate: 16.0 o2sat: 96.0 sbp: 113.0 dbp: 69.0 level of pain: 0 level of acuity: 2.0

Mr. ___, You were admitted to ___ with an infection. We treated you for a respiratory infection, and your symptoms improved. We would like you to complete a 14-day course of antibiotics to help clear this up. Your oncologist would like to see you in clinic on ___.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Omeprazole Attending: ___. Chief Complaint: Pneumonia Dyspnea/hypoxia Atrial fibrillation - new dx Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ woman with history notable for HTN and endometrial cancer with oligometastasis to the left lung status post TAH-BSO in ___ and radiation in ___, presenting with fever and dyspnea, sent in by PCP. She developed malaise and fatigue a few days ago, and yesterday (___) she developed a fever with Tmax of 100.8 (axillary). This was associated with some dyspnea on mild exertion, generalized fatigue/weakness, and decreased appetite. This morning, she was afebrile, but had a productive cough (mostly clear sputum; question of some sputum with a speck of blood). Of note, she has history of endometrial adenocarcinoma s/p TAH/BSO in ___ and was recently found to have an oligometastasis to the left lower lobe, which was treated with radiation completed on ___ (5 treatments over 2 weeks). At her baseline, she ambulates with a walker or cane; a few months ago she hurt her right knee and has been getting ___ at home to help with her recovery from this injury. No weight-bearing restrictions. In the ED, initial vitals: 97.4 83 105/53 w/ neg orthostatics RR 16 95% 2L Nasal Cannula In the ED, lung exam notable for b/l lower lobe crackles. ED course notable for: blood/urine cx sent, u/a obtained c/f UTI although sample likely contaminated, EKG with sinus rhythm 78 left axis, with episode of afib with RVR noted on telemetry. Cefepime 2gm and Vanco 1gm given. IVF given. Imaging showed CXR ___, discussed with ___, concern for early left lobe pneumonia in the right clincial setting, bilateral pleural effusion. Decision was made to admit for treatment of presumed pneumonia and UTI. Vitals prior to transfer: 98 77 112/58 24 98% Nasal Cannula Currently, she is feeling well with some mild shortness of breath when talking (on 4L O2). Has some left-sided chest pain that is reproducible with palpation. ROS: Notable for some dizziness with standing, chronic back/leg pain, swelling of her ankles when she stands, possible chronic mild orthopnea, paresthesias in her legs (equal b/l, chronic), mild constipation (last BM ___, and stress urinary incontinence. No chills, night sweats, or weight changes. No changes in vision or hearing. No chest pain or palpitations. No nausea or vomiting. No diarrhea. No dysuria or hematuria. No hematochezia, no melena. No focal deficits. Past Medical History: HTN Arthritis HLD spinal stenosis Uterine cancer s/p TAH/BSO with metastasis in left lung treated with radiation completed ___. Knee replacements (left x1, right x3, most recently in ___ cholecystectomy ___ TAH-BSO ___, ___) hernia repair surgery for stress incontinence (? sling) cateract surgeries Social History: ___ Family History: Brother with DM, ___ on HD Sister with breast and colon ca Brother with CAD s/p CABG Father with CVA Physical Exam: ADMISSION PHYSICAL EXAM ======================== VS: 97.7 139/48 77 22 97% on 4L NC GEN: Alert, lying in bed with family at bedside, no acute distress, slightly tachypneic, O2 via NC HEENT: MMM, anicteric sclerae NECK: Supple without LAD, no supraclavicular LAD PULM: Bibasilar crackles COR: RRR, (+)S1/S2 no m/r/g ABD: Soft, non-distended, mild diffuse tenderness to palpation, no guarding EXTREM: Warm, well-perfused, no pitting edema, 2+ DP pulses, thick yellow toenails. NEURO: A&Ox2 (oriented to person, place, "last month of ___" but not to year). CN II-XII intact, no pronator drift, ___ strength in biceps, triceps, hip flexors, and on ankle plantar/dorsiflexion. Sensation to light touch grossly intact. ON DISCHARGE: Vitals-97.6-98.5 ___ 130s-150s/50s-80s 18 93%RA General- Alert, oriented, no acute distress, ___ speaking HEENT- Sclera anicteric, MMM, no LAD, no elevated JVP Lungs- breathing comfortably on RA, +bibasilar crackles CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, non-tender, non-distended, bowel sounds present MSK: tender to palpation in lower extremities, R>L Ext- warm, well perfused, 2+ pulses, trace non-pitting edema Pertinent Results: ADMISSION LABS =============== ___ 12:00PM BLOOD WBC-6.9# RBC-3.80* Hgb-11.9 Hct-37.1 MCV-98 MCH-31.3 MCHC-32.1 RDW-14.6 RDWSD-52.8* Plt ___ ___ 12:00PM BLOOD Neuts-77.4* Lymphs-5.1* Monos-15.3* Eos-1.5 Baso-0.4 Im ___ AbsNeut-5.31# AbsLymp-0.35* AbsMono-1.05* AbsEos-0.10 AbsBaso-0.03 ___ 12:00PM BLOOD Glucose-111* UreaN-25* Creat-1.1 Na-139 K-4.5 Cl-101 HCO3-25 AnGap-18 ___ 12:00PM BLOOD Calcium-9.7 Phos-2.9 Mg-1.6 ___ 11:54AM BLOOD Lactate-1.9 DISCHARGE LABS =============== ___ 07:00AM BLOOD WBC-5.5 RBC-3.33* Hgb-10.4* Hct-33.0* MCV-99* MCH-31.2 MCHC-31.5* RDW-14.4 RDWSD-52.0* Plt ___ ___ 07:00AM BLOOD Glucose-109* UreaN-17 Creat-0.8 Na-140 K-4.2 Cl-98 HCO3-34* AnGap-12 ___ 04:47PM BLOOD ___ Temp-36.9 pO2-38* pCO2-49* pH-7.43 calTCO2-34* Base XS-6 Intubat-NOT INTUBA ___ 12:09AM BLOOD Lactate-0.9 ___ 12:09AM BLOOD O2 Sat-90 IMAGING AND OTHER STUDIES ========================== CXR ___: FINDINGS: Left lung base mass with fiducial markers is again noted. Elevated right hemidiaphragm is again seen. There is a small left pleural effusion and a trace right pleural effusion. There is no focal consolidation or pneumothorax. Left lower lobe opacity is best seen on the lateral view. The cardiomediastinal silhouette is normal. Imaged osseous structures are intact. No free air below the right hemidiaphragm is seen. IMPRESSION: Left lower lobe opacity is most likely atelectasis. In the appropriate clinical setting, pneumonia cannot be excluded, but this is thought to be less likely. CTA CHEST ___: Findings (excerpt):There is a right lower and middle lobe consolidation with areas of hypoenhancement in the inferior portions worrisome for pneumonia superimposed on atelectasis. There is obliteration of the segmental right lower lobe bronchi. Impression: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Concern for right lower and middle lobe pneumonia superimposed on atelectasis. 3. Mild pulmonary edema with small right and trace left pleural effusion. 4. Few new scattered 3mm pulmonary nodules, in the setting of edema and possible right lower lobe pneumonia/aspiration pneumonia is of uncertain significance and etiology. 5. No significant change in a 3.4 cm left lower lobe mass with fiducial markers. MICROBIOLOGY ============= ___ 11:50 am BLOOD CULTURE Blood Culture, Routine (Preliminary): GRAM POSITIVE COCCUS(COCCI). IN CLUSTERS. Aerobic Bottle Gram Stain (Final ___: Reported to and read back by ___ ___ 2:10PM. GRAM POSITIVE COCCI IN CLUSTERS. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 10 mg PO QPM 2. Gabapentin 600 mg PO QHS 3. Gabapentin 600 mg PO QAM 4. Gabapentin 300 mg PO NOON 5. NIFEdipine CR 30 mg PO QAM 6. Ranitidine 150 mg PO BID 7. Acetaminophen 1000 mg PO QAM 8. Acetaminophen 1000 mg PO QPM 9. Acetaminophen 500 mg PO NOON 10. Aspirin 81 mg PO DAILY 11. Vitamin D 1000 UNIT PO DAILY 12. Docusate Sodium 100 mg PO BID 13. Senna 8.6 mg PO BID:PRN constipation 14. Simethicone Dose is Unknown PO Frequency is Unknown Discharge Medications: 1. Acetaminophen 1000 mg PO QAM 2. Senna 8.6 mg PO BID:PRN constipation 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 10 mg PO QPM 5. Docusate Sodium 100 mg PO BID 6. Gabapentin 300 mg PO NOON 7. NIFEdipine CR 30 mg PO QAM 8. Ranitidine 150 mg PO BID 9. Acetaminophen 1000 mg PO QPM 10. Acetaminophen 500 mg PO NOON 11. Gabapentin 600 mg PO QHS 12. Gabapentin 600 mg PO QAM 13. Simethicone 40-80 mg PO PRN gas 14. Vitamin D 1000 UNIT PO DAILY 15. Diltiazem 30 mg PO Q6H 16. Warfarin 1 mg PO DAILY16 17. Enoxaparin Sodium 80 mg SC Q12H Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Pneumonia Atrial fibrillation - new dx Mild diastolic dysfunction 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 chest. INDICATION: ___ year old woman with h/o endometrial cancer metastatic to lungs s/p recent radiation now with acute shortness of breath/hypoxia (requiring 4L) and fever concerning for possible PE. Assess for pulmonary embolism. TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of 100 cc of Omnipaque intravenous contrast. Reformatted coronal, sagittal, thin slice axial images, and oblique maximal intensity projection images were submitted to PACS and reviewed. DOSE: Total DLP (Body) = 606 mGy-cm. COMPARISON: CT chest ___. , chest radiograph ___. FINDINGS: The aorta and its major branch vessels are patent, with no evidence of stenosis, occlusion, dissection, or aneurysmal formation. There is no evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present. The pulmonary arteries are well opacified to the subsegmental level, with no evidence of filling defect within the main, right, left, lobar, segmental or subsegmental pulmonary arteries. The main and right pulmonary arteries are top-normal in size without evidence of right heart strain. The heart is notable for coronary artery calcifications, mitral valve and aortic valve calcifications. The heart is notable for mild left atrial enlargement. There is no evidence of pericardial effusion. Multiple subcentimeter mediastinal and left hilar lymph nodes are noted, largest measuring 0.9 x 0.8 cm (02:35) within the mediastinum and 1 x 0.7 cm (02:34) within the left hilum which do not meet CT size criteria for enlargement. There is no supraclavicular, or axillary lymphadenopathy. The thyroid gland appears unremarkable. Interval increase in small right and trace left non hemorrhagic pleural effusion. The pulmonary parenchyma is notable for mild pulmonary edema with septal wall thickening. There is a right lower and middle lobe consolidation with areas of hypoenhancement in the inferior portions worrisome for pneumonia superimposed on atelectasis. There is obliteration of the segmental right lower lobe bronchi. Left lower lobe atelectasis is noted. The airways are otherwise patent to the subsegmental level. Pulmonary nodules are better characterized on prior examination. New 3 mm right upper lobe nodule (3:44, 56), new 3 mm (03:59) left upper lobe nodule, and new 3 mm left upper lobe pulmonary nodule are noted. Punctate nodules in the left lower lobe are not well seen on today's study. There is a 3.4 x 2.8 cm (3:114) left lower lobe mass (previously 3.6 x 2.8 cm) with a radiopaque fiducial similar to previous examination. Limited images of the upper abdomen are notable for a stable dilated 18mm common bile duct with mild central bile duct dilatation without peripheral duct dilatation in a patient who is status post cholecystectomy. Bilateral calcification of the rotator cuff is consistent with calcific tendinosis. No lytic or blastic osseous lesion suspicious for malignancy is identified. IMPRESSION: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Concern for right lower and middle lobe pneumonia superimposed on atelectasis. 3. Mild pulmonary edema with small right and trace left pleural effusion. 4. Few new scattered 3mm pulmonary nodules, in the setting of edema and possible right lower lobe pneumonia/aspiration pneumonia is of uncertain significance and etiology. 5. No significant change in a 3.4 cm left lower lobe mass with fiducial markers. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 4:35 ___, 15 minutes after discovery of the findings. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with Pna and hypercarbic respiratory failure // interval change COMPARISON: Chest x-ray from ___ at 1303 targeted review of chest CTA from ___ FINDINGS: Compared with ___, there has been considerable interval increase in CHF, with upper zone redistribution diffuse vascular blurring, left lower lobe collapse and/or consolidation, and small bilateral effusions. The rounded nodular opacity at the left lung base with 2 fiducials versus surgical clips is again noted, similar to the prior study. There are low inspiratory volumes, slightly worse than on the prior study. Persistent right hemidiaphragm elevation again noted. IMPRESSION: 1. Marked interval worsening of CHF findings. Worsening left lower lobe collapse and/or consolidation. 2. Please note that the ___ chest CT referred to concern for right lower and middle lobe pneumonia, which could be obscured by CHF findings on the current study. 3. Left base mass with 2 fiducials again noted. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ woman with history notable for HTN and endometrial cancer with oligometastasis to the left lung status post TAH-BSO in ___ and radiation in ___, presenting with fever and dyspnea found to have RML and RLL pneumonia and gram positive bacteremia being treated for CAP with ceftriaxone and and with vancomycin currently trasferred to the ICU for hypercarbic respiratory failure. // interval assessment COMPARISON: Chest x-ray dated ___ at 03:23 FINDINGS: Compared to ___ at 03:23, there may have been slight improvement in the CHF findings. Otherwise, I doubt significant interval change. IMPRESSION: As above. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old woman with PICC // Pt had a right picc,43cm ___ ___ Contact name: ___: ___ Pt had a right picc,43cm ___ ___ IMPRESSION: In comparison with the study of ___, there has been placement right subclavian PICC line that extends into the jugular system. Little change in the appearance of the heart and lungs. Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old woman with PICC // Malpositioned picc, ___ ___ Contact name: ___: ___ COMPARISON: ___, 09:30 IMPRESSION: The right PICC line continues to be malpositioned in the right internal jugular vein. No other changes are noted. No pneumothorax or other complications. Radiology Report EXAMINATION: UNILAT LOWER EXT VEINS RIGHT INDICATION: ___ year old woman with pneumonia, MICU callout, p/w R lower extremity tenderness. Evaluate for DVT. TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the right lower extremity veins. COMPARISON: Lower extremity Doppler of ___. FINDINGS: There is normal compressibility, flow and augmentation of the right common femoral, femoral, and popliteal veins. Normal compressibility is demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. A 4.0 x 1.3 x 1.8 cm ___ cyst is identified in the popliteal fossa. IMPRESSION: 1. No evidence of deep venous thrombosis in the right lower extremity veins. 2. 4.0 cm ___ cyst in the right popliteal fossa. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with pneumonia and volume overload // e/o pulm edema or congestion e/o pulm edema or congestion IMPRESSION: In comparison with the study of ___, the malpositioned PICC line is been removed. There again are very low lung volumes with elevation of the right hemi diaphragm and a mass with fiducial seeds at the left base. The pulmonary vascularity may still be mildly elevated. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ with s/p cyberknife fever cough with left lower lung crackles // eval for pna COMPARISON: Chest radiographs ___ FINDINGS: PA and lateral views of the chest provided. Left lung base mass with fiducial markers is again noted. Elevated right hemidiaphragm is again seen. There is a small left pleural effusion and a trace right pleural effusion. There is no pneumothorax. Left lower lobe opacity is best seen on the lateral view. The cardiomediastinal silhouette is normal. Imaged osseous structures are intact. No free air below the right hemidiaphragm is seen. IMPRESSION: Left lower lobe opacity is most likely atelectasis. In the appropriate clinical setting, pneumonia cannot be excluded, but this is thought to be less likely. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Fever Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED temperature: 97.4 heartrate: 83.0 resprate: 16.0 o2sat: 95.0 sbp: 105.0 dbp: 53.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, You were admitted to ___ because you had pneumonia. During your hospitalization you were transferred to the ICU because you were not breathing well, but this improved with positive airway pressure. You were also treated with antibiotics and responded well. You will be going to a rehab facility after discharge to continue your recovery. In the ICU you were also found to have a new diagnosis of atrial fibrillation, an irregular hearbeat. We started you on 2 medications to prevent clots and stroke. You will also get a call from the cardiology office to schedule an appointment for further management. Please also schedule an appointment with your PCP after you leave rehab. It was a pleasure taking care of you, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: lethargy Major Surgical or Invasive Procedure: NONE History of Present Illness: ___ nursing home dwelling male with past medical history HTN, HLD, DM, BPH, dementia, BPH and indwelling Foley with recent treatment for urinary tract infection on ciprofloxacin presents with worsening lethargy per family. History from chart review, transferring ___, limited input from patient. He was noted to be more tired than usual ___ and was started on cipro (no UA or micro records transferred.) He was noted to be more lethargic per family, Flagyl was added on, and labs were sent. When they revealed leukocytosis to 29 he was sent to the hospital. Records from ___ show he is on regular diet on thin liquids. He was started on ground in ED. He came with MOLST filled out this month filled out with nephew, HCP that states he would want CPR, intubation. In the ED, initial VS were: 97.6 81 116/64 16 100% RA Exam notable for: 4 out of 6 murmur best heard at second right intercostal space, Abdomen soft, nontender, nondistended, no masses Labs showed: Grossly hemolyzed specimen: k5.3, hco3 18, BUN/Cr 72/1.9, gluc 179, AST 60, ALT 25, bili 0.5 albumin 2.9 INR 1.2 UA with Lg leuk, pos nitrite, >182 WBC, mod bacteria +blood, protein lactate 2.0 Imaging showed: CT abd/pelvis: 1. No acute abnormality in the abdomen or pelvis. Specifically, no evidence of a fluid collection or obstruction in the abdomen or pelvis. Appendix not visualized but no secondary sign of acute appendicitis. 2. Bladder wall thickening likely due to bladder outlet obstruction from the enlarged prostate. Cystitis cannot be ruled out CT head: No acute intracranial abnormality. CXR: ___ opacity right lobe is nonspecific and could represent atelectasis or pneumonia, in the right clinical setting. Received: Vancomycin, ceftriaxone, 1L NS, asa 243mg, insulin 6 units at 16:13 No consults Transfer VS were: 98.6 89 ___ 99% RA On arrival to the floor, patient reports feeling tired. Nursing states he has incontinence of soft stool. Past Medical History: HTN HLD DM Dementia BPH Chronic foley Social History: ___ Family History: Unable to obtain Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.5 PO 123 / 72 84 18 99 RA GENERAL: elderly male laying in bed. He is arousable to voice but falls asleep within ___ seconds. He is oriented to self only. HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, harsh ___ murmur heard throughout the precordium, no gallops or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding EXTREMITIES: no cyanosis, clubbing. trace edema to B/L shins. L foot with toe deformity. b/l heals with stage I ulcers GU: foley draining dark yellow urine PULSES: 2+ DP pulses bilaterally NEURO: moving all 4 extremities with purpose. following commands. SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: VS: 98.7 120 / 69 83 18 99 RA GENERAL: elderly male laying in bed. More alert this AM. NAD. HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, harsh ___ murmur heard throughout the precordium, no gallops or rubs LUNGS: nonlabored respirations. no appreciable adventitious sounds. ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding EXTREMITIES: no cyanosis, clubbing, edema. L foot with toe deformity. b/l heals with stage I ulcers GU: foley in place PULSES: 2+ DP pulses bilaterally NEURO: moving all 4 extremities with purpose. following commands. Oriented to self. Mental status stable from yesterday. SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS: =============== ___ 08:10AM BLOOD ___ ___ Plt ___ ___ 08:10AM BLOOD ___ ___ ___ ___ 08:10AM BLOOD ___ ___ ___ 08:10AM BLOOD ___ ___ ___ 08:10AM BLOOD ___ ___ 08:10AM BLOOD ___ ___ 08:10AM BLOOD ___ ___ 08:23AM BLOOD ___ PERTINENT LABS: =============== ___ 11:00AM BLOOD ___ ___ 03:00PM BLOOD ___ ___ 12:15AM BLOOD ___ ___ 12:28AM BLOOD ___ ___ Base XS--5 ___ INTUBA ___ 12:28AM BLOOD ___ DISCHARGE LABS: =============== ___ 06:25AM BLOOD ___ ___ Plt ___ ___ 06:25AM BLOOD ___ ___ ___ 06:25AM BLOOD ___ MICROBIOLOGY: =============== ___ 7:56 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: PROTEUS MIRABILIS. >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. ENTEROBACTER CLOACAE COMPLEX. >100,000 CFU/mL. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROTEUS MIRABILIS | ENTEROBACTER CLOACAE COMPLEX | | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN--------- 1 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- 32 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S ___ 8:10 am BLOOD CULTURE #2. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 8:00 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 10:42 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. IMAGING/STUDIES: =============== CXR (___): IMPRESSION: ___ opacity right lobe is nonspecific and could represent atelectasis or pneumonia, in the right clinical setting. CT A/P (___): IMPRESSION: 1. No acute abnormality in the abdomen or pelvis. Specifically, no evidence of a fluid collection or obstruction in the abdomen or pelvis. Appendix not visualized but no secondary sign of acute appendicitis. 2. Bladder wall thickening likely due to bladder outlet obstruction from the enlarged prostate. Cystitis cannot be ruled out. CT HEAD W/O CONTRAST (___): IMPRESSION: No acute intracranial abnormality on noncontrast head CT. CXR (___): IMPRESSION: Mild left basilar opacity is likely secondary to atelectasis, however a superimposed infectious process can't be excluded. No evidence of a pleural effusion or pneumothorax. Interval improvement of the previously seen mild pulmonary edema with mild residual pulmonary vascular congestion. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 80 mg PO QPM 2. Aspirin 81 mg PO DAILY 3. Tamsulosin 0.8 mg PO QHS 4. Lisinopril 10 mg PO DAILY 5. Sertraline 50 mg PO DAILY 6. TraZODone 12.5 mg PO Q5PM 7. Haloperidol 2 mg PO QHS 8. Haloperidol 0.5 mg PO Q4PM 9. Levothyroxine Sodium 50 mcg PO DAILY 10. Vitamin D 1000 UNIT PO DAILY 11. Metoprolol Succinate XL 25 mg PO DAILY 12. Multivitamins 1 TAB PO DAILY 13. Humalog 6 Units Breakfast Humalog 6 Units Lunch Humalog 6 Units Dinner Lantus 26 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Ciprofloxacin HCl 250 mg PO Q12H Last day: ___. Glargine 22 Units Bedtime Humalog 6 Units Breakfast Humalog 6 Units Lunch Humalog 6 Units Dinner Insulin SC Sliding Scale using HUM Insulin 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. Levothyroxine Sodium 50 mcg PO DAILY 6. Lisinopril 10 mg PO DAILY 7. Metoprolol Succinate XL 25 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Sertraline 50 mg PO DAILY 10. Tamsulosin 0.8 mg PO QHS 11. Vitamin D 1000 UNIT PO DAILY 12. HELD- Haloperidol 2 mg PO QHS This medication was held. Do not restart Haloperidol until you see your PCP 13. HELD- Haloperidol 0.5 mg PO Q4PM This medication was held. Do not restart Haloperidol until you see your PCP 14. HELD- TraZODone 12.5 mg PO Q5PM This medication was held. Do not restart TraZODone until you see your PCP ___: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES: Urinary Tract Infection Dementia Altered Mental Status NSTEMI, type II Acute kidney injury SECONDARY DIAGNOSES: Hypertension Diabetes Mellitus Hypothyroidism Depression Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with lethargy// ?pneumonia COMPARISON: None FINDINGS: PA and lateral views of the chest provided. There is an ill-defined opacity in the right lower lobe. The cardiomediastinal silhouette is normal. Imaged osseous structures are intact. No free air below the right hemidiaphragm is seen. IMPRESSION: Ill-defined opacity right lobe is nonspecific and could represent atelectasis or pneumonia, in the right clinical setting. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: History: ___ with elevated wbc count, dementia, increased lethargy// ?infection TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain, intermediate and bone windows. Coronal and sagittal reformats were also performed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 8.0 s, 16.5 cm; CTDIvol = 48.6 mGy (Head) DLP = 802.7 mGy-cm. 2) Sequenced Acquisition 2.0 s, 4.1 cm; CTDIvol = 48.6 mGy (Head) DLP = 200.7 mGy-cm. Total DLP (Head) = 1,003 mGy-cm. COMPARISON: None. FINDINGS: There is no intra-axial or extra-axial hemorrhage, edema, shift of normally midline structures, or evidence of acute major vascular territorial infarction. Prominent ventricles and sulci are compatible with age-related involutional changes. Periventricular white matter hypoattenuation is nonspecific but likely represents chronic small vessel ischemic disease. There are moderate atherosclerotic calcifications of the carotid siphons. There is mild mucosal thickening of bilateral ethmoid air cells. An osteoma is noted in the anterior left ethmoid air cells. Remaining paranasal sinuses are clear. Mastoid air cells and middle ear cavities are well aerated. The bony calvarium is intact. IMPRESSION: No acute intracranial abnormality on noncontrast head CT. Radiology Report EXAMINATION: CT abdomen and pelvis without intravenous contrast. INDICATION: ___ with elevated wbc count in ___, dementia, increased lethargy. Evaluate for infection. TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired without intravenous contrast. Non-contrast scan has several limitations in detecting vascular and parenchymal organ abnormalities, including tumor detection. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 578 mGy-cm. COMPARISON: None. FINDINGS: LOWER CHEST: There is mild dependent atelectasis in the bilateral lower lobes. There are severe calcifications of the aortic roots and coronary arteries. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout. There is a simple cyst at the dome measuring 5.6 x 5.5 cm (series 2:8). There also scattered sub-centimeter hypodensities which are too small to characterize. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions within the limitations of an unenhanced scan. There is no pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size. There is no evidence of focal renal lesions within the limitations of an unenhanced scan. There is no hydronephrosis. There is no nephrolithiasis. Mild perinephric stranding bilaterally is within normal limits given the patient's age. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber and wall thickness throughout. The colon and rectum are within normal limits. The appendix is not visualized but there is no secondary sign of acute appendicitis. PELVIS: There is a Foley catheter in the bladder. Air in the anti dependent portions of the bladder is likely due to Foley insertion. There is bladder wall thickening likely due to outlet obstruction from prostatomegaly. REPRODUCTIVE ORGANS: Prostate is enlarged and protrudes into the base of the bladder. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Moderate to severe endplate degenerative changes are noted of the lower thoracic and lumbar spine. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. No acute abnormality in the abdomen or pelvis. Specifically, no evidence of a fluid collection or obstruction in the abdomen or pelvis. Appendix not visualized but no secondary sign of acute appendicitis. 2. Bladder wall thickening likely due to bladder outlet obstruction from the enlarged prostate. Cystitis cannot be ruled out. Radiology Report INDICATION: ___ year old man with leukocytosis and AMS// atelectasis vs PNA TECHNIQUE: Chest PA and lateral COMPARISON: Radiograph the chest from ___. FINDINGS: The heart size is normal. The hilar and mediastinal contours are normal. There has been interval improvement of the previously seen pulmonary edema with mild residual pulmonary vascular congestion. Mild left basilar opacity is seen. There is no evidence of a pleural effusion or pneumothorax. The visualized osseous structures are unremarkable. Aortic knob calcifications are seen. IMPRESSION: Mild left basilar opacity is likely secondary to atelectasis, however a superimposed infectious process can't be excluded. No evidence of a pleural effusion or pneumothorax. Interval improvement of the previously seen mild pulmonary edema with mild residual pulmonary vascular congestion. Gender: M Race: ASIAN - CHINESE Arrive by AMBULANCE Chief complaint: Lethargy Diagnosed with Urinary tract infection, site not specified, Sepsis, unspecified organism, Non-ST elevation (NSTEMI) myocardial infarction temperature: 97.6 heartrate: 81.0 resprate: 16.0 o2sat: 100.0 sbp: 116.0 dbp: 64.0 level of pain: 0 level of acuity: 3.0

Mr. ___, It was a pleasure to take care of you at ___. WHY WAS I HERE? - You were admitted to the hospital because you were found to be lethargic. WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL - You were found to have a urinary tract infection and were treated with antibiotics. - You were found to have low blood pressure which improved after receiving fluids through your IV. - Your mental status improved after starting antibiotics and giving fluids. - Your blood WHAT SHOULD I DO WHEN I GET HOME? - Follow up with your primary care physician - ___ taking antibiotics until ___ We wish you the best! Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Prochlorperazine Attending: ___. Chief Complaint: S/P fall at home Major Surgical or Invasive Procedure: Palliative radiation Cyber Knife History of Present Illness: Mr. ___ is a ___ year old man with a history of HBV, HCV cirrhosis with gastric varices, portal hypertension and splenomegaly, as well as type I DM and recurrent DLBCL s/p CHOP, EPOCH and Rituxan who presented to the ER after sustaining a fall and landing on his left knee. He states that he was walking across his tile kitchen wearing his diabetic sneakers and tripped over his feet. He landed with his left knee on the tile. He was on the floor unable to get up for about 10 minutes. He denies dizziness, lightheadedness, chest pain, shortness of breath, loss of consciousness or head trauma. He remembers the entire event. He waited until his son was able to help him and came to the ER for pain and inability to ambulate. Of note, he denies recent memory changes, difficulty concentrating, changes in speaking or swallowing, focal weakness or numbness. He notes a bizzare sound in his hear (a whoozing noise) which occurs only in his right ear every few days and lasts for a moment. He denies headaches or ear pain. He was recently admitted to ___ from ___ for hyperglycemia, hyperkalemia and hyponatremia which occurred in the setting of forgetting to take his insulin. His laboratory abnormalities resolved with treatment and he was discharged. In the emergency department, initial vitals: 98.5 61 135/87 20 100% 0. A knee film showed a non-displaced patellar fracture. Orthopedics was consulted and recommended conservative management with a knee immobilizer. A head CT was obatined which showed a new 1.3 cm cortical lesion in the right temporal lobe with vasogenic edema, highly suspicious for malignancy. The patient was given 10 mg IV decadron. Neurosurgery was consulted and recommended not continuing steriods and obtaining an MRI of the head to further characterize the lesion. They also recommended blood pressure control with a goal SBP < 160. The patient was also given 4 mg IV morphine and 10 units of regular insulin. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Past Medical History: PAST MEDICAL HISTORY: -chronic hepatitis B, chronic hepatitis C with resultant cirrhosis, portal hypertension, gastric varices and splenomegaly related to portal hypertension, thrombocytopenia and leukopenia as a consequence of his splenomegaly, possibly also with a contribution from lymphoma. -Diabetes mellitus: Type 1 DM diagnosed age ___. Followed at ___. -Diffuse large B-cell lymphoma: Dx ___ s/p CHOP with subsequent recurrence, s/p one cycle of EPOCH in ___, s/p single agent Rituxan ___, recent imaging with recurrence in his iliac bone -Hypertension -Hypothyroidism -Opioid dependence (on chronic methadone for pain vs. addiction) -Peripheral neuropathy in hands and feet. Patient attributes to chemotherapy but likely multifactorial given longstanding DM. -Chronic neck and low back pain -L ankle and back fractures in accidental ___, no surgery -Total right knee replacement ___ -moderate pulm HTN, R-THR ___ PAST ONCOLOGIC HISTORY: ___ seen by heme for progressive LAD in abdomen. ___ retroperitoneal LAD bx shows morphologic and immunophenotypic profile consistent with a diffuse large B cell lymphoma of possible germinal center cell derivation. ___ started on CHOP (Rituxan not used because of concern for HepB reactivation); ___ clinic visit - abd pain sent to ED and admitted. Abd pain thought secondary to biliary obstruction, stent was placed. ___: CHOP cycle 2 start ___ VAD port placed ___ left chest. ___ to ___ CHOP x 6 cycles, except from C5 - Oncovin held for neuropathy ___: Had planned to start rituxan after patient off of lamivudine. Continued thrombocytopenia and leukopenia, perhaps associated with start of tenofovir for hepB and therefore switched back to lamivudine. ___: Continued cytopenias. Bone marrow biopsy ___ with hypocellular marrow without evidence of lymphoma. Cytogenics and flow cytometry also negative. Rituxan deferred. ___: PET/CT without evidence of recurrent lymphoma ___: PET/CT without evidence of recurrent disease ___: PET/CT new low level FDG-uptake in right level II cervical lymph node (image 21; maxSUV 2.7); could be reactive node. ___: Persistent by stable 6mm right cervical LN and 11mm left infraclavicular LN with decreased SUV, limited by background noise. ___: biopsy recurrence of PET positive right iliac bone lesion with noted right inferior axillary positive lymph node ___: C1D1 EPOCH (no vincristine) ___: noted recurrence palpated in right axilla ___: cyclophos 600mg/m2 D1 and 8, etoposide 70mg/m2 D1-3, pred 60mg D ___: rituximab 375mg/m2 ___: rituximab 375mg/m2 ___: rituximab 375mg/m2 ___: rituximab 375mg/m2 ___: PET CT showed new FDG activity in right illiac area. Social History: ___ Family History: - Father died of colon cancer at ___, diagnosed age ___. - Mother had a heart attack in ___. - 2 brothers, both living, ___ s/p CABG. - Son is healthy. - No other significant family history of malignancy Physical Exam: ADMISSION PHYSICAL EXAM ======================= VS: T97.5 BP 130/60 HR 60 RR20 97%RA GENERAL: alert and oriented, appears chronically ill, NAD HEENT: No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, L cervical node is freely mobile, non-enlarged. CARDIAC: RR. Normal S1, S2. No m/r/g. LUNGS: CTA B, good air movement bilaterally. ABDOMEN: NABS. Protuberant abdomen without evidence of ascites. Soft, non-tender. Unable to appreciate liver or spleen EXTREMITIES: No c/c/e, 2+ dorsalis pedis/ posterior tibial pulses. MSK: L knee with swelling and clear effusion. No warmth or redness on exam. ROM limited by pain. NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Preserved sensation throughout. ___ strength throughout. ___ reflexes, equal ___. DISCHARGE PHYSICAL EXAM ======================== VS: Tm 98.4 Tc 97.5 130/70 79 20 98% on RA GENERAL: Chronically ill appearing, uncomfortable HEENT: MMM CARDIAC: RRR no m/r/g LUNGS: Limited due to limited participation during exam, but could not appreciate crackles, wheeze, rhonchi ABDOMEN: Nontender to palpation EXTREMITIES: Chronic venous stasis bilaterally, RLE with ulcer 1.5 inches in diameter at anterior surface, wrapped in bandage, c/d/i. NEURO: Sleepy but alert and oriented Pertinent Results: ADMISSION LABS ============== ___ 10:25AM BLOOD Lactate-1.5 ___ 10:15AM BLOOD Albumin-3.2* ___ 12:20AM BLOOD Calcium-8.1* Phos-3.4 Mg-2.0 ___ 10:15AM BLOOD CK-MB-5 cTropnT-0.01 ___ 10:15AM BLOOD ALT-59* AST-83* CK(CPK)-54 AlkPhos-136* TotBili-1.1 ___ 10:15AM BLOOD Glucose-390* UreaN-36* Creat-1.0 Na-130* K-5.0 Cl-96 HCO3-26 AnGap-13 ___ 10:15AM BLOOD ___ PTT-32.1 ___ ___ 10:15AM BLOOD Plt ___ ___ 10:15AM BLOOD Neuts-74.8* Lymphs-12.6* Monos-10.4 Eos-1.7 Baso-0.4 ___ 10:15AM BLOOD WBC-3.4* RBC-2.96* Hgb-9.8* Hct-30.2* MCV-102* MCH-33.3* MCHC-32.7 RDW-14.4 Plt ___ OTHER LABS ========== ___ 06:00PM BLOOD Ammonia-31 ___ 10:15AM BLOOD CK-MB-5 cTropnT-0.01 ___ 12:20AM BLOOD CK-MB-4 cTropnT-<0.01 ___ 12:00AM BLOOD cTropnT-<0.01 ___ 10:15AM BLOOD Lipase-9 RADIOLOGY ========= LEFT KNEE XRAY (___) Acute nondisplaced transverse fracture of the patella with large joint effusion. CT HEAD WITHOUT CONTRAST (___) New 1.3 cm right temporal hyperdense lesion suspicious for malignancy, possibly metastasis given this patient's history of lymphoma. Further characterization with MR is recommended. EKG (___) Sinus rhythm. Left anterior fascicular block. Compared to the previous tracing the findings are similar. FDG TUMOR IMAGING (PET-CT) (___) 1. Multiple new FDG-avid lymph nodes predominantly in the chest as detailed above. 2. New small volume ascites and diffuse mesenteric and retroperitoneal fat stranding with associated FDG-uptake as above. 3. Abnormal uptake appears to track along the right iliac vessels into the right leg with intense patchy uptake uptake in the proximal musculature (gluteus, abductor group, and hamstrings). 4. New uptake in the right iliac bone. 5. Pericardial uptake may be from the pericardium or from small pericardial lymph nodes, although these are not detected on the CT. 6. The constellation of findings is compatible with marked disease progression. MR HEAD W/ AND W/O CONTRAST (___) 1.9 cm inhomogeneously enhancing mass with internal enhancement and a small amount of peripheral hemorrhage seen in the right temporal lobe with surrounding vasogenic edema. This mass most likely arises from an extra-axial location. It does not have the typical characteristics of lymphoma as lymphoma lesions tend to be homogeneous and demonstrate slow diffusion. Abscess was also considered, however usually abscess also demonstrates slow diffusion. As the masses likely extra-axial, a glioma less likely. Thus, more likely differential for this mass include aggressive meningioma or metastatic disease. MR ABDOMEN (___) 1. Gallbladder sludge. No concerning gallbladder mass. 2. No intra or extrahepatic bile duct dilation. No ductal stones. 3. Extensive soft tissue throughout the right perinephric space and retroperitoneum, with compression of the IVC, in keeping with known history of lymphoma, corresponding to FDG avid soft tissue lesion on the PET-CT from ___. 4. Stable moderate right hydronephrosis with delayed contrast excretion from a head MRI examination on ___. 5. Mild bibasilar atelectasis. 6. Cirrhotic liver. Trace perihepatic ascites, mild splenomegaly, diffuse anasarca, and mild gallbladder wall edema likely secondary to chronic liver disease. CXR (___) Consolidation in the right upper lobe marginated by the major fissure is probably pneumonia. ___ a second region of pneumonia in the right lower lobe or fissural pleural fluid. Heart is top normal size and pulmonary vasculature is still engorged, but as yet no pulmonary edema. Left pleural effusion. Left subclavian infusion port ends low in the SVC. No pneumothorax. CXR ___ An ovalary structure now seen on the frontal radiograph reflects an intrafissural portion of right pleural effusion, as documented on the lateral image. The structure is not a mass. The pleural effusion on the right has minimally increased. Left and right atelectasis are seen in unchanged manner. No evidence of acute lung changes. Normal size of the cardiac silhouette. No pneumothorax. No evidence of pneumonia. URINALYSIS (___) Specific Gravity 1.009 1.001 - 1.035 DIPSTICK URINALYSIS Blood NEG Nitrite NEG Protein NEG mg/dL Glucose NEG mg/dL Ketone NEG mg/dL Bilirubin NEG mg/dL Urobilinogen 2* 0.2 - 1 mg/dL pH 5.0 5 - 8 units Leukocytes TR MICROSCOPIC URINE EXAMINATION RBC 1 0 - 2 #/hpf WBC 2 0 - 5 #/hpf Bacteria NONE Yeast NONE Epithelial Cells 0 #/hpf URINE CASTS Hyaline Casts 1* 0 - 0 #/lpf OTHER URINE FINDINGS Urine Mucous RARE VANCOMYCIN TROUGH ___ 05:58AM BLOOD Vanco-25.8* ___ 06:16AM BLOOD Vanco-42.3* ___ 06:15AM BLOOD Vanco-<1.7* DISCHARGE LABS ============== ___ 05:58AM BLOOD WBC-5.7 RBC-2.13* Hgb-7.2* Hct-22.3* MCV-105* MCH-33.7* MCHC-32.1 RDW-18.8* Plt Ct-39* ___ 05:58AM BLOOD Neuts-82.4* Lymphs-9.9* Monos-7.1 Eos-0.3 Baso-0.3 ___ 05:58AM BLOOD Plt Ct-39* ___ 05:58AM BLOOD Glucose-86 UreaN-23* Creat-1.0 Na-138 K-3.6 Cl-102 HCO3-30 AnGap-10 ___ 05:58AM BLOOD ALT-18 AST-34 LD(LDH)-611* AlkPhos-83 TotBili-0.7 ___ 05:58AM BLOOD Calcium-7.9* Phos-3.4 Mg-1.9 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q12H 2. Furosemide ___ mg PO DAILY 3. Lantus (insulin glargine) 12 units subcutaneous daily 4. Levothyroxine Sodium 100 mcg PO DAILY 5. Methadone 90 mg PO DAILY 6. Nadolol 10 mg PO DAILY 7. Omeprazole 40 mg PO DAILY 8. Glargine 16 Units Breakfast 9. LaMIVudine 100 mg PO DAILY Discharge Medications: 1. Acyclovir 400 mg PO Q12H 2. Glargine 11 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 3. LaMIVudine 100 mg PO DAILY 4. Levothyroxine Sodium 100 mcg PO DAILY 5. Nadolol 10 mg PO DAILY 6. Omeprazole 40 mg PO DAILY 7. Allopurinol ___ mg PO DAILY 8. CefePIME 2 g IV Q12H Please take through ___ to complete a ___. Gabapentin 100 mg PO Q8H 10. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain 11. Lactulose 30 mL PO Q4H 12. Lidocaine 5% Patch 1 PTCH TD QPM 13. Lorazepam 0.5 mg PO Q4H:PRN pain/agitation 14. Rifaximin 550 mg PO BID 15. Methadone 30 mg PO TID 16. Furosemide 40 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Diffuse Large B cell lymphoma Left patellar fracture HCAP pneumonia ___ ulcer/cellulitis Secondary: Chronic pain Diabetes Mellitus I Hyponatremia Thrombocytopenia Anemia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report HISTORY: Fall and syncope. COMPARISON: Chest radiograph from ___. FINDINGS: There are chronic small bilateral pleural effusions and thickening with chronic atelectasis/scarring of the lower lobes. The hilar and cardiomediastinal contours are normal and the lungs are otherwise clear. There is no pneumothorax. A left chest wall port catheter terminates in the low SVC. IMPRESSION: No acute cardiopulmonary process. Radiology Report HISTORY: Left knee pain after syncope and fall. COMPARISON: None. FINDINGS: Left knee, 3 views. There is a nondisplaced transverse patellar fracture at the inferior ___ of the bone. There is a large joint effusion without fat-fluid level on this cross-table lateral view. There are degenerative changes as well as chondrocalcinosis. A prominent superior patellar spur is present. IMPRESSION: Acute nondisplaced transverse fracture of the patella with large joint effusion. Radiology Report INDICATION: Fall with syncope. TECHNIQUE: Contiguous axial images were obtained through the brain without IV contrast. Coronal, sagittal, thin-section bone reconstruction algorithm images were prepared. COMPARISON: NECT of the head, ___. FINDINGS: There is a new 1.3 x 1.1 cm cortical lesion with hyperdense rim arising from the right temporal lobe (2:14). Also seen is surrounding vasogenic edema. None of these findings were present on ___. There is no shift of normally midline structures. The ventricles and sulci are prominent, consistent with global atrophy. The basal cisterns are patent. There is no hemorrhage. The calvaria are unremarkable. Bilateral lens replacements are seen. Sclerosis of the imaged portion of the right maxillary sinus is probably due to chronic inflammation. Mild mucosal thickening involves the anterior ethmoid air cells. The remaining visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. IMPRESSION: New 1.3 cm right temporal hyperdense lesion suspicious for malignancy, possibly metastasis given this patient's history of lymphoma. Further characterization with MR is recommended. These findings were discovered at 12:01 pm and communicated via phone call to Dr. ___ by Dr. ___ at 12:51 pm. on ___. Radiology Report HISTORY: Patient with history of DLBCL and new brain mass seen on CT, evaluate for lymphoma versus other malignancy. COMPARISON: NECT of the head on ___. TECHNIQUE: Multiplanar, multi sequence MRI of the head was performed before and after administration of IV contrast. FINDINGS: In the right temporal lobe, there is a 1.9 x 1.1 cm inhomogeneously enhancing lesion with internal enhancement and a small amount of hemorrhage at the margins, compatible with mass seen on most recent CT. There is vasogenic edema surrounding this mass. This lesion does not demonstrate slow diffusion. The mass appears to arise from an extra-axial location as it appears to exert mass effect on the surrounding cortex with enhancement of the adjacent dura on the postcontrast images. There is no acute infarct. Principal intracranial vascular flow voids are preserved. There is no shift of normally midline structures. Again noted is a punctate focus of low signal in the susceptibility sequence along the left periventricular region, likely representing a small focus of old microhemorrhage. Scattered T2/FLAIR hyperintensities throughout the periventricular white matter likely represent chronic small vessel ischemic disease. The brainstem, posterior fossa and cervical medullary junction are preserved. The orbits, periorbital and paracavernous spaces are normal. No abnormality of the skullbase or calvaria is identified. IMPRESSION: 1.9 cm inhomogeneously enhancing mass with internal enhancement and a small amount of peripheral hemorrhage seen in the right temporal lobe with surrounding vasogenic edema. This mass most likely arises from an extra-axial location. It does not have the typical characteristics of lymphoma as lymphoma lesions tend to be homogeneous and demonstrate slow diffusion. Abscess was also considered, however usually abscess also demonstrates slow diffusion. As the masses likely extra-axial, a glioma less likely. Thus, more likely differential for this mass include aggressive meningioma or metastatic disease. The findings were discussed with ___ by ___ telephone at 5:45pm on ___, 20 minutes after discovery. Radiology Report HISTORY: Cirrhosis with gallbladder mass suspected on recent ultrasound. History of lymphoma. TECHNIQUE: T1 and T2 weighted multiplanar images of the abdomen were acquired within a 1.5 Tesla magnet, including 3D dynamic sequences performed prior to, during, and following the administration of 7 cc of Gadavist intravenous contrast. 1 cc of Gadavist mixed with 50 cc of water were administered for oral contrast. COMPARISON: Ultrasound from ___. PET/CTs from ___ and ___. MRI OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: There is mild bibasilar atelectasis (series 6 image 3). The heart size is normal. There is no pericardial or pleural effusion. Diffuse anasarca is present. Trace perihepatic ascites is present (series 6 image 15). The liver contour is markedly nodular, in keeping with known history of cirrhosis. No discrete intrahepatic mass is detected. Conventional hepatic arterial anatomy is demonstrated. The portal and hepatic veins are patent and normal in caliber. The gallbladder contains a small amount of sludge. There is no gallbladder mass. Mild gallbladder wall edema is likely secondary to third spacing from chronic liver disease. There is no intra or extrahepatic bile duct dilation. No ductal stones are detected. The left kidney is normal. Moderate right hydronephrosis is unchanged since the ___ PET-CT examination (series 1,203 image 91), with precontrast T1 weighted sequences demonstrating uniformly high signal intensity within the renal pelvis and proximal right ureter, likely reflecting delayed excretion of gadolinium-based contrast from the head MRI examination on ___ (series 7 image 37). Again seen is extensive enhancing soft tissue throughout the right perinephric space and retroperitoneum, demonstrating restricted diffusion (series 8 image 31, 32, series 1,203 images 81), corresponding to the areas of high FDG avidity on the prior PET-CT. The IVC remains patent but compressed by the mass (series 1,203 image 102). The spleen is mildly enlarged (series 5 image 26). The adrenal glands, pancreas, and intra-abdominal loops of small and large bowel are normal. The abdominal aorta, celiac trunk, SMA, and renal arteries are patent. There are no bony lesions concerning for malignancy or infection. IMPRESSION: 1. Gallbladder sludge. No concerning gallbladder mass. 2. No intra or extrahepatic bile duct dilation. No ductal stones. 3. Extensive soft tissue throughout the right perinephric space and retroperitoneum, with compression of the IVC, in keeping with known history of lymphoma, corresponding to FDG avid soft tissue lesion on the PET-CT from ___. 4. Stable moderate right hydronephrosis with delayed contrast excretion from a head MRI examination on ___. 5. Mild bibasilar atelectasis. 6. Cirrhotic liver. Trace perihepatic ascites, mild splenomegaly, diffuse anasarca, and mild gallbladder wall edema likely secondary to chronic liver disease. Radiology Report AP CHEST, 10:58 A.M., ___ HISTORY: A ___ man, now neutropenic after chemotherapy. IMPRESSION: AP chest compared to ___: Consolidation in the right upper lobe marginated by the major fissure is probably pneumonia. ___ a second region of pneumonia in the right lower lobe or fissural pleural fluid. Heart is top normal size and pulmonary vasculature is still engorged, but as yet no pulmonary edema. Left pleural effusion. Left subclavian infusion port ends low in the SVC. No pneumothorax. Dr. ___ was paged at 1:15 p.m. and we discussed the findings by telephone. Radiology Report CHEST RADIOGRAPH INDICATION: Chest pain, evaluation for intrapulmonary process. COMPARISON: ___. FINDINGS: An ovalary structure now seen on the frontal radiograph reflects an intrafissural portion of right pleural effusion, as documented on the lateral image. The structure is not a mass. The pleural effusion on the right has minimally increased. Left and right atelectasis are seen in unchanged manner. No evidence of acute lung changes. Normal size of the cardiac silhouette. No pneumothorax. No evidence of pneumonia. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: L KNEE INJURY Diagnosed with FRACTURE PATELLA-CLOSED, UNSPECIFIED FALL, BRAIN CONDITION NOS temperature: 98.5 heartrate: 61.0 resprate: 20.0 o2sat: 100.0 sbp: 135.0 dbp: 87.0 level of pain: 10 level of acuity: 3.0

Dear Mr. ___, You were admitted to the hospital after you suffered a fall. You were found to have a patellar fracture of the left knee. Incidentally, you were also found to have progression of your lymphoma. During your hospital stay you underwent radiation and chemotherapy to alleviate the symptoms you were experiencing from the lymphoma. We treated you for a pneumonia seen on your chest X-ray with antibiotics, which you will continue through ___. We monitored your blood sugars closely and you will be discharged with insulin. You may bear weight as tolerated on your injured leg while wearing the brace provided. Please follow up with the appointments listed below.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: ___ Attending: ___ Chief Complaint: Altered mental status and intraparenchymal hemorrhage on CTH at ___ ___ Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ yo RHF with alcoholic cirrhosis c/b portal vein HTN, esophageal varices s/p TIPS ___, encephalopathy on lactulose, T2DM, and cervical stenosis who initially presented to ___ this morning for altered mental status and transferred to ___ after found to have right frontal IPH. Patient is poor historian, though improving mental status and interaction per daughter and ___ staff. Per daughter ___ at bedside, this morning around 530 AM she found her mother conscious but on the floor with phone in hand. Last known time normal was 1230 AM ___. Patient could not get up on own and was less responsive than normal. Patient adamant about not hitting her head during the fall but cannot actually describe the fall or events surround it. Due to continued weakness and change in mental status, daughter called EMS and patient was brought to ___. Per patient and daughter, she has been having increasing falls. She fell in ___ and fell again 2 days ago. During her fall in ___ she was brought ___ ___ where she had a CT cspine which showed severe cervical canal stenosis and a CTH with no acute intracranial process. Daughter notices pt does not pick up feet and feels that these are mechanical falls. She describes them that patient often "slides to the ground". Patient cannot describe the falls. Patient has limited mobility secondary to right knee fracture from these falls, for which she now wears a brace. She is currently going to ___, however daughter feels patient is moving less than usual, including issues with poor effort/motivation. She has not noticed any focal weakness. Patient has stopped taking lactulose on her own as she cannot make it to bathroom in context of limited mobility. She has a walker available however does not use it. Daughter also relates worsening short term memory over the past few months. Per family at ___ staff, patient's exam is improving while she has been in the ___. SBP primarily 140-160. Briefly required nicardipine gtt to keep SBP<150 Past Medical History: HTN alcoholic cirrhosis c/b esophageal varices and hepatic encephalopathy, s/p TIPS ___ T2DM Osteoporosis GERD ?Coronary Artery DIsease: cardiac catheterization in ___ after perfusion defect seen on stress, catch revealed mild CAD (___ ___ in OMR ___ Social History: ___ Family History: Father with alcoholic liver disease Deny family hx of strokes, bleeding disorders, or seizures Physical Exam: UPON ADMISSION Vitals: T: 98.4 BP: 163/75 HR: 80 RR: 16 SaO2:97% General: Awake, cooperative, NAD HEENT: NC/AT, no scleral icterus noted. No abrasions or hematomas noted on face/neck Neck: Supple, no nuchal rigidity Pulmonary: Normal work of breathing Cardiac: RRR, warm, well-perfused Abdomen: Soft, non-distended Extremities: non-pitting edema in R calf, not erythematous Skin: Excoriations on R anterior calf Neurologic: -Mental Status: Alert, oriented to ___ only and answering ___ to location, name, date. Poor historian. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Able to name both high and low frequency objects. Slight dysarthria (though did not have dentures in). Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and sluggish (eye surgery b/l in past). EOMI without nystagmus. Normal saccades. VFF to confrontation. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. Strength full with tongue-in-cheek testing. -Motor: Atrophy in L calf. paratonia in L arm, increased tone in L leg. Slight L arm pronator drift. No adventitious movements, such as tremor or asterixis noted. No myoclonus. [___] L 4+ 5 5 4- 4+ 5 5 5 5 5 5 5 R 5 5 5 poor effrt 5 5 5 5 5 5 5 -Sensory: No deficits to light touch throughout. No extinction to DSS. ___ deferred given risk of falls. -Reflexes: [Bic] [Tri] [___] [Pat] [Ach] L (IV) 2 2 2 1 R 2 2 2 2 1 Plantar response with upgoing toes bilaterally. -Coordination: Slight ataxia in R and L on FTN. Normal RAM. HKS on L unable to perform due to increased tone in L leg. -Gait: deferred due to risk of falls. UPON DISCHARGE: Neurologic: -Mental Status: Alert, oriented, attentive. Language is fluent with intact repetition and comprehension. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Speech was not dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. CN I: not tested II,III: VFF to confrontation, pupils 4mm->2mm bilaterally. III,IV,VI: EOMI, no ptosis. No nystagmus V: sensation intact V1-V3 to LT VII: L NLFF with symmetric activation, symmetric forehead raise, eye closure. VIII: hears finger rub bilaterally IX,X: palate elevates symmetrically, uvula midline XI: SCM/trapezeii ___ bilaterally XII: tongue protrudes midline, no dysarthria Motor: Normal bulk and tone, no rigidity; no asterixis or myoclonus. No pronator drift. Delt Bi Tri WE FE Grip IO C5 C6 C7 C6 C7 C8/T1 T1 L 5 ___ 5 5 5 R 5 ___ 5 5 5 IP Quad ___ PF L2 L3 L4-S1 L4 L5 S1/S2 L 5 5 5 ___ R 5 5 5 ___ Reflex: toes down bilaterally -Sensory: No deficits to light touch. No extinction to DSS. -Coordination: No ataxia on FNF bilaterally. -Gait: deferred Pertinent Results: ___ 12:10PM BLOOD WBC-3.8* RBC-4.08 Hgb-12.6 Hct-38.0 MCV-93 MCH-30.9 MCHC-33.2 RDW-14.6 RDWSD-49.7* Plt Ct-60* ___ 12:10PM BLOOD Neuts-68.0 ___ Monos-7.1 Eos-2.1 Baso-0.5 Im ___ AbsNeut-2.60 AbsLymp-0.84* AbsMono-0.27 AbsEos-0.08 AbsBaso-0.02 ___ 03:35PM BLOOD Poiklo-1+* Ovalocy-1+* RBC Mor-SLIDE REVI ___ 12:10PM BLOOD ___ PTT-31.6 ___ ___ 09:08AM BLOOD ___ 12:10PM BLOOD Glucose-256* UreaN-25* Creat-0.9 Na-143 K-5.3 Cl-110* HCO3-23 AnGap-10 ___ 12:10PM BLOOD ALT-27 AST-55* AlkPhos-166* TotBili-2.6* ___ 12:10PM BLOOD Lipase-56 ___ 12:10PM BLOOD cTropnT-0.03* ___ 07:10PM BLOOD cTropnT-0.01 ___ 12:10PM BLOOD Albumin-3.3* Calcium-9.2 Phos-3.0 Mg-1.5* ___ 09:23AM BLOOD %HbA1c-7.9* eAG-180* ___ 12:40PM BLOOD Ammonia-17 ___ 12:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 12:10PM BLOOD LtGrnHD-HOLD ___ 12:20PM BLOOD Lactate-1.7 ___ 06:30AM BLOOD WBC-4.4 RBC-3.64* Hgb-11.5 Hct-35.0 MCV-96 MCH-31.6 MCHC-32.9 RDW-14.8 RDWSD-51.5* Plt Ct-35* ___ 06:07AM BLOOD WBC-5.2 RBC-3.47* Hgb-11.0* Hct-33.0* MCV-95 MCH-31.7 MCHC-33.3 RDW-15.4 RDWSD-52.3* Plt Ct-69* ___ 10:15AM BLOOD ___ PTT-30.8 ___ ___ 06:07AM BLOOD Glucose-125* UreaN-19 Creat-1.0 Na-141 K-4.6 Cl-111* HCO3-20* AnGap-10 IMPRESSION: 1. Examination is moderately motion degraded. 2. Approximately 2.8 cm right frontal intraparenchymal hematoma with associated surrounding edema, grossly stable in size compared to the prior CT head examination. 3. No new areas of intracranial hemorrhage or evidence of acute to subacute infarction. 4. Within limits of study, no definite evidence of enhancing mass. Please note that a enhancing intracranial mass in region of right frontal intraparenchymal hemorrhage is not excluded on the basis of this examination. Recommend follow-up imaging to resolution. 5. Paranasal sinus disease, as detailed above. RECOMMENDATION(S): Within limits of study, no definite evidence of enhancing mass. Please note that a enhancing intracranial mass in region of right frontal intraparenchymal hemorrhage is not excluded on the basis of this examination. Recommend follow-up imaging to resolution. CTH ___ FINDINGS: Redemonstration of right inferior frontal lobe intraparenchymal hematoma, 2.9 x 2.2 cm, previously 2.7 x 2.0 cm, with surrounding edema. There is no significant mass-effect on the adjacent frontal horn of the right lateral ventricle. There is no evidence of acute infarction, new hemorrhage, or mass effect. There is no midline shift. There are grossly stable bilateral calcifications in the globus pallidus. The ventricle and sulci are grossly stable in size configuration. There is no evidence of fracture. There is mild mucosal thickening in the bilateral maxillary sinuses. Otherwise, the visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits demonstrate bilateral lens replacement postoperative changes. IMPRESSION: 1. Grossly stable right frontal lobe intraparenchymal hematoma, with surrounding edema and no definite midline shift. 2. Paranasal sinus disease , as described. CTA ___ IMPRESSION: 1. Redemonstration of the right inferior frontal lobe intraparenchymal hematoma, with surrounding edema. This is unchanged in appearance. No new intracranial hemorrhage. 2. Patent circle of ___ without definite evidence of stenosis,occlusion,or aneurysm. 3. Patent bilateral cervical carotid and vertebral arteries without definite evidence of stenosis, occlusion, or dissection. 4. Multiple pulmonary nodules measuring up to 4 mm in the right apex. For incidentally detected multiple solid pulmonary nodules smaller than 6mm, no CT follow-up is recommended in a low-risk patient, and an optional CT follow-up in 12 months is recommended in a high-risk patient. See the ___ ___ Guidelines for the Management of Pulmonary Nodules Incidentally Detected on CT" for comments and reference: ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Colestid (colestipol) 1 gram oral QID 2. Aspart Unknown Dose Glargine 60 Units Bedtime 3. Lactulose 30 mL PO TID 4. Pantoprazole 40 mg PO Q24H 5. rifAXIMin 550 mg PO BID 6. Spironolactone 25 mg PO DAILY 7. Citracal Regular (calcium citrate-vitamin D3) 250 mg calcium- 200 unit oral DAILY 8. Magnesium Oxide 400 mg PO BID 9. Multivitamins 1 TAB PO DAILY 10. Fish Oil (Omega 3) Dose is Unknown PO Frequency is Unknown Discharge Medications: 1. Captopril 6.25 mg PO TID 2. Glargine 30 Units Bedtime Humalog 6 Units Breakfast Humalog 6 Units Lunch Humalog 6 Units Dinner Insulin SC Sliding Scale using HUM Insulin 3. Citracal Regular (calcium citrate-vitamin D3) 250 mg calcium- 200 unit oral DAILY 4. Colestid (colestipol) 1 gram oral QID 5. Lactulose 30 mL PO TID 6. Magnesium Oxide 400 mg PO BID 7. Multivitamins 1 TAB PO DAILY 8. Pantoprazole 40 mg PO Q24H 9. rifAXIMin 550 mg PO BID 10. Spironolactone 25 mg PO DAILY 11. HELD- Fish Oil (Omega 3) Dose is Unknown PO Frequency is Unknown This medication was held. Do not restart Fish Oil (Omega 3) until you return home Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: intraparenchymal hemorrhage Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: History: ___ with altered mental status.// h/o cirrhosis, AMS. Please evaluate for PVT. TECHNIQUE: Grey scale, color, and spectral Doppler ultrasound images of the abdomen were obtained. COMPARISON: Liver ultrasound dated ___. FINDINGS: The liver appears diffusely coarsened and nodular consistent with known cirrhosis. No focal liver lesions are identified. There is no ascites. There is stable splenomegaly, with the spleen measuring 13.6 cm. There is no intrahepatic biliary dilation. The CHD measures 3 mm. Cholelithiasis without gallbladder wall thickening. The main portal vein is patent with hepatopetal flow. The TIPS is patent and demonstrates wall-to-wall flow. Portal vein and intra-TIPS velocities are as follows: Main portal vein: 21 cm/sec, previously 23 cm/sec Proximal TIPS: Measurements for the proximal tips are likely artifactual due to respiratory motion. Mid TIPS: 176 cm/sec, previously 278 cm/sec Distal TIPS: 124 cm/sec, previously 134 cm/sec Flow within the left portal vein is towards the TIPS shunt. Flow within the right anterior portal vein is towards the TIPS. Appropriate flow is seen in the hepatic veins and IVC. PANCREAS: The imaged portion of the pancreas appears within normal limits, without masses or pancreatic ductal dilation, with portions of the pancreatic tail obscured by overlying bowel gas. KIDNEYS: Limited views of the kidneys demonstrate no hydronephrosis. RETROPERITONEUM: Visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. Patent TIPS. Of note, the measurements for the proximal tips are inadequately obtained as the patient was unable to hold her breath. The velocities within the mid and the distal tips are within normal range. 2. Portal vein is patent. 3. Cirrhotic liver morphology with stable splenomegaly. No ascites. 4. Cholelithiasis without sonographic evidence of acute cholecystitis. Radiology Report EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK INDICATION: History: ___ with altered mental status// Altered mental status, requested by neuro TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 8.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 802.7 mGy-cm. 2) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 17.4 mGy (Body) DLP = 8.7 mGy-cm. 3) Spiral Acquisition 5.0 s, 39.5 cm; CTDIvol = 15.2 mGy (Body) DLP = 601.8 mGy-cm. Total DLP (Body) = 611 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: CT head from ___ at 06:43, CT head from ___, CT C-spine from ___. FINDINGS: CT HEAD WITHOUT CONTRAST: Redemonstration of right inferior frontal lobe intraparenchymal hematoma measuring approximately 2.9 x 2.2 cm, previously 2.7 x 2.0 cm, with surrounding edema. There is no mass-effect on the adjacent frontal horn of the right lateral ventricle. There is no evidence of acute infarction, new hemorrhage, or masses. There is no midline shift. The ventricle and sulci are normal in size and configuration. There is mild mucosal thickening of the bilateral maxillary sinuses. Otherwise, the visualized portion of the paranasal sinuses, mastoid air cells,and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. CTA HEAD: There is mild atheromatous calcification in the carotid siphons bilaterally. The vessels of the circle of ___ and their principal intracranial branches appear otherwise normal without stenosis, occlusion, or aneurysm formation greater than 3mm. The dural venous sinuses are patent. CTA NECK: There is mild atheromatous calcification of the bifurcation of both common carotid arteries and of the aortic arch. Bilateral carotid and vertebral artery origins are patent. There is no evidence of internal carotid stenosis by NASCET criteria. The carotidandvertebral arteries and their major branches appear normal with no evidence of stenosis or occlusion. The right vertebral artery is dominant. OTHER: There is mild emphysematous change at the right apex. There are multiple nodules in the right lung apex measuring up to 4 mm (3:51). The visualized portion of the thyroid gland is within normal limits. There is moderate cervical spondylosis, most marked at C3-C4, C5-C6 and C6-C7, with reduced intervertebral disc height and anterior osteophyte formation. There is 3 mm of anterolisthesis of C5 on C6. IMPRESSION: 1. Redemonstration of the right inferior frontal lobe intraparenchymal hematoma, with surrounding edema. This is unchanged in appearance. No new intracranial hemorrhage. 2. Patent circle of ___ without definite evidence of stenosis,occlusion,or aneurysm. 3. Patent bilateral cervical carotid and vertebral arteries without definite evidence of stenosis, occlusion, or dissection. 4. Multiple pulmonary nodules measuring up to 4 mm in the right apex. For incidentally detected multiple solid pulmonary nodules smaller than 6mm, no CT follow-up is recommended in a low-risk patient, and an optional CT follow-up in 12 months is recommended in a high-risk patient. See the ___ ___ Society Guidelines for the Management of Pulmonary Nodules Incidentally Detected on CT" for comments and reference: ___ Radiology Report EXAMINATION: UNILAT LOWER EXT VEINS RIGHT INDICATION: History: ___ with RLE swelling, AMS// Please eval for DVT TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the right lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, color flow, and spectral doppler of the right common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. There is extensive calcified atherosclerotic plaque, particularly in the common femoral artery. IMPRESSION: No evidence of deep venous thrombosis in the right lower extremity veins. Extensive calcified atherosclerotic plaque, particularly in the common femoral artery. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD INDICATION: ___ year old woman with IPH, unknown etiology. Evaluate for structural abnormalities in setting of right frontal IPH exam around 10AM on ___ for 24 hr scan. TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: CT head performed ___. CT head and neck performed ___. FINDINGS: Examination is moderately degraded by motion. Within these confines: There is a 2.8 x 2.6 cm (03:13) area of T1 hyperintensity centered within the right frontal lobe with associated susceptibility artifact and moderate adjacent FLAIR/T2 hyperintense edema signal compatible with known intraparenchymal hematoma. This appears relatively unchanged compared to ___, allowing for differences in imaging technique. Local sulcal mass effect also appears essentially unchanged. No other areas of intraparenchymal hemorrhage are identified. Susceptibility artifact in the bilateral basal ganglia are compatible with mineralization, as seen on prior CT head examinations. There is no evidence of recent infarction or midline shift. Prominence of the ventricles and sulci is likely related to age-related involutional change. Periventricular and subcortical T2/FLAIR hyperintensities are nonspecific but may reflect the sequelae of chronic microvascular ischemic disease. The major vascular flow voids appear relatively well preserved. Postcontrast images are moderately motion degraded. Within these confines, no definite abnormal postcontrast enhancement is identified. There is mild bilateral mucosal thickening of the maxillary sinuses, right greater than left. Minimal mucosal thickening of the anterior ethmoid air cells. Mild opacification of the left-sided mastoid air cells. Status post bilateral lens replacements. A 7 x 4 mm T1 and T2 isointense lesion arising from the superficial soft tissues overlying the right zygomatic process may reflect a skin tag versus sebaceous cyst (03:10). IMPRESSION: 1. Examination is moderately motion degraded. 2. Approximately 2.8 cm right frontal intraparenchymal hematoma with associated surrounding edema, grossly stable in size compared to the prior CT head examination. 3. No new areas of intracranial hemorrhage or evidence of acute to subacute infarction. 4. Within limits of study, no definite evidence of enhancing mass. Please note that a enhancing intracranial mass in region of right frontal intraparenchymal hemorrhage is not excluded on the basis of this examination. Recommend follow-up imaging to resolution. 5. Paranasal sinus disease, as detailed above. RECOMMENDATION(S): Within limits of study, no definite evidence of enhancing mass. Please note that a enhancing intracranial mass in region of right frontal intraparenchymal hemorrhage is not excluded on the basis of this examination. Recommend follow-up imaging to resolution. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman with IPH, liver disease and thrombocytopenia// worsening edema or bleed TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 747.5 mGy-cm. Total DLP (Head) = 747 mGy-cm. COMPARISON: ___ 06:43 noncontrast head CT. FINDINGS: Redemonstration of right inferior frontal lobe intraparenchymal hematoma, 2.9 x 2.2 cm, previously 2.7 x 2.0 cm, with surrounding edema. There is no significant mass-effect on the adjacent frontal horn of the right lateral ventricle. There is no evidence of acute infarction, new hemorrhage, or mass effect. There is no midline shift. There are grossly stable bilateral calcifications in the globus pallidus. The ventricle and sulci are grossly stable in size configuration. There is no evidence of fracture. There is mild mucosal thickening in the bilateral maxillary sinuses. Otherwise, the visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits demonstrate bilateral lens replacement postoperative changes. IMPRESSION: 1. Grossly stable right frontal lobe intraparenchymal hematoma, with surrounding edema and no definite midline shift. 2. Paranasal sinus disease , as described. Gender: F Race: ASIAN Arrive by AMBULANCE Chief complaint: Altered mental status, ICH, Transfer Diagnosed with Altered mental status, unspecified temperature: 98.4 heartrate: 80.0 resprate: 16.0 o2sat: 97.0 sbp: 163.0 dbp: 75.0 level of pain: 0 level of acuity: 2.0

Dear ___, You were hospitalized due to symptoms of altered mental status resulting from an INTRAPARENCHYMAL HEMORRHAGE, a condition where there is bleeding found in the brain tissue. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain can result in a variety of symptoms. Brain bleed can have many different causes, including stroke, trauma, medical conditions. We assessed you for medical conditions that might raise your risk of bleeding and stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: 1) Alcoholic cirrhosis (liver disease from alcoholism) with portal hypertension (elevated blood pressure) 2) Diabetes 3) smoking We are NOT changing your medications. Please take your other medications as prescribed. Please follow up with Neurology and your primary care physician as listed below. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Transient facial droop, right-sided weakness Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ old man with no significant past medical history who presents with transient facial droop and right-sided weakness. Patient was in his usual state of health this morning and returned from work driving a bus around 7:50 AM. His wife noticed that he had sudden onset slurred speech and a right facial droop and looked confused. He tried to grab a door to walk through the house and was unable to lift his right arm. His wife called EMS who brought him to ___ - ___. ___ stroke scale was notable for 1 for right facial droop. CT head did not show any bleed CTA showed a possible acute thrombus in the left M2 segment. No TPA was given. Patient did not go for thrombectomy given his rapidly improving symptoms. Given that neurology is not available at ___, patient was transferred for further management. On arrival to ___, patient felt back to normal and had a stroke scale of 0. On neuro ROS, the pt denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: Enlarged prostate Social History: ___ Family History: Noncontributory Physical Exam: ADMISSION PHYSICAL EXAM Vitals: T: 98.0 P: 61 R: 16 BP: 130/84 SaO2: 99% RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Pulmonary: Normal work of breathing Cardiac: RRR, warm, well-perfused Abdomen: soft, non-distended Extremities: No ___ edema. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FE IP Quad Ham TA ___ ___ L 5 ___ ___ 5 5 5 5 R 5 ___ ___ 5 5 5 5 -Sensory: No deficits to light touch. No extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. -Coordination: No intention tremor. No dysmetria on FNF or HKS bilaterally. -Gait: Deferred DISCHARGE PHYSICAL EXAMINATION: Vitals: Temperature: 99.5-97.9 Heart rate: ___ Blood pressure: 98/61-125/89 Respiratory rate: ___ O2 saturation: 96-98% General: Comfortable and in no distress Head: No irritation/exudate from eyes, nose, throat Neck: Supple with no pain to flexion or extension Cardio: Regular rate and rhythm, warm, no peripheral edema Lungs: Unlabored breathing Abdomen: Soft, non tender, non distended Skin: No rashes or lesions Neurologic examination: Mental status: Patient is pleasant and he has no problem with communication with examiner including expressing ideas and following commands. Fluent use of language. Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ 5 ___ 5 5 5 5 5 R 5 ___ 5 ___ 5 5 5 5 5 Sensory: No deficits to light touch, proprioception throughout. No extinction to DSS. Reflexes: Bi Tri ___ Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. Romberg absent. Pertinent Results: MRI/MRA of brain ___: A couple of punctate foci of hyperintense DWI signal in the left parietal cortex without definite correlate on ADC, T2 or FLAIR imaging. These lesions most likely represent tiny hyperacute infarcts, but in the differential consider the fact that these lesions may be artifactual in nature Periventricular and deep white matter T2 and FLAIR hyperintensities are nonspecific but most likely related to microangiopathy. Bilateral maxillary sinus mucosal thickening. MRV Pelvis ___: No evidence of deep vein thrombosis in the pelvis. Enlarged prostate Bilateral lower extremity US ___: No evidence of deep venous thrombosis in the right or left lower extremity veins. Medications on Admission: None Discharge Medications: Atorvastatin 80 mg daily Aspirin 81 mg daily Discharge Disposition: Home Discharge Diagnosis: Transient ischemic attacks Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: MRI AND MRA BRAIN PT12 MR HEAD INDICATION: ___ year old man with right sided weakness// eval for stroke TECHNIQUE: 3 dimensional time-of-flight MRA was performed through the brain. Sagittal and axial T1 weighted imaging were performed along with diffusion imaging. Axial imaging was performed with gradient echo, FLAIR, T2, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. Three dimensional maximum intensity projection and segmented images were generated. This report is based on interpretation of all of these images. COMPARISON: None. FINDINGS: MR BRAIN: A couple of punctate foci of hyperintense DWI signal in the left parietal lobe cortex (4:20, 4:19) without definite corresponding signal on ADC/T2/FLAIR could represent tiny hyperacute infarcts or less likely artifact. No intracranial hemorrhage. No mass. The ventricular system is symmetrical. Periventricular and deep white matter T2 and FLAIR hyperintensities are most likely secondary to microangiopathy. Mucosal thickening involving bilateral maxillary sinuses and to a lesser degree the ethmoid air cells. No CP angle masses. The globes appear normal. The pituitary gland appears normal. The craniocervical junction is normal. MRA brain: The intracranial vertebral and internal carotid arteries and their major branches appear normal without evidence of stenosis, occlusion, or aneurysm formation. IMPRESSION: 1. A couple of punctate foci of hyperintense DWI signal in the left parietal cortex without definite correlate on ADC, T2 or FLAIR imaging. These lesions most likely represent tiny hyperacute infarcts, but in the differential consider the fact that these lesions may be artifactual in nature. 2. Periventricular and deep white matter T2 and FLAIR hyperintensities are nonspecific but most likely related to microangiopathy. 3. Bilateral maxillary sinus mucosal thickening. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 1:53 pm, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ year old man with stroke with positive bubble study (PFO/ASD)// 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. Radiology Report EXAMINATION: MRI of the Pelvis INDICATION: ___ year old man with positive bubble study (PFO/ASD)// DVT TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen and pelvis were acquired in a 3.0 T magnet. Intravenous contrast: None. COMPARISON: None. FINDINGS: RECTUM AND INTRAPELVIC BOWEL: The rectum and visualized intrapelvic bowel loops are unremarkable. BLADDER AND DISTAL URETERS: Unremarkable appearance of the urinary bladder. The distal ureters are normal in caliber. PROSTATE, SEMINAL VESICLES, AND SCROTUM: The prostate is enlarged and indents the inferior urinary bladder. Seminal vesicles are unremarkable. LYMPH NODES: There are no enlarged pelvic lymph nodes. VASCULATURE: Normal caliber of the iliac arteries and veins. Flow void of the pelvic vessels are preserved. There is no evidence of venous thrombosis in the pelvis. OSSEOUS STRUCTURES AND SOFT TISSUES: No suspicious osseous or soft tissue lesion. Note is made of a small Tarlov cyst at the level of S2. IMPRESSION: 1. No evidence of deep vein thrombosis in the pelvis. 2. Enlarged prostate Gender: M Race: BLACK/CAPE VERDEAN Arrive by AMBULANCE Chief complaint: CVA, Transfer Diagnosed with Cerebral infarction, unspecified temperature: 98.0 heartrate: 61.0 resprate: 14.0 o2sat: 99.0 sbp: 130.0 dbp: 84.0 level of pain: 0 level of acuity: 1.0

Mr. ___, During this admission you were determined to have a transient ischemic attack and because you are at a high risk of stroke we have started you on aspirin 81 mg daily and atorvastatin 80 mg daily. We are uncertain exactly why you had this event, but to complete our workup we will discharge you with a monitor to look for abnormal rhythms. We will have you follow up in stroke follow up clinic with Dr. ___. Thank you for allowing us to care for you ___ Neurology

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Vicodin / Ciprofloxacin / Coumadin Attending: ___. Chief Complaint: Dysuria Shortness of Breath Lower extremity swelling Major Surgical or Invasive Procedure: ___ ___ History of Present Illness: Ms. ___ is an ___ y/o woman with history of HFpEF, paroxysmal atrial fibrillation, and HTN who presents with 2 months of worsening shortness of breath. History was obtained in part from records due to patient's poor memory, but key details were confirmed with the patient. Patient and providers report ___ gradual worsening of symptoms over the past ~2 months. Patient reports strict adherence to her diuretics, 1500cc fluid restriction, and low-sodium diet at home, but she has nonetheless experienced worsening SOB as well as ___ edema. She is now only able to walk about 4 steps before becoming short of breath. Her dry weight is around 150 lbs but she does not weight herself regularly. No orthopnea or PND. No chest pain, palpitations, diaphoresis, or dizziness. Patient was advised by her cardiologist to come into the CDAC over the last month for IV diuresis but declined. Today she noted new dysuria and vaginal itching and decided to come to the ED for these reasons. Of note, patient has a h/o recurrent UTIs and just completed a 7-day course of amox/clav today. She denies fevers, chills, rhinorrhea, cough, chest pain, N/V/D/abdominal pain, or rashes. In the ED, patient was afebrile and hemodynamically stable on room air. Exam, CXR, and BNP were consistent with heart failure exacerbation. EKG showed afib vs. flutter in ___ with no ischemic changes, and trop was negative. Cardiology was consulted and recommended admission for IV diuresis. Past Medical History: - Heart failure with preserved ejection fraction. - Paroxismal atrial fibrillation (s/p ___ ___ - Hypertension. - Dyslipidemia. - Osteoarthritis s/p R knee arthroscopy - Osteopenia - Sciatica - Recurrent UTIs - ___ cataracts - Thyroid nodule - R auricular perichondritis - Hx falls w/ T12 compression fracture in ___ - HTN - essential tremor Social History: ___ Family History: Father with heart problems, mother with arthritis. Both were killed in the ___. Physical Exam: ADMISSION EXAM ============== VS: Reviewed, afebrile, hemodynamically stable, SpO2 94% on 2L General: Elderly pleasant woman in NAD. HEENT: No icterus or injection. MMM. CV: Irregular rhythm, no murmurs. JVP modestly elevated. Resp: Normal work of breathing. Bilateral crackles to mid-back. Abd: Soft, NDNT. GU: No suprapubic tenderness. Extremities: 1+ edema bilaterally. No erythema or tenderness. Skin: No rashes or lesions. Neuro: Alert, oriented and interactive but poor short-term memory and attention consistent with mild dementia. CN ___ intact. Strength symmetric. No ataxia. DISCHARGE EXAM ============== VS: Reviewed, afebrile, hemodynamically stable, SpO2 96% on RA HEENT: No icterus or injection. MMM. CV: RRR, s1/s2, no mgr Resp: CTAB except decreased bibasilar breath sounds, no crackles Abd: Soft, NDNT. Extremities: 1+ ___ edema b/l after removal of compression stockings Neuro: Alert, oriented and interactive but poor short-term memory and attention consistent with mild dementia. +intention tremor b/l Pertinent Results: ___ 05:45PM BLOOD WBC-6.3 RBC-3.99 Hgb-12.2 Hct-35.4 MCV-89 MCH-30.6 MCHC-34.5 RDW-13.0 RDWSD-42.5 Plt ___ ___ 05:45PM BLOOD Glucose-105* UreaN-15 Creat-0.7 Na-134* K-4.0 Cl-93* HCO3-27 AnGap-14 ___ 05:45PM BLOOD ___ 05:45PM BLOOD TSH-3.5 ___ 03:56AM BLOOD calTIBC-328 Ferritn-34 TRF-252 IMAGING ___ CXR: significant bilateral pulmonary edema with small effusions ___ CXR: Underlying emphysematous changes noted. The considerable improvement to the bilateral pulmonary edema decrease to the size of the cardiac silhouette. No definite effusions appreciated. DISCHARGE LABS ___ 07:50AM BLOOD WBC-5.8 RBC-4.16 Hgb-12.6 Hct-38.4 MCV-92 MCH-30.3 MCHC-32.8 RDW-12.9 RDWSD-43.5 Plt ___ ___ 07:50AM BLOOD Glucose-111* UreaN-33* Creat-1.2* Na-142 K-4.1 Cl-98 HCO3-26 AnGap-18 ___ 07:50AM BLOOD Calcium-9.5 Phos-3.8 Mg-2.2 Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Rivaroxaban 15 mg PO DAILY 2. Propranolol 10 mg PO TID 3. Amiodarone 200 mg PO DAILY 4. Ciprofloxacin 0.3% Ophth Soln 1 DROP RIGHT EYE QID 5. Furosemide 60 mg PO BID 6. Losartan Potassium 100 mg PO DAILY 7. Atorvastatin 10 mg PO QPM 8. Amoxicillin-Clavulanic Acid ___ mg PO Q12H ?UTI 9. amLODIPine 10 mg PO DAILY Discharge Medications: 1. Bumetanide 3 mg PO DAILY 2. Nystatin Ointment 1 Appl TP TID:PRN pruritis 3. Propranolol 10 mg PO BID 4. Rivaroxaban 15 mg PO DINNER 5. Amiodarone 200 mg PO DAILY 6. Atorvastatin 10 mg PO QPM 7. Losartan Potassium 100 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY ======= Atrial fibrillation s/p DVVC Acute on chronic heart failure exacerbation SECONDARY ========= HTN Mild Cognitive Impairment Conjunctivitis Urinary retention Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with sob// ?pulmonary edema TECHNIQUE: Upright AP and lateral views of the chest COMPARISON: Chest radiograph ___ FINDINGS: Moderate to severe cardiac enlargement is re-demonstrated. The aorta is diffusely calcified. Enlargement of the hila bilaterally is unchanged. There is moderate interstitial pulmonary edema which is worse compared to the previous examination. Small bilateral pleural effusions are present. Lungs are hyperinflated likely indicative of chronic obstructive pulmonary disease. Patchy opacities in the lung bases may reflect atelectasis. No pneumothorax is demonstrated. No acute osseous abnormality is visualized. Moderate compression deformity of a vertebral body at the thoracolumbar junction is unchanged. IMPRESSION: Moderate interstitial pulmonary edema with small bilateral pleural effusions and bibasilar atelectasis. Radiology Report INDICATION: ___ year old woman with HFpEF s/p diuresis and DCCV w/SOB// interval changes, pleural effusion, pulm edema**Please perform ___ on ___ TECHNIQUE: Chest portable AP COMPARISON: ___ FINDINGS: Underlying emphysematous changes noted. The considerable improvement to the bilateral pulmonary edema decrease to the size of the cardiac silhouette. No definite effusions appreciated. IMPRESSION: Improved pulmonary edema. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Dyspnea on exertion, Pedal edema Diagnosed with Dyspnea, unspecified temperature: 98.6 heartrate: 73.0 resprate: 18.0 o2sat: 90.0 sbp: 111.0 dbp: 76.0 level of pain: 0 level of acuity: 3.0

Dear Ms ___, You were admitted to the ___ after you had worsening shortness of breath. We had to give you IV diuretic medications to help remove the extra fluid from your body and lungs. We found that you were still in an irregular heart rhythm, "atrial fibrillation," and after talking with your Cardiologist Dr ___ decided to perform an electrical cardioversion, which flipped your heart back into a normal sinus rhythm. - Your dry weight is 62.7 kg. - Our hope is that your heart stays in a normal heart rhythm. If you start to feel palpitations you may have atrial fibrillation again, so notify your MD. - You have urine retention. We discussed this with a urologist while you were here, and this is typically followed as an outpatient. You should have follow up with a urologist to figure out why this is happening. It is probably a chronic problem, and there is nothing urgent to do about it. - Please take your medications as below. - Weigh yourself every day, and if you gain or lose more than 3 lbs please notify your doctor. - If you aren't feeling well and have a little bit of fluid buildup again, it is important to call Dr ___ potentially have yourself scheduled for an appointment to be seen. It was a pleasure taking care of you! Zei Gezunt, Refuah Shlaimah, ve'hatzlachah rabah ad me'ah ve'esrim!! Your ___ Cardiology Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: right pneumothorax Major Surgical or Invasive Procedure: ___ Right pleural pigtail catheter placement History of Present Illness: Mr. ___ is a ___ man who is nearly 3 months status post VATS right lower lobe lobectomy for lung cancer, with a complicated postoperative course including ARDS requiring prolonged intubation ultimately tracheostomy and a right pneumothorax requiring a chest tube, presents from rehab with concern for worsening pneumothorax. When the patient left the hospital from his last admission, he had a moderate right-sided pneumothorax with a pleural effusion at the lung base. This is been followed at rehab with serial chest x-rays. On today's chest x-ray, the pleural effusion had resolved however the pneumothorax remained and was questionably enlarged. Therefore the patient was sent to the ___ emergency department for further evaluation. Patient is on full vent support, and thus detailed history is hard to obtain. However, he does report that his breathing has not changed recently. He has an intermittent cough, and intermittent dyspnea. His son does report that he thinks there has been a small increase in the amount of secretions recently. He denies fevers and chills. Past Medical History: PAST MEDICAL HISTORY: Hypercholesterolemia Anemia, iron deficiency Cancer of ascending colon Colonic adenoma History of herpes zoster Degenerative disc disease, lumbar Post-traumatic stress disorder, chronic Depressive disorder History of alcohol abuse Peripheral neuropathy due to chemotherapy Diverticulosis of large intestine without hemorrhage COPD mixed type PAST SURGICAL HISTORY: ___ VATS right lower lobe wedge resection followed by VATS right lower lobectomy, mediastinal lymph node dissection and bronchoscopy with lavage ___ Bronchoscopy ___ Bronchoscopy ___ Bronchoscopy ___ Bronchoscopy ___ Right pleural pigtail catheter placement ___ Portex Per-Fit tracheostomy tube placed percutaneously and a PEG tube placement. ___ Right PICC placement ___ Right common femoral Vein approach IVC filter placement. Right common femoral artery approach right subclavian arteriogram with gel foam embolization of lateral thoracic, pectoral, and humeral branch Social History: ___ Family History: Mother Father: throat cancer Siblings: brother : ___ Other Physical Exam: Temp 97.8 HR 86 BP 160/90 RR 22 O2 sat 96% General: frail appearing, alert and oriented in no distress however difficult to communicate secondary to tract HEENT: NC/AT, EOMI, trach in place Resp: on vent support via trach, lungs clear bilaterally, however decreased breathsounds on the right CV: mildly tachycardic, regular Abd: soft, mildly distended, mildly tender to palpation throughout Ext: well-perfused, no edema Pertinent Results: WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt Ct ___ 01:25 22.0* 4.11* 11.5* 37.5* 91 28.0 30.7* 16.0* 53.5* 356 ___ 01:05 16.7* 4.15* 11.5* 38.2* 92 27.7 30.1* 16.2* 54.2* 371 ___ 01:45 18.6* 4.17* 11.7* 38.1* 91 28.1 30.7* 15.9* 53.6* 394 ___ 01:35 22.7* 4.15* 11.5* 37.8* 91 27.7 30.4* 16.1* 53.9* 448* ___ 14:55 22.7* 4.58* 12.8* 41.4 90 27.9 30.9* 16.3* 53.3* 486* ___ 22:10 19.9* 4.12* 11.5* 37.6* 91 27.9 30.6* 16.0* 52.8* 451* Glucose UreaN Creat Na K Cl HCO3 AnGap ___ 01:25 ___ 135 4.9 93* 32 10 ___ 01:05 ___ 134* 5.0 96 30 8* ___ 01:45 ___ 136 4.8 94* 31 11 ___ 01:35 ___ 135 4.9 94* 30 11 ___ 14:55 ___ 135 5.3 96 26 13 ___ 22:10 ___ 134* 5.1 96 27 11 ___ CXR : Moderate right pneumothorax, with intervally resolved right pleural effusion. No signs of tension. Chronic lung disease re-demonstrated. PICC line appears well positioned. Tracheostomy in place. ___ Chest CT : 1. Small to moderate hydropneumothorax with some possibly loculated components. There is no obvious bronchopleural fistula. 2. Post right lower lobectomy. Consolidations in the left lower lobe and lingula are concerning for pneumonia, significantly progressed since ___. 3. The previously seen large right chest wall hematoma appears significantly decreased in size, now measuring 6.5 x 1.9 cm. 4. Post tracheostomy. Secretions are seen in the right main bronchus extending into the subsegmental bronchi of the right lower lobe 5. There is diffuse lower lobe predominance of interstitial reticulation and honeycombing, compatible with biopsy proven UIP. ___ CXR : In comparison with the study of ___, the monitoring and support devices are stable, as is the cardiomediastinal silhouette. The patient has taken a better inspiration with continued extensive reticular changes and right pleural effusion. Specifically, there is hazy opacification in the right apical region consistent with pleural fluid replacing the prior pneumothorax. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever 2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID 3. Diltiazem 60 mg PO Q6H 4. Gabapentin 600 mg PO TID 5. LORazepam 0.5 mg PO BID 6. Metoprolol Tartrate 25 mg PO Q6H 7. QUEtiapine Fumarate 25 mg PO QHS 8. Acetylcysteine 20% ___ mL NEB Q6H:PRN dyspnea 9. Atorvastatin 10 mg PO QPM 10. Heparin 5000 UNIT SC BID 11. Multivitamins W/minerals 1 TAB PO DAILY 12. Pantoprazole (Granules for ___ ___ 40 mg G TUBE DAILY 13. Ramelteon 8 mg PO QPM 14. Sodium Chloride 0.9% Flush ___ mL IV Q8H and PRN, line flush 15. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB 16. Bisacodyl ___AILY:PRN Constipation - Second Line 17. Docusate Sodium 100 mg PO BID 18. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheeze and w/ acetylcsyeine treatments 19. Ciprofloxacin 400 mg IV Q12H 20. OxyCODONE Liquid 5 mg NG Q4H:PRN Pain - Moderate Discharge Medications: 1. Famotidine 20 mg PO DAILY 2. GuaiFENesin ___ mL PO TID 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 4. Heparin 5000 UNIT SC TID 5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 6. LORazepam 0.5 mg NG Q8H:PRN anxiety Cruch and give via PEG tube, flush w/ 10 mls water 7. Metoprolol Tartrate 37.5 mg NG Q6H Use suspension and give via PEG tube, flush w/ 10 mls water 8. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line flush 9. Acetylcysteine 20% ___ mL NEB Q6H:PRN dyspnea 10. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB 11. Atorvastatin 10 mg PO QPM crush and give via PEG tube, flush w/ 10 mls water 12. Bisacodyl ___AILY:PRN Constipation - Second Line 13. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID 14. Diltiazem 60 mg NG Q6H Cruch and give via PEG tube, flush w/ 10 mls water 15. Gabapentin 600 mg NG TID crush and give via PEg tube. flush w/ 10 mls water 16. Multivitamins W/minerals 1 TAB PO DAILY use elixir and give via PEG tube, flush with 10 mls water 17. OxyCODONE Liquid 5 mg NG Q4H:PRN Pain - Moderate Give via PEG tube and flush with 10 mls water 18. QUEtiapine Fumarate 25 mg NG QHS Crush and give via PEG tube, flush w/ 10 mls water 19. Ramelteon 8 mg NG QPM Cruch and give via PEG tube, flush w/ 10 mls water Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Respiratory failure Trapped right lung 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: ___ with right pigtail placed.// eval pigtail position TECHNIQUE: Portable AP chest COMPARISON: Chest radiograph from 2 hours prior FINDINGS: Following insertion of the right basal pigtail pleural drain moderate to large right hydropneumothorax is not appreciably smaller. Severe chronic infiltrative abnormality persists in the left lung, with no evidence of an acute abnormality. Heart size is normal. Left pleural effusions small if any. Tracheostomy tube is midline. Caliber of the tube is less than half the diameter of the trachea and may be smaller than optimal. Clinical assessment advised. IMPRESSION: Status post right pigtail catheter placement without significant interval change in moderate right hydro pneumothorax. Chronic severe infiltrative lung disease. Size of tracheostomy tube should be re-evaluated clinically. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man s/p RLL now s/p R pigtail for pneumothorax// eval for interval change eval for interval change IMPRESSION: Tracheostomy is in place. Right PICC line tip is at the level of lower SVC. Right pigtail catheter is in place. Pneumothorax is moderate to large, unchanged. Interstitial opacities have substantially progressed in the interim concerning for progression of interstitial edema. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with afib with RVR// interval change. chest tube to H20 seal since last xr TECHNIQUE: Portable AP chest radiograph COMPARISON: Chest radiograph ___ from 7 hours prior FINDINGS: Again seen is a right-sided PICC at the cavoatrial junction and a tracheostomy tube, unchanged in position from prior. Redemonstration of a right pigtail pleural catheter seen along the inferior right hemithorax. Redemonstration of a large right sided pneumothorax without evidence of tension, unchanged in size from prior. Again, there are diffuse airspace and interstitial opacities, similar appearance to prior. No large pleural effusion. Cardiomediastinal contours are unchanged. IMPRESSION: Unchanged size of a large right pneumothorax. No evidence of tension. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man s/p RLL now s/p R pigtail for pneumothorax// Interval change TECHNIQUE: Chest AP COMPARISON: ___ IMPRESSION: Moderate right-sided pneumothorax with apical and basilar components is unchanged. Right-sided pigtail catheter is in place. Right PICC line projects to the cavoatrial junction and is also unchanged. Tracheostomy tube is also unchanged. Interstitial abnormality bilaterally left greater than right could represent a combination of pneumonia and edema. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man s/p RLL now s/p R pigtail for pneumothorax// Pigtail clamped. Please obtain at 12pm ___ TECHNIQUE: Portable AP chest radiograph COMPARISON: Chest radiograph ___ 6 hours prior FINDINGS: Unchanged positioning of a right-sided PICC, tracheostomy, and right-sided pigtail catheter. The large right pneumothorax is unchanged in size. No pleural effusions. There has been mild interval increase of the diffuse airspace opacities at the left lung base, concerning for worsening of the underlying parenchyma process. Cardiomediastinal silhouette is unchanged. IMPRESSION: Unchanged size of large right pneumothorax. Mild interval worsening of underlying parenchymal process at the left lung base. Radiology Report EXAMINATION: CT CHEST W/O CONTRAST INDICATION: ___ year old man with fibrotic disease, persistent PTX with pigtail // Disease progression TECHNIQUE: Axial 1.25 mm slice thickness images were obtained through the chest without the administration of intravenous contrast. Coronal, sagittal, and axial MIPS reconstructions were then obtained DOSE: Acquisition sequence: 1) Spiral Acquisition 2.3 s, 35.7 cm; CTDIvol = 10.1 mGy (Body) DLP = 360.0 mGy-cm. Total DLP (Body) = 360 mGy-cm. COMPARISON: CT chest without contrast from ___. CTA chest from ___ FINDINGS: NECK, THORACIC INLET, AXILLAE, CHEST WALL: Patient is status post tracheostomy. Aerated secretions are seen proximal to the tracheostomy tube. The thyroid gland is unremarkable. The previously seen large right chest wall hematoma appears significantly decreased in size, now measuring 6.5 x 1.9 cm (302:84). UPPER ABDOMEN: Limited views of the abdomen appear grossly unremarkable. MEDIASTINUM: There are multiple persistently enlarged mediastinal lymph nodes. For example, there is a right paratracheal lymph node which measures 1.3 cm (302:82), previously 1.6 cm in ___. A representative prevascular lymph node measures 1.3 cm (302:87), unchanged. A left pericardial lymph node measures 1.1 cm, unchanged (302:153). There is interval increase in pneumomediastinum since ___. HILA: Within limitations of a noncontrast enhanced exam, no obvious lymphadenopathy is identified. HEART and PERICARDIUM: The cardiac size is mildly prominent, but unchanged. Dense calcifications are seen in the aortic valve, mitral valve, and coronary arteries. Moderate amount of pneumomediastinum appears mildly progressed since ___. PLEURA: There is a small to moderate right hydropneumothorax. Some of the pleural fluid in the medial posterior right lower lung may be loculated. A right lateral approach percutaneous pigtail drainage catheter is seen terminating in the right lower lung. LUNG: 1. PARENCHYMA: Patient is status post right lower lobectomy. There is diffuse lower lobe predominance of interstitial reticulation and honeycombing, compatible with previously characterized interstitial lung disease. Diffuse consolidations in the left lower lobe and lingula are concerning for pneumonia and significantly progressed since ___. There are additional areas of ground-glass opacity in the upper lobes, which are nonspecific, possibly pulmonary edema versus developing infection. No definite bronchopleural fistula is seen. 2. AIRWAYS: Secretions are seen in the right main bronchus extending into the subsegmental bronchi of the right lower lobe (302:105-116). 3. VESSELS: Evaluation of the vasculature is limited on this noncontrast enhanced exam. Within these limitations, the thoracic aorta is not aneurysmally dilated. The main pulmonary artery is nonenlarged. CHEST CAGE: Degenerative changes are mild-to-moderate in the visualized spine. There is no concerning focal lesion identified. IMPRESSION: 1. Small to moderate hydropneumothorax with some possibly loculated components. There is no obvious bronchopleural fistula. 2. Post right lower lobectomy. Consolidations in the left lower lobe and lingula are concerning for pneumonia, significantly progressed since ___. 3. The previously seen large right chest wall hematoma appears significantly decreased in size, now measuring 6.5 x 1.9 cm. 4. Post tracheostomy. Secretions are seen in the right main bronchus extending into the subsegmental bronchi of the right lower lobe 5. There is diffuse lower lobe predominance of interstitial reticulation and honeycombing, compatible with biopsy proven UIP. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with right PTX, ILD// Interval CXR TECHNIQUE: Chest AP COMPARISON: ___ IMPRESSION: Lungs are low volume with mild improvement in the interstitial abnormality which most likely represents improving edema. The residual opacity bilaterally is consistent with known interstitial lung disease. The moderate right pleural effusion is unchanged. Right-sided pigtail catheter and right-sided PICC line are unchanged. Tracheostomy tube remains in place. Cardiomediastinal silhouette is stable. There is a stable small right pleural effusion. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with RLL lobectomy w/ not-fully reflated right lung s/p pig tail pulled today// interval change since removing pig tailplease obtain at 1600 ___ TECHNIQUE: AP portable chest radiograph COMPARISON: ___ from earlier in the day FINDINGS: The tip of the right PICC projects over the right atrium, unchanged. A tracheostomy tube is present. Interval increase in bilateral reticular opacities. No pleural effusion or. A small right pneumothorax is unchanged. The size the cardiac silhouette is unchanged. IMPRESSION: Unchanged small right apical and basal pneumothorax. Interval increase in reticular opacities possibly reflecting pulmonary edema. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with R pneumothorax and intermittent desaturtations// interval change IMPRESSION: In comparison with the study of ___, the monitoring and support devices are stable, as is the cardiomediastinal silhouette. The patient has taken a better inspiration with continued extensive reticular changes and right pleural effusion. Specifically, there is hazy opacification in the right apical region consistent with pleural fluid replacing the prior pneumothorax. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Pneumonia, Transfer Diagnosed with Pneumothorax, unspecified temperature: 97.8 heartrate: 86.0 resprate: 22.0 o2sat: 96.0 sbp: 160.0 dbp: 90.0 level of pain: 0 level of acuity: 2.0

* You were admitted to the hospital for evaluation of your right pneumothorax and failure to wean from the respirator following your surgery. * You have done well in weaning from the ventilator and breathing on your own and are now ready to return to rehab for more therapy. * You will continue to require tube feedings via your PEG tube and the Speech and Swallow therapist will evaluate you when you are ready to safely swallow food. * Continue to work hard with Physical Therapy to get strong and improve your endurance. * You will need to follow up with Dr. ___ in ___ weeks and the rehab will arrange transportation for you to return to the Thoracic Clinic. * Call ___ with any questions about this hospitalization.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: All allergies / adverse drug reactions previously recorded have been deleted Attending: ___. Chief Complaint: Right knee pain Major Surgical or Invasive Procedure: Right tibial plateau open reduction and internal fixation History of Present Illness: ___ otherwise healthy who was playing football today and suffered a hyperextension injury to the R knee. Immediate onset of pain, swelling, and inability to bear weight. No injuries elsewhere. Denies numbness or tingling distally. Past Medical History: None Social History: ___ Family History: NC Physical Exam: Exam on admission: AVSS A&O x 3 Calm and comfortable RLE: Moderate effusion in the knee No evidence of open fracture Knee unstable to valgus stress Knee stable to varus stress ___ SILT DP/SP/S/S/T distribution DP and ___ pulse 2+ toes wwp Exam on discharge: AFVSS A+Ox3, NAD RLE: Dressings c/d/i Compartments soft and compressible No pain with passive ankle or toe motion ___ SILT DP/SP/S/S/T distribution DP and ___ pulse 2+ toes wwp Pertinent Results: ___ 04:15PM BLOOD WBC-12.2* RBC-4.51* Hgb-14.4 Hct-42.0 MCV-93 MCH-31.9 MCHC-34.3 RDW-13.1 Plt ___ ___ 08:00PM BLOOD Neuts-84.6* Lymphs-9.9* Monos-4.5 Eos-0.6 Baso-0.3 ___ 04:15PM BLOOD Plt ___ ___ 08:00PM BLOOD ___ PTT-22.7* ___ ___ 08:00PM BLOOD Glucose-96 UreaN-23* Creat-0.8 Na-138 K-3.8 Cl-___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN pain 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*50 Tablet Refills:*0 3. Enoxaparin Sodium 40 mg SC DAILY Start: ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*14 Syringe Refills:*0 4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*80 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Right tibial plateau fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CT RIGHT LOWER EXTREMITY WITHOUT CONTRAST INDICATION: ___ year old man with comminuted fracture of the right tibial plateau // Please obtain CT of the right knee for pre-op planning TECHNIQUE: MDCT images were obtained through the right knee without intravenous contrast. Coronal and sagittal reformations were prepared. DLP: 1140.69 mGy-cm. COMPARISON: Right knee radiographs, ___. FINDINGS: Comminuted, depressed fracture involving the lateral tibial plateau extends to the lateral metaphyseal cortex as well as the median eminence. There is approximately 1.3 cm of depression spanning approximately 3.7 x 3.9 cm of the articular surface. There is lateral displacement of the dominant fracture fragment. The medial tibial plateau is spared. Lipohemarthrosis is noted along with a locule of air (5:26). There is surrounding soft tissue swelling as well as medial subcutaneous varices. There is bilateral patellar tilt. This examination is not dedicated to evaluation of the intra-articular structures. IMPRESSION: 1. Comminuted, depressed lateral tibial plateau fracture as described above with approximatly 1.3 cm of depression. 2. Secondary lipohemarthrosis and intraarticular air locule, most likely traumatic. Radiology Report INDICATION: ORIF of tibial plateau fracture. TECHNIQUE: Multiple intraoperative fluoroscopic spot images were acquired, without a radiologist present. COMPARISON: Outside hospital knee radiographs ___. Right lower extremity CT from ___. FINDINGS: The provided fluoroscopic spot images demonstrate open reduction and internal fixation of a lateral tibial plateau fracture, utilizing a side plate and several screws. There is no hardware complication. For additional details, please see the operative report in the ___ medical record. The total fluoroscopic time was 52.7 seconds. IMPRESSION: As above. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: R Leg pain Diagnosed with FX UPPER END TIBIA-CLOSE, OTHER OVEREXERTION AND STRENUOUS AND REPETIVE MOVEMENTS OR LOADS, ACTIVITIES INVOLVING AMERICAN TACKLE FOOTBALL temperature: 98.0 heartrate: 73.0 resprate: 18.0 o2sat: 96.0 sbp: 132.0 dbp: 75.0 level of pain: 0 level of acuity: 3.0

MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take lovenox 40mg daily for 2 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining. - Splint must be left on until follow up appointment unless otherwise instructed - Do NOT get splint wet ACTIVITY AND WEIGHT BEARING: - Nonweightbearing in the right leg - Range of motion at the right knee as tolerated, in an unlocked ___ brace Physical Therapy: NWB RLE ROMAT in unlocked ___ Treatments Frequency: Dressings may be changed as needed for drainage. No dressings needed if wound is clean and dry. Staples will be removed in ___ weeks at follow up appointment in Ortho trauma clinic.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: ___ Cardiac catheterization History of Present Illness: Mr. ___ is a ___ male with a history of CAD s/p CABG in ___, PCI in ___ and ___, AS s/p AVR in ___, atrial fibrillation, permanent pacemaker, chronic angina, hypertension, and hyperlipidemia who presented with worsening SOB and an episode of anginal symptoms, nausea, and pallor. Patient reports he first began feeling unwell a month ago after undergoing ___ surgery complicated by bleeding. He states neither his coumadin nor aspirin were stopped due to this event. Since then he began to notice his functional capacity was becoming reduced, especially one week PTA when he began noticing increased fatigue, SOB and chest pain with less exertion. He contacted his cardiologist, Dr. ___ suggested that he start Lasix 20 mg daily on ___ which he did not start because he was concerned about the side effects. He reports he is usually able to walk ~ ___ mile before having to stop because of chest pain and SOB. He takes nitroglycerin daily for anginal symptoms. Of note, a recent cardiology note from ___ states he reports not exerting himself or doing much activity because he is afraid something might happen. Five days PTA he experienced an episode of SOB after walking ___ feet, and had to rest for ___ minutes. On the day of admission he reports starting to have breakfast with a friend when he suddenly felt nauseous x4 but never vomited. He also reports anginal symptoms during this episode, but no worse than baseline, moderate SOB, pallor, and a general sense of feeling unwell. He denies diaphoresis, or radiating pain. He denied PND, and orthopnea. His wife reports noting worsened peripheral edema over the past days PTA. At ___, initial labs revealed Trop of 0.221 (previous one was normal in ___. TTE was completed which showed EF of ___ (prior ___ TTE from ___ with EF of >55%) with ? thrombus vs. vegetation on aortic valve. Patient was given lasix 20mg IV and levaquin 750mg IV for ?PNA. He was then transferred to ___ for further management. In the ___ ED, initial vitals were T 96.9 BP 127/79 HR 53 RR 15 O2sat 97%RA. Labs and imaging significant for troponins 0.18, Na 119, INR 4.7. He was given vancomycin, gentamicin, and rifampin. Vitals on transfer were to the floor where T 97.7 BP 122/63 HR 69 RR 20 O2sat 99%RA. On arrival to the floor, he reports feeling well and without symptoms or complaints. He denies chest pressure since yesterday and SOB currently. REVIEW OF SYSTEMS: On review of systems, he denied any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denied recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope Past Medical History: 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: ___ at ___ (LIMA to LAD, SVG to RCA, SVG to OM) -Atrial Fibrillation -Symptomatic Bradycardia -PERCUTANEOUS CORONARY INTERVENTIONS: - Last Cath in ___ at ___: BMS to OM2 (of note had a patent LM stent, 60% proximal, mid occluded LAD, 95% proximal LCx, 95% proximal OM3, patent LIMA to the LAD and occluded VG to RCA, occluded VG to OM) -PACING/ICD: single chamber pacemaker implant, VVI, ___ 3. OTHER PAST MEDICAL HISTORY: -Benign Prostatic Hyperplasia Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Father had emphysema and angina pectoris, died aged ___ of unspecified cause. Brother had emphysema and anginal pectories, died aged ___ of unspecified cardiovascular problems. Brother and sister both with CAD in ___. Mother died aged ___ of "old age." Daughter with history of ovarian cancer. A number of other children and grandchildren, all healthy. Physical Exam: Admission: Tmax 98.0 Tc 98.0 BP 125/75 (102-131/57-84) HR 65 (60-68) RR 18 (___) O2sat 95%RA (95-97%RA) Weight: 76.6kg I/O (as recorded): NPO, 200 IV, 525 (700) GU, no BM General:Alert, oriented x3, cooperative, in no acute distress HEENT: NCAT, PERRLA, EOMI, anicteric sclerae, oropharynx clear. No pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple, JVP of ~8cm, no palpable lymphadenopathy, masses or thyromegaly Cor: irreg irreg, mechanical heart sounds, no MRG. No thrills, lifts. No S3 or S4. Pulm: Dimished breath sounds on the right compared to left with crackles, as well as bilateral crackles at the bases. No wheezes or ronchi. Abdomen: soft, non-tender, non-distended, no rebound or guarding, no palpable masses or hepatosplenomagly, normoactive bowel sounds GU: No costovertebral angle tenderness, foley in place Extremities: WWP, no clubbing or cyanosis. 1+ pitting edema to midcalves. 2+ palpable carotid, radial, dorsalis pedis, and posterior tibial pulses bilaterally. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Discharge: VS: 97.8,96/54-122/70, 59-66, 18, 100% RA Tele: NSR, rate ___. Occasionally Vpaced. rare PVCs General: A&O x3, NAD Neck: Supple, JVP of ~8cm, no palpable masses CV: irreg irreg, mechanical heart sounds with loud S2, no MRG Pulm: Rales R > L. No wheezes or ronchi. Abdomen: soft, non-tender, non-distended, no rebound or guarding, no palpable masses or hepatosplenomagly, normoactive bowel sounds Extremities: WWP, no clubbing or cyanosis. 1+ pitting edema b/l. R femoral cath site CDI, no hematoma or bruit, 1+ ___ pulses b/l Pertinent Results: Admission: ___ 08:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 08:30PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 08:30PM ___ PTT-49.7* ___ ___ 08:30PM PLT COUNT-223 ___ 08:30PM NEUTS-76.1* LYMPHS-13.8* MONOS-9.5 EOS-0.5 BASOS-0.1 ___ 08:30PM WBC-4.9 RBC-3.37* HGB-12.0* HCT-34.5* MCV-102* MCH-35.7* MCHC-34.9 RDW-12.9 ___ 08:30PM OSMOLAL-255* ___ 08:30PM CALCIUM-8.4 PHOSPHATE-3.5 MAGNESIUM-1.9 ___ 08:30PM CK-MB-4 ___ 08:30PM cTropnT-0.18* ___ 08:30PM CK(CPK)-66 ___ 08:30PM estGFR-Using this ___ 08:30PM GLUCOSE-101* UREA N-25* CREAT-1.4* SODIUM-119* POTASSIUM-4.3 CHLORIDE-86* TOTAL CO2-24 ANION GAP-13 ___ 08:39PM LACTATE-1.4 Troponins: ___ 08:30PM BLOOD cTropnT-0.18* ___ 12:38AM BLOOD CK-MB-4 cTropnT-0.17* ___ 06:20AM BLOOD CK-MB-4 cTropnT-0.20* ___ 01:41AM BLOOD cTropnT-0.26* ___ 06:51AM BLOOD cTropnT-0.30* Discharge: ___ 06:32AM BLOOD Hct-32.4* ___ 01:00PM BLOOD ___ ___ 06:34AM BLOOD Glucose-83 UreaN-23* Creat-1.4* Na-132* K-4.7 Cl-94* HCO3-29 AnGap-14 ___ 06:34AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.0 ___ 08:30PM BLOOD Osmolal-255* ___ 06:20AM BLOOD TSH-1.9 Imaging: ___ ECG: There is marked baseline artifact. The rhythm is probably atrial fibrillation. Left bundle-branch block. No previous tracing available for comparison. TRACING #1 ___ ECG:Again marked baseline artifact is noted in this tracing. The rhythm is probably atrial fibrillation with controlled ventricular response. There also appear to be occasional paced beats. Compared to tracing #1 there is no diagnostic interval change. TRACING #2 ___ ECG: Atrial fibrillation. There is loss of R wave forces throughout the precordium. There are occasional wide complex beats which may represent aberrant conduction, although intermittent pacing may also be present. Compared to tracing #2 the loss of R waves in leads V4-V6 is new. TRACING #3 ___ CHEST (PORTABLE AP): FINDINGS: As compared to the previous radiograph, the extent of the partly loculated pleural effusions has increased. This is visible both in the fissural aspect of the pre-existing effusion as well as on the apical lateral compartment along the right chest wall. Unchanged evidence of moderate pulmonary edema with associated moderate cardiomegaly. No new parenchymal opacities. Unchanged position of the left pectoral pacemaker, unchanged course of the leads. TEE ___: There are simple atheroma in the descending thoracic aorta. A single tilting disk type aortic valve prosthesis is present. It is well seated and not rocking. No masses or vegetations are seen on the aortic valve. No aortic valve abscess is seen. Mild (1+) aortic regurgitation is seen, with a trivial amount of perivalvular leak. The mitral valve leaflets are mildly thickened. Centrally directed Moderate (2+) mitral regurgitation is seen. There is no abscess of the tricuspid valve. There is no pericardial effusion. CLINICAL IMPLICATIONS: Single tilting disk aortic valve with no evidence of vegetation or thrombus. Moderate mitral valve regurgitation. Cath ___: COMMENTS: 1) Selective coronary angiography of this right-dominant system demonstrated native three-vessel coronary artery disease. The LMCA had no apparent disease. The LAD was proximally occluded, with the distal vessel territory filling via the patent LIMA. The LCx had a subtotal occlusion at the ostium of the previously-placed bare-metal stent. The RCA was totally occluded in the mid-portion of the vessel, with the distal vessel territory filling via collaterals from the patent LIMA. 2) Arterial conduit angiography demonstrated a LIMA-LAD that was free of angiographically-apparent flow-limiting stenoses. 3) Fluoroscopy of the prosthetic aortic valve showed disk motion that was probably normal; however, it is unclear which type of prosthesis this is. 4) Limited resting hemodynamics revealed moderately-severe left-sided filling pressures, with a mean wedge pressure of 22 mmHg. There was moderately severe pulmonary arterial pressures, with a PA pressure of 66/21 mmHg. The cardiac index was slightly low at 1.84 l/min/m2. FINAL DIAGNOSIS: 1. Three vessel native coronary artery disease. 2. Patent LIMA-LAD. 3. Successful angioplasty of the proximal LCx stent. 4. Moderately severe elevation of left-sided and pulmonary pressures, with reduced cardiac output. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Warfarin 5 mg PO Frequency is Unknown 3. Hydrochlorothiazide 25 mg PO DAILY hold for sbp < 100 4. Ranexa *NF* (ranolazine) 1,000 mg Oral BID 5. Simvastatin 5 mg PO DAILY 6. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Ranexa *NF* (ranolazine) 1,000 mg Oral BID 3. Vitamin D 1000 UNIT PO DAILY 4. Lisinopril 10 mg PO DAILY RX *lisinopril 10 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 5. Metoprolol Succinate XL 25 mg PO DAILY RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 6. Simvastatin 5 mg PO DAILY 7. Outpatient Lab Work Please draw a ___ on ___ and fax results to Name: ___. Location: ___ MEDICINE Fax: ___ 8. Warfarin 5 mg PO 1X/WEEK (SA) 9. Warfarin 2.5 mg PO 6X/WEEK (___) Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: acute systolic heart failure, coronary artery disease Secondary: aortic valve replacement Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report CHEST RADIOGRAPH INDICATION: Questionable loculated pleural effusion, evaluation for interval change. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, the extent of the partly loculated pleural effusions has increased. This is visible both in the fissural aspect of the pre-existing effusion as well as on the apical lateral compartment along the right chest wall. Unchanged evidence of moderate pulmonary edema with associated moderate cardiomegaly. No new parenchymal opacities. Unchanged position of the left pectoral pacemaker, unchanged course of the leads. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: SHORTNESS OF BREATH Diagnosed with MYOCARDIAL INFARCTION NOS, INIT EPISODE OF CARE, PNEUMONIA,ORGANISM UNSPECIFIED, HYPOSMOLALITY/HYPONATREMIA temperature: 96.9 heartrate: 53.0 resprate: 15.0 o2sat: 97.0 sbp: 127.0 dbp: 79.0 level of pain: 0 level of acuity: 2.0

Mr. ___, You were transferred to ___ because of dyspnea. You had an ECHO of your heart that showed decreased function. A second ECHO was done to better evaluate your valve and there was no evidence of infection or clot. A cardiac cath was done and one of your stents was opened up. Medication changes: START lisinopril 10 mg by mouth daily for your heart and blood pressure START metoprolol XL 25 mg by mouth daily for your heart and blood pressure STOP hydrochlorothiazide as you will be on metoprolol XL and lisinopril for your blood pressure Please have INR drawn on ___.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Aspirin / Bactrim Attending: ___ Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: ___ with hx of COPD, tobacco abuse, atrial fibrillation on coumadin, hypercholesterolemia, stage IV CKD presenting with worsening shortness of breath, productive cough of white/yellow phlegm over the past 2 days. He denies any fever or chills. No chest pain or pressure. No abdominal pain. No recent hospitalizations. Is not on home oxygen and his normal oxygen saturation is around 93-95%? but once recently it has been as low as 88%at his cardiologist's office. + sick contacts in his dtr and grand dtr who both had URI sx. He has had diarrhea 2x in the course of hte past month. Prior to the development of this cough he felt well. He has chronic incontinence since his TURP and does not report dysuria. He does not have a pulmonologist. + rhinorrhea and sratchy throat. He has noticed that he does wake up sob and has to sleep on 3 pillows for the past year. He has noticed that he does need to take naps after dinner and he also takes a nap in the daytime. . He has had recent life stressors as he in the process of selling his 3 family home and moving into an ALF at ___. He is happy because he is getting a higher ___ for his home than he asked for. Wife of ___ years has been declining per PCP's recent note however. . In ER: (Triage Vitals:0 98.4 60 164/108 26 99% 6L neb) Meds Given: methylprednisone 125 mg IV, kayexelate 30 gm, levofloxacin 750 mg IV Fluids given: none Radiology Studies: CXR consults called. none Admission VS: 98.8, 60, 157/59, 20, 93% 3LNC . PAIN SCALE: ___ ________________________________________________________________ REVIEW OF SYSTEMS: 10 or 2 with "all otherwise negative" CONSTITUTIONAL: [] All Normal [ ] Fever [ ] Chills [ ] Sweats [+ ] Fatigue [ ] Malaise [ ]Anorexia [ ]Night sweats [ ] _____ lbs. weight loss/gain over _____ months Eyes [X] All Normal [ ] Blurred vision [ ] Loss of vision [] Diplopia [ ] Photophobia ENT [ ] Dry mouth [ ] Oral ulcers [ ] Bleeding gums [ +] Sore throat [] Sinus pain [ ] Epistaxis [ ] Tinnitus [ ] Decreased hearing [ +] Other:rhinorhrea RESPIRATORY: [] All Normal [ x] Shortness of breath at rest [+ ] Dyspnea on exertion [ ] Can't walk 2 flights [ +] Cough [ ] Wheeze [ +] Purulent sputum [ ] Hemoptysis [ ]Pleuritic pain [ ] Other: CARDIAC: [] All Normal [ ] Palpitations [ ] Edema [ ?] PND [ ] Orthopnea [- ] Chest Pain [ X] Dyspnea on exertion [ ] Other: GI: [] All Normal [- ] Nausea [-] Vomiting [] Abd pain [] Abdominal swelling [ X] Diarrhea x2 [ +] Constipation - otherwise usually constipated and has to take colace daily [ ] Hematemesis [ ] Blood in stool [ ] Melena [ ] Dysphagia: [ ] Solids [ ] Liquids [ ] Odynophagia [ ] Anorexia [ ] Reflux [ ] Other: GU: [X] All Normal [ ] Dysuria [ ] Incontinence or retention [ ] Frequency [ ] Hematuria []Discharge []Menorrhagia SKIN: [x] All Normal [ ] Rash [ ] Pruritus MS: [x] All Normal [ ] Joint pain [ ] Jt swelling [ ] Back pain [ ] Bony pain NEURO: [x] All Normal [ ] Headache [ ] Visual changes [ ] Sensory change [ ]Confusion [ ]Numbness of extremities [ ] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo [ ] Headache ENDOCRINE: [X] All Normal [ ] Skin changes [ ] Hair changes [ ] Heat or cold intolerance [ ] loss of energy HEME/LYMPH: [X] All Normal [ ] Easy bruising [ ] Easy bleeding [ ] Adenopathy PSYCH: [X] All Normal [ ] Mood change []Suicidal Ideation [ ] Other: [X]all other systems negative except as noted above Past Medical History: smoker prostate ca S/P prostatectomy: in ___ Dr. ___ urinary retention ___ - evaluated by Dr. ___ - no PVR Anxiety disorder w/ o/c characteristics Copd - ct in ___ revealed 'severe emphysema' Htn hycholesterolemia - CKD Stg IV: Seen by Dr. ___ ___ BID Renal: q6m renal ___ advised diastolic dysfunction - echo ___ - impaired relaxation LV EF > 65 % mild + 1 MR, ___ nuclear stress test NL done due to CP once in ___ while on distress anemia - ___ H/H 12.___, MCV 102.8 Irritable bowel diverticulosis - colonoscopy ___, Dr. ___ 4 hemangioma - MRI ___ restless leg syndrome - on ropenerol: in ___ Dr ___ rhinitis colonoscopy ___ showing diverticulosis of distal sigmoid colon, a polyp removed,adenoma, recomended repeat ___ years , or even ealrier if pt agrees atrial flutter sick sinus syndrome s/p pacemaker ___ f/up by cardiolgy Dr ___ (___) on Warfarin: Mx'd there (not BID System) Mild unsteady on his feet ___: hyperlipid ___: elev TSH ___: right breast lump, poster to nipple, ref'd Surg ___: FE defic anemia:ef'd gi ___ spinal stenosis multilevel spondylosis with degenerative disc disease prominent at L3-4, L4-5, foraminal stenosis at L4-5 and L5-S1 Social History: SOCIAL HISTORY/ FUNCTIONAL STATUS: I< ___ Lives with wife and he has 4 children . No ETOH-quit ___ years ago. 3 beers/night- never drank more than that. Cigarettes: [ ] never [ ] ex-smoker [x] current Pack-yrs: 10 quit: ______ ETOH: [x] No [ ] Yes drinks/day: _____ Drugs: none Occupation: ___ Marital Status: [ ] Married [] Single Lives: [ ] Alone [] w/ family [ ] Other: ___ dept of a ___ Received influenza vaccination in the past 12 months [ +]Y [ ]N Received pneumococcal vaccinationin the past 12 months [ ]Y [ ]N >65 ADLS: Independent of ADLS: [ ]dressing [ ]ambulating [ ]hygiene [ ]eating [ ]toileting Requires assitance with: [ [ ]dressing [ ]ambulating [ ]hygiene [ ]eating [ ]toileting IADLS: Independent of IADLS: [ ]shopping [ ] accounting [ ]telephone use [ ]food preparation Requires assitance with IADLS: [ ]shopping [ ] accounting [ ]telephone use [ ]food preparation [ ]has pre-existent home care services At baseline walks: [ ]independently [ ] with a cane [ ]walker [ ]wheelchair at ___ H/o fall within past year: []Y []N Visual aides [ ]Y [ ]N Dentures [ ]Y [ ]N Hearing Aides [ ]Y [ ] N Family History: Brother with DM. He is ___ and is "doing well." Motther died of lung ca and smoker Father died of asthma and heart disease Physical Exam: PHYSICAL EXAM: I3 - PE >8 VITAL SIGNS: GLUCOSE: PAIN SCORE VS Tm T 98.5 P 60 BP 138/58 RR 18 O2Sat on __92% on 3L __ liters O2 GENERAL: elderly male who looks his stated age. He is in NAD. Nourishment: at risk Grooming: good Mentation 2. Eyes: [X] WNL PERRL, EOMI without nystagmus, Conjunctiva: clear/injection/exudates/icteric Ears/Nose/Mouth/Throat: MMM, no lesions noted in OP 3. ENT [] WNL [] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____ cm [] Dry [+] Poor dentition - 2 teeth but they do not seem infected [] Thrush [] Swelling [] Exudate 4. Cardiovascular [] WNL JVP flat [] Regular [] Tachy [X] S1 [] S2 [X] Systolic Murmur ___, Location: LUSB [X] Irregular []Brady []S3 [] S4 [] Diastolic Murmur /6, Location: [X] Edema RLE None [] Bruit(s), Location: [X] Edema LLE None [] PMI [] Vascular access [] Peripheral [] Central site: 5. Respiratory [ ] [] CTA bilaterally [ +] Rales- RLL [ ] Diminshed [] Comfortable [ ] Rhonchi [ ] Dullness [ ] Percussion WNL [ ] Wheeze [] Egophony 6. Gastrointestinal [X] WNL [] Soft/firm [] Rebound [] No hepatomegaly [] Non-tender [] Tender [] No splenomegaly [] Non distended [] distended [] bowel sounds Yes/No [] guiac: positive/negative 7. Musculoskeletal-Extremities [X] WNL [ ] Tone WNL [ ]Upper extremity strength ___ and symmetrical [ ]Other: [ ] Bulk WNL [] Lower extremity strength ___ and symmetrica [ ] Other: [] Normal gait []No cyanosis [ ] No clubbing [] No joint swelling 8. Neurological [X] WNL [X ] Alert and Oriented x 3 [ ] Romberg: Positive/Negative [ ] CN II-XII intact [ ] Normal attention [ ] FNF/HTS WNL [] Sensation WNL [ ] Delirious/confused [ ] Asterixis Present/Absent [ ] Position sense WNL [ ] Demented [ ] No pronator drift [] Fluent speech 9. Integument [X] WNL [] Warm [] Dry [] Cyanotic [] Rash: none/diffuse/face/trunk/back/limbs [ ] Cool [] Moist [] Mottled [] Ulcer: None/decubitus/sacral/heel: Right/Left 10. Psychiatric [X] WNL [] Appropriate [] Flat affect [] Anxious [] Manic [] Intoxicated [] Pleasant [] Depressed [] Agitated [] Psychotic [] Combative 11. Hematologic/Lymphatic [ X]WNL [X] No cervical ___ TRACH: []present [X]none PEG:[]present [X]none [ ]site C/D/I COLOSTOMY: :[]present [X]none [ ]site C/D/I Pertinent Results: Admission Labs: ___ URINE COLOR-Yellow APPEAR-Clear SP ___ URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG LACTATE-1.0 GLC-98 BUN-26* CR-1.9* SODIUM-137 POTASSIUM-5.7* CHLORIDE-103 CO2-26 WBC-9.2 RBC-3.82* HGB-13.0* HCT-37.4* MCV-98 MCH-34.0* MCHC-34.7 RDW-12.5 NEUTS-82.2* LYMPHS-9.0* MONOS-5.4 EOS-2.5 BASOS-0.9 PLT COUNT-170 ___ PTT-32.6 ___ ECG: atrial paced at 60 bpm with no acute changes. CXR (___): Frontal and lateral views of the chest demonstrate irregular opacity punctuated with small lucencies possibly representing dilated bronchi. This could represent asymmetric edema versus infection, and could potentially represent entities such as bronchioloalveolar carcinoma. There may also be additional opacities in the right middle and left infrahilar lungs. There is no pneumothorax or pleural effusion. There is appearance of severe emphysema. Mild cardiomegaly is unchanged. Mediastinal and hilar contours are within normal limits. A left pectoral dual-channel pacer/AICD appears stable in location with leads terminating in the right atrium and right ventricle. Upper thoracic lordosis is unchanged. CXR (___) Comparison suggests mild regression of heart size and thymus, simultaneously lesser marked perivascular haze in the pulmonary circulation compatible with dehydration in patient previously suffering from fluid overload. The previously identified local suspicious hazy densities in the right mid lung field and lower lobe area as well as left upper lobe area have all regressed and suggest improvement of the previously identified multifocal densities suspicious to constitute exacerbation of the patient's chronic COPD status. No new parenchymal abnormalities are seen. Microbiology: Blood Cultures negative x2 Medications on Admission: albuterol sulfate [Ventolin HFA] 90 mcg HFA Aerosol Inhaler ___ puffs(s) inhaled every four (4) hours as needed for cough/wheeze/chest congestion/short of breath mdi with dose counter ___ carvedilol 25 mg Tablet 1 Tablet(s) by mouth twice a day (Prescribed by Other diazepam 5 mg Tablet 1 (One) Tablet(s) by mouth daily fluticasone [Flovent HFA] 220 mcg Aerosol 2 puffs(s) inhaled twice a day gabapentin 100 mg Capsule tid levothyroxine 50 mcg Tablet 1 Tablet(s) by mouth once a day (Prescribed by lisinopril 10 mg Tablet 1 Tablet(s) by mouth once a day (Prescribed by Other mometasone [Nasonex] 50 mcg Spray, Non-Aerosol 2 sparys in each nostril at ropinirole 2 mg Tablet 1 Tablet(s) by mouth twice a day (Prescribed by Other rosuvastatin [Crestor] 5 mg Tablet warfarin 5 mg Tablet 5 days a week and then 2.5 mg for two days a week * OTCs * cholecalciferol (vitamin D3) 1,000 unit Capsule docusate sodium 100 mg Capsule 1 Capsule(s) by mouth at bedtime (Prescribed by Discharge Medications: 1. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. diazepam 5 mg Tablet Sig: One (1) Tablet PO QHS PRN () as needed for insomnia. 3. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 4. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. ropinirole 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. Disp:*180 neb* Refills:*0* 11. fluticasone 220 mcg/actuation Aerosol Sig: Two (2) puffs Inhalation twice a day. 12. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 ___. 13. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1) Spray Nasal HS (at bedtime). 14. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:*30 Patch 24 hr(s)* Refills:*0* 15. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 16. Supplemental Oxygen Sig: Two (2) liters per minute continuous: via nasal cannula. Disp:*1 1* Refills:*0* 17. nebulizer accessories Misc Sig: One (1) nebulizer machine Miscellaneous use as directed. Disp:*1 unit* Refills:*0* Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Pneumonia COPD exacerbation Hypoxemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ male with shortness of breath and cough. Question pneumonia. ___. FINDINGS: Frontal and lateral views of the chest demonstrate irregular opacity punctuated with small lucencies possibly representing dilated bronchi. This could represent asymmetric edema versus infection, and could potentially represent entities such as bronchioloalveolar carcinoma. There may also be additional opacities in the right middle and left infrahilar lungs. There is no pneumothorax or pleural effusion. There is appearance of severe emphysema. Mild cardiomegaly is unchanged. Mediastinal and hilar contours are within normal limits. A left pectoral dual-channel pacer/AICD appears stable in location with leads terminating in the right atrium and right ventricle. Upper thoracic lordosis is unchanged. IMPRESSION: Findings concerning for multifocal pneumonia. Recommend treatment and followup to resolution. emphysema chk after edma rx mild cardiomegaly Radiology Report TYPE OF EXAMINATION: Chest PA and lateral. INDICATION: ___ male patient admitted with COPD exacerbation and volume overload. FINDINGS: PA and lateral chest views were obtained with patient in upright position. Analysis is performed in direct comparison with the next preceding similar study of ___. Comparison suggests mild regression of heart size and thymus, simultaneously lesser marked perivascular haze in the pulmonary circulation compatible with dehydration in patient previously suffering from fluid overload. The previously identified local suspicious hazy densities in the right mid lung field and lower lobe area as well as left upper lobe area have all regressed and suggest improvement of the previously identified multifocal densities suspicious to constitute exacerbation of the patient's chronic COPD status. No new parenchymal abnormalities are seen. The lateral and posterior pleural sinuses remain free as they were before. IMPRESSION: Improvement of previously diagnosed exacerbation of COPD, patient with multiple focal parenchymal infiltrates. The present chest findings are similar to what was noted on a more remote examination of ___. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: SOB Diagnosed with OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA, CARDIAC PACEMAKER STATUS temperature: 98.4 heartrate: 60.0 resprate: 26.0 o2sat: 99.0 sbp: 164.0 dbp: 108.0 level of pain: 0 level of acuity: 2.0

You were admitted to the hospital with difficulty breathing and were diagnosed with pneumonia and a COPD exacerbation. You were treated with antibiotics, steroids, and nebulizers with improvement in your breathing. You are being sent home with continuous oxygen, which you should use at all times. MEDICATION CHANGES: - you were started on Albuterol nebulizers and given a prescription for a nebulizer machine - you were started on home oxygen - you should use the Nicotine patch daily - do NOT smoke cigarettes while using oxygen

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: levofloxacin Attending: ___. Chief Complaint: Pulmonary embolism Shortness of breath Major Surgical or Invasive Procedure: Thoracentesis ___ History of Present Illness: ___ with recent dx of adenocarcinoma of the lung who presents as transfer from ___ with SOB found to have PE. The patient was recently admitted to ___ where he underwent a supraclavicular node bx which was positive for adeno carcinoma (seep path report below). He was also being treated for a RUL PNA with amoxicillin and axithromycin. He represented to ___ today for worsening SOB and CTA showed PE. He was transferred to ___ for evaluation for lysis. In the ED, initial vitals pain ___, T 99.1, HR 90, BP 149/70, RR 18, 92%RA. No exam documented on ED dash. Labs notable for unremarkable CBC, Chemistry with Bicarb 19, BUN/Cr ___. Troponin and BNP negative. Blood cx obtained. Imaging notable for subsegmental PE, large R effusion and a possible RUL post-obstructive PNA. Patient was continued on a heparin gtt, given 1L NS and 2gm Cefpepime. He was ordered for vancomycin but did not receive it. Cardiology was consulted for consideration of MASCOT activation. Given his clinical and hemodynamic stability, negative troponin and BNP MASCOT was not activated and he was maintained on a heparin gtt. On arrival to the floor, pt confirms the above history. In brief, he reports that he was discharged from ___ on ___ and worked ___ of this week. ___ he developed worsening cough and SOB and took ___. His sputum is occasionally blood tinged. He also found out about the results of his biopsy this week and was scheduled for a PET-CT on ___ with a plan to f/u with oncology for treatment options after. He also reports drenching night sweats and chills at home. He has never been lightheaded. He has some chest discomfort that has been present for several weeks. REVIEW OF SYSTEMS: No changes in vision or hearing, no changes in balance. No palpitations. No nausea or vomiting. No diarrhea or constipation. No dysuria or hematuria. No hematochezia, no melena. No numbness or weakness, no focal deficits. Past Medical History: Poorly differentiated Adenocarcinoma of Lung Social History: ___ Family History: He had two sisters deceased from cancer, though he is very vague on details. One is believed to be deceased from breast cancer at roughly age ___, the other is unclear. Father deceased from heart disease and alcohol. Mother is still alive. He has 3 other surviving siblings, reportedly well. His 2 biological sons are reportedly well, living locally. Physical Exam: Admission exam: Vitals: 98; 143/82; 92; 18; 95%2L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, JVP not elevated Lungs: Decreased BS at R base, RU exam with faint decrease relative to L, however no egophany. No wheezes, rales, ronchi. L lung CTA. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, no cyanosis or edema Skin: Without rashes or lesions Neuro: A&Ox3. Grossly intact. Discharge exam: Vitals: T:98.5 BP:131/69 P:82 RR:18 O2:94%RA General- Fatigued; tearful; alert, oriented HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, + lymphadenopathy Lungs- Normal work of breathing, +coarse rhonchi RML/RLL CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- no foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal Pertinent Results: Admission labs: ___ 11:35PM BLOOD WBC-9.6 RBC-4.56* Hgb-13.8 Hct-39.9* MCV-88 MCH-30.3 MCHC-34.6 RDW-12.3 RDWSD-39.4 Plt ___ ___ 11:35PM BLOOD Neuts-72.3* Lymphs-11.5* Monos-9.0 Eos-5.6 Baso-0.6 Im ___ AbsNeut-6.94* AbsLymp-1.10* AbsMono-0.86* AbsEos-0.54 AbsBaso-0.06 ___ 11:35PM BLOOD Glucose-87 UreaN-21* Creat-1.1 Na-135 K-4.2 Cl-99 HCO3-19* AnGap-21* ___ 11:35PM BLOOD Calcium-8.7 Phos-3.2 Mg-2.1 Discharge labs: ___ 04:50AM BLOOD WBC-8.4 RBC-4.15* Hgb-12.6* Hct-36.8* MCV-89 MCH-30.4 MCHC-34.2 RDW-12.3 RDWSD-40.2 Plt ___ ___ 04:50AM BLOOD ___ PTT-32.1 ___ ___ 04:50AM BLOOD Glucose-116* UreaN-16 Creat-1.0 Na-139 K-4.3 Cl-102 HCO3-25 AnGap-16 ___ 04:50AM BLOOD Calcium-8.3* Phos-3.5 ___ MRSA swab negative Pleural fluid studies: ___ 08:36AM PLEURAL WBC-___* ___ Polys-11* Lymphs-53* Monos-14* Eos-12* Atyps-1* ___ Macro-1* Other-8* ___ 08:36AM PLEURAL TotProt-3.8 Glucose-93 LD(LDH)-552 Albumin-2.4 Cholest-LESS THAN Triglyc-LESS THAN Misc-BODY FLUID Pleural fluid culture: GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. Pleural Fluid Cytology: POSITIVE FOR MALIGNANT CELLS. - Metastatic lung adenocarcinoma. - Immunohistochemical stains show the following pro file in lesional cells: Positive: TTF-1 Negative: Napsin A - Hematology slide reviewed. Note: The prepared cell block has high tumor cellul arity. Imaging: CXR (___): Comparison to ___. Minimal improvement of the large consolidation in the right lung apex. The paramediastinal consolidations as well as the enlargement of the right hilus and of the left hilus are stable. No new parenchymal opacities. Stable borderline size of the cardiac silhouette. Minimal right pleural effusion. Bone scan (___): 1. Slightly more intense focus of radiotracer uptake in the right inferior sacroiliac joint. Although this likely represents degenerative change, dedicated CT pelvis for further evaluation can be obtained if clinically indicated. 2. Diffuse right hemithoracic radiotracer uptake corresponds to a right pleural effusion. CT Chest w/ contrast (___): Massive perihilar lung mass, with bronchial, vascular, and mediastinal invasion, severe ipsilateral and contralateral lymphadenopathy, obstructive pneumonia, pleural implants, pleural effusion, postobstructive pneumonia, and propagation of the process along the bronchi. Known pulmonary embolism. Suspicious 1 cm right adrenal mass. No evidence of metastatic bone disease. Medications on Admission: None Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze RX *albuterol sulfate [ProAir HFA] 90 mcg 2 puff q4h prn Disp #*1 Inhaler Refills:*3 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 12 Days RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*19 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*1 4. Enoxaparin Sodium 90 mg SC Q12H Start: Today - ___, First Dose: Next Routine Administration Time RX *enoxaparin 100 mg/mL 90 mg SC every twelve (12) hours Disp #*60 Syringe Refills:*0 5. GuaiFENesin ER 600 mg PO Q12H Duration: 3 Days RX *guaifenesin 600 mg 1 tablet(s) by mouth q12h prn Disp #*20 Tablet Refills:*0 6. Ondansetron 4 mg PO Q8H:PRN nausea RX *ondansetron HCl 4 mg 1 tablet(s) by mouth q8h prn Disp #*60 Tablet Refills:*0 7. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Mild RX *oxycodone 5 mg 1 tablet(s) by mouth q3h prn Disp #*56 Tablet Refills:*0 8. Senna 8.6 mg PO BID RX *sennosides [senna] 8.6 mg 1 tablet by mouth BID prn Disp #*60 Tablet Refills:*0 9. Space Chamber Plus (inhalational spacing device) 1 oral Q6H:PRN wheezing Use with albuterol inhaler RX *inhalational spacing device [ProChamber] as dir Disp #*1 Package Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Malignant pleural effusion HCAP Adenocarcinoma of the lung Pulmonary embolism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with Rt effusion s/p thoracentesis // Residual fluid IMPRESSION: In comparison to outside chest x-ray of ___, a right pleural effusion has decreased in size, with no visible pneumothorax following recent thoracentesis. Extensive consolidation and atelectasis predominantly involving the right upper and middle lobes is likely post obstructive from a right juxta hilar mass more fully evaluated by outside CT of ___. Bulky intrathoracic lymphadenopathy is also more fully characterized on that study. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ with recent dx of adenocarcinoma of the lung who presents as transfer from ___ with SOB found to have PE, pneumonia, and right pleural effusion, now s/p thoracentesis // eval for metastatic lung cancer, diaphgragm invasion, bilateral nodules TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration, administration of intravenous contrast material, multiplanar reconstructions. DOSE: DLP: 811 mGy-cm COMPARISON: No comparison. FINDINGS: Small right thyroid nodule. No supraclavicular, infraclavicular or axillary lymphadenopathy. Several normal sized lymph nodes are seen in the axillary region. Several markedly enlarged anterior mediastinal lymph nodes (2, 20) as well as massively enlarged lymph nodes in the aortopulmonary window and in the pretracheal and paratracheal region (2, 24). Other pathologic lymph nodes are located at the level of the right and left hilus (2, 30) and in subcarinal location. As noted in the referring document, there is evidence of pulmonary embolism (2, 31). There also is a moderate right pleural effusion. In the upper abdomen, splenic calcifications are noted. A 1 cm right adrenal mass is visualized (2, 59). There also is a punctate renal calcification on the left (2, 65). No osteolytic lesions at the level of the ribs, thus sternum, or the vertebral bodies. Moderate degenerative vertebral disease. No vertebral compression fractures. Moderate pulmonary emphysema. Extensive right lymphangitis carcinomatosis a. extensive right upper lobe predominant consolidation, resulting from partial obstruction and narrowing of the upper lobe bronchi and tapering of the supplying arteries (603 a, 58). The consolidation has a more central and a more peripheral subpleural component (4, 125). On the pleural surfaces (4, 131) multiple nodular implants are noted. The bronchial walls are substantially thickened and show evidence of mucous impaction. Areas of pleural thickening are also seen at the basis of the right lower lobe (4, 192). IMPRESSION: Massive perihilar lung mass, with bronchial, vascular, and mediastinal invasion, severe ipsilateral and contralateral lymphadenopathy, obstructive pneumonia, pleural implants, pleural effusion, postobstructive pneumonia, and propagation of the process along the bronchi. Known pulmonary embolism. Suspicious 1 cm right adrenal mass. No evidence of metastatic bone disease. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ with recent dx of adenocarcinoma of the lung who presents as transfer from AJH with SOB found to have PE, pneumonia, and right pleural effusion, now s/p thoracentesis // eval for reaccumulation of pleural effusion eval for reaccumulation of pleural effusion IMPRESSION: Comparison to ___. Minimal improvement of the large consolidation in the right lung apex. The paramediastinal consolidations as well as the enlargement of the right hilus and of the left hilus are stable. No new parenchymal opacities. Stable borderline size of the cardiac silhouette. Minimal right pleural effusion. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Dyspnea, Transfer Diagnosed with Pneumonia, unspecified organism temperature: 99.1 heartrate: 90.0 resprate: 18.0 o2sat: 92.0 sbp: 149.0 dbp: 70.0 level of pain: 2 level of acuity: 2.0

Dear Mr. ___, You were admitted to ___ for shortness of breath and new blood clots in your lungs. You were also found to have a pneumonia (lung infection) and a pleural effusion (fluid accumulation in your chest). We treated you with blood thinners to prevent further clots. We also treated you with antibiotics and a procedure, called a thoracentesis, to drain the extra fluid. You were seen by our oncologists, who recommended that you ___ soon for further imaging and staging of your cancer. We are very sorry about this diagnosis. Please do the following once you leave the hospital: - Continue taking the prescribed antibiotics: Augmentin 875 mg every 12 hours, ending on ___, which will treat your pneumonia - Start taking oxycodone 5 mg every 3 hours as you need it for pain control. We have given you enough pills to last one week, before which you will see your primary care physician for ___ - Please also start taking the following medications: 1) Albuterol inhaler with spacer, and guaifenesin as needed for cough, 2) Colace and Senna as needed for constipation - Please continue doing the Lovenox injections (90 mg every 12 hours) to help prevent further blood clots It was a pleasure to participate in your care. We wish you all the best. Sincerely, Your ___ team

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Acute ischemic right occipital lobe stroke Major Surgical or Invasive Procedure: none History of Present Illness: Mr ___ is a ___ M with a h/o hypertension, hyperlipidemia and cerebral palsy (has baseline tone increase on left with some fine motor difficulties on that side) who has been seen in the Cognitive Neurology Clinic by Dr. ___ a ___ year history of progressive irritability and memory issues. As part of his work up he had a MRI of the brain that showed an acute left occipital stroke in addition to older encephalomalacia. He is therefore sent into the ED for admission for stroke work up. In regards to the symptoms he was being evaluated for, Mr. ___ has become more irritable and short tempered for the past year. Around this time, he had some incidents where he couldn't find his coat despite it being in very obvious places. He started to take longer to perform tasks than he had previously and was mis-interpreting emails and conversations. He has had difficulty remembering to lock up at the Archive that he works at as well as deactiviating alerms. He denies any visual symptoms or acute worsening of his baseline symptoms. Past Medical History: - cerebral palsy resulting in stiffness and weakness of his left arm and leg. He was born very prematurely at 3lb, 4oz - hypertension - hyperlipidemia. Social History: ___ Family History: Mother was diagnosed with Alzheimer's Disease around age ___, and died at age ___ from either a reaction to Abilify or "old age". His father had "heart problems" and died in his ___. His brother is healthy at age ___. As far as he knows no one else in his family has had dementia. Physical Exam: ON ADMISSION: General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt. was able to register 3 objects and recall ___ at 5 minutes. The pt. had good knowledge of current events. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, slight asymmetry in terms of left side being a little smaller VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, increased tone on left with cupping of left hand at baseline. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L 2 2 3 3 1 R 2 2 2 2 1 -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. left leg stiffening on walking ON DISCHARGE: unchanged Pertinent Results: Laboratory Data: ___ 09:40AM BLOOD WBC-9.4 RBC-5.29 Hgb-17.4 Hct-48.0 MCV-91 MCH-32.8* MCHC-36.2* RDW-13.3 Plt ___ ___ 09:40AM BLOOD Neuts-70.3* ___ Monos-5.8 Eos-2.4 Baso-0.5 ___ 09:40AM BLOOD ___ PTT-29.1 ___ ___ 09:40AM BLOOD Glucose-111* UreaN-23* Creat-1.3* Na-136 K-4.0 Cl-99 HCO3-24 AnGap-17 ___ 06:10AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.2 ___ 04:20PM BLOOD Cholest-184 ___ 04:20PM BLOOD %HbA1c-5.6 eAG-114 ___ 04:20PM BLOOD Triglyc-193* HDL-38 CHOL/HD-4.8 LDLcalc-107 Radiologic Data: CTA ___: 1. No evidence of acute infarction. Chronic infarction in the right frontal and parietal lobe. 2. Periventricular white matter low attenuation which is nonspecific but likely on the basis of chronic small vessel ischemic disease. 3. Unremarkable MRA of the head without evidence of stenosis, occlusion, or vascular malformation. 4. Stenosis at the origin of the left vertebral artery. Echo ___: The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets are moderately thickened. The aortic valve VTI = 58.4 cm. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: No intracardiac source of thromboembolism identified. Moderate aortic stenosis. Preserved biventricular size and systolic function. Normal pulmonary artery systolic pressure. ECG ___: Sinus rhythm with atrial premature depolarizations. Borderline left atrial abnormality. Minor non-specific repolarization abnormalities. No previous tracing available for comparison. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QID 2. Lisinopril 20 mg PO DAILY 3. Chlorthalidone 25 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Cyanocobalamin ___ mcg PO DAILY Discharge Medications: 1. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 2. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 3. Chlorthalidone 25 mg PO DAILY 4. Cyanocobalamin ___ mcg PO DAILY 5. Lisinopril 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: acute ischemic right occipital stroke Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CTA HEAD WANDW/O C AND RECONS INDICATION: History: ___ with chronic stroke on MRI // evaluate for vascluar lesions TECHNIQUE: Contiguous axial images were obtained through the brain without contrast material. Subsequently, rapid axial imaging was performed from the aortic arch through the brain during infusion of 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: DLP: 2396 mGy-cm; CTDI: 150 mGy COMPARISON: No prior CTA available for comparison. Prior MRI dated ___. FINDINGS: Head CT: There is encephalomalacia in the right frontal and parietal lobe with ex vacuo dilatation of the right lateral ventricle consistent with prior infarction in unchanged from prior MRI. There is no evidence of acute hemorrhage, edema, shift of midline, or extra-axial fluid collection. There is low attenuation in periventricular white matter which is nonspecific but in patient of this age likely reflecting chronic small vessel ischemic disease. There is mucosal thickening within the ethmoids. The remaining paranasal sinuses and mastoid air cells are clear. The calvarium and skullbase are intact appear Head CTA: There are no intracranial vascular abnormalities. There is no evidence of aneurysm, stenosis or occlusion. Neck CTA: There is stenosis at the origin of the left vertebral artery. The carotid and vertebral arteries and their major branches are otherwise patent with no evidence of stenoses. There is no evidence of internal carotid stenosis by NASCET criteria. IMPRESSION: 1. No evidence of acute infarction. Chronic infarction in the right frontal and parietal lobe. 2. Periventricular white matter low attenuation which is nonspecific but likely on the basis of chronic small vessel ischemic disease. 3. Unremarkable MRA of the head without evidence of stenosis, occlusion, or vascular malformation. 4. Stenosis at the origin of the left vertebral artery. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: ABN MRI Diagnosed with CEREBRAL ART OCCLUS W/INFARCT, HYPERTENSION NOS temperature: 97.6 heartrate: 94.0 resprate: 16.0 o2sat: 100.0 sbp: 122.0 dbp: 95.0 level of pain: 0 level of acuity: 3.0

Dear Mr. ___, You were hospitalized after your MRI revealed an ACUTE ISCHEMIC STROKE, a condition in which a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. Damage to the brain from being deprived of its blood supply can result in a variety of symptoms. Stroke can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: - high cholesterol - high blood pressure We are changing your medications as follows: - starting plavix - stopping aspirin - increasing your atorvastatin dose Because we did not find the cause of your stroke, you will have a cardiac monitor outpatient (called ___ of Hearts). Please call ___ to set this up. Please take your other medications as prescribed. Please followup with Neurology and your primary care physician. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - sudden partial or complete loss of vision - sudden loss of the ability to speak words from your mouth - sudden loss of the ability to understand others speaking to you - sudden weakness of one side of the body - sudden drooping of one side of the face - sudden loss of sensation of one side of the body - sudden difficulty pronouncing words (slurring of speech) - sudden blurring or doubling of vision - sudden onset of vertigo (sensation of your environment spinning around you) - sudden clumsiness of the arm and leg on one side or sudden tendency to fall to one side (left or right) - sudden severe headache accompanied by the inability to stay awake It was a pleasure providing you with care during this hospitalization.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: hypotension light-headedness ___ swelling Major Surgical or Invasive Procedure: None History of Present Illness: ___ hx DM2 on insulin, CAD, OSA who presents for evaluation of fatigue and lightheadedness for the last couple weeks. Pt states that over the last couple weeks he has been more fatigued with exercise intolerance. He normally walks ~1 mile to ___ but recently has been slower and unable to complete the walk. He also endorses intermittent episodes of lightheadedness usually with exertion, not orthostatic. He also endorses b/l thigh pain and L>R shoulder pain. Denies f/c, CP, palpitations, orthopnea, PND, DOE. No focal neuro symptoms or vision changes. BP at ___ ___ and noted to be ___. He went to PCP ___ ___ and was found to have BP in ___ and was referred to ___ ED. There he had normal labs and a negative ___. The plan was for observation overnight but pt left AMA given it was the Sabbath. He continued to experience symptoms and again went to ___ ___ ___ and was referred to the ED. Past Medical History: DM ED Obesity angina, stable CAD dyslipidemia s/p angioplasty/stent ___, LAD Lyme dz OSA (intolerant of CPAP) s/p appy Social History: ___ Family History: Patient's past medical history is not pertinent to reason for admission. Physical Exam: ADMISSION PHYSICAL EXAM: =============================== VS: ___ ___ Temp: 97.6 PO BP: 144/70 HR: 67 RR: 18 O2 sat: 96% O2 delivery: RA GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: No JVD. CARDIAC: RRR, no murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: 2+ pitting edema b/l to thighs R>L SKIN: WWP, no obvious rashes NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal sensation. Gait is normal. AOx3. DISCHARGE PHYSICAL EXAM: ============================== ___ 1144 Temp: 98.0 PO BP: 130/71 HR: 68 RR: 18 O2 sat: 91% O2 delivery: Ra FSBG: 275 GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. CARDIAC: RRR, ___ systolic murmur best heard at RUSB; no rubs/gallops LUNGS: Crackles in lower lung fields bilaterally, up to middle lung fields ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: 2+ pitting edema b/l to thighs R>L SKIN: WWP, no obvious rashes Pertinent Results: ADMISSION LABS: =================== ___ 05:52PM BLOOD WBC-9.0 RBC-3.70* Hgb-11.4* Hct-36.0* MCV-97 MCH-30.8 MCHC-31.7* RDW-12.5 RDWSD-44.4 Plt ___ ___ 05:52PM BLOOD Neuts-65.9 Lymphs-17.1* Monos-12.1 Eos-3.7 Baso-0.6 Im ___ AbsNeut-5.92 AbsLymp-1.54 AbsMono-1.09* AbsEos-0.33 AbsBaso-0.05 ___ 05:52PM BLOOD Glucose-78 UreaN-34* Creat-1.2 Na-142 K-4.7 Cl-103 HCO3-25 AnGap-14 ___ 05:52PM BLOOD Calcium-9.7 Phos-3.3 Mg-1.9 ___ 05:52PM BLOOD CRP-8.6* ___ 07:11AM BLOOD Cortsol-12.7 ___ 05:57PM BLOOD Lactate-0.9 DISCHARGE LABS: =================== ___ 06:58AM BLOOD WBC-7.0 RBC-3.52* Hgb-10.9* Hct-34.1* MCV-97 MCH-31.0 MCHC-32.0 RDW-12.7 RDWSD-44.4 Plt ___ ___ 06:58AM BLOOD Plt ___ ___ 06:58AM BLOOD Glucose-142* UreaN-19 Creat-1.0 Na-142 K-4.5 Cl-103 HCO3-26 AnGap-13 IMAGING CTA CHEST AND CT ABDOMEN ___: =========================================== IMPRESSION: 1. No evidence of pulmonary embolism to the segmental level. 2. Interval increase in retroperitoneal and mediastinal lymphadenopathy, compared to ___, raising the possibility of chronic lymphocytic leukemia. Interval stability to minimal increase in pelvic lymphadenopathy. If biopsy is to be considered, an enlarged right external iliac node (304:73) may be amenable to sampling. 3. Moderate bilateral pleural effusions with associated atelectasis. 4. Diffuse, moderate bronchial wall thickening, most prominent within the bilateral lower lobes, suggestive of inflammation. 5. Cholelithiasis, without evidence of acute cholecystitis. TTE ECHOCARDIOGRAM: ======================= FINDINGS: LEFT ATRIUM (LA)/PULMONARY VEINS: Mildly dilated LA. RIGHT ATRIUM (RA)/INTERATRIAL SEPTUM/INFERIOR VENA CAVA (IVC): Mildly dilated RA. Dilated IVC with normal inspiratory collapse==>RA pressure ___ mmHg. LEFT VENTRICLE (LV): Mild symmetric hypertrophy. Normal cavity size. Normal regional/global systolic function. The visually estimated left ventricular ejection fraction is 55-60%. No resting outflow tract gradient. Tissue Doppler suggests elevated PCWP. RIGHT VENTRICLE (RV): Mild cavity enlargement. Normal free wall motion. AORTA: Normal sinus diameter for gender. Normal ascending diameter for gender. Normal arch diameter. AORTIC VALVE (AV): Mildly thickend (3) leaflets. No stenosis. No regurgitation. MITRAL VALVE (MV): Normal leaflets. No systolic prolapse. Trivial regurgitation. PULMONIC VALVE (PV): Normal leaflets. Physiologic regurgitation. TRICUSPID VALVE (TV): Normal leaflets. Moderate [2+] regurgitation. Moderate pulmonary artery systolic hypertension. PERICARDIUM: No effusion. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 2. Senna 17.2 mg PO HS 3. Docusate Sodium 100 mg PO BID 4. ___ 0.4 mg PO DAILY 5. MetFORMIN (Glucophage) 1000 mg PO BID 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 20 mg PO QPM 8. Metoprolol Succinate XL 25 mg PO DAILY 9. Levemir 32 Units Breakfast Levemir 10 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 10. dulaglutide 0.75 mg/0.5 mL subcutaneous 1X/WEEK Discharge Medications: 1. Levemir 32 Units Breakfast Levemir 10 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 2. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 20 mg PO QPM 5. Docusate Sodium 100 mg PO BID 6. dulaglutide 0.75 mg/0.5 mL subcutaneous 1X/WEEK 7. MetFORMIN (Glucophage) 1000 mg PO BID 8. Senna 17.2 mg PO HS 9. HELD- Metoprolol Succinate XL 25 mg PO DAILY This medication was held. Do not restart Metoprolol Succinate XL until okay with PCP or cardiologist 10. HELD- ___ 0.4 mg PO DAILY Duration: 1 Dose This medication was held. Do not restart ___ until you speak to your PCP as it may be making you dizzy. Discharge Disposition: Home Discharge Diagnosis: Primary: -------------- Pulmonary Hypertension lower extremity edema, bilateral weakness lymphadenopathy bilateral pleural effusions thickened bronchial walls Secondary: -------------- insulin dependent diabetes mellitus coronary artery disease with stent placed in past obesity sleep apnea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CTA chest and CT abdomen and pelvis. INDICATION: ___ year old man with new pulmonary hypertension. Evaluate for pulmonary embolism. TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of intravenous contrast in the arterial phase. Then, imaging was obtained through the abdomen and pelvis in the portal venous phase. Reformatted coronal and sagittal images through the chest, abdomen, and pelvis, and oblique maximal intensity projection images of the chest were submitted to PACS and reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 2.7 s, 36.2 cm; CTDIvol = 23.6 mGy (Body) DLP = 852.8 mGy-cm. 2) Spiral Acquisition 3.9 s, 51.2 cm; CTDIvol = 24.1 mGy (Body) DLP = 1,231.7 mGy-cm. 3) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 5.4 mGy (Body) DLP = 2.7 mGy-cm. 4) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 2.7 mGy (Body) DLP = 1.3 mGy-cm. 5) Stationary Acquisition 5.4 s, 0.5 cm; CTDIvol = 24.2 mGy (Body) DLP = 12.1 mGy-cm. Total DLP (Body) = 2,101 mGy-cm. COMPARISON: CT torso ___. FINDINGS: CHEST: HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the segmental level without filling defect to indicate a pulmonary embolus. The thoracic aorta is normal in caliber without evidence of dissection or intramural hematoma. Moderate coronary artery calcifications. Mild aortic valvular calcifications. The heart is mildly enlarged. Otherwise, the heart, pericardium, and great vessels are within normal limits. No pericardial effusion is seen. The main pulmonary artery is top-normal in size. Mild atherosclerotic calcifications of the thoracic aorta. AXILLA, HILA, AND MEDIASTINUM: Multiple mediastinal nodes are prominent to enlarged. For example, several enlarged right paratracheal nodes measure up to 1.7 cm (302:67), previously 1.2 cm compared to the study from ___. Multiple, bilateral prepectoral and axillary nodes are prominent, but not pathologically enlarged by CT size criteria. No hilar lymphadenopathy. No mediastinal mass. PLEURAL SPACES: Moderate bilateral pleural effusions with associated atelectasis. No pneumothorax. LUNGS/AIRWAYS: The study is not optimized for evaluation of the lung parenchyma. Within these confines, aside from the aforementioned findings, the lungs are clear without masses or areas of parenchymal opacification. Diffuse, moderate bronchial wall thickening is most prominent within the bilateral lower lobes. The airways are patent to the level of the segmental bronchi bilaterally. BASE OF NECK: Visualized portions of the base of the neck show no abnormality. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. Tiny hyperdense stones layer within the gallbladder. No evidence of wall thickening or pericholecystic stranding. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. A right renal subcentimeter hypodensity in the upper pole is too small to characterize. There is no hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is normal. There is no free intraperitoneal fluid or free air. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: Coarse calcification within the prostate. A penile prosthesis is in place, partially imaged. LYMPH NODES: Multiple retroperitoneal nodes are enlarged, increased in size from ___. For example, a retroaortic node measures 1.4 cm, previously 1.3 cm (304:38). A retrocaval lymph node now measures 1.4 cm (304:40), previously 1.1 cm. Prominent bilateral iliac chain and right pelvic sidewall nodes appear stable to minimally increased in size (for example, 304:70, 304:65). Enlarged bilateral external iliac nodes measuring up to 1.9 cm (304:73, 75) are stable from prior. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. BONES AND SOFT TISSUES: Moderate, fat containing paraumbilical hernia. Otherwise, the abdominal and pelvic wall is within normal limits. There is no evidence of worrisome osseous lesions or acute fracture. IMPRESSION: 1. No evidence of pulmonary embolism to the segmental level. 2. Interval increase in retroperitoneal and mediastinal lymphadenopathy, compared to ___, raising the possibility of chronic lymphocytic leukemia. Interval stability to minimal increase in pelvic lymphadenopathy. If biopsy is to be considered, an enlarged right external iliac node (304:73) may be amenable to sampling. 3. Moderate bilateral pleural effusions with associated atelectasis. 4. Diffuse, moderate bronchial wall thickening, most prominent within the bilateral lower lobes, suggestive of inflammation. 5. Cholelithiasis, without evidence of acute cholecystitis. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 4:01 pm, 1 minutes after discovery of the findings. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Hypotension Diagnosed with Acute kidney failure, unspecified temperature: 96.7 heartrate: 57.0 resprate: 16.0 o2sat: 95.0 sbp: 137.0 dbp: 54.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL? - Your primary care doctor referred you to the ED for low blood pressures. - You told us you had been experiencing occasional dizziness, weakness in your legs, and leg swelling for quite some time. WHAT HAPPENED TO ME IN THE HOSPITAL? - You had lab work that showed your red blood cells and platelets were lower than normal levels. - You had an ultrasound of your heart (echocardiogram) that showed no change in heart function from prior studies, but did show pulmonary hypertension (increased pressures in your lungs). - You had CT-imaging done of your chest to help determine why you have pulmonary hypertension. - You had CT-imaging of your stomach and pelvis to help figure out why your legs have been swelling over the past year or so. This showed lymph nodes deep in your abdomen that are larger than normal, and will need to be biopsied to get a clear answer as to why. - We monitored your blood pressures, and they were never low. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? -Please continue to take all of your medications and follow-up with your appointments as listed below. -You will need an Interventional Radiologist (___) guided biopsy of a lymph node. We have asked your PCP to help you arrange this biopsy. -You will need to see a pulmonologist for your new diagnosis of pulmonary hypertension. See below for your appointment scheduling instructions with a pulmonary hypertension specialist. - We held your ___, as well as metoprolol since it may be contributing to your low blood pressures and light-headedness. Speak with your Primary physician about restarting ___ if you are still having difficulty with urinary symptoms. Speak with your cardiologist before restarting metoprolol. - Your cardiology office should call you with a follow-up appointment. Please contact them if you don't hear in the next few days. We wish you the best! Sincerely, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Penicillins Attending: ___. Chief Complaint: Abdominal pain, nausea/vomiting Major Surgical or Invasive Procedure: None History of Present Illness: ___ with remote history of small bowel resection and ?right colectomy with ileocolic anastomosis recently admitted to ___ colorectal surgery service ___ to ___ with a complete obstruction at the site of his prior anastomosis for which he underwent an exploratory laparotomy, extensive LOA, ileocolectomy with new ileocolic anastomosis formation, and incicisional hernia repair with Dr. ___ on ___. He now re-presents to ___ in transfer from ___ with bilious emesis similar to his prior obstruction and a CT scan showing SBO with tapering/transition at a loop that runs near his RLQ anastomosis where he has significant ___ inflammation, also with enteritis of the small bowel distal to the transition point. Patient states he hasn't passed gas in a couple days, has been having waves of abdominal pain since yesterday that are relieved when he vomits brown/green non-bloody fluid, and that his last BM was last night and was black and liquidy (says he has been having black liquidy stools for most of his time at the rehab since being discharged from ___. Last meal was ___ from the best he can remember. ROS: (+) per HPI, also says he has had some chills. (-) Denies fevers, chest pain, SOB, cough, dizziness/lightheadedness, syncope, difficulty urinating, or pain or swelling in his legs. Past Medical History: Type 2 diabetes mellitus Diabetic neuropathy with recurrent diabetic foot ulcers Admission to ___ for multilobar pneumonia, infected left great toe neuropathic ulcer, wound culture growing MSSA ___ COPD Lung nodules Coronary artery disease, stable angina pectoris Hypertension Hyperlipidemia Right patellar chondromalacia, degenerative joint disease Colon adenomas Cerebral cysts BPH, urinary retention Constipation Hypothyroidism B-12 deficiency anemia Incisional hernia History of heavy alcohol abuse Frontal temporal dementia without behavioral disturbance Severe insomnia Depression Orthostatic hypotension Past Surgical History: Left great toe amputation for osteomyelitis Left second toe amputation History of small bowel obstruction ×3 since ___, status post Small bowel resection with ileocolonic anastomosis, no details available Right knee arthroscopy Appendectomy Hernia repair Tonsillectomy Social History: ___ Family History: Mother with diabetes, ___ dementia in her ___, father had coronary artery disease, MI in late ___, some heart problems and died in his mid ___ Physical Exam: Physical Exam on Admission: Vitals: T 98.3, HR 76, BP 166/82, RR 18, SPO2 98% RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l ABD: Soft, obese, not appreciably distended, diffusely TTP but no R/G, midline incision with staples appears to be healing well with no surrounding erythema, breakdown, or drainage to correlate with the fluid collection seen in his incision on imaging, left abdominal port site also well healing with no evidence of infection or breakdown DRE: normal tone, no masses appreciated, no stool obtained to test FOB, no gross blood Ext: No ___ edema, ___ warm and well perfused Physical Exam on Discharge General: doing well, tolerating a regular diet, pain controlled, ambulating, mental status at baseline pleasant and oriented to himself however is poor historian. VSS Neuro: baseline, oriented to self Cardio/Pulm: no chest pain or shortness of breath Abd: midline incision staples removed, 5 cm area of proximal incision opened and packed with wick draining small amounts of serosang drainage, rest of incision with steristrips and is well approximated without signs of infection, abdomen is soft and nondistended. ___: no pedal edema, gait strong Pertinent Results: ___ 07:42AM BLOOD WBC-2.8* RBC-3.10* Hgb-9.6* Hct-29.8* MCV-96 MCH-31.0 MCHC-32.2 RDW-12.8 RDWSD-44.4 Plt ___ ___ 07:35AM BLOOD WBC-3.8* RBC-2.98* Hgb-9.2* Hct-28.4* MCV-95 MCH-30.9 MCHC-32.4 RDW-12.7 RDWSD-44.6 Plt ___ ___ 11:20AM BLOOD WBC-5.6 RBC-3.12* Hgb-9.6* Hct-29.7* MCV-95 MCH-30.8 MCHC-32.3 RDW-12.9 RDWSD-45.1 Plt ___ ___ 06:40AM BLOOD WBC-9.2 RBC-3.25* Hgb-10.0* Hct-31.0* MCV-95 MCH-30.8 MCHC-32.3 RDW-13.1 RDWSD-46.4* Plt ___ ___ 03:41PM BLOOD WBC-12.1* RBC-3.60* Hgb-11.2* Hct-34.0* MCV-94 MCH-31.1 MCHC-32.9 RDW-13.0 RDWSD-45.4 Plt ___ ___ 06:55AM BLOOD WBC-11.5* RBC-3.73* Hgb-11.6* Hct-35.4* MCV-95 MCH-31.1 MCHC-32.8 RDW-13.1 RDWSD-45.2 Plt ___ ___ 06:55AM BLOOD Neuts-85.0* Lymphs-7.7* Monos-6.1 Eos-0.3* Baso-0.3 Im ___ AbsNeut-9.77* AbsLymp-0.88* AbsMono-0.70 AbsEos-0.03* AbsBaso-0.03 ___ 07:42AM BLOOD Plt ___ ___ 07:35AM BLOOD Plt ___ ___ 11:20AM BLOOD Plt ___ ___ 06:40AM BLOOD Plt ___ ___ 03:41PM BLOOD Plt ___ ___ 06:55AM BLOOD Plt ___ ___ 06:55AM BLOOD ___ PTT-27.4 ___ ___ 07:42AM BLOOD Glucose-92 UreaN-3* Creat-0.9 Na-142 K-3.6 Cl-106 HCO3-25 AnGap-11 ___ 07:35AM BLOOD Glucose-103* UreaN-6 Creat-0.8 Na-142 K-3.8 Cl-106 HCO3-26 AnGap-10 ___ 11:20AM BLOOD Glucose-142* UreaN-8 Creat-1.0 Na-137 K-3.6 Cl-100 HCO3-27 AnGap-10 ___ 06:40AM BLOOD Glucose-129* UreaN-11 Creat-1.1 Na-140 K-4.0 Cl-100 HCO3-29 AnGap-11 ___ 06:55AM BLOOD Glucose-126* UreaN-9 Creat-0.9 Na-141 K-4.3 Cl-100 HCO3-27 AnGap-14 ___ 07:42AM BLOOD Calcium-8.0* Phos-3.1 Mg-2.2 ___ 07:35AM BLOOD Calcium-8.1* Phos-2.8 Mg-2.4 ___ 11:20AM BLOOD Calcium-8.0* Phos-2.5* Mg-1.7 ___ 06:40AM BLOOD Calcium-8.2* Phos-2.3* Mg-1.6 ___ 06:55AM BLOOD Calcium-9.2 Phos-2.9 Mg-1.9 ___ 06:40AM BLOOD Vit___-___ ___ 06:40AM BLOOD TSH-2.3 Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Losartan Potassium 50 mg PO DAILY 2. amLODIPine 5 mg PO DAILY 3. Citalopram 40 mg PO DAILY 4. Levothyroxine Sodium 88 mcg PO DAILY 5. QUEtiapine Fumarate 150 mg PO QHS 6. Simvastatin 10 mg PO QPM 7. Tamsulosin 0.4 mg PO QHS 8. TraZODone 50 mg PO QHS 9. Breo Ellipta (fluticasone-vilanterol) 100-25 mcg/dose inhalation DAILY 10. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H:PRN 11. Melatin (melatonin) 3 mg oral QHS 12. Enoxaparin Sodium 40 mg SC Q24H mucinex ___ bid Discharge Medications: 1. GuaiFENesin ER 600 mg PO Q12H 2. MetroNIDAZOLE 500 mg PO TID please take for 14 days RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three times a day Disp #*42 Tablet Refills:*0 3. amLODIPine 5 mg PO DAILY 4. Breo Ellipta (fluticasone-vilanterol) 100-25 mcg/dose inhalation DAILY 5. Citalopram 40 mg PO DAILY 6. Enoxaparin Sodium 40 mg SC Q24H Duration: 9 Days please take until ___, 9 more days, prevents blood clots after surgery RX *enoxaparin 40 mg/0.4 mL 40 mg subcutaneous once a day Disp #*9 Syringe Refills:*0 7. Levothyroxine Sodium 88 mcg PO DAILY 8. Losartan Potassium 50 mg PO DAILY 9. Melatin (melatonin) 3 mg oral QHS 10. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H:PRN 11. QUEtiapine Fumarate 150 mg PO QHS 12. Simvastatin 10 mg PO QPM 13. Tamsulosin 0.4 mg PO QHS 14. TraZODone 50 mg PO QHS Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: Chest: Frontal and lateral views INDICATION: History: ___ with SBO, NG tube, dyspnea// assess for NG tube placement TECHNIQUE: Chest: Frontal and Lateral COMPARISON: Chest radiograph ___ FINDINGS: The enteric tube is seen extending to the left upper quadrant with tip beyond view. The level of the side port of the enteric tube is not well assessed.The lungs are clear without focal consolidation. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are unremarkable. Moderate to large amount of gas is seen within the stomach. IMPRESSION: 1. Enteric tube is seen extending to the left upper quadrant with tip out of view of the image. Moderate to large amount of gas is seen within the stomach. 2. No acute cardiopulmonary process. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Abd pain, SBO, Transfer Diagnosed with Unspecified abdominal pain temperature: 98.3 heartrate: 80.0 resprate: 15.0 o2sat: 98.0 sbp: 161.0 dbp: 84.0 level of pain: 7 level of acuity: 3.0

Dear Mr. ___, You were admitted to the hospital for a small bowel obstruction. You were given bowel rest and intravenous fluids and a nasogastric tube was placed in your stomach to decompress your bowels. Your obstruction has subsequently resolved after conservative management. You have tolerated a regular diet, are passing gas and your pain is controlled with pain medications by mouth. You may return home to finish your recovery. You had some evidence of inflammation of the bowel on your cat scan and your symptoms improved with antibiotics. You will continue to take flagyl for 3 weeks. If you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or extended constipation. You have a midline incision from your prior surgery. We opened a portion of this wound and it will need to be packed with gauze. The rest of the incision is closed with steristrips. Please monitor for worsening signs of infection: increasing redness of the incision lines, white/green/yellow/malodorous drainage, increased pain at the incision, increased warmth of the skin at the incision, or swelling of the area. You may shower; pat the incisions dry with a towel, do not rub. The small incisions may be left open to the air. If closed with steri-strips (little white adhesive strips), these will fall off over time, please do not remove them. Please no baths or swimming until cleared by the surgical team. If you have pain you may take Tylenol as needed. Do not drink alcohol while taking Tylenol. Please do not take more than 3000mg of Tylenol in 24 hours. Thank you for allowing us to participate in your care! Our hope is that you will have a quick return to your life and usual activities.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Ampicillin Attending: ___. Chief Complaint: tachycardia Major Surgical or Invasive Procedure: none History of Present Illness: ___ with h/o DMII, CAD, and sCHF (LVEF <25% in ___ s/p recent L salpingoopherectomy (discharged ___ for an enlarged adnexal mass admitted with tachycardia and abdominal pain. On ___, pt underwent LSO for L adnexal mass (found to be serous cystadenoma, peritoneal cytology negative). Surgery was c/b extensive adnesions and omental bleeding and pt required laparotomy, L salpingo-ooperectomy and intubation over night. She was admitted to the ICU with post-op course complicated by respiratory failure, HCAP and e. coli/enterococcus UTI, as well as L shoulder pain. She was treated with clindamycin --> levofloxacin ___ - ___ 10d course intended).Discharged home, but developed nausea, vomiting, diarrhea and readmitted with symptoms felt secondary to viral gastroenteritis. She returns today with palpitations, nausea, vomiting x 3 days with worsening pain, most tender in her midepigastrium to LUQ. Pain is non pleuritic, no associated dyspnea. + Sick contacts. Also with chronic R shoulder pain s/p surgery. . On arrival to the ED, initial vitals were T: 98.7 HR: 70 bp: 148/100 02 SAT 100% RA. CT abdomen and pelvis was none revealing. She was found to have increased creatine from 1.0 to 2.1 and was having mid epigastic pain thus she was admitted to medicne. Currently, she has diffuse abdominal TTP, worse at site of recent surgery (steri strips in place). Denies chest pain. . ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: - Type 2 diabetes mellitus (A1C 6.4% in ___ - Coronary artery disease (s/p cath ___, no stents) - Left bundle branch block - Congestive heart failure due to cardiomyopathy ___ EF 20%) - Asthma (FEV1 79%) - Hypertension - Obesity - GERD - Diverticulitis - Lung adenocarcinoma s/p resection in ___ (PET neg) - Breast cancer s/p mastectomy remotely - Former tobacco use - Mastectomy - VATS wedge resection Social History: ___ Family History: Mother died of diabetic complications at age ___, she didn't know her father. Physical Exam: ADMISSION EXAM: VS - Temp 98.6 BP: 123/82 HR: 108 rr:22 98% RA R , R , O2-sat % RA GENERAL - NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD HEART - PMI non-displaced, RRR, nl S1-S2, no MRG LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use ABDOMEN - NABS, soft/NT/diffusely TTP, worst at surgicalsite, steris in place, no drainage, erythema,swelling. no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, gait deferred DISCHARGE EXAM: GENERAL - NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD HEART - PMI non-displaced, RRR, nl S1-S2, no MRG LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use ABDOMEN - NABS, soft/NT/none tender to palpation, steris in place, no drainage, erythema,swelling. no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, gait deferred Pertinent Results: ADMISSION LABS: ___ 11:58PM ALT(SGPT)-14 AST(SGOT)-15 LD(LDH)-168 CK(CPK)-51 ALK PHOS-62 TOT BILI-0.4 ___ 11:58PM LIPASE-54 ___ 11:58PM CK-MB-2 cTropnT-0.02* ___ 12:35PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 12:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-LG ___ 12:35PM URINE RBC-2 WBC-48* BACTERIA-FEW YEAST-NONE EPI-2 TRANS EPI-<1 ___ 12:35PM URINE HYALINE-18* ___ 12:35PM URINE MUCOUS-FEW ___ 10:51AM LACTATE-1.5 ___ 10:45AM GLUCOSE-228* UREA N-24* CREAT-2.1*# SODIUM-136 POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-19* ANION GAP-20 ___ 10:45AM CK(CPK)-43 ___ 10:45AM cTropnT-0.03* ___ 10:45AM CK-MB-2 ___ 10:45AM WBC-12.0* RBC-3.99* HGB-12.0 HCT-38.0 MCV-95 MCH-30.0 MCHC-31.6 RDW-15.1 ___ 10:45AM NEUTS-71.0* ___ MONOS-4.6 EOS-1.6 BASOS-0.2 ___ 10:45AM PLT COUNT-432 ___ 10:45AM ___ PTT-25.2 ___ . DISCHARGE LABS: ___ 09:45AM BLOOD WBC-9.2 RBC-3.44* Hgb-10.0* Hct-31.8* MCV-93 MCH-29.0 MCHC-31.4 RDW-14.8 Plt ___ ___ 10:30AM BLOOD WBC-8.8 RBC-3.23* Hgb-9.3* Hct-30.2* MCV-94 MCH-28.9 MCHC-30.9* RDW-14.8 Plt ___ ___ 09:45AM BLOOD Plt ___ . ___ 12:35 pm URINE MICRO: **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING: SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT) ___ IMPRESSION: Moderate degenerative change of the left acromioclavicular joint. . CXR ___ The cardiac silhouette remains enlarged. The mediastinum is stable. Slight tortuosity of a calcified aorta. No definite focal consolidation is seen on the current examination. No large pleural effusion or evidence of pneumothorax. Chain sutures are again seen overlying the left upper hemithorax. No overt pulmonary edema. No evidence of free air is seen beneath the diaphragms. IMPRESSION: Persistent cardiomegaly without other acute process seen. . CT ABDOMEN/PELVIS ___ FINDINGS: LUNG BASES: Partially imaged is a right lower lobe 5 mm pulmonary nodule (2, image 1), stable since at least ___. There is no pleural or pericardial effusion. ABDOMEN: Non-contrast-enhanced liver, gallbladder, spleen, pancreas, and adrenal glands are unremarkable. There are bilateral extrarenal pelves and minimal fullness of the renal collecting systems bilaterally. There is a small hiatal hernia. The stomach is relatively collapsed. No evidence of bowel obstruction is seen in the upper abdomen. There is no upper abdominal free fluid or free air. Underlying the patient's surgical wound in the anterior upper abdomen, an area of fat stranding is seen, deep to the incision site without drainable fluid collection, similar in extent as compared to the prior study. Evidence of vertical incision along the midline of the abdomen and pelvis is seen in the subcutaneous soft tissues. PELVIS: The appendix is normal in caliber and contains high-density material. Trace amount of mesenteric fluid/hemorrhage is stable. Patient is status post recent oophorectomy. Small amount of intermediate density fluid in the pelvis appears slightly decreased and may be post-surgical and hemorrhagic. Calcified uterine fibroids are again seen. The bladder is unremarkable and thin-walled. No free air is seen. OSSEOUS STRUCTURES: No acute fracture or dislocation. Vacuum phenomenon is again seen at L3/L4. Osseous structures are unchanged. IMPRESSION: No significant interval change in postoperative changes along the anterior abdomen as well as in the pelvis. Stable small amount of mesenteric fluid. Mild fullness of the renal collecting systems, but stable. . Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN pain do not exceed 3000mg/day 2. Albuterol Inhaler 1 PUFF IH Q6H:PRN sob 3. Aspirin 325 mg PO DAILY 4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 5. Isosorbide Mononitrate 30 mg PO DAILY hold for BP<100 6. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain hold for sedation, RR<12 7. Bisacodyl 10 mg PO DAILY:PRN CONSTIPATION 8. Docusate Sodium 100 mg PO BID HOLD FOR DIARRHEA 9. Metoprolol Succinate XL 200 mg PO DAILY 10. Valsartan 80 mg PO DAILY 11. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin 12. Senna 1 TAB PO BID Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain do not exceed 3000mg/day 2. Albuterol Inhaler 1 PUFF IH Q6H:PRN sob 3. Aspirin 325 mg PO DAILY 4. Bisacodyl 10 mg PO DAILY:PRN CONSTIPATION 5. Docusate Sodium 100 mg PO BID HOLD FOR DIARRHEA 6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 7. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin 8. Isosorbide Mononitrate 30 mg PO DAILY hold for BP<100 9. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain hold for sedation, RR<12 10. Senna 1 TAB PO BID 11. Valsartan 80 mg PO DAILY 12. Metoprolol Succinate XL 200 mg PO DAILY 13. Nitrofurantoin (Macrodantin) 100 mg PO BID RX *nitrofurantoin macrocrystal [Macrodantin] 100 mg 1 capsule(s) by mouth twice a day Disp #*14 Capsule Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Pyelonephritis Secondary ? Gastroenteritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Pain, non-small cell lung cancer, four views left shoulder. COMPARISON: None. FOUR TOTAL VIEWS LEFT SHOULDER: The glenohumeral joint is preserved. There is no acute fracture or dislocation. There are no amorphous soft tissue calcifications. The acromioclavicular joint demonstrates moderate degenerative changes. There are chain sutures within the left lung apex from prior surgery. The heart is enlarged. IMPRESSION: Moderate degenerative change of the left acromioclavicular joint. Radiology Report HISTORY: Left shoulder pain TECHNIQUE: Single AP upright portable view of the chest. COMPARISON: ___. FINDINGS: The cardiac silhouette remains enlarged. The mediastinum is stable. Slight tortuosity of a calcified aorta. No definite focal consolidation is seen on the current examination. No large pleural effusion or evidence of pneumothorax. Chain sutures are again seen overlying the left upper hemithorax. No overt pulmonary edema. No evidence of free air is seen beneath the diaphragms. IMPRESSION: Persistent cardiomegaly without other acute process seen. Radiology Report EXAM: Non-contrast-enhanced CT of the abdomen and pelvis. CLINICAL INFORMATION: History of oophorectomy 20 days ago with abdominal pain and nausea. ___. TECHNIQUE: Non-contrast-enhanced CT images of the abdomen were obtained. Reformatted coronal and sagittal images were also obtained. FINDINGS: LUNG BASES: Partially imaged is a right lower lobe 5 mm pulmonary nodule (2, image 1), stable since at least ___. There is no pleural or pericardial effusion. ABDOMEN: Non-contrast-enhanced liver, gallbladder, spleen, pancreas, and adrenal glands are unremarkable. There are bilateral extrarenal pelves and minimal fullness of the renal collecting systems bilaterally. There is a small hiatal hernia. The stomach is relatively collapsed. No evidence of bowel obstruction is seen in the upper abdomen. There is no upper abdominal free fluid or free air. Underlying the patient's surgical wound in the anterior upper abdomen, an area of fat stranding is seen, deep to the incision site without drainable fluid collection, similar in extent as compared to the prior study. Evidence of vertical incision along the midline of the abdomen and pelvis is seen in the subcutaneous soft tissues. PELVIS: The appendix is normal in caliber and contains high-density material. Trace amount of mesenteric fluid/hemorrhage is stable. Patient is status post recent oophorectomy. Small amount of intermediate density fluid in the pelvis appears slightly decreased and may be post-surgical and hemorrhagic. Calcified uterine fibroids are again seen. The bladder is unremarkable and thin-walled. No free air is seen. OSSEOUS STRUCTURES: No acute fracture or dislocation. Vacuum phenomenon is again seen at L3/L4. Osseous structures are unchanged. IMPRESSION: No significant interval change in postoperative changes along the anterior abdomen as well as in the pelvis. Stable small amount of mesenteric fluid. Mild fullness of the renal collecting systems, but stable. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: TACHYCARDIA Diagnosed with TACHYCARDIA NOS, ACUTE KIDNEY FAILURE, UNSPECIFIED, URIN TRACT INFECTION NOS, ABN SERUM ENZY LEVEL NEC temperature: 97.6 heartrate: 121.0 resprate: 20.0 o2sat: 100.0 sbp: 114.0 dbp: 59.0 level of pain: nan level of acuity: 1.0

You were admitted to the hospital because you had nausea, vomiting and abdominal pain. This was thought to be related to a urinary tract infection. You were started on antibiotics and you improved and will continue to take antibiotics for another 6 days. You had imaging of your shoulder snd your torso which was unremarkable. Weigh yourself every morning, call MD if weight goes up more than 3 lbs.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Celebrex Attending: ___. Chief Complaint: dypsnea Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ gentleman with high risk MDS currently on cycle 14 of decitabine, CKD III, chronic pleural effusions, diastolic heart failure, hypertension, and atrial tachycardia (previously on amiodarone, not on any anti-arrhythmics currently) who was recently admitted to ___ for HCAP and is now readmitted for shortness of breath with sputum culture from ___ is growing ___ transferred to the ICU for Afib with RVR on ___ for management, controlled with Dilt drip, transitioned to metoprolol, and now asymptomatic with normal hemodynamics, currently followed by ID for positive AFB sputum however most recent cultures negative and noted for +klebsiella PNA. Past Medical History: In ___, he was found upon routine lab testing with his PCP he was found to be anemic with a hemoglobin down to 8.2. He had normal WBC and platelets were slightly decreased at 132k. He was referred to hematology and bone marrow biopsy was performed on ___ which revealed the following: Hypercellular marrow with trilineage hematopoiesis,left shifted myeloid hyperplasia and multilineage dysplasia. Peripheral blood smear with absolute monocytosis and circulating blasts, consistent with myeloid neoplasm, best classified as CMML-1. CD34+, CD117+ myeloid blasts comprising ___ of the marrow cellularity. Aspirate smear with 500 cell count reveals 7% blasts. Cytogenetics reveal: 46,XY,inv(3)(q21q26,2)[22]. FISH panel for MDS is normal. CBC done on ___ revealed WBC: 12.4 with ANC of 8.1 Hgb/Hct: 7.4/25.2 Plts: 268k IPSS-R Cytogenetics: Poor Inv (3), Score: 3 Marrow Blasts: ___, Score: 2 Hemoglobin: 7.4, Score: 1.5 ANC:8.1, Score: 0 Platelet Count: 268k, Score: 0 ____________________________________________ Total Score: 6.5 Very High PAST MEDICAL/SURGICAL HISTORY: - MDS - Chronic diastolic CHF - Hypertension - Stage IV CKD - Hypercholesterolemia - Gout - Hypothyroidism - Anxiety - Lap chole ___ Social History: ___ Family History: Father: deceased at age ___- CAD Mother: deceased at age ___- ?MDS/leukemia. Had six siblings, 3 siblings (sisters) are alive between the ages of ___ all in relatively good health. Physical Exam: Admission Physical Exam: Vitals: 98.3 PO 131 / 37 R Sitting 66 20 95 RA Gen: comfortable, laying in bed HEENT: MMM, JVP slightly up, oropharynx clear CV: RRR Abd: Soft, NT/ND Lungs: Crackles at bases. Ext: No edema Chest: Port accessed, site clean Discharge Physical Exam: VS: TC 97.8 133/31 63 18 96%RA I/O: 1100/1000 BM x 1 Gen: comfortable, sitting in chair HEENT: MMM, JVP slightly up, oropharynx clear CV: s1/s2. RRR Abd: Moderately protuberant w/ well healed midline abdominal scar. Multiple ecchymosis from heparin injections. + hernia lateral to midline scar. Soft/Rounded, NT/ND, + BS Lungs: Mild cough on exam; Crackles at b/l bases > R, no wheezing or rhonchi Ext: Trace BLE edema; no tremors Chest: Port accessed, site w/o erythema, tenderness or discharge Skin: No rashes, eruptions or skin breakdown Neuro: No focal deficits, alert and oriented x 3 Pertinent Results: ___ 06:37AM BLOOD WBC-3.6* RBC-2.98* Hgb-7.8* Hct-24.7* MCV-83 MCH-26.2 MCHC-31.6* RDW-15.9* RDWSD-47.2* Plt ___ ___ 10:30AM BLOOD WBC-11.2* RBC-2.84* Hgb-6.9* Hct-23.0* MCV-81* MCH-24.3* MCHC-30.0* RDW-16.7* RDWSD-48.5* Plt ___ ___ 06:37AM BLOOD Neuts-39 Bands-0 ___ Monos-17* Eos-0 Baso-15* ___ Myelos-0 Blasts-3* AbsNeut-1.40* AbsLymp-0.94* AbsMono-0.61 AbsEos-0.00* AbsBaso-0.54* ___ 10:30AM BLOOD Neuts-78* Bands-0 Lymphs-13* Monos-7 Eos-0 Baso-2* ___ Myelos-0 NRBC-2* AbsNeut-8.74* AbsLymp-1.46 AbsMono-0.78 AbsEos-0.00* AbsBaso-0.22* ___ 06:37AM BLOOD Glucose-105* UreaN-27* Creat-1.0 Na-137 K-4.4 Cl-101 HCO3-25 AnGap-15 ___ 10:30AM BLOOD UreaN-62* Creat-1.8* Na-136 K-4.2 Cl-102 HCO3-21* AnGap-17 ___ 06:37AM BLOOD ALT-22 AST-26 LD(___)-235 AlkPhos-120 TotBili-0.4 ___ 10:30AM BLOOD ALT-19 AST-21 LD(LDH)-279* AlkPhos-90 TotBili-0.6 ___ 06:37AM BLOOD Albumin-3.3* Calcium-8.5 Phos-3.8 Mg-2.2 ___ 10:30AM BLOOD TotProt-6.0* Albumin-3.8 Globuln-2.2 Calcium-8.8 Phos-3.4 Mg-1.8 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Allopurinol ___ mg PO DAILY 3. Benzonatate 200 mg PO TID:PRN cough 4. Exjade (deferasirox) 500 mg oral BID 5. Furosemide 40 mg PO BID 6. Levothyroxine Sodium 125 mcg PO DAILY 7. Lisinopril 10 mg PO DAILY 8. Metoprolol Succinate XL 50 mg PO BID 9. Omeprazole 40 mg PO DAILY 10. PARoxetine 20 mg PO DAILY 11. Prochlorperazine 10 mg PO Q6H:PRN nausea 12. Simvastatin 10 mg PO QPM 13. Aspirin 81 mg PO DAILY 14. ValACYclovir 1000 mg PO DAILY Discharge Medications: 1. CefTRIAXone 1 gm IV Q24H RX *ceftriaxone in dextrose,iso-os 1 gram/50 mL 1 gm IV q24 hrs Disp #*7 Intravenous Bag Refills:*0 2. Acetaminophen 650 mg PO Q6H:PRN pain 3. Allopurinol ___ mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Benzonatate 200 mg PO TID:PRN cough 6. Furosemide 40 mg PO BID 7. Levothyroxine Sodium 125 mcg PO DAILY 8. Lisinopril 10 mg PO DAILY 9. Metoprolol Succinate XL 50 mg PO BID 10. Omeprazole 40 mg PO DAILY 11. PARoxetine 20 mg PO DAILY 12. Prochlorperazine 10 mg PO Q6H:PRN nausea 13. Simvastatin 10 mg PO QPM 14. ValACYclovir 1000 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: MDS pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT CHEST W/O CONTRAST INDICATION: ___ man with myelodysplastic syndrome, hemoptysis, fever/chills, evaluate for pneumonia versus tuberculosis TECHNIQUE: MDCT axial images were obtained through the chest. Coronal and sagittal reformatted images were acquired. Axial MIP images were also obtained. DOSE: Total DLP (Body) = 567 mGy-cm. COMPARISON: Chest CT ___ and ___ FINDINGS: The thyroid is unremarkable. Scattered axillary lymph nodes are not pathologically enlarged. Prominent supraclavicular lymph nodes measure up to 9 mm on the left, unchanged from ___. Mildly enlarged mediastinal lymph nodes are also unchanged from ___ measuring up to 16 mm in the right lower pretracheal station. The thoracic aorta is normal in caliber with moderate atherosclerotic calcification. Main pulmonary trunk is not enlarged. Heart size is mildly enlarged. Coronary artery calcifications are moderate, as are aortic annular calcifications. Relative low density of the blood pool is likely related to underlying anemia. The airways are patent to the segmental level. Motion at the lung bases limits evaluation of subsegmental airways. There has been interval progression of multifocal consolidative and ground-glass opacities, compared to prior, with multiple new bilateral upper lobe and right middle lobe opacities. Consolidative opacities at the right and left lung base have also increased. There are new small bilateral pleural effusions left greater than right with lower lobe septal thickening. Diffuse reticulation and upper lobe predominant septal thickening has not significantly changed. There is no pneumothorax. Views of the upper abdomen demonstrate unchanged pneumobilia. There is a small hiatal hernia. There are no suspicious bony lesions. IMPRESSION: 1. Progression of multifocal consolidative and ground-glass opacities, since ___ now involving all lobes, differential is broad but includes multifocal infection, vasculitis. Given the rapid interval progression cryptogenic organizing pneumonia, is felt to be less likely. 2. Unchanged mediastinal lymphadenopathy. 3. New small bilateral pleural effusions and lower lobe septal thickening, consistent with background pulmonary edema. Radiology Report INDICATION: ___ w/worsening sob and new tachycardia // interval changes, pulm edema, consolidations TECHNIQUE: Portable AP chest radiograph COMPARISON: Chest radiographs from ___. . CT of the chest from ___. FINDINGS: Multifocal opacities are unchanged from CT on ___. There is mild engorgement of the mediastinal vascular pedicle and mild pulmonary vascular pulmonary edema, unchanged from ___. Small bilateral pleural effusions are stable from ___. No pneumothorax. IMPRESSION: Multifocal opacities, mild pulmonary edema, and small bilateral pleural effusions are stable from ___. No significant interval change. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with high risk MDS // worsening sob/cough, eval for interval changes, pulm edema, consolidations worsening sob/cough, eval for interval changes, pulm edema, consolidations IMPRESSION: In comparison with study of ___, there is increasing diffuse bilateral pulmonary opacifications, most likely reflecting worsening pulmonary edema with bilateral effusions and compressive basilar atelectasis. In the appropriate clinical setting, several areas of more coalescent appearance bilaterally could possibly represent superimposed pneumonia. Gender: M Race: OTHER Arrive by WALK IN Chief complaint: Dyspnea, Fever, Hemoptysis Diagnosed with Pneumonia, unspecified organism temperature: 98.1 heartrate: 62.0 resprate: 22.0 o2sat: 98.0 sbp: 115.0 dbp: 34.0 level of pain: 0 level of acuity: 2.0

Mr. ___, You were admitted due to shortness of breath and cough, you were found to have pneumonia and will continue treatment with your IV antibiotic at home. Your symptoms greatly improved with your antibiotics. You will follow up in clinic as stated below. It was a pleasure taking care of you. Please call with any questions or concerns.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Hematuria, abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ hx of polycystic kidney disease on transplant waiting list (listed but inactive until GFR < 20, not on dialysis), currently stage IV ckd- b/l Cr 2.8-2.9, HTN, HLD and hx of diverticulosis who presents with flank pain/LLQ pain and hematuria. Today she had gone to a clinic appointment for transplant. Afterward in garage around 2pm she tripped and fell on her knees and left hip, landed on her hands. Subsequently she scraped her right knee. She iced her right knee but then at 4pm she went to urinate and saw that toilet bowl was full of red urine. Did not seem to decrease even at the end of her stream. Denies having any recent fevers, chills, N/V, chest pain, shortness of breath, dysuria. Has had no BM since having the fall. She is currently in ___ pain in her LLQ. She thinks it is like a rib pain. She does not have any blood in her underwear. No dizziness, lightheadedness, chest pain. No hx of anemia. Her baseline Cr is around 2.9. In the ED, initial vitals: 98.1 79 158/83 20 100% RA - Exam notable for: BACK: No CVA tenderness. MSK: No spinal tenderness Abd: Pain in LLQ / pelvic region. Also with some suprapubic pain. - Labs notable for: Cr 3.3. UA w/ lg blood, >182 RBC - Imaging notable for: 1. Multicystic enlarged kidneys and multiple hepatic cysts are in keeping with polycystic kidney disease. There are new areas of increased density in the left upper renal pole which may indicate cyst rupture with hemorrhagic contents. There is mild left perinephric stranding. 2. Colonic diverticulosis is seen without evidence of acute diverticulitis. 3. No acute fractures are seen XR Knee: .9 x 0.3 cm ovoid ossific structure along the superior patella may represent a fracture of indeterminate age. No acute fracture seen elsewhere. No suprapatellar joint effusion is seen. Consults: Orthopedics team reviewed imaging. Patient has intact quads muscle and able to extend knee. Cancelled orthopedics consult. Will refer patient to clinic, number provided. - Pt given: Tylenol, oxycodone 5mg x2, 1L NS Upon arrival to the floor, the patient reports history as above. She is interested in being discharged in the morning/afternoon, as she has a trip planned. Reports pain worse in her L knee, L flank able to ambulate. She takes tramadol at home about ___ times a week for pain related to her PCKD. Past Medical History: Abnormal ETT with typical angina HTN CKD IV Adult onset polycystic kidney disease PSH C-section x3 Diverticulitis x 2 Social History: ___ Family History: Sickle cell trait Physical Exam: =========================== ADMISSION PHYSICAL EXAM =========================== VITALS: 65 135/81 16 100% RA General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, pain in LUQ/LLQ, flank. Also with some suprapubic pain. Back: No CVA, spinal tenderness. GU: No foley Ext: Warm, well perfused. No ___ edema. Tenderness to palpation along anterior R knee. Skin: no bruising. Scrapes on right knee do not appear infected, some swelling and pain around right knee Neuro: CNII-XII intact. No focal deficits. Fluent speech =========================== DISCHARGE PHYSCIAL EXAM =========================== General: Alert, oriented, no acute distress CV: regular rate and rhythm, no murmurs Lungs: vesicular breath sounds bilaterally Abdomen: Left CVA tenderness; LLQ tenderness to deep palpation, no suprapubic pain GU: No foley Ext: Warm, well perfused. No ___ edema. Tenderness to palpation along anterior R knee. Right knee slightly more swollen than left but does not appear infected. Neuro: CNII-XII intact. No focal deficits. Fluent speech Pertinent Results: ====================== ADMISSION LAB RESULTS ====================== ___ 07:39PM BLOOD WBC-8.3 RBC-4.84 Hgb-13.2 Hct-43.1 MCV-89 MCH-27.3 MCHC-30.6* RDW-13.6 RDWSD-44.2 Plt ___ ___ 07:39PM BLOOD Neuts-73.1* Lymphs-17.7* Monos-6.9 Eos-1.6 Baso-0.2 Im ___ AbsNeut-6.07 AbsLymp-1.47 AbsMono-0.57 AbsEos-0.13 AbsBaso-0.02 ___ 07:39PM BLOOD ___ PTT-35.2 ___ ___ 07:39PM BLOOD Glucose-92 UreaN-38* Creat-3.3* Na-137 K-4.8 Cl-105 HCO3-18* AnGap-14 ====================== DISCHARGE LAB RESULTS ====================== ___ 05:25AM BLOOD WBC-7.9 RBC-4.41 Hgb-12.0 Hct-39.6 MCV-90 MCH-27.2 MCHC-30.3* RDW-13.5 RDWSD-44.6 Plt ___ ___ 05:25AM BLOOD Glucose-84 UreaN-36* Creat-3.4* Na-140 K-4.8 Cl-108 HCO3-17* AnGap-15 =================== IMAGING/REPORTS =================== CT ABDOMEN/PELVIS ___ IMPRESSION: 1. Multicystic enlarged kidneys and multiple hepatic cysts are in keeping with known polycystic kidney disease. There are new rounded areas of hyperattenuation in the left upper renal pole which may indicate cyst rupture with hemorrhagic contents. At least 1 of the previously seen simple appearing cyst now appears hyperdense. No free fluid. 2. Colonic diverticulosis without acute diverticulitis. 3. No acute fractures are seen KNEE X-RAY ___ IMPRESSION: 0.9 x 0.3 cm ovoid ossific structure along the superior patella may represent a fracture of indeterminate age. No acute fracture seen elsewhere. No suprapatellar joint effusion is seen. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Calcitriol 0.25 mcg PO EVERY OTHER DAY 3. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 4. Losartan Potassium 100 mg PO 4X/WK 5. Selsun Blue (pyrithione zinc) (pyrithione zinc) 1 % Other DAILY 6. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth Every six hours as needed Disp #*20 Tablet Refills:*0 2. amLODIPine 5 mg PO DAILY 3. Calcitriol 0.25 mcg PO EVERY OTHER DAY 4. Losartan Potassium 100 mg PO 4X/WK 5. Multivitamins 1 TAB PO DAILY 6. Selsun Blue (pyrithione zinc) (pyrithione zinc) 1 % Other DAILY 7. HELD- TraMADol 50 mg PO Q6H:PRN Pain - Moderate This medication was held. Do not restart TraMADol until cleared by your primary care doctor Discharge Disposition: Home Discharge Diagnosis: PRIMARY: -Ruptured renal cyst SECONDARY: -CKD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: History: ___ with recent fall, scratch on R knee, some swelling and pain on palpation// ? eval for fracture TECHNIQUE: Three views of the right knee COMPARISON: None. FINDINGS: 0.9 x 0.3 cm ovoid ossific structure along the superior patella may represent a fracture of indeterminate age. No acute fracture seen elsewhere. No suprapatellar joint effusion is seen. There is no dislocation. IMPRESSION: 0.9 x 0.3 cm ovoid ossific structure along the superior patella may represent a fracture of indeterminate age. No acute fracture seen elsewhere. No suprapatellar joint effusion is seen. Radiology Report EXAMINATION: CT abdomen and pelvis without contrast INDICATION: ___ year old woman with hx of Polycystic kidney disease not on HD, on renal transplant, stage IV ckd, presenting after a fall, with hematuria and LLQ/pelvic/rib pain. No hematoma on exam.// Please eval for trauma to bladder, kidneys, and any evidence of fracture. TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired without intravenous contrast. Non-contrast scan has several limitations in detecting vascular and parenchymal organ abnormalities, including tumor detection. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 6.7 s, 52.8 cm; CTDIvol = 19.1 mGy (Body) DLP = 1,006.6 mGy-cm. Total DLP (Body) = 1,007 mGy-cm. COMPARISON: CT abdomen and pelvis without contrast from ___ FINDINGS: LOWER CHEST: Atelectasis is seen in the dependent lung bases. There is no pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: There are multiple hypodense lesions scattered throughout the liver, compatible with biliary hamartomas or hepatic cysts, with the largest measuring up to 1.9 cm in the right hepatic lobe. Otherwise, the liver demonstrates homogeneous attenuation throughout within the limitations of an unenhanced scan. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions within the limitations of an unenhanced scan. There is no pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: There is enlarged multi cystic appearance of bilateral kidneys, compatible with polycystic kidney disease. Previously seen hypodense cyst in the upper pole the left kidney is now hyperdense and there are additional smaller hyperdensities in the left kidney. These new rounded areas of hyper-attenuation in the left upper renal pole which may indicate cyst rupture with hemorrhagic contents (60___:62). Some of the cysts demonstrate peripheral calcification, but are unchanged. There is no hydronephrosis. There is no nephrolithiasis. There is small amount of left perinephric stranding tracking medially and inferiorly along the left kidney. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber and wall thickness throughout. Colonic diverticulosis is seen without evidence of acute diverticulitis. Colon and rectum are within normal limits. The appendix is normal. PELVIS: The urinary bladder is minimally distended. There is no distal hydroureter. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus is unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Multicystic enlarged kidneys and multiple hepatic cysts are in keeping with known polycystic kidney disease. There are new rounded areas of hyperattenuation in the left upper renal pole which may indicate cyst rupture with hemorrhagic contents. At least 1 of the previously seen simple appearing cyst now appears hyperdense. No free fluid. 2. Colonic diverticulosis without acute diverticulitis. 3. No acute fractures are seen Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Hematuria, R Flank pain Diagnosed with Acute kidney failure, unspecified temperature: 98.1 heartrate: 79.0 resprate: 20.0 o2sat: 100.0 sbp: 158.0 dbp: 83.0 level of pain: 8 level of acuity: 3.0

Dear Ms ___, It was a pleasure taking part in your care here at ___! Why was I admitted to the hospital? - You were admitted for abdominal pain and blood in your urine What was done for me while I was in the hospital? - You had some imaging done of your abdomen. It looked like one of the cysts on your kidney had ruptured. - You were given pain medication and closely monitored. What should I do when I leave the hospital? - Continue to take all of your medications as prescribed. - Please obtain bloodwork at ___ prior to your appointment on ___. The order for your labwork has already been placed. Sincerely, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Tape ___ / Lisinopril / Bactrim / Pentamidine Isethionate / Levofloxacin Attending: ___. Chief Complaint: Elevated temperature Major Surgical or Invasive Procedure: none History of Present Illness: ___ yo F with complicated PMH here from dialysis with shaking chills. She has a long history of recurrent fevers, most recently with hospitalization ___ for Klebsiella bacteremia of unknown source. She reports she has not felt right since she completed her course of cefazolin, which she received at dialysis on ___, 10 days ago. She reports that she has been very tired, achy, complains of SOB with DOE, and has had several fevers to 100. She reported back pain radiating to lower extremities, associated with lower extremity weakness. Today at dialysis she became very cold and began having chills/rigors. Temp 100.0. She completed dialysis, and was given acetaminophen and either cefazolin or cefepime, then sent to the ED. Patient denies headache, chest pain, abdominal pain, nausea, vomiting, diarrhea, urinary symptoms. She has chronic cough which is at baseline. Denies n/v, states she is tolerating PO. She does report dental work 4 days prior, a ___ year old crown fell out and she had it replaced. She reports taking unknown prophylactic antibiotic. No longer makes urine. In the ED intial vitals were: 4 98.6 94 146/72 18 98% - Labs were significant for WBC 6.5, Hct 28.0, K of 4.1, Cre 3.7, Calcium 11.0, phos 3.5. INR 1.3. Lactate 1.9. - CXR showed small bilateral pleural effusion, no focal consolidation, pulmonary vasculature pronminant, unchanged from prior. RUQ large rim calcified structure (c/w known liver cyst) - Patient was given vancomycin Vitals prior to transfer were: 98.5 91 125/66 18 98% RA On the floor, patient is tired and feels chilly. Complains of itchiness from eczema. Review of Systems: (+) as above (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia. Past Medical History: * Recurrent fevers - E. coli bacteremia, ___ - s/p WBC scan ___ revealed chronic cholecystitis, s/p CCY - Klebsiella bacteremia ___ - h/o C. diff colitis * ESRD s/p failed ECD renal transplant in ___ on HD MWF - c/b urinary obstruction, multiple UTIs, nephrostomy tube - s/p coil embolization of graft artery on ___ - h/o multiple episodes of CMV viremia - h/o BK viremia * Chronic atrial fibrillation s/p modified AV ablation ___ - dCHF, last EF > 55% in ___ - Tachycardic cardiomyopathy - MR/TR * Aortic stenosis * PCKD s/p bilateral nephrectomies in ___ * HTN * Endometrial cancer * Primary Hyperparathyroidism * Hypothyroidism * Knee Osteoarthritis SURGICAL HISTORY -___ - cholecystectomy -___ - coil embolization tpx renal artery -___ - ECD kidney transplant and VHR with mesh -___ - RUE AV fistulogram, balloon angioplasty -___ - b/l nephrectomies for PKD -___ - RUE brachiocephalic AV fistula -___ - appendectomy and incisional hernia repair with mesh -___ - TAH/BSO for endometrial ca -___ - hysteroscopy -___ - R hemithyroidectomy and excision of R parathyroid adenoma, neck exploration -___ - hemorrhoidectomy and drainage of perirectal hematoma -s/p tonsillectomy Social History: ___ Family History: Father & daughter w/ PKD. No history of CAD. Physical Exam: ON ADMISSION: ============= Vitals - T: 99.6 BP: 136/75 HR: 81 RR: 20 02 sat: 99%RA Gen: female, tired but non-toxic appearing HEENT: MMM CV: Irregulary irregular, ___ SEM at ___ Pulm: CTAB, no w/r/r Abd: Soft, NTND, normoactive bowel sounds, well healed surgical scar with palpable transplanted kidney at RLQ. Ext: Warm, well-perfused, no edema, ? ___ cyst on Right. Neuro: AAOx3, CN II-XII grossly intact Skin: No concerning lesions, fistula is stable with good thrill, not hot. ON DISCHARGE: ============== Vitals 99.0(tmax), 83, 132/73, 17 Gen: female, tired but non-toxic appearing, laying in bed at HD HEENT: MMM, anicteric sclera, EOMI Neck: supple, no LAD CV: Irregulary irregular, ___ SEM at ___ Pulm: CTAB, no w/r/r Abd: Soft, NTND, normoactive bowel sounds, well healed surgical scar MSK: no vertebral process tenderness, no CVAT Ext: Warm, well-perfused, no edema, ? ___ cyst on Right. Skin: No concerning lesions, fistula is stable with good thrill, no warmth or erythma Pertinent Results: ON ADMISSON: ============= ___ 05:50PM BLOOD WBC-6.5 RBC-2.93* Hgb-8.3* Hct-28.0* MCV-96 MCH-28.5 MCHC-29.7* RDW-16.4* Plt ___ ___ 05:50PM BLOOD Neuts-85.7* Lymphs-8.3* Monos-4.3 Eos-1.5 Baso-0.3 ___ 05:50PM BLOOD ___ PTT-30.5 ___ ___ 05:50PM BLOOD Glucose-115* UreaN-18 Creat-3.7* Na-140 K-4.1 Cl-98 HCO3-28 AnGap-18 ___ 05:50PM BLOOD ALT-6 AST-21 AlkPhos-85 TotBili-0.4 ___ 05:50PM BLOOD Calcium-11.0* Phos-3.5 Mg-2.2 ___ 05:57PM BLOOD ___ FiO2-20 pO2-25* pCO2-48* pH-7.45 calTCO2-34* Base XS-6 Intubat-NOT INTUBA ___ 05:57PM BLOOD Lactate-1.9 MICRO: ====== ___: BLOOD CX-PND ___: OSH BLOOD CX FROM ___ DIALYSIS IN ___ ___: CMV VIRAL LOAD-PND PERTINENT LABS: ================ ___: SPEP-PND RADIOLOGY: =========== CXR ___: FINDINGS: The inspiratory lung volumes are appropriate. There is bilateral blunting of the costophrenic angles compatible with small bilateral pleural effusions. There is improved aeration of the right lung base in comparison to ___. No focal consolidation concerning for pneumonia is seen. There is no pneumothorax. The pulmonary vasculature is slightly prominent, unchanged from the prior exam. No overt pulmonary edema is present. The cardiomediastinal silhouette is within normal limits and unchanged. In the right upper quadrant, there is a large rim calcified rounded structure measuring 7.4 x 7.3 cm within the liver. IMPRESSION: 1. Small bilateral pleural effusions and mild pulmonary vascular congestion. 2. Improved aeration of the right lung base from ___. DISCHARGE LABS: =============== ___ 05:50PM BLOOD WBC-6.5 RBC-2.93* Hgb-8.3* Hct-28.0* MCV-96 MCH-28.5 MCHC-29.7* RDW-16.4* Plt ___ ___ 07:10AM BLOOD ___ PTT-30.9 ___ ___ 07:10AM BLOOD Glucose-120* UreaN-37* Creat-6.5*# Na-138 K-4.8 Cl-97 HCO3-25 AnGap-21* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Cinacalcet 60 mg PO DAILY 2. Digoxin 0.0625 mg PO 3X/WEEK (___) 3. Docusate Sodium 100 mg PO BID 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. Gabapentin 300 mg PO 3X/WEEK (___) 6. Levothyroxine Sodium 75 mcg PO DAILY 7. Lidocaine 5% Patch 1 PTCH TD QAM 8. Lorazepam 1 mg PO BID:PRN anxiety 9. Metoprolol Succinate XL 25 mg PO 4X/WEEK (___) 10. Midodrine 10 mg PO MWF 11. Montelukast Sodium 10 mg PO DAILY 12. Nephrocaps 1 CAP PO DAILY 13. sevelamer HYDROCHLORIDE 2400 mg OTHER TID 14. Warfarin 1 mg PO DAILY16 15. Cetirizine 10 mg oral daily prn allergy symptoms 16. Clobetasol Propionate 0.05% Cream 1 Appl TP BID 17. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN wheezing 18. Omeprazole 20 mg PO BID Discharge Medications: 1. Cinacalcet 60 mg PO DAILY 2. Clobetasol Propionate 0.05% Cream 1 Appl TP BID 3. Digoxin 0.0625 mg PO 3X/WEEK (___) 4. Docusate Sodium 100 mg PO BID 5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 6. Gabapentin 300 mg PO 3X/WEEK (___) 7. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN wheezing 8. Levothyroxine Sodium 75 mcg PO DAILY 9. Lidocaine 5% Patch 1 PTCH TD QAM 10. Lorazepam 1 mg PO BID:PRN anxiety 11. Metoprolol Succinate XL 25 mg PO 4X/WEEK (___) 12. Midodrine 10 mg PO MWF 13. Montelukast Sodium 10 mg PO DAILY 14. Nephrocaps 1 CAP PO DAILY 15. Omeprazole 20 mg PO BID 16. sevelamer HYDROCHLORIDE 2400 mg OTHER TID 17. Warfarin 1 mg PO DAILY16 18. Cetirizine 10 mg oral daily prn allergy symptoms Discharge Disposition: Home Discharge Diagnosis: Elevated temperatures Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Fever, here to evaluate for pneumonia. COMPARISON: Chest radiograph dated ___. TECHNIQUE: PA and lateral radiographs of the chest. FINDINGS: The inspiratory lung volumes are appropriate. There is bilateral blunting of the costophrenic angles compatible with small bilateral pleural effusions. There is improved aeration of the right lung base in comparison to ___. No focal consolidation concerning for pneumonia is seen. There is no pneumothorax. The pulmonary vasculature is slightly prominent, unchanged from the prior exam. No overt pulmonary edema is present. The cardiomediastinal silhouette is within normal limits and unchanged. In the right upper quadrant, there is a large rim calcified rounded structure measuring 7.4 x 7.3 cm within the liver. IMPRESSION: 1. Small bilateral pleural effusions and mild pulmonary vascular congestion. 2. Improved aeration of the right lung base from ___. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Fever Diagnosed with FEVER, UNSPECIFIED temperature: 98.6 heartrate: 94.0 resprate: 18.0 o2sat: 98.0 sbp: 146.0 dbp: 72.0 level of pain: 4 level of acuity: 3.0

Weigh yourself every morning, call MD if weight goes up more than 3 lbs.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Bactrim / Tylenol / ibuprofen Attending: ___ Chief Complaint: Confusion/weakness Major Surgical or Invasive Procedure: None History of Present Illness: ___ y/o male with history of cardiomyopathy, A-fib, DM and severe mid LAD stenosis s/p cath with one DES with presents from PCP with weakness. Pt states his symptoms started 3 weeks ago and relates it to his cardiac cath in ___. Described as progressive weakness with some dizziness associated with decreased PO intake. He fell last week on the curb last week and has had persistent pain in his left upper back. He denies recent fevers/chills, headaches, chest pain, SOB, abdominal pain. He has had no change in bowel or bladder habits, denies hematochezia, melena, dysuria or hematuria. Of note, the patient had an admission in ___ for sepsis related to infected nephrolithiasis. In the ED, initial vitals were: 97.7 92 115/73 20 100% RA with positive orthostatics Labs notable for: WBC 10.1, AP 133, creatinine 1.3 (baseline 1.2), INR 5.2 with PTT 56.5, ___ 58.7, troponin negative x1, lactate 2.3. He was bladder scanned and a urine sample was sent from straight cath, with clean UA. Imaging notable for: normal CT/CTA head, normal CXR Patient was given: 3 L NS Neuro was consulted and recommended: unlikely stroke but neuro will follow as inpatient. Vitals prior to transfer: 98.0 84 ___ 98% RA Decision was made to admit for weakness to Medicine with Dr. ___ as attending. On the floor initially, the patient was completely oriented and pleasant, overall comfortable and only complaining of weakness described before and R thigh pain. otherwise denying chest pain, shortenss of breath, fevers/chills ##At 03:20, a trigger was called for altered mental status and Afib with RVR into 150's. Pt had not yet received his home evening dose of Metoprolol tartrate 50 mg. At that time he was AOx1, more agitated. He had not received any meds by that time. Bladder scan at that time was 780 cc despite straight cath in ED. All AM labs were drawn early with BCx., A Foley was placed and UA/UCx were sent. Dr. ___ was made aware and will see pt at 8 AM. Past Medical History: Cardiac cath s/p DES x1 LAD ___ Hospitalization ___ for sepsis d/t obstructive nephrolithiasis, sCHF,afib RVR, hematuria Lumbar spinal operation scheduled at ___ ___ Hx of atrial fibrillation s/p cardioversion x2 - now in A.Fib. Hypertension Gout DM Osteoarthritis Hx of gastric ulcer in ___ /GI bleed s/p tonsillectomy and adenoidectomy s/p multiple prostate biopsies for elevated PSA - benign hx of fatty liver disease/hepatitis of unclear etiology Kyphoscoliosis DISH severe high Cholesterol refuses statin drugs. groin cyst removed upper endoscopy ___ mild esophagitis Colonoscopy ___nd back surgery ___ complicated by pneumonia and recurrent A fib Social History: ___ Family History: "All kinds". Denies heart attacks. Father with AAA. Strokes. Physical Exam: ============= ADMISSION EXAM ================ Vital Signs: 138 / 71 126 22 100 ra General: Initially AOx3 but by 3 AM was AOx1, speaking in a confused manner about nonsense. HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: Foley in place Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities but symmetric, grossly normal sensation, gait deferred. ============== DISCHARGE EXAM =============== Vitals T97.7 HR86 BP 107/60 RR 18 O2 98/RA General: NAD HEENT: no scleral icterus, MMM, clear oropharynx Neck: soft, supple CV: Irregularly irregular and tachycardic, no murmur Pulm: CTAB Abdomen: soft, nt/nd, no rebound or guarding Back: No focal pain, no CVA tenderness Ext: wwp, no edema Neuro: No focal weakness. A&Ox3 and able to name president. Full neuro exam deferred Pertinent Results: ======================== ADMISSION LABS ======================== ___ 01:28PM BLOOD WBC-10.1* RBC-4.49* Hgb-13.6* Hct-40.5 MCV-90 MCH-30.3 MCHC-33.6 RDW-13.3 RDWSD-43.8 Plt ___ ___ 01:28PM BLOOD Plt ___ ___ 02:44PM BLOOD ___ PTT-56.5* ___ ___ 01:28PM BLOOD Glucose-299* UreaN-28* Creat-1.3* Na-138 K-4.5 Cl-102 HCO3-24 AnGap-17 ___ 01:28PM BLOOD ALT-27 AST-25 CK(CPK)-61 AlkPhos-133* TotBili-0.8 ___ 01:28PM BLOOD proBNP-683 ___ 01:28PM BLOOD cTropnT-<0.01 ___ 03:42AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 01:28PM BLOOD Albumin-3.6 ___ 01:28PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 01:35PM BLOOD Lactate-2.3* ======================== DISCHARGE LABS ======================== ___ 05:00AM BLOOD ___ 05:00AM BLOOD Calcium-9.6 Phos-2.2* Mg-1.9 ___ 05:00AM BLOOD ALT-25 AST-25 AlkPhos-147* TotBili-1.3 ___ 05:00AM BLOOD Glucose-137* UreaN-18 Creat-1.1 Na-140 K-4.4 Cl-104 HCO3-26 AnGap-14 ___ 05:00AM BLOOD ___ PTT-43.6* ___ ___ 05:00AM BLOOD Plt ___ ___ 05:00AM BLOOD WBC-8.7 RBC-4.47* Hgb-13.7 Hct-40.3 MCV-90 MCH-30.6 MCHC-34.0 RDW-13.2 RDWSD-43.4 Plt ___ =================== MICROBIOLOGY =================== ___ Blood cx x2 - NGTD ___ Urine Cx - No growth =================== IMAGING =================== MRI HEAD ___ - 1. No evidence of acute or chronic large vascular territorial infarction. 2. Mild chronic small vessel ischemic disease. RENAL U/S ___ - 1. Bilateral non-obstructing renal stones.. 2. Massively enlarged prostate. CTA H/N ___. No CT evidence of acute intracranial abnormality. Please note that MRI provides greater sensitivity in evaluation of acute infarction. 2. Patent intracranial and neck vasculature without carotid stenosis by NASCET criteria. 3. Postsurgical changes of the cervical spine, as described, with small fluid collection at the posterior C1 arch decompression site of uncertain significance. Recommend clinical correlation. 4. Contiguous ossification of anterior longitudinal ligament consistent with diffuse idiopathic skeletal hyperostosis. 5. Ossification of the posterior longitudinal ligament causing multilevel spinal canal stenosis most advanced at C6-C7 where there is severe spinal canal stenosis. 6. 1 cm right thyroid lobe nodule. RECOMMENDATION(S): Per the ___ College of Radiology guidelines, thyroid nodules measuring less than 1.5 cm in patient's greater than ___ years of age do not necessitate imaging follow-up, in the absence of clinical risk factors. Recommend clinical correlation for 1 cm right thyroid lobe nodule. CXR ___ - No acute cardiopulmonary process Radiology Report INDICATION: ___ with back pain s/p fall // left posterior rib pain after fall and crackles in lower lobes TECHNIQUE: Single portable view of the chest. COMPARISON: ___. FINDINGS: The lungs are clear. There is no focal consolidation, effusion, or edema. No obvious pneumothorax. The cardiomediastinal silhouette is within normal limits. No visualized displaced fractures on this nondedicated exam. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK INDICATION: History: ___ with slurred speech // New onset slurred speech TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of 70 mL of Omnipaque intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 4.8 s, 12.0 cm; CTDIvol = 56.1 mGy (Head) DLP = 672.8 mGy-cm. 2) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 22.6 mGy (Body) DLP = 362.1 mGy-cm. 3) Stationary Acquisition 9.5 s, 0.5 cm; CTDIvol = 45.7 mGy (Body) DLP = 22.9 mGy-cm. 4) Spiral Acquisition 5.0 s, 39.3 cm; CTDIvol = 14.1 mGy (Body) DLP = 555.6 mGy-cm. Total DLP (Body) = 941 mGy-cm. Total DLP (Head) = 673 mGy-cm. COMPARISON: None. FINDINGS: CT head: The gray-white matter differentiation is intact without CT evidence of acute territorial infarct, hemorrhage, or mass effect. There is mild prominence of ventricles and cortical sulci. There is hyperostosis frontalis and calcification of the cerebral falx. The bilateral native lenses are absent. The soft tissues are unremarkable. Is a small mucous retention cyst within the left sphenoid sinus. The mastoid air cells and middle ears are clear. CTA head: There is calcification of the intracranial internal carotid arteries, which are patent. The anterior communicating artery is visualized. The bilateral posterior communicating arteries are not definitively seen. There are codominant vertebral arteries. The arterial circulation is patent without occlusion, dissection, stenosis, or aneurysm. There is normal dural venous sinus enhancement. CTA neck: There is a 3 vessel aortic arch with patent subclavian arteries. There is calcification of the right carotid bulb without stenosis by NASCET criteria. There is calcification of the left carotid bifurcation bulb, without stenosis by NASCET criteria. The vertebral arteries are patent and demonstrate codominant. The lung apices are clear. There multilevel degenerative changes of the cervical spine. There is posterior decompression of the C1 arch with a 1.6 cm fluid collection at the decompression bed (8:181). There is posterior there is left C3 through C6 hemilaminectomy with fixation hardware in place and a posterior midline scar. There is ossification of the posterior longitudinal ligament causing multilevel spinal canal stenosis, most advanced at C6-C7 where there is severe spinal canal stenosis (605b:30). There is ossification of the anterior longitudinal ligament, with bulky osteophytes causing mild mass effect on the pharynx. There is a 1 cm right thyroid lobe nodule (8:63). The salivary glands are unremarkable. There streak artifact secondary to dental hardware which obscures adjacent structures. The masticator and parapharyngeal spaces are unremarkable. There are no suspicious lymph nodes by size or morphology. IMPRESSION: 1. No CT evidence of acute intracranial abnormality. Please note that MRI provides greater sensitivity in evaluation of acute infarction. 2. Patent intracranial and neck vasculature without carotid stenosis by NASCET criteria. 3. Postsurgical changes of the cervical spine, as described, with small fluid collection at the posterior C1 arch decompression site of uncertain significance. Recommend clinical correlation. 4. Contiguous ossification of anterior longitudinal ligament consistent with diffuse idiopathic skeletal hyperostosis. 5. Ossification of the posterior longitudinal ligament causing multilevel spinal canal stenosis most advanced at C6-C7 where there is severe spinal canal stenosis. 6. 1 cm right thyroid lobe nodule. RECOMMENDATION(S): Per the ___ College of Radiology guidelines, thyroid nodules measuring less than 1.5 cm in patient's greater than ___ years of age do not necessitate imaging follow-up, in the absence of clinical risk factors. Recommend clinical correlation for 1 cm right thyroid lobe nodule. Radiology Report EXAMINATION: RENAL U.S. INDICATION: ___ year old man with history of obstructing ureteral stones, p/w weakness, leukocytosis, evaluate for obstruction TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: CTU ___ FINDINGS: The right kidney measures 12.8 cm. The left kidney measures 10.8 cm. There is no hydronephrosis or suspicious masses bilaterally. There is a 3.1 x 2.4 x 2.6 cm simple cyst in the upper pole of the right kidney and a 1.8 x 1.6 x 1.7 cm simple cyst in the upper pole of the left kidney. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally, although views of the left kidney are limited secondary to patient positioning. There are bilateral non-obstructing renal stones including a a 8 mm right mid pole and a 10 mm left lower pole stone. The bladder is moderately well distended and normal in appearance. The prostate is massively enlarged with a volume of 139 cc. This corresponds to a predicted PSA of 16.7. IMPRESSION: 1. Bilateral non-obstructing renal stones.. 2. Massively enlarged prostate. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD. INDICATION: ___ year old man with dysarthria, word finding difficulty, and unsteady gait. Please evaluate for acute/subacute/chronic ischemic event. TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of 10 mL of Gadavist intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: CT head from ___. FINDINGS: There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. There is mild prominence of the ventricles and sulci suggestive of age-related involutional changes. Scattered T2/FLAIR hyperintensities are nonspecific but likely reflect sequelae of chronic small vessel ischemic disease. There is no abnormal enhancement after contrast administration. The orbits are unremarkable. There is minimal mucosal thickening of the left maxillary sinus with a mucous retention cyst within the right maxillary sinus. Major intracranial flow voids are preserved. IMPRESSION: 1. No evidence of acute or chronic large vascular territorial infarction. 2. Mild chronic small vessel ischemic disease. Gender: M Race: AMERICAN INDIAN/ALASKA NATIVE Arrive by WALK IN Chief complaint: Weakness Diagnosed with Weakness temperature: 97.7 heartrate: 92.0 resprate: 20.0 o2sat: 100.0 sbp: 115.0 dbp: 73.0 level of pain: 0 level of acuity: 3.0

Dear Mr ___, You were admitted to the ___ after feeling weak and falling at home. You were evaluated by our neurology team, who also did CT and MRI scans of your head, which did not show a stroke. Because you were retaining urine, you were discharged with a foley in place. You have a follow up appointment with Dr. ___ on ___. During hospitalization you had imaging performed which revealed a 1 cm thyroid nodule. Please discuss with Dr. ___ an ultrasound of your thyroid to better characterize the nodule. Please take note of the following: - Please stop taking your Coumadin for 2 days. Your primary care physician, ___, has asked that you restart your Coumadin on ___ at 1 tablet of 5mg and check your INR. Contact Dr ___ with your INR results. - Please follow up with urology to have your foley removed on ___ - Please follow up with your PCP Dr ___ on ___ at 2:30 ___ - Continue all your other home medications as normal It was a pleasure taking care of you at ___. We wish you all the best! - Your ___ care team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: lactose Attending: ___. Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ female with a history of right inguinal hernia repair with mesh in ___ who presents with 3 days of right groin pain and a bulge. Patient underwent an uncomplicated elective open right inguinal hernia repair (direct) with mesh in ___ ___. Patient reports she has not had any had any problems since her repair until of approximately 3 days ago she started to feel a growing bulge on her right groin with an associated sharp pain. Her pain was the worst 3 days ago which was constant and worse with movement especially when walking. She denies any abdominal pain, distention, nausea or vomiting or change in bowel habits. She has been eating well with normal bowel movements and has been passing flatus. She wanted to come to the emergency room then however she had guests over so that she decided to come into the emergency room today although the pain had somewhat subsided. Upon presentation to the emergency room patient was in no acute distress, had normal vitals, and normal laboratory work-up. Her inguinal hernia was attempted to be reduced at the bedside by the emergency room staff however unsuccessful. Patient reports that her pain is currently approximately 7 out of 10. As previously mentioned, she does not have any other associated symptoms. Past Medical History: PMH: -GERD -IBS -Diverticulosis -IPMN Pancreas -Thyroid cancer (s/p total thyroidectomy) PSH: -R inguinal hernia repair w/mesh ___ (Dr. ___ -R knee arthroscopy ___ -Tonsillectomy -Total thyroidectomy Social History: ___ Family History: Family History: -Father HTN, CAD, HLC, deceased at ___ years from an accident. -Mother deceased at ___ years HTN, AF, Lupus, CAD, CHF in her early ___. Physical Exam: Physical Exam on Admission: 97.6 77 128/72 16 97% 2L NC General: No acute distress Cardiovascular: Regular rate Pulmonary: Nonlabored breathing on room air Abdomen: Soft, nondistended, nontender, no abdominal incisional scars. Right groin: Well-healed incisional scar over the right groin. A small bulge at the level of the inguinal ligament that is soft but tender on palpation. No overlying skin changes. Bedside reduction was attempted after administering 1 mg of IV Dilaudid and 1 mg of IV Ativan however unsuccessful. Physical Exam on Discharge: 97.7, 109/74, 75, 17, 94% RA Gen: NAD, AAOx3 CV: RRR Resp: breaths unlabored, CTAB Abdomen: soft Right groin: small bulge that is soft but tender on palpation. No overlying skin changes. Ext: warm Pertinent Results: CHEST (PA & LAT): ___ 1 cm nodular opacity projects over the left lung base may represent atelectasis, pulmonary nodule is not excluded. Recommend outpatient chest CT for further assessment. CT ABD & PELVIS WITH CONTRAST: ___ 1. Fat containing right inguinal hernia. Mild stranding of the herniated fat. 2. Pancreatic cystic likely reflecting side-branch IPMN, better evaluated on recent MRCP at which time repeat MRCP in ___ years was recommended. LAB DATA: ___ 02:52PM BLOOD WBC-7.6 RBC-4.18 Hgb-13.0 Hct-39.7 MCV-95 MCH-31.1 MCHC-32.7 RDW-11.9 RDWSD-41.7 Plt ___ ___ 02:52PM BLOOD Neuts-61.8 ___ Monos-7.0 Eos-3.6 Baso-0.7 Im ___ AbsNeut-4.70 AbsLymp-2.02 AbsMono-0.53 AbsEos-0.27 AbsBaso-0.05 ___ 02:52PM BLOOD ___ PTT-29.3 ___ ___ 02:52PM BLOOD Glucose-80 UreaN-21* Creat-0.7 Na-144 K-4.4 Cl-104 HCO3-24 AnGap-16 ___ 02:52PM BLOOD ALT-21 AST-23 AlkPhos-58 TotBili-0.3 ___ 02:52PM BLOOD Lipase-55 ___ 02:52PM BLOOD Albumin-4.3 ___ 04:40PM BLOOD Lactate-0.6 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Multivitamins 1 TAB PO DAILY 2. Pantoprazole 40 mg PO Q24H 3. Levothyroxine Sodium 150 mcg PO DAILY 4. Ascorbic Acid ___ mg PO DAILY 5. Vitamin D ___ UNIT PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever please limit to 4000mg in 24 hour period. 2. Hyoscyamine SO4 (Time Release) 0.375 mg PO DAILY 3. Ascorbic Acid ___ mg PO DAILY 4. Levothyroxine Sodium 150 mcg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Pantoprazole 40 mg PO Q24H 7. Vitamin D ___ UNIT PO BID Discharge Disposition: Home Discharge Diagnosis: Incarcerated right inguinal hernia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with abdominal pain // pna? pnx?CT: hernia eval COMPARISON: Chest radiograph ___ Chest CT ___ FINDINGS: PA and lateral views of the chest provided. Mild left base atelectasis is seen. 1 cm nodular opacity projecting over the left lung base may represent atelectasis, but pulmonary nodule is not excluded in the appropriate clinical setting. No pleural effusion or pneumothorax. Cardiomediastinal silhouette is within normal limits. IMPRESSION: 1 cm nodular opacity projects over the left lung base may represent atelectasis, pulmonary nodule is not excluded. Recommend outpatient chest CT for further assessment. RECOMMENDATION(S): Outpatient chest CT to assess left lung base nodular opacity. Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ with abdominal pain // pna? pnx?CT: hernia eval TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 670 mGy-cm. COMPARISON: MRCP ___ FINDINGS: LOWER CHEST: Mild bibasilar atelectasis. Lungs otherwise clear. No pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. 2.1 cm cyst in segment 2 is noted. Numerous additional subcentimeter hypodense lesions for better characterized as cysts or biliary hamartomas on recent MRCP. 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 pancreatic ductal dilatation. 7 mm hypodense lesion in the pancreatic body corresponds to side-branch IPMN seen on recent MRCP. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of solid renal lesions or hydronephrosis. Left-sided parapelvic cysts are noted. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. Cecum lies in the right upper quadrant anterior to the liver, consistent with cecal bascule. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: Uterus is unremarkable. No adnexal abnormalities. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: There is a fat containing right inguinal hernia with mild stranding of the contained fat and trace fluid within. Hernia repair material is noted along the right lower rectus musculature. IMPRESSION: 1. Fat containing right inguinal hernia. Mild stranding of the herniated fat. 2. Pancreatic cystic likely reflecting side-branch IPMN, better evaluated on recent MRCP at which time repeat MRCP in ___ years was recommended. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: R Inguinal pain Diagnosed with Right lower quadrant pain temperature: 99.0 heartrate: 89.0 resprate: 16.0 o2sat: 96.0 sbp: 145.0 dbp: 89.0 level of pain: 1 level of acuity: 2.0

Dear Ms. ___, You were admitted to ___ for evaluation of abdominal pain and you were found to have an incarcerated right inguinal hernia. You were therefore evaluated by the acute care surgery team and offered surgical repair, however you declined surgery during this hospital admission. Risks of delaying surgery were discussed at length, however you have elected to follow up as an outpatient with Dr. ___. You are therefore now ready for discharge. Please follow the instructions below to continue your recovery: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications.

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: BRBPR Major Surgical or Invasive Procedure: None. History of Present Illness: The patient is a ___ female with minimal PMH who presents with watery diarrhea, BRBPR, and abdominal cramping after running a 5K race. She is a runner and was participating in a 5K race this morning. Towards the end of the race, she felt like she needed to have a bowel movement, but did not think much of it. About two hours later, she had watery diarrhea, which was soon followed by BRBPR. She felt dehydrated and tried to drink some water and gatorade, but vomited all of her PO intake, with no visible blood in her emesis. Since her symptoms started, she has had constant lower abdominal cramping. She denies any fevers, chills, headaches, chest pain, SOB, or cough. She has not had any vaginal bleeding or discharge. She runs regularly, and this amount of activity is not unusual for her. She was feeling fine before the run. She denies any sick contacts. She has never had similar bleeding before. She does not have easy bruising or problems with excessive bleeding. She did have one beer after the race, but no alcohol last night. She takes Ibuprofen almost daily for shin pain, including 400 mg before the race, and averaging 400-600 mg daily. Initial vitals in ED triage were T 96.8, HR 64, BP 122/73, and SpO2 100% on RA. Exam was notable for guaiac positive brown stool. Her CBC showed WBC 14.7 with 88.3% neutrophils and Hct 40.3 with MCV 85. Her chemistry panel was notable for bicarb 21, anion gap 14, and lactate 2.6. Her urinalysis and UCG were negative. She was given a total of normal saline 3000 ml and Ondansetron 4 mg IV. She continued to have episodes of diarrhea and feel unwell. She was admitted to Medicine for further management of BRBPR and diarrhea. Vitals prior to floor transfer were T 97.9, HR 68, BP 128/76, RR 16, and SpO2 100% on RA. On reaching the floor, she reported continued lower abdominal pain, but no other current symptoms. She had a normal formed BM the day before the race. REVIEW OF SYSTEMS: (+) Per HPI. Poor appetite currently, but normal before race. She was feeling lightheaded before receiving IV fluids. Did have one episode of chills before presenting to ED. (-) No fevers, weight loss or gain, fatigue, or other constitutional symptoms. No headache, sinus tenderness, rhinorrhea, or congestion. No vertigo, syncope, vision changes, hearing changes, focal weakness, or paresthesias. No chest pain, pressure, palpitations, SOB, DOE, or cough. No dysphagia or odynophagia. No hematuria, dysuria, frequency, urgency, incontinence, or discharge. No back, neck, joint, or muscle pain. No rashes or concerning skin lesions. No easy bleeding or bruising. No recent depression or anxiety. Review of systems was otherwise negative. Past Medical History: PAST MEDICAL HISTORY: # Depression / Anxiety -- well controlled # Bulimia -- ___ years ago Social History: ___ Family History: No family history of GI malignancy, IBD, or abnormal bleeding. # Mother: ___ ulcers # Father: ___ # ___: Only child Physical Exam: ADMISSION: VS: T 99.0, BP 132/87, HR 72, RR 18, SpO2 100% on RA, Wt 75.9 kg Gen: Young athletic female in NAD. Oriented x3. HEENT: Sclera anicteric. PERRL, EOMI. MMM, OP benign. Neck: JVP not elevated. No cervical lymphadenopathy. CV: RRR with normal S1, S2. No M/R/G appreciated. Chest: Respiration unlabored, no accessory muscle use. CTAB without crackles, wheezes or rhonchi. Abd: Normal bowel sounds. Soft, ND. No organomegaly or masses. Tender to palpation in lower abdomen, particulary suprapubic area, without rebound or guarding. Ext: WWP. Digital cap refill <2 sec. No C/C/E. Distal pulses intact radial 2+, DP 2+, ___ 2+. Skin: No concerning rashes or lesions. Neuro: CN II-XII grossly intact. Strength ___ in all extremities. Normal speech. DISCHARGE: 98.5 118/76 69 18 100% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: JVP not elevated Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: NABS, NT/ND Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: No rashes Neuro: Alert and oriented, CN II-XII grossly intact, non-focal motor/sensory exam Pertinent Results: ADMISSION: ___ 05:05PM PLT COUNT-272 ___ 05:05PM NEUTS-88.3* LYMPHS-7.9* MONOS-3.2 EOS-0.3 BASOS-0.3 ___ 05:05PM WBC-14.7*# RBC-4.76 HGB-13.3 HCT-40.3 MCV-85 MCH-28.0 MCHC-33.1 RDW-12.7 ___ 05:05PM ALBUMIN-4.5 CALCIUM-9.1 PHOSPHATE-3.0 MAGNESIUM-2.0 ___ 05:05PM ALT(SGPT)-18 AST(SGOT)-29 LD(LDH)-226 ALK PHOS-55 TOT BILI-0.3 ___ 05:05PM estGFR-Using this ___ 05:05PM GLUCOSE-138* UREA N-13 CREAT-0.8 SODIUM-136 POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-21* ANION GAP-18 ___ 05:12PM LACTATE-2.6* ___ 05:21PM URINE MUCOUS-FEW ___ 05:21PM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE EPI-<1 ___ 05:21PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 05:21PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 05:21PM URINE UCG-NEG ___ 05:21PM URINE HOURS-RANDOM CT ABDOMEN ___: LUNG BASES: The bases of the lungs are clear without nodules, consolidations, or pleural effusions. The base of the heart is normal. There is no pericardial effusion. ABDOMEN: The liver is normal in shape and contour. There are no focal hepatic lesions. There is no intra- or extra-hepatic biliary duct dilation. Minimal periportal edema is likely due to recent hydration. The gallbladder, spleen, pancreas, adrenal glands, and kidneys are normal. There are no renal lesions. There is no pyelonephritis or hydronephrosis. The kidneys enhance and excrete contrast symmetrically. The stomach and small bowel are normal in course and caliber. There are no focal inflammatory changes. There is no free air or free fluid. There is no mesenteric, abdominal, or retroperitoneal lymphadenopathy. The abdominal vasculature is normal in course and caliber. PELVIS: The sigmoid colon is air filled. The remainder of the descending and transverse colon are mostly collapsed, which limits its evaluation, but there is no definite wall thickening or abnormal enhancement. There is no significant surrounding stranding. The ascending colon is somewhat collapsed, though there is a suggestion that the wall is thickened with very minimal surrounding stranding. This could be consistent with a very mild colitis. The appendix is visualized and normal. The bladder and uterus are normal. There are no adnexal abnormalities. There is a small amount of free fluid in the pelvis, which is nonspecific. OSSEOUS STRUCTURES: There are no concerning lytic or sclerotic osseous lesions. No fracture is identified. IMPRESSION: 1. Mild wall thickening of the ascending colon, which could be due to underdistention, however in conjunction with subtle adjacent stranding, a very mild colitis is a consideration. 2. Small amount of free fluid in the pelvis, which is nonspecific, and maybe physiologic. MICRO: ___ C. difficile DNA amplification assay (Final ___: Negative FECAL CULTURE (Pending): CAMPYLOBACTER CULTURE (Pending): FECAL CULTURE - R/O YERSINIA (Pending): FECAL CULTURE - R/O E.COLI 0157:H7(Final ___: NO E.COLI 0157:H7. DISCHARGE: ___ 06:45AM BLOOD WBC-12.8* RBC-4.58 Hgb-13.0 Hct-38.8 MCV-85 MCH-28.4 MCHC-33.5 RDW-13.0 Plt ___ ___ 06:45AM BLOOD Glucose-88 UreaN-4* Creat-0.7 Na-141 K-4.2 Cl-106 HCO3-28 AnGap-11 ___ 06:45AM BLOOD CK(CPK)-89 ___ 06:45AM BLOOD Calcium-8.6 Phos-2.8 Mg-2.0 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Sertraline 200 mg PO DAILY 2. Loestrin ___ Fe *NF* (norethindrone-e.estradiol-iron) ___ (24)-75(4) mg-mcg-mg Oral DAILY 3. Ibuprofen 400-600 mg PO Q8H:PRN pain Discharge Medications: 1. Loestrin ___ Fe *NF* (norethindrone-e.estradiol-iron) ___ (24)-75(4) mg-mcg-mg Oral DAILY 2. Sertraline 200 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis Hematochezia Diarrhea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Bright red blood per rectum after running a 5k. Has abdominal pain, nausea, and persistent bloody diarrhea. Evaluate for exercise-induced ischemic colitis. COMPARISONS: None. TECHNIQUE: Contiguous axial MDCT images were obtained through the abdomen and pelvis without the administration of IV contrast. Sagittal and coronal reformatted images were obtained and reviewed. FINDINGS: LUNG BASES: The bases of the lungs are clear without nodules, consolidations, or pleural effusions. The base of the heart is normal. There is no pericardial effusion. ABDOMEN: The liver is normal in shape and contour. There are no focal hepatic lesions. There is no intra- or extra-hepatic biliary duct dilation. Minimal periportal edema is likely due to recent hydration. The gallbladder, spleen, pancreas, adrenal glands, and kidneys are normal. There are no renal lesions. There is no pyelonephritis or hydronephrosis. The kidneys enhance and excrete contrast symmetrically. The stomach and small bowel are normal in course and caliber. There are no focal inflammatory changes. There is no free air or free fluid. There is no mesenteric, abdominal, or retroperitoneal lymphadenopathy. The abdominal vasculature is normal in course and caliber. PELVIS: The sigmoid colon is air filled. The remainder of the descending and transverse colon are mostly collapsed, which limits its evaluation, but there is no definite wall thickening or abnormal enhancement. There is no significant surrounding stranding. The ascending colon is somewhat collapsed, though there is a suggestion that the wall is thickened with very minimal surrounding stranding. This could be consistent with a very mild colitis. The appendix is visualized and normal. The bladder and uterus are normal. There are no adnexal abnormalities. There is a small amount of free fluid in the pelvis, which is nonspecific. OSSEOUS STRUCTURES: There are no concerning lytic or sclerotic osseous lesions. No fracture is identified. IMPRESSION: 1. Mild wall thickening of the ascending colon, which could be due to underdistention, however in conjunction with subtle adjacent stranding, a very mild colitis is a consideration. 2. Small amount of free fluid in the pelvis, which is nonspecific, and maybe physiologic. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: BRBPR Diagnosed with DIARRHEA, NONINF GASTROENTERIT NEC, DEHYDRATION temperature: 96.8 heartrate: 64.0 resprate: nan o2sat: 100.0 sbp: 122.0 dbp: 73.0 level of pain: 8 level of acuity: 2.0

Dear Ms. ___, It was a pleasure caring for you at ___. You presented with bloody diarrhea, which has since stopped. We are still unsure what caused it, but we think it either resulted from an infection in your colon, low blood flow to the colon while you exercised, or inflammation in the colon from another cause. You were given IV fluids and monitored closely. Your blood counts were stable, you are feeling better, are no longer having bloody diarrhea like you were yesterday, and are eating solid food, so we feel that you are ready for discharge. Additionally, the use of ibuprofen can exacerbate (or cause) gastrointestinal bleeding (typically from the stomach). Please use this sparingly and alternate with acetaminophen. Please keep yourself well-hydrated with drinks like gatorade while you continue to have diarrhea and only eat food that you can tolerate. Please review your medications below closely and take them as prescribed. Please keep your follow-up appointment below.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Tetracycline / aspirin / NSAIDS / Antihistamines - Alkylamine Attending: ___ Chief Complaint: Left subcapital femur fracture Major Surgical or Invasive Procedure: ___: Closed reduction with percutaneous pinning of Left subcapital femur fracture History of Present Illness: ___ with h/o bipolar disorder on lithium, nephrogenic DI, breast CA sp mastectomy in ___ who initially presented s/p mechanical fall on ___ and found to have L subcapital femur fx. She was admitted to ___ service for ORIF, now POD#1. Her course has been complicated by AMS with slurred speech, initially concerning for acute CVA but ruled out by head CT. Lab work has been notable for leukocytosis (WBC 14), hypernatremia (Na 148, increased from baseline of 145) and hypercalcemia (Ca ranging ___. . Currently, she is somnolent and unable to provide a history. Past Medical History: - Nephrogenic DI - breast cancer, ER+/PR+, HER2/neu-, grade II, invasive lobular carcinoma and lobular carcinoma in situ, s/p modified radical mastectomy with senitnel LN bx ___ - bipolar, dx ___, stable on lithium therapy - IBS - hyperparathyroidism (details not known) - hypothyroidism - CKD stage ___ - s/p bilateral salingo-oophorectomy, total abdominal hysterectomy ___ complicated appencitis s/p appendectomy in ___ Social History: ___ Family History: Mother had breast cancer, possibly in her ___. A maternal aunt may also have had cancer. Physical Exam: Examination on Tranfer: VS - Tm 100.5/Tc 100.4, BP 130/52, HR 90, 93% 2L GENERAL - Somnolent elderly female in NAD HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MM dry, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored HEART - RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs), L hip incision c/d/i SKIN - no rashes or lesions NEURO - Exam limited due to pt not following commands. AAOx3, CNs II-XII grossly intact, DTRs 2+ and symmetric . Discharge Exam: A&O x 3, awake and alert, interactive Calm and comfortable LLE skin clean and intact Tender lateral hip LLE shortened and externally rotated Thighs and legs are soft No pain with passive motion Saph Sural DPN SPN MPN LPN ___ FHL ___ TA PP Fire 1+ ___ and DP pulses Pertinent Results: Admission Labs: ___ 06:00PM GLUCOSE-129* UREA N-32* CREAT-1.7* SODIUM-144 POTASSIUM-4.3 CHLORIDE-112* TOTAL CO2-22 ANION GAP-14 ___ 06:00PM CALCIUM-11.4* PHOSPHATE-3.4 MAGNESIUM-2.5 ___ 06:00PM LITHIUM-1.0 ___ 08:43PM ___ PTT-25.7 ___ . Sodium Trend: . ___ 07:05PM BLOOD Na-149* ___ 05:30PM BLOOD Na-147* ___ 09:10PM BLOOD Na-147* ___ 05:03AM BLOOD Na-142 (IV D5W stopped) ___ 05:12AM BLOOD Na-144 . Calcium Labs: ___ 06:00PM BLOOD Calcium-11.4* Phos-3.4 Mg-2.5 ___ 05:35AM BLOOD Calcium-10.7* Phos-1.9* Mg-2.2 Cholest-194 ___ 11:40AM BLOOD TotProt-5.7* Albumin-3.5 Globuln-2.2 ___ 05:35AM BLOOD PTH-121* . Discharge Labs: ___ 05:12AM BLOOD WBC-7.3 RBC-3.29* Hgb-9.5* Hct-30.2* MCV-92 MCH-28.9 MCHC-31.5 RDW-13.9 Plt ___ ___ 05:12AM BLOOD Glucose-129* UreaN-34* Creat-1.3* Na-144 K-4.3 Cl-114* HCO3-22 AnGap-12 ___ 05:12AM BLOOD Calcium-10.9* Phos-2.7 Mg-2.4 . Micro: ___ 10:09 am URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. . IMAGING: Bilateral Hip Xrays ___: There is a subcapital fracture through the proximal left femur without substantial displacement, probably complete. IMPRESSION: Left subcapital femur fracture. . CT HEAD W/O CONTRAST ___: The majority of the images are degraded due to extensive motion artifact. Within this limitation, no large intracranial hemorrhage is identified. Focal hypodensities most pronounced in the right basal ganglia likely represents a remote infarct, unchanged. Apparent asymmetry of lateral ventricles is again noted. There is no shift of normal midline structures. No hydrocephalus is seen. Basal cisterns are patent. There is no large vascular territorial infarction. Sulci and ventricles are prominent, likely age-related involutional changes. . Imaged paranasal sinuses appear well aerated. The posterior mastoid air cells are opacified, more conspicuous from prior exam. No acute fracture is seen. . IMPRESSION: . 1. No evidence of large vascular territorial infarction. Study is suboptimal due to extensive motion artifact. 2. Prominent sulci and ventricles, likely age-related involutional changes. . CXR AP ___: Large hiatal hernia is projecting over the left lower lung behind the cardiac silhouette. There are bibasal opacities concerning for interval increase of areas of atelectasis. Infectious process is less likely but cannot be excluded. Small bilateral pleural effusions are present. Mild vascular engorgement is seen, might be consistent with interval fluid load on the patient. . MRI Head W/O CONTRAST ___: FINDINGS: The examination is limited due to patient motion; grossly there is no evidence of acute intraparenchymal hemorrhage, on the diffusion axial images, there is no evidence of intraparenchymal restricted diffusion or areas to indicate acute/subacute ischemic changes. Please consider obtaining a followup examination under conscious sedation if clinically warranted. IMPRESSION: Limited study due to patient motion, the patient refused to continue with the examination. Grossly, there is no evidence of acute hemorrhagic changes or areas with acute ischemia. Followup examination is recommended if clinically warranted under conscious sedation. Medications on Admission: Anastrozole 1 mg daily Levothyroxine 88 mcg daily Lithium carbonate 300 mg BID loperamide 2 mg PRN diarrhea. Vit D Discharge Medications: 1. senna 8.6 mg Tablet Sig: ___ Tablets PO DAILY (Daily): while taking oxycodone to prevent constipation, do not take if having loose stools. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): while taking oxycodone to prevent constipation, do not take if having loose stools. 3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation: while taking oxycodone, do not take if having loose stools. 4. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 5. enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Injection Subcutaneous Q24H (every 24 hours). 6. anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily (). 7. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. loperamide 2 mg Capsule Sig: One (1) Capsule PO once a day as needed for loose stool. 9. oxycodone 5 mg Tablet Sig: ___ Tablet PO every six (6) hours as needed for pain for 2 weeks: ___ cause drowsiness, do not drive while taking medication. Disp:*56 Tablet(s)* Refills:*0* 10. lithium carbonate 300 mg Capsule Sig: One (1) Capsule PO twice a day. 11. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 12. acetaminophen 325 mg Tablet Sig: ___ Tablets PO every six (6) hours as needed for pain. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left subcapital femur fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report BILATERAL HIP RADIOGRAPHS HISTORY: Trauma. Question fracture involving the left hip status post fall on the left hip. COMPARISONS: None, aside from CT torso dated ___. TECHNIQUE: Pelvis and bilateral hips, total of five views. FINDINGS: There is a subcapital fracture through the proximal left femur without substantial displacement, probably complete. IMPRESSION: Left subcapital femur fracture. Radiology Report CHEST RADIOGRAPH HISTORY: Preoperative radiograph. COMPARISONS: Scout view from a CT torso dated ___ and more recent chest radiograph from ___. TECHNIQUE: Chest, semi-upright AP. FINDINGS: There is a large hiatal hernia containing stomach and also apparently part of the colon, as seen previously. The heart is normal in size. The mediastinal and hilar contours appear unchanged. There is no pleural effusion or pneumothorax. The lungs appear clear. IMPRESSION: No evidence of acute disease. Large hiatal hernia, as seen previously. Radiology Report REASON FOR EXAMINATION: Pinning of the left hip. Note is made that the radiologist was not attending the procedure. Three fluoroscopic views obtained during fluoroscopy were brought to our review. Note is made that the fluoroscopy time of 82.4 seconds was provided. Internal pinning of the left hip is noted with no immediate complications. For precise details, please review procedure report. Radiology Report INDICATION: Patient with aphasia. Assess for stroke. COMPARISONS: CT head of ___. TECHNIQUE: MDCT-acquired contiguous images through the brain were obtained without intravenous contrast at 5 mm slice thickness. Coronally and sagittally reformatted images were displayed. Multiple attempts were made to obtain the images due to patient's agitation. FINDINGS: The majority of the images are degraded due to extensive motion artifact. Within this limitation, no large intracranial hemorrhage is identified. Focal hypodensities most pronounced in the right basal ganglia likely represents a remote infarct, unchanged. Apparent asymmetry of lateral ventricles is again noted. There is no shift of normal midline structures. No hydrocephalus is seen. Basal cisterns are patent. There is no large vascular territorial infarction. Sulci and ventricles are prominent, likely age-related involutional changes. Imaged paranasal sinuses appear well aerated. The posterior mastoid air cells are opacified, more conspicuous from prior exam. No acute fracture is seen. IMPRESSION: 1. No evidence of large vascular territorial infarction. Study is suboptimal due to extensive motion artifact. 2. Prominent sulci and ventricles, likely age-related involutional changes. Radiology Report REASON FOR EXAMINATION: Evaluation of the patient with mental status changes. COMPARISON: ___ radiograph. Large hiatal hernia is projecting over the left lower lung behind the cardiac silhouette. There are bibasal opacities concerning for interval increase of areas of atelectasis. Infectious process is less likely but cannot be excluded. Small bilateral pleural effusions are present. Mild vascular engorgement is seen, might be consistent with interval fluid load on the patient. Radiology Report STUDY: MRI of the head. CLINICAL INDICATION: Recurrent episodes of delirium and slurred speech, evaluate for stroke. COMPARISON: Prior head CT dated ___ and ___. TECHNIQUE: Limited examination, the patient refused to continue with the study after the diffusion-weighted sequence, only sagittal T1 and axial DWI sequences were provided. FINDINGS: The examination is limited due to patient motion; grossly there is no evidence of acute intraparenchymal hemorrhage, on the diffusion axial images, there is no evidence of intraparenchymal restricted diffusion or areas to indicate acute/subacute ischemic changes. Please consider obtaining a followup examination under conscious sedation if clinically warranted. IMPRESSION: Limited study due to patient motion, the patient refused to continue with the examination. Grossly, there is no evidence of acute hemorrhagic changes or areas with acute ischemia. Followup examination is recommended if clinically warranted under conscious sedation. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: LEFT HIP Diagnosed with FX FEMUR INTRCAPS NEC-CL, FALL FROM BED temperature: 98.5 heartrate: 70.0 resprate: 12.0 o2sat: 95.0 sbp: 104.0 dbp: 70.0 level of pain: 13 level of acuity: 3.0

Dear Ms. ___, ___ were admitted to ___ because ___ had a fall at home resulting in a hip fracture. ___ had surgery on ___ without complications. ___ were then transferred to the medicine service because ___ were confused and drowsy. Your labwork showed a high sodium, likely due to your lithium therapy. ___ were given IV fluids and your sodium returned to normal. ___ should continue to drink plenty of water at home to prevent your sodium level from getting too high. ___ also were noted to have high calcium levels, likely due to the effects of lithium on a gland called the parathyroid gland. ___ should follow up with an endocrinologist and general surgeon to discuss management of your calcium levels, which may require surgery. We made the following changes to your medications: -START lovenox injections 30 units once daily (continue until your follow up appointment with orthopedics) -START tylenol ___ every six hours as needed for pain -START oxycodone 2.5-5mg every six hours as needed for pain not relieved by tylenol -START senna, docusate, and bisacodyl to prevent constipation while taking oxycodone We made no other changes to your medications while ___ were in the hospital. Please continue taking your medications as prescribed by your outpatient providers. Please see below for your currently scheduled appointments. If ___ are unable to make an appointment please call and reschedule. It has been a pleasure taking care of ___ at ___ and we wish ___ a speedy recovery. Wound Care: - Keep Incision clean and dry. - ___ can get the wound wet or take a shower starting from 7 days after surgery, but no baths or swimming for at least 4 weeks. - Dry sterile dresssing may be changed daily. No dressing is needed if wound continues to be non-draining. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. Activity: - Continue to be full weight bearing on your left leg - ___ should not lift anything greater than 5 pounds. - Elevate left leg to reduce swelling and pain. Other Instructions - Resume your regular diet. - Avoid nicotine products to optimize healing. - Resume your home medications. Take all medications as instructed. - Continue taking the Lovenox to prevent blood clots. - ___ have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so plan ahead. ___ can either have them mailed to your home or pick them up at the clinic located on ___. We are not allowed to call in narcotic (oxycontin, oxycodone, percocet) prescriptions to the pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. - Narcotic pain medication may cause drowsiness. Do not drink alcohol while taking narcotic medications. Do not operate any motor vehicle or machinery while taking narcotic pain medications. Taking more than recommended may cause serious breathing problems. - If ___ have questions, concerns or experience any of the below danger signs then please call your doctor at ___ or go to your local emergency room.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Phenobarbital / Depakote / Zarontin / Gabapentin / Zonegran / Tranxene-SD / valproic acid / Levaquin Attending: ___. Major Surgical or Invasive Procedure: EGD ___ attach Pertinent Results: ADMISSION LABS: ================ ___ 10:00AM BLOOD WBC-14.6* RBC-2.37* Hgb-5.9* Hct-20.4* MCV-86 MCH-24.9* MCHC-28.9* RDW-18.3* RDWSD-58.1* Plt ___ ___ 10:00AM BLOOD Neuts-83.6* Lymphs-6.2* Monos-9.5 Eos-0.1* Baso-0.3 Im ___ AbsNeut-12.18* AbsLymp-0.90* AbsMono-1.39* AbsEos-0.02* AbsBaso-0.04 ___ 10:00AM BLOOD Glucose-99 UreaN-36* Creat-0.7 Na-139 K-4.4 Cl-106 HCO3-22 AnGap-11 ___ 10:00AM BLOOD ALT-9 AlkPhos-114 TotBili-<0.2 ___ 10:00AM BLOOD Albumin-3.0* Calcium-7.7* Phos-2.3* Mg-2.0 PERTINENT LABS/MICRO: ===================== ___ 10:00AM BLOOD WBC-14.6* RBC-2.37* Hgb-5.9* Hct-20.4* MCV-86 MCH-24.9* MCHC-28.9* RDW-18.3* RDWSD-58.1* Plt ___ ___ 04:40PM BLOOD WBC-12.6* RBC-2.80* Hgb-7.4* Hct-26.1* MCV-93 MCH-26.4 MCHC-28.4* RDW-16.9* RDWSD-57.7* Plt ___ ___ 08:55PM BLOOD WBC-8.0 RBC-2.19* Hgb-5.9* Hct-19.1* MCV-87 MCH-26.9 MCHC-30.9* RDW-16.8* RDWSD-52.6* Plt ___ ___ 10:50PM BLOOD WBC-6.4 RBC-2.06* Hgb-5.5* Hct-17.9* MCV-87 MCH-26.7 MCHC-30.7* RDW-16.5* RDWSD-51.8* Plt ___ ___ 03:57AM BLOOD WBC-7.1 RBC-2.79* Hgb-7.6* Hct-24.8* MCV-89 MCH-27.2 MCHC-30.6* RDW-16.0* RDWSD-51.8* Plt ___ ___ 10:00AM BLOOD Lipase-31 ___ 10:00AM BLOOD cTropnT-<0.01 ___ 09:36AM BLOOD Hapto-152 ___ 02:09PM URINE Color-Straw Appear-HAZY* Sp ___ ___ 02:09PM URINE Blood-TR* Nitrite-NEG Protein-50* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NORMAL pH-7.0 Leuks-LG* ___ 02:09PM URINE RBC-15* WBC->182* Bacteri-FEW* Yeast-NONE Epi-2 ___ BCx x2: NGTD ___ UCx: No growth DISCHARGE LABS: ================ ___ 09:36AM BLOOD WBC-4.6 RBC-3.12* Hgb-8.4* Hct-27.8* MCV-89 MCH-26.9 MCHC-30.2* RDW-17.0* RDWSD-54.3* Plt ___ ___ 09:36AM BLOOD ___ PTT-27.9 ___ ___ 09:36AM BLOOD Glucose-106* UreaN-11 Creat-0.6 Na-139 K-4.4 Cl-106 HCO3-23 AnGap-10 ___ 09:36AM BLOOD Calcium-8.3* Phos-2.6* Mg-2.0 PERTINENT IMAGING: ================== ___ CXR: No acute cardiopulmonary process. ___ KUB: There is a large amount of colonic stool. Non-specific, nonobstructive gas pattern. No pneumoperitoneum. ___: EGD: "Normal mucosa in the whole stomach" Medications on Admission: The Preadmission Medication list may be inaccurate and requires further investigation. 1. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 2. Phenytoin (Suspension) 150 mg PO BID 3. Rivaroxaban 20 mg PO DAILY 4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 5. Bisacodyl 10 mg PO Frequency is Unknown 6. Cyanocobalamin 1000 mcg PO DAILY 7. Felbamate 1400 mg PO BID 8. LevETIRAcetam 750 mg PO BID 9. Magnesium Citrate 300 mL PO Frequency is Unknown 10. Psyllium Powder 1 PKT PO DAILY 11. Selsun Blue (selenium sulfide) 1 % topical 3x/week prn 12. Senna 8.6 mg PO BID 13. Sucralfate 1 gm PO QID 14. Tamsulosin 0.4 mg PO QHS 15. Vitamin D 1000 UNIT PO DAILY 16. starch (thickening) ___ spoonfuls oral TID W/MEALS Discharge Medications: 1. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line 2. Lansoprazole Oral Disintegrating Tab 30 mg PO BID 3. Magnesium Citrate 300 mL PO DAILY 4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 5. Cyanocobalamin 1000 mcg PO DAILY 6. Felbamate 1400 mg PO BID 7. LevETIRAcetam 750 mg PO BID 8. Phenytoin (Suspension) 150 mg PO BID 9. Psyllium Powder 1 PKT PO DAILY 10. Rivaroxaban 20 mg PO DAILY 11. Selsun Blue (selenium sulfide) 1 % topical 3x/week prn 12. Senna 8.6 mg PO BID 13. starch (thickening) ___ spoonfuls oral TID W/MEALS 14. Sucralfate 1 gm PO QID 15. Tamsulosin 0.4 mg PO QHS 16. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: PRIMARY DIAGNOSIS ====================== - Upper GI bleed SECONDARY DIAGNOSIS ====================== - ___ syndrome Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report INDICATION: ___ with poor IV access // Poor IV access TECHNIQUE: AP and lateral views the chest. COMPARISON: Chest x-ray from ___. FINDINGS: Lung volumes are slightly low with left basilar atelectasis. There is no consolidation, effusion, or edema. Cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities. Old healed left lateral rib fractures are noted. Multilevel midthoracic vertebral body height loss as seen on prior. IMPRESSION: No acute cardiopulmonary process. Radiology Report INDICATION: ___ year old man with n/v and coffee ground emesis // R/o SBO or volvulus TECHNIQUE: Supine and decubitus abdominal radiographs were obtained. COMPARISON: CT abdomen pelvis ___ FINDINGS: There are no abnormally dilated loops of large or small bowel. There is a large amount of colonic stool. There is no free intraperitoneal air. The imaged bones are unremarkable. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: There is a large amount of colonic stool. Non-specific, nonobstructive gas pattern. No pneumoperitoneum. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old man S/P Midline placement. Line found to not be IV after receiving 300 mL LR and 40 mg propofol // R/O pleural collection of fluid from midline Contact name: ___: ___ TECHNIQUE: AP radiograph of the chest. COMPARISON: Chest radiograph ___. IMPRESSION: No vascular access catheter is identified. There is no focal consolidation, pleural effusion or pneumothorax. The cardiomediastinal silhouette is within normal limits. There are no acute osseous abnormalities. Healed left rib fractures are noted. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Coffee ground emesis Diagnosed with Anemia, unspecified temperature: 98.1 heartrate: 95.0 resprate: 16.0 o2sat: 98.0 sbp: 100.0 dbp: 58.0 level of pain: uta level of acuity: 2.0

Dear Mr. ___, WHY WERE YOU ADMITTED TO THE HOSPITAL? - You had bloody vomit WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? - You had a procedure performed, called an endoscopy, that tried to find a source of the blood. It did not find any single area of concern. - You were monitored closely and did not re-bleed. - You had a seizure in setting of acute illness WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - Take all of your medications as prescribed (listed below) - Follow up with your doctors as listed below Please see below for more information on your hospitalization. It was a pleasure taking part in your care here at ___. We wish you all the best, - Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: fever Major Surgical or Invasive Procedure: Cholangiogram and plasty of biliary tree (___) History of Present Illness: ___ year old woman with history of NASH cirrhosis s/p DDLT (___) on cyclosporine and mycophenolate sodium w/ aortic conduit complicated by biliary stricture s/p stent placement & multiple PTBD exchanges, who has had multiple hospitalizations for recurrent cholangitis who presents with fevers She was recently admitted from ___ for cholangitis, found to have perihepatic abscess s/p ___ drainage. Prior bile cultures growing VRE, pseudomonas resistant to ___. Initially was on linezolid/meropenem and narrowed back to suppressive ciprofloxacin per ID. She presents with 1 day of fever without any additional symptoms. In the ED, initial VS were: 99.2 87 140/65 18 100% RA Exam notable for: JP drain/PTBD site c/d/i, no signs of septic joint on knee exam, full ROM, no rashes, lungs CTA, abd unremarkable, systolic murmur Labs showed: ___ 30 AGap=15 ------------- 4.9 24 1.0 Cyclosporine: 104 Lactate: 2 ALT: 91 AP: 1025 Tbili: 0.7 Alb: 3.8 AST: 65 LDH: Imaging showed: RUQUS: 1. Patent hepatic vasculature. 2. No significant change in fluid collection adjacent to the falciform ligament when accounting for differences in technique. 3. Stable mild splenomegaly. 4. Right pleural effusion. CXR: No acute intrathoracic process. Unchanged small right pleural effusion. Patient received: linezolid/cipro Hepatology was consulted: Concern for recurrent cholangitis. OK to admit to ___. Please obtain RUQUS, blood cultures. Transfer VS were: 100.1 82 136/60 18 98% RA On arrival to the floor, patient reports she feels better. States she only had fever today. Denies any abdominal pain, changed output from her ___ drain, N/V, diarrhea, constipation, chest pain, SOB. She has been taking good PO. She has been compliant with all her medications including ciprofloxacin. REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as per HPI Past Medical History: -Idiopathic cirrhosis s/p DDLT with aortic conduit (___) with post-operative course complicated by biliary stricture and poor drainage of the left biliary system s/p PTBD -Psychosis -Malnutrition- moderate -Hypertension -Diabetes mellitus- on insulin -HLD -Asthma Social History: ___ Family History: HTN - mother and father CAD - father No significant family history of liver cancer Physical Exam: ADMISSION PHYSICAL EXAM VS: 98.9 167/71 87 16 98% RA GENERAL: laying comfortably in NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: soft, nontender, nondistedned. medial ___ drain & PTBD c/d/I without surrounding erythema. PTBD is capped. ___ drain w/ scant fluid in JP EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM GENERAL: pleasant, elderly woman, appears comfortable and in NAD, sitting up in bed HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva, MMM HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: soft, nontender, nondistended. medial ___ drain & PTBD c/d/i without surrounding erythema. PTBD capped. ___ drain w/ scant fluid in JP EXTREMITIES: warm and well perfused, no cyanosis, clubbing, or lower extremity edema NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS ___ 08:40AM BLOOD WBC-5.0 RBC-3.18* Hgb-8.3* Hct-26.4* MCV-83 MCH-26.1 MCHC-31.4* RDW-17.2* RDWSD-51.5* Plt ___ ___ 08:40AM BLOOD Neuts-76.5* Lymphs-13.1* Monos-5.8 Eos-3.8 Baso-0.2 Im ___ AbsNeut-3.79 AbsLymp-0.65* AbsMono-0.29 AbsEos-0.19 AbsBaso-0.01 ___ 08:40AM BLOOD ___ ___ 08:40AM BLOOD UreaN-30* Creat-1.0 Na-142 K-4.9 Cl-103 HCO3-24 AnGap-15 ___ 08:40AM BLOOD Glucose-173* ___ 08:40AM BLOOD ALT-91* AST-65* AlkPhos-1025* TotBili-0.7 ___ 08:40AM BLOOD Albumin-3.8 Calcium-9.2 Phos-4.3 Mg-1.5* ___ 08:40AM BLOOD Cyclspr-104 ___ 08:04PM BLOOD Lactate-2.0 PERTINENT LABS ___ 04:33AM BLOOD WBC-4.9 RBC-2.62* Hgb-6.9* Hct-21.7* MCV-83 MCH-26.3 MCHC-31.8* RDW-17.3* RDWSD-51.8* Plt ___ ___ 07:05AM BLOOD WBC-5.4 RBC-3.28* Hgb-8.6* Hct-27.4* MCV-84 MCH-26.2 MCHC-31.4* RDW-17.0* RDWSD-51.8* Plt ___ ___ 07:06AM BLOOD ALT-55* AST-25 LD(LDH)-151 AlkPhos-826* TotBili-0.8 ___ 04:22AM BLOOD ALT-32 AST-17 AlkPhos-838* TotBili-1.1 ___ 07:06AM BLOOD calTIBC-237* Ferritn-281* TRF-182* DISCHARGE LABS ___ 04:22AM BLOOD WBC-3.6* RBC-2.97* Hgb-7.7* Hct-24.6* MCV-83 MCH-25.9* MCHC-31.3* RDW-17.0* RDWSD-50.9* Plt ___ ___ 04:22AM BLOOD ___ PTT-31.5 ___ ___ 04:22AM BLOOD Glucose-120* UreaN-19 Creat-1.0 Na-139 K-5.1 Cl-102 HCO3-24 AnGap-13 ___ 04:22AM BLOOD ALT-40 AST-31 AlkPhos-916* TotBili-1.1 ___ 04:22AM BLOOD Albumin-3.5 Calcium-9.2 Phos-3.8 Mg-1.7 ___ 04:22AM BLOOD Cyclspr-190 IMAGING/STUDIES CXR (___)- No acute intrathoracic process. Unchanged small right pleural effusion. RUQ U/S (___)- 1. Patent hepatic vasculature. 2. No significant change in fluid collection adjacent to the falciform ligament when accounting for differences in technique. 3. Stable mild splenomegaly. 4. Right pleural effusion. Cholangiogram (___)- 1. Right 12 ___ percutaneous transhepatic biliary drainage catheters. 2. Cholangiogram showing distal occlusion of indwelling right internal external biliary drainage with absence of flow into the duodenum. Antegrade cholangiogram demonstrates common bile duct stricture with sluggish flow of contrast into the duodenum. Post cholangio plasty and ___ sweep cholangiogram demonstrates improved antegrade flow of bile into the duodenum. 3. Successful exchange of right 12 ___ percutaneous transhepatic biliary drainage catheter with new right 12 ___ internal external biliary catheter. 4. Successful exchange of subhepatic 8 ___ abscess drain. Radiology Report EXAMINATION: Chest Radiograph INDICATION: ___ with liver tx, p/w fevers// r/o PNA COMPARISON: Radiograph dated ___. FINDINGS: PA and lateral views of the chest provided.Low lung volumes. No focal consolidations. Cardiomediastinal and hilar silhouettes are unchanged. No pulmonary edema. Small right pleural effusion is again noted. No left pleural effusion. No pneumothorax. A percutaneous biliary drainage catheter is partially visualized in the right upper abdomen. IMPRESSION: No acute intrathoracic process. Unchanged small right pleural effusion. Radiology Report EXAMINATION: DUPLEX DOP ABD/PEL LIMITED INDICATION: r/o any abnl TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen was performed. COMPARISON: Ultrasound dated ___. CT dated ___. FINDINGS: Liver: The hepatic parenchyma is within normal limits. No focal liver lesions are identified. There is no ascites. Bile ducts: There is no intrahepatic biliary ductal dilation. A biliary drainage catheter is noted. The common hepatic duct measures 6 mm. A fluid collection adjacent to the falciform ligament is again noted, measuring 5.0 x 1.6 cm. Pancreas: The pancreas is largely obscured by overlying bowel gas, with imaged portions of the pancreas appearing within normal limits. Spleen: The spleen demonstrates normal echotexture, and measures 13.3 cm. Kidneys: The right kidney measures 10.4 cm. The left kidney measures 9.6 cm. No stones, masses, or hydronephrosis are identified in either kidney. Doppler evaluation: The main portal vein is patent, with flow in the appropriate direction. Main portal vein velocity is 36.3 cm/sec. Right and left portal veins are patent, with antegrade flow. The main hepatic artery is patent, with appropriate waveform. Right, middle and left hepatic veins are patent, with appropriate waveforms. Incidental note is made of a right pleural effusion. IMPRESSION: 1. Patent hepatic vasculature. 2. No significant change in fluid collection adjacent to the falciform ligament when accounting for differences in technique. 3. Stable mild splenomegaly. 4. Right pleural effusion. Radiology Report INDICATION: ___ aortic conduit complicated by biliary strictures and stent and multiple percutaneous transhepatic biliary drain exchanges with recurrent cholangitis, pseudomonas bacteremia, on suppressive Cipro, VRE infections, and left hepatic abscess who presented with fevers, and elevated ALP consistent with cholangitis// please evaluate PTBD and JP drain/fluid collection. COMPARISON: CT from ___ TECHNIQUE: OPERATORS: Dr. ___ radiologist performed the procedure. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 75 mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service time of 55 minutes during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site MEDICATIONS: None CONTRAST: 50 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 17.4 min, 85 mGy PROCEDURE: 1. Over-the-wire cholangiogram through existing right 12 ___ percutaneous internal external transhepatic biliary drainage access. 2. Exchange of the existing percutaneous trans-hepatic biliary drainage catheter with a new 12 ___ internal-external PTBD catheter. 3. Cholangio plasty and ___ sweep of common bile duct. 4. Abscessogram 5. 8 ___ abscess drain exchange. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The right/mid abdomen was prepped and draped in the usual sterile fashion. Initial scout images showed biliary drain in the appropriate position. The right tube was injected with dilute contrast. The images were stored on PACS. Following the subcutaneous injection of 1% lidocaine and instillation of lidocaine jelly into the skin site, the right catheter was cut and ___ wire was advanced through the catheter into the duodenum. The catheter was removed over the wire and a 8 ___ 25 cm sheath was advanced. Next a 5 ___ Kumpe catheter was advanced into the duodenum which was confirmed with contrast injection and exchange was made for an Amplatz wire. Antegrade cholangiogram was then performed. Based on the findings of the cholangiogram, cholangio plasty was performed in the common bile duct and at the level of the ampulla with a 10 mm Conquest balloon. Exchange was then made for a 5.5 ___ ___ balloon and multiple sweeps were performed within the common bile duct into the duodenum. Completion cholangiogram was then performed. The sheath was removed and a 12 ___ percutaneous trans hepatic internal external biliary drainage catheter was advanced into the duodenum. Side holes were positioned above and below the level of obstruction to facilitate internal drainage. The wire and inner stiffener were removed, the catheter was flushed, the loop was formed, the catheter was attached to a bag and sterile dressings were applied. Attention was then turned to the indwelling subhepatic abscess drain. The indwelling 8 ___ drain was injected with contrast which demonstrated persistent collection. No evidence of pericatheter leakage or fistulous communication. However there is difficulty with aspirating through the catheter. The catheter was cut and ___ wire was advanced into the collection. The catheter was removed over the wire and a new 8 ___ APDL drain was advanced into the collection. The wire and inner stiffener were removed, the catheter was flushed, the loop was formed. The catheter successfully flushed and aspirated. The catheter was attached to a JP bulb placed to suction and sterile dressings were applied. The patient tolerated the procedure well and there were no immediate post-procedure complications. FINDINGS: 1. Right 12 ___ percutaneous transhepatic biliary drainage catheters. 2. Cholangiogram showing distal occlusion of indwelling right internal external biliary drainage with absence of flow into the duodenum. Antegrade cholangiogram demonstrates common bile duct stricture with sluggish flow of contrast into the duodenum. Post cholangio plasty and ___ sweep cholangiogram demonstrates improved antegrade flow of bile into the duodenum. 3. Successful exchange of right 12 ___ percutaneous transhepatic biliary drainage catheter with new right 12 ___ internal external biliary catheter. 4. Successful exchange of subhepatic 8 ___ abscess drain. IMPRESSION: Successful exchange of existing percutaneous transhepatic biliary drainage catheters with new 12 ___ internal external biliary catheter. Successful exchange of subhepatic 8 ___ abscess drain. RECOMMENDATION(S): 1. The biliary drainage catheter can be capped when the output is bilious and nonbloody. Gender: F Race: HISPANIC/LATINO - PUERTO RICAN Arrive by WALK IN Chief complaint: Fever Diagnosed with Cholangitis temperature: 99.2 heartrate: 87.0 resprate: 18.0 o2sat: 100.0 sbp: 140.0 dbp: 65.0 level of pain: 8 level of acuity: 2.0

Dear ___, It was a pleasure taking care of you at ___ ___. Why was I in the hospital? - You were having fevers at home What was done while I was in the hospital? - We found that one of your drains was not draining properly - We had the interventional doctors ___ the ___ - You were put back on antibiotics that helped with your fevers What should I do when I get home from the hospital? - Be sure to take all of your medications as prescribed, especially your antibiotics (last day ___ and your immunosuppression drugs - Please go to your follow-up appointments with your primary care doctor, your liver doctor, and the infectious disease doctor - If you have fevers, chills, abdominal pain, yellowing of the skin, or generally feel unwell, please call your doctor or go to the emergency room Sincerely, Your ___ Treatment Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ___ Attending: ___. Chief Complaint: productive cough, hemoptysis, abdominal pain, nausea, and fever Major Surgical or Invasive Procedure: ___ Transcutaneous liver biopsy ___ Transcutaneous liver biopsy History of Present Illness: ___ with history of cirrhosis (HCV and EtOH, s/p orthotopic liver transplant ___ with subsequent recurrence of cirrhosis (s/p treatment with simeprevir/sofosbuvir ___, presents with ___ days of productive cough, hemoptysis, abdominal pain, nausea, and fever to 103. His symptoms began ___ with cough productive of white bloody sputum (not massive hemoptysis), head congestion, and diarrhea. On ___, he woke up feeling clammy alternating with feeling hot, and measured a temperature of 103. He also had dizziness and continued cough with blood-streaked sputum. His diarrhea improved after taking Immodium. On ___, he developed vomiting with all POs as well as pain in his "stomach," especially his RUQ and RLQ, which was severe and exacerbated by movement and coughing. He has never had pain of this type before. He also reported throbbing pain in his chest, which he thought was due to vomiting. He was reluctant to present to his PCP or the hospital due to frequent hospitalizations since liver transplant, but on ___ his symptoms persisted and he presented to his PCP. He then presented to the ___ ED. In the ED, initial vitals were: 8 98.8 82 124/78 20 98% RA Labs were significant for H/H 11.8/34.0 (below baseline of hemoglobin ___. He had no leukocytosis, with WBC 4.2, 63% neutrophils. Lactate 1.4. U/A clear. Imaging included negative CXR and CT abdomen and pelvis which was felt to be negative by the surgical team. He was given morphine 5mg IV x3, 2L NS and admitted to Medicine for workup of his nausea/abdominal pain/fever. Vitals prior to transfer were: 98.1 61 138/72 16 98% RA This morning, he reports continued abdominal pain with movement and coughing. He reports no vomiting today even after breakfast (he had vomited all POs prior). On ROS, he noted some hematuria one week prior to admission which had cleared. He has had ~35lbs weight loss over the past few months, partially intended, partially unintentional as he "wasn't eating well;" he is taking Ensures at home. He has chronic LBP after an accident. Remainder of ROS negative. Past Medical History: - S/p OLT liver transplant in ___ ago for HCV cirrhosis with recurrent HCV after transplant (stage 3 fibrosis per biopsy ___. Endoscopy ___ revealed two cords of grade 1 varices and esophagitis. - relapsed ETOH abuse - remote hx of sbp - chronic back pain on opiates, s/p bilateral RFA - T2DM complicated by nephropathy A1c 11% - depression - BPH - chronic back pain - hypertension - tobacco use - history or prior IVDU Social History: ___ Family History: Mother healthy, father passed away in the ___ due to prostate cancer. No known history of colon cancer. No history of MI. Physical Exam: EXAM AT ADMISSION: VS: T 97.7, Tm 98.2, HR 61, BP 132/93 (132-143/83-93), RR 20, O2S 97 RA, Wt 81kg. GENERAL: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated RESP: Coarse breath sounds at bases bilaterally, improves somewhat after cough. CV: RRR, Nl S1, S2, No MRG ABD: Soft, ND, bowel sounds present, TTP diffusely with pain referred to RLQ, especially TTP at RLQ with +rebound tenderness. Liver edge smooth and palpable >4cm below costal margin. No guarding GU: No foley EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema NEURO: CNs2-12 intact, motor function grossly normal SKIN: No excoriations or rash. EXAM AT DISCHARGE: VS: T:98.3 HR:77 BP:121/94 RR:18 O2:95RA FSG: 132-282 GENERAL: Well appearing, in bed HEENT: Sclerae anicteric, MMM NECK: Triple lumen IJ on R RESP: CTAB CV: RRR, Nl S1, S2, No MRG ABD: Abdomen soft, non-tender. EXT: Pitting edema to mid calf L>R NEURO: AAOx3, motor and sensory exam grossly intact Pertinent Results: LABS ON ADMISSION: ___ 02:06PM GLUCOSE-234* UREA N-18 CREAT-0.9 SODIUM-136 POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-26 ANION GAP-11 ___ 02:06PM ALBUMIN-3.4* CALCIUM-8.4 PHOSPHATE-2.8 MAGNESIUM-1.7 ___ 02:06PM LIPASE-22 ___ 02:06PM ALT(SGPT)-53* AST(SGOT)-63* ALK PHOS-207* TOT BILI-0.6 ___ 02:06PM WBC-4.2# RBC-3.83* HGB-11.8* HCT-34.0* MCV-89 MCH-30.8 MCHC-34.7 RDW-13.9 RDWSD-44.7 ___ 02:06PM NEUTS-63.6 ___ MONOS-9.5 EOS-2.6 BASOS-0.5 IM ___ AbsNeut-2.69# AbsLymp-1.00* AbsMono-0.40 AbsEos-0.11 AbsBaso-0.02 ___ 02:06PM PLT COUNT-103* ___ 02:06PM ___ PTT-28.1 ___ ___ 04:26PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 04:26PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.5 LEUK-NEG ___ 04:26PM URINE RBC-2 WBC-<1 BACTERIA-NONE YEAST-NONE EPI-0 ___ 04:26PM URINE MUCOUS-RARE DISCHARGE LABS: ___ 06:28AM BLOOD WBC-4.4 RBC-3.65* Hgb-11.1* Hct-33.9* MCV-93 MCH-30.4 MCHC-32.7 RDW-15.9* RDWSD-54.1* Plt Ct-89* ___ 06:28AM BLOOD Plt Ct-89* ___ 01:07PM BLOOD Glucose-123* UreaN-36* Creat-1.3* Na-138 K-5.1 Cl-103 HCO3-26 AnGap-14 ___ 06:28AM BLOOD ALT-82* AST-52* AlkPhos-270* TotBili-0.8 MICRO: CMV Viral Load (Final ___: CMV DNA not detected. URINE CULTURE (Final ___: NO GROWTH. ___ 2:06 pm BLOOD CULTURE Blood Culture, Routine ........... IMAGING: ___ Chest X-ray COMPARISON: ___ IMPRESSION: Bilateral lower lobe atelectasis and/or scarring. No radiographic evidence for pneumonia. ___ Chest X-ray COMPARISON: ___ at 13:22 FINDINGS: There has been interval placement of a right internal jugular central venous catheter which courses to the midline and appears to follow the expected location of the mid SVC. No pneumothorax is seen. Mild basilar atelectasis is seen without definite focal consolidation. No pleural effusion. Stable cardiac and mediastinal silhouettes. ___ CT abdomen and pelvis +IV contrast +PO contrast COMPARISON: CT abdomen and pelvis dated ___. +FINDINGS: LOWER CHEST: Visualized lower lung fields demonstrate mild bibasilar atelectasis. A 6 mm right lower lobe solid pulmonary nodule (02:14) and a 4 mm right lower lobe subpleural nodule (2:7) are unchanged from ___. HEPATOBILIARY: The patient is status post liver transplant, and the background liver attenuation appears heterogeneous, similar to the prior examination. Linear heterogeneity is seen involving segments 8 and 4. The gallbladder is surgically absent. PANCREAS: There is mild prominence the main pancreatic duct, which is unchanged from prior examination. A hypodensity within the pancreatic uncinate process measures 8 mm (02:34), unchanged from the prior examination. URINARY: Bilateral subcentimeter renal hypodensities are too small to characterize but unchanged from prior examination and likely cysts. LYMPH NODES: Multiple prominent retroperitoneal lymph nodes are again identified, none of which are pathologically enlarged by CT size criteria, and all of which appear grossly unchanged from the prior examination. VASCULAR: Moderate atherosclerotic disease is noted. IMPRESSION: 1. No evidence for acute intra-abdominal process. 2. Status post hepatic transplant with heterogeneous appearance of the hepatic parenchyma. Linear heterogeneity is seen involving segments 8 and 4. Focal ductal dilatation or underlying lesion not excluded. Findings could be further assessed on MRI. Patent portal vein. PATHOLOGY: ___ Pathology Tissue: LIVER, TRANSPLANT BIOPSY Compared to patient's prior biopsy (___) portal/septal inflammatory infiltrate appears unchanged. No definitive endothelialitis identified in this sample ___ Pathology Tissue: LIVER, TRANSPLANT BIOPSY The biopsy is limited by the high percentage of septal fibrous tissue. Within these septal/portal areas, mild to focally moderate, predominantly mononuclear inflammation is identified, comprised of lymphocytes and focally prominent plasma cells, with scattered neutrophils and rare eosinophils. Foci of mild venous endothelialitis and rare lymphocytic cholangitis are present. Minimal periportal and lobular inflammatory extension is seen; only a rare apoptotic is identified. In the clinical context of negative HCV viral load and initially undetectable serum immunosuppression level, these features are consistent with mild acute cellular rejection. In addition to these findings, the current biopsy shows progression of fibrosis and decreased steatosis as compared to the prior biopsy (___). Radiology Report INDICATION: ___ year old man with liver transplant and worsening LFTs // percutaneous liver biopsy COMPARISON: CT abdomen and pelvis ___. PROCEDURE: Ultrasound-guided non-targeted liver biopsy. OPERATORS: Dr. ___ trainee and Dr. ___ radiologist. Dr. ___ the procedure. FINDINGS: Limited preprocedure grayscale and Doppler ultrasound imaging of the right hepatic lobe was performed and a suitable approach for non targeted liver biopsy was determined. No other abnormalities were identified on the limited imaging. TECHNIQUE: The risks, benefits, and alternatives of the procedure were explained to the patient. After a detailed discussion, informed written consent was obtained. A pre-procedure timeout using three patient identifiers was performed per ___ protocol. Based on the preprocedure imaging, an appropriate skin entry site for the biopsy was chosen. The site was marked. The skin was then prepped and draped in the usual sterile fashion. The superficial soft tissues to the liver capsule were anesthetized with approximately 7 mL 1% lidocaine. Under real-time ultrasound guidance, an 18 gauge core biopsy needle was then advanced into the liver and a single core biopsy sample was obtained and placed in formalin. The sample was submitted for rush pathologic processing and hand delivered to the pathology pickup site in OR with telephone call to pathology. The skin was then cleaned and a dry sterile dressing was applied. There was no immediate complications. SEDATION: Moderate sedation was provided by administering divided doses of 1 mg Versed and 50 mcg fentanyl throughout the total intra-service time of 4 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. IMPRESSION: Uncomplicated rush non-targeted liver biopsy. Radiology Report INDICATION: ___ year old man with orthotopic liver transplant now with acute transplant rejection on immunosuppression // Assess for ongoing signs of rejection. Please expedite pathology. COMPARISON: Ultrasound-guided liver biopsy ___. PROCEDURE: Ultrasound-guided non-targeted liver biopsy. OPERATORS: Dr. ___ trainee and Dr. ___ radiologist. Dr. ___ supervised the trainee during the key components of the procedure and reviewed and agrees with the trainee's findings. FINDINGS: Limited preprocedure grayscale and Doppler ultrasound imaging of the right hepatic lobe was performed and a suitable approach for non targeted liver biopsy was determined. No other abnormalities were identified on the limited imaging. TECHNIQUE: The risks, benefits, and alternatives of the procedure were explained to the patient. After a detailed discussion, informed written consent was obtained. A pre-procedure timeout using three patient identifiers was performed per ___ protocol. Based on the preprocedure imaging, an appropriate skin entry site for the biopsy was chosen. The site was marked. The skin was then prepped and draped in the usual sterile fashion. The superficial soft tissues to the liver capsule were anesthetized with 10 mL 1% lidocaine. Under real-time ultrasound guidance, a 18 gauge core biopsy needle was then advanced into the transplanted liver and a single core biopsy sample was obtained and placed in formalin. The skin was then cleaned and a dry sterile dressing was applied. There was no immediate complications. SEDATION: Moderate sedation was provided by administering divided doses of 0.5 mg Versed and 25 mcg fentanyl throughout the total intra-service time of 15 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. IMPRESSION: Uncomplicated non-targeted liver biopsy. Radiology Report INDICATION: ___ year old man with acute rejection of orthotopic liver transplant on immunosuppressives, with persistent small amount hemoptysis c/f infection. // Assess for infection, masses TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of 100 cc of Omnipaque intravenous contrast. Reformatted coronal, sagittal, thin slice axial images, and oblique maximal intensity projection images were submitted to PACS and reviewed. DOSE: DLP: 351 mGy-cm COMPARISON: ___ FINDINGS: MEDIASTINUM: The imaged thyroid is normal. No pathologically enlarged supraclavicular, axillary, hilar or mediastinal lymph nodes. HEART AND GREAT VESSELS: The aorta and pulmonary arteries are normal in size. No large central filling defects in the pulmonary arteries. The right chambers are enlarged with relative straightening of the intraventricular septum and there is no pericardial effusion. Mild atherosclerotic calcifications of the thoracic aorta and moderate of the coronary arteries. PLEURA: There is no pneumothorax. There is new small to moderate right-sided pleural effusion. LUNGS AND TRACHEOBRONCHIAL TREE: The airways are patent. Mild paraseptal and centrilobular emphysema. Numerous sub 5 mm peribronchial nodules are stable dating back to ___ (5: 40, 54, 69, 95, 97). Peribronchial spiculated nodule in the right upper lobe measuring up to 7 mm is also stable dating back to ___ (5:75). There is a new peribronchial sub solid nodule in the left upper lobe (5:84) measuring 6 x 6 mm. Mild linear scarring and atelectasis in the right middle lobe, lingula and lower lobes bilaterally. There is also compressive atelectasis adjacent to the small right-sided pleural effusion. Mild interlobular septal thickening in keeping with mild interstitial edema. No bronchiectasis. BONES AND CHEST WALL: There are no destructive focal osseous or chest wall lesions concerning for malignancy within the imaged thoracic skeleton. Bilateral symmetric gynecomastia. UPPER ABDOMEN: Although this study is not designed for the evaluation of subdiaphragmatic structures, the patient has had prior orthotopic transplant surgical clips. The liver appears homogeneous on this late arterial phase and the portal veins are patent. Trace perihepatic stranding and small volume ascites. There is a wedge-shaped hypodensity at the hilum of the spleen likely a perfusional defect due to timing of contrast. IMPRESSION: 1. New 6 mmn nodule in the left upper lobe, potentially infectious or inflammatory in etiology. Numerous additional pulmonary nodules are stable dating back to ___ and are consistent with a benign etiology given long-term stability. 2. Mild interstitial edema and small to moderate right pleural effusion. Enlargement of the right atrium and ventricle with straightening of the interventricular septum, suggestive of right heart disease. 3. Trace perihepatic stranding and small volume ascites, incompletely assessed. 4. Wedge-shaped hypodensity at the splenic hilum, likely perfusional defect related to timing of contrast. RECOMMENDATION(S): Follow-up CT thorax in 3 months to reassess the left upper lobe nodule. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Abd pain, Dizziness Diagnosed with ABDOMINAL PAIN UNSPEC SITE temperature: 98.8 heartrate: 82.0 resprate: 20.0 o2sat: 98.0 sbp: 124.0 dbp: 78.0 level of pain: 8 level of acuity: 2.0

Dear Mr. ___, It has been a pleasure caring for you at ___. You presented to ___ on ___ with 4 days of cough with blood, abdominal pain, nausea, and fever. Your symptoms were likely due to a viral illness, and this resolved without antibiotics. However, the levels of tacrolimus in your blood were undetectable and your liver tests continued to increase throughout your hospitalization, raising concern for transplant rejection. Therefore, we increased your dose of tacrolimus. We also performed a biopsy of your liver which showed rejection of your liver by your immune system. We gave you additional medicines including steroids to suppress your immune system, however your liver tests remained elevated. You received a second liver biopsy which showed ongoing rejection of your liver. We then added another medicine called ATG (anti-thymocyte globlulin) to further suppress your immune system. After 7 days of therapy with ATG, your liver tests improved. You will need to return to ___ next week for another liver biopsy to make sure that your immune system has stopped rejecting your liver. You will be following up with pulmonology as you have coughed up small amounts of blood and were found to have a nodule in the lung as well as high pressures in the blood vessels of the lung. You will also need an ultrasound of the heart (echocardiogram) to further evaluate this. Your blood sugars have been high so please follow up with your ___ endocrinologist. It has been a pleasure taking care of you, Best wishes, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Gadolinium-Containing Contrast Media / glyburide Attending: ___ Chief Complaint: syncope Major Surgical or Invasive Procedure: none History of Present Illness: ___ with a hx of pancreatitis and membranous glomerulonephritis with nephrotic syndrome and recent admission for hyponatremia who was at clinic appointment, and had an unresponsive episode. ___ was at ___ with his nephrologist and they were discussing treatment options when he suddenly began to feel dizzy, nauseous and have slight headache. The next thing he knew, he was slumped over and there were a lot of people around. Per ED records, he "syncopized at some point and for an unknown period of time was pulseless, a CODE BLUE was called, and he regained pulses after no compressions." Timeframe of all of this is unclear. No shaking or urinary incontinence. No palpitations before or after. Subsequently he has felt an intermittent headache, dizziness and chest pain. The chest pain is on the left side of his chest, is described as "hollow pressure" and does not radiate. It does not change with position or breathing and is not reproducible. He endorses chills that he has especially noticed since the ED, but otherwise no fevers, nausea, vomiting, diarrhea, cp, sob, leg swelling, abd pain, flank pain. In the ED, initial vital signs were: 98.8 85 125/84 11 99% RA Labs were notable for WBC 8.6, H/H 13.1/36.7, Na 131, lactate 1.5. CXR showed no acute intrathoracic process. CT head with no acute intracranial process and age advanced involutional change. Patient was given 1L IVF. Vitals on transfer 98.8 88 122/81 14 99% RA Upon arrival to the floor, Mr. ___ endorses the above story. Of note, patient was recently discharged on ___ for hyponatremia, initially 126 that was improved with IVF. Patient's glipizide was stopped given concern for potential SIADH upon discharge. Patient also completed a 24-hour protein urine collection with ___ with his nephrologist, Dr. ___, ___ was significant for >6 g proteinuria over 24 hrs. Past Medical History: PANCREATITIS HYPERLIPIDEMIA NON-INSULIN DEPENDENT DIABETES MELLITUS MEMBRANOUS GLOMERULONEPHRITIS NEPHROTIC SYNDROME Social History: ___ Family History: Mother Living ___ Father Living ___ Brother Living ___ Physical Exam: ADMISSION PHYSICAL EXAM: ================== Vitals- 99 133/87 93 20 100% RA 62.8 kg General- Alert, oriented, no acute distress HEENT- Sclerae anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD, no carotid bruits bilaterally Lungs- CTAB no wheezes, rales, rhonchi CV- RRR, Nl S1, S2, no murmur rub or gallop appreciated Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, no unilateral swelling Neuro- CNs2-12 intact, motor function grossly normal DISCHARGE PHYSICAL EXAM: ================== Vitals- 97.8 129/82 80 16 100% RA orthostatics (___) 131/79 90 -> 128/81 90 -> 115/80 108 General- Alert, oriented, no acute distress HEENT- Sclerae anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- CTAB no wheezes, rales, rhonchi CV- RRR, Nl S1, S2, no murmur rub or gallop appreciated Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, no unilateral swelling Neuro- CNs2-12 intact, motor function grossly normal Pertinent Results: LABORATORY: ============ ___ 10:34AM BLOOD WBC-8.6 RBC-4.30* Hgb-13.1* Hct-36.7* MCV-85 MCH-30.6 MCHC-35.8* RDW-13.1 Plt ___ ___ 06:20AM BLOOD WBC-9.2 RBC-3.77* Hgb-11.6* Hct-32.8* MCV-87 MCH-30.8 MCHC-35.4* RDW-13.1 Plt ___ ___ 03:05PM BLOOD WBC-10.0 RBC-3.90* Hgb-12.3* Hct-34.1* MCV-88 MCH-31.7 MCHC-36.2* RDW-13.7 Plt ___ ___ 10:34AM BLOOD ___ PTT-24.5* ___ ___ 10:34AM BLOOD Glucose-190* UreaN-12 Creat-0.9 Na-131* K-4.1 Cl-98 HCO3-25 AnGap-12 ___ 06:20AM BLOOD Glucose-116* UreaN-13 Creat-0.7 Na-134 K-4.1 Cl-103 HCO3-24 AnGap-11 ___ 10:34AM BLOOD ALT-14 AST-17 CK(CPK)-46* AlkPhos-51 TotBili-0.5 ___ 10:34AM BLOOD Lipase-21 ___ 07:20PM BLOOD cTropnT-<0.01 ___ 10:34AM BLOOD CK-MB-<1 cTropnT-<0.01 ___ 06:20AM BLOOD Calcium-7.8* Phos-4.0 Mg-1.8 ___ 10:34AM BLOOD Albumin-2.5* Calcium-8.8 Phos-4.7* Mg-1.8 ___ 10:45AM BLOOD Lactate-1.5 IMAGING: ============ ECG: Normal sinus rhythm. Normal ECG. Compared to the previous tracing of ___ sinus tachycardia is no longer present. IntervalsAxes ___ ___ CT head without contrast FINDINGS: There is no intra-axial or extra-axial hemorrhage, edema, shift of normally midline structures, or evidence of acute major vascular territorial infarction. Ventricles are normal. Sulci are prominent for a patient of this age. Mild to moderate ethmoidal opacity is noted. Otherwise the paranasal sinuses are clear. Mastoid air cells and middle ear cavities are well aerated. The bony calvarium is intact. IMPRESSION: 1. No acute intracranial process. 2. Age advanced involutional change. ___ CXR IMPRESSION: No acute intrathoracic process. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 10 mg PO QPM 2. Atovaquone Suspension 1500 mg PO DAILY 3. CycloSPORINE (Sandimmune) 100 mg PO Q12H 4. Fluticasone Propionate NASAL 2 SPRY NU DAILY 5. Lisinopril 15 mg PO DAILY 6. PredniSONE 10 mg PO DAILY 7. Vitamin D 50,000 UNIT PO 1X/WEEK (___) Discharge Medications: 1. Atorvastatin 10 mg PO QPM 2. Atovaquone Suspension 1500 mg PO DAILY 3. CycloSPORINE (Sandimmune) 100 mg PO Q12H 4. Fluticasone Propionate NASAL 2 SPRY NU DAILY 5. Lisinopril 15 mg PO DAILY 6. PredniSONE 10 mg PO DAILY 7. Vitamin D 50,000 UNIT PO 1X/WEEK (___) Discharge Disposition: Home Discharge Diagnosis: vasovagal and orthostatic syncope hyponatremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (AP AND LAT) INDICATION: ___ with syncope, unresponsive episode COMPARISON: Prior exam from ___. FINDINGS: AP upright and lateral views of the chest provided. Overlying EKG leads noted. There is no focal consolidation, effusion, or pneumothorax. The cardiomediastinal silhouette is normal. Imaged osseous structures are intact. No free air below the right hemidiaphragm is seen. IMPRESSION: No acute intrathoracic process. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ with syncope, unresponsive episode, headache TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain, intermediate and bone windows. Coronal and sagittal reformats were also performed. DOSE: DLP: 891.93 mGy-cm COMPARISON: None available for comparison. FINDINGS: There is no intra-axial or extra-axial hemorrhage, edema, shift of normally midline structures, or evidence of acute major vascular territorial infarction. Ventricles are normal. Sulci are prominent for a patient of this age. Mild to moderate ethmoidal opacity is noted. Otherwise the paranasal sinuses are clear. Mastoid air cells and middle ear cavities are well aerated. The bony calvarium is intact. IMPRESSION: 1. No acute intracranial process. 2. Age advanced involutional change. Gender: M Race: ASIAN - ASIAN INDIAN Arrive by WALK IN Chief complaint: Unresponsive Diagnosed with SYNCOPE AND COLLAPSE temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: 1.0

Dear ___, It was a pleasure participating in your care while you were at ___. You had an episode of unresponsiveness while in your nephrologist's office, which we think was from a vagal response in response to nausea as well as reflective of decreased volume in your vessels. You were monitored on telemetry and we gave you IV fluids. Please schedule ___ in the near future with Dr. ___ your primary care doctor. We wish you the best! Your ___ team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: azithromycin / Prozac Attending: ___ ___ Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Pt is an ___ with a hx of NSCLC (diagnosed ___, recurrent L pleural effusion, COPD, hyponatremia who presents to the ED following outpatient CT imaging showing a complex L pleural effusion. Pt was in her usual state of healthy until two months ago. She developed dyspnea and presented to ___, where she was noted to have a LLL mass, L pleural effusion and hyponatremia. Biopsy and PET scan revealed Stage IV NSCLC. She was discharged home and underwent thoracentesis as an outpatient. She represented to ___ ___ with dyspnea and recurrent L pleural effusion. She was admitted to the ___ ICU where she underwent a thoracentesis and was treated with cefepime. Following discharge on ___, she presented to interventional pulmonology clinic on ___ (Dr. ___ where ultrasound revealed a loculated pocket. A thoracoscopy and possible placement of an indwelling catheter was planned for ___. A follow up Chest CT for interventional planning was performed yesterday (___). This CT revealed a "moderate-size complex left pleural effusion with suggestion of nodular peripheral enhancement the lung base", concerning for infection and malignancy. CBC on ___ was notable for WBC of 32. She was instructed by her outpatient IP to present to ___ ED by IP to receive antibiotics for further management. - In the ED, initial vitals were: T 97.6 HR 119 BP 156/59 RR 17 SpO2 95% RA - Exam was notable for: resting comfortably on room air - Labs were notable for: WBC 36.6 Na 130 - Studies were notable for: CXR: "Opacity in the left mid and lower lung better assessed on CT performed 1 day prior with malignancy suspected and probable adjacent pneumonia, with small left pleural effusion." - The patient was given: Vancomycin, zosyn and 1L LR. Chest tube was attempted to be placed, however, the pleural fluid was too dense to be evacuated. On arrival to the floor, pt reported feeling short of breath while exerting herself. She was placed on 2L NC and began to sit forward, which resolved her dyspnea. On interview, patient was leaning forward to allow herself to breathe comfortably. She reported ongoing dyspnea but denied chest pain, chest pressure, abdominal pain, fever, chills. She notes feeling weaker over the past three weeks and losing her appetite. She reports that she does not want any surgical intervention at this time but is amenable to interventional procedures. REVIEW OF SYSTEMS: ================== Per HPI, otherwise, 10-point review of systems was within normal limits. Past Medical History: Hyponatremia COPD Seasonal allergies Pelvic adhesions with a history of bowel obstruction Hysterectomy Hypertension History of anxiety Social History: ___ Family History: Breast cancer in sister Physical ___: ADMISSION PHYSICAL EXAM: ======================== VITALS: ___ 1736 Temp: 97.7 PO BP: 183/105 HR: 120 RR: 20 O2 sat: 94% O2 delivery: 2L GENERAL: Thin elderly woman, leaning forward, on NC. Can converse comfortably. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: No JVD. CARDIAC: Tachycardic. Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: R side clear to ausculation. No sounds in L base. Rhonchi in middle of L lung. BACK: No CVA tenderness. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rashes. NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs spontaneously. ___ strength throughout. DISCHARGE PHYSICAL EXAM ======================== VITALS: 24 HR Data (last updated ___ @ 819) Temp: 97.8 (Tm 97.9), BP: 138/78 (138-183/76-105), HR: 109 (104-120), RR: 18 (___), O2 sat: 96% (94-96), O2 delivery: 2L (2L-4L) GENERAL: Thin elderly woman, leaning forward, on NC. Can converse comfortably. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: No JVD. CARDIAC: Tachycardic. Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: R side clear to ausculation. No sounds in L base. Rhonchi in middle of L lung. BACK: No CVA tenderness. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rashes. NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. Pertinent Results: Admission Labs =============== ___ 04:30PM BLOOD WBC-33.2* RBC-3.54* Hgb-11.5 Hct-33.3* MCV-94 MCH-32.5* MCHC-34.5 RDW-14.3 RDWSD-49.1* Plt ___ ___ 04:30PM BLOOD Neuts-84* Bands-2 Lymphs-4* Monos-6 Eos-2 ___ Metas-2* AbsNeut-28.55* AbsLymp-1.33 AbsMono-1.99* AbsEos-0.66* AbsBaso-0.00* ___ 04:30PM BLOOD Plt Smr-HIGH* Plt ___ ___ 12:30PM BLOOD ___ PTT-25.8 ___ ___ 04:30PM BLOOD Glucose-107* UreaN-5* Creat-0.4 Na-130* K-4.1 Cl-91* HCO3-26 AnGap-13 ___ 04:30PM BLOOD ALT-14 AST-20 AlkPhos-82 TotBili-0.4 ___ 04:30PM BLOOD Albumin-3.3* Calcium-8.2* Phos-2.2* Mg-2.0 ___ 04:30PM BLOOD Osmolal-265* Important Imaging ================== CXR ___ IMPRESSION: Opacity in the left mid and lower lung better assessed on CT performed 1 day prior with malignancy suspected and probable adjacent pneumonia, with small left pleural effusion. Discharge Labs =============== ___ 08:02AM BLOOD WBC-30.8* RBC-3.22* Hgb-10.1* Hct-31.5* MCV-98 MCH-31.4 MCHC-32.1 RDW-14.7 RDWSD-52.8* Plt ___ ___ 08:02AM BLOOD Plt ___ ___ 08:02AM BLOOD ___ PTT-28.0 ___ ___ 08:02AM BLOOD Glucose-94 UreaN-8 Creat-0.4 Na-136 K-3.9 Cl-91* HCO3-31 AnGap-14 ___ 08:02AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.0 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. GuaiFENesin-CODEINE Phosphate ___ mL PO HS:PRN Sleeping 2. ibandronate 150 mg oral EVERY 4 WEEKS 3. LevoFLOXacin 750 mg PO Q48H 4. Mirtazapine 15 mg PO QHS 5. Calcium Carbonate 600 mg PO Q24H 6. Vitamin D 1000 UNIT PO DAILY 7. Fluticasone Propionate NASAL 1 SPRY NU DAILY 8. Lisinopril 2.5 mg PO DAILY 9. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours as needed Disp #*100 Tablet Refills:*0 2. Amoxicillin-Clavulanic Acid ___ mg PO/NG Q12H complicated pleural effusion RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab-cap by mouth every twelve (12) hours Disp #*60 Tablet Refills:*0 3. Bisacodyl 10 mg PO/PR DAILY RX *bisacodyl 5 mg 2 tablet(s) by mouth once a day Disp #*60 Tablet Refills:*0 RX *bisacodyl 10 mg ___aily PRN Disp #*30 Suppository Refills:*0 4. LORazepam 0.5 mg PO Q4H:PRN anxiety, insomnia RX *lorazepam 0.5 mg 1 tablet(s) by mouth every 4 hours as needed Disp #*42 Tablet Refills:*0 5. Morphine SR (MS ___ 15 mg PO Q12H RX *morphine 15 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 6. Morphine Sulfate (Oral Solution) 2 mg/mL 4 mg PO Q2H:PRN Dyspnea RX *morphine 20 mg/5 mL (4 mg/mL) 4 mg by mouth every 2 hours as needed Refills:*0 7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line 8. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 17 gram 1 packet(s) by mouth once a day Disp #*30 Packet Refills:*0 9. Senna 17.2 mg PO BID RX *sennosides [senna] 8.6 mg 2 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 10. TraZODone 25 mg PO QHS:PRN insomnia RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth QHS PRN Disp #*30 Tablet Refills:*0 11. GuaiFENesin-CODEINE Phosphate ___ mL PO Q2H:PRN cough 12. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID RX *budesonide-formoterol [Symbicort] 160 mcg-4.5 mcg/actuation 1 puff IH twice a day Disp #*1 Inhaler Refills:*0 13. Fluticasone Propionate NASAL 1 SPRY NU DAILY RX *fluticasone propionate 50 mcg/actuation 1 spray NU once a day Disp #*30 Spray Refills:*0 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis ================= Loculated pleural effusion Stage IV non-small cell lung cancer Secondary Diagnosis ==================== Hyponatremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ with pleural effusion// Pleural effusion characterization COMPARISON: CT of the chest from ___ FINDINGS: PA and lateral views of the chest provided. Opacity in the left lung base is better assessed on CT from 1 day prior representing a large mass, with adjacent small pleural effusion and consolidation which may represent atelectasis versus pneumonia. Please refer to CT report for further details. Right lung remains clear. Cardiomediastinal silhouette appears grossly unchanged. Imaged bony structures are intact. IMPRESSION: Opacity in the left mid and lower lung better assessed on CT performed 1 day prior with malignancy suspected and probable adjacent pneumonia, with small left pleural effusion. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Abnormal labs Diagnosed with Pneumonia, unspecified organism temperature: 97.6 heartrate: 119.0 resprate: 17.0 o2sat: 95.0 sbp: 156.0 dbp: 59.0 level of pain: 0 level of acuity: 2.0

Dear Ms ___, It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL? -You were admitted to the hospital because you were having shortness of breath. WHAT HAPPENED TO ME IN THE HOSPITAL? - You were seen by our lung experts who tried to drain the fluid around your lung. They were unable to drain the fluid unfortunately. We discussed possible surgery to treat this. You decided not to do surgery. We gave you antibiotics to control your lung infection and morphine to help with your shortness of breath. We arranged hospice services so help you spend quality time outside the hospital with family. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Take your medicines as prescribed. Take morphine 30 minutes before you exert yourself for best effect. - You have a follow-up appointment with your oncologist to check on you and make sure your symptoms are under control. If it is too difficult to make it to the office, your oncologist is happy to speak by phone instead. See below for details and phone number. We wish you the best! Sincerely, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Iodinated Contrast Media - IV Dye Attending: ___ Chief Complaint: neutropenic fever Reason for MICU transfer: severe anemia and neutropenic fever Major Surgical or Invasive Procedure: ___ Bone Marrow Biopsy ___ Bone Marrow Biopsy History of Present Illness: ___ woman who is otherwise healthy presented with malaise x 1 month and worsening DOE x 1 week to her PCP and was found to have pancytopenia after basic workup. She was referred urgently to ___ where labwork showed WBC 0.4 hbg 4.8 and plt 38. She was started on zosyn and then transferred ___ for further evaluation. On presentation to ___, her inital vitals were: ___ 20 100%. Her Tmax in the ED was 102.9. In regards to her fever, she has no localizing infectious symptoms cough, SOB, N/V/D, abd pain, rash or any focal pain. A CXR could not r/o pna. Chem 10 was unremarkable. AST was elevated to 50 and AP was 112. LDH was 224 and uric acid was 2.7. She was given vanco and cefepime. Hem-Onc was consulted and attempted for a BM bx x 6 attemps without success despite multiple medication for pain and anxiety control. She was also given ibuprofen for pain control. She was given 1 unit of p RBCs On arrival to the MICU, patient had no new complaints. She was given a second 2 unit of pRBC (ordered in the ED). 20 mins into the transfusion she develop severe arm pain at the PIV where the blood was being transfused. She became hypotensive and dizzy with MAP's in 40's (70-80/30's). The transfusion was immediately stopped. She was given hydrocort 50mgx2, benadryl 25mg x 2, and famotidine 20mg x 1 over the next hour. She was also bolused 4L of NS and eventually returned to being normotensive after approximately 1 hour. She denied CP, SOB, wheezing during this hour long episode. Blood bank was contacted. Past Medical History: 1. APML: diagnosed ___ treatment with ATRA/Arsenic 2. Perirectal fistula Social History: ___ Family History: No known family history of malignancy. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 100.8, 118, 90/32, 20, 97% General: Pale HEENT: No scleral icterus or conjunctival erythema. Pupils equal, round, and reactive to light. Extraocular movements intact. Moist mucous membranes with no oral ulcers, plaques, or thrush. Neck/Lymph: Supple. No cervical, supraclavicular, axillary or inguinal lymphadenopathy. Chest: Clear to auscultation throughout. No wheezes, rales, or rhonchi. Cardiovascular: Regular rate and rhythm, normal S1 and S2. No murmurs, rubs or gallops. Abdomen: Soft, nontender, nondistended. No hepatosplenomegaly or palpable masses. Back: No spinal/paraspinal tenderness to percussion. Extremities: Warm and well perfused, no peripheral edema Skin: No rashes or jaundice. Neurologic: Alert and oriented, appropriate mood and affect, normal gait, fluent speech. Face symmetric. DISCHARGE PHYSICAL EXAM: Pertinent Results: ADMISSION LABS: ___ 02:10PM BLOOD WBC-0.4* RBC-1.37* Hgb-4.7* Hct-13.8* MCV-101* MCH-34.3* MCHC-33.9 RDW-18.1* Plt Ct-33* ___ 02:10PM BLOOD Neuts-50 Bands-2 ___ Monos-8 Eos-0 Baso-0 Atyps-2* ___ Myelos-0 NRBC-4* ___ 02:10PM BLOOD ___ PTT-25.7 ___ ___ 02:10PM BLOOD Glucose-129* UreaN-9 Creat-0.7 Na-136 K-3.4 Cl-105 HCO3-22 AnGap-12 ___ 02:10PM BLOOD ALT-34 AST-50* LD(LDH)-224 AlkPhos-112* TotBili-0.6 ___ 02:10PM BLOOD Albumin-3.8 UricAcd-2.7 ___ 04:09AM BLOOD Calcium-7.1* Phos-2.9 Mg-1.9 ___ 02:37PM BLOOD Lactate-0.9 ___ 02:10PM BLOOD ___ 02:10PM BLOOD Ret Aut-3.7* ___ 10:30PM BLOOD VitB12-717 Folate-7.9 ___ 04:09AM BLOOD Ferritn-1187* ___ 04:56PM BLOOD Hapto-300* ___ 04:09AM BLOOD Triglyc-95 SEROLOGY & INTERVAL LABS: ___ 10:30PM BLOOD HBsAb-NEGATIVE HBcAb-NEGATIVE ___ 10:30PM BLOOD HIV Ab-NEGATIVE ___ 10:30PM BLOOD HCV Ab-NEGATIVE ___ PARVOVIRUS B19 ANTIBODY IGG 6.04 High ___ PARVOVIRUS B19 ANTIBODY IGM <0.9 negative ___ ___ VIRUS VCA-IgG AB POSITIVE BY EIA. ___ ___ VIRUS EBNA IgG AB POSITIVE BY EIA. ___ ___ VIRUS VCA-IgM NEGATIVE <1:10 BY IFA. ___ CMV IgG and IgM: negative DISCHARGE LABS: = = ================================================================ MICROBIOLOGY: ___ C. difficile DNA amplification assay: negative ___ Blood Culture, Routine-PENDING ___ Blood Culture, Routine-PENDING ___ MRSA SCREEN negative ___ Legionella Urinary Antigen -negative ___ URINE CULTURE no growth ___ BLOOD CULTURE no growth ___ BLOOD CULTURE no growth = = ================================================================ IMAGING: ___ CXR portable: Vague left lower lobe heterogeneous density, which may represent infection in the setting of neutropenia vs overlap of structures. ___ CT torso with contrast: 1.No lymphadenopathy in the chest, abdomen, or pelvis. 2.Severl small solid and ground-glass pulmonary nodules, some of which may be infectious or inflammatory in etiology. Comparison to prior exams may be helpful, otherwise, these could be followed. 3.Findings suggestive of anemia. 4.Tiny left renal hypodensity, too small to characterize, but could represent a small cyst or AML. 5.Gallbladder wall edema, a nonspecific finding - while inflammatory change (cholecystitis) can cause this appearance, as an incidental finding this could be related to other systemic processes such as underlying hypoalbuminemia, IV hydration or drug related effects. ___ CXR soon after CT reaction: Moderate generalized interstitial abnormality with mild bibasilar confluence has progressed substantially over the course of less than an hour, strong indication that the explanation is pulmonary edema. There is no appreciable pleural effusion and no pneumothorax. ___ CXR after central line placement: Right internal jugular central venous catheter tip in right atrium for which withdrawal of 4 cm is recommended. Interval improvement of pulmonary edema. ___ ECHO TTE: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 65%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. There is borderline/mild posterior leaflet mitral valve prolapse. A late systolic jet of Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. ___ ECG: Sinus rhythm. ___ ___ CXR after central line pulled back: compared to the previous image, the right internal jugular vein catheter has been pulled back. The catheter now projects over the inflow tract of the right atrium and is in correct position. No complications, notably no pneumothorax. Otherwise, unchanged radiographic appearance. ___ MRI PELVIS: **** ___ CXR: ***** = = ================================================================ ___: BONE MARROW ASPIRATE AND CORE BIOPSY. DIAGNOSIS: HYPERCELLULAR BONE MARROW WITH EXTENSIVE INVOLVEMENT BY ACUTE MYELOID LEUKEMIA WITH MORPHOLOGICAL FEATURES CONSISTENT WITH ACUTE PROMYELOCYTIC LEUKEMIA. The morphologic features favor a diagnosis of acute promyelocytic leukemia. Cytogenetics demonstrated a t(15:17) translocation, confirming this diagnosis. Concurrent flow cytometry showed that the neoplastic cells were positive for CD34, CD13, CD33, CD117, CD56 (dim), CD64 (dim), CD71 and CD2. By flow cytometry, blast cells comprised 53% of total gated events. Peripheral blood smear. The smear is adequate for evaluation. Erythrocytes are normochromic, and normocytic with marked anisopoikilocytosis including micro and macrocytes, many ovalocytes, occasional dacrocytes, scattered echinocytes, mild polychromasia with rare fine basophilic stippling. The white blood cell count is markedly decreased. The platelet count appears markedly decreased. Occasional large and giant platelets are seen. A 200 cell differential shows 45% neutrophils, 0% bands, 48% lymphocytes, 5% monocytes, 0% eosinophils, 1% basophils. Aspirate smear. The aspirate material is inadequate for evaluation due to lack of spicules and hemodilution. Scattered hemophagocytic macrophages are seen. A 200 cell differential shows 21% blasts, 24% promyelocytes, 9% myelocytes, 4% metamyelocytes, 8% bands/neutrophils, 1% eosinophils, 16% erythroids, 17% lymphocytes, 0% plasma cells. Clot section and biopsy slides. The core biopsy material is adequate for evaluation. It consists of a 2.0 cm core biopsy of trabecular marrow with a cellularity of nearly 100%. The M:E ratio estimate is increased. There is an interstitial infiltrate of immature mononuclear cells, consistent with blasts and promyelocytes occupying greater than 90% of overall cellularity. These cells have high N:E ratio, prominent nucleoli, irregular to cleaved nuclei and granular cytoplasm. Mitoses and apoptotic cells are common. In the remaining cellularity, erythroid precursors are relatively proportionately decreased in number, and have overall normoblastic maturation. Myeloid precursors are relatively proportionately increased in number, with left-shifted maturation. Megakaryocytes are normal in number, and include occasional hyperlobulated forms. Clot sections show blood and clusters of hematopoietic precursors, with findings similar to the above = = ================================================================ ___: BONE MARROW ASPIRATE AND CORE BIOPSY. HYPERCELLULAR BONE MARROW WITH EXTENSIVE INVOLVEMENT BY ACUTE PROMYELOCYTIC LEUKEMIA, SEE NOTE. The morphologic features favor a diagnosis of acute promyelocytic leukemia, given the increased blasts, neoplastic promyelocytes (enumerated at 55% of cellularity) and severely left-shifted maturation. FISH study showed the presence of the characteristic t(15:17)(q22;q12) translocation, confirming this diagnosis. Flow cytometry showed that the abnormal cells (53% of total events) were positive for CD34, CD13, CD33, CD117, CD56 (dim), CD64 (dim), CD71 and CD2. Peripheral blood smear. The smear is adequate for evaluation. Erythrocytes are normochromic and normocytic with anisopoikilocytosis including micro and macrocytes, many ovalocytes, occasional dacrocytes, scattered schistocytes, mild polychromasia and fine basophilic stippling. The white blood cell count is markedly decreased. Occasional neutrophils are hypolobated and hypogranular. The platelet count appears markedly decreased. Occasional large and giant platelets are seen. A 100 cell differential shows 52% neutrophils, 2% bands, 33% lymphocytes, 4% monocytes, 0% eosinophils, 0% basophils, 2% atypical lymphocytes. Aspirate smear. The aspirate material is inadequate for evaluation due to lack of spicules and hemodilution. Instead, a second core biopsy sent in saline was used to create a touch prep for evaluation. The M:E ratio is 10:1. Erythroid precursors are decreased in number and exhibit megaloblastic maturation, including cells with irregular nuclear contour. Myeloid precursors are increased in number and show left-shifted/dyspoietic maturation, including large aggregates of neoplastic promyelocytes with irregular to cleaved nuclear outlines, prominent nucleoli, and coarse azurophilic cytoplasmic granules, very few maturing cells are seen. Rare cells with Aur rods are seen. Megakaryocytes are not seen. Hemaphagocytic macrophages are seen. A 500 cell differential shows 13% blasts, 55% promyelocytes, 5% myelocytes, 1% metamyelocytes, 1% bands/neutrophils, 1% eosinophils, 7% erythroids, 13% lymphocytes, 2% plasma cells, 1% macrophages. Clot section and biopsy slides. The core biopsy material is adequate for evaluation. It consists of a 1.2 cm core biopsy of trabecular marrow with a cellularity of 100%. The M:E ratio estimate is increased. There is an interstitial infiltrate of immature mononuclear cells, consistent with blasts and promyelocytes with a high N:C ratio, prominent nucleoli, irregular to cleaved nuclei, and granular cytoplasm, occupying > 90% of overall cellularity. Erythroid precursors are decreased in number and have overall normoblastic maturation. Myeloid precursors are increased in number with left-shifted maturation. Mitoses and apoptotic cells are seen, as well as hemophagocytic cells. Megakaryocytes are decreased in number. There is one small interstitial lymphoid infiltrate composed of small mature lymphocytes. Clot section contains blood and marrow elements and similar findings as above. = = ================================================================ BM biopsy ___ SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY DIAGNOSIS: CELLULAR BONE MARROW WITH MYELOID DOMINANT MATURATION. NO MORPHOLOGIC EVIDENCE OF INVOLVEMENT BY PROMYELOCYTIC LEUKEMIA. SEE NOTE. Note: The marrow shows myeloid dominant maturation with terminal differentiation. No abnormal promyelocytes are identified. However, in a patient with a history of promyelocytic leukemia and differentiation therapy, correlation with cytogenetic and molecular studies is recommended to assess minimal residual disease. Mild dyspoiesis is noted within the erythroids, possibly due to recent therapy. Clinical correlation is recommended. MICROSCOPIC DESCRIPTION: Peripheral blood smear: The smear is adequate for evaluation. Erythrocytes are decreased, normochromic and normocytic with slight anisopoikilocytosis including elliptocytes, polychromatophils, and occasional dacrocytes and schistocytes. The white blood cell count is markedly decreased. A subset of neutrophils (5%) show abnormal maturation with nuclear-cytoplasmic dyssynchrony. Nucleated RBCs are seen with rare asymptomatic nuclear budding. No increase in promyelocytes is seen. The platelet count appears markedly decreased. Occasional large and giant platelets are seen. A 200 cell differential shows 49% neutrophils, 3% bands, 39% lymphocytes, 5% monocytes, 0% eosinophils, 0% basophils, 1% metas, 2% myelo, 2% atyps. 4% nrbcs per 100 WBCs. Aspirate smear: The aspirate material is inadequate for evaluation due to lack of spicules and hemodilution. Erythroid precursors exhibit dyspoietic maturation, including cells with irregular nuclear contours and asymmetric nuclear budding. Myeloid precursors show dyspoietic maturation with nuclear cytoplasmic dyssynchrony. Terminal granulocytic differentiation is seen. Rare megakaryocytes are present. Abnormal forms are not seen. A 500 cell differential shows less than 1% blasts, less than 1%% promyelocytes, 5%% myelocytes, 3% metamyelocytes, 71% bands/neutrophils, 1% eosinophils, 13% erythroids, 6% lymphocytes, less than 1% plasma cells. Clot section and biopsy slides: The core biopsy material is adequate for evaluation though aspiration artifact is present. It consists of a 0.9 cm core biopsy of trabecular marrow with a cellularity of 50-70%. The M:E ratio estimate is increased. Erythroid precursors are relatively decreased in number and have overall normoblastic maturation. Myeloid precursors are increased in number with full spectrum maturation. Megakaryocytes are normal in number with focal loose clustering. Additional Studies: Flow cytometry: Not performed. Cytogenetics: See separate report. Molecular studies: See separate report. Medications on Admission: nitroglycerin topical Discharge Medications: 1. Acyclovir 400 mg PO Q8H RX *acyclovir 400 mg 1 tablet(s) by mouth every eight (8) hours Disp #*90 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID:PRN consitpation RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 3. Lorazepam 0.5-1 mg IV Q4H:PRN nausea RX *lorazepam [Ativan] 1 mg ___ tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 4. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*90 Tablet Refills:*0 5. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 6. Ondansetron 4 mg PO Q8H:PRN nausea (may subsitute with non-dissolving tablets instead) RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*90 Tablet Refills:*0 7. Outpatient Lab Work please check blood work on ___ CEM10 CBC with diff fax to:Dr ___ ___ Office ___ dx: AML Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: primary: APML, perianal phlegmon secondary: neutropenia, anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Neutropenic fever. Evaluate for pneumonia. COMPARISON: None. FINDINGS: Frontal views of the chest were obtained. Vague heterogeneous density in the left lower lobe is nonspecific but in the setting of neutropenia may represent infection. No substantial pleural effusion or pneumothorax. Heart size is top normal and cardiomediastinal contours are otherwise unremarkable. No radiopaque foreign body. IMPRESSION: Vague left lower lobe heterogeneous density, which may represent infection in the setting of neutropenia vs overlap of structures. If the patient is able, dedicated PA and lateral views would be helpful for further evaluation. Radiology Report INDICATION: ___ female presents with neutropenic fever and concerning bone marrow biopsy. Question lymphadenopathy or mass. COMPARISON: None available. TECHNIQUE: MDCT images were acquired from the thoracic inlet through the pubic symphysis prior to and following the administration of intravenous contrast with multiphasic imaging performed through the abdomen, and multiplanar reformations provided. CT CHEST: There is no mediastinal, hilar, or axillary lymphadenopathy. The heart is normal in size without pericardial effusion. There is relative myocardial ___ to the blood pool, suggestive of anemia. Although not tailored for assessment of pulmonary embolism, no large central thrombus is present. In the right upper lobe, there are two sub-4-mm pulmonary nodules (3, 23), and a tubular 5-mm opacity in the right middle lobe (3, 27) could represent an additional nodule. A 6-mm ground-glass pulmonary nodule is seen in the anterior basal segment of the left lower lobe (3, 41). A 6-mm triangular nodule is seen in the left upper lobe (3, 22). These could be either compared to prior imaging when available or followed. There is no confluent consolidation or pleural effusion. Central airways are patent. There is posterior fissural thickening on the right (3, 27). CT ABDOMEN: There is no focal lesion in the liver. There is no biliary dilatation. The hepatic and portal veins are patent. The gallbladder demonstrates mild diffuse mural edema, without pericholecystic fluid or stranding, which is a nonspecific finding. The spleen, a tiny splenule, pancreas, and adrenal glands are unremarkable. The kidneys enhance symmetrically without hydronephrosis or hydroureter. A subcentimeter hypodensity in the lower pole of the left kidney may represent a tiny cyst or AML, but is too small to definitively assess (5, 44). Small and large bowel loops are normal in caliber. There is no mesenteric or retroperitoneal lymphadenopathy. The appendix is normal. Great vessels are patent. CT PELVIS: The bladder is collapsed, containing a Foley catheter. The uterus contains a small fibroid. The ovaries are normal. A small enhancing corpus luteal cyst is seen in the left ovary. Moderate amount of likely physiologic fluid is seen in the cul-de-sac. There is no inguinal or pelvic sidewall lymphadenopathy. No free fluid in the pelvis. BONE WINDOWS: A circumscribed focus of sclerosis in the left iliac wing likely represents a small bone island. There is no concerning osseous lesion. Minimal endplate sclerosis and spondylosis is seen at T11 anterosuperiorly. IMPRESSION: 1. No lymphadenopathy in the chest, abdomen, or pelvis. 2. Several small solid and ground-glass pulmonary nodules, some of which may be infectious or inflammatory in etiology. Comparison to prior exams may be helpful, otherwise, these could be followed. 3. Findings suggestive of anemia. 4. Tiny left renal hypodensity, too small to characterize, but could represent a small cyst or AML. 5. Gallbladder wall edema, a nonspecific finding - while inflammatory change (cholecystitis) can cause this appearance, as an incidental finding this could be related to other systemic processes such as underlying hypoalbuminemia, IV hydration or drug related effects. Radiology Report AP CHEST, 3:05 P.M., ___ HISTORY: A ___ woman with new pancytopenia and acute respiratory distress. Is there pneumonia or pleural effusion. IMPRESSION: AP chest compared to ___, read in conjunction with a torso CT, ___ at 2:30 p.m.: Moderate generalized interstitial abnormality with mild bibasilar confluence has progressed substantially over the course of less than an hour, strong indication that the explanation is pulmonary edema. There is no appreciable pleural effusion and no pneumothorax. Findings were discussed by telephone with Dr. ___ at 4:20 p.m., 1 minute after the findings were recognized. Radiology Report INDICATION: ___ female patient with AML and new right IJ placement. COMPARISON: Prior chest radiograph from ___. TECHNIQUE: Portable chest AP radiograph. FINDINGS: As compared to prior chest radiograph from ___, there has been interval placement of a right IJ central venous catheter with its tip projecting within the right atrium. There is no pneumothorax. There are low lung volumes. However, pulmonary edema has markedly improved. No pleural effusions are identified. The heart is top normal in size. IMPRESSION: Right internal jugular central venous catheter tip in right atrium for which withdrawal of 4 cm is recommended. Interval improvement of pulmonary edema. A wet read of this report was provided to Dr. ___ telephone on ___ at 20:30. Radiology Report CHEST RADIOGRAPH INDICATION: AML, line placement. COMPARISON: ___. FINDINGS: As compared to the previous image, the right internal jugular vein catheter has been pulled back. The catheter now projects over the inflow tract of the right atrium and is in correct position. No complications, notably no pneumothorax. Otherwise, unchanged radiographic appearance. Radiology Report MR PELVIS WITH AND WITHOUT CONTRAST COMPARISON: CT torso from ___. INDICATION: ___ woman with APML and worsening anal fissure for two weeks, evaluate for perirectal abscess or possible fistula. TECHNIQUE: Multiplanar, multisequence MR imaging was obtained before and after administration of 10 cc of Gadovist IV contrast. FINDINGS: MR PELVIS: Visualized bowel is normal. There is a mild-to-moderate amount of pelvic free fluid noted within the cul-de-sac. The uterus demonstrates a small 1.9 x 1.6-cm fibroid within the anterior uterine wall. Additionally, there are cysts within the bilateral ovaries, the largest measuring up to 2 cm within the left ovary (9:7). Small vessels with bulbous components, left greater than right are noted within the intersphincteric space, likely representing small hemorrhoids. A vascular blush is noted along the posterior wall of the vagina at the level of the introitus. However, there is no underlying discrete fistula seen. This is best appreciated on series 1101 without significant T2 signal edema. Additionally, there is a 2.3 x 1.1 x 3.7 cm area of infrasphincteric phlegmonous inflammation in the left medial ischio-anal fossa without evidence of intrinsic fluid to suggest abscess formation. No discrete fistulous tract is identified originating from this. No evidence of sphincteric involvement. BONES AND SOFT TISSUES: No signal abnormalities are noted within the osseous structures. Incidental note of a left-sided Tarlov cyst. Nonspecific edema is noted within the anterior thigh subcutaneous soft tissues and muscles. IMPRESSION: 1. Infrasphincteric phlegmon without sphinteric involvement and without origin from the anal canal. No discrete fistulous tract or drainable fluid collection is noted. 2. Nonspecific vascular blush is noted about the posterior wall of the vagina at the level of the introitus. No discrete fistula is seen. Recommend clinical correlation of this region. Inflammation can have a similar appearance. 3. Small anterior uterine fibroid is noted. 4. Nonspecific mild-to-moderate amount of pelvic free fluid within the cul-de-sac. 5. Left-sided Tarlov's cyst is seen. Radiology Report CHEST RADIOGRAPH INDICATION: Evaluation for pulmonary edema. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, there is no relevant change. Low lung volumes, moderate cardiomegaly, no evidence of pulmonary edema. No pleural effusions. No focal parenchymal opacities. Unchanged position of the right internal jugular vein catheter. Radiology Report PROCEDURE: 1. Placement of tunneled right-sided triple-lumen central venous catheter. 2. Removal of right-sided temporary triple-lumen venous line. HISTORY: ___ female with advanced promyelocytic leukemia requiring: central venous access. OPERATOR: Dr. ___, attending, performed the procedure. ANESTHESIA: Conscious sedation was provided by administering divided doses of Versed (3 mg) and fentanyl (200 mcg) throughout the total intraservice time of 30 minutes during which the patient's hemodynamic parameters were continuously monitored. In addition, the patient received 1% lidocaine and 1% lidocaine with epinephrine over the right internal jugular vein access site and along the right anterior chest wall subcutaneous tunnel. PROCEDURE NOTE IN DETAIL: Informed consent was obtained outlining the risks and benefits of the proposed procedure. The patient was then brought to the angio department and placed supine on the imaging table. The skin overlying the right internal jugular vein, existing catheter and right chest were prepped and draped in the usual sterile fashion. A preprocedure huddle and timeout were performed as per ___ protocol. Under real-time ultrasound guidance, following administration of 1% buffered lidocaine, a micropuncture needle was advanced into the patent and compressible right internal jugular vein. Following return of blood, an 0.018 nitinol wire was easily advanced into the SVC. The needle was removed and exchanged for a 4.5 ___ micropuncture sheath. Via the sheath, an 035 ___ wire was advanced to the level of the right atrium and appropriate measurements for catheter length were calculated. This wire was then advanced into the ___ for stability. Attention was then turned to creation of an anterior chest wall tunnel. Following administration of 1% lidocaine and 1% lidocaine with epinephrine, a 2 mm incision was made using an 11 blade. A 13 ___ triple-lumen catheter was then advanced with the aid of a tunneling device to exit at the venotomy site. The catheter was cut to the appropriate length (21 cm) and the cuff was positioned approximately 2 cm from the skin incision. The venotomy tract was dilated using sequential 8-, 10- and ___ dilators. This was followed by placement of a 13 ___ peel-away sheath. Via the sheath the port tubing was incrementally advanced and the peel-away sheath was removed. A scout fluoroscopic image demonstrated satisfactory catheter tip positioned in the mid right atrium with no evidence of kinking of the catheter tubing. The catheter was secured to the skin using 0 silk anchor sutures. The catheter was aspirated and flushed normally and sterile caps applied. The venotomy incision was closed using a ___ Vicryl subcuticular suture and Steri-Strips and sterile dressings were again applied. The existing temporary triple-lumen catheter was removed from the right internal jugular vein and manual pressure held for 15 minutes. Good hemostasis was achieved. Patient was transferred in stable condition to the floor for further post-procedure monitoring. The catheter may be used immediately for infusion therapy. IMPRESSION: Uncomplicated placement of a 13 ___ Hickman catheter (triple-lumen) via the right internal jugular vein. The catheter may be used for infusion therapy immediately. The tip lies in the right atrium. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: FEVER/NEUTROPENIC Diagnosed with OTHER PANCYTOPENIA temperature: 102.0 heartrate: 120.0 resprate: 20.0 o2sat: 100.0 sbp: 134.0 dbp: 76.0 level of pain: 0 level of acuity: 2.0

You came to the hospital because you felt fatigued. While you were here you were diagnosed with AML and we started on treatment with ATRA and arsenic. You tolerated the chemotherapy well and your blood cells went up at first and then went down. Also while here you were seen by the colorectal surgeons for a perianal phlegmon. They did not want to do any surgery on it and you were treated with antibiotics. You will continue with antibiotics till Dr. ___ you and tells you that you don't need to take them anymore. If you have a temp of 100.4 please come to the hospital

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Aminophylline / Bactrim / Erythromycin Base / Benadryl Decongestant / Scopolamine / Codeine / Keflex / Tagamet / Cytotec / Azmacort / Cipro / Zantac / Pepcid / Celebrex / Hydrocodone / yellow dye / red dye / Lasix / metformin / triamcinolone / Quinolones / Cephalosporins / metoprolol / aspirin / latex / ___ / oxycodone / Milk Containing Products / Milk Containing Products Attending: ___. Major Surgical or Invasive Procedure: None attach Pertinent Results: ADMISSION LABS ============== ___ 06:40PM BLOOD WBC-7.7 RBC-4.03 Hgb-10.4* Hct-34.7 MCV-86 MCH-25.8* MCHC-30.0* RDW-18.1* RDWSD-56.1* Plt ___ ___ 06:40PM BLOOD Neuts-63.1 ___ Monos-8.1 Eos-0.0* Baso-0.3 Im ___ AbsNeut-4.88 AbsLymp-2.17 AbsMono-0.63 AbsEos-0.00* AbsBaso-0.02 ___ 06:40PM BLOOD ___ PTT-26.9 ___ ___ 06:40PM BLOOD Glucose-127* UreaN-11 Creat-1.0 Na-137 K-6.5* Cl-106 HCO3-20* AnGap-11 ___ 05:39AM BLOOD ALT-19 AST-19 AlkPhos-96 TotBili-0.3 ___ 06:40PM BLOOD cTropnT-<0.01 ___ 10:59PM BLOOD cTropnT-<0.01 ___ 06:40PM BLOOD proBNP-59 OTHER PERTINENT LABS ==================== ___ 01:16AM BLOOD %HbA1c-7.0* eAG-154* ___ 06:40PM BLOOD Triglyc-195* HDL-45 CHOL/HD-3.7 LDLcalc-81 ___ 06:40PM BLOOD Cholest-165 DISCHARGE LABS ============== ___ 05:39AM BLOOD WBC-10.1* RBC-3.65* Hgb-9.4* Hct-32.3* MCV-89 MCH-25.8* MCHC-29.1* RDW-17.8* RDWSD-57.4* Plt ___ ___ 05:39AM BLOOD ___ PTT-37.5* ___ ___ 05:39AM BLOOD Glucose-159* UreaN-12 Creat-1.0 Na-139 K-4.5 Cl-103 HCO3-24 AnGap-12 ___ 05:39AM BLOOD Calcium-9.4 Phos-3.3 Mg-2.3 MICRO ===== ___ 06:40PM URINE Color-Straw Appear-Clear Sp ___ ___ 06:40PM URINE Blood-NEG Nitrite-NEG Protein-TR* Glucose-1000* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM* ___ 06:40PM URINE RBC-0 WBC-4 Bacteri-NONE Yeast-NONE Epi-1 ___ 6:40 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: BETA STREPTOCOCCUS GROUP B. 10,000-100,000 CFU/mL. IMAGING ======= CXR ___ PA and lateral views of the chest provided. Lungs are clear. No large effusion or pneumothorax. Previously noted NG tube has been removed. Cardiomediastinal silhouette appears mildly prominent though unchanged. No definite signs of congestion or edema. Bony structures are intact. Partially visualized spinal hardware is noted in the upper abdomen. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Tiotropium Bromide 1 CAP IH DAILY 2. Pulmicort Flexhaler (budesonide) 180 mcg/actuation inhalation BID 3. Breo Ellipta (fluticasone furoate-vilanterol) 200-25 mcg/dose inhalation DAILY 4. azelastine 137 mcg (0.1 %) nasal DAILY 5. Montelukast 10 mg PO QPM 6. Diltiazem Extended-Release 240 mg PO DAILY 7. Clopidogrel 75 mg PO DAILY 8. Propafenone HCl 225 mg PO BID 9. Pantoprazole 40 mg PO Q24H 10. TraZODone 200 mg PO QHS 11. DULoxetine ___ 60 mg PO BID 12. Levothyroxine Sodium 200 mcg PO DAILY 13. Gabapentin 300 mg PO BID 14. TraMADol 50 mg PO BID 15. Potassium Chloride 10 mEq PO BID 16. Vitamin D ___ UNIT PO 1X/WEEK (SA) 17. Invokana (canagliflozin) 100 mg oral DAILY 18. Fexofenadine 180 mg PO DAILY 19. Docusate Sodium 100 mg PO BID 20. Polyethylene Glycol 17 g PO DAILY 21. Magnesium Oxide 500 mg PO DAILY 22. FoLIC Acid ___ mg PO DAILY 23. Vitamin D 1000 UNIT PO DAILY 24. Pyridoxine 100 mg PO DAILY 25. Cyanocobalamin 2500 mcg PO DAILY 26. Acetaminophen 1000 mg PO BID 27. Sodium Chloride Nasal 1 SPRY NU DAILY AND PRN nasal dryness 28. azithromycin 500 mg oral 1X:ASDIR 29. Methylprednisolone 4 mg PO ASDIR taper for asthma attacks This is dose # of tapered doses Discharge Medications: 1. Atorvastatin 40 mg PO QPM RX *atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 2. Acetaminophen 1000 mg PO BID 3. azelastine 137 mcg (0.1 %) nasal DAILY 4. Azithromycin 500 mg oral 1X:ASDIR 5. Breo Ellipta (fluticasone furoate-vilanterol) 200-25 mcg/dose inhalation DAILY 6. Clopidogrel 75 mg PO DAILY 7. Cyanocobalamin 2500 mcg PO DAILY 8. Diltiazem Extended-Release 240 mg PO DAILY 9. Docusate Sodium 100 mg PO BID 10. DULoxetine ___ 60 mg PO BID 11. Fexofenadine 180 mg PO DAILY 12. FoLIC Acid ___ mg PO DAILY 13. Gabapentin 300 mg PO BID 14. Invokana (canagliflozin) 100 mg oral DAILY 15. Levothyroxine Sodium 200 mcg PO DAILY 16. Magnesium Oxide 500 mg PO DAILY 17. Methylprednisolone 4 mg PO ASDIR taper for asthma attacks This is dose # of tapered doses 18. Montelukast 10 mg PO QPM 19. Pantoprazole 40 mg PO Q24H 20. Polyethylene Glycol 17 g PO DAILY 21. Potassium Chloride 10 mEq PO BID 22. Propafenone HCl 225 mg PO BID 23. Pulmicort Flexhaler (budesonide) 180 mcg/actuation inhalation BID 24. Pyridoxine 100 mg PO DAILY 25. Sodium Chloride Nasal 1 SPRY NU DAILY AND PRN nasal dryness 26. Tiotropium Bromide 1 CAP IH DAILY 27. TraMADol 50 mg PO BID 28. TraZODone 200 mg PO QHS 29. Vitamin D 1000 UNIT PO DAILY 30. Vitamin D ___ UNIT PO 1X/WEEK (SA) Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES ================= GERD Chest Pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ with history of A. fib, chief complaint of left-sided chest pain and shortness of breath // Pneumonia? Chest pathology? COMPARISON: Prior study from ___ FINDINGS: PA and lateral views of the chest provided. Lungs are clear. No large effusion or pneumothorax. Previously noted NG tube has been removed. Cardiomediastinal silhouette appears mildly prominent though unchanged. No definite signs of congestion or edema. Bony structures are intact. Partially visualized spinal hardware is noted in the upper abdomen. IMPRESSION: No acute findings. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Chest pain, Dyspnea Diagnosed with Chest pain, unspecified temperature: 98.5 heartrate: 67.0 resprate: 22.0 o2sat: 97.0 sbp: 126.0 dbp: 76.0 level of pain: 8 level of acuity: 2.0

Dear Ms. ___, It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL? - You were having chest pain WHAT HAPPENED TO ME IN THE HOSPITAL? - You were given medications to treat a heart problem however the origin of the chest pain seemed less likely to be caused by the heart so those were stopped. You were given medications to treat you indigestion and nausea which did help. You were chest pain free on trial off the medications and were doing well with walking around. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? -Please continue to take all of your medications and follow-up with your appointments as listed below. We wish you the best! Sincerely, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Codeine Attending: ___ Chief Complaint: Aphasia, R sided plegia Major Surgical or Invasive Procedure: NA History of Present Illness: Neurology at bedside for evaluation after code stroke activation within: 4 minutes Time (and date) the patient was last known well: 22:00 on ___ ___ Stroke Scale Score: 24 t-PA given: No Reason t-PA was not given or considered: The patinet was out side of the window for IV t-PA. she also had a supratherapeutic INR. I was present during the CT scanning and reviewed the images instantly within 20 minutes of their completion. HPI: The patient is a ___ yo woman with PMH significant for afib on coumadin, HLD, depression and hypothyroidism who presented as a code stroke. The patient was last seen normal at 10pm on the night prior to her presentation. She and her husband were up watching television when they both fell asleep. The patient's husband woke up around 2am and tried to get his wife to come to bed, but found her unresponsive. He tried to carry her to bed but was unable to lift her and she fell to the floor from the chair. The husband then called ___. Code stroke was called at 0341 and I began my evaluation at 0345. Past Medical History: afib on coumadin anxiety/depression hypothyroidism HTN osteoarthritis DM Social History: ___ Family History: No known neurologic diseases. Positive for breast cancer in her mother and diabetes in her father. There is no h/o dementia. Physical Exam: Admission Examination: The patient's exam improved some what from initial evaluation. She was able to follow some simple commands (close your eyes and raise your hand) but unable to follow more complex commands for ataxia testing. She was able to regard the examiner on the left and not the right. She was able to hold Left arm and leg up for 10 sec. minimal response no noxious stim on the left, none on the right. toes up on the R, down on the left. **************** Discharge exam: MS: awake and alert. interactive. speaking very softly in ___. able to repeat some times. follows some commands inconsistently. CN: R facial droop. PERRL. EOMI. Motor: flacid on the right (upper and lower). at least antigravity on the left. sensory: grimace to pain on the left. Pertinent Results: admit labs: ___ 03:50AM BLOOD WBC-6.8 RBC-4.71 Hgb-15.3 Hct-46.2 MCV-98 MCH-32.5* MCHC-33.1 RDW-13.0 Plt ___ ___ 03:50AM BLOOD ___ PTT-31.5 ___ ___ 03:50AM BLOOD Glucose-193* UreaN-22* Creat-0.9 Na-143 K-5.3* Cl-105 HCO3-26 AnGap-17 ___ 03:56AM BLOOD Creat-1.7* ___ 06:10AM BLOOD ALT-18 AST-39 AlkPhos-43 TotBili-0.4 ___ 06:10AM BLOOD Albumin-4.4 Mg-2.2 Cholest-225* Stroke labs: ___ 06:10AM BLOOD Triglyc-107 HDL-51 CHOL/HD-4.4 LDLcalc-153* ___ 06:10AM BLOOD %HbA1c-5.7 eAG-117 studies: ___ NCHCT: There also appears to be a hyperdense left MCA. Findings are concerning for acute ischemia. Recommend MRI for further evaluation. ___ MRI/MRA Acute infarction in the left caudate putamen and temporal lobe with hemorrhagic transformation. Lack of flow related enhancement beyond the proximal left M1 MCA. ___ NCHCT Evolving subacute infarct involving the left basal ganglia and temporal lobe with stable hemorrhagic transformation. ___ CT chest Airways are overall patent until the subsegmental level bilaterally. Assessment of the lung parenchyma reveals biapical scarring. Lingular nodule, 6, 159, is 7.6 x 9 mm, new and although most likely represent atelectasis, should be reassessed in 10 weeks for documentation of stability and to exclude the remote possibility of a neoplasm. No lytic or sclerotic lesions worrisome for infection or neoplasm demonstrated. Wedge compression fractures are demonstrated at the level of T8-T10 as well as L2. ___ CT abd/pelvis No evidence malignancy or in the abdomen or pelvis. ___ ___ Evolution of Re- demonstrated subacute infarction with hemorrhagic transformation involving the left basal ganglial and temporal lobe. No new areas of hemorrhage or large infarction. Medications on Admission: Pravastatin 40mg coumadin 5mg vesicare 10mg levoxyl 0.005mg lexapro 10mg cymbalta 60mg mirtazapine 7.5mg ritalin 10mg metoprolol tartrate 20mg Discharge Medications: 1. Metoprolol Tartrate 25 mg PO TID 2. Atorvastatin 40 mg PO DAILY 3. CeftriaXONE 1 gm IV Q24H Duration: 5 Doses 5 day course started ___. Dabigatran Etexilate 150 mg PO BID 5. Levothyroxine Sodium 50 mcg PO DAILY 6. Vitamin D 1000 UNIT PO DAILY 7. Vesicare (solifenacin) 10 mg oral daily 8. Escitalopram Oxalate 10 mg PO DAILY 9. Mirtazapine 7.5 mg PO HS 10. Duloxetine 60 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: - ACUTE ISCHEMIC STROKE with hemorrhagic conversion - atrial fibrillation - hypertention - hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: History: ___ with right sided weakness // r/o ich TECHNIQUE: Axial helical MDCT images were obtained through the brain without administration of IV contrast. Multiplanar reformatted images in coronal and sagittal axes and thin section bone algorithm reconstructed images were acquired. DOSE: DLP: 1003 mGy-cm CTDI: 56 mGy COMPARISON: Nonenhanced head CT dated ___ FINDINGS: There is possible very subtle loss of gray-white differentiation in the left MCA territory. There is no evidence of hemorrhage, edema or mass effect. There is unchanged appearance of hypodensities in the bilateral lentiform nuclei likely enlarged perivascular spaces. Prominent ventricles and sulci suggest age related atrophy. Periventricular white matter hypodensities are nonspecific but likely represent sequela of chronic small vessel ischemic disease. The basal cisterns appear patent differentiation. No fracture is identified. The visualized paranasal sinuses, mastoid air cells and middle ear cavities are clear. The globes are unremarkable. Atherosclerotic mural calcification of the vertebral and internal carotid arteries is noted. IMPRESSION: 1. No evidence of intracranial hemorrhage. 2. Possible very subtle loss of gray-white differentiation in the left MCA territory is equivocal but could represent early ischemic changes. Of note MRI, would be more sensitive for detection of acute ischemic changes. COMMENT ON ATTENDING REVIEW: There also appears to be a hyperdense left MCA. Findings are concerning for acute ischemia. Recommend MRI for further evaluation. Radiology Report INDICATION: History: ___ with ? fall // r/o fracture TECHNIQUE: Axial helical MDCT images were obtained from the skullbase through the C6 level. The entire T7 vertebral body was not imaged. Reformatted images in sagittal and coronal axes were obtained. DOSE: DLP: 711 mGy-cm CTDIvol: 37 mGy COMPARISON: ___ FINDINGS: There is no evidence of acute fracture or traumatic malalignment. Multilevel degenerative changes with loss of disc height and anterior and posterior osteophytes are noted worse at C4-5. There is no evidence of prevertebral soft tissue swelling. CT is not able to provide intrathecal detail compared to MRI, but the visualized outline of the thecal sac appears unremarkable. No lymphadenopathy is present by CT size criteria. IMPRESSION: No evidence of acute fracture or traumatic malalignment. Of note, the anterior inferior corner of C7 was not included in the study. If high clinical concern for lower cervical spine injury, could repeat to include the C7 level. Radiology Report EXAMINATION: MRI AND MRA BRAIN AND MRA NECK INDICATION: ___ year old woman with stroke // stroke TECHNIQUE: Sagittal T1 weighted and axial T1 weighted, T2 weighted, FLAIR, susceptibility and diffusion weighted images were obtained through the head. Following the uneventful administration of intravenous contrast, multiplanar T1 weighted images of the head were obtained. Three dimensional time of flight MR arteriography of the head, and two dimensional time of flight and three dimensional pre and post contrast enhanced MR arteriography of the neck were performed with rotational reconstructions. COMPARISON: ___ FINDINGS: MRI HEAD: There is an acute infarction in the left caudate, putamen and temporal lobe with hemorrhage on the gradient echo images. There is mild mass effect on the left lateral ventricle There are chronic small vessel ischemic changes in the supratentorial white matter and the pons. . There is no mass effect, edema, or hydrocephalus. Ventricles and sulci are normal in size and configuration. Principal vascular flow voids are preserved. There is no abnormal parenchymal, vascular or meningeal enhancement after the administration of gadolinium. Globes and soft tissues are unremarkable. Visualized paranasal sinuses and mastoid air cells are well aerated. HEAD MRA: There is lack of flow related enhancement beyond the proximal left M1 MCA segment. Attenuated appearance of the right MCA branches could be artifactual or could reflect atherosclerotic disease. NECK MRA: There is no high-grade stenosis in the carotid and vertebral arteries. There is marked enlargement of the left thyroid lobe measuring up to 2.9 x 2.3 cm which could represent a goiter any appears unchanged from the CT from ___ IMPRESSION: Acute infarction in the left caudate putamen and temporal lobe with hemorrhagic transformation. Lack of flow related enhancement beyond the proximal left M1 MCA. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with stroke s/p dobhoff placement // Confirm dobhoff placement COMPARISON: ___ IMPRESSION: As compared to the previous radiograph, the patient has received a Dobbhoff catheter. The catheter is in correct position in the middle to distal parts of the stomach. No evidence of complications. The lung volumes have decreased. Mild fluid overload but no overt pulmonary edema. Radiology Report EXAMINATION: Video oropharyngeal fluoroscopy swallowing study. INDICATION: Dysphagia. TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in conjunction with the speech and swallow division. Multiple consistencies of barium were administered. COMPARISON: None. FINDINGS: Barium passes freely through the oropharynx and esophagus without evidence of obstruction. There was aspiration with thin nectar consistency. IMPRESSION: Aspiration with thin nectar consistency. 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 INDICATION: ___ year old woman with afib on coumadin, presented with L MCA infarct with some hemorrhagic conversion. // evaluate for interval change in hemorrhage TECHNIQUE: Contiguous axial MDCT images were obtained from the skull base through the vertex, without IV administration of contrast. Reformatted coronal and sagittal and thin-section bone algorithm-reconstructed images were acquired, and all images are viewed in brain and bone window on the workstation. DOSE: DLP (mGy-cm): 935 CTDIvol (mGy): 54 COMPARISON: Brain MRI from ___ FINDINGS: Redemonstrated is evolution of subacute infarct involving the left basal ganglia and temporal lobe with stable appearance of hemorrhagic transformation. No new hemorrhage is identified. Ventricles are unchanged in size and configuration. Basal cisterns are patent. Paranasal sinuses are notable for mild mucosal thickening of the ethmoid air cells. Mastoid air cells and middle ear cavities are clear. Orbits are unremarkable. Partially imaged nasogastric tube is noted. IMPRESSION: Evolving subacute infarct involving the left basal ganglia and temporal lobe with stable hemorrhagic transformation. Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ year old woman with large R MCA stroke with INR of 3.1 // ? occult malignancy TECHNIQUE: Multidetector CT of the abdomen and pelvis was done as part of CT torso with IV Contrast. A single bolus of IV contrast was injected and the abdomen and pelvis were scanned in the portal venous phase, followed by scan of the abdomen in equilibrium (3-minute delay) phase. Coronal and sagittal reformations were performed and submitted to PACS for review. Oral contrast was not administered. DOSE: DLP: 832 mGy-cm (chest, abdomen and pelvis. COMPARISON: ___ FINDINGS: LOWER CHEST: Bibasilar atelectasis is noted at the lung bases. Please refer to separate report of CT chest performed on the same day for description of the thoracic findings. Small hiatal hernia. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits, without stones or gallbladder wall thickening. SPLEEN: The spleen and accessory spleen shows normal size and attenuation throughout, without evidence of focal lesions. PANCREAS: The pancreas is largely fatty replaced, but has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. ADRENALS: The right and left adrenal glands are normal. URINARY: The kidneys enhance symmetrically and excrete contrast promptly without hydronephrosis. GASTROINTESTINAL: A nasoenteric tube ends in the stomach. The small and large bowel are normal in course and caliber without obstruction. Colon and rectum are within normal limits. There is a large amount of stool within the rectum. Oral contrast from a prior study is seen within the ascending colon as no oral contrast was administered for this study. Appendix contains air, has normal caliber without evidence of fat stranding. MESENTERY AND RETROPERITONEUM: There is no evidence of retroperitoneal and mesenteric lymphadenopathy. There is no free fluid and no free air. VASCULAR: There is no abdominal aortic aneurysm. There is moderate calcium burden in the abdominal aorta and great abdominal arteries. The main portal vein, splenic vein and SMV are patent. PELVIS: The bladder is decompressed by a Foley catheter with a small amount of air. There is no evidence of pelvic or inguinal lymphadenopathy. Small free pelvic fluid in the presacral space and mesorectal fascia is nonspecific, and may be related to constipation, new from ___. The uterus is small with coarse calcifications, likely within fibroids. No adnexal mass is seen. BONES AND SOFT TISSUES: No bone finding suspicious for infection or malignancy is seen. Degenerative change is noted in the thoracolumbar spine. Severe compression deformity of L2 and more mild compression deformities with exaggerated kyphosis of the thoracic spine are similar to ___.. IMPRESSION: 1. No evidence malignancy or in the abdomen or pelvis. 2. CT chest reported separately. Radiology Report REASON FOR EXAMINATION: Evaluation of the patient with large right MCA stroke, suspicion for occult malignancy. COMPARISON: CT of the chest from ___. TECHNIQUE: MDCT of the chest was obtained from thoracic inlet to upper abdomen after administration of IV contrast. Axial images were reviewed in conjunction with coronal and sagittal reformats. FINDINGS: Large goiter originating from the left thyroid lobe is demonstrated, and appears to be overall similar to the prior study except for one larger or new nodule demonstrated in its lower right portion, 5:7, approaching 2.2 cm in diameter. The goiter provides pressure of the left and posterior aspect of the trachea with mild-to-moderate narrowing of the tracheal lumen. The NG tube tip is in the stomach. Thickening of the distal esophagus is unchanged, most likely due to small hiatal hernia, unchanged since the prior study. No mediastinal, hilar or axillary enlarged lymph nodes demonstrated with small hilar lymph nodes being unchanged as compared to previous imaging, interval stability of the aortopulmonic lymph node, approaching 11 mm. Heart size is enlarged. Predominantly, there is an enlargement of the left atrium up to 5.6 cm in the anterior posterior diameter. No pleural or pericardial effusion is present. Airways are overall patent until the subsegmental level bilaterally.Assessment of the lung parenchyma reveals biapical scarring. Lingular nodule, 6, 159, is 7.6 x 9 mm, new and although most likely represent atelectasis, should be reassessed in 10 weeks for documentation of stability and to exclude the remote possibility of a neoplasm. No lytic or sclerotic lesions worrisome for infection or neoplasm demonstrated. Wedge compression fractures are demonstrated at the level of T8-T10 as well as L2. Radiology Report INDICATION: ___ year old woman with stroke and dysphagia // post stroke swallow eval TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in conjunction with the speech and swallow division. Multiple consistencies of barium were administered. FINDINGS: Barium passes freely through the oropharynx and esophagus without evidence of obstruction. aspiration with thin liquid and nectar thick liquid was demonstrated. The aspiration was silent with small amount, but larger amount triggered cough reflex. IMPRESSION: Aspiration with thin liquid and nectar thick liquids was demonstrated. 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 INDICATION: ___ year old woman with L MCA infarct // f/u stroke, hemorrhagic conversion 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: 54 mGy DLP: 891.93 mGy-cm COMPARISON: CT head without contrast ___ FINDINGS: Re- demonstrated subacute infarction with hemorrhagic transformation involving the left basal ganglia and temporal lobe which is stable in appearance. No New hemorrhage or large territorial infarction is identified. The basal cisterns appear patent. The visualized bony structures are grossly unremarkable. The paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The globes are unremarkable. IMPRESSION: Evolution of Re- demonstrated subacute infarction with hemorrhagic transformation involving the left basal ganglial and temporal lobe. No new areas of hemorrhage or large infarction. Gender: F Race: WHITE - OTHER EUROPEAN Arrive by AMBULANCE Chief complaint: Altered mental status Diagnosed with CEREBRAL ART OCCLUS W/INFARCT, ATRIAL FIBRILLATION temperature: 98.0 heartrate: 128.0 resprate: 12.0 o2sat: 93.0 sbp: 158.0 dbp: 90.0 level of pain: 0 level of acuity: 1.0

Dear ___ were hospitalized due to symptoms of difficulty talking and right sided weakness resulting from an ACUTE ISCHEMIC STROKE, a condition in which a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. Stroke can have many different causes, so we assessed ___ for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: - afib - high blood pressure - high cholesterol We are changing your medications as follows: - START Dabigatran Etexilate 150 mg PO BID - STOP coumadin Please take your other medications as prescribed. Please followup with Neurology and your primary care physician as listed below. If ___ experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - sudden partial or complete loss of vision - sudden loss of the ability to speak words from your mouth - sudden loss of the ability to understand others speaking to ___ - sudden weakness of one side of the body - sudden drooping of one side of the face - sudden loss of sensation of one side of the body - sudden difficulty pronouncing words (slurring of speech) - sudden blurring or doubling of vision - sudden onset of vertigo (sensation of your environment spinning around ___ - sudden clumsiness of the arm and leg on one side or sudden tendency to fall to one side (left or right) - sudden severe headache accompanied by the inability to stay awake It was a pleasure providing ___ with care during this hospitalization.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Penicillins / ciprofloxacin / Flagyl Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: none. History of Present Illness: ___ with low factor 11 levels, now with a 1 day h/o mild RLQ abdominal pain that initially started in the epigatric area. She had an outpatient CT scan which was concerning for acute appendicitis. She denies any fevers, but has had some chills. She has had some mild nausea, without emesis, as well as bloating. She denies any other symptoms, and has never had this type of pain before. She reports that she is currently hungry. Past Medical History: PMH: strong family history of factor 11 deficiency, with her level on the low end of normal for factor 11, anxiety, varicose veins PSH: varicose vein surgery (no bleeding problems) Social History: ___ Family History: strong family history of breast and ovarian cancer (BRCA negative); mother - DM, HTN; sister - ovarian CA; MGM - ovarian or uterine CA, cousins - breast CA, brother - lymphoma Physical ___: Admission PE: 97.6 66 160/86 16 100% RA no acute distress, alert, responsive unlabored breathing regular rate and breathing abd soft, nondistended, mildly tender in the RLQ, no rebound, no guarding, non rigid ext warm and well perfused Discharge Physical Exam: VS: 97.9 PO 105 / 70 L Lying 53 18 98 16 GEN: Awake, alert, pleasant and interactive. CV: RRR PULM: Clear to auscultation bilaterally. ABD: Soft, non-tender, non-distended. Active bowel sounds. EXT: Warm and dry. ___ pulses. NEURO: A&Ox3. Follows commands and moves all extremities equal and strong. Speech is clear and fluent. Pertinent Results: ___ 06:35AM BLOOD WBC-4.3 RBC-3.35* Hgb-9.7* Hct-29.9* MCV-89 MCH-29.0 MCHC-32.4 RDW-13.9 RDWSD-45.1 Plt ___ ___ 07:50PM BLOOD WBC-6.1 RBC-3.70* Hgb-10.9* Hct-33.2* MCV-90 MCH-29.5 MCHC-32.8 RDW-14.0 RDWSD-45.5 Plt ___ ___ 07:50PM BLOOD ___ PTT-31.8 ___ ___ 06:35AM BLOOD Glucose-83 UreaN-7 Creat-0.8 Na-141 K-4.2 Cl-107 HCO3-22 AnGap-12 ___ 07:50PM BLOOD Glucose-84 UreaN-9 Creat-0.9 Na-137 K-3.8 Cl-102 HCO3-21* AnGap-14 ___ 07:50PM BLOOD ALT-10 AST-13 AlkPhos-49 TotBili-0.3 ___ 06:35AM BLOOD Calcium-9.0 Phos-3.9 Mg-1.8 ___ 04:47PM URINE Color-Yellow Appear-Clear Sp ___ ___ 04:47PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM* CT A/P: Acute uncomplicated appendicitis with an appendicolith. Medications on Admission: None. Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 9 Days RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*18 Tablet Refills:*0 3. MetroNIDAZOLE 500 mg PO Q8H Duration: 9 Days RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day Disp #*27 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Acute Appendicitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ year old woman with RLQ abd pain,bloating,nausea ;tenderness// r/o appendicitis(call MD on call,please) TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 657 mGy-cm. COMPARISON: None. FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: Hemangioma within the right lobe of the liver. Additional subcentimeter hypodensities within the liver are too small to characterize, but likely represent cysts or biliary hamartomas. Otherwise, the liver demonstrates homogenous attenuation throughout. There is no evidence of suspicious enhancing 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. Small accessory spleen near the hilum. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The appendix is dilated and fluid-filled with mild adjacent fat stranding, compatible with acute uncomplicated appendicitis. There is suggestion of an appendicolith(series 5, image 53). There are no focal fluid collections. The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are also unremarkable in appearance. PELVIS: The urinary bladder and distal ureters are unremarkable. Small volume free fluid in the pelvis, likely physiologic. REPRODUCTIVE ORGANS: Uterus is slightly bulbous in appearance, which may reflect small fibroids. No adnexal masses. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease is noted. BONES: Small sclerotic lesions throughout the pelvis likely represent bone islands. There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: Acute uncomplicated appendicitis with an appendicolith. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 7:11 pm, 5 minutes after discovery of the findings. Gender: F Race: WHITE - EASTERN EUROPEAN Arrive by WALK IN Chief complaint: Appendicitis, RLQ abdominal pain Diagnosed with Unspecified acute appendicitis temperature: 97.6 heartrate: 66.0 resprate: 16.0 o2sat: 100.0 sbp: 160.0 dbp: 86.0 level of pain: 2 level of acuity: 3.0

Dear Ms. ___, You were admitted to the Acute Care Surgery Service with abdominal pain and found to have inflammation in your appendix. You were counseled on different treatment options and elected for antibiotics. Your pain improved with antibiotics and you are now ready to be discharged home to complete a course of oral antibiotics. Please note the following discharge instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Bone pain, metastatic nonsmall cell lung cancer Major Surgical or Invasive Procedure: Fine needle aspiration Radiation therapy History of Present Illness: ___ with history of HTN, HLD, Depression admitted for pain control with MRI/CT highly suggestive of metastatic disease, etiology unknown. MRI of spine done at OSH on ___ revealed multiple lesions c/w mets. Patient also has severe cutaneous and sub-cutaneous nodules suspicious for malignancy. Lesions are located over RUQ of abdomen, lower left back, right inner thigh - states she was told they are lipomas. Non-painful, non-purulent. + history of subjective fevers and weight loss. + headaches, + weakness in lower extremities - no bowel or bladder incontinence or falls. No chest pain, palpitations, SOB, cough, abdominal pain, N/V/D, dysuria/hematuria. Regarding health screening, no colonoscopy, last mammogram in ___. . In the ED, VS 98.5 123 167/91 20 98%, pain 6. Given morphine and ativan. Chem 7, LFTs, CBC WNL except for WBC of 12.0 (N:81.2 L:11.3 M:5.0 E:1.5 Bas:0.9). Lactate 1.4. CT chest/abd/pelvis performed just prior to arrival to the floor, negative for PE - previous concerning bony/abdominal wall lesions noted. . On the floor, patient triggered for sustained HR in 130's, asymptommatic, VSS. Pain ___ located in lower back. Otherwise no complaints. On O2, no subjective SOB. Past Medical History: Hypertension Low Back Pain Depression Hypothyroidism Eczema Hyperlipidemia New diagnosis of nonsmall cell lung cancer with mets to the skin and bone (this admission) Social History: ___ Family History: dad with metastatic prostate cancer, grandmother with breast cancer. Physical Exam: ADMISSION EXAM: Vitals: T: 98.5 BP: 154/82 P: 132 R: 20 O2: 94%3L General: Alert, oriented, appears anxious, thin HEENT: dry MM, no OP lesions Neck: supple, JVP not elevated, no LAD Lungs: poor inspiratory effort, decresed BS at left lower base, minimal crakle at right posterior base. no rhonchi. CV: tachycardic, regular rhythm. no m/g/r. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: 1.5 cm elevated hard, indurated, non-supporative, non-painful lesion on right upper quadrant of abdomen with minimal surrounding erythema (appears chronic, not acute). Hard, irregular subcutaneous nodule in lower left back and right medial thigh. no other rash. Neuro: anxious, CN II-XII grossly intact. strength ___ in all 4 extremities. no sensation deficits appreciated. no nystagmus. Discharge Exam: Vitals: Tm/c: 98.5 BP: 110/60, 69 22 96% 1L General: Alert, oriented, more cooperative this morning, thin HEENT: MMM, no OP lesions Neck: supple, JVP not elevated, no LAD Lungs: CTAB. Breathing comfortably. CV: RRR no m/g/r. Chest wall and sternum TTP Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: 1.5 cm elevated pupuric, hard, indurated, non-supporative, non-painful lesion on right upper quadrant of abdomen with minimal surrounding erythema, biopsy clean and not bleeding. Hard, irregular subcutaneous nodule in lower left back, LUQ, and right medial thigh. no rash. Neuro: anxious, CN II-XII grossly intact. strength ___ in all 4 extremities. no sensation deficits appreciated. Pertinent Results: ADMISSION LABS: ___ 03:10PM WBC-12.0* RBC-4.79 HGB-14.8 HCT-43.8 MCV-92 MCH-30.8 MCHC-33.6 RDW-13.7 ___ 03:10PM NEUTS-81.2* LYMPHS-11.3* MONOS-5.0 EOS-1.5 BASOS-0.9 ___ 03:10PM PLT COUNT-353# ___ 03:10PM GLUCOSE-88 UREA N-11 CREAT-0.7 SODIUM-137 POTASSIUM-4.2 CHLORIDE-95* TOTAL CO2-29 ANION GAP-17 ___ 03:10PM ALT(SGPT)-10 AST(SGOT)-25 ALK PHOS-100 TOT BILI-0.3 ___ 03:10PM LIPASE-17 ___ 03:10PM ALBUMIN-4.1 CALCIUM-10.3 PHOSPHATE-3.2 MAGNESIUM-1.9 ___ 03:10PM TSH-4.8* ___ 03:26PM LACTATE-1.4 ___ 03:10PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR ___ 03:10PM URINE RBC-5* WBC-5 BACTERIA-FEW YEAST-NONE EPI-4 . DISCHARGE LABS: ___ 07:00AM BLOOD Glucose-91 UreaN-14 Creat-0.5 Na-136 K-4.5 Cl-95* HCO3-33* AnGap-13 ___ 07:00AM BLOOD Calcium-9.5 Phos-3.7 Mg-1.9 . Imaging: ___ CTA TORSO: CHEST: There is no evidence of pulmonary embolus. There is no aortic dissection. In the superior portion of the left lower lobe, there is a heterogeneously enhancing spiculated mass measuring 4.2 x 5.3 cm in AP and transverse ___, respectively. The bulk of the mass is nodular and centered within the lung parenchyma; however, there is medial linear extension which courses along the descending thoracic aorta approximately 8.7 cm in craniocaudal dimension. There is mild post-obstructive pneumonitis (5:51). The mass causes narrowing of the coursing pulmonary arteries without evidence of pulmonary embolus. There is mass effect on the lower lobe bronchi with occlusion of the inferomedial bronchi (___). 6-mm right upper lobe pulmonary nodule is evident (2:27). There is a 1-2 mm right lower lobe pulmonary nodule (5:41). Peripheral ground-glass opacity in the right upper lobe, just superior to the major fissure (2:32) is nonspecific. There is no pleural effusion. Extensive coronary artery and aortic atherosclerotic calcifications are evident. There appears to be mild irregularity/ulceration of the left lateral margin of the aortic arch (5A:12). The ascending aorta measures 3.1 cm. Left hilar and subcarinal adenopathy is evident; measuring 1.5 cm in the left hilum and 1.1 cm in the subcarinal region. There is no right hilar or axillary adenopathy. The right atrium is enlarged. Also at the right base, there is nodular opacity at the periphery with associated linear atelectasis (5a:72) which may represent rounded atelectasis with attention on followup recommended. ABDOMEN: Ill-defined 5-mm hypodensity in hepatic segment II (5B:87) is too small to accurately characterize. No additional liver lesions are identified. The portal and hepatic veins are patent. The spleen, pancreas and gallbladder are within normal limits. Bilateral adrenal nodules which are heterogeneous in appearance are evident. Nodule in the left adrenal gland measures 9 mm (5B:85). The remainder of the left adrenal gland is thickened. In the right adrenal gland, there is a hypodense 1.3-cm nodule (5B:86). There are bilateral hypodense renal lesions. The largest is in the mid-to-lower pole of the left kidney measuring slightly higher than water density in ___ units and 4.7 cm. This likely represents a cyst with possible hemorrhagic or proteinaceous debris. In the interpolar region of the right kidney, there is an 8-mm hypodense lesion which measures 97 in ___ units. Non-contrast imaging through the kidneys was not performed to confirm enhancement. The kidneys demonstrate symmetric uptake and excretion of contrast. There is extensive atherosclerotic calcification within the normal caliber abdominal aorta. There is no obvious mesenteric or retroperitoneal adenopathy. Visualized bowel loops are grossly unremarkable. Multiple enhancing subcutaneous nodules are evident; for example, measuring 1.9 cm overlying the lateral right lower ribs, measuring 1.4 cm in the left flank and measuring 1.3 cm in the mid left anterior abdominal wall. These are suspicious for subcutaneous metastases. PELVIS: The bladder and rectum are grossly unremarkable. The uterus is not identified, possibly surgically absent. The ovaries are also not identified. There is no pelvic adenopathy or free fluid. OSSEOUS STRUCTURES: Multiple lytic osseous metastases are identified in the left tip of the scapula, T11 vertebral body, posterior ninth rib on the right, left posterior iliac bone, right anterior iliac bone, and sternum. In addition, there are multiple osseous sclerotic lesions in the posterior left rib, left iliac bone surrounding the lytic lesions, and left sacral ala. IMPRESSION: 1. No pulmonary embolism. 2. Left lower lobe spiculated lung mass measuring 4.2 x 5.3 x 7.7 cm, concerning for a primary lung malignancy. The spiculated mass runs along the descending thoracic aorta with its linear medial component approximately 8.7 cm in craniocaudal dimension. There are two small right pulmonary nodules, possibly representing metastases measuring 6 and 2 mm. 3. Osseous metastatic disease with mixed lytic and sclerotic lesions. 4. Enhancing subcutaneous nodules concerning for metastases. 5. Bilateral adrenal nodules, likely metastases. 6. 8mm inter-polar right renal lesion is incompletely evaluated on this examination. This does not measure fluid density. When clinically appropriate, further characterization with ultrasound may be beneficial. Additional simple left renal cyst and too small to characterize lesions. 7. Significant aortic atherosclerotic disease and extensive coronary artery calcifications. . ___ MRI head: There is a 20 x 11 mm measuring oval right temporal-occipital calvarium lesion, which likely represents a bone metastasis and is pushing on the dura without evidence of adjacent FLAIR signal abnormality or involvement of the intra-axial space. Additional osseous metastases are not identified in the imaged volume. A briskly enhancing 12 (AP) x 9 (TRV) x 15 (SI) left parasagittal frontal lesion appears to be extra-axial and is exerting mass effect on the adjacent sulcus. There is no associated parenchymal FLAIR signal abnormality and the lesion most likely corresponds to a parafalcine meningioma. There is no evidence of intra-axial metastatic lesions. Extensive periventricular, subcortical and deep white matter FLAIR/T2 signal abnormalities are in keeping with sequela of small vessel ischemic disease. Flow voids of the major intracranial vessels are preserved. The visualized paranasal sinuses and mastoid air cells are clear. IMPRESSION: 1. Right occipital calvarium lesion, likely representing bony metastasis. 2. Left frontal parasagittal mass, most likely representing a meningioma. 3. There is no evidence of intraparenchymal metastatic disease and no acute findings, such as hemorrhage or infarct. . ___ L tib/fib XRAY TWO VIEWS OF THE TIBIA AND FIBULA: No definitive lytic or sclerotic lesions are seen, however there is an area of trabecular rarefaction within the distal fibula. While this may be projectional, please correlate clinically and consider dedicated ankle radiographs. . ___ CYTOLOGY FNA, Right abdominal lesion: POSITIVE FOR MALIGNANT CELLS, consistent with a poorly differentiated non-small cell carcinoma; see note. . ___ PATHOLOGY Cell block, right abdominal lesion, FNA: Positive for malignant cells, consistent with a poorly-differentiated non-small cell carcinoma; Note: By immunohistochemistry, the tumor cells are positive for cytokeratin cocktail (keratin AE1/AE3, Cam 5.2), CK7, and TTF-1 and are negative for CK20, CDX-2, S-100, and desmin. Smooth muscle actin highlights background stromal cells. The histologic and immunohistochemical findings are compatible with a tumor of lung origin. Correlation with clinical and radiographic findings is recommended. Medications on Admission: Fluticasone daily Anaprox DS 550 mg q12 h prn back pain synthroid ___ mcg daily Lisinopril 10 mg daily Ativan 1 mg TID Vicodin 7.5/325 q4h prn pain zofran prn Discharge Medications: 1. fluticasone Nasal 2. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. Disp:*30 Tablet(s)* Refills:*0* 4. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for Pain: Please do not take if you are feeling tired or confused. Do not operate heavy machinery or drive while on this medication. Disp:*90 Tablet(s)* Refills:*0* 5. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for Pain. Disp:*30 Tablet(s)* Refills:*0* 6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every six (6) hours. Disp:*160 Tablet(s)* Refills:*0* 7. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. propranolol 20 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 11. ondansetron 4 mg Tablet, Rapid Dissolve Sig: ___ Tablet, Rapid Dissolves PO every eight (8) hours as needed for nausea. Disp:*40 Tablet, Rapid Dissolve(s)* Refills:*0* 12. OxyContin 30 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO twice a day: Do not operate heavy machinery or drive while on this medication. Disp:*20 Tablet Extended Release 12 hr(s)* Refills:*0* 13. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once a day as needed for constipation. Disp:*30 packets* Refills:*0* 14. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Apply patch to area of most significant pain (i.e. sternum). Leave leave patch on for 12 hours only. Remove patch, and reapply 12 hours later. Disp:*15 Adhesive Patch, Medicated(s)* Refills:*0* 15. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO BID (2 times a day) as needed for constipation. Disp:*1 bottle* Refills:*0* 16. Supplemental Oxygen ___ continuous pulse dose for portability Dx: metastatic nonsmall cell lung cancer RA sat 84% Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Metastatic lung cancer Secondary Diagonsis: Hypertension Low Back Pain Depression Hypothyroidism Eczema Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report CTA CHEST, ABDOMEN AND PELVIS WITH AND WITHOUT CONTRAST DATE: ___. COMPARISON: Reference MR lumbar spine ___. CLINICAL INDICATION: ___ female with known spine lesions, low back pain, tachycardia and hypoxic. Evaluate for PE as well as other lesions. TECHNIQUE: Unenhanced low-dose axial images through the chest were obtained. Subsequently, axial contrast-enhanced images of the chest were obtained in the arterial phase to evaluate for pulmonary embolus after the uneventful intravenous administration of 130 mL Optiray. Axial images of the abdomen and pelvis were obtained in the portal venous phase subsequently. Coronal and sagittal reformatted images were constructed. TOTAL EXAM DLP: 555.6 mGy-cm. FINDINGS: CHEST: There is no evidence of pulmonary embolus. There is no aortic dissection. In the superior portion of the left lower lobe, there is a heterogeneously enhancing spiculated mass measuring 4.2 x 5.3 cm in AP and transverse ___, respectively. The bulk of the mass is nodular and centered within the lung parenchyma; however, there is medial linear extension which courses along the descending thoracic aorta approximately 8.7 cm in craniocaudal dimension. There is mild post-obstructive pneumonitis (5:51). The mass causes narrowing of the coursing pulmonary arteries without evidence of pulmonary embolus. There is mass effect on the lower lobe bronchi with occlusion of the inferomedial bronchi (___). 6-mm right upper lobe pulmonary nodule is evident (2:27). There is a 1-2 mm right lower lobe pulmonary nodule (5:41). Peripheral ground-glass opacity in the right upper lobe, just superior to the major fissure (2:32) is nonspecific. There is no pleural effusion. Extensive coronary artery and aortic atherosclerotic calcifications are evident. There appears to be mild irregularity/ulceration of the left lateral margin of the aortic arch (5A:12). The ascending aorta measures 3.1 cm. Left hilar and subcarinal adenopathy is evident; measuring 1.5 cm in the left hilum and 1.1 cm in the subcarinal region. There is no right hilar or axillary adenopathy. The right atrium is enlarged. Also at the right base, there is nodular opacity at the periphery with associated linear atelectasis (5a:72) which may represent rounded atelectasis with attention on followup recommended. ABDOMEN: Ill-defined 5-mm hypodensity in hepatic segment II (5B:87) is too small to accurately characterize. No additional liver lesions are identified. The portal and hepatic veins are patent. The spleen, pancreas and gallbladder are within normal limits. Bilateral adrenal nodules which are heterogeneous in appearance are evident. Nodule in the left adrenal gland measures 9 mm (5B:85). The remainder of the left adrenal gland is thickened. In the right adrenal gland, there is a hypodense 1.3-cm nodule (5B:86). There are bilateral hypodense renal lesions. The largest is in the mid-to-lower pole of the left kidney measuring slightly higher than water density in ___ units and 4.7 cm. This likely represents a cyst with possible hemorrhagic or proteinaceous debris. In the interpolar region of the right kidney, there is an 8-mm hypodense lesion which measures 97 in ___ units. Non-contrast imaging through the kidneys was not performed to confirm enhancement. The kidneys demonstrate symmetric uptake and excretion of contrast. There is extensive atherosclerotic calcification within the normal caliber abdominal aorta. There is no obvious mesenteric or retroperitoneal adenopathy. Visualized bowel loops are grossly unremarkable. Multiple enhancing subcutaneous nodules are evident; for example, measuring 1.9 cm overlying the lateral right lower ribs, measuring 1.4 cm in the left flank and measuring 1.3 cm in the mid left anterior abdominal wall. These are suspicious for subcutaneous metastases. PELVIS: The bladder and rectum are grossly unremarkable. The uterus is not identified, possibly surgically absent. The ovaries are also not identified. There is no pelvic adenopathy or free fluid. OSSEOUS STRUCTURES: Multiple lytic osseous metastases are identified in the left tip of the scapula, T11 vertebral body, posterior ninth rib on the right, left posterior iliac bone, right anterior iliac bone, and sternum. In addition, there are multiple osseous sclerotic lesions in the posterior left rib, left iliac bone surrounding the lytic lesions, and left sacral ala. IMPRESSION: 1. No pulmonary embolism. 2. Left lower lobe spiculated lung mass measuring 4.2 x 5.3 x 7.7 cm, concerning for a primary lung malignancy. The spiculated mass runs along the descending thoracic aorta with its linear medial component approximately 8.7 cm in craniocaudal dimension. There are two small right pulmonary nodules, possibly representing metastases measuring 6 and 2 mm. 3. Osseous metastatic disease with mixed lytic and sclerotic lesions. 4. Enhancing subcutaneous nodules concerning for metastases. 5. Bilateral adrenal nodules, likely metastases. 6. 8mm inter-polar right renal lesion is incompletely evaluated on this examination. This does not measure fluid density. When clinically appropriate, further characterization with ultrasound may be beneficial. Additional simple left renal cyst and too small to characterize lesions. 7. Significant aortic atherosclerotic disease and extensive coronary artery calcifications. Radiology Report CLINICAL HISTORY: Metastatic cancer. Rule out lytic lesion. COMPARISON: None. TWO VIEWS OF THE TIBIA AND FIBULA: No definitive lytic or sclerotic lesions are seen, however there is an area of trabecular rarefaction within the distal fibula. While this may be projectional, please correlate clinically and consider dedicated ankle radiographs. Radiology Report INDICATION: ___ patient with bone metastasis in the spinal axis. Assess for metastatic disease to the brain. COMPARISON: None available for comparison. TECHNIQUE: Sagittal T1 and axial T1, T2, gradient echo, FLAIR and diffusion with ADC map images were obtained without contrast. Following IV administration of gadolinium, sagittal MP-RAGE and axial T1 spin echo sequences were acquired. FINDINGS: There is a 20 x 11 mm measuring oval right temporal-occipital calvarium lesion, which likely represents a bone metastasis and is pushing on the dura without evidence of adjacent FLAIR signal abnormality or involvement of the intra-axial space. Additional osseous metastases are not identified in the imaged volume. A briskly enhancing 12 (AP) x 9 (TRV) x 15 (SI) left parasagittal frontal lesion appears to be extra-axial and is exerting mass effect on the adjacent sulcus. There is no associated parenchymal FLAIR signal abnormality and the lesion most likely corresponds to a parafalcine meningioma. There is no evidence of intra-axial metastatic lesions. Extensive periventricular, subcortical and deep white matter FLAIR/T2 signal abnormalities are in keeping with sequela of small vessel ischemic disease. Flow voids of the major intracranial vessels are preserved. The visualized paranasal sinuses and mastoid air cells are clear. IMPRESSION: 1. Right occipital calvarium lesion, likely representing bony metastasis. 2. Left frontal parasagittal mass, most likely representing a meningioma. 3. There is no evidence of intraparenchymal metastatic disease and no acute findings, such as hemorrhage or infarct. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: BACK PAIN, ABNL MRI Diagnosed with MALIGNANT NEOPLASM NOS, BACKACHE NOS, HYPOTHYROIDISM NOS temperature: 98.5 heartrate: 123.0 resprate: 20.0 o2sat: 98.0 sbp: 167.0 dbp: 91.0 level of pain: 6 level of acuity: 3.0

Dear ___ you for coming to the ___. You were in the hospital because of your pain and skin lesions that were concerning for cancer. We performed a biopsy which showed that you have metastatic lung cancer. You started radiation therapy to help with your pain. You will need to follow up with a lung cancer specialist to discuss further treatment options. We started you on oxycontin (long acting oxycodone), oxycodone, tylenol, and a lidocaine patch for pain. You should continue to take ativan and citalopram for anxiety. You were also noticed to need supplemental oxygen when walking around, which is being provided to you. You have been feeling weak throughout the admission, however physical therapy has evaluated you several times and feel that you are safe for discharge. It is important that you continue to drink water and eat food to keep your nutrition status up. . Medication Recommendations: Please START: -Supplemental oxygen at ___ -Oxycontin 30 mg twice daily -Oxycodone ___ tabs) every 4 hours as needed for pain. If you are feeling drowsy or confused, it is possible you are taking too much of this medication. Please avoid this medication until you are feeling back to normal. -Zofran (ondansetron) ___ mg three times per day as needed for nausea -Ibuprofen 600 mg every 8 hours as needed for pain -Acetaminophen 1000 mg every 6 hours for pain -Senna 8.6 mg twice daily as needed for constipation -Docusate 100 mg twice daily for constipation -Milk of magnesia as needed for constipation -Miralax 1 packet daily as needed for constipation -Citalopram 20 mg daily -Propanolol 20 mg every 8 hours It is important you continue to have regular bowel movements as the prescribed pain medications frequently cause constipation in patients. Please take colace daily and senna, miralax and milk of magnesia as needed so that you are having a bowel movement a day. . Please STOP lisinopril.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: amoxicillin Attending: ___. Chief Complaint: right hip pain Major Surgical or Invasive Procedure: Open reduction and internal fixation of right acetabular fracture; ___ ___. History of Present Illness: ORTHOPAEDIC SURGERY CONSULT NOTE NAME: ___ MRN: ___ DATE: ___ RESIDENT: ___, MD ATTENDING: Dr ___ ___ SERVICE: Ortho trauma CC: R hip pain DATE OF INJURY: ___ MECHANISM: fall SIDE: RIGHT BONE: acetabulum , pubic ramus LOCATION: PROXIMAL PATTERN: COMMINUTED DISPLACEMENT: DISPLACED TYPE: CLOSED TISSUE CLASSIFICATION: CLOSED EPISODE OF CARE: SUBSEQUENT HPI: ___ male patient with history of alcohol abuse presenting as a transfer from ___ for comminuted displaced right iliac wing, acetabular and superior inferior pubic rami fractures as well as a minimally displaced left superior and inferior pubic rami fracture. Patient was found down at a liquor store last night and was brought to the outside hospital where imaging was done and he was found to have the above fractures. He was transferred here for orthopedic care. He is not anticoagulated. He is a chronic alcoholic. He currently complains of right hip pain but denies any numbness or tingling. PMH: Alcohol abuse PSH: Right hip surgery Right ankle surgery MEDS: Atenolol 50 mg daily ALL: Amoxicillin SHx: Daily alcohol use about ___ beers per day ROS: A complete 10-point review of systems was completed and is negative except as noted above. PHYSICAL EXAMINATION: General: Alert and oriented Vitals: Afebrile vital signs stable Right lower extremity: Skin intact, closed injury but with tenderness palpation over the right hip. Limited range of motion at the hip and knee secondary to pain. Full range of motion of the ankle. ___ firing. SILT SPN/DPN/TN/saphenous/sural distributions. 1+ ___ pulses, foot warm and well-perfused but with significant pitting edema in the right lower extremity as well as the right foot. Significant amount of ecchymosis in the bilateral upper extremities. LABS: See ___ medical record IMAGING: CT pelvis without contrast (OSH) IMPRESSION: 1. Comminuted displaced right iliac wing, acetabulum and superior and inferior pubic rami fractures. Surround right pelvic sidewall/extraperitoneal hematoma. 2. Minimally displaced left superior and inferior pubic rami fractures. 3. Probable nondisplaced sacral fracture. 4. Moderate compression fracture of L3 vertebral body, age indeterminate. No significant bony retropulsion, into the spinal canal. 5. Left inguinal hernia containing portion of colon. ASSESSMENT/RECOMMENDATIONS: ___ male patient presenting as a transfer from outside hospital status post fall, found to have comminuted displaced right iliac wing, acetabular and superior and inferior pubic rami fractures. He was also found to have left superior inferior pubic rami fracture and nondisplaced sacral fracture. He is neurovascularly intact distally. At this time, we will treat this non-operatively. Recommend ED observation overnight for physical therapy and case management. Past Medical History: Alcohol abuse hypertension Social History: ___ Family History: non-contributory. Physical Exam: Exam on Discharge: No acute distress Unlabored breathing Abdomen soft, non-tender, non-distended Incision clean/dry/intact with no erythema or discharge, minimal ecchymosis Right lower extremity fires ___ Right lower extremity SILT sural, saphenous, superficial peroneal, deep peroneal and tibial distributions Right lower extremity dorsalis pedis pulse 2+ with distal digits warm and well perfused Pertinent Results: labs reviewed and unremarkable. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 50 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO 5X/DAY RX *acetaminophen [8HR Muscle Ache-Pain] 650 mg 1 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills:*0 2. Baclofen 10 mg PO TID RX *baclofen 10 mg 1 tablet(s) by mouth every 8 hours Disp #*21 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID use while taking narcotic pain medication. RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice daily Disp #*14 Capsule Refills:*0 4. Enoxaparin Sodium 40 mg SC QDAY RX *enoxaparin 40 mg/0.4 mL 1 injection subcutaneously daily Disp #*28 Syringe Refills:*0 5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain OK to request partial fill. Wean as tolerated. RX *oxycodone 10 mg ___ tablet(s) by mouth every 4 hours as needed Disp #*60 Tablet Refills:*0 6. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 tablet(s) by mouth daily as needed Disp #*30 Tablet Refills:*0 7. Senna 8.6 mg PO BID use when taking narcotic pain medication. RX *sennosides [Evac-U-Gen (sennosides)] 8.6 mg 2 tablets by mouth twice daily Disp #*28 Tablet Refills:*0 8. Tamsulosin 0.4 mg PO QHS RX *tamsulosin [Flomax] 0.4 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 9. Atenolol 50 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: right, closed acetabular fracture. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ status post fall. Study performed to evaluate for rib fracture or pneumonia. TECHNIQUE: Chest: Frontal and Lateral views COMPARISON: None. FINDINGS: The lungs are clear without focal consolidation. No pleural effusion or pneumothorax is seen. The cardiomediastinal silhouettes are unremarkable. There are chronic appearing deformities of the right lateral ribs. There is an angulated appearance of the left lateral third rib, which could be acute in nature. There is callus formation at the lateral fifth rib on the left, which is chronic in appearance. No other acute osseous abnormalities are seen within the limitations of the study. IMPRESSION: 1. No acute cardiopulmonary process. 2. Angulated appearance of the left lateral third rib, which could be acute in nature. Correlation with prior imaging or dedicated rib series is recommended as clinically indicated. 3. Other chronic appearing rib deformities as described above. Radiology Report INDICATION: ___ with r acetabular fx. pls do AP pelvis X-ray with inlet and outlet views AND R hip with judet views// eval fx. pls do AP pelvis X-ray with inlet and outlet views AND R hip with judet views TECHNIQUE: AP, bilateral oblique, inlet and outlet views of pelvis. AP and cross-table lateral views of the proximal right femur. COMPARISON: CT pelvis from earlier the same day performed at an outside institution. FINDINGS: Bones are diffusely demineralized. Mildly displaced fracture through the right acetabulum is noted with step-off of the iliopectineal line. Known nondisplaced right inferior pubic ramus fracture is better seen by CT. There are fractures through the left superior and inferior pubic rami as well. Femoroacetabular joints are anatomically aligned. Hardware from prior right femoral neck ORIF is noted without periprosthetic lucency. No acute femoral fracture identified. Lucency over the left groin is compatible with colonic containing left inguinal hernia. IMPRESSION: Pelvic fractures as seen on prior CT. Radiology Report EXAMINATION: CT CHEST W/O CONTRAST INDICATION: ___ with fall p/w trauma and rib fracture// eval for rib fractures TECHNIQUE: Multidetector helical scanning of the chest was performed without intravenous contrast agent reconstructed as contiguous 5- and 1.25-mm thick axial, 2.5-mm thick coronal and parasagittal, and 8 x 8 mm MIPs axial images. DOSE: DLP: 466 mGy cm. COMPARISON: None FINDINGS: Thyroid is unremarkable. Supraclavicular, axillary, and mediastinal lymph nodes are not enlarged. Moderate calcification is noted at the aortic valve. Coronary artery calcification is moderate to severe. Thoracic aorta and main pulmonary artery are normal size. There is no pericardial effusion. There is no pleural effusion. Airways are patent to subsegmental levels. Mild bronchial wall thickening is noted. Centrilobular emphysema is mild. 10 mm subpleural nodule is identified in the right lower lobe (4:177). 7 mm nodule is identified in right lower lobe (4:137). Limited evaluation of upper abdomen is notable for calcified granulomas in the spleen. Colonic diverticulosis is noted. Bilateral gynecomastia is noted. Minimally displaced fractures are identified in right lateral 4, 5, and 6 ribs, of unknown chronicity. Bony bridge between lateral right 7 and 8 ribs may be sequela of old trauma. T12 and L1 vertebral body height loss is chronic in appearance. IMPRESSION: 1. Minimally displaced fractures at right lateral 4, 5, and 6 ribs are of unknown chronicity but likely chronic. To be correlated clinically. 2. 2 pulmonary nodules measuring up to 10 mm are identified in the right lower lobe. Please see recommendation below. 3. Mild pulmonary emphysema. 4. Bilateral gynecomastia. RECOMMENDATION(S): 1. For incidentally detected multiple solid pulmonary nodules bigger than 8mm, a CT follow-up in 3 to 6 months is recommended in a low-risk patient, with an optional CT follow-up in 18 to 24 months. In a high-risk patient, both a CT follow-up in 3 to 6 months and in 18 to 24 months is recommended. See the ___ ___ Society Guidelines for the Management of Pulmonary Nodules Incidentally Detected on CT" for comments and reference: ___ Radiology Report INDICATION: ___ year old man with acetab fx// eval pelvis fx TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired without intravenous contrast. Non-contrast scan has several limitations in detecting vascular and parenchymal organ abnormalities, including tumor detection. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 8.3 s, 40.6 cm; CTDIvol = 17.9 mGy (Body) DLP = 727.7 mGy-cm. 2) Spiral Acquisition 1.3 s, 6.4 cm; CTDIvol = 14.7 mGy (Body) DLP = 93.3 mGy-cm. Total DLP (Body) = 821 mGy-cm. COMPARISON: CT scan of the pelvis performed earlier the same day at 02:59. FINDINGS: PELVIS: There is a colonic containing left inguinal hernia without secondary obstruction. The partially visualized small and large bowel are otherwise unremarkable. The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. There is however right-sided pelvic sidewall stranding compatible with hematoma. REPRODUCTIVE ORGANS: Prostate and seminal vesicles are within normal limits. LYMPH NODES: There is no pelvic or inguinal lymphadenopathy. VASCULAR: Moderate atherosclerotic disease is noted. BONES: Again seen are multiple pelvic fractures, specifically minimally displaced left inferior pubic ramus fracture and mildly displaced left superior pubic ramus fracture. Nondisplaced right inferior pubic ramus fractures identified. Comminuted fracture through the right acetabulum is identified with superior extension through the portion of the iliac wing and involvement of the superior pubic ramus. Pubic symphysis is preserved. Sacrum is within normal limits. SI joints are preserved. Orthopedic hardware in the proximal right femur is noted without evidence of complication. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: Bilateral superior and inferior pubic ramus fractures with comminuted right acetabular fracture and pelvic sidewall hematoma. Radiology Report EXAMINATION: PELVIS (AP, INLET AND OUTLET) INDICATION: RT ACETABULER FX.ORIF TECHNIQUE: Intraoperative fluoroscopic images. COMPARISON: CT ___. FINDINGS: Multiple intraoperative fluoroscopic images of the right acetabulum was obtained without a radiologist present. Images demonstrate progressive sideplate and screw fixation of acetabular fracture. IMPRESSION: Multiple intraoperative images were obtained during right acetabular fracture ORIF. Please refer to operative report for further details. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Found down, Transfer Diagnosed with Oth fracture of right pubis, init encntr for closed fracture, Unspecified fall, initial encounter temperature: 98.2 heartrate: 82.0 resprate: 20.0 o2sat: 97.0 sbp: 154.0 dbp: 86.0 level of pain: 5 level of acuity: 3.0

Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - touch down weight bearing on the right lower extremity. MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take enoxaparin daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Please remain in your dressing and do not change unless it is visibly soaked or falling off. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB Physical Therapy: touch down weight bearing as tolerated on the right lower extremity. no hip precautions. Treatments Frequency: incision may be left open to air.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: ___ - Aortic valve replacement with 25 mm Epic supra valve. Coronary artery bypass grafting x 3, left internal mammary artery graft to left anterior descending, reverse saphenous vein grafts to the ramus intermedius and the posterior descending artery. History of Present Illness: Mr. ___ is a nice ___ year old man with a history of coronary artery disease, diabetes mellitus, hyperlipidemia, hypertension, and prior NSTEMI. He was admitted to ___ for type I NSTEMI, found to have 3 vessel CAD with 90% thrombotic stenosis of proximal RCA s/p POBA to proximal and mid-RCA with plans for future CABG, who was discharged from ___ ___ and now presents with unstable angina. He initially presented to ___ on ___, with chest pain and found to have NSTEMI. Cardiac cath ___ was notable for 3 vessel CAD (90% stenosis RI, 90% stenosis in distal LAD, 80% stenosis in OM1, 70% stenosis in mid LCx, 90% stenosis in proximal RCA, 70% mid-RCA, and sub-occlusive stenosis in distal RCA). He underwent balloon angioplasty of proximal and mid RCA, with plan for CABG in ___ weeks. He was discharged from ___ on ___. Since then, he had been doing well and was chest pain free until this morning at around 6:30AM. He reports recurrence of intermittent left-sided, chest pressure at rest with radiation to R arm and axilla and associated shortness of breath. This is similar to prior NSTEMI symptoms. On EMS arrival, he was treated with ASA 324mg and SL nitro with improvement in symptoms. He was taken to ___, where EKG was notable for T wave inversions in inferior leads and elevated Trop I of 1.17 (although decreased from prior 6.69 on ___, 16.60 ___. Past Medical History: Basal Cell Carcinoma s/p Mohs Coronary Artery Disease, s/p PCI ___ Diabetes Mellitus, Insulin Dependent Glaucoma Hyperlipidemia Hypertension Non-ST Elevation Myocardial Infarction ___ Prostate Cancer s/p XRT Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: Admission: VS: ___ Temp: 98.3 PO BP: 149/79 HR: 76 RR: 18 O2 sat: 96% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___ FSBG: 235 GENERAL: Well developed, well nourished male in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. NECK: Supple. No JVD. CARDIAC: PMI located in ___ intercostal space, midclavicular line. Regular rate and rhythm. Normal S1, S2. Crescendo-decrescendo early-peaking systolic murmur, no rubs or gallops. no thrills or lifts. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. . Discharge 97.7 PO 119 / 73 L Sitting 81 18 98 Ra . General: NAD, complaining of arthritic pain Neurological: A/O x3 [x] No focal deficits. HEENT: PERRLA [] Cardiovascular: RRR [x] Irregular [] Murmur [] Rub [] Paced [] Respiratory: CTA [x] No resp distress [x] Intubated [] GI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] NT [x] Extremities: Right Upper extremity Warm [x] Edema Left Upper extremity Warm [x] Edema Right Lower extremity Warm [x] Edema Trace Left Lower extremity Warm [x] Edema Trace Skin/Wounds: Dry [x] intact [x] Sternal: CDI [x] no erythema or drainage [x] Sternum stable [] Prevena [x]; Pacer site C/D/I Lower extremity: Right [] Left [x] CDI [x] Pertinent Results: ADMISSION LABS: ___ 05:05PM BLOOD WBC-7.8 RBC-3.70* Hgb-11.1* Hct-32.8* MCV-89 MCH-30.0 MCHC-33.8 RDW-13.2 RDWSD-42.5 Plt ___ ___ 05:05PM BLOOD ___ PTT-25.1 ___ ___ 05:05PM BLOOD Glucose-219* UreaN-17 Creat-1.0 Na-132* K-4.2 Cl-97 HCO3-25 AnGap-10 ___ 05:05PM BLOOD cTropnT-0.48* ___ 05:05PM BLOOD Calcium-9.0 Phos-3.6 Mg-1.6 ___ 07:40AM BLOOD %HbA1c-9.0* eAG-212* IMAGING: TTE ___ The left atrial volume index is normal. The estimated right atrial pressure is ___ mmHg. There is normal left ventricular wall thickness with a normal cavity size. There is mild regional left ventricular systolic dysfunction with near akinesis of the basal inferior wall (see schematic) and preserved/normal contractility of the remaining segments. Quantitative 3D volumetric left ventricular ejection fraction is 55 %. Left ventricular cardiac index is low normal (2.0-2.5 L/min/m2). There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with normal free wall motion. Tricuspid annular plane systolic excursion (TAPSE) is normal. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. There is a normal descending aorta diameter. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (valve area 1.0-1.5 cm2). There is a centrally directed jet of mild [1+] aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is mild [1+] mitral regurgitation. The pulmonic valve leaflets are not well seen. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. The pulmonary artery systolic pressure could not be estimated. There is no pericardial effusion. IMPRESSION: Moderate aortic valve stenosis. Mild aortic regurgitation. Normal left ventricular cavity size with mild regional systolic dysfunction most consistent with single vessel coronary artery disease (PDA distribution). Mild mitral regurgitation. MICRO: No relevant DISCHARGE LABS: ___ 09:05AM BLOOD Hct-25.3* ___ 04:52AM BLOOD WBC-9.7 RBC-2.55* Hgb-7.6* Hct-23.8* MCV-93 MCH-29.8 MCHC-31.9* RDW-14.8 RDWSD-50.6* Plt ___ ___ 09:05AM BLOOD ___ PTT-24.9* ___ ___ 04:52AM BLOOD Glucose-127* UreaN-21* Creat-1.1 Na-136 K-4.4 Cl-101 HCO3-25 AnGap-10 ___ 03:23AM BLOOD Glucose-119* UreaN-25* Creat-1.3* Na-135 K-4.8 Cl-97 HCO3-29 AnGap-9* ___ 04:52AM BLOOD Calcium-8.0* Phos-3.6 Mg-1.8 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 80 mg PO QPM 2. Clopidogrel 75 mg PO DAILY 3. Pantoprazole 40 mg PO Q24H 4. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 5. Metoprolol Tartrate 50 mg PO BID 6. Lisinopril 20 mg PO DAILY 7. Detemir 34 Units Breakfast Detemir 38 Units Bedtime Novolog 6 Units Breakfast Novolog 10 Units Lunch Novolog 16 Units Dinner 8. Aspirin 81 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever 2. Furosemide 20 mg PO DAILY Duration: 5 Days RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*5 Tablet Refills:*0 3. Detemir 34 Units Breakfast Detemir 38 Units Bedtime Novolog 6 Units Breakfast Novolog 10 Units Lunch Novolog 16 Units Dinner 4. Metoprolol Tartrate 50 mg PO TID RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*1 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 80 mg PO QPM 7. Pantoprazole 40 mg PO Q24H Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Coronary Artery Disease - IDDM - Hypertension - Dyslipidemia - Glaucoma - Prostatic CA s/p XRT - Basal cell carcinoma Past Surgical History: - s/p MOHs surgery (___) - left inguinal hernia repair (strangulated per pt but no bowel resected) Past Cardiac Procedures: - CAD s/p proximal LAD PCI (___) after positive stress test for angina symptoms - NSTEMI (___) with coronary angiogram showing 3 vessel CAD (90% RI, 90% distal LAD, 90% ___ RCA s/p POBA Discharge Condition: Alert and oriented x3 non-focal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema- trace Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PRE-OP PA AND LAT) INDICATION: ___ year old man with multivessel CAD undergoing CABG w/u// acute pulmonary process Surg: ___ (CABG) IMPRESSION: In comparison with the outside studies of ___, there is little overall change. Cardiomediastinal silhouette is within normal limits. There is diffuse prominence of reticular markings bilaterally, with hyperexpansion of the lungs and flattening hemidiaphragms, worrisome for chronic fibrotic interstitial lung disease. No evidence of acute focal consolidation or definite vascular congestion. Large hiatal hernia is seen. Radiology Report EXAMINATION: VEIN MAPPING-Lower extremities INDICATION: ___ year old man with CAD with multivessel disease on LHC, undergoing workup for CABG// vein mapping for CABG TECHNIQUE: Real-time grayscale and Doppler ultrasound imaging of bilateral lower extremity veins. COMPARISON: None. FINDINGS: RIGHT: The great saphenous vein is patent with diameters ranging from 0.20 to 0.53 cm. The right small saphenous vein is patent with diameters ranging from 0.15 to 0.24 cm. LEFT: The great saphenous vein is patent with diameters ranging from 0.17 to 0.57 cm. The left small saphenous vein is patent with diameters ranging from 0.18 to 0.25 cm. IMPRESSION: The great and small saphenous veins are patent bilaterally. Please see digitized image on PACS for formal sequential measurements. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old man s/p CABG// FAST TRACK EARLY EXTUBATION CARDIAC SURGERY Contact name: ___, Phone: 1 TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: The patient is post median sternotomy and CABG. The tip of the endotracheal tube projects at the level of the clavicular heads. A right internal jugular central venous catheter projects over the cavoatrial junction. Chest tubes and mediastinal drains are present. Retrocardiac opacities likely reflect atelectasis and small volume pleural fluid. Atelectasis is also present at the right lung base. A trace right apical pneumothorax is noted. There is unchanged prominence of reticular lung markings bilaterally. IMPRESSION: Trace right apical pneumothorax Left lower lobe atelectasis and small pleural effusion. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man s/p CABG with + AL and right apical ptx// eval for ptx extension IMPRESSION: In comparison with the study of ___, the endotracheal tube and nasogastric tube have been removed. Left chest tube remains in place and any residual pneumothorax would be extremely small. Little overall change in the appearance of the heart and lungs. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with CABG/AVR// eval ptx-H2O Seal eval ptx-H2O Seal IMPRESSION: Comparison to ___. With the chest tubes on waterseal, there is now a 1 cm right apical pneumothorax. No evidence of tension. No change in appearance of the lung parenchyma and the heart. Radiology Report EXAMINATION: CHEST (PORTABLE AP) ___ INDICATION: ___ year old man s/p CABG, tiss AVR// please eval for pneumothorax increase with CT clamped please eval for pneumothorax increase with CT clamped IMPRESSION: Compared to chest radiographs ___ through ___. Mild postoperative pulmonary edema after ___ has improved since ___. No pneumothorax. Small left pleural effusion is stable or improved. Left lower lobe atelectasis is moderate. Normal postoperative appearance the cardiomediastinal silhouette. Heavy asbestos related calcified pleural plaque noted. Right jugular line ends in the low SVC. Midline and at least one pleural drain in place. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man s/p CABGx3(LIMA-LAD; SVG-RI; SVG-PDA) AVR (25mm SJ Epic)// please eval for pneumothorax s/p CT removal TECHNIQUE: Chest AP COMPARISON: ___ IMPRESSION: Lungs are low volume with stable interstitial edema. Right IJ line is unchanged. Patchy parenchymal opacity in the left lower lobe is unchanged. Lungs are low in volume. Small bilateral effusions left greater than right are stable. No pneumothorax. Radiology Report EXAMINATION: CHEST (PORTABLE AP) ___ INDICATION: ___ year old man s/p CABG/ AVR with dropping hct// eval for hemothorax eval for hemothorax IMPRESSION: Compared to chest radiographs ___ through ___. Mild pulmonary edema unchanged since ___. Small left pleural effusion is likely. No pneumothorax. Normal postoperative appearance cardiomediastinal silhouette. Heavy asbestos related pleural calcification. Right jugular line ends in the low SVC. Radiology Report EXAMINATION: Chest radiograph, portable AP upright. INDICATION: Query pneumothorax. COMPARISON: Prior study from ___. FINDINGS: Trace right apical pneumothorax appears stable. No significant change. IMPRESSION: No short-term change in very small right apical pneumothorax. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man with new PPM.// Check leads Check leads IMPRESSION: Right internal jugular line tip terminates at the level of mid to lower SVC. Heart size and mediastinum are stable. Left sided pacemaker leads terminate in right atrium and right ventricle. There is interval improvement in pulmonary edema and better aeration of the lung fields. Bilateral basal opacities and interstitial lung disease as well as calcified pleural plaques are re-demonstrated. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Chest pain, Transfer Diagnosed with Chest pain, unspecified, Athscl heart disease of native coronary artery w/o ang pctrs temperature: 97.6 heartrate: 70.0 resprate: 18.0 o2sat: 99.0 sbp: 142.0 dbp: 74.0 level of pain: 0 level of acuity: 2.0

Please shower daily -wash incisions gently with mild soap, no baths or swimming, look at your incisions daily Please - NO lotion, cream, powder or ointment to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics Clearance to drive will be discussed at follow up appointment with surgeon No lifting more than 10 pounds for 10 weeks Encourage full shoulder range of motion, unless otherwise specified **Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours**

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo F w/ hx of HTN, LHD and recent C2 decompression with C1-C3 laminectomy/fusion on ___ who was sent in from rehab facility due to altered mental status. Pt was in her usual state of health until this morning when she was found to be confused. Pt does promote feeling confused at the time. She and the facility both deny a recent hx of fever, chills, or any constitutional symptoms. She has been constipated and promotes ___ lower abdominal pain over this time. No hx of diarrhea. She did have episode of hematuria yesterday but denies any dysuria or increase freq. Denies any CP, lH, dizziness, or SOB. No pain at surgical site. Denies any weakness. Continues to have b/l lower extremity numbness which she says is her baseline and unchanged. In the ED, initial vitals were: 97.4 68 118/51 24 97%. She was noted to be A&Ox3 but agitated. Labs were notable for UA with pyuria, mod bacteria, large ___, blood, and nitrites. No leukocytosis on CBC with stable H/H. Chem 7 notable for K+ of 5.5. A CT head was normal. CXR was normal. She was started on CTX for UTI. On the floor, she no longer feels confused and has no concerns. She continues to promote mild lower abdominal/suprapubic discomfort. Past Medical History: PMHx (per OMR and patient): - Broke cervical vertebrae at ___, with C2 decompression on ___ C1-C3 laminectomy/fusion - hypertension - arthritis - hyperlipidemia - anxiety Meds: - Aspirin 325mg daily - Bisacodyl 5mg tablet,delayed release daily - Clonazepam 0.25mg BID - Diltiazem ER 180mg capsule,extended release daily - Losartan 100mg tablet daily - Metoprolol tartrate 25mg daily - Simvastatin 10mg qhs - Oxycodone 5mg q3hrs PRN pain - Melatonin 3mg qhs PRN insomnia - Gabapentin 100mg TID - OxyContin 10mg tablet,extended release BID Allergies: - NKDA Social History: ___ Family History: Non contributory Physical Exam: Admission: Vitals: T:98.2 BP: 96/50 P: 80 R: 16 O2: 94% RA General: Pt appears comfortable laying in bed A&Ox3 HEENT: NCAT, EOMI, ___, OMM with no lesions Neck: No masses appreciated, collar in place. Surgical scar healing without erythema. CV: RRR, no m/r/g, no JVD Lungs: CTABL with no r/w/r Abdomen: TTP in suprapubic region, also ttp in RUQ with deep palpation, no g/r. NO HSM. Bandage over lumbar spine c/d/i GU: no foley in place Ext: No edema, no rashes Neuro: CN ___ grossly intact with ___ strength in all extm, no focal deficits. Skin: No rashes or ecchymosis appreciated Vitals: T:98.7 BP: 121/75 P: 88 R: 16 O2: 94% RA General: Pt appears uncomfortable sitting up in bed A&Ox3 HEENT: NCAT, EOMI, ___, OMM with no lesions Neck: No masses appreciated, collar in place. Surgical scar healing without erythema. CV: RRR, no m/r/g, no JVD Lungs: CTABL with no r/w/r Abdomen: TTP in suprapubic region, also ttp in RUQ with deep palpation, no g/r. NO HSM. Bandage over lumbar spine c/d/i GU: no foley in place Ext: No edema, no rashes Neuro: CN ___ grossly intact with ___ strength in all extm, no focal deficits. Skin: No rashes or ecchymosis appreciated Pertinent Results: Admission: ___ 09:10AM BLOOD WBC-9.3 RBC-3.36* Hgb-10.8* Hct-32.7* MCV-97 MCH-32.0 MCHC-32.9 RDW-12.9 Plt ___ ___ 09:10AM BLOOD Neuts-84.7* Lymphs-10.1* Monos-3.9 Eos-0.9 Baso-0.4 ___ 09:10AM BLOOD Glucose-102* UreaN-25* Creat-1.2* Na-136 K-7.5* Cl-102 HCO3-23 AnGap-19 ___ 09:10AM BLOOD Calcium-8.4 Phos-4.3 Mg-2.4 Discharge: ___ 06:30AM BLOOD WBC-7.3 RBC-3.00* Hgb-9.4* Hct-28.9* MCV-96 MCH-31.4 MCHC-32.6 RDW-13.2 Plt ___ ___ 06:30AM BLOOD Neuts-82.3* Lymphs-13.7* Monos-2.9 Eos-1.0 Baso-0.1 ___ 06:30AM BLOOD Glucose-109* UreaN-19 Creat-0.9 Na-137 K-3.9 Cl-101 HCO3-22 AnGap-18 ___ 06:30AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.1 Iron-PND Imaging: CXR: IMPRESSION: Minimal left basilar atelectasis. CT Head: IMPRESSION: No evidence of acute intracranial abnormality. MRI is more sensitive in the detection of acute stroke. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H 2. Diazepam 5 mg PO Q6H:PRN spasm/anxiety 3. Diltiazem Extended-Release 180 mg PO DAILY 4. ClonazePAM 0.25 mg PO BID 5. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 6. Docusate Sodium 100 mg PO BID 7. Losartan Potassium 100 mg PO DAILY 8. Metoprolol Tartrate 25 mg PO DAILY 9. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN Pain 10. Simvastatin 10 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 3. ClonazePAM 0.25 mg PO BID 4. Diltiazem Extended-Release 180 mg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Losartan Potassium 100 mg PO DAILY 7. Metoprolol Tartrate 25 mg PO DAILY Hold for HR <60, Systolic blood pressure <100 8. Simvastatin 10 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: Urinary Tract Infection Toxic Metabolic Encephalopathy Stage 1 Sacral decubitus Secondary Diagnosis Status Post C1-C3 laminectomy/fusion 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 HISTORY: Altered mental status. TECHNIQUE: AP view of the chest. COMPARISON: ___. FINDINGS: The heart size is normal. The aortic knob is calcified. Mediastinal and hilar contours are unremarkable. The pulmonary vascularity is normal. Minimal patchy left basilar opacity likely reflects atelectasis. There is no focal consolidation. No pleural effusion or pneumothorax is seen. Cervical spinal fusion hardware is partially imaged. IMPRESSION: Minimal left basilar atelectasis. Radiology Report INDICATION: Altered mental status, found altered at 6 a.m.; last normal, last night; evaluate for bleed or stroke. COMPARISON: ___. TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without administration of IV contrast. Coronal and sagittal reformatted images were generated. DLP: 897 mGy-cm. FINDINGS: Streak artifact from occipitocervical fusion hardware limits assessment of the posterior fossa. There is no evidence of hemorrhage, edema, mass effect, or acute large vascular territorial infarction. Prominent ventricles and sulci likely reflect age-related involutional changes. Periventricular white matter hypodensities are compatible with chronic small vessel ischemic disease. Basal cisterns are patent and there is preservation of gray-white matter differentiation. No acute fracture is identified. Mild mucosal thickening is seen within the ethmoid air cells. Mastoid air cells and middle ear cavities are clear. Orbits are unremarkable. IMPRESSION: No evidence of acute intracranial abnormality. MRI is more sensitive in the detection of acute stroke. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Altered mental status Diagnosed with URIN TRACT INFECTION NOS, HYPERTENSION NOS temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: 1.0

Dear Ms. ___, It was a pleasure taking care of you at ___ ___. You were brought in for increasing confusion and weakness. We believe this was due to a urinary tract infection in addition to the pain medications you were taking. You were started on antibiotics which you will continue to take at hpme. Your pain medication regimen was also modified. You have decided to go home and not back to rehab. Your PCP ___ follow up with you at home this coming week.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Thiazides Attending: ___ Chief Complaint: Back pain Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a ___ yo female past medical history significant for Bechets vasculitis (on cyclophosphamide and prednisone) admitted to ___ following concern for epidural abscess in setting of increased low back pain following and LP done approximately 3 weeks prior. The LP was done to r/o Guillain ___ syndrome. Further review of imaging showed no evidence of epidural abscess, however there is evidence of a subacute fracture of L4 vertebral body height loss and mild spinal stenosis. A chronic fracture at S1 was also observed. Plan to brace ___ for management of the compression fracture. Past Medical History: Diagnosed with Behcets ___ years ago. Has history of vaginal, lip, skin, and colon ulcers. Was previously hospitalized for a colonic bleed. Has also had ulcers "in the front of her eye". Has history of 15 pulmonary emboli ___ years ago) related to her Behcets disease now on chronic warfarin. Has history of left median neuropathy. Social History: ___ Family History: Many women in her father's side of the family has autoimmune disease including RA and Crohn's. Physical Exam: On admission: PHYSICAL EXAM: O: T: 100.2 BP:140 /102 HR:112 R: 18 97% O2Sats Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 3mm reactive bilaterally, EOMs intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T WE WF IP Q H AT ___ G R 5 5 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 3 5 3 5 5 Sensation: Intact to light touch, proprioception, pinprick and vibration bilaterally. Proprioception intact Toes downgoing bilaterally Rectal exam normal sphincter control on DISCHARGE: alert and oriented ___ strength in all extremities senstation grossly intact Pertinent Results: ___ MRI Lspine: IMPRESSION: 1. Subacute fracture of L4 with mild to moderate vertebral body height loss and mild spinal canal stenosis. Enhancement of the anterior epidural space at L4 is either due to prominence of the venous plexus or a small epidural hematoma. Recommend CT scan for further evaluation 2. Chronic fracture of S1 without height loss. ___ CXR No acute intrathoracic process. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 20 mg PO DAILY 2. Tizanidine 2 mg PO Q8H:PRN muscle spasm 3. HydrOXYzine 25 mg PO BID:PRN anxiety 4. Methylprednisolone ACETATE 32 mg IM DAILY 5. Oxymorphone HCl 1 tab PO EVERY 8HRS 6. HYDROmorphone (Dilaudid) 10 mg PO Q4H:PRN Pain 7. Lorazepam 1 mg PO DAILY:PRN anxiety 8. Metoprolol Tartrate 25 mg PO BID 9. Furosemide 20 mg PO DAILY Discharge Medications: 1. Furosemide 20 mg PO DAILY 2. HYDROmorphone (Dilaudid) 12 mg PO Q4H:PRN Pain RX *hydromorphone 12 mg 1 tablet(s) by mouth Q4H PRN pain Disp #*42 Tablet Refills:*0 3. HydrOXYzine 25 mg PO BID:PRN anxiety 4. Lisinopril 20 mg PO DAILY 5. Lorazepam 1 mg PO DAILY:PRN anxiety 6. Metoprolol Tartrate 25 mg PO BID 7. Tizanidine 2 mg PO Q8H:PRN muscle spasm 8. Acetaminophen 650 mg PO Q6H:PRN pain 9. Atovaquone Suspension 750 mg PO BID 10. Cyclobenzaprine 10 mg PO TID:PRN leg tightness RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth TID PRN pain/muscle spas, Disp #*90 Tablet Refills:*0 11. Fluticasone Propionate NASAL 2 SPRY NU BID 12. OxyCODONE SR (OxyconTIN) 60 mg PO Q8H RX *oxycodone [OxyContin] 60 mg 1 tablet(s) by mouth Q8 hours PRN pain Disp #*90 Tablet Refills:*0 13. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 14. Warfarin 2.5 mg PO DAILY16 HOLD THIS MEDICATION ON ___. Methylprednisolone ACETATE 32 mg IM DAILY 16. Outpatient Physical Therapy outpatient ___ for mangement of SIJ arthopathy Discharge Disposition: Home Discharge Diagnosis: Subacute L4 compression fracture with no canal compromise Pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (AP AND LAT) INDICATION: ___ with Bechet's on immunosuppresants with back pain, fevers // eval pna COMPARISON: None FINDINGS: Upright AP and lateral views of the chest provided. Lung volumes are low though the lungs appear clear. There is no focal consolidation, effusion, or pneumothorax. The cardiomediastinal silhouette is normal. Imaged osseous structures are intact. No free air below the right hemidiaphragm is seen. Clips noted in the right upper quadrant. IMPRESSION: No acute intrathoracic process. Radiology Report EXAMINATION: MRI lumbar spine without and with intravenous contrast INDICATION: History: ___ with bechet's disease with LP 2 weeks ago with new LLE weakness and low back pain with fever // code cord : eval epidural abscess/hematoma TECHNIQUE: MRI of the lumbar spine was performed before and following the intravenous administration of 8 cc Gadavist. Sagittal T2, sagittal STIR, sagittal T1, axial T2, axial T1, sagittal T1 post-contrast, and axial T1 post contrast images were obtained. COMPARISON: CT lumbar spine ___ FINDINGS: There is irregularity of the superior endplate of L4 that is T2 mixed intensity, STIR hyperintense, T1 hypointense, and non-enhancing. The signal characteristics and the intact nature of the adjacent L3 inferior endplate suggests that L4 irregularity and height loss is due to a subacute fracture. This is new from CT on ___. There is mild to moderate vertebral body height loss of L4 and mild spinal canal stenosis. There is edema of the L3-4 disc without enhancement, consistent with reactive edema. There is thin enhancement of the anterior epidural space at L4, either prominence of the venous plexus or a small epidural hematoma. There is no epidural abscess. Alignment is preserved. The conus is normal in appearance and position, terminating at L1. There is a fracture of S1 without height loss, chronic in nature but new from CT on ___. IMPRESSION: 1. Subacute fracture of L4 with mild to moderate vertebral body height loss and mild spinal canal stenosis. Enhancement of the anterior epidural space at L4 is either due to prominence of the venous plexus or a small epidural hematoma. Recommend CT scan for further evaluation 2. Chronic fracture of S1 without height loss. NOTIFICATION: The discrepancy between the wet read and final read was discussed with ___ of the Neurosurgery service at approximately 11:00 ___. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: BACK PAIN FEVER Diagnosed with INTRASPINAL ABSCESS temperature: 100.3 heartrate: 112.0 resprate: 18.0 o2sat: 97.0 sbp: 140.0 dbp: 102.0 level of pain: 7 level of acuity: 2.0

•Do not smoke. •No pulling up, lifting more than 10 lbs., or excessive bending or twisting. ___ must wear your brace when out of bed or when sitting. ___ may shower briefly without the collar or back brace; unless ___ have been instructed otherwise. •Take your pain medication as instructed; ___ may find it best if taken in the morning when ___ wake-up for morning stiffness, and before bed for sleeping discomfort. •Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc. unless directed by your doctor. •Increase your intake of fluids and fiber, as pain ___ (narcotics) can cause constipation. We recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. •Clearance to drive and return to work will be addressed at your post-operative office visit. ***** YOUR PAIN MANAGEMENT PLAN ***** ___ will ___ a 7 day supply of dilaudid 12mg every 4 hours, after this ___ should resume taking your home dose of dilaudid as prescribed by Dr. ___ will ___ a 30 day supply of oxycontin 60mg three times daily. After this ___ should refer to your pain Dr. ___ further pain medication. ___ should continue to take cyclobenzaprine. ___ should follow up with Dr. ___ call his office if ___ have questions about your pain managment.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Lipitor / Lisinopril / vancomycin Attending: ___. Chief Complaint: mental status changes Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo W with no psychiatric hx, MMP, including s/p R. MCA stroke, CAD, DM, COPD, recent TKR, was sent from ___ at ___ for a change in mental status. Per records from rehab, on ___ at 8 am pt requested to go home,was refusing exam, medications, and when she was told that she needed to wait for MD to see her she called ___. In addition, she was screaming, verbally abusive and combative with staff. Expressed paranoia that "you are just using my Medicare". Pt sent to ED for eval. In ED pt seen by psych. Was pleasant and cooperative. Did not remember above incident. On arrival to floor pt again pleasant and cooperative. Does not know why she was brought to hospital. States she needs to go home so she can pay her rent. No complaints. ROS: Denies fever, chills, chest pain, shortness of breath, cough abdominal pain, nausea, vomiting diarrhea, constipation, or dysuria. A full review of systems was performed and is otherwise unremarkable except as noted above. Past Medical History: per last discharge summary -Rheumatoid Arthritis -CAD s/p RCA stent ___, patent on ___ cath -mild dCHF (EF 60% in ___ -COPD (2L NC at night only) -CVA ___ (left sided weakness, speech affected) -PVD/PAD -DM type 2 -HTN -AAA (MRI ___- 3.4cm, ___ 3.5cm) -Right lacunar infarct (___) - on coumadin, then stopped ___ -erosive gastritis, angiodysplasia (Normal EGD ___ -diverticulosis, angioectasias on CSPY ___ -migraines manifest as left facial numbness -Lumbar stenosis and cervical spondylosis, C5-7 radiculopathy -OSA -Neurologic bladder on daily bactrim per urol -Depression/Anxiety -Recurrent UTIs -Anemia -Hyponatremia (baseline Na low 130s) -Right total knee replacement Social History: ___ Family History: no history of psych illness Physical Exam: VS: 98 150/90 67 18 98%ra PAIN: 0 GEN: no acute signs of distress. CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops. RESP: Good air movement bilaterally, no rhonchi or wheezing. ABD: Soft, non-tender, non-distended, + bowel sounds. EXTR: No lower leg edema, no clubbing or cyanosis Neuro: alert, oriented to person, place and time, follows commands, moving all extremities PSYCH: pleasant, cooperative Pertinent Results: ___ 08:53PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 08:53PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 08:53PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG ___ 08:53PM URINE RBC-2 WBC-22* BACTERIA-FEW YEAST-NONE EPI-3 TRANS EPI-<1 ___ 08:53PM URINE HYALINE-10* ___ 08:53PM URINE MUCOUS-OCC ___ 06:00PM GLUCOSE-94 UREA N-18 CREAT-0.9 SODIUM-134 POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-24 ANION GAP-14 ___ 06:00PM CALCIUM-10.0 PHOSPHATE-3.9 MAGNESIUM-1.9 ___:00PM TSH-1.4 ___ 06:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 06:00PM WBC-10.5 RBC-3.43* HGB-9.0* HCT-28.8* MCV-84 MCH-26.2* MCHC-31.2 RDW-16.2* ___ 06:00PM NEUTS-72.2* LYMPHS-15.9* MONOS-6.3 EOS-4.9* BASOS-0.8 ___ 06:00PM PLT COUNT-540* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q8H:PRN pain 2. Citalopram 10 mg PO DAILY 3. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with min-lycopene-lutein;<br>mv-min-folic acid-lutein) 0.4-300-250 mg-mcg-mcg Oral daily 4. Valsartan 160 mg PO DAILY 5. Fluticasone Propionate NASAL 2 SPRY NU DAILY 6. Nifedical XL *NF* (NIFEdipine) 60 mg Oral daily 7. Nitroglycerin SL 0.3 mg SL PRN chest pain 8. Hydroxychloroquine Sulfate 200 mg PO BID 9. Clopidogrel 75 mg PO DAILY 10. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation Inhalation daily 11. Metoprolol Succinate XL 200 mg PO DAILY 12. Albuterol Inhaler 2 PUFF IH Q8H:PRN wheezing 13. Aspirin 81 mg PO DAILY 14. calcium carbonate-vitamin D3 *NF* 500mg (1,250mg) -600 unit Oral BID 15. Chlorthalidone 25 mg PO DAILY 16. Docusate Sodium 100 mg PO BID 17. FoLIC Acid 1 mg PO DAILY 18. Lovastatin *NF* 40 mg Oral daily 19. melatonin *NF* 3 mg Oral hs 20. Methotrexate 15 mg PO 1X/WEEK (___) 21. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain 22. Pantoprazole 40 mg PO Q24H 23. Polysaccharide Iron *NF* (polysaccharide iron complex) 150 mg iron Oral BID 24. Zolpidem Tartrate 5 mg PO HS Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN pain 2. Albuterol Inhaler 2 PUFF IH Q8H:PRN wheezing 3. Aspirin 81 mg PO DAILY 4. Clopidogrel 75 mg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Fluticasone Propionate NASAL 2 SPRY NU DAILY 7. FoLIC Acid 1 mg PO DAILY 8. Hydroxychloroquine Sulfate 200 mg PO BID 9. Metoprolol Succinate XL 100 mg PO DAILY Hold for SBP <110 and hold for HR <60. 10. Nitroglycerin SL 0.3 mg SL PRN chest pain 11. Pantoprazole 40 mg PO Q24H 12. Psyllium 1 PKT PO TID:PRN constipation 13. Valsartan 160 mg PO DAILY 14. Vitamin D 1000 UNIT PO DAILY 15. Insulin SC Sliding Scale Fingerstick QACHS, HS Insulin SC Sliding Scale using HUM Insulin 16. Linezolid ___ mg PO Q12H 17. calcium carbonate-vitamin D3 *NF* 500mg (1,250mg) -600 unit Oral BID 18. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with min-lycopene-lutein;<br>mv-min-folic acid-lutein) 0.4-300-250 mg-mcg-mcg Oral daily 19. Ferrous Sulfate 325 mg PO DAILY 20. Lovastatin *NF* 40 mg ORAL DAILY 21. melatonin *NF* 3 mg Oral hs 22. Methotrexate 15 mg PO 1X/WEEK (___) Every ___ 23. Multivitamins 1 TAB PO DAILY 24. Polysaccharide Iron *NF* (polysaccharide iron complex) 150 mg iron Oral BID 25. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation Inhalation daily 26. Senna 1 TAB PO HS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Delirium Urinary Tract Infection Secondary Rheumatoid Arthritis -CAD s/p RCA stent ___, patent on ___ cath -mild dCHF (EF 60% in ___ -COPD (2L NC at night only) -CVA ___ (left sided weakness, speech affected) -PVD/PAD -DM type 2 -HTN -AAA (MRI ___- 3.4cm, ___ 3.5cm) -Right lacunar infarct (___) - on coumadin, then stopped ___ -erosive gastritis, angiodysplasia (Normal EGD ___ -diverticulosis, angioectasias on CSPY ___ -migraines manifest as left facial numbness -Lumbar stenosis and cervical spondylosis, C5-7 radiculopathy -OSA -Neurologic bladder on daily bactrim per urol -Depression/Anxiety -Recurrent UTIs -Anemia -Hyponatremia (baseline Na low 130s) -Right total knee replacement Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Mental Status: Confused - always. Followup Instructions: ___ Radiology Report HISTORY: Delirium, status post fall. COMPARISON: ___. TECHNIQUE: Contiguous axial MDCT images were obtained of the head without contrast. Multiplanar reformatted images were generated in the coronal and sagittal planes as well as thin section bone algorithm images. DLP: 1410.36 mGy-cm. FINDINGS: No hemorrhage, edema, mass effect or acute vascular territorial infarct. There is re-demonstration of encephalomalacia in the right corona radiata extending inferiorly into the insular white matter compatible with a prior right MCA territory infarct. Prominent ventricles and sulci are suggestive of age-related involutional change. Areas of confluent periventricular and subcortical white matter hypodensity is compatible with chronic small vessel ischemic disease. No fracture is identified. There is re-demonstration of a significant mucosal wall thickening with aerated material of the bilateral maxillary sinuses, sphenoid sinuses, frontal sinuses and ethmoid air cells. The mastoid air cells and middle ear cavities are clear. The globes are intact. Dense vascular calcifications are noted in the vertebral arteries and carotid siphons. IMPRESSION: 1. No acute intracranial process. 2. Encephalomalacia from prior right MCA territorial infarct. 3. Extensive sinus disease as above appears acute. Radiology Report HISTORY: Delirium, status post fall. COMPARISON: ___. TECHNIQUE: PA and lateral chest radiograph, four views. FINDINGS: The heart size is normal with tortuosity of the thoracic aorta. The hilar contours are unchanged. The lungs are mildly hyperexpanded. Again appreciated are diffuse increased interstitial lung markings suggestive of chronic interstitial abnormality. There is no focal consolidation worrisome for pneumonia. There is no pleural effusion or pneumothorax. The osseous structures are grossly unremarkable. IMPRESSION: No significant change compared to prior study with redemonstration of mild hyperinflation and global increased interstitial markings most compatible with emphysema. Radiology Report HISTORY: Delirium, status post fall with knee pain. COMPARISON: Right knee radiographs ___. TECHNIQUE: Right knee radiograph, three views. FINDINGS: The patient is status post right total knee revision arthroplasty with rotation hinge in place. There is no perihardware lucency or hardware fracture. No fracture is identified. Surrounding heterotopic ossification is unchanged from prior study. There is no effusion. IMPRESSION: No fracture. Revision total arthroplasty in place without hardware complication. Gender: F Race: WHITE - OTHER EUROPEAN Arrive by AMBULANCE Chief complaint: ___ Diagnosed with URIN TRACT INFECTION NOS, SEMICOMA/STUPOR, HYPERTENSION NOS temperature: 98.3 heartrate: 64.0 resprate: 18.0 o2sat: 98.0 sbp: 116.0 dbp: 65.0 level of pain: 0 level of acuity: 2.0

You were admitted with delirium. You were found to have a urinary tract infection. You were started on linezolid. Given the interaction between linezolid and celexa, your celexa was held. Given your delirium zolpidem was also held. Given your delirum plans were made for you to go to a geriatric psychiatric unit.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: N/V Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a pleasant ___ w/ HTN, non-ischemic CMY (LVEF 45-50% TTE ___, LBBB, and recently diagnosed NSCLC (___) w/ brain mets s/p CK, on ___, course c/b afib w/ RVR requiring ICU, subsegmental PE now on enoxaparin, who p/w persistent n/v after her C8 on ___. She received on ___ C8 pembrolizumab and pemetrexed, and at that time she felt like she was just recovering from her previous cycles. ___ she presented to ED w/ N/V/dehydration and improved with IV hydration and antiemetics. SHe was discharged home. Since then she continues to have no appetite, persistent nausea, unable to hold down PO, and is feeling orthostatic. She presented again to the ED today unable to keep anything down. IN fact, she has been too weak to take her lovenox shots and not taking her scheduled meds consistently. She denied F/C, no diarrhea. Her last BM was about 7 days ago and it was normal then. She normally moves her bowels daily. She is feeling orthostatic but denied any CP/SOB. SHe has a cough and that is dry and unchanged from baseline. She lives at home w/ her partner and does not have any exposure to sick contacts. Of note, with her recent cycles, she had N/V "iso not using zofran/compazine/decadron" per her oncologist. In the ED, Tmax 99.5F. HR 94, 102/61. She received IV morphine, Zofran, and 1L NS and admitted. She does feel improved. Past Medical History: PAST ONCOLOGIC HISTORY (per OMR): 1. Status post ___ cGy stereotactic brain radiotherapy to 2 left cerebellar and 1 right temporal brain lesion on ___. 2. Status post 6 cycles of carboplatin 5->4->3.5->0 AUC, pemetrexed 500 mg/m2 and pembrolizumab 200 mg fixed dose on ___ Ms. ___ is a ___ year-old white woman with a current smoking history (10 pack-years) who presented to medical care with possible post-obstructive pneumonia (requiring antibiotics), cough and dyspnea with exertion. Some fatigue and anorexia was also noted. A PET/CT Scan from ___ showed an FDG avid right upper lobe mass with numerous scattered FDG-avid pulmonary nodules and FDG avid mediastinal and right hilar lymphadenopathy. There was a small right pleural effusion, a 9mm artocaval lymph node, and subtle focus of posterior right twelfth rib. Brain MRI from ___ showed there are three new enhancing foci (left cerebellar hemisphere and right temporal lobe) worrisome for metastatic disease. A bronchoscopy was performed by Interventional Pulmonology on ___ and the right lobe lesion, level 7 and level 4R nodes were positive for adenocarcinoma. The tumor cells were positive for CK7 and negative for TTF-1 and Napsin-A. Tumor has KRAS G12I mutation, STK11 splice site 464+2T>G mutation, KEAP1 T545fs*1 mutation and PD-L1 IHC TPS 0% (not yet confirmed in second specimen). Material was insufficient for tumor mutation burden or microsatellite instability status. It is noteworthy that the biopsy material from ___ showed an adenocarcinoma but without the pathognomonic markers of TTF-1 and Napsin-A. Therefore, one cannot be completely certain of the site of origin. Imaging studies don't disclose another primary site but some of the multiple lung lesions could be from a metastatic process. The results from comprehensive genomic profiling with a KRAS G12I mutation cannot pinpoint another primary site. She is now status post ___ cGy stereotactic brain radiotherapy to 2 left cerebellar and 1 right temporal brain lesion on ___. MRI brain from ___ showed mostly stable brain disease burden. MRI brain from ___ showed some improvement in previously treated lesions. She completed four cycles ___, but ___ was held for cycles 5 and 6 while pemetrexed and pembro were continued. Her restaging scans following 6 cycles demonstrated a "mixed response" with improvement in all sites of disease except for increased FDG avidity/enlargement of a R hilar node conglomerate, LLL nodule and 1mm increase in size of dominant brain metastasis. Given otherwise improved disease and overall clinical stability we recommended continuation of pemetrexed/pembrolizumab for another two cycles to be followed by re-staging scans. She did additionally have new bone metastases in her sphenoid and left frontal bones noted on her last brain MRI, appear to be causing pain that is quite intense at times. PAST MEDICAL HISTORY (per OMR): - Unclear cardiac event/myocardial disorder with normal ejection fraction in ___ (in follow-up); - Prior ___ esophagus; - Arthritis not active; - Migraines not active; - Hypertension under medical control; - Prior depression. Social History: ___ Family History: Esophageal cancer in mother. No other recurrent cancers. Physical Exam: ADMISSION PHYSICAL EXAM: VITAL SIGNS: 99.5 94 102/61 16 94% RA General: NAD, Resting in bed comfortably with her sister at bedside, notable for generalized weakness HEENT: MM dry, no OP lesions, no thrush, raised prominence over the L eye CV: RR, NL S1S2 no S3S4 No MRG PULM: CTAB, No C/W/R, No respiratory distress but has persistent dry cough ABD: BS+, soft, NTND, no peritoneal signs LIMBS: WWP, no ___, no tremors SKIN: No notable rashes on trunk nor extremities NEURO: CN III-XII intact, strength b/l ___ intact, she has a left PSYCH: Thought process logical, linear, future oriented ACCESS::KV DISCHARGE PHYSICAL EXAM VS: ___ 0748 Temp: 98.0 PO BP: 100/60 HR: 77 O2 sat: 100% O2 delivery: Ra GENERAL: Alert, NAD, appears well HEENT: Anicteric, PERRL, no periorbital erythema appreciated, mmm, OP clear CV: NR/RR, no m/r/g RESP: CTAB GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs PSYCH: pleasant, appropriate affect Pertinent Results: CBCs ___ 03:40PM BLOOD WBC-1.8* RBC-3.31* Hgb-10.7* Hct-33.4* MCV-101* MCH-32.3* MCHC-32.0 RDW-12.4 RDWSD-45.9 Plt ___ ___ 08:00AM BLOOD WBC-1.1* RBC-3.23* Hgb-10.5* Hct-32.3* MCV-100* MCH-32.5* MCHC-32.5 RDW-12.5 RDWSD-45.7 Plt ___ ___ 07:00AM BLOOD WBC-0.7* RBC-2.77* Hgb-9.0* Hct-27.5* MCV-99* MCH-32.5* MCHC-32.7 RDW-12.4 RDWSD-45.0 Plt Ct-78* ___ 07:25AM BLOOD WBC-1.0* RBC-2.63* Hgb-8.5* Hct-26.1* MCV-99* MCH-32.3* MCHC-32.6 RDW-12.4 RDWSD-44.9 Plt Ct-65* ___ 07:15AM BLOOD WBC-1.2* RBC-2.45* Hgb-8.0* Hct-24.4* MCV-100* MCH-32.7* MCHC-32.8 RDW-12.3 RDWSD-44.3 Plt Ct-71* ___ 06:43AM BLOOD WBC-1.4* RBC-2.38* Hgb-7.8* Hct-23.8* MCV-100* MCH-32.8* MCHC-32.8 RDW-12.4 RDWSD-45.2 Plt Ct-78* ___ 07:39AM BLOOD WBC-2.6* RBC-2.48* Hgb-8.0* Hct-24.6* MCV-99* MCH-32.3* MCHC-32.5 RDW-12.3 RDWSD-44.5 Plt ___ Diffs ___ 03:40PM BLOOD Neuts-77.1* Lymphs-15.4* Monos-6.3 Eos-0.0* Baso-0.6 Im ___ AbsNeut-1.35* AbsLymp-0.27* AbsMono-0.11* AbsEos-0.00* AbsBaso-0.01 ___ 08:00AM BLOOD Neuts-56.3 ___ Monos-9.8 Eos-0.9* Baso-0.9 AbsNeut-0.63* AbsLymp-0.36* AbsMono-0.11* AbsEos-0.01* AbsBaso-0.01 ___ 07:00AM BLOOD Neuts-43.2 ___ Monos-20.3* Eos-2.7 Baso-0.0 AbsNeut-0.32* AbsLymp-0.25* AbsMono-0.15* AbsEos-0.02* AbsBaso-0.00* ___ 07:25AM BLOOD Neuts-58 Lymphs-17* Monos-22* Eos-3 Baso-0 AbsNeut-0.58* AbsLymp-0.17* AbsMono-0.22 AbsEos-0.03* AbsBaso-0.00* ___ 07:15AM BLOOD Neuts-58.5 ___ Monos-15.3* Eos-4.2 Baso-0.0 Im ___ AbsNeut-0.69* AbsLymp-0.25* AbsMono-0.18* AbsEos-0.05 AbsBaso-0.00* ___ 06:43AM BLOOD Neuts-51.5 ___ Monos-19.1* Eos-4.4 Baso-0.0 Im ___ AbsNeut-0.70* AbsLymp-0.30* AbsMono-0.26 AbsEos-0.06 AbsBaso-0.00* ___ 07:39AM BLOOD Neuts-63.2 Lymphs-13.3* Monos-20.5* Eos-1.5 Baso-0.4 Im ___ AbsNeut-1.67 AbsLymp-0.35* AbsMono-0.54 AbsEos-0.04 AbsBaso-0.01 coag ___ 03:40PM BLOOD ___ PTT-30.0 ___ BMPs ___ 03:40PM BLOOD Glucose-148* UreaN-12 Creat-0.9 Na-134* K-4.2 Cl-100 HCO3-23 AnGap-11 ___ 07:15AM BLOOD Glucose-107* UreaN-5* Creat-0.6 Na-138 K-3.9 Cl-105 HCO3-24 AnGap-9* LFTs ___ 08:00AM BLOOD ALT-11 AST-15 LD(LDH)-363* AlkPhos-61 TotBili-0.2 Other chemistry ___ 03:40PM BLOOD Albumin-3.4* Calcium-7.4* Phos-1.9* Mg-2.2 ___ 08:00AM BLOOD Albumin-3.1* Calcium-7.2* Phos-1.9* Mg-2.1 ___ 07:00AM BLOOD Calcium-6.3* Phos-1.7* Mg-1.9 ___ 07:25AM BLOOD Calcium-7.0* Phos-2.7 Mg-1.8 ___ 07:15AM BLOOD Calcium-7.2* Phos-2.1* Mg-1.8 ___ 07:00AM BLOOD Cortsol-15.5 ___ 08:00AM BLOOD freeCa-1.02* ___ 07:05AM BLOOD freeCa-0.92* ___ 03:13PM BLOOD freeCa-1.04* ___ 07:38AM BLOOD freeCa-1.01* ___ 08:08AM BLOOD freeCa-1.07* ___ 07:39AM BLOOD Glucose-96 UreaN-4* Creat-0.8 Na-137 K-3.4* Cl-104 HCO3-24 AnGap-9* ___ 07:39AM BLOOD Calcium-7.5* Phos-2.5* Mg-2.1 Blood cx ngtd CT chest IMPRESSION: When compared to the PET-CT from ___, a new consolidation is noted in the right upper lobe which is likely related to recurrent atelectasis, post obstructive. Again redemonstrated is a mass in the right upper lobe, known lung cancer, slightly larger when compared to prior. Several scattered lung nodules are relatively unchanged in size. No new or growing lymphadenopathies or osseous lesions. CT A/P IMPRESSION: 1. No evidence of acute intra-abdominal process. 2. Sclerotic lesions in the L4 vertebral body and right iliac bone consistent with known metastases. 3. Please refer to separate report of CT chest performed on the same day for description of the thoracic findings. MR brain IMPRESSION: 1. A 1.4 x 1.3 cm rim enhancing metastasis in the left cerebellar hemisphere has increased in size, previously 1.2 x 1.1 cm. Smaller enhancing metastases in the left cerebellar hemisphere and lateral right temporal lobe are unchanged. No new intra-axial lesions identified. 2. Metastatic infiltration of the left sphenoid wing and left frontal bone has increased since the prior examination. Evidence of adjacent left temporalis muscle involvement is new. Extensive left cerebral pachymeningeal thickening and enhancement is not appreciably changed. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Enoxaparin Sodium 70 mg SC Q12H 2. Benzonatate 100 mg PO TID 3. Escitalopram Oxalate 20 mg PO DAILY 4. FoLIC Acid 1 mg PO DAILY 5. Guaifenesin-CODEINE Phosphate ___ mL PO Q8H:PRN wheezing/cough 6. LORazepam 0.5 mg PO BID:PRN nausea 7. Omeprazole 20 mg PO BID 8. Amiodarone 200 mg PO DAILY 9. Dronabinol 2.5 mg PO BID:PRN nausea or lack of appetite 10. Metoprolol Succinate XL 50 mg PO DAILY 11. Multivitamins 1 TAB PO DAILY 12. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN rash 13. Ondansetron 8 mg PO Q8H:PRN nausea 14. Prochlorperazine 10 mg PO Q8H:PRN nausea 15. Ipratropium Bromide Neb 1 NEB IH Q6H 16. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second Line 17. Senna 8.6 mg PO BID:PRN Constipation 18. Fluticasone Propionate NASAL ___ SPRY NU DAILY 19. Morphine SR (MS ___ 15 mg PO Q12H 20. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - Moderate Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Headache Reason for PRN duplicate override: Alternating agents for similar severity RX *acetaminophen 325 mg 2 capsule(s) by mouth every six (6) hours Disp #*240 Capsule Refills:*0 2. Amoxicillin 500 mg PO Q8H RX *amoxicillin 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*14 Tablet Refills:*0 3. Calcium Carbonate 1000 mg PO TID RX *calcium carbonate [Calcium 500] 500 mg calcium (1,250 mg) 2 tablet(s) by mouth three times daily Disp #*90 Tablet Refills:*0 4. Metoprolol Succinate XL 25 mg PO DAILY RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Sulfameth/Trimethoprim DS 2 TAB PO BID RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 2 tablet(s) by mouth twice a day Disp #*18 Tablet Refills:*0 6. Dronabinol 2.5 mg PO BID nausea or lack of appetite RX *dronabinol 2.5 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 7. Enoxaparin Sodium 60 mg SC Q12H RX *enoxaparin 60 mg/0.6 mL ___very twelve (12) hours Disp #*60 Syringe Refills:*0 8. Amiodarone 200 mg PO DAILY 9. Benzonatate 100 mg PO TID 10. Escitalopram Oxalate 20 mg PO DAILY 11. Fluticasone Propionate NASAL ___ SPRY NU DAILY 12. FoLIC Acid 1 mg PO DAILY 13. Guaifenesin-CODEINE Phosphate ___ mL PO Q8H:PRN wheezing/cough 14. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN rash 15. Ipratropium Bromide Neb 1 NEB IH Q6H 16. LORazepam 0.5 mg PO BID:PRN nausea 17. Multivitamins 1 TAB PO DAILY 18. Omeprazole 20 mg PO BID 19. Ondansetron 8 mg PO Q8H:PRN nausea RX *ondansetron 4 mg ___ tablet(s) by mouth up to three times daily as needed Disp #*90 Tablet Refills:*0 20. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second Line 21. Prochlorperazine 10 mg PO Q8H:PRN nausea 22. Senna 8.6 mg PO BID:PRN Constipation Discharge Disposition: Home Discharge Diagnosis: Nausea and vomiting Pancytopenia due to chemotherapy Febrile neutropenia Preseptal cellulitis Hypocalcemia Hypophosphatemia Metastatic non small cell lung cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD INDICATION: ___ w/ NSCLC w/ brain mets s/p CK, on immunotherapy, now p/w FTT and persistent nausea/vomiting// rule out progressive brain mets and evaluate for possible hypophysitis TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: ___ brain MRI and ___ brain MRI FINDINGS: A ring-enhancing lesion in the left cerebellar hemisphere has increased in size and measures 1.4 x 1.3 cm, previously 1.2 x 1.1 cm. Adjacent vasogenic edema is unchanged with no significant effacement of the fourth ventricle. Subtle associated susceptibility artifact is unchanged and likely reflects prior hemorrhage. A 4 mm enhancing nodule located more laterally within the left cerebellar hemisphere is essentially unchanged (series 14, image 38). A 4 mm enhancing nodule in the lateral right temporal lobe is unchanged (series 14, image 69). No new enhancing intra-axial lesions identified. Extensive T1 marrow signal hypointensity with associated enhancement and slowed diffusion in the left sphenoid wing and left frontal bone has increased since ___. Expansion of the adjacent left temporalis muscle associated with T2 signal hyperintensity and enhancement and loss of fat striations is new since the prior examination. Extensive left cerebral pachymeningeal enhancement is similar to the prior examination. There is no evidence of new hemorrhage or infarction. Nonenhancing periventricular and subcortical white matter T2/FLAIR hyperintensities are nonspecific and unchanged, likely sequelae of chronic small vessel ischemic disease. The major arteries of the circle of ___ in the proximal branches appear unremarkable. The dural venous sinuses are patent. There is mild paranasal sinus mucosal thickening. A left lens replacement is noted. IMPRESSION: 1. A 1.4 x 1.3 cm rim enhancing metastasis in the left cerebellar hemisphere has increased in size, previously 1.2 x 1.1 cm. Smaller enhancing metastases in the left cerebellar hemisphere and lateral right temporal lobe are unchanged. No new intra-axial lesions identified. 2. Metastatic infiltration of the left sphenoid wing and left frontal bone has increased since the prior examination. Evidence of adjacent left temporalis muscle involvement is new. Extensive left cerebral pachymeningeal thickening and enhancement is not appreciably changed. Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ w/ NSCLC w/ brain mets s/p CK, on immunotherapy, now p/w FTT and persistent nausea/vomiting// please assess for disease progression and/or infection TECHNIQUE: Oncology 2 phase: Multidetector CT of the abdomen was done with IV contrast. A single bolus of IV contrast was injected and the abdomen and pelvis was scanned in the portal venous phase, followed by scan of the abdomen in equilibrium (3-min delay) phase. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 1.5 mGy-cm. 2) Stationary Acquisition 0.8 s, 0.2 cm; CTDIvol = 13.7 mGy (Body) DLP = 2.7 mGy-cm. 3) Spiral Acquisition 9.9 s, 64.4 cm; CTDIvol = 9.3 mGy (Body) DLP = 593.9 mGy-cm. 4) Spiral Acquisition 4.9 s, 31.9 cm; CTDIvol = 9.0 mGy (Body) DLP = 281.4 mGy-cm. Total DLP (Body) = 880 mGy-cm. COMPARISON: PET-CT ___ FINDINGS: LOWER CHEST: Please refer to separate report of CT chest performed on the same day for description of the thoracic findings. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. Few subcentimeter hypodensities are too small to characterize, but grossly stable from recent PET-CT where they did not appear FDG avid. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. No hydronephrosis. Subcentimeter hypodensity in the interpolar region of the left kidney likely represents a simple cyst. There is no perinephric abnormality. GASTROINTESTINAL: Small hiatal hernia. Stomach is otherwise unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: Uterus is unremarkable. No adnexal abnormalities are seen. LYMPH NODES: Few prominent left periaortic lymph nodes are unchanged, grossly stable, and not pathologically enlarged by CT size criteria. No mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Minimal atherosclerotic disease is noted. BONES: Sclerotic lesion in the anterior L4 vertebral body measures 1.4 cm and is concerning for metastasis (5:75). A 3.3 cm area of sclerosis in the right iliac bone which was avid on recent PET-CT is also consistent with a metastasis (5:97). SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. No evidence of acute intra-abdominal process. 2. Sclerotic lesions in the L4 vertebral body and right iliac bone consistent with known metastases. 3. Please refer to separate report of CT chest performed on the same day for description of the thoracic findings. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ w/ NSCLC w/ brain mets s/p CK, on immunotherapy, now p/w FTT and persistent nausea/vomiting// please assess for disease progression and/or infection TECHNIQUE: Multi-detector helical scanning of the chest, coordinated with intravenous infusion of nonionic, iodinated contrast agent, following oral administration of contrast agent for selected abdominal studies, and/or followed by scanning of the neck, was reconstructed as contiguous 5 mm and 1.0 or 1.25 mm thick axial, 2.5 or 5 mm thick coronal and parasagittal, and 8 mm MIP axial images. Concurrent scanning of the abdomen and pelvis and/or neck will be reported separately. All images of the chest were reviewed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 1.5 mGy-cm. 2) Stationary Acquisition 0.8 s, 0.2 cm; CTDIvol = 13.7 mGy (Body) DLP = 2.7 mGy-cm. 3) Spiral Acquisition 9.9 s, 64.4 cm; CTDIvol = 9.3 mGy (Body) DLP = 593.9 mGy-cm. 4) Spiral Acquisition 4.9 s, 31.9 cm; CTDIvol = 9.0 mGy (Body) DLP = 281.4 mGy-cm. Total DLP (Body) = 880 mGy-cm. ** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND PELVIS WITH CONTRAST) COMPARISON: Multiple prior chest CTs, most recently ___. FINDINGS: NECK, THORACIC INLET, AXILLAE AND CHEST WALL: The thyroid is mildly heterogeneous with small hypodense nodules, unchanged. No enlarged lymph nodes in either axilla or thoracic inlet. No abnormalities on the chest wall. No atherosclerotic calcifications in the head and neck arteries. HEART AND VASCULATURE: The heart is normal size and shape. No pericardial effusion. No atherosclerotic calcifications in the coronary arteries, aorta or cardiac valves. The pulmonary arteries and aorta are normal in caliber throughout. MEDIASTINUM AND HILA: The esophagus is unremarkable. Small mediastinal lymph nodes, none pathologically enlarged by CT size criteria size some borderline enlarged, for example in the prevascular station measuring 7 mm (previously 10 mm). No left hilar lymphadenopathy. PLEURA: Small right pleural effusion. Mild bilateral apical scarring. LUNGS: Several nodules ranging in size from 2-11 mm scattered throughout both lungs, the largest in the left lower lobe, (6:192), all relatively unchanged in size. The right upper lobe which substantially re-expanded between ___ and the ___ PET-CT on ___, has now largely collapsed again due to probable growth of the large right hilar and upper lobe mass which continues to obstruct the upper lobe bronchus. Admittedly, it is difficult to measure the mass precisely given the adjacent atelectasis and/or postobstructive pneumonia CHEST CAGE: No acute fractures. No suspicious lytic or sclerotic lesions. Mild dorsal spondylosis. UPPER ABDOMEN: Please refer to same day abdominal CT report for subdiaphragmatic findings. IMPRESSION: Progressive right upper lobe collapse since PET-CT on ___ due to persistent obliteration of the right upper lobe bronchus by the likely growth of the large right hilar mass. There may be a component of postobstructive pneumonia. Several scattered lung nodules are relatively unchanged in size since ___. No new or growing lymphadenopathy or osseous lesions. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Fatigue, N/V Diagnosed with Adult failure to thrive temperature: 99.3 heartrate: 103.0 resprate: 18.0 o2sat: 97.0 sbp: 112.0 dbp: 63.0 level of pain: 7 level of acuity: 3.0

You were admitted to the hospital because of nausea, vomiting, and poor appetite, which were most likely due to your chemotherapy. While in the hospital, you also had low blood counts due to your chemotherapy. Because you developed a fever and had evidence of a skin infection around your left eye, we needed to keep you on IV antibiotics for several days. When you leave the hospital you will need a few more days of oral antibiotics to complete the course. You also had low calcium and phosphorus levels, which were most likely due to the zometa you received recently. By the time of discharge, your calcium and phosphorus were stable with you receiving additional supplementation by mouth. While in the hospital you also had discussions with Dr. ___, Dr. ___ Dr. ___ about next steps in your cancer care. You have follow-up scheduled with each of their teams. We have reduced your metoprolol dose from 50 mg to 25 mg daily since your blood pressures were slightly low in the hospital. We also recommend taking your dronabinol twice daily instead of on an as-needed basis.

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Tetracycline Analogues / Niacin / Almond Oil / Tree Nut / Fruit Extracts / Nafcillin / cefazolin Attending: ___. Chief Complaint: altered mental status and rash Major Surgical or Invasive Procedure: temporary HD line placement under general anesthesia History of Present Illness: ___ yo M with h/o CAD, CHF, a-fib, AVR, ? prior CVA, DM, HTN, HLD and recent admission (___) for MSSA bacteremia that was c/b ___ felt to be due to AIN at the time, requiring 2 sessions of HD, prednisone tx (Cr improving at d/c), NSTEMI, possible stroke or recrudescence of an old infarct, afib w/ RVR requiring CV and a new onset rash at time of discharge who is brought from the ___ for an evaluation of worsening ___ edema, worsening rash and confusion. Please see recent d/c summary for this gentleman's complicated recent hospital course. He was discharged on a prednisone taper, vancomycin IV (completed ___ and amiodarone as new medications. Since discharge to rehab, he was noted to have episodes of confusion as noted by staff and family. During the nights he was often agitated, combative and rude to staff. His sleep was disrupted with daytime sleepiness and nightime agitaion. His daughter noted that although initially he would respond appropriately to questions, over the past 3 days she noted increasing incongruence in his resopnses (e.g. "Dad would you like to return to the hospital?" -> "No there are lawyers there and I am hungry."). At other times he would be noted to trail off to sleep in the middle of a sentence and require awakening to maintain conversation. There were some neologisms noted as well as mild dysarthria. No reported falls. Daughter also noted that his leg rash had spread b/l to LEs and UEs as well as his head. She also noted an ulceration on the left dorsal aspect of the foot. There is some report of him receiving valium per ED notes, however, none per daughter or rehab notes. Re: his rash, notably at time of discharge on ___ his skin exam was: "the original skin reaction to the antibiotic is resolving with some lingering drying ulcers. However, there is a new petechial rash on the back of his right leg . No excoriations. The same petechial rash is present on the back of his left elbow, but in a more limited area. I did not notice the rash there yesterday but I may have missed it." In the ED, initial VS: 97 69 153/69 20 100%. Pt. underwent an evaluation that revealed a PMN predominant leukocytosis of 17K, hyperkalemia of 6.0 and hypochloremia w/ AG of 14, INR of 4.2 and lactate of 1.7. BCx were collected. He did not receive any interventions and was admitted to Medicine. Past Medical History: IDDM c/b neuropathy HTN HLD CAD s/p CABG in ___ and ___ and multiple stents s/p biologic AVR ___ c/b transient heart block post op treated with pacer insertion ___ Sensia dual-chamber pacemaker). Paroxysmal Atrial Fibrillation (last pacer interrogation demonstrated no episodes of AF) Chronic Systolic Heart Failure (EF 35% to 40% in ___ BPH Hypothyroidism CKD Social History: ___ Family History: Notable for a mother who died at ___ and had a brain tumor and a sibling with Alzheimer disease. There is also thyroid, lung cancer in other family members. Brother: pancreatic and liver cancer in his brother. No family history of CAD or sudden cardiac death. Physical Exam: ADMISSION EXAM: VS - 98.1F 172/79 69 18 93%RA GENERAL - confused, non-toxic appearing man, looking around the room, grabbing at his clothes. HEENT - NC/AT,sclerae anicteric, MMM, OP clear w/o petechiae. There are petechial and ulcerated lesions over the vertex of his head. NECK - supple, no meningismus, neg. ___. LUNGS - crackles at bases b/l. HEART - PMI non-displaced, RR, ___ SM at apex. nl S1-S2 ABDOMEN - Obese, soft/NT/ND, no masses or HSM, no rebound/guarding, there is a band like erythematous, nonpapular, nonpalpable rash on the abdomen. EXTREMITIES - 2+ edema to mid thigh. unable to assess pulses. There is a clean based, nectrotic ulcer on L dorsal aspect of the foot, it is non-tender. Blistering lesion on R foot. SKIN - petechial, palpable rash on LEs, UEs head and trunk. LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, oriented to ___, ___. DOWf intact, DOWb could not get past ___, took 5 tries. Able to name glasses, nose bridge and stethoscope. Able to read. No apraxia. Some L /R confusion. Unable to follow 2 step commands. Able to follow axial commands readily. Unwilling for memory assessment. CNs: VF unable to assess due to inattention, EOMI, 4-2mm b/l, some slight RLF flattening, there is R ocular muscle weakness. tongue midline, palate elevates symmetricaly. Shoulder shrug nl. Motor: nl tone. Full at D/Tri/Bi/WE/FE b/l and ___ are full at IP/Q/H/TA b/l. Sensory - unable due to inattention, but notes discomfort w/ pressure b/l. No true pronator drift, left arm falls inferiorly. He has profound asterisis notable w/ estension of wrists. There is occasional myoclonus as well. Impaired FNF b/l, unable to assess HKS or tap due to inattention. Gait deferred for safety concerns. . DISCHARGE EXAM: Discharge changes: Mental status: Patient is alert and plesent but still somewhat confused. Extremities 1+ edema, Lungs clear and without crackles, resolving rash with no new lesions on hands or legs, Pertinent Results: ADMISSION LABS: ___ 04:10PM BLOOD WBC-16.6* RBC-3.16* Hgb-8.6* Hct-28.2* MCV-90 MCH-27.3 MCHC-30.5* RDW-16.9* Plt ___ ___ 04:10PM BLOOD Neuts-93.2* Lymphs-5.3* Monos-1.3* Eos-0 Baso-0.1 ___ 11:10AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-OCCASIONAL Schisto-OCCASIONAL Ellipto-1+ ___ 04:10PM BLOOD ___ PTT-36.0 ___ ___ 04:10PM BLOOD Glucose-195* UreaN-177* Creat-5.0* Na-135 K-6.1* Cl-95* HCO3-26 AnGap-20 ___ 04:10PM BLOOD ALT-36 AST-82* LD(LDH)-720* AlkPhos-116 TotBili-0.5 ___ 04:10PM BLOOD Calcium-9.0 Phos-7.0* Mg-2.7* ___ 11:10AM BLOOD Hapto-325* DISCHARGE LABS: ___ 05:30AM BLOOD WBC-9.6 RBC-3.22* Hgb-8.2* Hct-27.4* MCV-85 MCH-25.6* MCHC-30.1* RDW-15.3 Plt ___ ___ 04:30AM BLOOD Neuts-80* Bands-0 Lymphs-14* Monos-4 Eos-2 Baso-0 ___ Myelos-0 ___ 04:30AM BLOOD ___ ___ 08:50AM BLOOD Glucose-252* UreaN-62* Creat-2.9* Na-140 K-3.5 Cl-99 HCO3-31 AnGap-14 ___ 04:30AM BLOOD Glucose-47* UreaN-70* Creat-2.8* Na-140 K-3.4 Cl-100 HCO3-30 AnGap-13 ___ 05:30AM BLOOD Glucose-84 UreaN-68* Creat-2.6* Na-137 K-3.7 Cl-99 HCO3-27 AnGap-15 ___ 05:30AM BLOOD Calcium-8.2* Phos-3.1 Mg-1.8 ___ 04:10PM BLOOD ___ ___ 08:50AM BLOOD ANCA-NEGATIVE B ___ 11:30AM BLOOD TSH-0.20* ___ 08:50AM BLOOD HIV Ab-NEGATIVE MICRO DATA: ___ 11:24PM URINE Color-Yellow Appear-Clear Sp ___ ___ 11:24PM URINE RBC-19* WBC-14* Bacteri-MOD Yeast-NONE Epi-0 TransE-<1 ___ 11:24PM URINE Hours-RANDOM UreaN-766 Creat-83 Na-20 K-40 Cl-19 ___ 4:10 pm BLOOD CULTURE x2 **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 8:25 am URINE TAKEN FROM HEM ___. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 7:12 am BLOOD CULTURE Blood Culture, Routine (Pending): ___ 12:53 pm STOOL CONSISTENCY: FORMED Source: Stool. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST: negative ___ 10:40AM URINE Color-Yellow Appear-Clear Sp ___ ___ 10:40AM URINE Blood-SM Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG ___ 10:40AM URINE RBC-6* WBC-7* Bacteri-NONE Yeast-NONE Epi-0 ___ 10:40AM URINE CastHy-1* ___ 10:40AM URINE Mucous-RARE LYME SEROLOGY (Final ___: NO ANTIBODY TO B. BURG___ DETECTED BY EIA. Reference Range: No antibody detected. Negative results do not rule out B. burg___ infection. Patients in early stages of infection or on antibiotic therapy may not produce detectable levels of antibody. Patients with clinical history and/or symptoms suggestive of lyme disease should be retested in ___ weeks ___ 6:15 am SEROLOGY/BLOOD **FINAL REPORT ___ RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE. Reference Range: Non-Reactive. Blood cultures no growth and pending. ___ EKG Normal sinus rhythm, rate 70. Left axis deviation. Right bundle-branch block. Low voltage in the inferior leads. These changes are unchanged compared with the previous tracing of ___. CXR ___ Low lung volumes. Cardiomegaly without pulmonary edema. CT HEAD W/O CONTRAST ___ 1. No acute intracranial process. 2. Chronic atrophy, microvascular changes, and multifocal infarcts. 3. Mild pansinus mucosal thickening, with resolution of prior left sphenoid air-fluid level. DOPPLER RENAL U/S ___ 1. No hydronephrosis. Two simple left renal cysts. 2. Arterial and venous flow is seen in the right kidney; however, the Doppler examination is limited as the patient is unable to hold his breath. Note is made that the patient declined to complete the Doppler examination and consequently the exam is very limited and no Doppler images were obtained of the left kidney. ART EXT (REST ONLY) ___ IMPRESSION: Moderate left tibial disease. Echo ___ The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild to moderate regional left ventricular systolic dysfunction with inferior and inferolateral akinesis. The remaining segments contract normally (LVEF = 35-40%). Right ventricular chamber size and free wall motion are normal. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Moderate (2+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild to moderate left ventricular systolic dysfunction, c/w CAD. Moderate mitral regurgitation. Moderate tricuspid regurgitation. Mild pulmonary hypertension. Compared with the prior study (images reviewed) of ___, mitral and tricuspid regurgitation severity has increased. The other findings are similar. Medications on Admission: -- clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY -- aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable -- multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO DAILY -- metoprolol succinate 100 mg BID -- cholecalciferol 1000 unit Tablet Sig: Two (2) Tablet PO DAILY -- amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY -- camphor-menthol 0.5-0.5 % Lotion QID as needed for itching. -- hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal BID -- albuterol sulfate 2.5 mg /3 mL neb Q6H prn -- senna 8.6 mg Tablet Sig: One (1) Tablet PO BID -- bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) -- calcium acetate 667 mg Capsule Sig: Three (3) Capsule PO TID - vancomycin completed on ..... -- prednisone 50 mg tapering by 5mg Q3 days, currently at 40 mg -- insulin lispro SS -- atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. -- furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. -- levothyroxine 25 mcg daily -- warfarin 1 mg daily Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO once a day. 4. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO twice a day. 5. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day. 12. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 13. insulin glargine 100 unit/mL Solution Sig: Fifteen (15) Units Subcutaneous at bedtime. 14. insulin lispro 100 unit/mL Solution Sig: Per sliding scale Subcutaneous qac. 15. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 ___. 16. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 17. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for pruritis. 18. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 19. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal PRN (as needed) as needed for hemorrhoids. 20. mupirocin calcium 2 % Cream Sig: One (1) Appl Topical DAILY (Daily). 21. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO at bedtime. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Acute on chronic kidney disease, acute interstitial nephritis, Uremia, Vasculitic skin rash Secondary: Coronary artery disease, diabetes, hyperthyroidism Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Worsening renal failure. COMPARISON: ___. UPRIGHT AP VIEW OF THE CHEST: The patient is status post median sternotomy, CABG, and left-sided pacemaker device with leads terminating in the right atrium and right ventricle. Right PICC tip terminates in the region of the SVC. There are low lung volumes. The heart size remains moderate-to-severely enlarged, but the mediastinal contour appears stably widened. There is crowding of the bronchovascular structures, but no overt pulmonary edema is present. Retrocardiac opacity likely reflects atelectasis as does minimal linear opacity within the right lung base. No large pleural effusion or pneumothorax is identified. The right internal jugular central venous catheter has been removed. IMPRESSION: Low lung volumes. Cardiomegaly without pulmonary edema. Radiology Report INDICATION: ___ male with paroxysmal atrial fibrillation and pacemaker, history of prior CVAs, now with supratherapeutic INR of 4.2 and altered mental status. Assess for intracranial hemorrhage or infarct. ___. TECHNIQUE: Contiguous non-contrast axial images were obtained through the brain, and reconstructed at 5-mm intervals. FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect, or vascular territorial infarct. The ventricles and sulci are prominent, consistent with age-related involutional changes. Multiple periventricular and subcortical white matter hypodensities reflect small vessel ischemic disease. Lacunes are also noted in the bilateral temporal and occipital lobes. There is additional encephalomalacia in the right anterolateral cerebellum, with coarse calcifications suggesting laminar necrosis and/or dystrophic changes. Dense calcifications of the bilateral cavernous carotid and vertebral arteries. Mild pansinus mucosal thickening is present. Prior left sphenoid air-fluid level has resolved. The mastoid air cells and middle ear cavities are clear. Orbits and intraconal structures are symmetric. IMPRESSION: 1. No acute intracranial process. 2. Chronic atrophy, microvascular changes, and multifocal infarcts. 3. Mild pansinus mucosal thickening, with resolution of prior left sphenoid air-fluid level. Radiology Report INDICATION: A ___ man with renal failure. COMPARISON: Renal ultrasound ___. FINDINGS: The right kidney measures 10.0 cm and the left kidney measures 11.8 cm. There is no hydronephrosis. A simple cyst which measures 1.9 cm is again seen at the lower pole of the left kidney. A simple cyst is also seen at the upper pole of the left kidney measuring 1.5 cm. DOPPLER EXAMINATION: Color Doppler and pulse-wave Doppler images were obtained. Note is made that this is a very limited study of the right kidney only as the patient declined the completion of the exam. This exam is also limited due to the patient's inability to hold his breath. Arterial waveforms are seen in the main right renal artery and in the intraparenchymal arteries of the right kidney. No antegrade diastolic flow can be seen on these waveforms; however, it is unclear whether this finding is related to the technically limited nature of this exam. Venous flow is seen in the main right renal vein. IMPRESSION: 1. No hydronephrosis. Two simple left renal cysts. 2. Arterial and venous flow is seen in the right kidney; however, the Doppler examination is limited as the patient is unable to hold his breath. Note is made that the patient declined to complete the Doppler examination and consequently the exam is very limited and no Doppler images were obtained of the left kidney. Radiology Report INDICATION: Acute renal failure, for emergent dialysis, place temporary line. OPERATORS: Dr. ___, and ___ performed the procedure. Dr. ___ attending radiologist, supervised the procedure. PROCEDURE AND FINDINGS: The patient was brought to the angiography suite and placed supine on the angiography table. Written informed consent had previously been obtained from the patient's wife, his healthcare proxy, after thorough discussion of the risks, benefits and alternatives. Monitored anesthesia care was administered due to the patient's mental status. A preprocedure timeout was performed using three patient identifiers. The left neck was prepped and draped in usual sterile fashion. 1% buffered lidocaine was instilled in the subcutaneous tissues for local anesthesia. Subsequently, under sonographic guidance, a micropuncture needle was advanced into the patent left internal jugular vein. Pre- and post-venipuncture sonographic images were printed. A 0.018 nitinol wire was advanced through the needle into the superior vena cava. The needle was exchanged for a micropuncture sheath and subsequently the inner dilator and nitinol wire were removed. A short ___ wire was inserted into the micropuncture sheath, but could not be advanced into the inferior vena cava and as a result was exchanged for a 0.035 ___ wire. This was successfully advanced into the inferior vena cava. The ___ wire was exchanged for an Amplatz wire through the use of a 4 ___ Kumpe catheter. Over the Amplatz wire, sequential dilatation was performed with subsequent insertion of a ___ double-lumen 20 cm hemodialysis catheter. Tip was left in the lower SVC with approximately 1 cm of catheter exterior to the venotomy site. Final scout image was obtained demonstrating tip in appropriate position. The line was then aspirated and flushed and secured in position with two single 0 silk interrupted sutures and dressed with a sterile dressing. The patient tolerated the procedure well without immediate post-procedure complication. The line is ready for use. IMPRESSION: Successful insertion of a ___ temporary dialysis catheter in the left internal jugular vein with tip in the lower SVC. The line is ready for use. Radiology Report NON-INVASIVE ARTERIAL STUDY AT REST INDICATION: ___ man with diabetes mellitus, acute renal failure on hemodialysis with vasculitis rash on the lower extremities, presenting with cold toes and nonpalpable, but dopplerable dorsalis pedis pulses. Evaluation for vascular disease. No studies available for comparison. TECHNIQUE: Doppler waveforms, pulse volume recordings, and segmental blood pressures were obtained in lower extremities bilaterally at rest. FINDINGS: There is normal triphasic Doppler waveform at the right common femoral, popliteal, posterior tibial, and dorsalis pedis arteries and at the left common femoral, popliteal, and posterior tibial arteries. There is a monophasic Doppler waveform at the level of the left dorsalis pedis artery. The ABI index on the right is 1.13 and on the left is 1.26. Pulse volume recordings are symmetrical bilaterally. IMPRESSION: Moderate left tibial disease. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: BLE EDEMA/INCREASED CONFUSION Diagnosed with OTHER FLUID OVERLOAD, NONSPECIF SKIN ERUPT NEC, ACUTE KIDNEY FAILURE, UNSPECIFIED temperature: 97.0 heartrate: 69.0 resprate: 20.0 o2sat: 100.0 sbp: 153.0 dbp: 69.0 level of pain: 0 level of acuity: 2.0

Mr. ___, you presented to us with worsening rash on your legs and worsening mental status due to your kidneys' inability to clear toxins from your blood. We treated these problems by initially giving you a temporary hemodialysis line and performing hemodialysis to clear some toxins. We also had dermatology evaluate your rash and they felt that a biopsy was not indicated at this time. You were also evaluated by the ophthomology team and they stated that your eyes did not have evidence of cholesterol clots. You began to make urine and your creatinine decreased and we determined that you did not need more hemodialysis at the moment. We made the following changes to your medications: Please START Omeprazole 20mg daily while on steroids START Nephrocaps START Miconazole cream, Hyrdocortisone cream rectally, and Mupriocin cream STOP amitriptyline STOP gabapentin STOP levothyroxine CHANGE PhosLo to 1 tab daily CHANGE Prednisone to 10mg daily CONTINUE Warfarin 5mg daily adjust to INR

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: syncope Major Surgical or Invasive Procedure: Pacemaker placement History of Present Illness: ___ y/o M with chronic AF (on dabigatran) and prior TIA, sent to ED from ___ clinic for abnormal holter findings with tachy-brady syndrome. Five days PTA, patient had rigorous hiking. Afterwards, he felt faint in the car and lost consciousness for a few seconds. Upon awakening, he was alert and denied confusion. His PCP, ___. ___ holter monitor on ___, which showed atrial fibrillation nearly 100% of the time, with ventricular rates ranging from 37 to 240 bpm (average 79 bpm). Longest pause was 3+ seconds. There were 8 runs of nonsustained WCT, with the longest run lasting 14 beats at 219 bpm and the fastest run lasting 6 beats at 240 bpm. He had been hiking during monitoring and the most strenuous episode correlated with the 14-beat run of WCT, which was asymptomatic. Due to these findings, he was advised to present to ED for admission for PPM. In the ED, initial vitals were HR 120 BP 136/105 RR18 100%RA. Patient was asymptomatic. CXR unremarkable. CBC, chem 10 and coags are wnl. Transfer vitals are 70 140/101 18 98% RA. Patient went to EP labs prior from ED and received single lead RV pacemaker on the right. Past Medical History: 1) permanent atrial fibrillation, on dabigatran 2) strokes, with brain MRI showing multiple areas of subacute infarct in the right occipital lobe, right temporoparietal area, and right central sulcus area 3) hyperlipidemia Social History: ___ Family History: --Mother died at 80 of unknown causes --Father died at ___ with Alzheimers disease --3 Daughters: All healthy Physical Exam: Admission PE: VS: 97.8; 135/93; 82; 16; 99%RA General: well appearing, NAD HEENT: PERRLA Neck: no JVP CV: irregularly irregular, normal S1, S2. no MRG, L sided dressing in place and sling, no oozing Lungs: CTAB Abdomen: NDNT, normal BS Ext: no edema Neuro: AAOx3, CN II-XII grossly intact PULSES: 2+ ___, DP Discharge PE: Pacemaker site C/D/I, nontender otherwise unchanged Pertinent Results: Labs: ___ 02:00PM BLOOD WBC-6.5 RBC-5.00 Hgb-16.2 Hct-49.1 MCV-98 MCH-32.5* MCHC-33.1 RDW-12.6 Plt ___ ___ 02:00PM BLOOD Neuts-60.3 ___ Monos-7.8 Eos-2.4 Baso-0.7 ___ 02:00PM BLOOD ___ PTT-38.7* ___ ___ 02:00PM BLOOD Glucose-91 UreaN-11 Creat-1.0 Na-137 K-4.9 Cl-101 HCO3-24 AnGap-17 ___ 02:00PM BLOOD Calcium-9.7 Phos-3.0 Mg-2.3 CXR ___ IMPRESSION: PA and lateral chest compared to ___: Transvenous right ventricular pacer lead tip projects over the anterior wall of the right ventricle, continuous from the left pectoral generator. There is no pneumothorax, mediastinal widening or appreciable pleural effusion. Lungs are clear and the heart size is normal. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Dabigatran Etexilate 150 mg PO BID 2. Simvastatin 20 mg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Testim (testosterone) unknown transdermal unk 5. Cialis (tadalafil) unknown oral unk Discharge Medications: 1. Dabigatran Etexilate 150 mg PO BID 2. Multivitamins 1 TAB PO DAILY 3. Diltiazem Extended-Release 180 mg PO DAILY RX *diltiazem HCl 180 mg 1 capsule, extended release(s) by mouth daily Disp #*30 Capsule Refills:*0 4. Cialis (tadalafil) 0 tab ORAL UNK 5. Testim (testosterone) 0 gel TRANSDERMAL UNK 6. Simvastatin 10 mg PO DAILY RX *simvastatin 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 7. Cephalexin 500 mg PO Q6H Duration: 2 Days RX *cephalexin 500 mg 1 tablet(s) by mouth every six (6) hours Disp #*8 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Pacemaker Tachy-brady syndrome atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Ventricular tachycardia, to get a pacer today. Pre-operative assessment. TECHNIQUE: PA and lateral views of the chest. COMPARISON: ___. FINDINGS: The cardiac, mediastinal and hilar contours are normal. Lungs are clear and the pulmonary vasculature is normal. No pleural effusion or pneumothorax is seen. There are no acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary process. Radiology Report PA AND LATERAL CHEST. HISTORY: Recent RV pacemaker. IMPRESSION: PA and lateral chest compared to ___: Transvenous right ventricular pacer lead tip projects over the anterior wall of the right ventricle, continuous from the left pectoral generator. There is no pneumothorax, mediastinal widening or appreciable pleural effusion. Lungs are clear and the heart size is normal. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: ABNORMAL HOLTER STUDY Diagnosed with PAROX VENTRIC TACHYCARD, SYNCOPE AND COLLAPSE temperature: 95.0 heartrate: 120.0 resprate: 18.0 o2sat: 100.0 sbp: 136.0 dbp: 105.0 level of pain: 0 level of acuity: 2.0

Mr. ___, It was a pleasure taking care of you at ___. You were admitted for a pacemaker for atrial fibrillation with tachycardia and bradycardia. Your procedure went smoothly. We started you on a low dose of calcium channel blocker. Please take as directed. Diltiazem 180mg daily. Please also decrease simvastatin to 10mg daily as this interacts with diltiazem.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: sulfamethoxazole / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Weakness Major Surgical or Invasive Procedure: None History of Present Illness: ___ female with past medical history of atrial fibrillation, on Coumadin, CKD stage IV, and heart failure with a preserved ejection fraction, spinal stenosis presents with several days of feeling unwell, fatigue, bilateral leg aches, new onset of nonbloody diarrhea one day prior to admission. Patient states that she has been feeling generally unwell for several days, with lightheadedness and generalized weakness. She usually ambulates with a walker at home and is feels too weak to walk. In addition to her fatigue, she has bilateral pain in her calves that only occurs when she walks around. One day prior to admission, she began having watery diarrhea, without blood. She is unsure how many episodes of diarrhea she had. She has not had a bowel movement since this time. She has not had fevers, abdominal pain, nausea, vomiting, melena, or BRBPR. She has not had cough, SOB, or dysuria. She thinks that she has been eating less because she just does not enjoy food anymore. Reports shortness of breath with ambulation, which she thinks started around the time of her atrial fibrillation and cardioversion during her admission in ___. The shortness of breath has not increased in severity recently. She has no orthopnea. She reports that she has some lower extremity edema at baseline, which is helped by her Lasix. She does endorse urinary frequency since her Lasix dose was increased at a nephrology appointment in ___. She has to urinate more frequently but thinks that her stream is not as good. Of note she had a recent admission in ___ for bradycardia and hypotension in the setting of being on beta blockers. She is now managed with amiodarone. She underwent a successful TEE cardioversion in ___, and continues on amiodarone and Coumadin In the ED, her initial vitals were: 97.8, HR 62, BP 160/30, RR 18, 98% RA CXR showed mild pulmonary edema and cardiomegaly. She received: 1 L IVF, home amiodarone, lidocaine patch, tylenol, and omeprazole. ROS: Full 10 pt review of systems negative except for above. Past Medical History: -Hypertension -CHF with preserved EF -Afib -CKD -hyperlipidemia -spinal stenosis -glaucoma -osteoarthritis -gastroesophageal reflux -Anemia -thalassemia minor -bilateral breast cancer Social History: ___ Family History: Her mother was diagnosed with breast cancer at ___. Physical Exam: ADMISSION PHYSICAL EXAM ========================== Vitals: 98.7 PO 169 / 72 L 67 16 93 RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, no LAD, no visible JVD Lungs: Bilateral crackles up to the midlung, no wheezes or rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: 2+ pitting edema up to the mid shins. Warm, well perfused, 2+ pulses, no clubbing, cyanosis. Neuro: CNII-XII intact, ___ strength in upper and lower extremities, sensation grossly intact DISCHARGE PHYSICAL EXAM =========================== Vitals: 98.___ General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, no LAD, no visible JVD Lungs: Bibasilar crackles, no wheezes or rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: 2+ pitting edema up to the mid shins. Warm, well perfused, 2+ pulses, no clubbing, cyanosis. Neuro: CNII-XII intact, ___ strength in upper and lower extremities, sensation grossly intact Pertinent Results: ADMISSION LABS ======================== ___ 10:50PM BLOOD WBC-8.9 RBC-3.34* Hgb-7.6* Hct-23.7* MCV-71* MCH-22.8* MCHC-32.1 RDW-16.8* RDWSD-42.5 Plt ___ ___ 10:50PM BLOOD Neuts-81.1* Lymphs-8.2* Monos-8.6 Eos-0.8* Baso-0.3 Im ___ AbsNeut-7.24* AbsLymp-0.73* AbsMono-0.77 AbsEos-0.07 AbsBaso-0.03 ___ 10:50PM BLOOD ___ PTT-37.7* ___ ___ 10:50PM BLOOD Ret Aut-2.2* Abs Ret-0.07 ___ 10:50PM BLOOD Glucose-131* UreaN-34* Creat-1.9* Na-138 K-4.7 Cl-104 HCO3-20* AnGap-19 ___ 10:50PM BLOOD LD(___)-303* ___ 10:50PM BLOOD Calcium-8.8 Phos-4.6* Mg-2.3 ___ 10:50PM BLOOD Hapto-210* DISCHARGE LABS ========================== ___ 07:47AM BLOOD WBC-12.3* RBC-3.61* Hgb-8.1* Hct-26.5* MCV-73* MCH-22.4* MCHC-30.6* RDW-16.7* RDWSD-43.3 Plt ___ ___ 07:47AM BLOOD Glucose-99 UreaN-29* Creat-1.7* Na-141 K-3.9 Cl-106 HCO3-20* AnGap-19 ___ 07:47AM BLOOD Calcium-8.9 Phos-4.4 Mg-2.2 IMAGING =========================== CXR ___ IMPRESSION: Mild pulmonary edema with mild cardiomegaly. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amiodarone 200 mg PO DAILY 2. amLODIPine 10 mg PO DAILY 3. Atorvastatin 10 mg PO QPM 4. Furosemide 20 mg PO DAILY 5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 6. Lidocaine 5% Patch 1 PTCH TD QAM 7. Lisinopril 2.5 mg PO DAILY 8. Omeprazole 20 mg PO DAILY 9. Warfarin 2.5 mg PO 5X/WEEK (___) 10. Warfarin 3.75 mg PO 2X/WEEK (MO,FR) 11. Acetaminophen 500 mg PO BID:PRN Pain - Mild 12. Ascorbic Acid ___ mg PO DAILY 13. Vitamin D ___ UNIT PO DAILY 14. Docusate Sodium 100 mg PO DAILY:PRN constipation 15. Ferrous Sulfate 325 mg PO DAILY 16. Multivitamins 1 TAB PO DAILY 17. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate Discharge Medications: 1. Acetaminophen 500 mg PO BID:PRN Pain - Mild 2. Amiodarone 200 mg PO DAILY 3. amLODIPine 10 mg PO DAILY 4. Ascorbic Acid ___ mg PO DAILY 5. Atorvastatin 10 mg PO QPM 6. Docusate Sodium 100 mg PO DAILY:PRN constipation 7. Ferrous Sulfate 325 mg PO DAILY 8. Furosemide 20 mg PO DAILY 9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 10. Lidocaine 5% Patch 1 PTCH TD QAM 11. Lisinopril 2.5 mg PO DAILY 12. Multivitamins 1 TAB PO DAILY 13. Omeprazole 20 mg PO DAILY 14. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 15. Vitamin D ___ UNIT PO DAILY 16. Warfarin 3.75 mg PO 2X/WEEK (MO,FR) 17. Warfarin 2.5 mg PO 5X/WEEK (___) Discharge Disposition: Home With Service Facility: ___ ___: Primary diagnosis: Volume depletion likely due to diarrhea Secondary diagnoses: Atrial fibrillation HTN Chronic kidney disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: PA and lateral chest radiographs INDICATION: ___ with weakness, lightheadedness // Evaluate for pneumonia TECHNIQUE: Chest PA and lateral COMPARISON: ___ chest radiographs ___ chest radiographs FINDINGS: The lungs are well-expanded. There is mild pulmonary edema. No focal consolidation. No pleural effusion or pneumothorax. Mild cardiomegaly. Cardiomediastinal hilar silhouettes are otherwise unremarkable. An apparent compression deformity in the lower thoracic spine is unchanged. IMPRESSION: Mild pulmonary edema with mild cardiomegaly. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Diarrhea, Lightheaded Diagnosed with Anemia, unspecified temperature: 97.8 heartrate: 62.0 resprate: 18.0 o2sat: 98.0 sbp: 161.0 dbp: 38.0 level of pain: 6 level of acuity: 3.0

Dear Ms. ___, It was a pleasure treating you at ___! Why was I admitted to the hospital? -You were admitted because you had had diarrhea, and because you were feeling dizzy. -When you were admitted, we also saw that your blood levels were low What was done while I was admitted? -We gave you some fluids to make sure you weren't dehydrated -We made sure your blood level was increasing and that your kidney was functioning well -We gave you diuretics to bring fluid off of your lungs and your legs -We made sure you were able to walk around without falling down What should I do when I go home? -Please continue to follow-up with the ___ clinic to dose your warfarin -Please continue to take iron supplementation for anemia -Please continue to follow a diet that is low in salt -Please weigh yourself every morning and call your doctor if weight goes up more than 3 lbs.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left tibia and fibula fracture Major Surgical or Invasive Procedure: placement of left tibial IM nail ___ History of Present Illness: ___ is a ___ male with a history of hypertension who was transferred from an outside hospital with a left tibia and fibula fracture. He was reduced and splinted at the outside hospital before being transferred. He was at work when he fell backwards and a utility pole fell onto his left tibia. No head strike or LOC. He was transferred here for further management. He denies any numbness or tingling into the left foot or pain elsewhere. Past Medical History: PMH/PSH: Hypertension Social History: ___ Family History: NC Physical Exam: General: Well-appearing, breathing comfortably MSK: LLE - primary DSD/ace thigh to foot ___ edema. - compartments soft, appropriately tender - Full, painless PROM of digits, knee, some tenderness with ankle PROM - wiggling toes - SILT throughout exposed toes - 2+ distal pulses, brisk cap refill Pertinent Results: ___ 05:25PM BLOOD WBC-11.1* RBC-4.76 Hgb-14.4 Hct-43.0 MCV-90 MCH-30.3 MCHC-33.5 RDW-15.1 RDWSD-49.2* Plt ___ ___ 07:05AM BLOOD WBC-10.2* RBC-3.86* Hgb-11.6* Hct-35.9* MCV-93 MCH-30.1 MCHC-32.3 RDW-14.7 RDWSD-49.3* Plt ___ ___ 05:25PM BLOOD Neuts-65.7 ___ Monos-8.2 Eos-1.4 Baso-0.5 Im ___ AbsNeut-7.28* AbsLymp-2.64 AbsMono-0.91* AbsEos-0.15 AbsBaso-0.06 ___ 07:05AM BLOOD Plt ___ ___ 05:25PM BLOOD ___ PTT-28.9 ___ ___ 05:25PM BLOOD Plt ___ ___ 05:25PM BLOOD Glucose-87 UreaN-7 Creat-0.7 Na-142 K-4.0 Cl-101 HCO3-29 AnGap-12 ___ 07:05AM BLOOD Glucose-109* UreaN-10 Creat-0.7 Na-140 K-4.3 Cl-99 HCO3-29 AnGap-12 ___ 07:05AM BLOOD Calcium-8.4 Phos-4.3 Mg-1.9 Medications on Admission: None Discharge Medications: 1. Acetaminophen 650 mg PO Q6H RX *acetaminophen 500 mg 1 to 2 tablet(s) by mouth three times a day Disp #*60 Tablet Refills:*0 2. Aspirin 325 mg PO DAILY RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. crutch miscellaneous as needed for ambulation RX *crutch Disp #*1 Each Refills:*0 4. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*50 Tablet Refills:*0 5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*36 Tablet Refills:*0 6. Senna 8.6 mg PO BID RX *sennosides [senna] 8.6 mg 1 tab by mouth twice daily Disp #*50 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: left tibia fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: TIB/FIB (AP AND LAT) LEFT INDICATION: History: ___ with reduction// reduction reduction TECHNIQUE: Frontal and lateral view radiographs of the left tibia and fibula. COMPARISON: None FINDINGS: Evaluation for fine detail is limited due to overlying cast material. There is comminuted fracture of the distal fibula with 1.6 cm overriding of the midshaft with slight apex anterior angulation. There is minimal apex anterior angulation of tibial fracture. Transverse fracture through the distal tibial diaphysis demonstrates half bone width lateral translation of the distal fracture fragment. Limited assessment of the knee demonstrates apparent mild degenerative changes. IMPRESSION: Transverse fracture of the distal diaphysis of the tibia with half bone width lateral translation of the distal fracture fragment and mild apex anterior angulation. Comminuted fracture of the distal fibula with 1.6 cm overriding at the midshaft. Radiology Report EXAMINATION: Left tibia-fibula intraoperative radiographs INDICATION: Operative fixation, surgical guidance. TECHNIQUE: A total of 209.6 seconds continuous fluoroscopic time was employed without a radiologist present. COMPARISON: Prior exam performed same day. FINDINGS: 5 intraoperative images were acquired without a radiologist present. Images show placement of a tibial IM rod with 1 proximal and 1 distal interlocking screw traversing a distal shaft tibial fracture with near anatomic alignment. A segmental proximal and midshaft fracture of the fibula is again noted. IMPRESSION: Intraoperative images were obtained during ORIF. Please refer to the operative note for details of the procedure. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: L Leg injury, Leg pain Diagnosed with Displaced comminuted fracture of shaft of left tibia, init, Oth cause of strike by thrown, projected or fall obj, init temperature: 99.5 heartrate: 86.0 resprate: 14.0 o2sat: 96.0 sbp: 161.0 dbp: 97.0 level of pain: 5 level of acuity: 2.0

INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - weight bearing as tolerated to the left lower extremity MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take aspirin 325mg daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Please remain in your dressing and do not change unless it is visibly soaked or falling off. - Splint must be left on until follow up appointment unless otherwise instructed - Do NOT get splint wet DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB FOLLOW UP: Please follow up with your Orthopaedic Surgeon, Dr. ___. You will have follow up with ___, NP in the Orthopaedic Trauma Clinic 14 days post-operation for evaluation. Call ___ to schedule appointment upon discharge. Please follow up with your primary care doctor regarding this admission within ___ weeks and for and any new medications/refills. Physical Therapy: weight bearing as tolerated to the left lower extremity Treatments Frequency: Any staples or superficial sutures you have are to remain in place for at least 2 weeks postoperatively. Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. You may shower and allow water to run over the wound, but please refrain from bathing for at least 4 weeks postoperatively. Please remain in the splint until follow-up appointment. Please keep your splint dry. If you have concerns regarding your splint, please call the clinic at the number provided.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: UROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: OBSTRUCTING NEPHROLITHIASIS, ACUTE RENAL INJURY, ETOH ABUSE Major Surgical or Invasive Procedure: CYSTOSCOPY, BILATERAL RPG W/ LEFT LASER LITHO AND URETERAL STENT PLACEMENT History of Present Illness: ___ yo M with MMP including nephrolithiasis, CKD who was found to be in ARF with creatinine to 3.4 in PCP's office. Sent to ED. Known 1.2 cm L UPJ stone with hydronephrosis. No flank pain. No fevers/chills/n/v. Urology was consulted. Past Medical History: PMH: HTN HLD DM2 Nephrolithiasis Dermatitis CKD Depression Obesity PSH: SWL PCNL on the left URS Social History: ___ Family History: MI CHF Nephrolithiasis Physical Exam: WDWN male, NAD, AVSS abdomen obese, nt/nd extremities w/out edema, pitting Pertinent Results: CT Scan ___: Mild-to-moderate hydronephrosis of the left kidney with perinephric stranding. Limited evaluation of the renal parenchyma for underlying pyelonephritis due to lack of IV contrast. Partially obstructing 1.8-cm stone is seen in the left UPJ. A partially obstructing 1.4-cm stone is seen in the right. Cortical atrophy likely from prior insults. ___ 07:45AM BLOOD WBC-6.7 RBC-4.04* Hgb-12.2* Hct-35.5* MCV-88 MCH-30.2 MCHC-34.4 RDW-13.6 Plt ___ ___ 04:05PM BLOOD WBC-7.4 RBC-4.27* Hgb-13.5* Hct-37.7* MCV-88 MCH-31.7 MCHC-35.9* RDW-13.4 Plt ___ ___ 07:45AM BLOOD Glucose-132* UreaN-33* Creat-2.6* Na-138 K-4.9 Cl-106 HCO3-21* AnGap-16 ___ 06:55AM BLOOD Glucose-128* UreaN-38* Creat-3.1* Na-140 K-4.8 Cl-109* HCO3-19* AnGap-17 ___ 04:05PM BLOOD Glucose-87 UreaN-37* Creat-3.1* Na-140 K-5.2* Cl-107 HCO3-23 AnGap-15 ___ 11:13AM BLOOD UreaN-34* Creat-3.2*# Na-140 K-5.8* Cl-108 HCO3-22 AnGap-16 ___ 07:45AM BLOOD Calcium-9.4 Phos-3.7 Mg-1.8 ___ 11:13AM BLOOD Calcium-10.0 Medications on Admission: allopurinol ___ daily amlodipine/atorvastatin ___ one daily carvedilol 25 b.i.d. doxazosin 4 mg daily gemfibrozil 600mg bid glyburide hydrochlorothiazide 12.5 daily lisinopril 40 mg daily glimiperide 1 mg bid Allergies: NKDA Discharge Medications: 1. acetaminophen 325 mg tablet Sig: ___ tablets PO Q6H (every 6 hours) as needed for pain or fever. 2. allopurinol ___ mg tablet Sig: One (1) tablet PO DAILY (Daily). 3. amlodipine 5 mg tablet Sig: One (1) tablet PO DAILY (Daily). 4. atorvastatin 20 mg tablet Sig: One (1) tablet PO DAILY (Daily). 5. carvedilol 12.5 mg tablet Sig: Two (2) tablet PO BID (2 times a day). 6. doxazosin 1 mg tablet Sig: Two (2) tablet PO HS (at bedtime). 7. gemfibrozil 600 mg tablet Sig: One (1) tablet PO BID (2 times a day). 8. glimepiride 1 mg tablet Sig: One (1) tablet PO daily (). 9. oxycodone 5 mg tablet Sig: ___ tablets PO Q4H (every 4 hours) as needed for pain. Disp:*25 tablet(s)* Refills:*0* 10. Colace 100 mg capsule Sig: One (1) capsule PO twice a day: take to prevent constipation. Disp:*60 capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Nephrolithiasis, obstructing Acute renal failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Left kidney stone. COMPARISON: CT abdomen and pelvis from ___. FINDINGS: 15 spot fluoroscopic images, obtained without a radiologist present, were submitted for review. Images demonstrate catheterization of the right ureter with contrast opacification demonstrate a filling defect in the right renal pelvis consistent with stone seen on CT. A complex diverticulum with layering stones is seen off the superior pole collecting system. Subsequently contrast opacification of the left ureter demonstrates moderate hydronephrosis. The wire was then introduced into the left renal pelvis followed by placement of a double-J stent with the upper coil in the left renal pelvis and the lower coil is in the bladder. For further details see operative note in the ___ medical record. Radiology Report HISTORY: Left renal and ureteral stones question left stone. COMPARISON: ___. FINDINGS: There is a new double J stent on the left. There are few scattered radio opacities in the abdomen but none are definitively within the left kidney or in the course of the left ureteral stent. Given patient body habitus small stones could be missed. Gas is seen in multiple loops of small and large bowel. The transverse colon is mildly dilated at 8 cm. IMPRESSION: No definite kidney stones. The study is limited by patient body habitus. Ileus. Gender: M Race: WHITE - RUSSIAN Arrive by WALK IN Chief complaint: ABNL LABS Diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED, CALCULUS OF KIDNEY temperature: 99.2 heartrate: 60.0 resprate: 18.0 o2sat: 97.0 sbp: 171.0 dbp: 95.0 level of pain: 2 level of acuity: 3.0

-You can expect to see occasional blood in your urine and to possibly experience some urgency and frequency over the next month; this may be related to the passage of stone fragments or the indwelling ureteral stent (if there is one). -The kidney stone may or may not have been removed AND/or there may fragments/others still in the process of passing. -You may experience some pain associated with spasm of your ureter.; This is normal. Take the narcotic pain medication as prescribed if additional pain relief is needed. -Ureteral stents MUST be removed or exchanged and therefore it is IMPERATIVE that you follow-up as directed. -Do not lift anything heavier than a phone book (10 pounds) -You may continue to periodically see small amounts of blood in your urine--this is normal and will gradually improve -Resume all of your pre-admission medications, except HOLD aspirin until you see your urologist in follow-up -You can expect to see occasional blood in your urine and to possibly experience some urgency and frequency over the next month; this may be related to the passage of stone fragments or the indwelling ureteral stent. -The kidney stone may or may not have been removed AND/or there may fragments/others still in the process of passing. -You may experience some pain associated with spasm of your ureter.; This is normal. Take the narcotic pain medication as prescribed if additional pain relief is needed. -Ureteral stents MUST be removed or exchanged and therefore it is IMPERATIVE that you follow-up as directed.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Latex / Zocor / tramadol Attending: ___. Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: None History of Present Illness: This is a ___ with h/o CAD and ischemic cardiomyopathy who presents with chest pain. Reports the pain started while she was in bed at 3AM on ___. She describes the pain as piercing L parasternal pain and experienced 4 quick episodes. The pain went away when she called EMS at 5 AM. Denies nausea, vomiting or SOB. No pleuritic component. Denies cough. Patient did receive full-dose ASA prior to transfer. In the ED, initial vitals were: 97.7 82 106/55 20 97% 3L - ECG: LAD, QRS widening, stable TWF in V4-V6 - Labs notable for: H/H 10.5/34.8, otherwise normal labs - Pt given: nothing - Pt admitted for ? cath - Vitals on transfer: 81 107/58 15 96% 3L NC Past Medical History: Depression, schizoaffective disorder, NIDDM, cataracts, hx of C. difficile enterocolitis, hypertension, elevated cholesterol, hx of DVT, constipation, seasonal allergies, osteoarthritis and osteoporosis. Social History: ___ Family History: Non-contributory. Physical Exam: >>Admission: General: NAD, comfortable, pleasant, dysarthric HEENT: NCAT, PERRL, EOMI, noticed a left sided facial droop (mouth and eyelid), facial sensation in tact Neck: supple, JVP CV: regular rhythm, no m/r/g Lungs: CTAB, no w/r/r Abdomen: soft, NT/ND, BS+ Ext: WWP, no c/c/e, 2+ distal pulses bilaterally Neuro: CN II-XII grossly in tact, moving all extremities grossly, ___ strength in b/l ___ , ___ strength in b/l UE . >>Discharge: VS: 98.4 122/76 65 18 97% RA General: NAD, comfortable, pleasant, dysarthric HEENT: NCAT, PERRL, EOMI, noticed a left sided facial droop (mouth and eyelid), facial sensation in tact Neck: supple, no JVP CV: regular rhythm, no m/r/g Lungs: CTAB, no w/r/r Abdomen: soft, NT/ND, BS+ Ext: WWP, no c/c/e, 2+ distal pulses bilaterally Neuro: CN II-XII grossly in tact, moving all extremities grossly, ___ strength in b/l ___ , ___ strength in b/l UE Pertinent Results: >>Admission: ___ 10:35AM BLOOD WBC-5.2 RBC-3.89* Hgb-10.5* Hct-34.8* MCV-89 MCH-27.1 MCHC-30.3* RDW-14.7 Plt ___ ___ 10:35AM BLOOD ___ PTT-32.4 ___ ___ 10:35AM BLOOD Glucose-112* UreaN-26* Creat-0.8 Na-137 K-4.5 Cl-100 HCO3-27 AnGap-15 . >>Imaging: ECHO: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is moderate to severe regional left ventricular systolic dysfunction with focal severe hypokinesis to akinesis of the inferior and inferolateral walls, and hypokinesis of the inferior septum and apex. (EF 30%). The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Moderate left ventricular dilatation with moderate to severe regional variation c/w multivessel CAD. Normal right ventricular cavity size and systolic function. Right ventricle not well-visualized. Mild mitral and aortic regurgitation. No cardiac source of embolism identified. . MRI Head w/o contrast, MRA head and neck: 1. Subtle focus of slowed diffusion adjacent to the cortex of the right parietal lobe is concerning for a focus of infarction. 2. Small micro-hemorrhage in the right temporal lobe series 16, image 11 is likely subacute. 3. Diffuse bifrontal and right frontoparietal T2 and FLAIR hyperintensities is consistent with patient's known encephalomalacia. . >>Discharge: Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation 2 puffs q6hr PRN SOB 2. Alendronate Sodium 70 mg PO 1X/WEEK (___) 3. Aripiprazole 10 mg PO DAILY 4. Duloxetine 60 mg PO DAILY 5. Furosemide 40 mg PO DAILY 6. Gabapentin 100 mg PO TID 7. Lactulose 15 mL PO BID 8. MetFORMIN (Glucophage) 500 mg PO BID 9. Metoprolol Succinate XL 12.5 mg PO DAILY 10. Omeprazole 40 mg PO BID 11. Pravastatin 10 mg PO DAILY 12. QUEtiapine extended-release 200 mg PO QHS 13. Aspirin 81 mg PO DAILY 14. Vitamin D 1000 UNIT PO DAILY 15. Docusate Sodium 100 mg PO BID 16. Senna 8.6 mg PO BID Discharge Medications: 1. Aripiprazole 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Duloxetine 60 mg PO DAILY 5. Gabapentin 100 mg PO TID 6. Lactulose 15 mL PO BID 7. Omeprazole 40 mg PO BID 8. QUEtiapine extended-release 200 mg PO QHS 9. Senna 8.6 mg PO BID 10. Vitamin D 1000 UNIT PO DAILY 11. Alendronate Sodium 70 mg PO 1X/WEEK (___) 12. Furosemide 40 mg PO DAILY Please do not start this medication until ___. 13. MetFORMIN (Glucophage) 500 mg PO BID 14. Metoprolol Succinate XL 12.5 mg PO DAILY 15. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation 2 puffs q6hr PRN SOB 16. Pravastatin 10 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnosis: Atypical chest pain, CVA Secondary diagnosis: ischemic cardiomyopathy 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: MRI AND MRA BRAIN AND MRA NECK INDICATION: ___ year old woman with CAD, ischemic cardiomyopathy, HTN, HLD, SDH s/p craniotomy with associated R frontal lobe encephalomalacia who is admitted to the cardiology service after presenting to ___ with chest pain which started at 3am this morning // questionable stroke TECHNIQUE: MRI of the head, MRA of the brain, MRA of the neck with contrast. COMPARISON: CT from ___. FINDINGS: MRI: There is a subtle focus of slowed diffusion adjacent to the cortex of the right parietal lobe series 4, image 15, concerning for a focus of infarction. There is no evidence of an acute intracranial mass, mass effect or shift of the normally midline structures. The prominence of the ventricles and sulci is likely related to age-related involutional changes. The basilar cisterns are patent. On the gradient echo sequences, there is a area of blooming artifact consistent with a small micro hemorrhage in the right temporal lobe series 16, image 11 measuring up to 4 mm. Diffused bifrontal and right frontoparietal T2 and FLAIR hyperintensity is consistent with patient's known encephalomalacia. MRA: There is no evidence of significant stenosis, aneurysm or occlusion. The vessels of the neck and circle of ___ appear to be patent. Note is made of mild narrowing at the origin of the left vertebral artery which otherwise appears patent throughout its intracranial course. Burr holes are seen throughout the calvaria. Patient is status post right parietal craniotomy with adjacent areas of magnetic susceptibility. IMPRESSION: 1. Subtle focus of slowed diffusion adjacent to the cortex of the right parietal lobe is concerning for a focus of infarction. 2. Small micro-hemorrhage in the right temporal lobe series 16, image 11 is likely subacute. 3. Diffuse bifrontal and right frontoparietal T2 and FLAIR hyperintensities is consistent with patient's known encephalomalacia. NOTIFICATION: Findings were discussed with Dr. ___ by Dr. ___ by phone at 4:30p on the day of the exam. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Chest pain Diagnosed with CHEST PAIN NOS temperature: 97.7 heartrate: 82.0 resprate: 20.0 o2sat: 97.0 sbp: 106.0 dbp: 55.0 level of pain: 0 level of acuity: 2.0

Dear ___, ___ were hospitalized on ___ at ___ for your chest pain. During your hospitalization, we did not see any signs of heart attack by your blood work and EKG. While ___ were here, we were concerned about possible slurred speech so ___ got scans of your head and neck to look for a possible stroke. Neurology evaluated ___ had an MRI that showed ___ may have had a small stroke. We have made appointments with your PCP and cardiologist within the next week, so please keep these appointments. In addition, please keep your previously made doctor appointments. Please note that your other home medications have not been changed.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Novahistine / Benadryl Decongestant / seasonal allergies Attending: ___ Chief Complaint: seizures Major Surgical or Invasive Procedure: None. History of Present Illness: from Dr. ___ note: ___ is a ___ F with h/o autism and epilepsy who is transferred from ___ after having 2 breakthrough seizures today. The patient was at her group home earlier today eating lunch when she had a generalized tonic clonic seizure. She was brought to ___ and subsequently discharged back to her group home. Later in the evening while eating dinner, the patient had a second genearlized tonic clonic seizure. She was sitting in a chair eating and fell to the ground. The event is reported to have lasted 5 minutes, but her mother is not sure if the actual seizure event lasted this long or she perhaps had a shorter seizure and was post ictal afterwards. She was again taken to ___ where she was given a dose of lorazepam and transferred to ___. The patient is non-verbal at baseline. A thorough history of the patient's epilepsy is available in clinic notes from Dr. ___ and Dr. ___. She is currently treated with zonisamide 700mg nightly, which has provided good seizure control. Her mother reports that her last seizure was in ___. Prior to that she had 2 seizures on ___ and ___, the provokation of which was not clear. Today mom reports that she has not been ill recently and she has been taking her zonisamide regularly. Mom does state that while ___ was at home over the weekend she had 2 large, "explosive" type bowel movements, which were not diarrhea per ___ tends to have contipation resulting in some abdominal distention followed by these types of large bowel movements. Per the group home she has been having regular bowel movements recently. In the past ___ has been treated with phenobarbital, dilantin, tegretol, carbatrol, trileptal and gabapentin. As stated above, she has recently been treated with zonisamide alone, which has provided good control. Per OMR notes, if a second agent is needed, Dr. ___ like to start Lamictal. Unable to obtain ROS as patient is non-verbal. Past Medical History: epilepsy autism, non-verbal at baseline Social History: ___ Family History: non-contributory Physical Exam: ADMISSION EXAM: Vitals: 99.8 ___ 18 99% GEN: sleeping, arousable, NAD HEENT: acne rosacea, ecchymoses over left orbit and cheek RESP: CTAB no w/r/r CV: RRR, no m/r/g ABD: soft, NT/ND EXT: No edema, no cyanosis SKIN: no rashes or lesions noted. NEURO EXAM: MS: Sleeping, easily arousable, non-verbal, does not participate with exam CN: II: PERRLA 3 to 2mm and brisk. ___, IV, VI: EOM passivly intact, no nystagmus. VII: Facial musculature symmetric. XII: Tongue protrudes midline. Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements. No asterixis. Spontaneous movement of all extremities symmetrically with good strength. Sensory: Reacts appropriately to LT throughout Reflexes: Bi Tri ___ Pat Ach L ___ 2 2 R ___ 2 2 Toes downgoing bilaterally Coordination: No ataxia DISCHARGE EXAM: General: Thin young woman lying in bed in NAD, father at bedside. HEENT: L periorbital eccymosis Neuro: MS: Sleeping but wakens to voice. Alert, looks around at team. Does not speak but reaches out to her father. ___ with the exam with encouragement from her father. CN: ___, IV, VI: EOMI to casual gaze around room. VI: Face activates symmetrically. Motor: Moves all extremities spontaneously and to command. Coordination: Reaches for her father and examiner's hand with no dysmetria. Pertinent Results: Admission Labs: ___ 10:15AM BLOOD Glucose-102* UreaN-13 Creat-0.7 Na-138 K-3.4 Cl-107 HCO3-20* AnGap-14 ___ 10:15AM BLOOD ALT-26 AST-21 AlkPhos-39 TotBili-0.4 ___ 10:15AM BLOOD Calcium-8.6 Phos-2.4* Mg-2.1 ___ 10:15AM BLOOD WBC-7.5 RBC-3.72* Hgb-11.9* Hct-35.7* MCV-96 MCH-32.1* MCHC-33.4 RDW-12.7 Plt ___ ___ 10:15AM BLOOD Plt ___ EEG: final read pending, but no preliminary read of seizures CXR: FINDINGS: AP semi-upright and lateral views of the chest were obtained. Heart is normal size and cardiomediastinal silhouette is unremarkable. Lungs are clear. There is no pleural effusion or pneumothorax. IMPRESSION: No evidence of pneumonia. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fluticasone Propionate NASAL 1 SPRY NU DAILY 2. Lorazepam 0.5 mg PO X2 PRN seizure 3. Zonisamide 700 mg PO QPM 4. Acetaminophen 325-650 mg PO Q6H:PRN pain 5. Calcium Carbonate 400 mg PO DAILY 6. melatonin unknown oral daily 7. Multivitamins 1 TAB PO DAILY 8. colloidal oatmeal 43 % topical PRN unknown Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain 2. Calcium Carbonate 400 mg PO DAILY 3. Fluticasone Propionate NASAL 1 SPRY NU DAILY 4. Multivitamins 1 TAB PO DAILY 5. Zonisamide 700 mg PO QPM 6. colloidal oatmeal 43 % topical PRN unknown 7. Lorazepam 0.5 mg PO X2 PRN seizure 8. melatonin 1 dose ORAL DAILY Discharge Disposition: Home Discharge Diagnosis: epilepsy autism Discharge Condition: Mental status: Nonverbal, alert, follows some commands, cooperates with exam. Ambulatory status: weight bearing as tolerated Followup Instructions: ___ Radiology Report INDICATION: ___ woman with epilepsy presents with two seizures, no history of cough, rule out pneumonia. COMPARISON: None. FINDINGS: AP semi-upright and lateral views of the chest were obtained. Heart is normal size and cardiomediastinal silhouette is unremarkable. Lungs are clear. There is no pleural effusion or pneumothorax. IMPRESSION: No evidence of pneumonia. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Seizure Diagnosed with EPILEPSY, NOS WITHOUT INTRACTABLE EPILEPSY temperature: 99.8 heartrate: 103.0 resprate: 18.0 o2sat: 99.0 sbp: 96.0 dbp: 56.0 level of pain: 0 level of acuity: 3.0

___ was admitted to the hospital because she had two seizures. She underwent EEG in the hospital which did not show any ongoing seizures. She had no further clinical seizures and her mental status returned to baseline. We did not find any trigger for her breakthrough seizures - there was no sign of infection or electrolyte abnormalities. A discussion with her outpatient epileptologist was held and no changes were made to her anti-epileptic medications. We are waiting for the results of a blood test to monitor the level of her Zonegran to make sure her dose is at the therapeutic level.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: chest pain, fatigue, malaise Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ man with h/o IVDU c/b endocarditis s/p mitral valve replacement in ___, with recurrent prosthetic valve endocarditis in ___ and ___, presenting with intermittent substernal chest pain, fatigue, and malaise in setting of recent IV cocaine use. History was obtained directly from the patient but was somewhat limited by his poor memory and difficulty describing symptoms. His reports his chest pain started about 5 days ago after he injected and smoked cocaine. Lasted about 1 minute, then resolved without intervention. Felt like someone punched him in the chest, then burning. No radiation to back, arm, or jaw. No tearing or ripping sensation. Pain was associated with dizziness, dyspnea, palpitations, diaphoresis, and nausea. He later vomited several times. He has continued having intermittent chest pain since then - both a stabbing/poking sensation and burning. Hard for him to quantify how often. Comes and goes without clear trigger. Pain not associated with exertion, though he has been getting dizzy when walking. Also reports feeling terrible overall - fatigued, drained. At first thought this was just a hangover from partying but became worried when it didn't get better. No subjective fevers or chills. +Dry cough. +Dyspnea on exertion. No wheezing. Regarding his cocaine use, he was abstinent for several years but relapsed this week when an acquaintance was staying with him and offered him cocaine for free. He has been using "a lot" of cocaine all week, about ___ grams per day. He mostly smoked it but also injected several times. He last injected ___ days ago, and last smoked cocaine 2 days ago. Regarding other substance use, he smoked marijuana this week as well but denies any other recreational drugs, including opioids and MDMA. He drinks about ___ beers per night at baseline but says he has actually been drinking less this week. He normally does not smoke daily but has been smoking about 10 cigarettes per day this week. He previously smoked up to 1ppd for about ___ years. In the ED, initial VS were: 97.5 74 192/103 18 100% RA BP improved to the 140s-160s/90s-100s without intervention. Exam, EKG, and CXR were unremarkable. Labs were notable for trop <0.01, WBC 10.2 (72% PMNs), chem10 wnl, ALT/AST 77/90, AP/Bili wnl. Blood and urine cultures were sent and patient was admitted for further evaluation. No medications were given. On arrival to the floor, patient reports no ongoing chest pain/burning, palpitations, dyspnea, or dizziness. Past Medical History: Enterococcal Endocarditis s/p MVR with 29mm porcine valve ___ DVT Strep viridans bacteremia with MV vegetation suggestive of endocarditis secondary to dental procedure Hep C, s/p vaccination for hep A&B neg for HIV ___ yrs ago IVDU, including cocaine GERD h/o multiple abcess I&D Social History: ___ Family History: Positive for alcoholism Physical Exam: ADMISSION PHYSICAL EXAM ======================= GENERAL: Middle-aged man in NAD. HEENT: No icterus or injection. MMM. CV: Bradycardic, regular, normal S1, loud S2 in mitral area, no murmurs/rubs/gallops. RESP: Normal work of breathing. Diffuse coarse breath sounds. No wheezes or crackles. GI: Soft, NDNT, no palpable HSM. EXTR: No stigmata of endocarditis. No c/c/e. SKIN: Large soft mobile nodule on back c/w lipoma. No other lesions or rashes. NEURO: Alert, oriented, attentive. CN ___ intact. Normal strength and coordination. DISCHARGE PHYSICAL EXAM ======================= GENERAL: Middle-aged man in NAD. HEENT: No icterus or injection. MMM. CV: Bradycardic, regular, normal S1, loud S2 in mitral area, no murmurs/rubs/gallops. RESP: Normal work of breathing. Diffuse coarse breath sounds. No wheezes or crackles. GI: Soft, NDNT, no palpable HSM. EXTR: No stigmata of endocarditis. No c/c/e. SKIN: Large soft mobile nodule on back c/w lipoma. No other lesions or rashes. NEURO: Alert, oriented, attentive. CN ___ intact. Normal strength and coordination. Pertinent Results: ADMISSION LABS ============== ___ 12:20AM BLOOD WBC-10.2* RBC-4.78 Hgb-14.6 Hct-45.2 MCV-95 MCH-30.5 MCHC-32.3 RDW-14.0 RDWSD-48.7* Plt ___ ___ 12:20AM BLOOD Glucose-70 UreaN-19 Creat-1.0 Na-140 K-5.4 Cl-100 HCO3-30 AnGap-10 ___ 12:20AM BLOOD ALT-77* AST-90* CK(CPK)-506* AlkPhos-48 TotBili-0.3 DISCHARGE LABS ============== ___ 08:23AM BLOOD WBC-8.3 RBC-4.64 Hgb-14.4 Hct-44.1 MCV-95 MCH-31.0 MCHC-32.7 RDW-13.8 RDWSD-48.4* Plt ___ ___ 08:23AM BLOOD Glucose-89 UreaN-15 Creat-1.1 Na-145 K-4.3 Cl-103 HCO3-30 AnGap-12 ___ 08:23AM BLOOD ALT-73* AST-67* LD(LDH)-433* AlkPhos-56 TotBili-0.5 RELEVANT IMAGING ================ CXR ___ IMPRESSION: No acute intrathoracic process. CTA Chest ___ IMPRESSION: No pulmonary emboli. The pulmonary artery is mildly enlarged, pulmonary arterial hypertension should be excluded. No pneumonia. No suspicious pulmonary nodules or masses. Mild, but diffuse bronchial wall thickening is nonspecific, most likely reflecting underlying bronchial inflammation. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Amiodarone 200 mg PO DAILY 3. Levothyroxine Sodium 100 mcg PO EVERY OTHER DAY 4. Levothyroxine Sodium 150 mcg PO EVERY OTHER DAY 5. Lisinopril 10 mg PO DAILY 6. Ascorbic Acid ___ mg PO DAILY 7. Ibuprofen 200-400 mg PO Q8H:PRN Pain - Mild Discharge Medications: 1. Amiodarone 200 mg PO DAILY 2. Ascorbic Acid ___ mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Levothyroxine Sodium 100 mcg PO EVERY OTHER DAY 5. Levothyroxine Sodium 150 mcg PO EVERY OTHER DAY 6. Lisinopril 10 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: ================== Cocaine use SECONDARY DIAGNOSIS: ==================== History of intravenous drug use complicated by endocarditis status-post mitral valve replacement Recurrent prosthetic valve endocarditis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ man with prior heart valve surgery for endocarditis presents with recent IV drug use and subjective fevers chills and chest pain. TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiographs performed ___ and ___. FINDINGS: Interval removal of a left PICC line. Lungs are well expanded. No focal consolidation is seen. No large pleural effusion or pneumothorax. The cardiomediastinal silhouette is within normal limits. Patient is status post mitral valve replacement and median sternotomy. Mild compression deformities of the thoracic spine are unchanged. IMPRESSION: No acute intrathoracic process. Radiology Report EXAMINATION: CTA CHEST INDICATION: ___ year old man with h/o IVDU and endocarditis, here with burning chest pain and malaise after cocaine use// eval for aortic dissection, PE, septic emboli TECHNIQUE: Multidetector CT PA DOSE: Acquisition sequence: 1) Spiral Acquisition 2.6 s, 34.9 cm; CTDIvol = 7.1 mGy (Body) DLP = 246.2 mGy-cm. 2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 1.7 mGy (Body) DLP = 0.8 mGy-cm. 3) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 1.7 mGy (Body) DLP = 0.8 mGy-cm. 4) Stationary Acquisition 2.4 s, 0.5 cm; CTDIvol = 6.8 mGy (Body) DLP = 3.4 mGy-cm. Total DLP (Body) = 251 mGy-cm. COMPARISON: Prior CT chest study done ___ FINDINGS: NECK, THORACIC INLET, AXILLAE, CHEST WALL: Slightly bulky appearance of the thyroid, but no focal thyroid lesions. No supraclavicular or axillary adenopathy. No gross breast lesions. UPPER ABDOMEN: No subdiaphragmatic pathology. MEDIASTINUM: Subcentimeter mediastinal lymph nodes. HILA: Mildly increased hilar peribronchial soft tissue/lymph nodes. HEART and PERICARDIUM: Evidence of prior mitral valve replacement. Left atrial enlargement. There is no pericardial effusion. PLEURA: No pleural effusion. LUNG: 1. PARENCHYMA: Mild biapical pleural-parenchymal scarring. Mild centrilobular pulmonary emphysematous changes. No suspicious pulmonary nodules or masses. No confluent airspace consolidation. 2. AIRWAYS: Small small tracheal diverticulum (series 301, image 81). The airways are patent to the subsegmental level. Mild, but diffuse bronchial wall thickening. 3. VESSELS: The pulmonary artery is mildly enlarged (34 mm) and pulmonary hypertension should be excluded. CHEST CAGE: Degenerative changes of the thoracic spine. No lytic/destructive bony lesions. IMPRESSION: No pulmonary emboli. The pulmonary artery is mildly enlarged, pulmonary arterial hypertension should be excluded. No pneumonia. No suspicious pulmonary nodules or masses. Mild, but diffuse bronchial wall thickening is nonspecific, most likely reflecting underlying bronchial inflammation. Gender: M Race: WHITE - OTHER EUROPEAN Arrive by WALK IN Chief complaint: Chest pain Diagnosed with Chest pain, unspecified, Other fatigue temperature: 97.5 heartrate: 74.0 resprate: 18.0 o2sat: 100.0 sbp: 192.0 dbp: 103.0 level of pain: 1 level of acuity: 3.0

Dear Mr. ___, Thank you for allowing us to take part in your care! WHY WERE YOU ADMITTED: - You were having chest pain and we wanted to figure out why. WHAT HAPPENED IN THE HOSPITAL: - We did bloodwork and a CAT scan, and everything was normal. - We think your chest pain was related to cocaine use. WHAT SHOULD YOU DO AFTER LEAVING: - Follow-up with your doctors as ___. - Take your medications as prescribed. - Please stop using IV drugs, as you have already had multiple heart infections related to drug use. - If you notice severe chest pain, shortness of breath, or headache, please return to the hospital. Thank you for allowing us to take part in your care! your ___ team

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Found down Major Surgical or Invasive Procedure: None History of Present Illness: ___ PMHx hypothyroidism, ___ disorder (___) presents after having been found down for up to 36 hours in his apartment. Difficult to obtain details from the patient who is oriented x 3 but confused as to day of week. Upon further review, the patient notes that he was walking in his house when he might have slipped on the sawdust in his house which is undergoing construction. Limited history possible at the time of assessment given the patient's hoarse voice. Information corroborated with the patient's son. Son notes that there is at least 36 hours of elapsed time during which his father was unaccounted. He advised neighbors and police who entered the house to find the patient down. Vitals upon arrival to ED, 97.6 86 127/76 16 100% . Underwent CT C-spine which revealed pre vertebral edema without fracture; NCHCT without acute intracranial process; TSH 16; fT4 5.1; CK 2193.; SCr 0.8; lactate 1.8. Received 2L IVF and transferred to the floor. Upon arrival to the floor, 98.1 138/62 85 20 99%/RA Review of Systems: (+) (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: ___ Disease (Diagnosed ___, Followed by ___ MD, PhD at ___, ___, ___ Thyroid nodule s/p partial thyroidectomy Hypothyroidism Orthostatic Hypotension Social History: ___ Family History: (Per OMR, unable to review with patient) Sibling deceased from Hodgkin's lymphoma Physical Exam: ADMISSION PHYSICAL EXAM: ------ Vitals: 98.1 138/62 85 20 99%/RA General: Alert, oriented HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: Unable to assess. Lungs: Limited exam. Clear to auscultation bilaterally, no wheezes, rales, ronchi. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: Foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNs2-12 intact, In hard collar. Frothy sputum at mouth. DISCHARGE PHYSICAL EXAM: ---------------- VSS General: Alert, oriented HEENT: Sclera anicteric, MM dry, oropharynx clear Lungs: Decreased at the left base. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: Foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNs2-12 intact, in soft collar. + cog wheeling. strength ___ bilateral upper and lower extremities Pertinent Results: ADMISSION LABS: ------- ___ 10:50AM BLOOD WBC-11.9* RBC-4.72# Hgb-14.3# Hct-44.5# MCV-94 MCH-30.3 MCHC-32.2 RDW-12.6 Plt ___ ___ 10:50AM BLOOD Neuts-84.6* Lymphs-11.1* Monos-3.1 Eos-0.4 Baso-0.7 ___ 10:50AM BLOOD Glucose-116* UreaN-27* Creat-0.8 Na-145 K-3.9 Cl-106 HCO3-23 AnGap-20 ___ 10:50AM BLOOD ALT-40 AST-74* CK(CPK)-2193* AlkPhos-75 TotBili-1.0 ___ 10:50AM BLOOD Lipase-14 ___ 10:50AM BLOOD cTropnT-0.02* ___ 10:50AM BLOOD TSH-16* ___ 10:50AM BLOOD Cortsol-27.4* ___ 10:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 10:59AM BLOOD Lactate-1.8 DISCHARGE LABS: ------ ___ 06:45AM BLOOD WBC-7.9 RBC-3.63* Hgb-10.9* Hct-35.2* MCV-97 MCH-30.1 MCHC-31.0 RDW-12.4 Plt ___ ___ 06:45AM BLOOD Glucose-127* UreaN-14 Creat-0.7 Na-146* K-3.5 Cl-109* HCO3-26 AnGap-15 ___ 06:30AM BLOOD Calcium-8.6 Phos-1.6* Mg-1.7 IMAGING: ----- TRAUMA TORSO PLAIN FILM ___ FINDINGS: CHEST: Underlying trauma board partially obscures the view. The lungs are relatively hyperinflated. No definite focal consolidation is seen. There is no pleural effusion or evidence of pneumothorax. The cardiac silhouette is not enlarged. The aorta is slightly tortuous. There is a minimally displaced fracture of the anterolateral left ninth rib with subtle suggestion of adjacent sclerosis indicating that it may be subacute. There is also a fracture of the lateral left eighth rib again with subtle evidence of callus suggesting that it may not be acute. There are old-appearing fractures of the posterior left ninth and tenth ribs. A non-displaced fracture of the lateral right eighth to ninth ribs on the right is not excluded. PELVIS: There is slight irregularity along the inferomedial aspect of the right femoral neck and a non-displaced possibly slightly impacted fracture is not excluded. Recommend clinical correlation and if clinical concern, dedicated imaging of the right hip. There is no diastasis of the pubic symphysis or sacroiliac joints. IMPRESSION: Left-sided rib fractures as above, some of which appear old, others of which may be subacute. Non-displaced fracture of the lateral right eighth to ninth ribs of indeterminate age not excluded. Please correlate clinically. Slight irregularity along the inferomedial aspect of the right femoral neck, correlate with site of pain and dedicated imaging of the right hip. ___ ___ FINDINGS: There is no evidence of acute intracranial hemorrhage, mass effect, edema or vascular territorial infarction. Ventricles and sulci are appropriate in size and configuration for the patient's age, and periventricular and subcortical white matter hypodensities are likely sequela of chronic small vessel ischemic disease. The basilar cisterns appear patent, and there is preservation of normal gray-white matter differentiation. No fracture is identified. The globes are intact. IMPRESSION: No acute intracranial abnormality. CT C-Spine ___ FINDINGS: There is no evidence of acute fracture or malalignment. There is prevertebral edema seen from C1-C4/C5, ligamentous injury is not excluded. A 5 mm left apical lung nodule is again seen (3:69) along with pleural thickening and scarring. The thyroid gland is unremarkable. IMPRESSION: 1. Prevertebral/retropharyngeal edema anterior to the C1-C4/C5 cervical spine, non-specific but ligamentous injury not excluded. Recommend further evaluation and clinical correlation with MRI. 2. Left 5 mm apical lung nodule. Recommend CT imaging to assess stability in ___ months if patient is at high risk for lung cancer, otherwise in 12 months. Findings were discussed with Dr. ___ by Dr. ___ telephone at approximately 1:30 p.m. on ___ immediately following wet read change. MRI C-Spine ___ FINDINGS: Exaggerated lordosis of the cervical spine is present. Vertebral body alignment is maintained without evidence of subluxation. There is mild loss of height of the C6 vertebral body and with associated STIR hyperintensity and T1 hypointensity. Mildy increased STIR signal is seen within the C5-C6 disc as well mainly at its right aspect. Mild prevertebral edema extends from the level of C2 -through C4- C5, slightly diminished compared to the previous CT examination. There is no evidence for ligamentous disruption. There are areas of focal fat within the T1, T2 and T4 vertebral bodies. C2-C3: A small posterior disc protrusion effaces the ventral subarachnoid space. There is mild right neural foraminal narrowing secondary to uncinate and facet hypertrophy. The left neural foramen is patent. C3-C4: There is a posterior disc protrusion which completely effaces the ventral subarachnoid space and abuts the anterior cervical cord. Mild bilateral neural foraminal narrowing secondary to uncinate and facet hypertrophy. C4-C5: A disc osteophyte complex effaces the ventral subarachnoid space and abuts the anterior cervical cord. Moderate bilateral neural foraminal narrowing at this level secondary to uncinate and facet hypertrophy. C5-C6: A posterior disc bulge is present which effaces the ventral subarachnoid space and abuts the ventral cervical cord. There is moderate bilateral neural foraminal narrowing, right slightly greater than left, secondary to uncovertebral hypertrophy. C6-C7: A posterior disc osteophyte complex partially effaces the ventral subarachnoid space but does not contact the cord although there is mild flattening of the ventral cord at this level. There is moderate left and mild right neural foraminal narrowing secondary to uncovertebral hypertrophy. C7-T1: No significant spinal canal or neural foraminal narrowing is present. IMPRESSION: Mild loss of height of the C6 vertebral body with associated STIR hyperintensity consistent with marrow edema from trauma or degenerative change. Mild prevertebral edema has slightly diminished compared to the previous study CT examination. There is no evidence for ligamentous disruption. Multilevel degenerative changes as described above with disc bulging indenting the cord from C2-3 to C4-5 levels without frank cord compression or abnormal signal within the cervical cord. Medications on Admission: Acetylsalicylic Acid (ASPIRIN) 81 MG PO QD Fludrocortisone Acetate 0.2 MG PO QD Levothyroxine Sodium 100 MCG PO QD Ropinirole Extended Release 12 MG (12 MG TAB ER 24H Take 1) PO TID (Yes, this is the correct dosage and formulation, if Q's call Dr. ___ at ___ Selegiline Hcl 5 MG PO BID Sinemet ___ (CARBIDOPA/LEVODOPA ___ ) 25MG-100MG TABLET 1 tab every 3 hrs, 2 at bed, for total of 8/day; Tasmar (TOLCAPONE) 50 MG with each dose of SInemet (7x/day) Vitamin B12 (CYANOCOBALAMIN) PO QD; No Change (Taking) Discharge Medications: 1. Carbidopa-Levodopa (___) 2 TAB PO Q3H *** THIS IS DOUBLE HOME DOSE WHILE PATIENT IS UNABLE TO TAKE TOLCAPONE*** 2. Carbidopa-Levodopa (___) 2 TAB PO HS *** THIS IS DOUBLE HOME DOSE WHILE PATIENT IS UNABLE TO TAKE TOLCAPONE*** 3. Fludrocortisone Acetate 0.2 mg PO DAILY 4. Levothyroxine Sodium 100 mcg PO DAILY 5. Selegiline HCl 5 mg PO BID 6. Ropinirole 12 mg PO TID 7. Aspirin 81 mg PO DAILY 8. Cyanocobalamin 50 mcg PO DAILY 9. Senna 1 TAB PO BID 10. Tasmar (tolcapone) 50 mg ORAL Q3H ***PATIENT IS CURRENTLY UNABLE TO TAKE THIS AS IT CANNOT BE CRUSHED-- SINEMET DOUBLED FOR NOW*** 11. trospium 20 mg oral bid 12. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES: RETROPHARYNGEAL EDEMA ___ DISEASE RHABDOMYOLYSIS DEHYDRATION SECONDARY DIAGNOSES: HYPOTHYROIDISM Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAM: Single supine AP portable view of the chest and single supine AP portable view of the pelvis. CLINICAL INFORMATION: Found down. ___. FINDINGS: CHEST: Underlying trauma board partially obscures the view. The lungs are relatively hyperinflated. No definite focal consolidation is seen. There is no pleural effusion or evidence of pneumothorax. The cardiac silhouette is not enlarged. The aorta is slightly tortuous. There is a minimally displaced fracture of the anterolateral left ninth rib with subtle suggestion of adjacent sclerosis indicating that it may be subacute. There is also a fracture of the lateral left eighth rib again with subtle evidence of callus suggesting that it may not be acute. There are old-appearing fractures of the posterior left ninth and tenth ribs. A non-displaced fracture of the lateral right eighth to ninth ribs on the right is not excluded. PELVIS: There is slight irregularity along the inferomedial aspect of the right femoral neck and a non-displaced possibly slightly impacted fracture is not excluded. Recommend clinical correlation and if clinical concern, dedicated imaging of the right hip. There is no diastasis of the pubic symphysis or sacroiliac joints. IMPRESSION: Left-sided rib fractures as above, some of which appear old, others of which may be subacute. Non-displaced fracture of the lateral right eighth to ninth ribs of indeterminate age not excluded. Please correlate clinically. Slight irregularity along the inferomedial aspect of the right femoral neck, correlate with site of pain and dedicated imaging of the right hip. Radiology Report HISTORY: Found down, evaluate for fracture or dislocation. TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without the administration of IV contrast material. Reformatted coronal and sagittal and thin section bone algorithm reconstructed images were obtained. COMPARISON: Non-enhanced CT of the head from ___. FINDINGS: There is no evidence of acute intracranial hemorrhage, mass effect, edema or vascular territorial infarction. Ventricles and sulci are appropriate in size and configuration for the patient's age, and periventricular and subcortical white matter hypodensities are likely sequela of chronic small vessel ischemic disease. The basilar cisterns appear patent, and there is preservation of normal gray-white matter differentiation. No fracture is identified. The globes are intact. IMPRESSION: No acute intracranial abnormality. Radiology Report HISTORY: Found down, evaluate for fracture or dislocation. TECHNIQUE: Contiguous axial MDCT images were obtained from the skull base to the T2 level. Reformatted coronal and sagittal axis images were obtained. COMPARISON: CT C-spine from ___. FINDINGS: There is no evidence of acute fracture or malalignment. There is prevertebral edema seen from C1-C4/C5, ligamentous injury is not excluded. A 5 mm left apical lung nodule is again seen (3:69) along with pleural thickening and scarring. The thyroid gland is unremarkable. IMPRESSION: 1. Prevertebral/retropharyngeal edema anterior to the C1-C4/C5 cervical spine, non-specific but ligamentous injury not excluded. Recommend further evaluation and clinical correlation with MRI. 2. Left 5 mm apical lung nodule. Recommend CT imaging to assess stability in ___ months if patient is at high risk for lung cancer, otherwise in 12 months. Findings were discussed with Dr. ___ by Dr. ___ telephone at approximately 1:30 p.m. on ___ immediately following wet read change. Radiology Report HISTORY: ___ man with ___ and fall with prevertebral swelling on CT cervical spine now with difficulty managing secretions. TECHNIQUE: Multiplanar, multi sequence MR images of the cervical spine were obtained without the use of intravenous contrast. COMPARISON: CT cervical spine dated ___. FINDINGS: Exaggerated lordosis of the cervical spine is present. Vertebral body alignment is maintained without evidence of subluxation. There is mild loss of height of the C6 vertebral body and with associated STIR hyperintensity and T1 hypointensity. Mildy increased STIR signal is seen within the C5-C6 disc as well mainly at its right aspect. Mild prevertebral edema extends from the level of C2 -through C4- C5, slightly diminished compared to the previous CT examination. There is no evidence for ligamentous disruption. There are areas of focal fat within the T1, T2 and T4 vertebral bodies. C2-C3: A small posterior disc protrusion effaces the ventral subarachnoid space. There is mild right neural foraminal narrowing secondary to uncinate and facet hypertrophy. The left neural foramen is patent. C3-C4: There is a posterior disc protrusion which completely effaces the ventral subarachnoid space and abuts the anterior cervical cord. Mild bilateral neural foraminal narrowing secondary to uncinate and facet hypertrophy. C4-C5: A disc osteophyte complex effaces the ventral subarachnoid space and abuts the anterior cervical cord. Moderate bilateral neural foraminal narrowing at this level secondary to uncinate and facet hypertrophy. C5-C6: A posterior disc bulge is present which effaces the ventral subarachnoid space and abuts the ventral cervical cord. There is moderate bilateral neural foraminal narrowing, right slightly greater than left, secondary to uncovertebral hypertrophy. C6-C7: A posterior disc osteophyte complex partially effaces the ventral subarachnoid space but does not contact the cord although there is mild flattening of the ventral cord at this level. There is moderate left and mild right neural foraminal narrowing secondary to uncovertebral hypertrophy. C7-T1: No significant spinal canal or neural foraminal narrowing is present. IMPRESSION: Mild loss of height of the C6 vertebral body with associated STIR hyperintensity consistent with marrow edema from trauma or degenerative change. Mild prevertebral edema has slightly diminished compared to the previous study CT examination. There is no evidence for ligamentous disruption. Multilevel degenerative changes as described above with disc bulging indenting the cord from C2-3 to C4-5 levels without frank cord compression or abnormal signal within the cervical cord. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: S/P FALL Diagnosed with DEHYDRATION, RHABDOMYOLYSIS temperature: 97.6 heartrate: 86.0 resprate: 16.0 o2sat: 100.0 sbp: 127.0 dbp: 76.0 level of pain: 0 level of acuity: 1.0

Dear Mr. ___, It was a privilege caring for you at ___. You were admitted because you were found on the ground in your apartment. You underwent imaging of your neck and head which did not reveal any fractures. You sustained an injury to your neck "whiplash" which caused swelling at the back of your throat, which made it difficult to swallow. You were kept in a soft collar neck brace for your comfort and should follow up with orthopedics (Dr. ___ in ___ weeks. While the swelling continues to improve, it will remain difficult to swallow. Your diet will be initially restricted to consistencies which decreases the risk that food and drink inappropriately pass down your windpipe instead of your esophagus. While you are having difficulty swallowing, your medications are given crushed in applesauce. Unfortunately your tolcapone cannot be crushed, so while you are unable to take this, we are doubling your dosage of sinemet to prevent worsening ___ symptoms. Once you are able to swallow better again your medications should be changed back to the previous doses. We wish you and your wife a speedy recovery. Best, Your ___ team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: pelvic pain Major Surgical or Invasive Procedure: bilateral percutaneous nephrostomy tube placement History of Present Illness: ___ yo male with advanced prostate cancer, with suprapubic catheter and home hospice care for past month presents with right groin/pelvic pain and renal failure. Per patient and wife, home hospice care had been working well until a few weeks ago, when he started developing constant bladder spasms, right groin pain, and urgency. Oxycontin was converted to methadone, and various anti-spasmodics have been tried; he is currently on Pyridium. This week, his home hospice nurse attempted to replace suprapubic catheter, has since noted drainage of blood tinged fluid from around suprapubic catheter. Continues to have urine output from cath, although minimal over past few days. Approximately 3 days prior to presentation patient noted shaking chills and fever to 100.8, and was started on levofloxacin. On the morning prior to ED presentation, he had worsening symptoms, not relieved with oxycodone, and presented to the ED later on that day. In the ED, urology replaced his suprapubic catheter without complication, and patient was admitted for further evaluation and management. He received morphine 5 mg IV x 3 ED with excellent pain control. Currently, the patient is without complaint, and feels well resting in bed. 12 point ROS as noted above, otherwise negative. Past Medical History: Hypertension Colonic polyps Hyperlipidemia Cataract Macular degeneration history of Zoster Social History: ___ Family History: not pertinent to this hospitalization Physical Exam: VS: 98.4 BP 112/64 HR 80 RR 18 93% RA General: elderly male, very pleasant, hard of hearing, no distress HEENT: anicteric sclerae, temporal wasting CV: RRR, normal S1, S2, no m,r,g Pulm: clear lungs bilaterally, comfortable Abdomen: suprapubic catheter in place, minimal output, no abdominal tenderness, no evidence of suprapubic distention MSK: bilateral ___ edema, trace; hips without pain on passive range of motion, no spinal process tenderness Neuro: CNs II-XII intact, strength and sensation grossly intact, ambulatory with cane and one assist Psych: appropriate, insightful Pertinent Results: ___ 07:15AM BLOOD WBC-15.0* RBC-3.02* Hgb-8.5* Hct-27.1* MCV-90 MCH-28.1 MCHC-31.2 RDW-15.7* Plt ___ ___ 07:15AM BLOOD WBC-12.6* RBC-3.10* Hgb-8.5* Hct-28.7* MCV-93 MCH-27.5 MCHC-29.8* RDW-15.4 Plt ___ ___ 07:55AM BLOOD WBC-14.9* RBC-3.48* Hgb-9.7* Hct-31.5* MCV-91 MCH-27.9 MCHC-30.8* RDW-16.4* Plt ___ ___ 08:00AM BLOOD WBC-12.7* RBC-3.58* Hgb-9.8* Hct-32.5* MCV-91 MCH-27.5 MCHC-30.3* RDW-15.3 Plt ___ ___ 04:25AM BLOOD WBC-8.9 RBC-3.09* Hgb-8.5* Hct-27.6* MCV-89 MCH-27.6 MCHC-30.8* RDW-15.4 Plt ___ ___ 09:05PM BLOOD WBC-8.5 RBC-3.24* Hgb-8.9*# Hct-28.7* MCV-89 MCH-27.5# MCHC-31.1 RDW-15.4 Plt ___ ___ 09:05PM BLOOD Neuts-93.1* Lymphs-3.6* Monos-1.8* Eos-1.3 Baso-0.1 ___ 04:25AM BLOOD ___ ___ 07:15AM BLOOD Glucose-96 UreaN-26* Creat-1.4* Na-139 K-4.7 Cl-102 HCO3-26 AnGap-16 ___ 07:15AM BLOOD UreaN-35* Creat-1.8* Na-137 K-5.1 Cl-102 HCO3-26 AnGap-14 ___ 07:55AM BLOOD Glucose-110* UreaN-38* Creat-2.6* Na-139 K-5.4* Cl-102 HCO3-28 AnGap-14 ___ 04:25AM BLOOD Glucose-105* UreaN-55* Creat-4.6*# Na-131* K-5.5* Cl-99 HCO3-24 AnGap-14 ___ 07:15AM BLOOD Phos-2.4*# Mg-2.0 ___ 08:00AM BLOOD Calcium-8.9 Phos-4.2 Mg-2.8* ___ 04:25AM BLOOD Calcium-7.8* Phos-4.3 Mg-3.0* ___ 04:25AM BLOOD Osmolal-290 . ___ URINE URINE CULTURE-PENDING INPATIENT ___ URINE URINE CULTURE-FINAL INPATIENT ___ URINE URINE CULTURE-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL {CANCELLED} EMERGENCY WARD ___ BLOOD CULTURE Blood Culture, Routine-FINAL {CANCELLED} EMERGENCY WARD ___ URINE URINE CULTURE-FINAL EMERGENCY . Renal u/s: IMPRESSION: New bilateral hydronephrosis, mild on the right and mild to moderate on the left. The urinary bladder could not be assessed. ___ 07:10AM BLOOD WBC-12.7* RBC-3.24* Hgb-8.9* Hct-28.2* MCV-87 MCH-27.5 MCHC-31.6 RDW-17.1* Plt ___ ___ 07:10AM BLOOD WBC-15.3* RBC-3.27* Hgb-9.1* Hct-28.3* MCV-87 MCH-27.9 MCHC-32.2 RDW-16.8* Plt ___ ___ 07:10AM BLOOD Glucose-116* UreaN-24* Creat-1.1 Na-135 K-4.5 Cl-99 HCO3-25 AnGap-16 ___ 07:10AM BLOOD Glucose-110* UreaN-25* Creat-1.2 Na-135 K-4.3 Cl-99 HCO3-27 AnGap-13 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 5 mg PO DAILY hold for SBP < 100, HR < 55 2. Docusate Sodium 100 mg PO BID 3. Enablex *NF* (darifenacin) 15 mg Oral daily 4. Furosemide 20 mg PO DAILY 5. Methadone 2.5 mg PO TID 6. Polyethylene Glycol 17 g PO DAILY 7. Phenazopyridine 100 mg PO TID 8. Mirtazapine 7.5 mg PO HS 9. Senna 2 TAB PO TID 10. Acetaminophen 325-650 mg PO Q6H:PRN pain 11. atropine *NF* ___ drops SL Q4H secretions 12. Bisacodyl ___AILY:PRN constipation 13. Fleet Enema ___AILY:PRN constipation 14. Haloperidol 0.5-2 mg PO TID:PRN restlessness 15. Ibuprofen 400 mg PO Q8H:PRN pain 16. Lorazepam 0.5-2 mg PO Q4H:PRN restlessness 17. Ondansetron 8 mg PO Q8H:PRN nausea 18. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 19. OxycoDONE (Concentrated Oral Soln) ___ mg PO Q1H:PRN pain, respiratory distress Discharge Medications: 1. Bisacodyl ___AILY:PRN constipation 2. Docusate Sodium 100 mg PO BID 3. Mirtazapine 7.5 mg PO HS 4. Ondansetron 8 mg PO Q8H:PRN nausea 5. Polyethylene Glycol 17 g PO DAILY 6. Senna 2 TAB PO TID 7. Milk of Magnesia 30 mL PO Q6H:PRN constipation can be purchased over the counter 8. Acetaminophen 325-650 mg PO Q6H:PRN pain 9. Amlodipine 5 mg PO DAILY 10. atropine *NF* ___ drops SL Q4H secretions 11. Fleet Enema ___AILY:PRN constipation 12. Haloperidol 0.5-2 mg PO TID:PRN restlessness 13. Lorazepam 0.5-2 mg PO Q4H:PRN restlessness 14. Lidocaine 5% Patch 1 PTCH TD DAILY 15. Morphine Sulfate (Concentrated Oral Soln) ___ mg PO Q1H:PRN pain/dyspnea concentration=50mg/ml. dispense 60ml RX *morphine concentrate 100 mg/5 mL (20 mg/mL) ___ mg by mouth q1hr prn. Disp ___ Milliliter Refills:*0 16. Oxybutynin 5 mg PO TID RX *oxybutynin chloride 5 mg 1 tablet(s) by mouth three times a day Disp #*21 Tablet Refills:*0 17. Morphine Sulfate ___ ___ mg PO Q3H:PRN pain ___ q3hrs. PLease given 30mg ___ RX *morphine 15 mg ___ tablet(s) by mouth q3hrs Disp #*60 Tablet Refills:*0 18. Fentanyl Patch 25 mcg/h TD Q72H Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Renal failure due to post obstructive uropathy Advanced prostate cancer Constipation Discharge Condition: Mental Status: Clear and coherent, occasionally confused with medication. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report INDICATION: Advanced prostate cancer, suprapubic catheter, admitted from home with pelvic pain and renal failure, likely post-obstructive. Please evaluate for urinary tract obstruction. COMPARISON: Renal ultrasound of ___. TECHNIQUE: Renal ultrasound. FINDINGS: The right kidney measures 12.9 cm. The left kidney measures 11.0 cm. There is bilateral hydronephrosis, mild on the right and mild-to-moderate on the left, which is new from the prior ultrasound. The ureters are not well visualized, and the urinary bladder could not be visualized due to dressing material and the presence of a suprapubic catheter. No renal stones or masses are appreciated. IMPRESSION: New bilateral hydronephrosis, mild on the right and mild to moderate on the left. The urinary bladder could not be assessed. Results were discussed via telephone with ___ by Dr. ___ on ___ at 4:32 p.m. Radiology Report INDICATION: ___ man with advanced prostate cancer admitted with renal failure and bilateral hydronephrosis, please place bilateral percutaneous nephrostomy tube. PHYSICIANS: Dr. ___ (radiology fellow), Dr. ___ ___ (radiology attending) who was present throughout and supervised the procedure. MEDICATION: The patient received 100 mcg of fentanyl and 2 mg of Versed in divided doses for a total intraservice time of 1 hour and 3 minutes, during which time the patient's hemodynamic parameters were continuously monitored. In addition, the patient received 1 g of cefazolin prior to the procedure. RADIATION: 11.1 minutes of fluoroscopy time. PROCEDURE: 1. Bilateral 8 ___ percutaneous nephrostomy placement. PROCEDURE DETAILS: Following discussion of the risks, benefits and alternatives to the procedure, informed written patient consent was obtained. The patient was brought to the angiographic suite and placed prone on the table. A preprocedure timeout was performed using three patient identifiers. The skin overlying both kidneys was prepped and draped in the usual sterile fashion. Initial limited ultrasound demonstrated bilateral hydronephrosis. Approximately 6 cc of 1% lidocaine was infiltrated into the skin and subcutaneous tissues bilaterally prior to accessing the lower pole calices using a Cook 21-gauge needle. Contrast was injected via the needle to confirm access to the collecting system and a nitinol wire was advanced through the needle. A small skin incision was made and an AccuStick sheath was advanced over the needle. On the left side using a combination of a Glidewire and a 5 ___ sheath, we did attempt to access the distal ureter. The proximal ureter was readily navigated; however, the distal ureter was extremely tortuous and although the Glidewire did eventually pass into the bladder, the patient experienced mild discomfort at the sensation. Therefore, we elected not to place a nephroureteral stent at this time. ___ wire was advanced through the AccuStick sheath which was removed and dilatation was performed over the wire with an 8 ___ dilator followed by placement of bilateral 8 ___ nephrostomy tube. Positioning of both tubes was confirmed by injection of a small amount of contrast. Both catheters were sutured to the skin with a 0 silk suture and a Flexi-Trak was also placed for security. Sterile dressings were applied and the catheters were attached to bag for free drainage. There were no immediate post-procedure complications. IMPRESSION: 1. Technically successful placement of bilateral 8 ___ nephrostomy tube. 2. Tortuous distal left ureter consistent with extrinsic compression. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: SUPERPUBIC PAIN Diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED, SECOND MALIG NEO GENITAL, HX-PROSTATIC MALIGNANCY, HYPERTENSION NOS temperature: 98.6 heartrate: 92.0 resprate: 16.0 o2sat: 98.0 sbp: 148.0 dbp: 66.0 level of pain: 9 level of acuity: 3.0

You were admitted to the hospital with pelvic pain and kidney failure. Your pain was better controlled by adjusting your pain medications and by addressing constipation. You were also found to have kidney failure which was due to obstruction from prostate cancer; this was managed with tubes placed in the back to drain each kidney. Your kidney function improved. . Please see below for your medications. . The urology doctors also ___ and replaced your suprapubic catheter. You were started on a medication for potential bladder spasms. . You will continue to be followed closely by Hospice of ___ ___ when you return home.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Headache, vomiting Major Surgical or Invasive Procedure: none History of Present Illness: REASON FOR CONSULTATION: headache, vomiting HPI: Mr. ___ is a ___ man with past medical history of HTN, HLD, poorly controlled DM, CAD, and recent admission for right ICA and MCA occlusion s/p TPA, ICA stent placement, and thrombectomy with TICI3 reperfusion with ___ hemorrhagic transformation who presented as a transfer from ___ for severe headache, nausea and vomiting. Patient was interviewed with telephone ___ interpreter. Per patient he has had a persistent daily headaches since his stroke though they have always been tolerable. He says the headaches are usually all over his head none one particular location. Today at 2 ___ at his rehab the headache gradually became quite severe. Headache was initially located posteriorly and then migrated to the front of his head. He describes the pain as a "tight" pain that was holocephalic. The severe headache was associated with nausea and vomiting in addition to photophobia and phonophobia. He says the headache improved some after vomiting. He was taken to ___ where he was given Zofran, Tylenol with some improvement of his headache. His vitals on arrival at ___ were: T98.2, HR 102, RR16, BP 183/93. He had a CT at the outside hospital that showed area of prior infarct and hemorrhagic conversion. ___ was unable to compare to prior imaging and transferred patient for further evaluation and workup. In addition to his headache he has some mild neck pain but thinks it is due to the pillow. He also endorses some diarrhea and mild abdominal pain. The diarrhea he says started on ___ and has continued. Otherwise he denies any new or worsening weakness, sensory changes, difficulty speaking, or difficulty understanding what other people are saying. The dizziness and nausea have completely resolved now though he does still have a mild headache. He says he has had headaches before his stroke but they were never this severe. He denies any history of migraines. In reguards to his recent admission patient was discharge on ___ after R ICA and MCA occlusion s/p TPA, thrombectomy and ICA stenting, with ___ hemorrhagic conversion. His deficits at discharge were largely left hemiparesis. He was discharged on ASA 81mg and Plavix 75mg. He also had issues with urinary retention during that hospitalization that required straight catheterization. Per patient he did not have a foley at rehab but one was placed when he was at ___ this evening. On neuro ROS, pertinent positives in HPI, currently the pt denies loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies new focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. On ___ review of systems, patient endorses diarrhea and mild abdominal pain, nausea and vomiting with headache. the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Time (and date) the patient was last known well:1400 ___ (24h clock) ___ Stroke Scale Score: 9 t-PA given: No Reason t-PA was not given or considered: outside window, recent IPH, recent ischemic stroke I was present during the CT scanning and reviewed the images instantly within 20 minutes of their completion. The NIHSS was performed: Date: ___ Time: 0400 (within 6 hours of patient presentation or neurology consult) ___ Stroke Scale score was : 9 1a. Level of Consciousness: 0 1b. LOC Question: 0 1c. LOC Commands: 0 2. Best gaze: 0 3. Visual fields: 0 4. Facial palsy: 2* 5a. Motor arm, left: 2* 5b. Motor arm, right: 0 6a. Motor leg, left: 2* 6b. Motor leg, right: 0 7. Limb Ataxia: 1* 8. Sensory: 1 9. Language: 0 10. Dysarthria: 1* 11. Extinction and Neglect: 0 *Prior deficits noted in discharge exam from right MCA infarct* Past Medical History: Diabetes mellitus Hypertension Hyperlipidemia Social History: Currently patient is living at ___ ___. He does not smoke cigarettes, drink alcohol or use any drugs - Modified Rankin Scale: [] 0: No symptoms [] 1: No significant disability - able to carry out all usual activities despite some symptoms [] 2: Slight disability: able to look after own affairs without assistance but unable to carry out all previous activities [] 3: Moderate disability: requires some help but able to walk unassisted [x] 4: Moderately severe disability: unable to attend to own bodily needs without assistance and unable to walk unassisted [] 5: Severe disability: requires constant nursing care and attention, bedridden, incontinent [] 6: Dead Family History: No family history of strokes in members younger than ___. Physical Exam: ADMISSION PHYSICAL EXAM: Physical Exam: Vitals: T98.8, HR82, BP 176/90, RR18, 97% RA ___: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, No nuchal rigidity Pulmonary: Normal work of breathing Cardiac: warm, well-perfused Abdomen: soft, non-distended Extremities: No ___ edema. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty in ___. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Able to read without difficulty. +Dysarthria most significant with lingual and labial, Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. Fundoscopic exam revealed no papilledema, exudates, or hemorrhages on the left, unable to visualize on the right V: Facial sensation decreased to light touch and pinprick on the left V2-V3 VII: left facial droop, mild left ptosis, eye closure is strong bilaterally VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in SCM bilaterally, right shoulder shrug ___, left sluggish movement at least ___ XII: Tongue protrudes to the left, slow movements to the left. Strength full with tongue-in-cheek testing on right, weak on left -Motor: Normal bulk, increased tone in left upper and lower extremity No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FE IP Quad Ham TA Gastroc L 4- 4 4+ 3+ ___ 4- 3 5 R ___ ___ 5 5 5 5 -Sensory: Decreased sensation to light touch on the left upper extremity compared to the right, decreased pinprick on the left upper extremity compared to the right, intact in bilateral lower extremities, early extinction to vibration in bilateral toes (5 seconds bilaterally), intact in upper extremities though slightly less on left (10 seconds on left, 15 on right), proprioception intact in upper extremities and intact to large movements in bilateral lower extremities, no extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L 3+ 2 3+ 3+ 4 R 2 2 2 2 1 Plantar response was flexor on right, mute on left +sustained clonus on left suprapatellar reflex on left patella -Coordination: Right FTN is fast and smooth, left is slow with overshoot, slightly out of proportion to his weakness. Finger tapping is slowed and clumsy on left, fast and smooth on right -Gait: deferred as patient is non ambulatory after stroke ==================================================== DISCHARGE EXAM: Vitals: T98.1, HR 72, BP 140/85, RR 16, 96% RA ___: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple Pulmonary: Normal work of breathing Cardiac: warm, well-perfused Extremities: No ___ edema. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert Language is fluent Normal prosody. There were no paraphasic errors. Able to follow both midline and appendicular commands. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. VII: mild left facial droop, mild left ptosis, eye closure is strong bilaterally VIII: Hearing intact to conversation. IX, X: Palate elevates symmetrically. XI: ___ strength in SCM bilaterally, right shoulder shrug ___, left sluggish movement at least ___ -Motor: Normal bulk, increased tone in left upper and lower extremity No adventitious movements, such as tremor, noted. No asterixis noted. Pronator drift on left UE. Left UE ___ with increased tone, left ___ ___. -Sensory: Reports symmetric and intact on both sides to light touch, no extinction to DSS. -Coordination: intact FTN with right arm Pertinent Results: ___ 04:46AM URINE HOURS-RANDOM ___ 04:46AM URINE UHOLD-HOLD ___ 04:46AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 04:46AM URINE BLOOD-TR* NITRITE-NEG PROTEIN-TR* GLUCOSE-300* KETONE-TR* BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-MOD* ___ 04:46AM URINE RBC-12* WBC-11* BACTERIA-FEW* YEAST-NONE EPI-0 ___ 04:46AM URINE MUCOUS-RARE* ___ 03:41AM GLUCOSE-268* UREA N-7 CREAT-0.6 SODIUM-137 POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-27 ANION GAP-11 ___ 03:41AM estGFR-Using this ___ 03:41AM CALCIUM-9.5 PHOSPHATE-3.2 MAGNESIUM-2.0 ___ 03:41AM WBC-10.1* RBC-4.87 HGB-14.2 HCT-41.4 MCV-85 MCH-29.2 MCHC-34.3 RDW-12.9 RDWSD-39.8 ___ 03:41AM NEUTS-70.9 LYMPHS-18.4* MONOS-7.9 EOS-2.1 BASOS-0.4 IM ___ AbsNeut-7.14* AbsLymp-1.85 AbsMono-0.80 AbsEos-0.21 AbsBaso-0.04 ___ 03:41AM PLT COUNT-219 ___ 03:41AM ___ PTT-31.2 ___ ___ 06:19AM BLOOD WBC-6.4 RBC-4.58* Hgb-13.2* Hct-39.3* MCV-86 MCH-28.8 MCHC-33.6 RDW-13.0 RDWSD-39.8 Plt ___ ___ 03:41AM BLOOD Neuts-70.9 Lymphs-18.4* Monos-7.9 Eos-2.1 Baso-0.4 Im ___ AbsNeut-7.14* AbsLymp-1.85 AbsMono-0.80 AbsEos-0.21 AbsBaso-0.04 ___ 06:19AM BLOOD Plt ___ ___ 06:19AM BLOOD ___ PTT-32.2 ___ ___ 06:19AM BLOOD Glucose-118* UreaN-5* Creat-0.6 Na-143 K-3.9 Cl-104 HCO3-24 AnGap-15 ___ 06:19AM BLOOD Calcium-9.3 Phos-4.4 Mg-2.1 ___ 06:38AM BLOOD Triglyc-100 HDL-35* CHOL/HD-5.3 LDLcalc-131* ___ 06:38AM BLOOD %HbA1c-9.9* eAG-237* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 80 mg PO DAILY 2. Lisinopril 20 mg PO DAILY 3. Famotidine 20 mg PO BID 4. MetFORMIN (Glucophage) 1000 mg PO BID 5. Aspirin 81 mg PO DAILY 6. Clopidogrel 75 mg PO DAILY 7. amLODIPine 5 mg PO DAILY 8. Sertraline 25 mg PO DAILY 9. Baclofen 5 mg PO TID:PRN Pain - Moderate 10. Finasteride 5 mg PO DAILY 11. Tamsulosin 0.4 mg PO DAILY 12. Artificial Tears 1 DROP BOTH EYES TID 13. Artificial Tear Ointment 1 Appl LEFT EYE QHS Discharge Medications: 1. Amoxicillin 500 mg PO Q8H 2. amLODIPine 5 mg PO DAILY 3. Artificial Tear Ointment 1 Appl LEFT EYE QHS 4. Artificial Tears 1 DROP BOTH EYES TID 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 80 mg PO DAILY 7. Baclofen 5 mg PO TID:PRN Pain - Moderate 8. Clopidogrel 75 mg PO DAILY 9. Famotidine 20 mg PO BID 10. Finasteride 5 mg PO DAILY 11. Lisinopril 20 mg PO DAILY 12. MetFORMIN (Glucophage) 1000 mg PO BID 13. Sertraline 25 mg PO DAILY 14. Tamsulosin 0.4 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Sequelae of Right MCA stroke with hemorrhagic transformation ___ edema 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: CTA HEAD AND CTA NECK Q16 CT NECK INDICATION: History: ___ with prior R MCA infarct s/p TPA and thrombectomy with new headache and sensory changes, worsening edema on OSH scan// evaluate for new vessel occlusion, infarct *Please get CVT to evaluate for CVST* TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 802.7 mGy-cm. 2) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 59.9 mGy (Head) DLP = 30.0 mGy-cm. 3) Spiral Acquisition 2.5 s, 19.7 cm; CTDIvol = 30.0 mGy (Head) DLP = 592.2 mGy-cm. 4) Spiral Acquisition 5.1 s, 39.8 cm; CTDIvol = 31.1 mGy (Head) DLP = 1,238.4 mGy-cm. 5) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 3,466 mGy-cm. COMPARISON: Brain MR and MRA ___. Head CT ___. FINDINGS: CT head: Evolving right basal ganglia intraparenchymal hematoma appears overall unchanged measuring approximately 2.2 x 2.1 cm. Surrounding edema which extends inferiorly into the right temporal lobe is overall unchanged or minimally increased from the most recent CT given differences in scan. Similarly mass effect of the right lateral ventricle is overall unchanged. Minimal 1-2 mm of leftward midline shift appears minimally increased. The basal cisterns are patent. Slight asymmetric prominence of the temporal horn of the right lateral ventricle with trace surrounding edema may be minimally increased suggesting trapping with very mild hydrocephalus versus extension the existing edema (08:12). No new intracranial hemorrhage or definite infarct. CTA head: Patent circle ___ and ___ tributaries. There is narrowing and irregularity dense calcification of the right greater than left vertebral artery V4 segment with moderate focal narrowing on the right and are widely patent distally. Dural venous sinuses are patent. Atherosclerotic calcification the supraclinoid internal carotid arteries bilaterally causes mild narrowing on the left. CTV neck: Bolus timing moderately limits evaluation. Crossing the right carotid bifurcation, a metallic stent demonstrates intraluminal enhancement and unchanged vessel caliber proximal and distal to it suggesting patency. Within the limits of the study, the visualized carotid and vertebral arteries appear patent. OTHER: The visualized portion of the lungs are clear. The visualized portion of the thyroid gland is within normal limits. There is no lymphadenopathy by CT size criteria. IMPRESSION: 1. Evolving right putaminal and adjacent white matter hematoma with edema and mass-effect. The edema appears unchanged to slightly more prominent compared to ___ but markedly increased since ___. 2. Limited view of the neck due to bolus timing. The vertebral and internal carotid arteries appear patent but are not well characterized. 3. Right carotid stent in place with apparent patency of the vessel. Radiology Report EXAMINATION: MR HEAD W/O CONTRAST ___ MR HEAD INDICATION: ___ year old man with h/o right ICA and MCA occlusion w hemorrhagic transformation of stroke, now with worsening of headache, no DVST on CTV// eval for stroke TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was performed with gradient echo, FLAIR, diffusion, and T2 technique were then obtained. COMPARISON MRI and MRA of the brain from ___ and CTA of the head and neck from ___ FINDINGS: Redemonstration of evolution of the putaminal intraparenchymal hematoma which appears unchanged from the prior CT, measuring approximately 2.3 x 2.1 cm (AP X TR). There is surrounding edema that extends inferiorly into the right temporal lobe, unchanged from the most recent prior CT. There is similar mass effect on the right lateral ventricle with partial effacement and 1 to 2 mm leftward midline shift, unchanged. The basal cisterns remain patent. There is no crowding at the level of the foramen magnum. There is no evidence of new hemorrhage. There is mild mucosal thickening in the left maxillary sinus. The remainder of the paranasal sinuses mastoid air cells appears clear. The orbits appear grossly unremarkable. IMPRESSION: 1. Evolution of the right putamen hematoma with surrounding edema, unchanged from the most recent prior CT but increased from initial presentation. 2. No significant change of mild 1-2 mm leftward midline shift with partial effacement of the right lateral ventricle and mild asymmetric prominence of the temporal horn of the right lateral ventricle. 3. No new intracranial abnormality identified. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: CVA, Headache, Transfer Diagnosed with Headache temperature: 98.8 heartrate: 82.0 resprate: 18.0 o2sat: 97.0 sbp: 176.0 dbp: 90.0 level of pain: 1 level of acuity: 2.0

Mr. ___, You were admitted to ___ due to headache, vomiting. On brain imaging, we found that the bleed in your known stroke from previous admission was stable, but the swelling around this brain bleed was increased. This swelling can increase up to 3 weeks after initial brain bleed, therefore we felt your symptoms were caused by the expected increase in the swelling around the known bleed. As your headache and vomiting improved soon after presentation, we did not have to give you medications to lower pressure in the brain. We also found that you had a Urinary tract infection, therefore we started you an antibiotic to treat this. [ ] Please take amoxicillin by mouth till ___ for urine infection. [ ] continue other medications as prescribed. You were seen by our physical therapist who recommendation continuation of rehabilitation. You were discharged to rehab on ___. It was a pleasure taking care of you, Sincerely ___ Neurology Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: vancomycin Attending: ___. Chief Complaint: Tb rule out; rash Major Surgical or Invasive Procedure: NONE History of Present Illness: ___ year old woman with a PMH of HIV, HCV, IVDU, chronic pain admitted from ___ to ___ with MRSA vertebral osteomyelitis, paraspinal abscess and arachnoiditis/meningeal enhancement. . The patient presented on her PREVIOUS Admission to an OSH with severe lumbar pain. An LP was performed and showed WBC 59K with cultures growing MRSA. Blood cultures also grew MRSA. MRI was performed after the LP showed a 3.1 x 1.6 cm abscess in the right paraspinal musculature at the L3-5 level with involvement of the right L4-5 facet joint and the L4 spinous process with additional leptomeningeal enhancement. It was unclear if the LP fluid that was obtained was from the abscess or from the spinal fluid, given the close proximity and the unknown presence of abscess at the time of LP. The patient was given vancomycin, ceftriaxone and acyclovir and was transfered to ___. On arrival to ___ she was intubated due to altered mental status. . Neurosurgery evaluated the patient and she underwent ___ guided drainage of her paraspinal abscess, cultures also grew MRSA. She was continued on vancomycin alone. She was taken back for repeat ___ guided drainage of her abscess on ___ with and a drain was removed prior to discharge. TTE revealed no vegetations. She was discharged on vancomycin with a planned prolonged duration of therapy. Her ID follow up was transitioned to her PCP prior to discharge. . After discharge her ___ abscess fluid grew AFB with speciation pending. Due to this, and a truncal rash, she was referred back to the ___ for admission ___ At the time of admission, she reported feeling better and her abscess continuing to heal. She still doesn't walk back to normal, but is constantly improving. No fevers/chills/SOB/CP/N/V/D/C. In the ED, 98.4 84 100/73 16 98%. On the floor, patient is comfortable, NAD, but anxious. Past Medical History: HIV IVDA - including heroin. on methadone. h/o PE chronic low back pain Social History: ___ Family History: Unknown. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T:98.2 BP:108/82 P:88 R:20 O2:98RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, S4 gallop appreciated Abdomen: soft, non-tender, non-distended, bowel sounds present. Escoriations throughout abdomen. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Scatterred rash on upper right back, chest, and on extremities. Erythematous, partially blanching, macules. Neuro: A and O x3. CN II-XII grossly intact. Strength ___ in b/l upper and lower extremities. 2+ reflexes in knees, brachioradialis. Gait with limp due to favoring R side DISCHARGE Pertinent Results: ADMISSION: ___ 05:45PM BLOOD WBC-7.4 RBC-4.00* Hgb-10.9* Hct-33.3* MCV-83 MCH-27.3 MCHC-32.7 RDW-14.3 Plt ___ ___ 05:45PM BLOOD Neuts-69.8 ___ Monos-6.9 Eos-1.1 Baso-0.6 ___ 07:45AM BLOOD WBC-5.4 Lymph-22 Abs ___ CD3%-91 Abs CD3-1083 CD4%-35 Abs CD4-413 CD8%-54 Abs CD8-642 CD4/CD8-0.6* ___ 05:45PM BLOOD Glucose-99 UreaN-9 Creat-0.9 Na-139 K-4.1 Cl-97 HCO3-28 AnGap-18 ___ 07:45AM BLOOD ALT-50* AST-74* AlkPhos-82 TotBili-0.3# ___ 07:45AM BLOOD Calcium-9.4 Phos-4.9* Mg-1.8 Iron-57 ___ 07:45AM BLOOD calTIBC-324 Ferritn-103 TRF-249 DISCHARGE: ___ 07:50AM BLOOD WBC-5.7 RBC-4.13* Hgb-11.5* Hct-35.0* MCV-85 MCH-27.9 MCHC-32.9 RDW-15.0 Plt ___ ___ 07:50AM BLOOD Neuts-59.2 ___ Monos-8.6 Eos-2.5 Baso-0.9 ___ 07:50AM BLOOD ESR-82* ___ 07:50AM BLOOD Glucose-106* UreaN-8 Creat-0.9 Na-137 K-4.3 Cl-99 HCO3-29 AnGap-13 ___ 07:50AM BLOOD ALT-86* AST-113* CK(CPK)-21* AlkPhos-101 TotBili-0.3 ___ 07:50AM BLOOD Calcium-9.3 Phos-4.4 Mg-1.9 ___ 07:50AM BLOOD HBsAg-PND HBsAb-PND HBcAb-PND ___ 07:50AM BLOOD CRP-3.0 MICRO: ___ BCx: Pending ___ Sputum: ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ___ Sputum: ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ___ 10:07 pm SPUTUM Source: Induced. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ___ HIV VL Pending: ___ HCV VL Pending: ___ Mycolytic BCx Pending: STUDIES: ___ CXR: No acute cardiopulmonary process Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 2. Raltegravir 400 mg PO BID 3. Acetaminophen 325-650 mg PO Q8H:PRN pain/HA 4. Docusate Sodium 100 mg PO BID 5. Polyethylene Glycol 17 g PO DAILY 6. Senna 1 TAB PO BID 7. Vancomycin 1250 mg IV Q 8H 8. Heparin 5000 UNIT SC TID 9. Oxycodone SR (OxyconTIN) 30 mg PO Q12H 10. Oxycodone SR (OxyconTIN) 45 mg PO QHS Discharge Medications: 1. Acetaminophen 325-650 mg PO Q8H:PRN pain/HA 2. Docusate Sodium 100 mg PO BID 3. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 4. Polyethylene Glycol 17 g PO DAILY 5. Raltegravir 400 mg PO BID 6. Senna 1 TAB PO BID 7. Oxycodone SR (OxyconTIN) 30 mg PO Q12H 8. Oxycodone SR (OxyconTIN) 45 mg PO QHS 9. Linezolid ___ mg PO Q12H day 1 = ___ RX *linezolid [Zyvox] 600 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 10. Methadone 30 mg PO DAILY 11. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN itch Discharge Disposition: Home Discharge Diagnosis: Tuberculosis rule out Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Positive AFB cultures with paraspinal abscesses. TECHNIQUE: PA and lateral views of the chest. COMPARISON: Chest radiograph ___. FINDINGS: Right PICC terminates at the SVC/right atrial junction. Cardiac, mediastinal and hilar contours are normal. Pulmonary vascularity is normal. Lungs are clear. No pleural effusion or pneumothorax is present. No acute osseous abnormalities are present. IMPRESSION: No acute cardiopulmonary process. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: + AFB Diagnosed with OTHER NONSPECIFIC FX ON EXAM temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: 0 level of acuity: 2.0

Dear Ms. ___, It was a pleasure taking care of you at the ___ ___. You came to ___ with concern that you had Tuberculosis. After we took 3 sputum samples, it was determined that you do NOT have Tuberculosis in your lungs. You will continue to need anti-biotics for your spine infection. You will be treated with oral antibiotics for your spine infection for another 30 days. You should follow-up with Dr. ___) for weekly blood work while taking this ___ antibiotics.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / morphine / Macrobid / Biaxin Attending: ___. Chief Complaint: right upper abdominal pain Major Surgical or Invasive Procedure: EGD History of Present Illness: This is a ___ yo F with a PMHx of gastric by pass, depression with recent suicide attempt and was at ___ on a ___ after a reported alcohol and clonodine overdose who was transfered for c/o abdominal pain X5 days. . Patient was seen at ___ for similar complaints and had a CT was was reportedly normal. Her intial evalaution there was for OD with 40-60 clonodine tablets while drinking alcohol. She was intially admitted to the ICU for close monitoring. She had self limiting bradycardia and hypotension at ___. LFT's and lipase also wnl. At that time, reports last normal BM was 5 days ago and since has only had small stools. Was medically cleared and sent to ___, sent to ___ ___ for continued abdominal pain. . In our ED, VSS. Rectal exam done in ED showed hard dark stool in rectal vault, guaiac negative without CVA tenderness. The patient was teary in the ED and anxious due husbands death ___ years ago from complications of gastric bypass. Enemas given with moderate amounts of BM after. Patient placed on 1:1 sitter and sent to the floor. . On the floor the patient reports that she began to have sharp pains in her abdomen about 1 month ago. Theses pains got worse in intensity and duration shortly after her overdose 5 days ago. The pains prior to her OD lasted seconds and now they are lasting minutes to hours. The pains are usually related to po intake. The patient also reports constipation X5 days that was releived by an enema in the ED. The patient has never had an EGD and had a colonoscopy at ___ in ___ of this year due to LGIB which was thought to be due to a bleeding polyp. The polyp was removed and the bleed stopped. The patient does reported black stools recently but her medications on transfer included iron. The patient denies a h/o pancreatitis or ulcers. The patient has had multiple suicide attempts in the past, most recently ___ when she was inpatient. The suicide attempts were in the setting of alcohol abuse. Denies current HI or SI. . 10 point ROS is otherwise negative except above . Past Medical History: PMH: 1) polysubstance abuse including alcohol 2) suicide attempt recently with clonodine and alcohol 3) anxiety/depression 4) history of SVT 5) asthma 6) colonic polyps - per patient c-scope for mild bleeding in ___, improved after polypectomy-at ___ 7) neuropathy ___ to accident 8) idiopathic intermitent abdominal pain 9) ADD Past Surgical Hx: 1) Roux en y gastric bypass + chole ___ at ___. Incisions consistent with Lap-assisted procedure. 2) Multiple ortho surgeries - left shoulder, upper spine, lower back, left knee. 3) Patient recalls appendectomy "long time ago" 4) desmoid tumor resection in thoracic spine X3 Social History: ___ Family History: Mother: positive for DM Father: positive for gout, gastric ulcers Brother:healthy Physical ___: Admission PE: VS: 98 124/70 70 18 99 RA General: AAOX3, NAD HEENT: OP clear, MMM CV: RRR, no RMG Lungs: CTAB no WRR Abdominal: obese, active BS X4, no rebound or guarding, mild TTP in epigastric region, soft Extremities: WWP, pulses 2+ and equal Neuro: CN's, MS, sensation and strength wnl Psyc: mood and affect wnl . Discharge PE VS Tm-98.5 Tc-97.5 BP 116/62 HR 56 RR 20 SaO2: 100 RA General: AAOX3, NAD HEENT: OP clear, MMM CV: bradycardic, otherwise RRR, no RMG Lungs: CTAB, no WRR Abdomen: ND, mild TTP in epigastrum, no HSM, no rebound and no guarding Extremities: WWP, no edema, pulses 2+ and equal Neuro: CNs and MS wnl, strength, sensation wnl, and gait wnl Psyc: patient continues to have mood lability and is tearful at times . Pertinent Results: ___ 11:54PM LACTATE-1.4 ___ 11:46PM GLUCOSE-94 UREA N-7 CREAT-0.7 SODIUM-141 POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-29 ANION GAP-13 ___ 11:46PM ALT(SGPT)-7 AST(SGOT)-15 ALK PHOS-114* TOT BILI-0.3 ___ 11:46PM LIPASE-21 ___ 11:46PM ALBUMIN-4.3 ___ 11:46PM WBC-6.3 RBC-4.55 HGB-12.9 HCT-37.8 MCV-83 MCH-28.3 MCHC-34.0 RDW-15.1 ___ 11:46PM NEUTS-54.8 ___ MONOS-6.1 EOS-2.9 BASOS-0.7 ___ 11:46PM ___ PTT-32.0 ___ . OSH ___ ___ Ct with contrast -Imp: no explaination for acute abdominal pain -s/p gastric bypass and ccy, no obstruction, 14 cm spleen, liver adrenal, kidneys and pancreas and remaining bowel are unremarkable, uterus and ovaries are wnl -moderate amount of stool present within the colon, appendix is not defintately visualized, lung bases are clear . ___ AXR IMPRESSION: 1. Nonspecific bowel gas pattern without definite evidence of obstruction. 2. 5-mm nodular opacity overlying the left base should be further evaluated with conventional chest radiographs. . ___ CXR IMPRESSION: 1) No acute pulmonary process identified. 2) No free air detected beneath the diaphragm . CT AP ___ IMPRESSION: 1. Large quantity of oral contrast material within the excluded stomach, without clear evidence of reflux via the pancreatobiliary limb, indicating a likely communication between the gastric pouch and excluded stomach. Further evaluation could be performed with direct visualization or an upper GI barium study. 3. Extrahepatic and central intrahepatic biliary ductal dilation, without evidence of an obstructing lesion, a finding that can be seen in patients who have undergone prior cholecystectomy, although correlation with right upper quadrant abdominal pain and LFT's is recommended. Further evaluation could be performed with MRCP, if clinically indicated. 3. Possible hepatic steatosis. 4. Mild splenomegaly. . ___ 11:00 am SEROLOGY/BLOOD **FINAL REPORT ___ HELICOBACTER PYLORI ANTIBODY TEST (Final ___: POSITIVE BY EIA. (Reference Range-Negative). . Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. BuPROPion (Sustained Release) 150 mg PO QAM 2. BuPROPion (Sustained Release) 150 mg PO QPM 3. Bisacodyl 10 mg PO DAILY:PRN constipation 4. Ferrous Sulfate 325 mg PO DAILY 5. Gabapentin 800 mg PO BID 6. Nicotine Polacrilex 2 mg PO Q1H:PRN tobacco craving 7. Thiamine 100 mg PO DAILY 8. Vitamin D 400 UNIT PO DAILY 9. Calcium Carbonate 1250 mg PO DAILY Discharge Medications: 1. Bisacodyl 10 mg PO DAILY:PRN constipation 2. BuPROPion (Sustained Release) 150 mg PO QAM 3. BuPROPion (Sustained Release) 150 mg PO QPM 4. Ferrous Sulfate 325 mg PO DAILY 5. Gabapentin 800 mg PO BID 6. Thiamine 100 mg PO DAILY 7. Vitamin D 400 UNIT PO DAILY 8. Calcium Carbonate 1250 mg PO DAILY 9. Acetaminophen 1000 mg PO Q8H 10. Bismuth Subsalicylate 30 mL PO QID Duration: 14 Days 11. Docusate Sodium 100 mg PO BID 12. Doxycycline Hyclate 100 mg PO Q12H please do not take with calcium within 2 hours 13. Lorazepam 0.5 mg PO Q4H:PRN anxiety 14. MetRONIDAZOLE (FLagyl) 250 mg PO Q6H Duration: 14 Days 15. Multivitamins 1 CAP PO DAILY 16. Nicotine Patch 14 mg TD DAILY:PRN Tobacco withdrawal 17. Omeprazole 20 mg PO BID 18. Ondansetron 4 mg PO Q8H:PRN nausea 19. OxycoDONE (Immediate Release) 15 mg PO Q3H:PRN severe pain 20. Polyethylene Glycol 17 g PO DAILY:PRN constipation 21. Sucralfate 1 gm PO QID CRUSH AND ADD WATER TO MAKE LIQUID FORM 22. TraMADOL (Ultram) 50 mg PO Q6H:PRN moderate pain Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Marginal ulcer near the g-j anastomosis Gastro-gastric fistula Depression Anxiety SVT Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: ___ female with abdominal pain and tenderness. Evaluate for small bowel obstruction. COMPARISON: None. FINDINGS: Upright and supine views of the abdomen were obtained. There is gaseous distention of a few loops of small bowel. A few air-fluid levels are identified in the left lower quadrant on the upright view. Oral contrast is present in the large bowel, which is non-distended. No pneumatosis or pneumoperitoneum. A 5-mm nodular opacity overlies the left base. Several surgical clips overlie the right upper abdomen. IMPRESSION: 1. Nonspecific bowel gas pattern without definite evidence of obstruction. 2. 5-mm nodular opacity overlying the left base should be further evaluated with conventional chest radiographs. Findings were communicated via phone call by Dr. ___ to Dr. ___ ___ on ___ at 0756 am. Radiology Report HISTORY: Gastric bypass. Now acute abdominal pain, question free air, opacity. CHEST, TWO VIEWS: No previous chest x-rays on PACS record for comparison. Possible hyperinflation, consistent with COPD. The heart is not enlarged. There is no CHF, focal infiltrate, or gross effusion. There is slight blunting of the left and ? right costophrenic angle posteriorly. At the periphery of these films, fusion hardware in the cervical spine is incompletely imaged. No free air detected beneath the diaphragm. No dilated loops of bowel are identified in the visualized portion of the upper abdomen. Increased density in the splenic flexure of the colon suggests oral contrast. Surgical clips are also noted at the level of the diaphragm posteriorly. IMPRESSION: 1) No acute pulmonary process identified. 2) No free air detected beneath the diaphragm. Radiology Report INDICATION: History of gastric bypass with recurrent abdominal pain. Assess for presence of ulcer at anastomosis, biliary duct dilatation, pancreatic pathology, or hernia with strangulation at incision site. COMPARISON: None. TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis following the administration of both oral and intravenous contrast material. A total of 150 cc of Omnipaque intravenous contrast material was administered. Multiplanar reformats were performed. The total DLP is 883 mGy-cm. ABDOMEN CT: There is minimal dependent bilateral lower lobe atelectasis. The liver may be slightly hypodense, possibly indicating fat deposition. No focal liver lesions are seen. There is mild central intrahepatic biliary duct dilatation. The common duct is dilated, measuring up to 13 mm, although tapers to a normal caliber at the level of the pancreatic head (300B:29). There is no evidence of an intra- or periductal mass. The portal vein is patent. The patient is status post cholecystectomy. The spleen is mildly enlarged, measuring up to 13.9 cm in its greatest axial dimension. The spleen is otherwise unremarkable. The pancreas is normal, without evidence of ductal dilatation. The adrenal glands are normal. The kidneys are unremarkable, with symmetric excretion of intravenous contrast material. The patient is status post Roux-en-Y gastric bypass. A large quantity of oral contrast material is seen within the excluded stomach and duodenum, as well as within the proximal portion of the pancreatobiliary limb but with no contrast within the distal portion of the pancreatobiliary limb, signifying a likely communication between the gastric pouch and the remnant stomach. Patulousness of several contrast filled loops of small bowel in the mid right abdomen is noted without transition point, likely the result of this segment of bowel being filled with oral contrast material. Oral contrast material passes into the colon, which is normal in appearance. There is no evidence of bowel obstruction or wall thickening. No free fluid or free air is seen in the abdomen. There are no pathologically enlarged abdominal lymph nodes. The abdominal aorta is normal in caliber. Scattered aortic calcifications are noted. Surgical clips are seen within the central mesentery. PELVIS CT: The bladder is unremarkable. The uterus and adnexa are grossly normal. There is no free fluid in the pelvis. No pathologically enlarged pelvic lymph nodes are seen. BONE WINDOW: A 15-mm sclerotic lesion within the right iliac bone (2:71) is likely a bone island. Additional scattered smaller sclerotic lesions are seen throughout the pelvis, also most consistent with bone islands. Multilevel degenerative changes of the thoracolumbar spine are noted, most severe at L4-L5 and L5-S1. Small metallic densities overlying and within the right paraspinous musculature are of uncertain etiology (___). IMPRESSION: 1. Large quantity of oral contrast material within the excluded stomach, without clear evidence of reflux via the pancreatobiliary limb, indicating a likely communication between the gastric pouch and excluded stomach. Further evaluation could be performed with direct visualization or an upper GI barium study. 3. Extrahepatic and central intrahepatic biliary ductal dilation, without evidence of an obstructing lesion, a finding that can be seen in patients who have undergone prior cholecystectomy, although correlation with right upper quadrant abdominal pain and LFT's is recommended. Further evaluation could be performed with MRCP, if clinically indicated. 3. Possible hepatic steatosis. 4. Mild splenomegaly. Updated findings were discussed with Dr. ___ by Dr. ___ at 6:56 p.m. via telephone on the day of the study. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: ABDOMINAL PAIN Diagnosed with ABDOMINAL PAIN PERIUMBILIC, UNSPECIFIED CONSTIPATION temperature: 97.8 heartrate: 88.0 resprate: 20.0 o2sat: 99.0 sbp: 121.0 dbp: 88.0 level of pain: 8 level of acuity: 3.0

You were admitted to ___ for abdominal pain from ___ ___ in ___. You got an endoscopy which showed an ulcer and a fistula between two parts of your stomach. You were also found to have a bacteria called h. pylori in your blood. You will need to be on 4 medications for this for 14 days. Take your last dose of bismuth, metronidazole and doxycycline on ___. You continue the omeprazole after that date if it help with your symptoms. You should follow up with your PCP after your discharge from ___. . Medication changes see next page .

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Bactrim / rosuvastatin / atorvastatin Attending: ___ Chief Complaint: dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo F with history of ESRD from T2DM s/p renal transplant ___, complicated by chronic rejection, currently on Rituxan), Afib on Coumadin, CAD s/p CABG, TIA, Roux-en-Y bypass, hypertension, recent admission for diastolic CHF exacerbation, presenting with dyspnea. Patient reports that after discharge from recent hospitalization, she felt well and without cough. About a week ago she noticed increased dyspnea both on exertion and at rest. Today she started wheezing. Her husband has a pulse oximeter which showed sats lower ___ on RA. Consulted with their PCP who recommended she come to the ED for evaluation. In the ED, initial vitals were: 97.8 91 136/69 18 92% RA - Exam notable for: Crackles bilateral lung bases Bilateral lower extremity edema, left greater than right, at baseline per patient - Labs notable for: Cr 2.1 INR 3.9 BNP 11k WBC 11.1 Top 0.03 with MB of 3 - Imaging was notable for: CXR PA & LAT Stable mild cardiomegaly and central pulmonary vascular congestion without frank pulmonary edema or focal consolidation. Renal US 1. Persistent elevated intrarenal artery resistive indices, overall slightly increased compared to prior (0.82 to 0.87 today compared to 0.77-0.82 prior study). 2. No hydronephrosis. - Transplant nephrology was consulted: - Concern for dCHF exacerbation, OK for diuresis, can use 40mg IV Lasix. - If any infectious symptoms, would obtain flu swab - Renal transplant ultrasound unchanged from prior - INR elevated, hold warfarin - Continue home IS in the ED: mycophenolate sodium 360mg QID, prednisone 5mg daily, tacrolimus 2mg q12h. Check AM tacrolimus trough. - Continue home ppx: valganciclovir 450mg daily, dapsone 100mg daily - Patient was given: ___ 21:34 IV Furosemide 40 mg - Vitals prior to transfer: 99.2 86 151/83 22 95% Nasal Cannula Upon arrival to the floor, patient reports she has been taking home Lasix as prescribed. Her tacrolimus has been increased to 2mg bid by her nurse manager. She denies history of asthma. No chest pain, fevers, dysuria. She has been urinating ___ times daily, which is normal for her. Leg swelling has recently increased. REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise negative. Past Medical History: - ESRD s/p living related renal transplant ___. Formerly on HD via tunneled catheter. - Type 2 diabetes mellitus. - History of urinary stones about ___ years ago, status post prior light lithotripsies - Hypertension. - Hypercholesterolemia. - History of TIA - Osteoporosis - Obesity, status post Roux-en-Y gastric bypass in ___. - Glaucoma - Abdominal hernia status post repair - CCY - C-section Social History: ___ Family History: Sister with MI at age ___. Father died at age ___ due to heart failure. Mother was a smoker, died at age ___ due to chronic obstructive pulmonary disease. No family history of renal disease. Physical Exam: Admission ========= Vital Signs: 98.2 133/70 87 18 96 4L General: somewhat distressed breathing HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL. Neck: JVP appears up to mid neck when patient sitting at 90 degrees CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs, gallops. Lungs: no crackles, some scattered wheezes Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: 2+ pitting edema up to knees bilaterally Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. Discharge ========= Vital Signs: 97.8 152/75 81 20 95 Ra General: Middle-aged female, breathing comfortably on room air. HEENT: No icterus or injection. No nasal discharge. MMM. Neck: JVP <10cm. CV: Irregularly irregular. No m/r/g. No thrills or heaves. Lungs: Speaking comfortably. No accessory muscle use. Few scattered wheezes. Mildly decreased breath sounds at lung cases. No rhonchi or crackles. Abdomen: Soft, non-distended, non-tender GU: No suprapubic tenderness Ext: trace edema Neuro: Normal mental status. No asterixis. Pertinent Results: Admission Labs ============== ___ 07:55PM BLOOD WBC-11.1*# RBC-2.68* Hgb-8.7* Hct-27.6* MCV-103* MCH-32.5* MCHC-31.5* RDW-15.9* RDWSD-59.9* Plt ___ ___ 07:55PM BLOOD Neuts-92.5* Lymphs-1.5* Monos-4.9* Eos-0.1* Baso-0.2 NRBC-0.2* Im ___ AbsNeut-10.25*# AbsLymp-0.17* AbsMono-0.54 AbsEos-0.01* AbsBaso-0.02 ___ 07:55PM BLOOD ___ PTT-47.6* ___ ___ 07:55PM BLOOD Glucose-193* UreaN-56* Creat-2.1* Na-134 K-3.8 Cl-100 HCO3-19* AnGap-19 ___ 07:55PM BLOOD CK(CPK)-248* ___ 07:55PM BLOOD Calcium-8.6 Phos-3.4 Mg-1.9 Discharge Labs ============== ___ 04:49AM BLOOD WBC-1.9* RBC-2.38* Hgb-7.5* Hct-24.2* MCV-102* MCH-31.5 MCHC-31.0* RDW-15.0 RDWSD-55.7* Plt ___ ___ 04:49AM BLOOD Neuts-73.0* Lymphs-12.7* Monos-9.0 Eos-3.7 Baso-0.5 Im ___ AbsNeut-1.38*# AbsLymp-0.24* AbsMono-0.17* AbsEos-0.07 AbsBaso-0.01 ___ 04:49AM BLOOD Plt ___ ___ 04:49AM BLOOD Glucose-162* UreaN-56* Creat-1.8* Na-137 K-3.6 Cl-103 HCO3-21* AnGap-17 ___ 04:49AM BLOOD ALT-48* AST-73* LD(LDH)-403* AlkPhos-54 TotBili-0.8 ___ 04:49AM BLOOD Albumin-3.6 Calcium-8.1* Phos-4.0 Mg-2.1 Pertinent Interval Labs ======================== ___ 06:13AM BLOOD CK-MB-2 cTropnT-0.03* ___ 07:55PM BLOOD cTropnT-0.03* ___ 07:55PM BLOOD CK-MB-3 ___ ___ 04:49AM BLOOD tacroFK-5.4 ___ 04:38AM BLOOD tacroFK-4.8* ___ 06:13AM BLOOD tacroFK-4.0* Imaging & Studies ================= Renal u/s ___ FINDINGS: The right iliac fossa transplant renal morphology is normal. Specifically, the cortex is of normal thickness and echogenicity, pyramids are normal, there is no urothelial thickening, and renal sinus fat is normal. There is no hydronephrosis and no perinephric fluid collection. The resistive index of intrarenal arteries ranges from 0.82 to 0.87, compared to 0.77-0.82 on the prior study slightly elevated. The main renal artery shows a normal waveform, with prompt systolic upstroke and continuous antegrade diastolic flow, with peak systolic velocity of 64.3 centimeters/second. Vascularity is symmetric throughout transplant. The transplant renal vein is patent and shows normal waveform. IMPRESSION: 1. Persistent elevated intrarenal artery resistive indices, overall slightly increased compared to prior (0.82 to 0.87 today compared to 0.77-0.82 prior study). 2. No hydronephrosis. CXR ___ FINDINGS: The lungs are well expanded. There is mild central pulmonary vascular congestion without frank pulmonary edema. No focal consolidation is seen. Postoperative mediastinum with sternotomy wires, surgical clips, sternotomy cerclage wires appears unchanged. Mild cardiomegaly is stable. No pleural effusion or pneumothorax is seen. IMPRESSION: Stable mild cardiomegaly and central pulmonary vascular congestion without frank pulmonary edema or focal consolidation. Microbiology ============ __________________________________________________________ ___ 3:39 pm Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. **FINAL REPORT ___ Respiratory Viral Culture (Final ___: TEST CANCELLED, PATIENT CREDITED. Refer to Influenza PCR (results listed under "OTHER" tab) for further information.. Respiratory Viral Antigen Screen (Final ___: TEST CANCELLED, PATIENT CREDITED. Refer to Influenza PCR (results listed under "OTHER" tab) for further information.. __________________________________________________________ ___ 1:56 pm URINE Source: ___. **FINAL REPORT ___ Legionella Urinary Antigen (Final ___: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. __________________________________________________________ ___ 1:56 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Alendronate Sodium 70 mg PO QMON 2. Calcitriol 0.25 mcg PO 5X/WEEK (___) 3. Carvedilol 6.25 mg PO BID 4. ClonazePAM 0.5 mg PO QHS:PRN insomnia 5. Dapsone 100 mg PO DAILY 6. HydrALAZINE 100 mg PO BID 7. Mycophenolate Sodium ___ 360 mg PO QID 8. PredniSONE 5 mg PO DAILY 9. Pregabalin 50 mg PO DAILY 10. Simvastatin 20 mg PO QPM 11. Sodium Bicarbonate 650 mg PO BID 12. ValGANCIclovir 450 mg PO Q24H 13. bimatoprost 0.01 % ophthalmic QHS 14. Fish Oil (Omega 3) 1000 mg PO BID 15. Furosemide 40 mg PO BID 16. Tacrolimus 2 mg PO Q12H 17. Guaifenesin-Dextromethorphan 10 mL PO Q6H:PRN cough 18. Benzonatate 100 mg PO TID 19. Warfarin 2 mg PO DAILY16 20. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 21. Glargine 34 Units Bedtime Discharge Medications: 1. Albuterol Inhaler ___ PUFF IH Q6H:PRN Shortness of breath, wheezing RX *albuterol sulfate [ProAir HFA] 90 mcg ___ puffs inhaled Every 6 hours as needed Disp #*1 Inhaler Refills:*0 2. OSELTAMivir 30 mg PO Q12H Continue until ___ RX *oseltamivir 30 mg 1 capsule(s) by mouth Twice a day Disp #*5 Capsule Refills:*0 3. Tacrolimus 3.5 mg PO Q12H RX *tacrolimus 0.5 mg 7 capsule(s) by mouth Twice a day Disp #*60 Capsule Refills:*0 4. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 5. Alendronate Sodium 70 mg PO QMON 6. Benzonatate 100 mg PO TID 7. bimatoprost 0.01 % ophthalmic QHS 8. Calcitriol 0.25 mcg PO 5X/WEEK (___) 9. Carvedilol 6.25 mg PO BID 10. ClonazePAM 0.5 mg PO QHS:PRN insomnia 11. Dapsone 100 mg PO DAILY 12. Fish Oil (Omega 3) 1000 mg PO BID 13. Furosemide 40 mg PO BID 14. Guaifenesin-Dextromethorphan 10 mL PO Q6H:PRN cough 15. HydrALAZINE 100 mg PO BID 16. Glargine 34 Units Bedtime 17. Mycophenolate Sodium ___ 360 mg PO QID 18. PredniSONE 5 mg PO DAILY 19. Pregabalin 50 mg PO DAILY 20. Simvastatin 20 mg PO QPM 21. Sodium Bicarbonate 650 mg PO BID 22. ValGANCIclovir 450 mg PO Q24H 23. Warfarin 2 mg PO DAILY16 Discharge Disposition: Home Discharge Diagnosis: Flu Acute on chronic diastolic heart failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: History: ___ with dyspnea, hx CHF// Eval for volume overload TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph from ___. CT chest from ___. FINDINGS: The lungs are well expanded. There is mild central pulmonary vascular congestion without frank pulmonary edema. No focal consolidation is seen. Postoperative mediastinum with sternotomy wires, surgical clips, sternotomy cerclage wires appears unchanged. Mild cardiomegaly is stable. No pleural effusion or pneumothorax is seen. IMPRESSION: Stable mild cardiomegaly and central pulmonary vascular congestion without frank pulmonary edema or focal consolidation. Radiology Report EXAMINATION: RENAL U.S. INDICATION: History: ___ with renal transplant, poss CHF exacerbation// Eval for evidence of rejection, vascular occlusion to transplant TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images of the renal transplant were obtained. COMPARISON: Renal ultrasound from ___. FINDINGS: The right iliac fossa transplant renal morphology is normal. Specifically, the cortex is of normal thickness and echogenicity, pyramids are normal, there is no urothelial thickening, and renal sinus fat is normal. There is no hydronephrosis and no perinephric fluid collection. The resistive index of intrarenal arteries ranges from 0.82 to 0.87, compared to 0.77-0.82 on the prior study slightly elevated. The main renal artery shows a normal waveform, with prompt systolic upstroke and continuous antegrade diastolic flow, with peak systolic velocity of 64.3 centimeters/second. Vascularity is symmetric throughout transplant. The transplant renal vein is patent and shows normal waveform. IMPRESSION: 1. Persistent elevated intrarenal artery resistive indices, overall slightly increased compared to prior (0.82 to 0.87 today compared to 0.77-0.82 prior study). 2. No hydronephrosis. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Dyspnea Diagnosed with Heart failure, unspecified, Acute pulmonary edema temperature: 97.8 heartrate: 91.0 resprate: 18.0 o2sat: 92.0 sbp: 136.0 dbp: 69.0 level of pain: 0 level of acuity: 3.0

Dear Ms. ___, You were admitted to the hospital for shortness of breath. You were found to have the flu that is causing your difficulty breathing. You also had mild heart failure from the flu. You should continue to take the oseltamivir (Tamiflu) for flu treatment until ___. Please follow-up with your transplant doctors next week as they will need to check your labs again. They also recommend you take 3.5 mg twice a day of your tacrolimus. Please continue to take your furosemide (Lasix) as previously prescribed. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Take care. Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine / Hydrocodone Attending: ___. Chief Complaint: RUQ pain, nausea, vomiting Major Surgical or Invasive Procedure: Percutaneous cholecystostomy on ___ by Interventional Radiology History of Present Illness: Ms. ___ is a ___ yo F with PMH significant for HLD, CAD s/p CABG and multivessel PCI, GERD, HTN, DM initially presenting with right upper abdominal pain. Patient was in her normal state of health until approximately 2 days prior to admission when she began experiencing abdominal pain in her RUQ. This pain progressed through the day prior to admission, described as a burning pain that was constant and occasionally sharp. The pain did not radiate, and was associated with nausea, providing her with minimal appetite. On the day prior to admission, she attempted to drink Sprite and eat bread, though had an episode of bilious yellow emesis afterwards. She denied any associated fevers, though did note chills. She also endorsed 5 episodes of watery brown diarrhea. Of note, she also denied any night sweats, SOB, dysuria, hematochezia, or hematuria. She endorses chronic exertional substernal chest pressure/tightness that has been stable since her open heart surgery approximately ___ years ago. She did have a similar episode of chest tightness earlier on the day of admission, which resolved without intervention In the ED: Initial vital signs: T96.3, HR60, BP164/58, RR18, PO298% RA Exam notable for: Awake, alert, slightly confused about day of week but appropriate responses to all questions, slightly slowed mentation (unclear baseline), Slightly dry mucous membranes, unable to take a deep breath due to severe RUQ pain when doing so; severely tender to moderate (but not light) palpation of the RUQ; she does not have signs of generalized peritonitis and is not tender to firm palpation or percussion in LUQ or LLQ. Labs were notable for: WBC 11.3, hgb 11.9, ANC 9, INR 1.2, Cr 0.9, UA large ___ protein/10 ketones/49 WBCs/few bacteria/10 epis, AST 25, ALT 17, AP 70, Tbili 0.4, albumin 4.4, troponin negative x1, Studies performed include: -RUQUS: Cholelithiasis in a distended gallbladder, with gallstone at the gallbladder neck. Unable to accurately assess for sonographic ___ sign since the patient was given pain medication. Ensuing acute cholecystitis not excluded. In addition, while the common hepatic duct is normal in diameter, CBD is dilated, and a distal obstructing process such as stone or lesion not excluded. Correlate with LFTs and consider MRCP/ERCP as clinically warranted. -EKG: NSR rate 60, normal axis, nl intervals, TWI in V1-4 (old) Patient was given: IV Morphine Sulfate 4 mg IV Ondansetron 4 mg IV Morphine Sulfate 4 mg IV Ondansetron 4 mg IV Morphine Sulfate 4 mg IV Ampicillin-Sulbactam 3 g IV Morphine Sulfate 4 mg IV Ampicillin-Sulbactam 3 g PO Acetaminophen 1000 mg IV Ondansetron 4 mg Consults: - Surgery - ___ Vitals on transfer: T100.3, HR99, BP161/79, RR16, PO2 97% RA Upon arrival to the floor, patient is in significant pain and is endorsing nausea. She denies any fevers or chills, though still does not have an appetite. Past Medical History: -HLD -CAD s/p CABG and multiple PCI -HTN -DM -OA -GERD -s/p partial hysterectomy (remote) *is scheduled for right rotator cuff repair soon Social History: ___ Family History: -Mother: CHF -Father: died of stroke -Brother: died of leukemia -Brother: died of lung disease (heavy smoker) -Brother: living, has DM Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: REVIEWED IN ___ GENERAL: Sitting on side of bed, moaning in pain HEENT: Sclera anicteric, MMM CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. Decreased respiratory effort ___ pain ABDOMEN: Normal bowels sounds, tender to palpation in RUQ, worse with inspiration EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rash. DISCHARGE PHYSICAL EXAM: VITALS: ___ ___ Temp: 98.0 PO BP: 145/71 R Lying HR: 91 RR: 18 O2 sat: 93% O2 delivery: Ra GENERAL: Elderly woman sitting in chair with eyes open, in NAD HEENT: Sclera anicteric, MMM CARDIAC: Regular rhythm, tachycardic. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: CTAB ABDOMEN: Hypoactive bowels sounds, tender to palpation in RUQ, worse with inspiration, no rebound or guarding EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm, no rash. Pertinent Results: ============================ LABS ============================ ADMISSION LABS ___ 07:06PM BLOOD WBC-11.3* RBC-4.42 Hgb-11.9 Hct-36.9 MCV-84 MCH-26.9 MCHC-32.2 RDW-13.3 RDWSD-41.1 Plt ___ ___ 07:06PM BLOOD Neuts-79.7* Lymphs-12.0* Monos-6.5 Eos-1.0 Baso-0.4 Im ___ AbsNeut-9.01* AbsLymp-1.36 AbsMono-0.74 AbsEos-0.11 AbsBaso-0.04 ___ 07:06PM BLOOD ___ PTT-32.1 ___ ___ 07:06PM BLOOD Glucose-156* UreaN-12 Creat-0.9 Na-142 K-4.5 Cl-102 HCO3-24 AnGap-16 ___ 01:55PM BLOOD Albumin-4.3 Calcium-9.3 Phos-3.2 Mg-1.6 ___ 08:39PM BLOOD Lipase-21 ___ 08:39PM BLOOD cTropnT-<0.01 ___ 08:39PM BLOOD ALT-17 AST-25 AlkPhos-70 TotBili-0.4 DISCHARGE LABS ___ 07:30AM BLOOD WBC-13.4* RBC-3.75* Hgb-10.2* Hct-32.0* MCV-85 MCH-27.2 MCHC-31.9* RDW-13.6 RDWSD-42.3 Plt Ct-92* ___ 07:30AM BLOOD ___ PTT-24.9* ___ ___ 07:30AM BLOOD Glucose-163* UreaN-13 Creat-0.8 Na-133* K-4.1 Cl-97 HCO3-20* AnGap-16 ___ 07:30AM BLOOD Albumin-3.0* Calcium-8.2* Phos-2.1* Mg-1.9 ___ 07:30AM BLOOD ALT-26 AST-50* LD(___)-337* AlkPhos-63 TotBili-0.7 ============================ IMAGING ============================ ___ RUQUS IMPRESSION Cholelithiasis in a distended gallbladder, with gallstone at the gallbladder neck. Unable to accurately assess for sonographic ___ sign since the patient was given pain medication. Ensuing acute cholecystitis not excluded. In addition, while the common hepatic duct is normal in diameter, CBD is dilated, and a distal obstructing process such as stone or lesion not excluded. Correlate with LFTs and consider MRCP/ERCP as clinically warranted. ___ PERCUTANEOUS CHOLECYSTOSTOMY IMPRESSION: Successful ultrasound-guided placement of ___ pigtail catheter into the gallbladder. Samples was sent for microbiology evaluation. ___ MRCP IMPRESSION: 1. Findings of acute gangrenous cholecystitis with a percutaneous cholecystostomy tube appearing well positioned. There is persistent mild distension of the gallbladder lumen and new perihepatic ascites, which raises concern for a leak around the tube or tube obstruction. Correlation with tube output is recommended and confirmation of placement by injection of contrast under fluoroscopy could be considered. 2. No choledocholithiasis. Mild extrahepatic biliary ductal dilatation attributable to a periampullary duodenal diverticulum. 3. Mild hepatic steatosis. ___ T-TUBE CHOLANGIO (POST-OP) IMPRESSION: Patent cystic duct with contrast passing into the common bile duct. No definite evidence of leak. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN asthma 2. Clopidogrel 75 mg PO DAILY 3. diclofenac sodium 1 % topical TID:PRN 4. Vitamin D ___ UNIT PO EVERY 2 WEEKS (MO) 5. Fluticasone Propionate NASAL 2 SPRY NU DAILY 6. Flovent HFA (fluticasone) 220 mcg/actuation inhalation BID 7. Furosemide 20 mg PO DAILY 8. Gabapentin 300 mg PO BID 9. Gabapentin 900 mg PO QHS 10. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - Moderate 11. Humalog ___ 95 Units Breakfast Humalog ___ 95 Units DinnerMax Dose Override Reason: home dosage 12. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY 13. Lactulose 30 mL PO BID 14. Metoprolol Succinate XL 100 mg PO DAILY 15. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 16. Nystatin-Triamcinolone Cream 1 Appl TP QID:PRN rash 17. Potassium Chloride 20 mEq PO DAILY 18. promethazine-codeine 6.25-10 mg/5 mL oral Q6H:PRN 19. Ranitidine 300 mg PO DAILY 20. Simvastatin 5 mg PO QPM 21. TraMADol 50 mg PO TID 22. Venlafaxine XR 150 mg PO DAILY 23. Aspirin 81 mg PO DAILY 24. Cetirizine 10 mg PO DAILY 25. Niacin 500 mg PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever 2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second Line 3. Senna 8.6 mg PO BID:PRN Constipation - First Line 4. Sulfameth/Trimethoprim DS 2 TAB PO/NG BID 5. Glargine 75 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 6. Albuterol Inhaler 2 PUFF IH Q6H:PRN asthma 7. Aspirin 81 mg PO DAILY 8. Cetirizine 10 mg PO DAILY 9. Clopidogrel 75 mg PO DAILY 10. Flovent HFA (fluticasone) 220 mcg/actuation inhalation BID 11. Fluticasone Propionate NASAL 2 SPRY NU DAILY 12. Furosemide 20 mg PO DAILY 13. Gabapentin 300 mg PO BID 14. Gabapentin 900 mg PO QHS 15. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY 16. Metoprolol Succinate XL 100 mg PO DAILY 17. Niacin 500 mg PO BID 18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 19. Nystatin-Triamcinolone Cream 1 Appl TP QID:PRN rash 20. Ranitidine 300 mg PO DAILY 21. Simvastatin 5 mg PO QPM 22. TraMADol 50 mg PO TID 23. Venlafaxine XR 150 mg PO DAILY 24. Vitamin D ___ UNIT PO EVERY 2 WEEKS (MO) 25. HELD- diclofenac sodium 1 % topical TID:PRN This medication was held. Do not restart diclofenac sodium until you follow-up with your PCP 26. HELD- HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - Moderate This medication was held. Do not restart HYDROcodone-Acetaminophen (5mg-325mg) until you follow-up with your PCP 27. HELD- Lactulose 30 mL PO BID This medication was held. Do not restart Lactulose until you follow-up with your PCP 28. HELD- Potassium Chloride 20 mEq PO DAILY This medication was held. Do not restart Potassium Chloride until you follow up with your physician (risk of high potassium with bactrim use) 29. HELD- promethazine-codeine 6.25-10 mg/5 mL oral Q6H:PRN This medication was held. Do not restart promethazine-codeine until you follow-up with your PCP ___: Extended Care Facility: ___ Discharge Diagnosis: =================== PRIMARY DIAGNOSIS =================== Acute cholecystitis =================== SECONDARY DIAGNOSIS =================== Coronary artery disease Type 2 diabetes Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: MRCP INDICATION: ___ year old woman with acute cholecystectomy and ?CBD dilatation, evaluate for stone. TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were acquired in a 1.5 T magnet. Intravenous contrast: 8 mL Gadavist. Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered for oral contrast. COMPARISON: Liver gallbladder ultrasound dated ___. FINDINGS: Lower Thorax: There is no pleural or pericardial effusion. There is mild elevation of the right hemidiaphragm. Liver: Liver morphology is normal. There is no suspicious liver lesion. Drop in signal intensity on T1-weighted GRE out of phase imaging compared with in phase imaging is consistent with mild hepatic steatosis with an estimated fat fraction of 7.5%. Portal and hepatic veins are patent. Biliary: There is extensive gallbladder wall edema and surrounding fat stranding with areas of hypoenhancement of gallbladder wall consistent with acute partially gangrenous cholecystitis. A cholecystostomy tube appears to terminate within the lumen, however the lumen remains mildly distended and there is new small to moderate perihepatic ascites. There is a large stone lodged at the gallbladder neck with surrounding hyperemia (16:58, 4:31). The common bile duct is mildly dilated measuring up to 9 mm in diameter (04:35). There is no choledocholithiasis. There is an abrupt transition point in bile duct caliber in the region of a large periampullary duodenal diverticulum. Pancreas: Normal in signal intensity and morphology without focal lesion or ductal dilatation. Spleen: Normal in size. Adrenal Glands: Unremarkable. Kidneys: There is no suspicious renal lesion or hydronephrosis. Gastrointestinal Tract: Visualized loops of large small bowel are unremarkable. Lymph Nodes: No suspicious lymphadenopathy. Vasculature: Unremarkable. Osseous and Soft Tissue Structures: No suspicious osseous lesion. IMPRESSION: 1. Findings of acute gangrenous cholecystitis with a percutaneous cholecystostomy tube appearing well positioned. There is persistent mild distension of the gallbladder lumen and new perihepatic ascites, which raises concern for a leak around the tube or tube obstruction. Correlation with tube output is recommended and confirmation of placement by injection of contrast under fluoroscopy could be considered. 2. No choledocholithiasis. Mild extrahepatic biliary ductal dilatation attributable to a periampullary duodenal diverticulum. 3. Mild hepatic steatosis. Radiology Report INDICATION: ___ year old woman with acute cholecystitis; on ASA Plavix for stable CAD w/ remote hx of stents ___ last dose of both ASA Plavix was ___// placement of cholecystostomy for acute cholecystitis**Please send any fluid obtained for gram stain culture** COMPARISON: Ultrasound from ___ PROCEDURE: Ultrasound-guided percutaneous cholecystostomy. OPERATORS: Dr. ___, radiology fellow and Dr. ___, attending radiologist. Dr. ___ personally supervised the trainee during the key components of the procedure and reviewed and agrees with the trainee's findings. TECHNIQUE: The risks, benefits, and alternatives of the procedure were explained to the patient. After a detailed discussion, informed written consent was obtained. A pre-procedure timeout using three patient identifiers was performed per ___ protocol. The patient was placed in aslight left decubitus position on the ultrasound table. Limited preprocedure imaging was performed to localize the gallbladder. An appropriate skin entry site was chosen and the site marked. Local anesthesia was administered with 1% Lidocaine solution. Using continuous sonographic guidance, an ___ drainage catheter was advanced via trocar technique into the gallbladder. A sample of fluid was aspirated, confirming catheter position within the collection. The plastic stiffener was removed. The pigtail was deployed. The position of the pigtail was confirmed within the collection via ultrasound. Ultrasound images were stored on PACS. Approximately 110 cc of serosanguinous fluid was drained with a sample sent for microbiology evaluation. The gallbladder was under pressure. The catheter was secured by a StatLock. The catheter was attached to bag. Sterile dressing was applied. The procedure was tolerated well, and there were no immediate post-procedural complications. SEDATION: Moderate sedation was provided by administering divided doses of 1 mg Versed and 75 mcg fentanyl throughout the total intra-service time of 14 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. FINDINGS: There is redemonstration of the distended gallbladder. IMPRESSION: Successful ultrasound-guided placement of ___ pigtail catheter into the gallbladder. Samples was sent for microbiology evaluation. Radiology Report EXAMINATION: T-TUBE CHOLANGIO (POST-OP) INDICATION: ___ year old woman with acute gangrenous cholecystitis s/p PCN. Looking more septic clinically and with new perihepatic ascites on MRCP concerning for tube leak// ? PCN leak given MRCP finding of new perihepatic ascites TECHNIQUE: Water soluble contrast was hand injected into the pre-existing cholecystostomy tube. Selected fluoroscopic images were obtained. DOSE: Acc air kerma: 21 mGy; Accum DAP: 513.6 uGym2; Fluoro time: 01:22 COMPARISON: MRCP dated ___ FINDINGS: Contrast readily opacified the gallbladder and cystic duct, passing freely into the common bile duct and retrograde into the intrahepatic ducts. Filling defect at the fundus of the gallbladder corresponds to gallstone seen on recent MRCP. IMPRESSION: Patent cystic duct with contrast passing into the common bile duct. No definite evidence of leak. Gender: F Race: HISPANIC/LATINO - PUERTO RICAN Arrive by WALK IN Chief complaint: Upper abdominal pain Diagnosed with Calculus of gallbladder w/o cholecystitis w/o obstruction, Unspecified abdominal pain temperature: 96.3 heartrate: 60.0 resprate: 18.0 o2sat: 98.0 sbp: 164.0 dbp: 58.0 level of pain: 10 level of acuity: 3.0

Dear Ms. ___, It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL? - You were admitted to the hospital because you were having severe abdominal pain, nausea, and vomiting. WHAT HAPPENED TO ME IN THE HOSPITAL? - You had lab tests and imaging that showed that you had inflammation of the gallbladder (cholecystitis) that was causing your symptoms. - The Interventional Radiology team performed a percutaneous cholecystostomy (tube placement in the gallbladder to drain bile). - Tests showed that there was an infection with E. coli in the gallbladder. - You were treated with antibiotics and your pain and nausea and fevers improved. You received IV fluids for rehydration and then slowly restarted eating and drinking. - You were seen by the Cardiology and Surgery teams, who recommended that you get a cholecystectomy (gall bladder removal) in the future after your acute infection resolves. - You worked with Physical Therapy who recommended that you go to ___ rehab to regain your strength before returning home. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Please continue to take all of your medications and follow-up with your appointments as listed below. - You are going to need to continue your antibiotics until you have your gallbladder surgery. - You will need to keep the gallbladder drain in place until your follow-up appointment with the surgery team. You will have help draining this at rehab. - Please discuss with your cardiologist and their team about timing of stopping your Plavix prior to surgery. We wish you the best! Sincerely, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: metformin Attending: ___. Chief Complaint: Diplopia and vertigo S/p fall Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old male presented after a fall tonight. He was recently diagnosed with a large cerebellar mass which he has been symptomatic from, with double vision and ataxia. The fall occurred after he had difficulty judging where a step was. Per the patient, after he had a MRI demonstrating a large right mostly cystic cerebellar lesion which extends into the cerebellar pontine angle, he has been attempting to establish care with a neurosurgeon. The patient has been symptomatic since ___ of this year with right facial numbness, diplopia, and ataxia. He endorses a number of recent frequent falls. Past Medical History: HLD Hypothyroidism Diabetes Social History: ___ Family History: mother and sister had breast CA Physical Exam: Upon Discharge: Exam: Opens eyes: [X]spontaneous [ ]to voice [ ]to noxious Orientation: [X]Person [X]Place [X]Time Follows commands: [ ]Simple [X]Complex [ ]None Pupils: Right ___ Left ___ EOM: [ ]Full [X]Restricted / bilateral partial ___ nerve palsy Face Symmetric: [X]Yes [ ]NoTongue Midline: [X]Yes [ ]No Pronator Drift [ ]Yes [X]No Speech Fluent: [X]Yes [ ]No Comprehension intact [X]Yes [ ]No Bilateral dysmetria L>R Motor: DeltoidBicepTricepGrip IPQuadHamATEHLGast Pertinent Results: OSH MRI: Right cerebellopontine angle mass which is enhancing and mostly cystic. Approximately 3x4cm in size and likely represents a vestibular schwannoma. Significant mass effect on ___ ventricle but no hydrocephalus. ___ CTA Head: IMPRESSION: 1. No evidence of dissection, occlusion, stenosis, or aneurysm formation within the great vessels of the head or neck. 2. Re-demonstration of a hypodense mass at the right cerebellopontine angle measures 4 cm x 3 cm and is pressing upon the brainstem, compatible with likely vestibular schwannoma as visualized on prior MR from ___. 3. Basilar artery and right vertebral artery appear closely adjacent to the previously characterized mass, however neither appears to be encased by the mass. Medications on Admission: atorvastatin, Humalog, lisinopril, levothyroxine, victiva Discharge Medications: 1. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild 2. Dexamethasone 4 mg PO TID 3. Docusate Sodium 100 mg PO BID 4. Famotidine 20 mg PO BID 5. Heparin 5000 UNIT SC BID 6. Senna 8.6 mg PO QHS 7. Glargine 40 Units Breakfast Glargine 40 Units Bedtime Humalog 22 Units Breakfast Humalog 22 Units Lunch Humalog 22 Units Dinner Insulin SC Sliding Scale using HUM Insulin 8. Atorvastatin 20 mg PO QPM 9. Levothyroxine Sodium 137 mcg PO DAILY 10. Lisinopril 5 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: right cerebellopontine angle mass Bilateral partial ___ nerve palsy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK INDICATION: ___ year old man with history of CPA lesion. Pre-operative evaluation. TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of mL of Omnipaque intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 746.8 mGy-cm. 2) Spiral Acquisition 5.0 s, 39.4 cm; CTDIvol = 13.3 mGy (Body) DLP = 522.6 mGy-cm. 3) Stationary Acquisition 4.1 s, 0.5 cm; CTDIvol = 24.3 mGy (Body) DLP = 12.1 mGy-cm. Total DLP (Body) = 535 mGy-cm. Total DLP (Head) = 747 mGy-cm. COMPARISON: Head CT from ___. MRA from ___. FINDINGS: CT HEAD WITHOUT CONTRAST: A hypodense mass at the right cerebellopontine angle measuring 4 cm x 3 cm is pressing upon the brainstem, compatible with likely vestibular schwannoma as visualized on prior MR from ___. No evidence of infarction or hemorrhage. The ventricles and sulci are normal in size and configuration. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. CTA HEAD: The vessels of the circle of ___ and their principal intracranial branches appear normal without dissection, stenosis, occlusion, or aneurysm formation. The right ___ appears mildly enlarged/dominant, while the right AICA is not visualized on this exam. The hypodense mass at the right cerebellopontine angle appears to abut the basilar artery as well as the right vertebral artery, however neither appears to be encased by the mass. The dural venous sinuses are patent. CTA NECK: The carotid and vertebral arteries and their major branches appear normal with no evidence of stenosis or occlusion. There is no evidence of internal carotid stenosis by NASCET criteria. OTHER: The visualized portion of the lungs are clear. The visualized portion of the thyroid gland is within normal limits. There is no lymphadenopathy by CT size criteria. IMPRESSION: 1. No evidence of dissection, occlusion, stenosis, or aneurysm formation within the great vessels of the head or neck. 2. Re-demonstration of a hypodense mass at the right cerebellopontine angle measures 4 cm x 3 cm and is pressing upon the brainstem, compatible with likely vestibular schwannoma as visualized on prior MR from ___. 3. Basilar artery and right vertebral artery appear closely adjacent to the previously characterized mass, however neither appears to be encased by the mass. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: s/p Fall, Transfer Diagnosed with Disorder of brain, unspecified, Fall on same level, unspecified, initial encounter temperature: 97.7 heartrate: 104.0 resprate: 22.0 o2sat: 95.0 sbp: 150.0 dbp: 88.0 level of pain: 0 level of acuity: 2.0

Mr. ___, You were admitted after sustaining a fall secondary to the visual deficits from the mass in your brain. You underwent work-up including a CTA, Audiogram, Speech and Swallow, and Ophthalmology evaluation. We are transferring you to Dr. ___ at ___ for further care.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Compazine / Compazine Tablets / Reglan Attending: ___. Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: Exploratory laparotomy/ lysis of adhesions History of Present Illness: ___ well known to surgical service, with history of multiple SBOs s/p exploratory laparotomies for the same (last one ___ who presents with diffuse abdominal pain associated with several episodes of nausea and one episode of bilious emesis. Of note, admitted to ___ surgical service on ___ for same issue. Treated with conservative measures and was discharged home with normal return of bowel function and tolerating regular diet. After discharge, reports feeling weak at home with intermittent chronic abdominal pain, episodic cramping. Overall poor oral tolerance. Nausea began acutely last night and lasted throughout day. Per daughter, pt vomited approximately 750 ml dark brown material. Patient claims to continue passing flatus with small BM this AM. Pain is now severe and diffuse with distention. NGT placed but pt still nauseous even with NGT. ROS: (+) per HPI, otherwise negative Past Medical History: multiple SBOs, atrial fibrillation, SMA atherosclerosis, blindness secondary to juvenile glaucoma, osteoarthritis, neurogenic bladder requiring straight caths, s/p open appendectomy (approx ___, s/p open cholecystectomy (approx ___, s/p ex-lap/LOA for SBO ___ ___, ex-lap for SBO (___), s/p ex-lap for SBO (___), s/p right shoulder surgery, s/p bilateral hip surgery, s/p multiple eye surgeries Social History: ___ Family History: Sisters with breast and cervical Ca, both parents with CAD Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: Temp 97.0 HR 85 BP 101/66 RR 18 100% GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: Irregularly irregular, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Distended, diffusely tender but more in RLQ with TTP, voluntary, guarding, no rebound, no palpable masses Rect - deferred Ext: No ___ edema, ___ warm and well perfused DISCHARGE PHYSICAL EXAM: VS: 98.4 97.9 54 134/66 18 97ra Gen: NAD, A/Ox3 Card: RRR Lungs: CTA bil Abd: soft, no rebound/guarding, minimally tender to palpation, mildy distended Wound: C/D/I, mild erythema around staples Ext: no CCE Pertinent Results: ADMISSION LABS: ___ 08:30PM BLOOD WBC-14.6*# RBC-5.58*# Hgb-16.6*# Hct-49.5*# MCV-89 MCH-29.8 MCHC-33.6 RDW-13.9 Plt ___ ___ 08:30PM BLOOD ___ PTT-29.8 ___ ___ 08:30PM BLOOD Glucose-169* UreaN-23* Creat-1.7* Na-138 K-4.7 Cl-96 HCO3-27 AnGap-20 ___ 09:05AM BLOOD Albumin-3.4* Calcium-8.3* Phos-2.9 Mg-1.9 ___ 08:46PM BLOOD Lactate-3.4* ___ 01:28PM BLOOD Lactate-1.1 DISCHARGE LABS: ___ 05:30AM BLOOD WBC-3.4* RBC-3.56* Hgb-10.5* Hct-32.2* MCV-90 MCH-29.4 MCHC-32.5 RDW-14.6 Plt ___ ___ 05:35AM BLOOD Glucose-118* UreaN-24* Creat-0.4 Na-135 K-4.4 Cl-105 HCO3-24 AnGap-10 ___ 05:35AM BLOOD Calcium-8.1* Phos-2.3* Mg-1.8 ___ 08:59AM BLOOD Triglyc-391* ___ 08:59AM BLOOD PREALBUMIN-Test IMAGING: CT A/P - High grade small bowel obstruction with transition point in right lower quadrant. No evidence of ischemia. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 325 mg PO DAILY 2. Digoxin 0.25 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Lisinopril 10 mg PO BID 5. Metoprolol Succinate XL 25 mg PO HS 6. Travatan Z (travoprost) 0.004 % OD DAILY 7. ___ 128 (sodium chloride) 5 % OS BID 8. PrednisoLONE Acetate 0.12% Ophth. Susp. 1 DROP BOTH EYES ___ 9. Cephalexin 250 mg PO EVERY OTHER DAY 10. Combigan (brimonidine-timolol) 0.2-0.5 % ___ BID 11. AcetaZOLamide S.R. 500 mg PO DAILY 12. Pantoprazole 40 mg PO Q24H 13. Senna 1 TAB PO BID:PRN constipation Discharge Medications: 1. PrednisoLONE Acetate 0.12% Ophth. Susp. 1 DROP BOTH EYES ___ 2. Travatan Z (travoprost) 0.004 % OD DAILY 3. Senna 1 TAB PO BID:PRN constipation 4. Pantoprazole 40 mg PO Q24H 5. ___ 128 (sodium chloride) 5 % OS BID 6. Metoprolol Succinate XL 25 mg PO HS 7. Lisinopril 10 mg PO BID 8. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills:*1 9. Digoxin 0.25 mg PO DAILY 10. Combigan (brimonidine-timolol) 0.2-0.5 % ___ BID 11. Cephalexin 250 mg PO EVERY OTHER DAY 12. Aspirin 325 mg PO DAILY 13. AcetaZOLamide S.R. 500 mg PO DAILY 14. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*50 Tablet Refills:*0 15. Ondansetron ___ mg PO Q8H:PRN nausea RX *ondansetron HCl 4 mg ___ tablet(s) by mouth every 8 hours Disp #*40 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: History of SBO, one day of nausea and vomiting; evaluate for SBO. COMPARISON: CT abdomen and pelvis on ___. TECHNIQUE: MDCT images were obtained through the abdomen and pelvis with IV and oral contrast. Coronal and sagittal reformations were performed. FINDINGS: There is mild dependant atelectasis bilaterally. The visualized heart and pericardium are unremarkable. An enteric tube ends in the stomach. The liver enhances homogeneously and there are no focal hepatic lesions. The gallbladder is not well visualized. The pancreas enhances normally and there are no focal pancreatic lesions. The spleen is normal. The adrenal glands are normal. There are subcentimeter hypodensities in the kidneys that are too small to characterize. Otherwise, kidneys are unremarkable. No hydronephrosis. The stomach is distended. Multiple loops of dilated small bowel and a transition point in the right lower quadrant (601B, 26), with collapsed distal ileum. The colon is also relatively decompressed. There is no bowel wall thickening or ascites. There is no pneumatosis or portal venous gas. There is no retroperitoneal or mesenteric lymphadenopathy. There is no free air. There is a relatively narrow channel for the duodenum and left renal vein between the aorta and superior mesenteric artery, unchanged, but without clear evidence for functional obstruction. PELVIS: The rectum is normal. The bladder contains a Foley catheter and air. No free fluid in the pelvis. The uterus and adnexa are not well visualized. The aorta is normal in caliber and there are mild-to-moderate atherosclerotic calcifications. BONES: There are multiple compression fractures throughout the lower thoracic and lumbar spine, unchanged compared to ___. IMPRESSION: High-grade small-bowel obstruction with a transition point in the right lower quadrant. These findings were discussed with Dr. ___ by Dr. ___ at 2:15 a.m. on ___ in person at the time of discovery. Radiology Report ABDOMEN FILMS ON ___ HISTORY: Worsening distention and nausea. FINDINGS: Again seen are multiple dilated loops of small bowel with air-fluid levels compatible with patient's known small bowel obstruction. A loop in the mid abdomen measures up to 7.6 cm. There is a paucity of colonic gas. No free air is identified. IMPRESSION: Continued small-bowel obstruction with worsening dilatation of small bowel loop in the mid abdomen. Radiology Report CHEST, ___ HISTORY: New left PICC line. FINDINGS: There is a new left-sided PICC line. the tip crosses midline and extends more laterally than typical before pointing centrally. it is unclear if this is in the SVC. Lateral radiograph would be helpful. There is volume loss in both lower lungs. NG tube tip is in the stomach. Again seen are dilated loops of bowel in the visualized portions of the abdomen. Radiology Report CHEST, TWO VIEWS, ___ HISTORY: Small-bowel obstruction. Check PICC line. FINDINGS: Again seen are dilated loops of bowel with air-fluid levels in the upper abdomen. There is volume loss at both bases. The PICC line appears to be in the distal SVC. Radiology Report CHEST ON ___ HISTORY: New PICC line. FINDINGS: PICC line tip is in the SVC. NG tube tip is in the stomach. Again seen are dilated loops of bowel in the abdomen. There is volume loss at both bases. Radiology Report HISTORY: Recurrent SBO. Preop for possible small bowel resection. CHEST, SINGLE AP PORTABLE VIEW. ___ chest x-ray. An apparent NG tube is present, coiled in the stomach with tip overlying the expected site of the fundus. A left-sided PICC line is present, tip over proximal/mid SVC. No pneumothorax is detected. Heart size is at the upper limits of normal and the aorta is tortuous, unchanged. No CHF, focal infiltrate or gross effusion is identified. New minimal blunting of the right costophrenic angle is seen. Trace atelectasis/scarring at both bases is again noted. No CHF or focal infiltrate. IMPRESSION: No significant change compared with ___. Possible small right effusion. Otherwise, no acute pulmonary process identified. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Vomiting Diagnosed with INTESTINAL OBSTRUCT NOS temperature: 96.2 heartrate: 94.0 resprate: 16.0 o2sat: 95.0 sbp: 113.0 dbp: 70.0 level of pain: 8 level of acuity: 3.0

Mrs. ___, ___ were admitted to ___ due to a recurrent small bowel obstruction. Due to your history of multiple prior surgeries as well as your other comorbidies, we initially attempted to treat your small bowel obstruction with bowel rest and a nasogastric tube. ___ were started on total parental nutrition to maintain your caloric intake. Ultimately, ___ did undergo an exploratory laparotomy with Dr. ___ did have several adhesive bands that he did release to resolve your obstruction. ___ will need to follow-up in clinic with him. Incision Care: *Please call your doctor or nurse practitioner if ___ have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. ___ may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If ___ have staples, they will be removed at your follow-up appointment. *If ___ have steri-strips, they will fall off on their own. Please remove any remaining strips ___ days after surgery. General Discharge Instructions: 1. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. 2. Avoid lifting weights greater than ___ lbs or lifting that requires ___ to strain until ___ follow-up with your surgeon, who will instruct ___ further regarding activity restrictions. 3. Resume your regular medications unless instructed otherwise and take any new meds as ordered . 4. ___ may take your prescribed pain medication for moderate to severe pain. ___ may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging. Please note that Percocet and Vicodin have Tylenol as an active ingredient so do not take these meds with additional Tylenol. 5. Take prescription pain medications for pain not relieved by tylenol. 6. Take Colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication if ___ are experiencing constipation. ___ may use a different over-the-counter stool softener if ___ wish. 7. Do not drive or operate heavy machinery while taking any narcotic pain medication. ___ may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); ___ should continue drinking fluids, ___ may take stool softeners, and should eat foods that are high in fiber. 8. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Please call your doctor or nurse practitioner or return to the nearest ER if ___ experience the following: ___ experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If ___ are vomiting and cannot keep down fluids or your medications. ___ 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. ___ see blood or dark/black material when ___ vomit or have a bowel movement. ___ experience burning when ___ urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. ___ 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 ___. It was a pleasure taking care of ___ here in the hospital and we wish ___ a speedy recovery.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Morphine / Prochlorperazine / Tramadol Attending: ___. Chief Complaint: Abdominal pain, coffee ground emesis Major Surgical or Invasive Procedure: R IJ placement History of Present Illness: Ms. ___ is a ___ year old woman with a past medical history of Type 1 diabetes on insulin, ESRD on HD (___), and gastroparesis with history ___ tears who presents with abdominal pain, nausea, and dark brown emesis. Pt was recently discharged from ___ on ___ for hematemesis vs hemoptysis and gastroparesis and her abdominal pain had been controlled. Since her discharge, she went to HD on ___ and was feeling well through the weekend. This morning, the patient awoke complaining of severe ___ epigastric pain. She also was vomiting with small amounts of dark-brown emesis and unsure if "coffee-ground" appearance. She reports taking her medications including her insulin up until yesterday, though did not take her insulin this morning as she was feeling ill. In the ED, initial vitals: 97.9 ___ 98% RA Exam/labs were notable for: WBC 12.1 Hct 32.8 Plt 174 NA 127 K 5.6 Cl 87 HC03 24 BUN 53 Cr 7.5 Glucose 1245 Imaging showed: 1. Right central venous catheter with tip in the upper right atrium. No pneumothorax. 2. Severe pulmonary edema, significantly worsened since the previous exam. Patient was given: Zofran, Dilaudid, labetalol 10 mg IV x1 On transfer, vitals were: HR 105 BP 200/122 RR 20 99% 2L NC On arrival to the MICU T:97.5 BP:167/109 P:92 R:18 O2: 98% 2L Past Medical History: - DM1 complicated by nephropathy, gastroparesis - ESRD, started HD ___ - Severe anxiety and panic attacks - Depression with psychotic features followed by Dr. ___ - Hyperlipidemia - Esophagitis due to H. pylori s/p triple therapy in ___ - Chronic low back pain s/p MVA in ___ Social History: ___ Family History: Grandmother (deceased) with DM Physical Exam: ADMISSION Vitals- T:97.5 BP:167/109 P:92 R:18 O2: 98% 2L GENERAL: Alert, tired appearing, moaning HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, R IJ in place, oozing blood LUNGS: Bibasilar crackles CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: Soft, diffusely tender EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema NEURO: Tired but oriented x3 . DISCHARGE Vitals- 98.4 HR 90 BP 153/92 RR17 98% O2sat RA blood glucose: 573->300s->200s General- A+Ox3, drowsy HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- Clear to auscultation bilaterally, no wheezes, rales, ronchi CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- well healed midline scare, soft, minimally tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- no foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, RUE fistula with palpaple thrill and audible bruit Neuro- CNs2-12 intact, motor function grossly normal Pertinent Results: ADMISSION LABS ___ 11:59AM BLOOD WBC-12.1*# RBC-3.04* Hgb-9.0* Hct-32.8* MCV-108*# MCH-29.6 MCHC-27.4* RDW-17.0* Plt ___ ___ 11:59AM BLOOD Neuts-96* Bands-0 Lymphs-3* Monos-1* Eos-0 Baso-0 ___ Myelos-0 ___ 11:59AM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-1+ Macrocy-3+ Microcy-NORMAL Polychr-1+ Ovalocy-1+ Schisto-OCCASIONAL Tear Dr-1+ Envelop-OCCASIONAL Bite-OCCASIONAL ___ 12:15PM BLOOD ___ PTT-58.6* ___ ___ 11:59AM BLOOD Glucose-1245* UreaN-53* Creat-7.5*# Na-127* K-5.6* Cl-87* HCO3-24 AnGap-22* ___ 11:59AM BLOOD ALT-102* AST-96* AlkPhos-307* TotBili-0.4 ___ 11:59AM BLOOD Lipase-50 ___ 11:59AM BLOOD Albumin-3.9 Calcium-8.9 Phos-8.3*# Mg-2.6 ___ 12:05PM BLOOD ___ Temp-36.6 pO2-84* pCO2-35 pH-7.43 calTCO2-24 Base XS-0 Comment-PERIPHERAL ___ 12:05PM BLOOD Glucose-GREATER TH Lactate-1.5 ___ 03:25PM URINE Color-Straw Appear-Hazy Sp ___ ___ 03:25PM URINE Blood-SM Nitrite-NEG Protein->600 Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG ___ 03:25PM URINE RBC-1 WBC-4 Bacteri-FEW Yeast-NONE Epi-16 . DISCHARGE LABS .___ 05:03AM BLOOD WBC-8.6 RBC-3.20* Hgb-9.4* Hct-31.9* MCV-100* MCH-29.3 MCHC-29.4* RDW-16.6* Plt ___ ___ 05:03AM BLOOD Glucose-573* UreaN-51* Creat-8.5*# Na-128* K-5.5* Cl-90* HCO3-25 AnGap-19 ___ 05:03AM BLOOD Calcium-8.8 Phos-5.8* Mg-2.5 IMAGING ___ Imaging UNILAT LOWER EXT VEINS No evidence of deep venous thrombosis in the left lower extremity veins. ___ Imaging CHEST (PORTABLE AP) 1. Right central venous catheter with tip in the upper right atrium. No pneumothorax. 2. Severe pulmonary edema, significantly worsened since the previous exam. ___ Imaging Chest (AP/Lateral) No acute cardiopulmonary abnormalities resolved pulmonary edema MICROBIOLOGY ___ URINE CULTURE - Contaminated ___ BLOOD CULTURE - pending Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 10 mg PO DAILY 2. Benzonatate 100 mg PO TID 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Furosemide 40 mg PO DAILY 5. Labetalol 400 mg PO TID 6. Lorazepam 0.5 mg PO DAILY:PRN anxiety 7. Metoclopramide 5 mg PO QIDACHS 8. Nephrocaps 1 CAP PO DAILY 9. Ondansetron 4 mg PO Q8H:PRN nausea 10. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain 11. Pantoprazole 40 mg PO Q12H 12. sevelamer CARBONATE 800 mg PO TID W/MEALS 13. Sodium Bicarbonate 650 mg PO BID Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Docusate Sodium 100 mg PO BID:PRN constipation 3. Labetalol 400 mg PO TID 4. Lorazepam 0.5 mg PO DAILY:PRN anxiety 5. Metoclopramide 5 mg PO QIDACHS 6. Nephrocaps 1 CAP PO DAILY 7. Ondansetron 4 mg PO Q8H:PRN nausea 8. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain 9. Pantoprazole 40 mg PO Q12H 10. sevelamer CARBONATE 1600 mg PO TID W/MEALS 11. Furosemide 40 mg PO DAILY 12. Glargine 6 Units Breakfast Glargine 10 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Home Discharge Diagnosis: PRIMARY: 1. hyperglycemia 2. insulin dependent diabetes mellitus 3. end stage renal disease, on hemodialysis 4. hypertension 5. gastroparesis 6. abdominal pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with RIJ CVL // presence of ptx, proper CVL placement TECHNIQUE: Single AP view of the chest. COMPARISON: Chest radiograph ___. FINDINGS: A new right internal jugular approach central venous catheter is present with tip terminating in the upper right atrium.There is no pneumothorax or large pleural effusion. Moderate cardiomegaly is unchanged. The mediastinal and hilar contours are unremarkable. The lungs are well-expanded without focal consolidation concerning for pneumonia. Severe pulmonary edema, again showing a more confluent pattern in the right lower lung but now also affecting the upper lobes and the left perihilar area, is worsened compared to the most recent prior study. IMPRESSION: 1. Right central venous catheter with tip in the upper right atrium. No pneumothorax. 2. Severe pulmonary edema, significantly worsened since the previous exam. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 2:05 ___. Radiology Report EXAMINATION: UNILAT LOWER EXT VEINS LEFT INDICATION: ___ y/o poorly controlled T1DM, ESRD on HD, and gastroparesis who presented with hemoptysis, nausea, vomiting, and abdominal pain found to have elevated blood sugars in and acidosis, consistent with DKA with left leg pain. Evaluate for DVT. TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the left lower extremity veins. COMPARISON: Bilateral lower extremity DVT study from ___. FINDINGS: There is normal compressibility, flow and augmentation of the left common femoral, superficial 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. Prominent but morphologically normal lymph nodes are noted in the left groin, the largest measuring 1.4 (Trv) x 0.7 (Short axis, AP) x2.4 (CC) cm. IMPRESSION: No evidence of deep venous thrombosis in the left lower extremity veins. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with IDDM, ESRD, and HTN admitted for abdominal pain, hyperglycemia, and volume overload. // Prior CXR on this admission showed ?interstitial changes. Are these still present now that pt is euvolemic? TECHNIQUE: Chest PA and lateral COMPARISON: ___ FINDINGS: Mild to moderate cardiomegaly is stable. The lungs are clear. There is no pneumothorax or pleural effusion. The osseous structures are unremarkable right IJ catheter tip is in the lower SVC IMPRESSION: No acute cardiopulmonary abnormalities resolved pulmonary edema Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Abd pain Diagnosed with DIAB HYPEROSM COMA IDDM, DIAB NEURO MANIF IDDM, GASTROPARESIS, GASTROINTEST HEMORR NOS, RENAL FAILURE, UNSPECIFIED temperature: 97.9 heartrate: 100.0 resprate: nan o2sat: 98.0 sbp: 208.0 dbp: 134.0 level of pain: 8 level of acuity: 2.0

Dear Ms. ___, It was a pleasure taking care of you during your admission to ___. You were admitted for abdominal pain, hyperglycemia, and hypertension. You with treated with insulin drip, labetolol drip, and dialysis. Your sugars improved although they remained difficult to control. Your abdominal pain improved and you were able to tolerated liquids and food. During this hospitalization, you also met with a pain specialist who recommended you discuss a referral to the pain clinic with your PCP. You met with interventional radiology who will schedule you for a port catheter placement as outpatient. The port placement will help give you long-term access for the frequent blood draws you require. Please continue taking your home medication regimen and follow up with your outpatient dialysis center, your endocrinologist, and your PCP. Sincerely, Your team at ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Aspirin / fentanyl Attending: ___ Chief Complaint: Chest pain and headache Major Surgical or Invasive Procedure: Cardiac catheterization (no stents placed) History of Present Illness: Ms. ___ is a ___ yo woman with multiple cardiovascular risk factors (HLD, pre-DM, Fhx, ongoing cig smoking), CAD s/p stent with prior MI in ___, CVAs x2 including left occipital stroke in ___, lung CA s/p chemotherapy and surgery, atypical chest pain, who presents with headache and chest pain. She reports having an ___ headache that started 4 days ago and ___ chest pain that started on ___. She reports that the CP radiated to her neck and arm and she experienced a tingling in her right hand. She took her morning aspirin on ___ and then again in the evening when she had the chest pain and nitroglycerin x2 which "helped a little" to relieve the CP. She reports that her current symptoms are identical to those she had several months ago. Because the CP and headache did not resolve she presented the next day on ___ to the ___ ED. Per cardiology note from the ED, she has continued to have CP since her cath in ___. Her hx is variable and she is a poor/vague historian. Activity is limited. The CP comes on at any time, including at rest. No apparent provocation by eating or exertion. She has been tried on pantoprazole, without effect, and was given nitro to take prn by Dr. ___. Her cardiologist. About 10 ___ last night, she began to have recurrent lower retrosternal and L parasternal chest pressure, which incr with breathing in, and rad into the neck and the arms. She describes taking ASA and nitro without effect, but then says that she had recurrent epis which lasted ___ sx. Says that sx are similar to those prior to card stent and similar to CP which has been recurring since the stenting. Has been having a HA for 4 days. In the ED, her BP was 111/68, HR 80, 96% sat on RA, afebrile. Per the cardiology evaluation in the ED, there was no evidence JVD at 45% on stretcher. Her lungs were clear and she had discomfort to pressure on the lower sternal and L parasternal areas. She had no audible M/R/G. No palp liver. No edema or calf tenderness. LABS: Hgb 10.0 (prior Hgb 9.9-10.8 in ___. Nl W and plat. BS ___. Nl BUN/Cr and lytes. Nl LFT's. Trop <0.01 x 2. Nl D-dimer. EKG in ambulance and here: within normal limits. No change CPT of ___. On transfer to the floor, vital signs were Tc 97.5 BP 132/51 HR 70 RR 20 O2 100% on RA. She continues to endorse ___ chest pain and ___ headache and is frustrated at having to recount her history and confirm her medications. She was upset that an allergy to fentanyl was listed in her OMR. She endorses nausea, but no vomiting. She denies SOB, D/C. REVIEW OF SYSTEMS: As per HPI Past Medical History: -Major depressive disorder (started after CVA in ___, with 2 prior psych admissions (___) -Metastastic lung adeno involving lung and bronchus w/thoracic ___ and taxol s/p 6 cycles in ___. Near complete response to therapy. PET scan: clear in ___. Avastin q 3 weeks from ___ (maintenance). Managed by Dr. ___ at ___. -Left occipital stroke ___ (on plavix) -CAD s/p MI in the ___ -Hyperlipidemia -Hypertension -Chronic low back pain -Chronic atypical chest pain -GERD -Hypothyroidism -Acute confusional state -Urge incontinence -Pre-diabetes, HbA1c 6.3% ___ -HTN, off medications Social History: ___ Family History: Stroke in daughter, cousin, aunt. MI in ___ in mother, uncle, grandfather. ___ in grandmother, uncle, mother. DM in paternal grandmother and maternal uncle. Physical Exam: On admission: Vitals: Tc 97.5 BP 132/51 HR 70 RR 20 O2 100% on RA General: Elderly woman laying in bed in NAD eating dinner, talking on the phone with religious texts on her bed. Annoyed at having to answer questions again. HEENT: Sclera anicteric, MMM Neck: Supple, JVP not elevated Lungs: CTAB, no wheezes/rales/rhonchi CV: TTP on sternum, RRR, normal S1/S2, no MRG Abdomen: Soft, obese, NT, ND, normoactive bowel sounds GU: No Foley Ext: Warm, well-perfused, no cyanosis/clubbing/edema, 2+ pulses Neuro: AAOx3, CN II-XII grossly intact. ___ strength in RLE versus ___ strength in LLE (per pt, ___ stroke). ___ strength in upper extremities bilaterally. On discharge: Vitals: Tm 98.7 Tc 98.7 HR 78 BP 99/59-112/52 RR 18 O2 99% on RA General: AAOx3, in no acute distress, walking around her room and concerned because she was having diarrhea after receiving docusate and senna HEENT: sclera anicteric, EOM grossly intact Neck: supple, JVP not elevated Lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi; has discomfort over right rib on deep inspiration CV: TTP on sternum and on right rib, RRR, normal S1/S2, no MRG Abdomen: Soft, obese, NT, ND, normoactive bowel sounds GU: No Foley Ext: Warm, well-perfused, no cyanosis/clubbing/edema, 2+ pulses Neuro: AAOx3, CN II-XII intact, with mildly reduced abduction of the right eye c/w mild right CN6 palsy and decreased visual field on the right c/w h/o left occipital stroke, 4+/5 strength in RLE versus 5+/5 strength in LLE (per pt, ___ stroke). 4+/5 strength in RUE versus 5+/5 in left upper extremities c/w h/o of left sided stroke. Pertinent Results: LABS ================== On Admission: ___ 02:10AM BLOOD WBC-8.8 RBC-3.41* Hgb-10.0* Hct-30.7* MCV-90 MCH-29.3 MCHC-32.6 RDW-14.3 RDWSD-46.5* Plt ___ ___ 02:10AM BLOOD Neuts-61.6 ___ Monos-6.3 Eos-1.7 Baso-0.5 Im ___ AbsNeut-5.44 AbsLymp-2.59 AbsMono-0.56 AbsEos-0.15 AbsBaso-0.04 ___ 02:10AM BLOOD ___ PTT-32.1 ___ ___ 02:10AM BLOOD Glucose-103* UreaN-15 Creat-1.0 Na-141 K-4.2 Cl-105 HCO3-24 AnGap-16 ___ 02:10AM BLOOD cTropnT-<0.01 ___ 08:00AM BLOOD cTropnT-<0.01 ___ 03:46PM BLOOD CK-MB-4 cTropnT-<0.01 On discharge: ___ 11:25AM BLOOD WBC-10.2* RBC-3.42* Hgb-9.8* Hct-31.6* MCV-92 MCH-28.7 MCHC-31.0* RDW-14.5 RDWSD-48.9* Plt ___ ___ 11:25AM BLOOD Glucose-80 UreaN-20 Creat-1.0 Na-140 K-5.2* Cl-106 HCO3-25 AnGap-14 ___ 11:25AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.0 IMAGING ================== ___ CHEST (PA & LAT) IMPRESSION: No acute intrathoracic process. ___ HEAD W/O CONTRAST IMPRESSION: 1. No acute intracranial abnormality. Specifically no acute intracranial hemorrhage or territorial infarct. 2. Nonspecific white matter hypodensities are unchanged and commonly seen in setting of chronic microangiopathy in a patient of this age. 3. If there remains high clinical suspicion for infarct, MRI would be more sensitive if there no contraindications. PROCEDURE NOTES ================== ___ Cardiac catheterization notes Impression: Double vessel CAD with widely patent mild RCA stent and long CTO of a small OM1 with brisk collateral flow. The LAD has no significant disease and LV size and function are normal. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. nitroglycerin 0.4 mg sublingual Q5MIN PRN CHEST PAIN 2. melatonin 3 mg oral QHS 3. Aspirin 81 mg PO DAILY 4. Levothyroxine Sodium 50 mcg PO DAILY 5. Atorvastatin 80 mg PO QPM 6. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain 7. Gabapentin 600 mg PO TID 8. Clopidogrel 75 mg PO DAILY 9. Pantoprazole 40 mg PO Q24H 10. Cyanocobalamin 1000 mcg PO DAILY 11. TraZODone 150 mg PO QHS 12. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H:PRN SOB 13. HydrOXYzine 10 mg PO TID:PRN pruritus 14. Cetirizine 10 mg PO DAILY:PRN allergy 15. Nicotine Patch 14 mg TD DAILY 16. Multivitamins 1 TAB PO DAILY 17. Fish Oil (Omega 3) Dose is Unknown PO Frequency is Unknown 18. Calcium 500 + D (calcium carbonate-vitamin D3) unknown mg oral unknown 19. sennosides unknown oral unknown Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Clopidogrel 75 mg PO DAILY 4. Gabapentin 600 mg PO TID 5. Levothyroxine Sodium 50 mcg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain 8. Pantoprazole 40 mg PO Q24H 9. Cetirizine 10 mg PO DAILY:PRN allergy 10. melatonin 3 mg oral QHS 11. Nicotine Patch 14 mg TD DAILY 12. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H:PRN SOB 13. nitroglycerin 0.4 mg sublingual Q5MIN PRN CHEST PAIN 14. HydrOXYzine 10 mg PO TID:PRN pruritus 15. TraZODone 50 mg PO QHS:PRN insomnia Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1. Unstable Angina Secondary Diagnosis: 2. Headache Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ with pain // eval for chest pain TECHNIQUE: Chest PA and lateral COMPARISON: PA and lateral views of the chest dated ___ FINDINGS: The cardiomediastinal silhouette and pulmonary vasculature are unremarkable. The lungs are clear. There is no pleural effusion or pneumothorax. IMPRESSION: No acute intrathoracic process. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: History: ___ with hx cva, headache // eval for stroke TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained without intravenous contrast. Coronal and sagittal reformations and bone algorithms reconstructions were also performed. DOSE: Total DLP (Head) = 702 mGy-cm. COMPARISON: CT head dated ___, MRI head of ___ FINDINGS: There is no evidence of large territorial infarction, hemorrhage, edema, or mass effect. There is mild cortical volume loss, which is age-related. Subcortical and periventricular white matter hypodensities are noted, likely consistent with small vessel ischemic disease and unchanged from prior exam. No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: 1. No acute intracranial abnormality. Specifically no acute intracranial hemorrhage or territorial infarct. 2. Nonspecific white matter hypodensities are unchanged and commonly seen in setting of chronic microangiopathy in a patient of this age. 3. If there remains high clinical suspicion for infarct, MRI would be more sensitive if there no contraindications. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Chest pain, Dizziness Diagnosed with Other chest pain, Headache temperature: 97.8 heartrate: 80.0 resprate: 18.0 o2sat: 96.0 sbp: 111.0 dbp: 68.0 level of pain: 9 level of acuity: 2.0

Dear Ms. ___, It was a pleasure being able to participate in your medical care during your stay at the ___. You came to the hospital because of your headache and chest pain. We performed several tests of your heart and there were no major signs of a heart attack. We also performed a CT scan of your head that was normal and did NOT show a stroke. You had an episode of chest pain while in the hospital and we repeated tests of your heart, which again did not show a heart attack. Because you continued to have chest pain while you were in the hospital, we contacted the cardiology team and they performed a cardiac catheterization, which is a procedure to look at your heart vessels. They did not see any changes compared to the last examination of your heart vessels. We continued your home medications, which we would like you to continue as prescribed. Thank you for letting us participate in your care. Please follow-up with your cardiologist as indicated below. We wish you all the best, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Concern for Portal Vein Thrombosis Major Surgical or Invasive Procedure: EGD with dobhoff placement ___ Diagnostic paracentesis ___ Diagnsotic paracentesis ___ History of Present Illness: Ms. ___ is a ___ y/o female with HCV s/p treatment, EtOH cirrhosis c/b ascites, varices, and HE, and recent admission for alcoholic hepatitis who presents as a transfer for c/f portal vein thrombosis. Pt was recently admitted in ___ for abdominal pain, found to have alcohol hepatitis. She was continued on prednisone 40 mg daily (ending on ___. Since then, she saw her PCP, who reports that patient has continued drinking alcohol since discharge. She reports 4 days of persistent nausea, vomiting, and inability to tolerate PO. She endorses continued RUQ abdominal pain, but says it is improved from when she last left the hospital. She has unfortunately continued drinking alcohol, approximately ___ drinks per day. Her last drink was on ___. She denies confusion, but reports she has not had a BM recently and has not been taking her lactulose. She says she has been taking the rest of her medications. She denies fevers, chills, chest pain, cough, dyspnea. She is not sure if she has ever had withdrawal seizures. Pt presented to ___ on ___ because of the above symptoms. RUQUS there showed no flow related Doppler signal in the main portal vein and apparent flow reversal in splenic vein, c/f PVT. She was given 1mg/kg Lovenox and transferred to ___. In the ED, initial vitals were T 98.8, HR 100, BP 110/50, RR 19, O2 98% RA. Exam notable for TTP in the epigastric region but otherwise soft/nondistended abdomen. Labs notable for WBC 5.2, Hgb 11.3 (baseline 11.0), Plt 48, INR 2.0, Cr 0.6, Na 132, K 3.0 (repleted, K 5.2), ALT 44, AST 245 (increased from 111 on recent discharge), Alk phos 157, Tbili 4.4 (down from 5.1), EtOH level 213, lactate 3.8. Blood and urine cx drawn. CXR with no acute intrathoracic process. Hepatology was consulted and recommended no further anticoagulation, MRI Liver, CIWA scale, pan-culture, and admission to ET. She was given diazepam 10 mg IV x1 and Zofran. Upon arrival to the floor, the patient provides the above history. She endorses RUQ abdominal pain and feeling "shaky" all over. K was 2.8, so she was ordered for 60 of IV and 40 of PO K. She was started on mIVF. EKG showed QTc 511 so Zofran and amitryptiline were stopped. EKG showed NSR, no ischemic changes. REVIEW OF SYSTEMS: + per HPI, - otherwise Past Medical History: PAST MEDICAL HISTORY: Hypertension ? h/o acute intermittent coproporhyria h/o HCV (treated with ___ years ago at ___ with unknown medication with SVR) Hypothyroidism History of headaches Low folic acid Abdominal pain NASH PAST SURGICAL HISTORY: Right knee surgery (___) LN removal for unknown reason (she reports maybe it was from infectious mononucleosis) Ovarian cyst removal Social History: ___ Family History: Not-pertinent to the current admission. Not aware of anyone in the family with hemochromatosis. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: 98.8, BP 121 / 74, HR 105, RR 20, O2 96 Ra General: Alert, oriented x3, appears calm, no asterixis, mild tremor present HEENT: Sclerae anicteric, MMM NECK: supple, JVP not elevated CV: Tachycardic, regular rhythm, normal S1 + S2 Lungs: Clear to auscultation bilaterally, no wheezes Abdomen: Soft, non-distended, markedly tender in RUQ and epigastric region GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Warm, dry, no rashes or notable lesions. Neuro: Normal speech DISCHARGE PHYSICAL EXAM: VITALS: T 98.4 PO BP 108 / 56 L HR 51RR 18O2 94Ra HEENT: Sclerae mildly icteric, MMM CV: reg rate, regular rhythm, normal S1 + S2 Lungs: Clear to auscultation bilaterally, no wheezes Abdomen: normal bowel sounds. Soft, mildly distended, nontender in all quadrants Ext: 1+ pitting edema b/l, WWP, no rash Neuro: Normal speech; moves all 4 extremities, AAOx4, no asterixis Pertinent Results: ADMISSION LABS: ================ ___ 09:20PM BLOOD WBC-5.2 RBC-3.07* Hgb-11.3 Hct-30.9* MCV-101* MCH-36.8* MCHC-36.6 RDW-12.4 RDWSD-45.7 Plt Ct-48* ___ 09:20PM BLOOD Neuts-44.5 ___ Monos-14.9* Eos-0.4* Baso-1.0 Im ___ AbsNeut-2.31 AbsLymp-2.02 AbsMono-0.77 AbsEos-0.02* AbsBaso-0.05 ___ 09:20PM BLOOD ___ PTT-50.1* ___ ___ 09:20PM BLOOD Glucose-106* UreaN-4* Creat-0.6 Na-132* K-3.0* Cl-87* HCO3-31 AnGap-14 ___ 09:20PM BLOOD ALT-44* AST-245* AlkPhos-157* TotBili-4.4* ___ 09:20PM BLOOD Albumin-2.7* Calcium-7.9* Phos-2.0* Mg-1.7 DISCHARGE LABS: ================= ___ 01:05PM ASCITES TNC-118* RBC-82* Polys-0 Lymphs-4* ___ Mesothe-2* Macroph-94* ___ 05:45AM BLOOD WBC-8.9 RBC-2.84* Hgb-9.9* Hct-30.2* MCV-106* MCH-34.9* MCHC-32.8 RDW-14.1 RDWSD-55.0* Plt Ct-56* ___ 05:45AM BLOOD ___ PTT-36.2 ___ ___ 05:45AM BLOOD Glucose-92 UreaN-10 Creat-0.7 Na-137 K-3.7 Cl-101 HCO3-29 AnGap-7* ___ 05:45AM BLOOD ALT-37 AST-76* AlkPhos-144* TotBili-5.1* IMAGING AND STUDIES: ====================== MRI ___ IMPRESSION: Cirrhosis, portal hypertension and splenomegaly without any evidence of portal vein thrombosis. Newly developed liver steatosis, not present on ___. Mild to moderate ascites. Very small low suspicious liver lesion in the lateral segments which is amenable to consideration of attention in followup. EGD ___: 1. 2 cords of Grade II varices in distal esophagus 2. portal hypertensive gatropathy Paracentesis ___: IMPRESSION: 1. Technically successful ultrasound guided diagnostic paracentesis. 2. 20 cc of fluid were removed and sent for requested analysis. KUB ___: IMPRESSION: 1. Mildly distended loops of small bowel with air-fluid levels most likely consistent with mild ileus. PERITONEAL FLUID: ___ 01:05PM ASCITES TNC-118* RBC-82* Polys-0 Lymphs-4* ___ Mesothe-2* Macroph-94* ___ 05:45AM BLOOD WBC-8.9 RBC-2.84* Hgb-9.9* Hct-30.2* MCV-106* MCH-34.9* MCHC-32.8 RDW-14.1 RDWSD-55.0* Plt Ct-56* ___ 05:45AM BLOOD ___ PTT-36.2 ___ ___ 05:45AM BLOOD Glucose-92 UreaN-10 Creat-0.7 Na-137 K-3.7 Cl-101 HCO3-29 AnGap-7* ___ 05:45AM BLOOD ALT-37 AST-76* AlkPhos-144* TotBili-5.1* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amitriptyline 25 mg PO DAILY 2. FoLIC Acid 1 mg PO DAILY 3. Furosemide 20 mg PO DAILY 4. Lactulose 30 mL PO BID 5. Levothyroxine Sodium 75 mcg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Thiamine 100 mg PO DAILY 8. Omeprazole 40 mg PO BID 9. Propranolol LA 80 mg PO BID 10. Spironolactone 100 mg PO DAILY Discharge Medications: 1. Baclofen 5 mg PO TID RX *baclofen 5 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 2. Nicotine Patch 21 mg/day TD DAILY RX *nicotine 21 mg/24 hour apply patch as directed daily Disp #*14 Patch Refills:*0 3. Polyethylene Glycol 17 g PO DAILY 4. PredniSONE 40 mg PO DAILY RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 5. Simethicone 40-80 mg PO TID:PRN gas, bloating RX *simethicone 80 mg 1 tablet by mouth daily Disp #*30 Tablet Refills:*0 6. Furosemide 40 mg PO DAILY RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 7. Propranolol LA 80 mg PO DAILY RX *propranolol 80 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 8. FoLIC Acid 1 mg PO DAILY 9. Lactulose 30 mL PO BID 10. Levothyroxine Sodium 75 mcg PO DAILY 11. Multivitamins 1 TAB PO DAILY 12. Omeprazole 40 mg PO BID RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 13. Spironolactone 100 mg PO DAILY RX *spironolactone 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 14. Thiamine 100 mg PO DAILY 15. HELD- Amitriptyline 25 mg PO DAILY This medication was held. Do not restart Amitriptyline until until discussed with your ___. This was held because of prolonged QTc Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: ==================== Alcoholic hepatitis Alcohol use disorder Secondary Diagnosis: ====================== Ileus HCV/ alcoholic cirrhosis Prolonged Qtc Thrombocytopenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ with ETOH cirrhosis here w/ possible PVT// r/o infection COMPARISON: None FINDINGS: AP portable upright view of the chest provided. Lung volumes are slightly low bilaterally. There is no focal consolidation, effusion, or pneumothorax. The cardiomediastinal silhouette is normal. Imaged osseous structures are intact. No free air below the right hemidiaphragm is seen. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: MRI of the Abdomen INDICATION: Ms. ___ is a ___ y/o female with HCV s/p treatment, EtOH cirrhosis c/b ascites, varices, and HE, and recent admission for alcoholic hepatitis who presents as a transfer for portal vein thrombosis.// eval portal vein thrombosis TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were acquired in a 1.5 T magnet. Intravenous contrast: 8 mL Gadavist. COMPARISON: MRCP from ___. FINDINGS: Lower Thorax: No pleural effusion or focal consolidation. No pericardial effusion. Liver: Fat fraction of 8.7%, consistent with mild steatosis. Heterogeneous arterial enhancement also suggests acute or active component to parenchymal disease. The liver is mildly nodular in contour, there is hypertrophy of the left lobe in keeping with cirrhosis. There is mild-to-moderate ascites in the upper abdomen. The pelvis was not imaged. There is no evidence of any highly suspicious liver nodule, no abnormal enhancement. A small hypoenhancing focus is found in the left lateral segments measuring only 8 mm on delayed images only (84: 84). It is not found on the last contrast-enhanced series but the latter is affected by motion artifact. It correlates to a slightly hypointense lesion on T2-weighted images but is otherwise isointense and/or inconspicous on all other sequences. The portal vein is unremarkable and is of normal size without evidence of thrombus or occlusion. Biliary: No intrahepatic or extrahepatic bile duct dilation. The walls of the gall bladder are thickened, likely due to the presence of ascites and liver disease. There is no gallstone. Pancreas: The pancreas is unremarkable. The main pancreatic duct is not dilated. Spleen: There is splenomegaly, the spleen measures 15.2 cm. Adrenal Glands: The adrenal glands are unremarkable. Kidneys: There is bilateral symmetrical nephrogram. There is an 8 mm simple appearing cyst in the right kidney. The left kidney is unremarkable. There is no hydronephrosis. Gastrointestinal Tract: The stomach and visualized bowel are unremarkable without dilation or significant wall thickening. Lymph Nodes: Mildly prominent retroperitoneal nodes, are probably due to underlying liver disease. Vasculature: There is conventional hepatic arterial anatomy. The portal and hepatic veins are patent. There are left large esophageal and paraesophageal varices as well as collateral vessels arising from the falciform ligament, possibly including umbilical vein in addition to others. Varices are also prominent along gastric cardia. Osseous and Soft Tissue Structures: There is no evidence of suspicious bony lesion. IMPRESSION: Cirrhosis, portal hypertension and splenomegaly without any evidence of portal vein thrombosis. Newly developed liver steatosis, not present on ___. Mild to moderate ascites. Very small low suspicious liver lesion in the lateral segments which is amenable to consideration of attention in followup. Radiology Report EXAMINATION: Ultrasound-guided diagnostic paracentesis INDICATION: ___ year old woman with alcoholic hepatitis and moderate ascites// Diagnostic and therapeutic paracentesis TECHNIQUE: Limited images of the abdomen were obtained to identify a suitable pocket, followed by ultrasound-guided paracentesis. COMPARISON: Ultrasound dated ___. FINDINGS: Limited grayscale ultrasound imaging of the abdomen demonstrated a trace amount of ascites. A suitable target in the deepest pocket in the right upper quadrant was selected for paracentesis. PROCEDURE: Ultrasound guided diagnostic paracentesis Location: right upper quadrant Fluid: 20 cc of clear, straw-colored fluid Samples: Fluid samples were submitted to the laboratory the requested analysis (chemistry, hematology, microbiology). The procedure, risks, benefits and alternatives were discussed with the patient and written informed consent was obtained. A preprocedure time-out was performed discussing the planned procedure, confirming the patient's identity with 3 identifiers, and reviewing a checklist per ___ protocol. Under ultrasound guidance, an entrance site was selected and the skin was prepped and draped in the usual sterile fashion. 1% lidocaine was instilled for local anesthesia. Ascites fluid was aspirated via a 5 ___ catheter advanced into the largest fluid pocket. The patient tolerated the procedure well without immediate complication. Estimated blood loss was minimal. Dr. ___ personally supervised the trainee during the key components of the procedure and reviewed and agrees with the trainee's findings. IMPRESSION: 1. Technically successful ultrasound guided diagnostic paracentesis. 2. 20 cc of fluid were removed and sent for requested analysis. Radiology Report INDICATION: ___ year old woman with alcoholic hepatitis, abdominal distension// Evaluate for air fluid levels, evidence of ileus TECHNIQUE: Supine and upright abdominal radiographs were obtained. COMPARISON: Abdominal radiograph dating ___ FINDINGS: Mild distension of the small bowel with mild air-fluid levels are seen. Air is seen in the large bowel, there is no evidence of obstruction. Paucity of bowel gas most likely consistent with abdominal ascites. There is no free intraperitoneal air. Osseous structures are unremarkable. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: 1. Mildly distended loops of small bowel with air-fluid levels most likely consistent with mild ileus. Radiology Report EXAMINATION: ULTRASOUND-GUIDED DIAGNOSTIC AND THERAPEUTIC PARACENTESIS INDICATION: ___ year old woman with alcoholic cirrhosis/hepatitis with worsening abdominal distension and pain c/f worsening ascites and SBP. Evaluation for diagnostic and therapeutic paracentesis TECHNIQUE: Limited abdominal ultrasound was performed to determine a suitable fluid pocket, followed by ultrasound-guided paracentesis. COMPARISON: Comparison to prior ultrasound-guided paracentesis from ___. FINDINGS: Limited grayscale ultrasound imaging of the abdomen demonstrated a small amount of ascites. A suitable target in the deepest pocket in the right lower quadrant was selected for paracentesis. PROCEDURE: Ultrasound guided diagnostic and therapeutic paracentesis Location: right lower quadrant Fluid: 2.75 L of clear, straw-colored fluid Samples: Fluid samples were submitted to the laboratory for the requested analysis (chemistry, hematology, microbiology). The procedure, risks, benefits and alternatives were discussed with the patient and written informed consent was obtained. A preprocedure time-out was performed discussing the planned procedure, confirming the patient's identity with 3 identifiers, and reviewing a checklist per ___ protocol. Under ultrasound guidance, an entrance site was selected and the skin was prepped and draped in the usual sterile fashion. 1% lidocaine was instilled for local anesthesia. Ascites fluid was aspirated via a 5 ___ catheter advanced into the largest fluid pocket. The patient tolerated the procedure well without immediate complication. Estimated blood loss was minimal. Dr. ___ supervised the trainee during the key components of the procedure and reviewed and agrees with the trainee's findings. IMPRESSION: 1. Technically successful ultrasound guided diagnostic and therapeutic paracentesis. 2. 2.75 L of clear, straw-colored fluid were removed and sent for requested analysis. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Portal vein thrombosis, Transfer Diagnosed with Portal vein thrombosis, Alcoholic hepatitis without ascites temperature: 98.8 heartrate: 100.0 resprate: 19.0 o2sat: 98.0 sbp: 110.0 dbp: 50.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, WHY WERE YOU ADMITTED TO THE HOSPITAL? - You were admitted to the hospital because your liver was damaged from drinking alcohol again WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? - You were continued on steroids to help you recover. - You improved and were ready to leave the hospital. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - Please take all of your medications as prescribed and go to your follow up appointments with your doctors ___ below) - Weigh yourself every morning, before you eat or take your medications. Call your doctor if your weight increases by more than 3 pounds - Please maintain a low salt diet and monitor your fluid intake - Seek medical attention if you have new or concerning symptoms or you develop - Please continue to work towards sobriety ****MEDICATIONS**** You will need to continue taking prednisone 40mg for 28 days (last day on ___. We are working on getting you an appointment at that point with Dr. ___ further evaluation. It was a pleasure participating in your care. We wish you the best! - Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Back Pain w/Breathing Major Surgical or Invasive Procedure: ___ CT-guided left lower lobe lung mass/consolidation biopsy. History of Present Illness: This is a ___ male with no significant past medical history who presented as transfer from ___ due to abnormal CTA chest. The patient reports that he woke up around 4AM on the day of presentation with pain in his back while breathing. He states that the pain is localized to the left scapular area. For ___ days prior to presentation he felt like he had a "virus" in which he had chills and general malaise and fatigue, though no cough, sputum production, SOB, congestion, ST, or fevers. He smokes marijuana daily -- smokes it from concentrate and also flower. No tobacco use. He went to ___ where he was initially noted to be tachycardic to the 110s. His labs were notable for a WBC 12, other wise normal CBC and Chem-10. He received 1 L IV fluids and ceftriaxone/azithromycin for presumed community-acquired pneumonia coverage based on a RLL infiltrate on CXR. Flu was negative. Given the nature of his pain and his tachycardia, a CTA was done which showed no evidence of PE but did show ground-glass opacity in the periphery with halo sign concerning for bronchoalveolar carcinoma versus fungal infection. He was transferred to ___ for admission to medicine for pulmonary consult likely bronchoscopy. On arrival to the ED, the patient only reported having pain in left scapular area when he takes a deep breath but no chest pain or no shortness of breath. His vitals were notable for tachycardia to the 120s, T-99.5, BPs 157/93, RR 18, O2 96% RA. Exam was unremarkable with the exception of tachycardia. Labs done at ___ included a lactate which was normal and blood cultures which were pending (see above for labs from ___. He was given acetaminophen and ketorolac for pain and then admitted to medicine for pulmonary consult and possible bronchoscopy. On the floor, patient reports feeling well. Pain in left upper back is overall improved, thinks that pain meds helped. History reported as above. Asking for sleep meds to help with insomnia. Past Medical History: None Social History: ___ Family History: Maternal GM had COPD Paternal GF had stomach cancer in his ___ Maternal GF had some kind of lung disease late in life Physical Exam: ADMISSION PHYSICAL EXAM: ====================== VITALS: 98.6PO,156 / 84,114,20,95Ra General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple CV: borderline tachycardic, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Back: no TTP Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation DISCHARGE PHYSICAL EXAM: ====================== Vital Signs: ___ 0722 Temp: 98.1 PO BP: 141/78 R Lying HR: 98 RR: 20 O2 sat: 97% O2 delivery: Ra General: NAD, alert, anxious appearing HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, neck supple CV: borderline tachycardic, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, grossly normal Pertinent Results: ADMISSION LABS: ============== ___ 07:35PM BLOOD WBC-10.7* RBC-4.71 Hgb-13.3* Hct-41.1 MCV-87 MCH-28.2 MCHC-32.4 RDW-11.9 RDWSD-38.0 Plt ___ ___ 07:35PM BLOOD Neuts-70.9 Lymphs-14.7* Monos-13.1* Eos-0.6* Baso-0.3 Im ___ AbsNeut-7.55* AbsLymp-1.57 AbsMono-1.40* AbsEos-0.06 AbsBaso-0.03 ___ 07:35PM BLOOD Glucose-122* UreaN-8 Creat-0.7 Na-140 K-4.1 Cl-104 HCO3-23 AnGap-13 ___ 07:35PM BLOOD ALT-28 AST-22 AlkPhos-70 TotBili-0.6 ___ 07:35PM BLOOD Calcium-9.4 Phos-2.7 Mg-2.0 MICROBIOLOGY: ============ ___ 4:24 pm TISSUE Source: Lung, left lower lobe. GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): ___ Legionella Urinary Antigen: NEGATIVE FOR SEROGROUP 1 ANTIGEN. ___ Blood Culture x3: NGTD ___ Streptococcus pneumoniae Antigen DetectionResults Pending ___ ASPERGILLUS GALACTOMANNAN ANTIGENResults Pending ___ B-GLUCANResults Pending STUDIES: ======== CTA chest ___ ___ IMPRESSION: Exam is limited due to respiratory motion artifact. However, within these limitations: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Large solitary 5 cm dense left lower lobe peripheral mass with surrounding ground-glass opacity is concerning for malignancy such as a bronchoalveolar carcinoma, particularly in the setting of unilateral hilar lymphadenopathy. Alternatively, this may represent a fungal infection, particularly if the patient is in immunocompromised state, or an atypical bacterial infection. Infarction is less likely as associated pulmonary arterial vasculature appears well opacified. Considering location, differential diagnosis also includes a pleural based mass such as a benign fibrous tumor or plasmacytoma. 3. Hilar lymphadenopathy may represent nodal metastasis, or may be reactive. CXR ___ No evidence of pneumothorax. DISCHARGE LABS: =============== ___ 05:33AM BLOOD WBC-8.9 RBC-4.58* Hgb-12.8* Hct-40.3 MCV-88 MCH-27.9 MCHC-31.8* RDW-12.1 RDWSD-38.9 Plt ___ ___ 05:33AM BLOOD Glucose-101* UreaN-9 Creat-0.7 Na-144 K-5.0 Cl-105 HCO3-23 AnGap-16 ___ 05:33AM BLOOD Calcium-9.6 Phos-2.9 Mg-2.1 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: None Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Lung mass Back pain Sinus tachycardia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ year old man with no PMH but heavy inhaled marijuana use, presenting with large left lower lobe lung mass, concerning for malignancy vs infection. Patient asymptomatic except for left subscapular pain.// micro and pathology of LLL lung mass COMPARISON: Prior CT chest done ___ PROCEDURE: CT-guided left lower lobe lung mass/consolidation biopsy. OPERATORS: Dr. ___, radiology trainee and Dr. ___ radiologist. Dr. ___ supervised the trainee during the key components of the procedure and reviewed and agrees with the trainee's findings. TECHNIQUE: The risks, benefits, and alternatives of the procedure were explained to the patient. After a detailed discussion, informed written consent was obtained. A pre-procedure timeout using three patient identifiers was performed per ___ protocol. The patient was placed in a prone position on the CT scan table. Limited preprocedure CTscan of the intended biopsy area was performed. Based on the CT findings an appropriate position for the biopsy was chosen. The site was marked. The site was prepped and draped in the usual sterile fashion. 1% lidocaine were administered to the subcutaneous and deep tissues for local anesthetic effect. Under CT guidance, a 17 gauge coaxial needle was introduced into the lesion. An 18 gauge core biopsy device with a 22 mm throw was used to obtain 3 core biopsy specimens, which were sent for pathology. The procedure was tolerated well and there were no immediate post-procedural complications. DOSE: Acquisition sequence: 1) Spiral Acquisition 11.4 s, 34.9 cm; CTDIvol = 13.7 mGy (Body) DLP = 467.0 mGy-cm. 2) Spiral Acquisition 11.1 s, 34.0 cm; CTDIvol = 13.4 mGy (Body) DLP = 444.2 mGy-cm. 3) Stationary Acquisition 13.0 s, 1.4 cm; CTDIvol = 98.9 mGy (Body) DLP = 142.4 mGy-cm. Total DLP (Body) = 1,065 mGy-cm. SEDATION: Moderate sedation was provided by administering divided doses of 1.5 mg Versed and 75 mcg fentanyl throughout the total intra-service time of 21 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. FINDINGS: 1. 3 x 18 gauge core biopsy was performed of the left lower lobe lung mass/consolidation. IMPRESSION: Technically successful CT-guided biopsy of the left lower lobe lung mass/consolidation. No immediate complications. Radiology Report EXAMINATION: Chest radiograph, portable AP upright. INDICATION: Status post CT-guided lung biopsy of the left lower lobe nodule. COMPARISON: Radiographs and CT from ___. FINDINGS: Cardiac, mediastinal and hilar contours appear stable. Rounded pleural based opacity is again demonstrated in the lateral left lower chest. Otherwise, lungs appear clear. There is no pneumothorax or pleural effusion. IMPRESSION: No evidence of pneumothorax. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Abnormal CT, Back pain, Transfer Diagnosed with Pneumonia, unspecified organism temperature: 99.0 heartrate: 105.0 resprate: 18.0 o2sat: 97.0 sbp: 154.0 dbp: 77.0 level of pain: 6 level of acuity: 2.0

Dear Mr. ___, It was a pleasure caring for you at ___. WHY WERE YOU ADMITTED? - You had back pain and were found to have abnormal lung findings on chest CT. WHAT HAPPENED THIS ADMISSION? - You were seen by the lung doctors and ___. You received a procedure called a percutaneous ("through the skin") lung biopsy. WHAT SHOULD YOU DO ON DISCHARGE? - Take your medicines as prescribed. - Go to your follow up appointments as scheduled. We wish you the best, Your ___ team

Name: ___ Unit ___: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: tree nut Attending: ___. Chief Complaint: Ms. ___ is a ___ woman with relapsing remitting multiple sclerosis who presents with vision changes. Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ woman with relapsing remitting multiple sclerosis who presents with vision changes. Last ___, she had a headache that gradually worsened, eyes somewhat sensitive to light, better with Tylenol and coffee. Does not usually get headaches (although it seems she does get headaches on chart review). Headache got better, but then on ___, she started seeing little square-like black and quite shapes in her peripheral vision. Was also seeing lightning bolts and squiggly lines. The was constant until ___, when the shapes changed and became circles and developed into different colors. This is what brought her into the hospital to be evaluated. She has also had more blurry vision since ___ despite getting new glasses. Earlier last evening, she developed another headache where everything "really hurt," unable to describe why, endorsed photophobia and phonophobia. Sleep made it better, worse with stress/crying. ___ radiation. ___ recent infections. ___ urinary frequency or urgency. ___ coughs/colds/rhinorrhea. Per Dr. ___ recent note on ___, she presented with blurred vision in the left eye in ___. Brain MRI showed white matter lesions in the corpus callosum, left parietal periventricular area, and L frontal area consistent with MS. ___ enhancement of the L optic nerve. Also had some headaches with the left eye and slight blurring of her vision for which she got steroids. Usually gets headaches twice per month, better with fioricet. Due to LFT elevation, she has stopped Aubagio and is not on any medications for her multiple sclerosis. She has tried copaxone and tecfidera in the past. Past Medical History: PMH/PSH: MS, depression/anxiety, headaches, TMJ Social History: ___ Family History: FAMILY HISTORY: mother with ?migraines, ___ history of MS, brain aneurysms in aunts and uncles Physical Exam: Admission PHYSICAL EXAMINATION Vitals: T: 98.4F HR: 97 BP: 107/60 RR: 18 SaO2: 100% RA General: NAD HEENT: NCAT, ___ oropharyngeal lesions, neck supple ___: RRR, ___ M/R/G Pulmonary: CTAB, ___ crackles or wheezes Abdomen: Soft, NT, ND, +BS, ___ guarding Extremities: Warm, ___ edema Neurologic Examination: - Mental status: Awake, alert, oriented x 3. Able to relate history without difficulty. Attentive, speech is fluent with full sentences and intact verbal comprehension. ___ paraphasias. ___ dysarthria. Normal prosody. ___ evidence of hemineglect. ___ left-right confusion. Able to follow both midline and appendicular commands. - Cranial Nerves: PERRL 8->6 brisk. VF full to movement. ___ red desaturation. Visual acuity: R ___ +2, L ___ -2, trouble with C's and O's, Ds and Bs. Optic disc on L looks different than the R, R disc crisp, L disc perhaps mildly paler. EOMI, ___ nystagmus. V1-V3 without deficits to light touch bilaterally. ___ facial movement asymmetry. Hearing intact to finger rub bilaterally. Palate elevation symmetric. SCM/Trapezius strength ___ bilaterally. Tongue midline. - Motor: Normal bulk and tone. ___ drift. ___ tremor or asterixis. [Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas] [C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1] L 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 - Reflexes: [Bic] [Tri] [___] [Quad] [Gastroc] L 2+ 2+ 2+ 2+ 1 R 2+ 2+ 2+ 2+ 1 Plantar response flexor bilaterally - Sensory: ___ deficits to light touch or pin prick throughout - Coordination: ___ dysmetria with finger to nose testing bilaterally. Good speed and intact cadence with rapid alternating movements. - Gait: deferred DISCHARGE Examination: MS: During hospitalization would often forget the details which had been discussed in prior conversations. CN: R homonymous hemianopsia. Otherwise unchanged. Pertinent Results: Admission labs: WBC-15.3*# HGB-11.6 HCT-37.4 PLT COUNT-289 NEUTS-79.7* LYMPHS-14.4* MONOS-5.1 EOS-0.0* BASOS-0.1 IM ___ AbsNeut-12.20*# AbsLymp-2.20 AbsMono-0.78 AbsEos-0.00* AbsBaso-0.02 ___ PTT-26.7 ___ SODIUM-140 POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-20* UREA N-15 CREAT-0.9 GLUCOSE-147* ALT(SGPT)-19 AST(SGOT)-13 ALK PHOS-79 TOT BILI-<0.2 ALBUMIN-4.1 UTox: bnzodzpn-POS* barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG STox: ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG UA: Contaminated Imaging: MRI Brain/Orbits ___ IMPRESSION: 1. Interval development of multiple lesions demonstrating hyperintense FLAIR signal abnormality compatible with multiple sclerosis, with majority demonstrating abnormal enhancement and slow diffusion suggestive of an acute process. The largest of these lesion is involving the left calcarine cortex and optic radiation tracks, likely attributing to patient's symptomology. 2. ___ evidence of optic neuritis. Medications on Admission: These medications were not verified. - klonopin 0.5mg BID - lamotrigine 150mg BID for depression - venlafaxine 150mg BID Discharge Medications: 1. MethylPREDNISolone Sodium Succ 1000 mg IV Q24H Duration: 2 Doses RX *methylprednisolone sodium succ 1,000 mg 1000 mg IV Q24h Disp #*2 Vial Refills:*0 2. Omeprazole 40 mg PO DAILY 3. TraMADol 100 mg PO Q4H:PRN Pain - Moderate RX *tramadol 50 mg ___ tablet(s) by mouth Q6:PRN Disp #*20 Tablet Refills:*0 4. ClonazePAM 0.5 mg PO BID 5. Topiramate (Topamax) 25 mg PO BID 6. Venlafaxine XR 150 mg PO BID 7. Venlafaxine XR 37.5 mg PO DAILY 8. Vitamin D 4000 UNIT PO DAILY 9.Sodium Chloride 0.9% Flush 3 mL IV; pre- and post- infusion and PRN replacement of IV. Dispense 8 flushes. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Multiple sclerosis flare Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: MRI BRAIN AND ORBITS PT4 MR ___ INDICATION: ___ female with multiple sclerosis presenting with right homonymous hemianopsia. TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of 10 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. Orbit images acquired at 3 mm slice thickness. Precontrast sequences included axial and coronal T1, coronal STIR. Postcontrast sequences included axial and coronal T1 with fat saturation. COMPARISON: ___ FINDINGS: MRI BRAIN: There is interval development of multiple FLAIR hyperintense foci within bilateral cerebral white matter and the cerebellum compatible with known multiple sclerosis. Majority of these lesions demonstrate corresponding enhancement and slow diffusion compatible with active process. The largest of these lesions is seen within the left occipital lobe involving the calcarine cortex in the region of the optic radiation tracts (8:11 and 11:11). The ventricles are normal in size. There is no mass effect or midline shift. There is no hemorrhage or cortical infarction. The paranasal sinuses and mastoid air cells appear clear. MRI ORBITS: There is no evidence of optic nerve enlargement or enhancement to suggest optic neuritis. The globes are intact and normal in appearance. The extraocular muscles are uniform in size and normal in signal. IMPRESSION: 1. Interval development of multiple lesions demonstrating hyperintense FLAIR signal abnormality compatible with multiple sclerosis, with majority demonstrating abnormal enhancement and slow diffusion suggestive of an acute process. The largest of these lesion is involving the left calcarine cortex and optic radiation tracks, likely attributing to patient's symptomology. 2. No evidence of optic neuritis. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Headache, Visual changes Diagnosed with Multiple sclerosis temperature: 98.0 heartrate: 101.0 resprate: 18.0 o2sat: 97.0 sbp: 116.0 dbp: 74.0 level of pain: 4 level of acuity: 2.0

Dear Ms. ___, You came to the hospital because you were having symptoms of vision loss in your right eye with flashing patterns and lights. We saw that you cannot see well out of the right side of your vision. On MRI we see that you have an MS flare, which is affecting the part of your brain that processes vision. We have started you on a course of steroids to treat the flare. You have received three doses here and you will complete the course as an outpatient. Your MS ___, is aware of the plan. We have given you his clinic number. You should call to set up an appointment soon to discuss your options for long term treatment to reduce your risk of flares. He has prescribed vitamin D for you in the past. We recommend that you take this as it is helpful for people with multiple sclerosis. Unfortunately, it is not safe for you to drive right now. You cannot see out of the right half of your vision. We have given you a note for work to let them know that you cannot drive for now. It will take some time for the steroids to take effect. You will need to be evaluated by Dr. ___ to be cleared to drive again. It was a pleasure taking care of you. Sincerely - ___ Neurology Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Leaking biliary drain Major Surgical or Invasive Procedure: ___ Billiary drain placement and replacement History of Present Illness: Mr. ___ is a ___ man with history notable for prostate cancer s/p XRT, complex renal cysts, colonic tubular adenoma, and ___ esophagus who was recently found to have a liver mass biopsied to be adenocarcinoma with markers not consistent with colonic or lung origin who presented from the ___ clinic with fevers and a left biliary tube leak. He was having abdominal pain during ___ and had a CT at ___ that showed a liver mass. He underwent liver biopsy at ___ on ___ with severe bleeding complications leading to hemorrhagic shock. He was transferred to ___ and underwent ___ embolization followed by exploratory laparotomy Argon-beam coagulation of liver with abdomen left open status post procedure and ultimately closed on ___. He had a very complicated course during a prolonged hospitalization from ___. Per OMR- Hematology/Oncology consult during the admission raised the likelihood that this was a metastatic cancer to his liver from a GI source and that he was likely not a candidate for chemotherapy due to his performance status at the time. The findings suggested an upper gastrointestinal, pancreatic or biliary primary. There does not appear to be extra-hepatic disease, and the mass is causing biliary obstruction. He presented to the GI ___ clinic today endorsing a one week history of fevers, nausea, vomiting. Blood cultures from ___ grew VRE in 1 of 2 bottles. He was started on ampicillin, gentamicin, and metronidazole. He continued to spike intermittent fevers on ___ and again on ___. He was switched to ceftriaxone, linezolid, and metronidazole on ___. Per verbal report from ___ Rehab, no additional blood or urine cultures have been positive. In the setting of biliary leakage and fevers he was referred to the ED for further evaluation. In the ED, VS: 98.4 HR 100 BP 95/63 RR 20 100% RA Notable labs: WBC 12.3, Hgb 7.5 Hct 23.6 Plt 511, AP 1355, T.bili 1.6, Dbili 1.2, AST 64, Albumin 2.5, Total protein 5.6, lactate 1.9 Consults: ___ Recommendations: NPO at midnight for tomorrow: Cholangiogram + exchange + possible drainage of new ?bilomas As he was awaiting a bed on the oncology floor he became tachycardic and hypotensive to ___. He received 3L NS, Vancomycin and Zosyn, and was started on phenylephrine through his PICC prior to transfer to the FICU. On arrival to the FICU, he appears comfortable and is without complaint. His daughter who is at bedside provides additional history that he has been febrile up to 102-103 for the past ___s nausea, vomiting, and poor PO intake for the past week. Past Medical History: Prostate cancer s/p XRT, colonic tubular adenoma, ___ esopahgus, hypertension, renal mass (left kidney, 1.3 cm) PSH: None Social History: ___ Family History: No Family History of liver disease/cancer Physical Exam: ================== ADMISSION PHYSICAL ================== Vitals: T:99 BP: 106/65 P:113 R:18 O2:98% RA GENERAL: Lying in bed, comfortable appearing HEENT: Anicteric sclera, dry mucous membranes NECK: Soft, supple, full ROM, no JVD LUNGS: Crackles at the right lung base CV: Tachycardic but regular ABD: Soft, non-distended, mid-line surgical scar. Two biliary drains in place draining bilious fluid EXT: Warm and well perfused, no edema ================== DISCHARGE PHYSICAL ================== Vitals: T:98. BP: 115/82 P: 85 R: 17 O2: 99 ra Gen: NAD ___: regular Lungs: bibasilar crackles, coughing, no increase WOB Abd: Soft, non-distended, mid-line surgical scar. Two biliary drains in place draining bilious fluid Ext no edema Pertinent Results: ============== ADMISSION LABS ============== ___ 11:45AM BLOOD WBC-12.3*# RBC-2.56* Hgb-7.5* Hct-23.6* MCV-92 MCH-29.3 MCHC-31.8* RDW-19.8* RDWSD-67.2* Plt ___ ___ 11:45AM BLOOD Neuts-84.1* Lymphs-10.1* Monos-4.9* Eos-0.0* Baso-0.2 Im ___ AbsNeut-10.33* AbsLymp-1.24 AbsMono-0.60 AbsEos-0.00* AbsBaso-0.02 ___ 11:45AM BLOOD ___ PTT-33.8 ___ ___ 11:45AM BLOOD UreaN-9 Creat-0.7 Na-132* K-3.4 Cl-100 HCO3-23 AnGap-12 ___ 11:45AM BLOOD ALT-35 AST-64* AlkPhos-1355* TotBili-1.6* DirBili-1.2* IndBili-0.4 ___ 11:45AM BLOOD TotProt-5.6* Albumin-2.5* Globuln-3.1 ___ 11:45AM BLOOD TSH-0.68 ___ 11:45AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE ___ 11:45AM BLOOD AFP-3.6 ___ 11:45AM BLOOD HCV Ab-NEGATIVE ___ 03:54PM BLOOD Lactate-1.1 ___ 08:11PM BLOOD Lactate-1.9 ___ 11:45AM BLOOD HCV Ab-NEGATIVE ___ 11:45AM BLOOD AFP-3.6 ___ 11:45AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE ___ 11:45AM BLOOD TSH-0.68 ============= PERTINENT LABS ============ ___ 05:05AM BLOOD calTIBC-91* Hapto-287* Ferritn-548* TRF-70* ___ 11:45AM BLOOD TSH-0.68 ___ 11:45AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE ___ 11:45AM BLOOD AFP-3.6 ___ 11:45AM BLOOD HCV Ab-NEGATIVE ___ 08:11PM BLOOD Lactate-1.9 ___ 03:54PM BLOOD Lactate-1.1 ============== DISCHARGE LABS ============== ___ 04:04AM BLOOD WBC-9.7 RBC-2.79*# Hgb-8.3* Hct-25.7* MCV-92 MCH-29.7 MCHC-32.3 RDW-19.1* RDWSD-64.4* Plt ___ ___ 04:04AM BLOOD ___ PTT-36.6* ___ ___ 04:04AM BLOOD Glucose-89 UreaN-8 Creat-0.6 Na-134 K-3.4 Cl-107 HCO3-21* AnGap-9 ___ 04:04AM BLOOD ALT-23 AST-52* AlkPhos-731* TotBili-1.2 ___ 04:04AM BLOOD Calcium-7.6* Phos-1.9* Mg-2.1 ================ MICROBIOLOGY ================ ___ 3:43 pm BLOOD CULTURE Blood Culture, Routine (Preliminary): PSEUDOMONAS AERUGINOSA. PRELIMINARY SENSITIVITY. These preliminary susceptibility results are offered to help guide treatment; interpret with caution as final susceptibilities may change. Check for final susceptibility results in 24 hours. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFTAZIDIME----------- S CIPROFLOXACIN--------- R GENTAMICIN------------ S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ S Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE ROD(S). ___ BLOOD CX WITH VRE, SENSITIVITIES ARE PENDING ================ STUDIES ================ ___ CT ABD&PELVIS IMPRESSION: 1. At least 3 new hypodensities noted within the liver, 1 of which is adjacent to the recently inserted left-sided biliary drainage catheter with additional months in segment ___ and segment 7 respectively, likely represent bilomas. These do not have enhancement pattern suggestive of cholangitic abscesses. 2. Residual dilatation of the intrahepatic biliary ducts as described above, post placement of bilateral internal external percutaneous biliary drains. Underlying cholangitis cannot be excluded. 3. Right lower lobe subsegmental consolidation as detailed above, concerning for focal aspiration pneumonitis. 4. The large heterogeneously enhancing mass in the right lobe of the liver compatible with the known tumor appears more solid on today's exam. There is an exophytic component of the tumor that appears to be invading the hepatic flexure of the colon, there is however no bowel obstruction. 5. Revisualization of the solid 1.7 cm renal lesion within the right kidney, suspicious for renal cell carcinoma. 6. Stable lucency at the T12 vertebral body, which should eventually be evaluated with a bone scan as previously recommended. ___ CXR IMPRESSION: As compared to the previous radiograph, no relevant change is seen. Elevation of the hemidiaphragm with subsequent right basilar atelectasis. The ventilated lung parenchyma shows no evidence of pneumonia, pulmonary edema or pleural effusions. Unchanged silhouette Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain 2. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN sore throat 3. Docusate Sodium 100 mg PO BID 4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES QAM 5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 6. Metoclopramide 10 mg PO QIDACHS 7. Nystatin Oral Suspension 5 mL PO BID 8. Senna 8.6 mg PO BID:PRN constipation 9. TraZODone 25 mg PO QHS:PRN insomnia 10. Sodium Chloride Nasal ___ SPRY NU TID:PRN nasal congestion 11. Pantoprazole 40 mg PO Q24H 12. Piperacillin-Tazobactam 4.5 g IV Q8H 13. OxycoDONE Liquid ___ mg PO Q4H:PRN pain 14. Guaifenesin-Dextromethorphan 10 mL PO Q6H:PRN cough Discharge Medications: 1. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN sore throat 2. Docusate Sodium 100 mg PO BID 3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES QAM 4. Guaifenesin-Dextromethorphan 10 mL PO Q6H:PRN cough 5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 6. Piperacillin-Tazobactam 4.5 g IV Q8H 7. Senna 8.6 mg PO BID:PRN constipation 8. Sodium Chloride Nasal ___ SPRY NU TID:PRN nasal congestion 9. TraZODone 25 mg PO QHS:PRN insomnia 10. Linezolid ___ mg IV Q12H 11. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain 12. Metoclopramide 10 mg PO QIDACHS 13. Nystatin Oral Suspension 5 mL PO BID 14. OxycoDONE Liquid ___ mg PO Q4H:PRN pain 15. Pantoprazole 40 mg PO Q24H Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: SEPTIC SHOCK BILLIARY OBSTRUCTION CHOLANGITIS SECONDARY DIAGNOSIS: ADENOCARCINOMA IN LIVER (UNKNOWN PRIMARY) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CT scan of the abdomen and pelvis. INDICATION: dx gi malignancy with mets to liver,fevers,rule out intra-abdominal abcess // dx gi malignancy with mets to liver,fevers,rule out intra-abdominal abcess 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 5 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) Stationary Acquisition 14.5 s, 0.2 cm; CTDIvol = 246.4 mGy (Body) DLP = 49.3 mGy-cm. 5) Spiral Acquisition 5.1 s, 61.1 cm; CTDIvol = 5.0 mGy (Body) DLP = 278.8 mGy-cm. Total DLP (Body) = 330 mGy-cm. COMPARISON: CT from ___. FINDINGS: LOWER CHEST: There is focal consolidation within the medial right lower lobe, aspiration pneumonitis is a possibility. Stable 8 mm cardiophrenic lymph node. ABDOMEN: HEPATOBILIARY: Again visualized is a large lobulated heterogeneously enhancing mass in the right lobe of the liver. It appears overall unchanged in size when compared to previous,measuring 12.6 x 6.6 by 7.7 cm. There has been interval placement of percutaneous internal external biliary drainage catheters, traversing both the right as well as the left main ducts with the internal component terminating appropriately within the duodenum. There is interval development of a new bilobed fluid ___ lesion along the left biliary drainage catheter measuring approximately 6.3 cm in total length with 2 bulbous components measuring 2.0 x 1.9 and 1.8 x 2.7. This likely represents a bilobed biloma. A second new hypodense lesion is seen in segment ___ (07:33) measuring approximately 1.8 by 1.4 by 4.0 cm (AP by trans by CC). A third lesion is seen more cranially, in segment 7 measuring 1.7 x 2.2 cm (05:17). These latter 2 lesions likely represent additional bilomas versus metastatic lesions. Although cholangitic abscesses are a possibility, they do not have a rim enhancement pattern to suggest the same. A new linear hypodense lesion is seen at the periphery of segment 6. It measures 1.9 cm in length and 4 mm in thickness, and may represent postprocedural changes, possibly a needle tract. There is persistent dilatation of left hepatic lobe (segment 3 posterior and segment 2) bile ducts. Segment 7 and 8 ducts also remain moderately dilated, slightly prominent than before. There is narrowing of the right proximal portal vein, however it remains patent. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: A 1.6 cm lesion is seen within the right kidney, at the mid polar region is unchanged from previous. Although no precontrast images available, it does have some internal density suggestive of internal enhancement, and is concerning for small renal cell carcinoma. This could be further evaluated with dedicated non urgent ultrasound or MRI after the acute episode resolves. There are multiple bilateral simple appearing renal cysts, unchanged from previous. GASTROINTESTINAL: The appendix is mildly thickening measuring up to 8 mm. This appearance however is unchanged when compared to previous, there is no significant periappendiceal fat stranding. Focal appendicitis is unlikely. First there is concentric wall thickening of the hepatic flexure of the colon with an exophytic component of the mass closely abutting the hepatic flexure (07:18) suspicious for invasion of the hepatic flexure of the colon. No bowel obstruction noted. A 1.0 cm portacaval lymph node is once again seen, unchanged from previous. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: There are 3 fiducial markers within the prostate. LYMPH NODES: There is a 1 cm necrotic lymph node anterior to the IVC (05:37). VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. BONES AND SOFT TISSUES: There is linear calcification/ossification noted posterior to the right acetabulum within the right gluteus minimus muscles. This was not seen on prior examinations, and may represent focal myositis ossificans. Divarication of recti noted. There is a small fat containing umbilical hernia as before. Focal lucency is seen at the posterior aspect of the T12 vertebral body, unchanged from previous. IMPRESSION: 1. At least 3 new hypodensities noted within the liver, 1 of which is adjacent to the recently inserted left-sided biliary drainage catheter with additional months in segment ___ and segment 7 respectively, likely represent bilomas. These do not have enhancement pattern suggestive of cholangitic abscesses. 2. Residual dilatation of the intrahepatic biliary ducts as described above, post placement of bilateral internal external percutaneous biliary drains. Underlying cholangitis cannot be excluded. 3. Right lower lobe subsegmental consolidation as detailed above, concerning for focal aspiration pneumonitis. 4. The large heterogeneously enhancing mass in the right lobe of the liver compatible with the known tumor appears more solid on today's exam. There is an exophytic component of the tumor that appears to be invading the hepatic flexure of the colon, there is however no bowel obstruction. 5. Revisualization of the solid 1.7 cm renal lesion within the right kidney, suspicious for renal cell carcinoma. 6. Stable lucency at the T12 vertebral body, which should eventually be evaluated with a bone scan as previously recommended. NOTIFICATION: The treating Hematology/Oncology Team was made aware of the findings at 12:10 On ___. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ with PMH adenocarcinoma of liver mass presents with fever, diarrhea, biliary tube leakage COMPARISON: ___ and CT abdomen pelvis from ___. FINDINGS: AP portable upright view of the chest. A right upper extremity PICC line is seen with its tip likely in the upper SVC. Biliary drainage catheters project over the right upper quadrant. There is elevation of the right hemidiaphragm which is unchanged. Lungs appear clear without large effusion or pneumothorax. Cardiomediastinal silhouette appears stable. No bony abnormalities. IMPRESSION: 1. Stable elevation the right hemidiaphragm. 2. PICC line positioned appropriately. 3. Biliary drainage catheters overlie the right upper quadrant. 4. No signs of pneumonia. Radiology Report INDICATION: ___ year old man with likely cholangitis // PTBD check/change COMPARISON: ___. TECHNIQUE: OPERATORS: Dr. ___, Interventional Radiology Fellow, Dr. ___ resident), and Dr. ___ radiologist performed the procedure. Dr. ___ supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 125 mcg of fentanyl and 2.5 mg of midazolam throughout the total intra-service time of 40 min during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. CONTRAST: 20 ml of Optiray contrast. Fluoroscopy time: 7 min 32 seconds. Fluoroscopy dose: 1364 cGy-cm2 PROCEDURE: 1. Bilateral over-the-wire sheath cholangiograms. 2. Bilateral exchange of existing percutaneous trans-hepatic biliary drainage catheters with a new 10 ___ PTBD catheters. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The abdomen was prepped and draped in the usual sterile fashion. Initial scout images showed biliary drains in the appropriate position. The left PTBD was injected with contrast and demonstrated opacification of left lobe biloma but no distal opacification. The hub of the catheter was cut and a Glidewire was advanced into the small bowel. The glidewire was exchanged for ___ wire using a Kumpe catheter. A 6 ___ sheath was advanced over the ___ wire and a pull-back cholangiogram was performed, findings below. The right PTBD was injected with contrast and demonstrated patency of the tube and biliary system. The decision was made to replace the right PTBD to facilitate placement of the left PTBD. The hub of the catheter was cut and a ___ wire was advanced into the small bowel. A 6 ___ sheath was advanced over the ___ wire and a pull-back cholangiogram was performed, findings below. The left sheath was removed over the wire and a 10 ___ percutaneous trans hepatic biliary drainage catheter was advanced into the duodenum. Side holes were positioned above and below the level of obstruction to facilitate internal drainage. The wire and inner stiffener were removed, the catheter was flushed, the loop was formed, the catheter was attached to a bag and sterile dressings were applied. Similarly, on the right, the right sheath was removed over the wire and a 10 ___ percutaneous trans hepatic biliary drainage catheter was advanced into the duodenum. Side holes were positioned above and below the level of obstruction to facilitate internal drainage. The wire and inner stiffener were removed, the catheter was flushed, the loop was formed, the catheter was attached to a bag and sterile dressings were applied. The patient tolerated the procedure well and there were no immediate post-procedure complications. FINDINGS: 1. Existing bilateral 10 ___ percutaneous transhepatic biliary drainage catheters in appropriate position. 2. Occlusion of existing left PTBD with contrast injection demonstrating opacification of biloma without contrast passing distally. 3. Patent existing right PTBD. 4. Left cholangiogram demonstrating patent left ducts. 5. Right cholangiogram demonstrating patent right ducts. 6. Successful placement of new appropriately positioned 10 ___ PTBDs. IMPRESSION: 1. Occluded left PTBD. 2. Successful exchange for new bilateral 10 ___ PTBDs. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: Mr. ___ is a ___ year old gentleman with a history of adenocarcinoma of unknown primary causing biliary obstruction now s/p biliary drain placement x2 during his prior admission, who is admitted to the MICU w/ sepsis likely ___ biliary source, now c/o worsening cough. Also now noted to have new onset of air in biliary drain. // eval PNA, pulm edema or PTX; also please evaluate upright CXR to look for air COMPARISON: ___. IMPRESSION: As compared to the previous radiograph, no relevant change is seen. Elevation of the hemidiaphragm with subsequent right basilar atelectasis. The ventilated lung parenchyma shows no evidence of pneumonia, pulmonary edema or pleural effusions. Unchanged silhouette Gender: M Race: BLACK/CARIBBEAN ISLAND Arrive by AMBULANCE Chief complaint: Fever, Diarrhea Diagnosed with CHOLANGITIS temperature: 98.4 heartrate: 100.0 resprate: 20.0 o2sat: 100.0 sbp: 95.0 dbp: 63.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, It was a pleasure taking care of you during your hopsitalization. You were admitted in order to treat an infection of your blood. We believe that the infection was caused by a blockage of your bile system in your liver. We replaced these biliary drains and gave you antibiotics to treat the bacteria in the blood stream and you felt better by time of discharge. We wish you all the best. Sincerely, Your ___ team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Morphine / Shellfish / Ferrous Sulfate / Orange Syrup / metronidazole Attending: ___. Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: none History of Present Illness: ___ with history of crohns disease and collagenous colitis s/p colectomy, chronic abdominal pain on narcotics, history of multiple previous central lines complicated by possible ___ syndrome presenting with increasing watery diarrhea over the last month. Pt presented today after she had difficulty walking up stairs as she was too weak to climb. She promoted palpipations, lh, and dizziness at tis time. In terms of her diarrea, she has chronic watery stools which have increased in freq over the last several weeks. She promotes having ___ loose bm daily. Often times notes bright red blood in them. She did travel to ___ in early ___ after which symptoms worsened. Infectious work up on ___ as an outpatient was unrevealing. She completed a course of cipro/flagyl without improvement in symptoms. Patient denies any fevers or chills. She denies any chest pain. Does promote shortness of breath with exertion. She denies any urinary symptoms. Pt believes symptoms are secondary to crohns flare. She also notes increased swelling over her neck, L>R over the last month. Asymptomatic from swelling, causing mostly just discomfort. She is concerned her prev dx ___ syndrome is returning. Had initially resolved in ___ following stent placement and angioplasty. In the ED, initial vs were: 98.3 ___ 31 100%. Labs were notable for an INR of 4, cr 2.4 (baseline .9), Na 130 and lactate 3.7. Im the ED he received pain control with dilaudid and zofran for nausea. CT abd/pelvis without any acute findings. Vascular surg was consulted for with recs pending at the time of admission. Vitals on Transfer: 98.2 78 125/88 16 98% Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Ten point review of systems is otherwise negative. Past Medical History: 1. Question collagenous colitis dx'd by bx ___ status post laparoscopic ileostomy in ___ followed by colectomy with ileorectal anastomosis in ___ 2. Question Crohn's disease treated with Remicade in past c/b ?serum sickness and Pentasa. 3. Question seronegative spondyloarthropathy treated with methotrexate--off since ___. 4. Chronic abdominal pain for which she is maintained on chronic narcotic medications and followed by the pain clinic 5. Multiple prior central venous lines Hickman catheter in the right subclavian in ___ and a Port-A-Cath in the left subclavian in ___, Hickman in the right, removed ___ in setting of VRE bacteremia. She has had recurrent ___ syndrome with narrowing of the L subclavian s/p venoplasty in ___. She had a nonocclusive thrombus of the ___ stent ___. Most recently MRV ___ showed patent vasculature. She had been on coumadin and fondaparanox in the past, now on coumadin with a current goal INR of 2.5-3.5; some notes indicate an even higher goal of ___. 6. History of bilateral pneumothoraces 7. Raynaud's phenomenon 8. Migraine headaches 9. Irregular menses 10. Anxiety/depression, pt has not wanted to see psychiatry. 11. Acid reflux 12. Macrocytic anemia 13. Right-sided lumpectomy for benign mass 14. Question ___ syndrome; per Dr. ___ is s/p ___ stent placement (NO filter) in the setting of chronic indwelling catheter status post failed attempt at ___ in ___, resolution of swelling upon line removal ___. H/o multiple PE - on coumadin 16. H/o Klebsiella bacteremia 17. H/o Thrush 18. Polyclonal gammopathy. 19. Pancreatic insufficiency 20. Mult rib fractures 21. Osteonecrosis 22. ?TIA ___ years ago) Social History: ___ Family History: father - polycythemia, melanoma mother - melanoma Physical ___: ADMISSION: Vitals: T: 98.1 134/67 P72 RR16 99% RA General: Ill appear, flat affect, A&Ox3 HEENT: , NCAT, EOMI, ___, dry mucous membranes Neck: Notable swelling of neck, L>R CV: RRR, No m/r/g Lungs: CTABl no w/r/r Abdomen:ttp in all quadrants, tenderness appears superficial vs viceral, prior surgical scars well healed inferior to umbilicus. No ostomy. Ext: No edema, rash, clubbing Neuro: Cn ___ grossly intact, ___ strength in all extm, no focal deficits Skin: No rashes or skin shanges DISCHARGE: VS: 98.2 135/75 61 19 99RA Gen: middle aged female, laying in bed comfortably in NAD HEENT: NCAT, significant supraclavicular soft tissue swelling encircling neck, no erythema or plethora CV: nl s1, s2, rrr, no mrg Resp: CTA ___ no w/r/c Abd: Right sided stoma scar well healed, infra-umbilical scar is well healed. soft, tender to minimal palpation in RLQ, LLQ (improved from prior), hyperactive bowel sounds Ext: no cce Pertinent Results: ADMISSION: ___ 12:45PM BLOOD WBC-9.2 RBC-5.16 Hgb-12.8 Hct-39.7 MCV-77* MCH-24.8* MCHC-32.2 RDW-18.6* Plt ___ ___ 12:45PM BLOOD ___ PTT-52.3* ___ ___ 12:45PM BLOOD Glucose-73 UreaN-15 Creat-2.5*# Na-130* K-6.2* Cl-88* HCO3-22 AnGap-26* ___ 06:25AM BLOOD Albumin-3.0* Calcium-7.1* Phos-2.8 Mg-1.7 ___ 12:44PM BLOOD Lactate-3.7* ___ 05:28PM BLOOD Lactate-1.6 DISCHARGE: ___ 09:00AM BLOOD WBC-6.3 RBC-3.29* Hgb-8.2* Hct-26.2* MCV-80* MCH-24.8* MCHC-31.1 RDW-19.5* Plt ___ ___ 09:00AM BLOOD ___ PTT-54.7* ___ ___ 09:00AM BLOOD Glucose-86 UreaN-4* Creat-0.8 Na-140 K-3.4 Cl-104 HCO3-29 AnGap-10 ___ 09:00AM BLOOD Calcium-7.8* Phos-3.4 Mg-1.7 TRYPTASE 7 ___ ng/mL STRONGYLOIDES IGG ANTIBODY, ___ <1.00 LESS THAN 1.00 REPORTS: CT ABD/PELVIS IMPRESSION: 1. Status post total colectomy. Mild dilatation of the ileoanal J-pouch without evidence of obstruction. 2. Unchanged wide-mouth ventral hernia containing small bowel without evidence of strangulation. 3. Unchanged perisplenic and adnexal cystic structures. 4. Unchanged presacral soft tissue thickening which is likely postoperative in nature. MRV CHEST: IMPRESSION: 1. Assessment of the superior vena cava is slightly limited by the indwelling stent however the vessel opacifies well with no direct or secondary evidence of ___ thrombosis. 2. Slightly prominent nodes within the lower neck which are unchanged/borderline enlarged when compared to the prior CT. Further assessment with ultrasound could be performed if clinically relevant. U/S NECK: FINDINGS: Ultrasound of cervical lymph node levels II, III, VI bilaterally reveal only normal lymph nodes. Supraclavicular stations also contain lymph nodes of normal size and morphology. The location of the patient's concern contains only normal subcutaneous fat and benign lymph nodes. Based on physical examination and ultrasound appearance of supraclavicular region, lipodystrophy should be considered as a potential etiology. No fluid collection or mass is seen. IMPRESSION: Area of swelling contains only normal fat, without lymphadenopathy or other mass. Lipodystrophy should be considered as a potential etiology. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Calcium Carbonate 500 mg PO BID 2. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID Apply to affected area Avoid face and intrigenous areas 3. gabapentin *NF* 250 mg/5 mL Oral TID 10ml TID 4. Opium Tincture 10 DROP PO Q6H:PRN Diarrhea 5. Dronabinol 10 mg PO TID:PRN nausea and cramping 6. ClonazePAM 1 mg PO BID please take in morning and afternoon 7. ClonazePAM 2 mg PO QHS 8. Warfarin Dose is Unknown PO DAILY16 9. Multivitamins W/minerals 1 TAB PO DAILY 10. Fentanyl Patch 75 mcg/h TP Q72H 11. HYDROmorphone (Dilaudid) ___ mg PO Q4-6HOURS:PRN Pain Hold for sedation or RR<12 12. Fluticasone Propionate 110mcg 2 PUFF IH BID 13. Omeprazole 40 mg PO BID 14. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB 15. Citalopram 40 mg PO DAILY 16. Vitamin D 50,000 UNIT PO 1X/WEEK (FR) Discharge Medications: 1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB 2. Calcium Carbonate 500 mg PO BID 3. Citalopram 40 mg PO DAILY 4. ClonazePAM 1 mg PO BID 5. ClonazePAM 2 mg PO QHS 6. Dronabinol 10 mg PO TID:PRN nausea and cramping 7. Fentanyl Patch 75 mcg/h TP Q72H 8. Fluticasone Propionate 110mcg 2 PUFF IH BID 9. HYDROmorphone (Dilaudid) ___ mg PO Q4-6HOURS:PRN Pain 10. Multivitamins W/minerals 1 TAB PO DAILY 11. Omeprazole 40 mg PO BID 12. Opium Tincture 10 DROP PO Q6H RX *opium tincture 10 mg/mL (morphine) 10 drop by mouth q6 Disp #*1000 Milliliter Refills:*0 13. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID 14. Vitamin D 50,000 UNIT PO 1X/WEEK (FR) 15. Warfarin 12 mg PO DAILY16 RX *warfarin 4 mg 3 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 16. LOPERamide 2 mg PO QID:PRN diarrhea 17. gabapentin *NF* 250 mg/5 mL Oral TID 18. Enoxaparin Sodium 80 mg SC DAILY Duration: 5 Days please take until INR>2 RX *enoxaparin 80 mg/0.8 mL 80 mg sc daily Disp #*5 Syringe Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Chronic Diarrhea Acute Kidney Injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Multiple complaints including diarrhea abdominal pain and dyspnea. History of Crohn's status post colectomy. TECHNIQUE: PA and lateral chest radiograph 2 views. COMPARISON: ___. FINDINGS: Heart size is normal. Cardiomediastinal silhouette and hilar contours are unremarkable. There is redemonstration of a superior vena caval stent unchanged in position. Lungs are clear. There is no pleural effusion or pneumothorax. The visualized osseous structures are grossly unremarkable. IMPRESSION: No acute intrathoracic process. Radiology Report HISTORY: Multiple complaints including diarrhea, abdominal pain and dyspnea. History of Crohn's status post colectomy. TECHNIQUE: Axial helical MDCT images were obtained of the abdomen and pelvis after the administration of oral contrast only. Multiplanar reformatted images were generated in the coronal and sagittal planes. DLP: 283.24 mGy-cm. COMPARISON: CTA abdomen and pelvis ___. FINDINGS: The imaged lung bases are clear. CT Abdomen: The study was performed without contrast which somewhat limits evaluation of the intra-abdominal structures. The liver is grossly unremarkable without focal lesion or intrahepatic biliary duct dilatation. The gallbladder is nondilated and is without stones. The pancreas and adrenal glands are unremarkable. A 2.7 cm cystic structure at the inferior margin of the spleen is unchanged. There is redemonstration of the atrophic left kidney. The kidneys are otherwise unremarkable without stones or hydronephrosis. The patient is status post colectomy with multiple scattered surgical clips. The small bowel is unremarkable in appearance without evidence of obstruction or focal wall thickening. There is re- demonstration of a wide-mouth ventral hernia (2:33) containing small bowel with clear fat planes without evidence of strangulation. The abdominal aorta is of normal caliber with mild atherosclerotic mural calcifications. There are no enlarged mesenteric or retroperitoneal lymph nodes by CT size criteria. CT pelvis: The bladder and uterus are unremarkable. A 1 cm right adnexal cyst is unchanged. There is dilatation of the ileo anal J-pouch with air-fluid level and there appears to have been passage of contrast into the J-pouch. Mild presacral soft tissue thickening is unchanged from prior study and is likely postoperative in nature. There is no pelvic free fluid or air. Osseous structures: There are no focal blastic or lytic lesions in the visualized osseous structures concerning for malignancy. IMPRESSION: 1. Status post total colectomy. Mild dilatation of the ileoanal J-pouch without evidence of obstruction. 2. Unchanged wide-mouth ventral hernia containing small bowel without evidence of strangulation. 3. Unchanged perisplenic and adnexal cystic structures. 4. Unchanged presacral soft tissue thickening which is likely postoperative in nature. Radiology Report HISTORY: History of SVC syndrome with some neck swelling. Query SVC syndrome. TECHNIQUE: Multiplanar T1 and T2 weighted imaging was obtained on a 1.5 T magnet, including dynamic 3D imaging obtained prior to, during and subsequent to the intravenous administration of 16 mL of MultiHance. COMPARISON: CT ___ and MRI ___. FINDINGS: There is some irregularity of the lumen of the superior vena cava, likely related to artifact from the indwelling stent. Within this limitation, the SVC appears patent. The veins of the upper chest and neck are normal in caliber and are unchanged from the prior study. No evidence of venous collateralization to suggest new venous thrombosis. The thoracic aorta is of normal caliber. No aneurysm or dissection. The great vessels are normal in appearance. The heart is unremarkable on this non dedicated study. No pericardial effusion. No hilar or mediastinal lymphadenopathy or mass lesion. There are bilateral trace pleural effusions. There is a small amount of atelectasis bilaterally, no suspicious pulmonary lesion identified on this non dedicated study. Small lymph nodes are noted within the lower neck bilaterally. These measure up to 1.3 x 0.9 cm (2, 9). When compared to the prior CT these are unchanged/borderline enlarged. Normal signal within the remainder of the soft tissues and visualized skeletal system. IMPRESSION: 1. Assessment of the superior vena cava is slightly limited by the indwelling stent however the vessel opacifies well with no direct or secondary evidence of SVC thrombosis. 2. Slightly prominent nodes within the lower neck which are unchanged/borderline enlarged when compared to the prior CT. Further assessment with ultrasound could be performed if clinically relevant. Radiology Report INDICATION: ___ woman with ulcerative colitis with clinical concern for enlarging lower neck mass. Evaluate for lymphadenopathy or mass. COMPARISON: MRV of the chest from ___. FINDINGS: Ultrasound of cervical lymph node levels II, III, VI bilaterally reveal only normal lymph nodes. Supraclavicular stations also contain lymph nodes of normal size and morphology. The location of the patient's concern contains only normal subcutaneous fat and benign lymph nodes. Based on physical examination and ultrasound appearance of supraclavicular region, lipodystrophy should be considered as a potential etiology. No fluid collection or mass is seen. IMPRESSION: Area of swelling contains only normal fat, without lymphadenopathy or other mass. Lipodystrophy should be considered as a potential etiology. Gender: F Race: OTHER Arrive by WALK IN Chief complaint: TACHYCARDIA Diagnosed with DEHYDRATION temperature: nan heartrate: 161.0 resprate: nan o2sat: 100.0 sbp: nan dbp: nan level of pain: nan level of acuity: 1.0

Dear Ms. ___, You were admitted to ___ for abdominal pain and diarrhea. While you were here your kidney function was found to be worsened, likely because you were not eating or drinking very much while also having diarrhea. This improved with IV fluid, encouraging you to drink more, and medications to improve the diarrhea. You were started on a medicaton called tincture of opium which has improved your diarrhea. You should continue this medication until you speak with Dr. ___. We evaluated the swelling of your neck, which was not caused by a problem with your blood vessels. An ultrasound was performed which did not show enlarged lymph nodes but instead an odd fat distribution. You can follow up with Dr. ___ this. Please return to the hospital if you discover you cannot tolerate eating or drinking or your diarrhea severely worsens from your baseline.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: malaise, hypoglycemia Major Surgical or Invasive Procedure: NONE History of Present Illness: Patient is a ___ with history of atrial fibrillation on Coumadin (chads2 4), HFpEF (LVEF 63% ___, hypertension, and T2DM who presents with weakness in setting of hypoglycemia. History is limited by patient participation. Patient by report had not been feeling well since early this weak, he describes overall weakness as well as some low-level nausea. He also endorses a recent headache. A concerned neighbor called for EMS and patient was brought to ___ ED for further evaluation and treatment. In the ED, initial vital signs were: 97.8 80 139/88 18 99% RA - Labs were notable for: INR >13.1 -> 11.6 PTT 107.5 ___ 150 Prolatctin 7.7 Mg 1.5 VBG ___ UA: 46RBCs, 30 Prot, 300 Glu Upon arrival, patient was noted to be quite lethargic and slow to respond. Head imaging subsequently obtained showed a 3.5x 1.3cm hyperdensity in the sella eroding into the sphenoid sinus (see below). Neurosurgery was consulted and recommended INR reversal and admission to medicine for further work-up, no acute indication for surgical intervention. - Studies performed include: MRI BRAIN 1. Study was prematurely aborted due to significant pain and claustrophobia experienced by the patient. 2. Large expansile pituitary mass that erodes the sphenoid sinuses anteriorly, suspicious for a probably hemorrhagic invasive macroadenoma. 3. Additional 5.5 x 1.1 cm plaque-like lesion extending from the prepontine cistern inferiorly to the foramen magnum is likely a separate entity, may represent a meningioma. 4. MRI brain with contrast is required for further characterization of both findings. NCCTH 1. 3.5 x 1.3 cm hyperdense expansile mass in the sella eroding through the roof of the sphenoid sinus, which may reflect a pituitary mass. Dedicated MRI the sella is recommended for further characterization. 2. No intracranial hemorrhage. 3. Paranasal sinus disease. Please correlate with clinical findings. CXR INDINGS: Cardiac silhouette size is moderately enlarged but similar compared to the prior exam. The mediastinal and hilar contours are not substantially changed in the interval. Mild pulmonary vascular congestion is similar to the prior exam. There is no focal consolidation, pleural effusion, or pneumothorax is detected. There are no acute osseous abnormalities visualized. IMPRESSION: Similar mild pulmonary vascular congestion. - Patient was given: ___ 12:44 PO/NG Phytonadione 5 mg ___ 14:57 PO Lorazepam 1 mg ___ 19:30 IV Phytonadione 5 mg ___ 19:30 IV Kcentra ___ 19:42 SC Insulin 8 Units ___ 20:05 IV Kcentra 4 Units ___ 21:45 IV LORazepam ___ 22:32 SC Insulin 5 Units ___ 22:32 PO Pravastatin 80 mg ___ 22:32 PO Omeprazole 20 mg ___ 23:04 IV Magnesium Sulfate ___ 00:07 IV Magnesium Sulfate 2 gm - Vitals on transfer: 98.0 94 161/100 20 98% RA Upon arrival to the floor, the patient is slow with his responses. He is able to say ___ and eventually says ___ He says he is at the hospital because of 'low...something.' He denies any acute complaints. No headaches. He does endorse chronic blurry vision in his L eye for the past ___. Patient says that he manages all of his medications by himself, though is unable to name any of them. He is not sure what dose of Coumadin he takes, but is sure that he has been taking it. 10-point ROS is limited by patient participation/mental status. Past Medical History: 1. AFib s.p. three prior ___; amiodarone, coumadin. 2. DM (HbA1c 6.8% (1.16)) 3. GERD 4. HTN 5. Gout 6. Obstructive sleep apnea, uses CPAP. 7. dCHF. History of tachy mediated CM, EF 30%->normalized. Social History: ___ Family History: Multiple family members died at early age from cardiac complications. Mom died at ___ of CVA, Father died ___ with HTN, MI, pancreatic cancer, Brother died at ___ of MI and CVA. Physical Exam: ADMISSION: Vitals- 100.9 ___ 93 RA GENERAL: AOx1, slow speech HEENT: Normocephalic, atraumatic. Pupils equal, round, and reactive bilaterally, extraocular muscles intact. No conjunctival pallor or injection, sclera anicteric and without injection. Moist mucous membranes. Oropharynx is clear. NECK: No elevated JVP. CARDIAC: Irregular rhythm, normal rate, no murmurs/rubs/gallops. No JVP elevation. LUNGS: Clear to auscultation bilaterally w/appropriate breath sounds appreciated in all fields. No wheezes, rhonchi or rales. BACK: No spinous process tenderness. No CVAT. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Radial pulses 2+ bilaterally. SKIN: No evidence of ulcers, rash or lesions suspicious for malignancy. NEUROLOGIC: AOx1. CN2-12 intact. Peripheral visual fields full b/l. ___ strength througout. Normal sensation. No dysmetria. Gait deferred. DISCHARGE: VS: 97.9 112-147/69-100 88 21 97 RA GENERAL: NAD HEENT: anicteric sclera, pink conjunctiva HEART: irregular, normal rate, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants EXTREMITIES: warm, no edema NEURO: No gross motor deficits, ___ strength in UE, CN II-XII grossly intact. Pertinent Results: ADMISSION LABS: ___ 11:11AM BLOOD WBC-7.5 RBC-6.15* Hgb-15.9 Hct-48.4 MCV-79* MCH-25.9* MCHC-32.9 RDW-15.3 RDWSD-40.4 Plt ___ ___ 11:11AM BLOOD Neuts-61.6 ___ Monos-11.8 Eos-1.2 Baso-0.9 NRBC-0.3* Im ___ AbsNeut-4.60 AbsLymp-1.81 AbsMono-0.88* AbsEos-0.09 AbsBaso-0.07 ___ 11:11AM BLOOD ___ PTT-107.5* ___ ___ 11:11AM BLOOD Glucose-359* UreaN-10 Creat-1.1 Na-141 K-3.6 Cl-100 HCO3-22 AnGap-19* ___ 06:44PM BLOOD Calcium-9.8 Phos-3.6 Mg-1.5* ___ 11:11AM BLOOD Prolact-7.7 ___ 08:46AM BLOOD Cortsol-3.5 Testost-26* ___ 08:46AM BLOOD FSH-6.1 LH-3.3 TSH-2.0 INR: ___ 11:11AM BLOOD ___ PTT-107.5* ___ ___ 06:44PM BLOOD ___ PTT-117.2* ___ ___ 05:40AM BLOOD ___ PTT-33.6 ___ ___ 08:10AM BLOOD ___ PTT-35.9 ___ ___ 08:01AM BLOOD ___ PTT-36.2 ___ ___ 06:10AM BLOOD ___ PTT-40.5* ___ ___ 06:15AM BLOOD ___ PTT-47.9* ___ PERTINENT LABS ___ 08:46AM BLOOD FSH-6.1 LH-3.3 TSH-2.0 ___ 11:11AM BLOOD Prolact-7.7 ___ 08:46AM BLOOD Free T4-1.2 ___ 08:46AM BLOOD Cortsol-3.5 Testost-26* DISCHARGE LABS ___ 06:15AM BLOOD WBC-6.6 RBC-5.30 Hgb-13.9 Hct-42.1 MCV-79* MCH-26.2 MCHC-33.0 RDW-14.0 RDWSD-39.5 Plt ___ ___ 06:15AM BLOOD Glucose-106* UreaN-17 Creat-1.0 Na-139 K-3.8 Cl-99 HCO3-27 AnGap-13 ___ 06:15AM BLOOD Calcium-9.4 Phos-3.5 Mg-1.8 IMAGING ___ CT head 1. 3.5 x 1.3 cm hyperdense expansile mass in the sella eroding through the roof of the sphenoid sinus. This may reflect a pituitary mass. Dedicated MRI of the sella is recommended for further characterization. 2. No intracranial hemorrhage. 3. Paranasal sinus disease. Please correlate with clinical findings. ___ CTA head 1. Re-demonstration of the precontrast hyperdense pituitary macroadenoma which shows fairly diffuse enhancement postcontrast. No new enhancing lesions. No compromise of the ICAs. 2. The macro adenoma extends into the sphenoid sinus below with associated mucosal thickening/air-fluid level in the left sphenoid sinus. Please note that a CSF leak cannot be excluded, but this may also be due to retained mucus in the sinus due to narrowing of the left sign and ostium. 3. No significant stenosis by NASCET criteria of the imaged carotid arteries. MICROBIOLOGY Urine culture negative ___ BCx negative ___ ___ MRI w/ and w/o contrast IMPRESSION: 1. Motion limited exam. 2. Large lobulated sellar mass invading the medial portions of bilateral sphenoid sinuses, with mild extension to the left cavernous sinus and abutment of the left ICA without evidence for narrowing, and with mild retro clival extension. Subacute blood products in the left superior sellar component of the mass. 3. In addition to the mild retro clival extension of the sellar mass, there is a larger retro clival nonenhancing signal abnormality from the dorsum sellae to the top of the dens, with small amount of layering subacute blood products at the level of the craniocervical junction. Given the presence of subacute blood products in the sellar mass, this may represent a chronic hematoma. 4. While the retro clival abnormality compatible with hematoma effaces the prepontine and pre medullary cisterns, there is no compression of the brainstem and no significant mass effect on the cervicomedullary junction. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Amiodarone 200 mg PO DAILY 3. Ascorbic Acid ___ mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. FLUoxetine 20 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Omeprazole 20 mg PO DAILY 9. Pravastatin 80 mg PO QPM 10. Vitamin D 400 UNIT PO DAILY 11. Furosemide 40 mg PO DAILY 12. Glargine 20 Units Breakfast Glargine 20 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 13. Lisinopril 10 mg PO DAILY 14. Metoprolol Succinate XL 100 mg PO DAILY 15. Spironolactone 50 mg PO DAILY 16. Tamsulosin 0.4 mg PO QHS 17. Warfarin 2.5 mg PO 4X/WEEK (___) 18. Warfarin 5 mg PO 3X/WEEK (___) Discharge Medications: 1. Hydrocortisone 20 mg PO QAM RX *hydrocortisone 20 mg 1 tablet(s) by mouth QAM Disp #*30 Tablet Refills:*0 2. Hydrocortisone 10 mg PO QPM RX *hydrocortisone 10 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet Refills:*0 3. Glargine 16 Units Breakfast Glargine 16 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 4. Acetaminophen 650 mg PO Q6H:PRN pain 5. Amiodarone 200 mg PO DAILY 6. Ascorbic Acid ___ mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Docusate Sodium 100 mg PO BID 9. FLUoxetine 20 mg PO DAILY 10. Furosemide 40 mg PO DAILY 11. Metoprolol Succinate XL 100 mg PO DAILY 12. Multivitamins 1 TAB PO DAILY 13. Omeprazole 20 mg PO DAILY 14. Pravastatin 80 mg PO QPM 15. Spironolactone 50 mg PO DAILY 16. Tamsulosin 0.4 mg PO QHS 17. Vitamin D 400 UNIT PO DAILY 18. Warfarin 2.5 mg PO 4X/WEEK (___) 19. Warfarin 5 mg PO 3X/WEEK (___) 20. HELD- Lisinopril 10 mg PO DAILY This medication was held. Do not restart Lisinopril until told by your primary care physician ___: Home With Service Facility: ___ Discharge Diagnosis: likely pituitary macroadenoma Hypoglycemia supratherapeutic INR atrial fibrillation type II diabetes Hypertension Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CTA HEAD WANDW/O C AND RECONSQ1213CTHEAD INDICATION: ___ year old man with afib on warfarin and DM2 presenting with pituitary mass and supratherapeutic INR// Please perform CTA with EEA protocol to further characterize pituitary mass 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 mL of Omnipaque intravenous contrast material. Three-dimensional angiographic volume rendered and segmented images were then generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 7.0 s, 28.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 1,307.8 mGy-cm. 2) Spiral Acquisition 3.9 s, 30.5 cm; CTDIvol = 27.6 mGy (Head) DLP = 840.8 mGy-cm. 3) Spiral Acquisition 3.9 s, 30.8 cm; CTDIvol = 27.6 mGy (Head) DLP = 849.0 mGy-cm. 4) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 43.4 mGy (Head) DLP = 21.7 mGy-cm. 5) Stationary Acquisition 5.6 s, 0.5 cm; CTDIvol = 68.3 mGy (Head) DLP = 34.1 mGy-cm. Total DLP (Head) = 3,053 mGy-cm. COMPARISON: Prior CTA done ___ and MRI a done ___ FINDINGS: CT HEAD WITHOUT CONTRAST: Re-demonstration of a hyperdense expansile avidly enhancing mass (2, 31) in the sella invading through the region of the sphenoid sinus. No obvious focal areas of non enhancement. There is mild thickening of the infundibulum. Again demonstrated is mucosal thickening of the left sphenoid sinus +/- fluid/mucous resulting in an air fluid level. The ostium of the left sphenoid sinus is narrowed, which is likely related to expansion of the mass arising from the sella. Mild suprasellar extension without contact with the optic chiasm, was better seen on MRI performed ___. No involvement of the internal carotid arteries. There is no evidence of large territorial infarction, hemorrhage, or edema. There is prominence of the ventricles and sulci suggestive of involutional changes. Bilateral periventricular, subcortical, and deep white matter hypodensities are nonspecific but most likely represent sequelae of chronic small vessel ischemic changes. The visualized portion the bilateral mastoid air cells and middle ear cavities are clear. The visualized portion the bilateral orbits are unremarkable. The vessels of the circle of ___ and their principal intracranial branches appear normal with no evidence of stenosis, occlusion, or aneurysm. The basilar artery terminates as the superior cerebellar arteries. Bilateral fetal origin of the PCAs. The dural venous sinuses are patent. Significant dental disease, most extensive in posterior-most right maxillary molar and posterior most right mandibular molar with osseous resorption surrounding the ___ be from extensive periodontal disease or infection; extension of periodontal disease is more likely. No surrounding rim enhancing collection to suggest periodontal abscess. Consider dental consult. IMPRESSION: 1. Re-demonstration of the precontrast hyperdense pituitary macroadenoma which shows fairly diffuse enhancement postcontrast. No new enhancing lesions. No compromise of the ICAs. 2. The macro adenoma extends into the sphenoid sinus below with associated mucosal thickening/air-fluid level in the left sphenoid sinus. Please note that a CSF leak cannot be excluded, but this may also be due to retained mucus in the sinus due to narrowing of the left sign and ostium. 3. No significant stenosis by NASCET criteria of the imaged carotid arteries. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST INDICATION: ___ year old man with insulin-dependent diabetes, atrial fibrillation on Coumadin, presenting with headache and ear pain, found to have a pituitary mass. Pituitary views to evaluate pituitary mass. TECHNIQUE: Sagittal T1 weighted, and axial T1 weighted, T2 weighted, FLAIR, gradient echo, and diffusion-weighted images of the brain were obtained. Following intravenous gadolinium administration, axial T1 weighted images of the brain and sagittal MPRAGE images of the brain with multiplanar reformations were obtained. COMPARISON: Incomplete pituitary MRI, ___. CTA head and neck, ___. Head CT, ___. FINDINGS: Postcontrast MP RAGE images are severely degraded by motion artifact despite 2 acquisition attempts. Multiple other sequences are mildly or moderately limited by motion artifact. There is no acute infarction. There is no edema, mass effect, or evidence for blood products in the brain parenchyma. There are extensive confluent T2 hyperintensities in the subcortical, deep, and periventricular white matter of the cerebral hemispheres, nonspecific but most likely sequela of chronic small vessel ischemic disease given the patient's cardiovascular risk factors. There is mild tumor global parenchymal volume loss with prominent ventricles and sulci. The previously seen pituitary mass is not optimally imaged in the absence of dedicated high-resolution precontrast and postcontrast coronal and sagittal T1 weighted images through the sella, and given the severe motion degradation of the postcontrast MP RAGE images. The ___ pituitary MRI is incomplete as the patient could not tolerate postcontrast imaging. Again seen is a large lobulated mass extending from the sella into the medial portions of bilateral maxillary sinuses, which measures 2.7 cm AP x 1.7 cm craniocaudad on image 2:13 and 2.9 cm transverse on image 3:10. The mass demonstrates heterogenous contrast enhancement. The left superior sellar component of the mass demonstrates high signal on precontrast T1 weighted images with low signal on T2 weighted and gradient echo images, as well as relative ___ on the prior CT, compatible with subacute blood products. There is no mass effect on the optic chiasm. Prior incomplete pituitary MRI better demonstrates that the mass extends into the left cavernous sinus and abuts the cavernous left internal carotid artery, without evidence for flow void narrowing. In addition, there is an extra-axial retro clival abnormality extending from the dorsum sellae to the top of the dens, which measures 5.7 cm craniocaudad by 0.8 cm AP on sagittal image 02:13, and up to 2.2 cm transverse on image 14:8. Sagittal reformatted images of the ___ CT demonstrate linear calcification along the upper dorsal margin of this abnormality. The superior ventral portion of this abnormality, abutting the dorsum sellae and upper clivus, demonstrates heterogenous high and low signal on T1 weighted images with apparent contrast enhancement on postcontrast images, images 2:13, 12:89, 3:8, 10:8, as well as intermediate T2 signal on image 14:8, suggesting retroclival extension of the sellar mass. The remainder of this abnormality demonstrates low signal on T1 weighted images and high signal on T2 weighted images, without evidence for significant contrast enhancement. In the inferior aspect of this abnormality at the level of the craniocervical junction, there is a small amount of layering T2 hypointensity and T1 hyperintensity with blooming artifact on gradient echo images (14:3, 3:3, 13:3), consistent with layering subacute blood products. While the prepontine and pre medullary cisterns are effaced, there is no compression of the brainstem or fourth ventricle. Ventral CSF space in the foramen magnum is narrowed but not completely effaced. Dorsal CSF space in the foramen magnum is preserved. There is mild mucosal thickening in the ethmoid air cells and left greater than right maxillary sinuses. In addition to invasion of the sphenoid sinuses by the above-described sellar mass, there is also fluid in the left maxillary sinus and mild mucosal thickening in bilateral maxillary sinuses. IMPRESSION: 1. Motion limited exam. 2. Large lobulated sellar mass invading the medial portions of bilateral sphenoid sinuses, with mild extension to the left cavernous sinus and abutment of the left ICA without evidence for narrowing, and with mild retro clival extension. Subacute blood products in the left superior sellar component of the mass. 3. In addition to the mild retro clival extension of the sellar mass, there is a larger retro clival nonenhancing signal abnormality from the dorsum sellae to the top of the dens, with small amount of layering subacute blood products at the level of the craniocervical junction. Given the presence of subacute blood products in the sellar mass, this may represent a chronic hematoma. 4. While the retro clival abnormality compatible with hematoma effaces the prepontine and pre medullary cisterns, there is no compression of the brainstem and no significant mass effect on the cervicomedullary junction. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Dizziness, R Ear pain Diagnosed with Other specified disorders of brain temperature: 97.8 heartrate: 80.0 resprate: 18.0 o2sat: 99.0 sbp: 139.0 dbp: 88.0 level of pain: UTA level of acuity: 3.0

Dear Mr. ___, You came to the hospital at ___ because you were feeling unwell and had low blood sugar. You were found to have a mass in the middle of your brain, called a pituitary macroadenoma. You were seen by neurosurgery, who recommended an outpatient follow up along with ENT (ear nose and throat surgeons) follow-up with discussion for possible surgery. Because this tumor presses on and damages areas that release certain hormones, you required replacement hormones and will need to continue these when you leave. See the rest of your paperwork for these changes. You should follow up with endocrinology after you leave the hospital. **You will need to have your labs checked on ___ before your endocrinology appointment. Please go to ___, these labs are ordered for you** When you initially came to the hospital, your INR (warfarin level) was very high. We stopped this and put you on an injection blood thinner until your level normalized. You were discharged on warfarin again and will need to follow up VERY CLOSELY with your primary care doctor to ensure that this level does not get high again. High INRs can result in severe bleeding!! You will need your INR checked ONCE A WEEK at the ___ ___ above ___. We adjusted your insulin because one of your new medications, hydrocortisone, can make your sugars higher than normal. It was a pleasure participating in your care. We wish you all the best in the future. Sincerely, Your ___ team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Bactrim / niacin / Benadryl / donepezil / Exelon / Librax (with clidinium) Attending: ___ Chief Complaint: left sided weakness Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old woman with HTN and DM who presented from her assisted living facility with acute onset left leg and face weakness with slurred speech at 12:00 noon today. She was walking with her rollator when she suddenly started dragging the left leg behind her and her speech sounded slurred. She was helped into bed (required 2 aides, normally she is able to do this alone) then slept for 1.5 hours. When she awoke, she continued to have left leg weakness therefore she was sent to the ED. Upon arrival, BP elevated to 182/63 but came down without intervention. Her daughter met her in the ED and at that time, symptoms had resolved. She noticed some tremulousness of the hands and word finding difficulties slightly worse than usual, but otherwise appeared well with no clear weakness or numbness and without slurred speech. CT/ CTA revealed hypodensity in the R basal ganglia and no significant vascular abnormalities. Toxic/metabolic/infectious workup was negative. ROS: On neurologic review of systems, the patient denies headache, lightheadedness. Denies difficulty with producing or comprehending speech. Denies loss of vision, blurred vision, diplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or dysphagia. Denies current focal muscle weakness, numbness, parasthesia. Denies loss of sensation. Denies bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the patient denies fevers, rigors, night sweats, or noticeable weight loss. Denies chest pain, palpitations, dyspnea, or cough. Denies nausea, vomiting, diarrhea, constipation, or abdominal pain. No recent change in bowel or bladder habits. Denies dysuria or hematuria. Denies myalgias, arthralgias, or rash. Past Medical History: DEMENTIA DIABETES ___ HYPERTENSION OSTEOARTHRITIS DEPRESSION HYPERLIPIDEMIA PERIPHERAL NEUROPATHY DIARRHEA OSTEOPOROSIS MACULAR DEGENERATION THYROID NODULE ANXIETY PROTEINURIA OBSESSIVE-COMPULSIVE DISORDER CHRONIC KIDNEY DISEASE VITAMIN D DEFICIENCY GAIT DISTURBANCE ORAL MASS Social History: Social History (Last Verified ___ by ___, MD): Marital status: Married Children: Yes: 1 son 2 daughters Lives with: Other: ___ ___ Lives in: Group Setting Work: ___ Tobacco use: Former smoker Year Quit: ___ Years Since ___ Quit: Pack Years: 0 Alcohol use: Present Alcohol use may have a drink on special occasions comments: Recreational drugs Denies (marijuana, heroin, crack pills or other): Depression: Based on a PHQ-2 evaluation, the patient does not report symptoms of depression Exercise: Activities: at ___ Diet: Regular Comments: Lives in memory unit. medications managed through pharmacy and aides at ___ ___. Uses a cane. Family History: Family History (Last Verified ___ by ___, MD): Relative Status Age Problem Onset Comments Mother ___ DIABETES ___ STOMACH CANCER in her ___ Father ___ ALZHEIMER'S DISEASE Sister ___ BREAST CANCER in her ___ Comments: Physical Exam: ADMISSION PHYSICAL EXAM Vitals: T: 97.8 HR: 70 BP: 182/63; current 149/64 RR: 16 SaO2:99% RA General: NAD HEENT: Atraumatic/normocephalic, no oropharyngeal lesions, neck supple Extremities: Warm, no edema Neurologic Examination: - Mental status: Awake, alert, oriented x 2. Able to state day and month of birth but not year. Speech is fluent with full sentences, intact repetition, and intact verbal comprehension. Naming intact. No dysarthria. Normal prosody. No evidence of hemineglect. No left-right confusion. Able to follow both midline and appendicular commands. - Cranial Nerves: PERRL 3->2.5. EOMI, no nystagmus. V1-V3 without deficits to light touch bilaterally. No facial movement asymmetry. Palate elevation symmetric. SCM/Trapezius strength ___ bilaterally. Tongue midline. - Motor: Normal bulk and tone. No drift. No tremor or asterixis. [___] L 5 5 5 5 ___ 5 5 5 5 5 R 5 5 5 5 ___ 5 5 5 5 5 - Reflexes: [Bic] [Tri] [___] [Quad] [Gastroc] L 2+ 2+ 3+ 2+ 2+ R 2+ 2+ 3+ 2+ 2+ Plantar response withdrawal bilaterally - Sensory: No deficits to light touch. Unable to cooperate with DSS - Coordination: No dysmetria with finger to nose testing bilaterally. - Gait: Normal initiation. Kyphotic posture. Narrow base with walker. Walks around examination room, pivoting, sitting and standing from the bed with minimal assistance DISCHARGE PHYSICAL EXAM General: NAD HEENT: NCAT, no oropharyngeal lesions, neck supple Extremities: Warm, no edema Neurologic Examination: - Mental status: Awake, oriented to self. Not able to state year or month, or where she is, which is baseline her daughter. Speech is fluent with full sentences, intact repetition, and intact verbal comprehension. Naming intact. No dysarthria. Normal prosody. No evidence of hemineglect. No left-right confusion. Able to follow both midline and appendicular commands. - Cranial Nerves: PERRL 3->2.5. EOMI, no nystagmus. V1-V3 without deficits to light touch bilaterally. No facial movement asymmetry. Palate elevation symmetric. SCM/Trapezius strength ___ bilaterally. Tongue midline. - Motor: Normal bulk and tone. No drift. No tremor or asterixis. [___] L 4+ 5 5- 5 ___- 5 5- 5 5 5 R 5 5 5 5 ___ 5 5 5 5 5 - Reflexes: deferred - Sensory: No deficits to light touch. Unable to cooperate with DSS - Coordination: No dysmetria with finger to nose testing bilaterally. Pertinent Results: ___ 06:52AM BLOOD WBC-8.8 RBC-3.28* Hgb-9.9* Hct-31.2* MCV-95 MCH-30.2 MCHC-31.7* RDW-12.9 RDWSD-44.6 Plt ___ ___ 06:52AM BLOOD ___ PTT-26.3 ___ ___ 06:52AM BLOOD Glucose-100 UreaN-29* Creat-1.2* Na-143 K-4.8 Cl-107 HCO3-24 AnGap-12 ___ 06:52AM BLOOD ALT-11 AST-14 LD(LDH)-197 CK(CPK)-52 AlkPhos-59 TotBili-0.2 ___ 07:30PM BLOOD Lipase-23 ___ 06:52AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 06:52AM BLOOD TotProt-6.0* Albumin-3.9 Globuln-2.1 Cholest-PND ___ 06:52AM BLOOD %HbA1c-5.5 eAG-111 ___ 07:30PM BLOOD Triglyc-374* HDL-36* CHOL/HD-7.9 LDLcalc-173* ___ 06:52AM BLOOD TSH-PND ___ 06:52AM BLOOD CRP-3.9 MRI brain w/o contrast ___ " FINDINGS: Acute infarcts in the right putamen as well as body of the right caudate nucleus. No intracranial hemorrhage. No mass. Generalized cerebral atrophy with ex vacuo dilatation of the ventricular system. Mild periventricular white matter T2 and FLAIR hyperintense changes are most likely sequela of microangiopathy. Partially empty sella. The craniocervical junction appears normal. Degenerative changes of the cervical spine. The orbits appear normal. The major intracranial vessels demonstrate normal T2 flow voids. Mild mucosal thickening involving the paranasal sinuses. IMPRESSION: 1. Acute infarcts in the right basal ganglia as described above. " CTA h/n ___ (preliminary read) "Wet Read by ___ on FRI ___ 7:42 ___ Noncontrast head CT: No acute intracranial process. CTA head and neck: Patent intracranial cervical vasculature without dissection or aneurysm greater than 3 mm. Final read pending 3D reconstruction. " ============================================ AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (x) Yes, confirmed done - () Not confirmed () No 2. DVT Prophylaxis administered? (x) Yes - () No 3. Antithrombotic therapy administered by end of hospital day 2? (x) Yes - () No 4. LDL documented? (x) Yes (LDL = 173) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL ] 6. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? () Yes - () No 9. Discharged on statin therapy? (x) Yes - () No [if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL 10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) Antiplatelet - () Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - () No - (x) N/A Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Escitalopram Oxalate 10 mg PO DAILY 3. Lidocaine 5% Patch 1 PTCH TD QAM 4. Lisinopril 2.5 mg PO DAILY 5. Memantine 5 mg PO DAILY 6. Mirtazapine 15 mg PO QHS 7. OLANZapine 5 mg PO DAILY 8. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 9. Aspirin 81 mg PO DAILY 10. calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit oral BID Discharge Medications: 1. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*6 2. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*6 3. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 4. amLODIPine 5 mg PO DAILY 5. calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit oral BID 6. Escitalopram Oxalate 10 mg PO DAILY 7. Lidocaine 5% Patch 1 PTCH TD QAM 8. Lisinopril 2.5 mg PO DAILY 9. Memantine 5 mg PO DAILY 10. Mirtazapine 15 mg PO QHS 11. OLANZapine 5 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: acute ischemic stroke Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). mild left sided weakness Followup Instructions: ___ Radiology Report EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD INDICATION: ___ year old woman with 2 hours of left sided weakness now resolved; hypodensity in R putamen on CTH// stroke eval TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was performed with gradient echo, FLAIR, diffusion, and T2 technique were then obtained. COMPARISON Prior CT done ___ FINDINGS: Focal areas of slow diffusion are consistent with acute infarcts in the right putamen as well as body of the right caudate nucleus. There is no evidence of mass effect or hemorrhagic transformation, generalized cerebral atrophy with ex vacuo dilatation of the ventricular system. Mild periventricular white matter T2 and FLAIR hyperintense changes are most likely sequela of microangiopathy. Partially empty sella. The craniocervical junction appears normal. Degenerative changes of the cervical spine. The orbits appear normal. The major intracranial vessels demonstrate normal T2 flow voids. Mild mucosal thickening involving the paranasal sinuses. IMPRESSION: 1. Focal areas of slow diffusion consistent with acute infarcts in the right putamen and body of the right caudate nucleus as described above. 2. T2/FLAIR hyperintensities in the subcortical white matter suggests chronic microvascular ischemic changes. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the ___ ___ at 10:09 am, 10 minutes after discovery of the findings. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Altered mental status, Slurred speech Diagnosed with Disorientation, unspecified, Hypokalemia, Altered mental status, unspecified temperature: 97.7 heartrate: 74.0 resprate: 16.0 o2sat: 99.0 sbp: 182.0 dbp: 63.0 level of pain: 0 level of acuity: 2.0

Dear ___, ___ were hospitalized due to symptoms of left sided weakness resulting from an ACUTE ISCHEMIC STROKE, a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. We saw on MRI that ___ had a small stroke (not a TIA) that caused your weakness. This was most likely caused by small vessel disease, which is from high blood pressure, diabetes, high cholesterol. We stopped your aspirin, started Plavix, which is similar to aspirin, and increased your atorvastatin to decrease your risk of stroke in the future. ___ will have physical therapy at home per physical therapy recommendations. Stroke can have many different causes, so we assessed ___ for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: high blood pressure diabetes atherosclerosis of your blood vessels high cholesterol We are changing your medications as follows: stop aspirin start Plavix (clopidogrel) 75 mg daily increase atorvastatin to 80 mg nightly Please take your other medications as prescribed. Please followup with Neurology and your primary care physician. If ___ experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to ___ - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology Team

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Open Right Hemicolectomy History of Present Illness: ___ y/o M ___ with ___ duodenal ulcer in ___ (NSAID induced per patient), s/p H. pylori eradication ___, p/w 3 days of RLQ pain and BRBPR. No nausea, vomiting, hematemesis or melena. No history of abdominal surgeries. Patient reports that he had BRBPR and intermittent diarrhea and constipatino x 2 months. Presented to OSH 2 months ago, had KUB, and was given stool softeners. Symptoms continued, and started having ___ diarrhea, so he had colonoscopy 3 weeks ago with Dr. ___ ___ affiliate). He was told he has "cancer" of some kind, but was supposed to discuss details with Dr. ___ ___. No fevers/chills at home, currently ___ diarrhea/day. No sick contacts at work or home, no recent travel. Initial VS in the ED: 98 80 131/77 20 99%. Labs notable for Hct 34 on arrival, 32 on repeat. Patient was given 5mg IV morphine, but continued to have pain and unable to tolerate PO CT abdomen: 1. bowel wall thickening and edema and surrounding inflammatory changes in the distal and terminal ileum, inflammation at cecum at the level of the ileocecal valve. c/w an enteritis, either inflammatory or infectious. Normal appendix VS prior to transfer: 98.8 73 ___ 99% Past Medical History: vericose veins duodenal ulcer Social History: ___ Family History: No history of GI bleeding or other GI disorders. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.5, 109/72, 72, 18, 98%RA General: no acute distress, pleasant HEENT: Sclera anicteric Neck: supple Lungs: CTAB, no wheezes, rales, ronchi CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, mild TTP in RLQ, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly SKIN: no rash NEURO: A+Ox3, CN ___ grossly intact DISCHARGE PHYSICAL EXAM: General: Ambulating inpatient floor without issue. Pain controlled. Tolerating regular diet. Reports passing flatus. VS: 97.8, 89, 106/63, 18, 97% RA Neuro: A&OX3 Resp: no issues Abd: midline incison closed with dermabond, no drainage or errythema noted Lower Extremities: No edema. Pertinent Results: ADMISSION LABS: ___ 09:48PM WBC-8.5 RBC-4.05* HGB-9.8* HCT-32.1* MCV-79* MCH-24.2* MCHC-30.5* RDW-13.7 ___ 02:06PM GLUCOSE-93 UREA N-6 CREAT-0.9 SODIUM-142 POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-27 ANION GAP-15 ___ 02:06PM ALT(SGPT)-9 AST(SGOT)-16 ALK PHOS-76 TOT BILI-0.3 ___ 02:06PM LIPASE-19 ___ 02:06PM WBC-8.8 RBC-4.37* HGB-10.5*# HCT-34.3*# MCV-79*# MCH-24.1*# MCHC-30.7* RDW-13.9 ___ 07:10AM BLOOD WBC-10.4 RBC-4.23* Hgb-10.2* Hct-33.5* MCV-79* MCH-24.0* MCHC-30.4* RDW-14.2 Plt ___ ___ 08:20PM BLOOD Hct-33.7* ___ 07:30AM BLOOD WBC-8.0 RBC-3.91* Hgb-9.8* Hct-30.9* MCV-79* MCH-25.1* MCHC-31.8 RDW-13.8 Plt ___ ___ 09:48PM BLOOD WBC-8.5 RBC-4.05* Hgb-9.8* Hct-32.1* MCV-79* MCH-24.2* MCHC-30.5* RDW-13.7 Plt ___ ___ 09:48PM BLOOD Neuts-74.2* Lymphs-17.8* Monos-6.5 Eos-1.3 Baso-0.2 ___ 02:06PM BLOOD Neuts-80.4* Lymphs-12.7* Monos-6.0 Eos-0.7 Baso-0.2 ___ 07:10AM BLOOD Plt ___ ___ 07:30AM BLOOD Plt ___ ___ 07:30AM BLOOD ___ PTT-36.7* ___ ___ 09:48PM BLOOD Plt ___ ___ 02:06PM BLOOD Plt ___ ___ 02:06PM BLOOD ___ PTT-38.1* ___ ___ 07:10AM BLOOD Glucose-89 UreaN-8 Creat-0.8 Na-141 K-3.9 Cl-107 HCO3-24 AnGap-14 ___ 08:20PM BLOOD Na-140 K-3.9 Cl-105 ___ 07:30AM BLOOD Glucose-81 UreaN-9 Creat-0.8 Na-140 K-3.6 Cl-104 HCO3-26 AnGap-14 ___ 07:10AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.8 ___ 08:20PM BLOOD Mg-1.9 ___ 07:30AM BLOOD CEA-21* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325-650 mg PO Q6H:PRN pain Discharge Medications: 1. Acetaminophen 650 mg PO Q6H do not take more than 3000mg of tylenol in ___ hrs or drink alcohol while taking RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID ok to not take if loose stool develops RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 3. Ibuprofen 400 mg PO Q8H:PRN pain Please take with food. RX *ibuprofen [Advil] 200 mg ___ tablet(s) by mouth every eight (8) hours Disp #*30 Tablet Refills:*0 4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain Do not drink alcohol or drive a car while taking this medication. RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*35 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Right Sided Colon Cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: History of peptic ulcer disease with right lower quadrant pain and bright red blood per rectum for three days. COMPARISONS: None. TECHNIQUE: Contiguous axial MDCT images were obtained through the abdomen and pelvis after the administration of IV contrast only. Sagittal and coronal reformatted images were obtained and reviewed. FINDINGS: LUNG BASES: There is dependent basilar atelectasis. The bases of the lungs are otherwise clear. There are no nodules, consolidations or pleural effusion. The base of the heart is normal. There is no pericardial effusion. ABDOMEN: The liver is normal in shape and contour. There are no focal hepatic lesions. The portal vein is patent. The gallbladder is normal in appearance. There is no intra- or extra-hepatic biliary duct dilation. The spleen, pancreas, adrenal glands, and kidneys are normal. There is no evidence of pyelonephritis or hydronephrosis. The kidneys enhance and excrete contrast symmetrically. The stomach is mostly collapsed. The proximal small bowel is normal in course and caliber. There is no evidence of obstruction. There is no free air. In the distal ileum, extending into the terminal ileum, there is marked small bowel wall thickening, surrounding stranding, and tracer associated ascites. There is no stricturing or surrounding abscess. There is mild surrounding inflammatory change around the cecum at the level of the ileo-cecal valve. There is trace free fluid in the right pelvis. There are enlarged scattered mesenteric lymph nodes, likely reactive. There is no retroperitoneal lymphadenopathy. The pbdominal vasculature is normal in course and caliber. PELVIS: The rectum is unremarkable. The large bowel is normal in course and caliber without focal inflammatory changes, other than the mild changes in the cecum, as described above. The appendix is visualized and normal. The bladder and prostate are normal. There is no pelvic or inguinal lymphadenopathy. OSSEOUS STRUCTURES: There are no concerning lytic or sclerotic osseous lesions. No fractures identified. IMPRESSION: 1. Extensive bowel wall edema, surrounding inflammatory changes, and associated trace acites in the distal and terminal ileum. Additionally, there is some inflammatory changes in the cecum at the level of the ileocecal valve. This is most consistent with an enteritis, either inflammatory or infectious. 2. Normal appendix. Radiology Report PA AND LATERAL CHEST ___ No prior studies for comparison. FINDINGS: Heart size, mediastinal and hilar contours are normal. Lungs and pleural surfaces are grossly clear. No pleural effusion or acute skeletal finding. IMPRESSION: No acute cardiopulmonary radiographic abnormality. Gender: M Race: ASIAN Arrive by WALK IN Chief complaint: ABD PAIN Diagnosed with ABDOMINAL PAIN OTHER SPECIED temperature: 98.0 heartrate: 80.0 resprate: 20.0 o2sat: 99.0 sbp: 131.0 dbp: 77.0 level of pain: 8 level of acuity: 3.0

You were admitted to the hospital after a Right Sided Colectomy for surgical management of your Colon Cancer. You have recovered from this procedure well and you are now ready to return home. Samples from your colon were taken and this tissue has been sent to the pathology department for analysis. You will receive these pathology results at your follow-up appointment. If there is an urgent need for the surgeon to contact you regarding these results they will contact you before this time. You have tolerated a regular diet, passing gas and your pain is controlled with pain medications by mouth. You may return home to finish your recovery. Please monitor your bowel function closely. You may or may not have had a bowel movement prior to your discharge which is acceptable, however it is important that you have a bowel movement in the next ___ days. After anesthesia it is not uncommon for patient’s to have some decrease in bowel function but you should not have prolonged constipation. Some loose stool and passing of small amounts of dark, old appearing blood are expected. However, if you notice that you are passing bright red blood with bowel movements or having loose stool without improvement please call the office or go to the emergency room if the symptoms are severe. If you are taking narcotic pain medications there is a risk that you will have some constipation. Please take an over the counter stool softener such as Colace, and if the symptoms do not improve call the office. If you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or extended constipation. You have a long vertical incision on your abdomen that is closed with dermabond. This incision can be left open to air or covered with a dry sterile gauze dressing if the staples become irritated from clothing. The staples will stay in place until your first post-operative visit at which time they can be removed in the clinic, most likely by the office nurse. Please monitor the incision for signs and symptoms of infection including: increasing redness at the incision, opening of the incision, increased pain at the incision line, draining of white/green/yellow/foul smelling drainage, or if you develop a fever. Please call the office if you develop these symptoms or go to the emergency room if the symptoms are severe. You may shower, let the warm water run over the incision line and pat the area dry with a towel, do not rub. No heavy lifting for at least 6 weeks after surgery unless instructed otherwise by Dr. ___ Dr. ___. You may gradually increase your activity as tolerated but clear heavy exercise with Dr. ___ Dr. ___. You will be prescribed a small amount of the pain medication Oxycodone. Please take this medication exactly as prescribed. You may take Tylenol as recommended for pain. Please do not take more than 4000mg of Tylenol daily. You may also take Ibuprofen as prescribed for pain. Please take this medication with food to protect your stomach. Do not drink alcohol while taking narcotic pain medication or Tylenol. Please do not drive a car while taking narcotic pain medication. Thank you for allowing us to participate in your care! Our hope is that you will have a quick return to your life and usual activities. Good luck!

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Reglan / Benadryl Decongestant / Phenergan / Prochlorperazine / Depakote / vancomycin / Compazine Attending: ___. Chief Complaint: abdominal pain, facial weakness Major Surgical or Invasive Procedure: None History of Present Illness: This is a ___ G6P3 @ 10w2d by LMP (LMP ___ which makes ___ ___ although states she was given ___ of ___ with h/o chronic abdominal pain, longstanding narcotic use, adrenal insufficiency (per notes likely secondary to chronic narcotic use) who presents to the ED with multiple complaints including abdominal pain, nausea/vomiting and right facial numbness. Seen by Neurology for evaluation of right facial numbness and multiple other neurologic complaints. Per their initial impression, most c/w functional, have not yet recommended imaging. OBGYN consulted re: abdominal pain/nausea/vomiting in the setting of early pregnancy. Pt states she has had abdominal pain x 1 month, mostly periumbilical, constant. Pain has become worse over the past week, also associated with nausea and vomiting. Has had vomiting since early pregnancy, was using ginger chews earlier in pregnancy, no longer using, no other meds. Vomits 4 times per day, usually bilious or yellow. No documented fever, chills. No abnormal vaginal discharge, no bleeding. Has been using narcotics x ___ years. Has been using fentanyl patch (changes every other day) and dilaudid 2mg every 4 hours, although she hasn't been taking the dilaudid this week due to her nausea and vomiting. Has not yet seen an OB. Unplanning pregnancy, but desired, planning to continue. Past Medical History: POBhx: SAB x 2, SVD x 3 (full term, aged ___, 4) PGynhx: h/o endometriosis diagnosed by laparoscopy, regular periods, no STIs, denies abnl Paps PMH: - chronic abdominal pain s/p negative work-up - chronic narcotic use: has been using x 7 days, states prescribed by her PCP ___, currently on fentanyl patch and PO dilaudid 2mg q4h, although has not taken dilaudid for approx 1 week, states she "thinks patch fell off today" - adrenal insufficiency thought to be secondary to chronic narcotic use, last saw in ___ - hyperprolactinemia - H/o hyperprolactinemia - Conversion disorder - migraine - Anxiety/Depression - Iron deficiency anemia - History of gastric ulcer - Iron deficiency anemia - Asthma - Eczema - pt reports h/o upper extremity DVT (although unable to find in her record); pt states she received short course of anticoagulation but unsure if it was a pill or injection PSH: diagnostic laparoscopy, occipital nerve decrompression surgery Social History: ___ Family History: Non-contributory Physical Exam: On admission: VITALS: Yest 19:19 94 120/70 18 100% RA Yest ___ 114/62 10 99% RA Yest 21:48 8 68 ___ 10 100% RA Yest ___ 118/58 9 99% RA Yest ___ 124/69 9 99% RA Yest ___ 108/66 15 100% RA Yest 23:46 8 98.4 79 109/61 12 100% RA General: NARD, appears uncomfortable Abdomen: Mildly tender diffusely but distractable, nondistended, no rebound, no guarding Back: No CVAT SSE: No bleeding, posterior multiparous cervix Bimanual: 10 week sized anteverted uterus, nontender, no CMT, no adnexal masses or tenderness. On discharge: VSS Gen: NAD CV: RRR Abd: soft, non-tender Ext: non-tender SVE: deferred Pertinent Results: LABORATORY On admission: ___ 07:10PM BLOOD WBC-6.2 RBC-4.88 Hgb-13.0 Hct-39.9 MCV-82 MCH-26.6 MCHC-32.6 RDW-14.2 RDWSD-41.6 Plt ___ ___ 07:10PM BLOOD Glucose-114* UreaN-8 Creat-0.7 Na-138 K-4.5 Cl-106 HCO3-15* AnGap-22* ___ 07:10PM BLOOD ALT-9 AST-23 AlkPhos-48 TotBili-0.4 ___ 07:10PM BLOOD Albumin-4.2 UricAcd-3.1 ___ 07:10PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Urine: ___ 01:55AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-80 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM ___ 01:55AM URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG F/U LABS: RADIOLOGY: PELVIC ULTRASOUND: An intrauterine gestational sac is seen and a single living embryo is identified with a crown rump length of 33 mm representing a gestational age of 10 weeks 2 days. This corresponds satisfactorily with the menstrual dates of 10 weeks 2 days. The uterus is normal. The ovaries are normal. IMPRESSION: Single live intrauterine pregnancy with size equal to dates. ___ OB Ultrasound - NT 1.2 mm (normal) Medications on Admission: colace, linzess, hydrocortisone 20 mg qAM and 10 mg qPM, advair, singulair, spiriva, fentanyl patch, dilaudid 2mg q4h prn Discharge Medications: 1. Docusate Sodium (Liquid) 100 mg PO BID RX *docusate sodium 50 mg/5 mL 10 mL by mouth twice daily Refills:*2 2. doxylamine succinate 10 mg ORAL QPM 3. Fentanyl Patch 100 mcg/h TD Q72H RX *fentanyl 100 mcg/hour Place 1 patch on a large patch of skin every 3 days Disp #*1 Patch Refills:*0 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. Ondansetron ___ mg PO Q8H:PRN nausea RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp #*40 Tablet Refills:*2 6. Prenatal Vitamins 1 TAB PO DAILY 7. Pyridoxine 25 mg PO TID RX *pyridoxine 25 mg 1 tablet(s) by mouth three times daily Disp #*40 Tablet Refills:*2 8. HYDROmorphone (Dilaudid) 2 mg PO BID:PRN severe pain 9. Lorazepam 0.5 mg PO Q8H:PRN nausea RX *lorazepam [Ativan] 0.5 mg 1 tablet by mouth every 8 hours Disp #*21 Tablet Refills:*0 10. Montelukast 10 mg PO DAILY 11. Hydrocortisone 20 mg PO QAM 12. Hydrocortisone 10 mg PO QPM 13. Solu-CORTEF (hydrocorTISone Sod Succinate) 100 mg intramuscular ONCE If feeling unwell, you can take one quarter of the injection. If vomiting and unable to tolerate oral medication, take half of solution RX *hydrocortisone sod succinate [Solu-Cortef] 100 mg 0.25 mg IM as needed Disp #*3 Vial Refills:*0 14. Syringe 3cc/21Gx1 (syringe with needle (disp)) 3 mL 21 x 1 miscellaneous ONCE RX *syringe with needle (disp) [Syringe 3cc/21Gx1"] 21 gauge X 1" Use syringe for intramuscular injection once Disp #*10 Syringe Refills:*0 15. Ranitidine 150 mg PO BID RX *ranitidine HCl 150 mg 1 tablet by mouth twice daily Disp #*40 Tablet Refills:*2 Discharge Disposition: Home Discharge Diagnosis: Nausea and vomiting of pregnancy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ year old woman with Ndobhoff placement // ? dobhoff placement COMPARISON: Radiographs from ___ IMPRESSION: There is a Dobbhoff tube which is too high, with the distal tip in the mid to lower esophagus. This should be advanced at least 20-25 cm or removed. Cardiomediastinal silhouette is within normal limits. There are no focal consolidations, pleural effusion, or pulmonary edema. There are no pneumothoraces. Radiology Report INDICATION: ___ year old woman with nausea, vomiting of pregnancy, f/u dobhoff placement // dobhoff placement COMPARISON: Radiographs from ___ at 18:00 IMPRESSION: The Dobbhoff tube has been advanced with the distal tip well within the body of the stomach, appropriately sited. Heart size is within normal limits. There are no focal consolidations, pleural effusion, or pulmonary edema. There are no pneumothoraces. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: R Numbness, Abd pain, Vomiting Diagnosed with OTH CURR COND-ANTEPARTUM, CHEST PAIN NOS, SKIN SENSATION DISTURB temperature: 98.4 heartrate: 118.0 resprate: 16.0 o2sat: 100.0 sbp: 118.0 dbp: 79.0 level of pain: 8 level of acuity: 1.0

Ms. ___, You were admitted to the antepartum service for nausea, vomiting, and abdominal pain. You were observed in the hospital for several days. Because you were unable to tolerate sufficient amount of nutrition, you were started on tube feeds. You received tube feeding for about a week, and subsequently you were able to tolerate some oral intake. You were not able to tolerate full amounts of normal nutrition, however we felt it would be helpful for you to trial being at home to see if that would help with your oral intake. Thus the tube was removed and we made a plan for close outpatient ___. As you recover from this acute episode of worsened nausea, it is important to take small sips and small bites of bland food when feeling nauseous. The most important thing is to stay hydrated, and you can do this by taking small sips of water or gatorade. The following medications are very helpful for nausea and vomiting of pregnancy: *Zofran (can take 3 times daily) *Pyridoxine (can take 4 times daily) *Doxylamine (to be taken at night) *Zantac (twice daily) In addition, while in the hospital, we addressed the following issues: 1. Adrenal insuffiency: While you were in the hospital you received stress dose steroids for your adrenal insufficiency. The endocrinology team felt it was safe for you to go home on the regular dose. If you start feeling sick again and cannot tolerate oral medication, you can take an intramuscular injection of hydrocortisone. You have been prescribed hydrocortisone in order to do this. Please ___ with Dr. ___, as detailed in the ___ instructions. 2. Chronic narcotic use: Regarding your narcotic use, you were continued on a fentanyl patch. You also took dilaudid when you were able to tolerate oral pills. We have given you a fentanyl patch, and you should ___ with your primary care doctor in order to obtain more patches in the future, as well as more narcotics to treat your chronic pain. 3. Ativan use: In addition, for you ativan has been helpful in the past. We have provided you with a short course of this to help get you through this period of nausea. This is not a medication we recommend to use chronically, however, it is reasonable to use in pregnancy intermittently. While taking narcotics, do not drive or drink alcohol. For your prenatal care, we have arranged for you to ___ in the ___ Clinic, which meets on ___ afternoons. Please see ___ information for the date and time of your clinic. Your first visit in clinic will be this ___ morning to ___ on your weight and diet. Please keep a log of your food you take at home.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: emesis Major Surgical or Invasive Procedure: none History of Present Illness: (Patient is non-verbal with severe dementia, all information is from ___) . ___ with history of severe vascular dementia (non-verbal at baseline), lives in a nursing home who presents with 1 day of nausea/vomiting. She vomited brown liquid today x3 with 2 episodes of diarrhea (per EMS report). Pt non-verbal and can not communicate symptoms or story. In ED Labs notable for lactate 2.1, K 6.5, Na 147, Cr 3.6. Trop 0.03. WBC 21 with 92% neuts. HCT 43, Plt 241. INR 1.0, PTT 25. EKG showed no peaked T waves. Pt given 30 kayexelate but drank very little of it. CT abd showed: dilated small bowel loops, 3.3cm, ___oncern for possible obstruction caused by internal hernia. No evid of bowel ischemia. NGT placed. Pt given vanc and zosyn. Power of attorney decided against surgical intervention and ultimately decided to transition to comfort measures only. . Patient currently appears comfortable and is in no acute distress. . REVIEW OF SYSTEMS: can not obtain Past Medical History: vascular dementia TIA recurrent UTI Osteoporois benign breast lump Social History: ___ Family History: unable to obtain Physical Exam: ADMISSION EXAM VS - 97.4, HR 108, 158/90, RR 20 GENERAL - NAD, comfortable, non verbal, opens eyes to voice HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART- tachycardic ABDOMEN - soft, nt, nd. EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) NEURO - non verbal, looks comfortable, currently with eyes closed . DISCHARGE EXAM GENERAL - NAD, comfortable, non verbal, opens eyes to voice HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART- tachycardic ABDOMEN - soft, nt, nd. EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) NEURO - non verbal, looks comfortable, currently with eyes closed Pertinent Results: ADMISSION LABS ___ 10:30PM BLOOD WBC-20.9* RBC-4.99 Hgb-14.1 Hct-43.5 MCV-87 MCH-28.3 MCHC-32.4 RDW-14.0 Plt ___ ___ 10:30PM BLOOD Neuts-92.2* Lymphs-3.7* Monos-3.3 Eos-0.5 Baso-0.4 ___ 10:30PM BLOOD ___ PTT-25.1 ___ ___ 10:30PM BLOOD Glucose-150* UreaN-82* Creat-3.6* Na-147* K-6.2* Cl-109* HCO3-25 AnGap-19 ___ 03:50AM BLOOD Glucose-160* UreaN-82* Creat-3.4* Na-144 K-5.7* Cl-107 HCO3-21* AnGap-22* ___ 10:30PM BLOOD ALT-14 AST-20 AlkPhos-61 TotBili-0.4 ___ 10:30PM BLOOD Lipase-75* ___ 10:30PM BLOOD cTropnT-0.03* . URINE ___ 02:45AM URINE Color-Yellow Appear-Hazy Sp ___ ___ 02:45AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM ___ 02:45AM URINE RBC-1 WBC-10* Bacteri-MOD Yeast-NONE Epi-<1 ___ 02:45AM URINE CastHy-9* . MICROBIOLOGY Blood culture pending x 1 . IMAGING CXR IMPRESSION: Right upper lobe mass with pleural tag, concerning for primary lung malignancy. Additional nodular opacity in left mid lung is indeterminate. A CT chest is recommended for further evaluation. Bibasilar opacities may reflect aspiration, atelectasis or infectious pneumonia. These may be further evaluated at the time of CT. . CT ABDOMEN PELVIS 1. Small-bowel obstruction, with at least two transition points in the lower-to-mid abdomen, with creation of closed loop where the bowel loop is dilated up to 2.6 cm. No evidence of bowel ischemia on this non-contrast CT study. 2. A 2.1-cm left adrenal and 1.2-cm right adrenal nodules, are not characterized in this study, may represent lipid poor adenomas or metastatic disease. If clinically feasible, adrenal protocol CT scan or an MRI can be obtained for further evaluation. 3. Pelvic free fluid, with minimal internal hemorrhage. 4. Sigmoid colonic diverticulosis without evidence of acute diverticulitis. A 2.7-cm left adnexal cyst, given the postmenopausal status, a pelvic ultrasound is recommended for further evaluation. 5. Fecal impaction in the rectum. . Medications on Admission: actonel 35mg allopurinol ___ calcium antacid ___ citalopram 20mg docusate 100mg lasix 20mg indomethacin 50mg lisinopril 2.5mg nystatin powder olanzapine 2.5mg senna vit D 400 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Small Bowel Obstruction Hyperkalemia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Followup Instructions: ___ Radiology Report INDICATION: ___ woman with NG tube placement. COMPARISON: Chest radiograph, ___, CHEST/ABDOMEN RADIOGRAPHS: A nasogastric tube coils in the fundus of the stomach with the tip terminating in the gastric body. Mildly dilated small bowel loops are partially imaged in this study. A circumscribed 3.0 cm right upper lobe opacity with a pleural tag, is concerning for a malignancy. Again seen are multifocal pulmonary opacities in the left mid lung and possibly the lung bases, reflective of multifocal infection. IMPRESSION: Nasogastric tube coils in the fundus and terminates in the gastric body. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: N/V/D Diagnosed with INTESTINAL OBSTRUCT NOS, ACUTE KIDNEY FAILURE, UNSPECIFIED, DEHYDRATION, HYPERKALEMIA, ARTERIOSCLER DEMENT NOS, CEREBRAL ATHEROSCLEROSIS temperature: 98.5 heartrate: 110.0 resprate: 18.0 o2sat: 92.0 sbp: 168.0 dbp: 87.0 level of pain: nonverbal level of acuity: 2.0

Ms ___, It was a pleasure participating in your care while your were admitted to ___. You were admitted because there was a blockage in your intestine that was causing you to become very ill. In speaking with your power of attorney it was decided that the focus of your care would be on making you comfortable. You were given medications to help with this and will be returning to your nursing home facility. You should stop all medications with the exception of the following: -Roxicet ___ mg/5 mL Solution: ___ mL PO every 2hr as needed for pain -ZOFRAN ODT 4 mg Tablet, Rapid Dissolve, One 1 Tab, Rapid Dissolve by mouth every four hours as needed for nausea. -lorazepam 0.5 mg Tablet every four hours as needed for agitation, under your tongue. Going forward, the goal should be focused on your comfort and further hospitalizations should be avoided in an effort to keep you comfortable.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins Attending: ___ Chief Complaint: Dyspnea on exertion, hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: Mrs ___ is a ___ with CLL, secondary ITP on Prednisone and recently started on Rituxan, HTN, HL, carotid artery stenosis, likely CAD s/p recent demand-type NSTEMI with TTE showing regional WMAs c/w CAD and increased LVEDP, who presents with dyspnea on exertion. She was here a couple weeks ago for management of ITP in context of admission for hypovolemia and demand-type NSTEMI in setting of diarrhea due to Norovirus. She was discharged home and per family has been doing very well. Her platelets continued to be low, so she was started on Rituximab and had infusion on ___, which she tolerated fine. On ___, she felt some fatigue. Then today she noticed dyspnea while going up the stairs. No chest pain, leg swelling, cough or cold symptoms, fevers, nor chills. She complained to her daughters, who around the same time noticed increased dyspnea during conversation. They brought her to an urgent care where her initial vitals showed SpO2 of 84, so they brought her to the ED. In the ED, she was mildly hypoxic and tachycardic. Vitals and symptoms normalized with ___ supplemental oxygen. Labs showed mild hyponatremia, chronic hemogram abnormalities, Tn of 0.13-->0.10 down from her prior values in our system. UA negative. CXR showed pulmonary edema. CTA chest showed no PE but confirmed infiltrates c/w pulmonary edema along with moderate bilateral pleural effusions. Admission was requested for possible CHF. ROS is negative in 10 points except as noted Past Medical History: CLL, secondary ITP on Prednisone and recently started on Rituxan HTN HL Carotid artery stenosis currently on aspirin, family reports that she has 75-99% stenosis, followed by Dr. ___ at ___ ___ CAD s/p recent demand-type NSTEMI with TTE showing regional WMAs c/w CAD and increased LVEDP Surgeries: Hysterectomy, wrist ORIF Social History: ___ Family History: Not relevant to current presentation Physical Exam: Admission Exam: Vitals AVSS Gen NAD, quite pleasant Abd soft, NT, ND, bs+ CV RRR, no MRG Lungs slightly diminished bilateral bases, scant bibasilar crackles Ext WWP, no edema Skin no rash, anicteric GU no foley Eyes EOMI HENT MMM, OP clear Neuro nonfocal, moves all extremities, steady gait Psych normal affect Discharge exam: AF, BP 100s-120s (most recent reading 144/75, HR 95-115, RR 18, SaO2 96/RA General: well-appearing woman in NAD, AO X 3 HEENT: MMM, OP clear Neck: supple, JVP approx. 8 cm Chest: bibasilar crackles CV: RR tachy, no m/g/r Abd: soft, NT/ND, NABS Ext: 1+ pedal edema b/l mainly at ankles Neuro (per Neurology consultant on ___: - Mental status: Awake, alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Speech is fluent with full sentences, intact repetition, and intact verbal comprehension. Naming intact. No paraphasias. No dysarthria. Normal prosody. No evidence of hemineglect. No left-right confusion. Able to follow both midline and appendicular commands. - Cranial Nerves: PERRL 3->2 brisk. VF full to number counting. EOMI, no nystagmus. V1-V3 without deficits to light touch bilaterally. No facial movement asymmetry. Hearing intact to finger rub bilaterally. Palate elevation symmetric. SCM/Trapezius strength ___ bilaterally. Tongue midline. - Motor: Normal bulk and tone. [Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas] [C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1] L ___ 5 R ___ 5 - Reflexes: [Bic] [Tri] [___] [Quad] [Gastroc] L 2+ 2+ 2+ 3+ 2 R 2+ 2+ 2+ 3+ 2 Plantar response flexor bilaterally - Sensory: No deficits to light touch, +extinction to LT on the left when testing both simultaneously - Coordination: No dysmetria with finger to nose testing bilaterally. - Gait: deferred On re-examination several hours later, Ms. ___ had R gaze deviation while she was sitting up in bed after waking up from a nap where she was sleeping upright. Had paraphasias and unable to name fingers ___ a pinking a "pee-wee," could not name index finger, could name thumb). Unable to say how much money 7 quarters is (said 4 quarters is $1). Able to draw a clock but on circling A's on a page, she only circled one A on the right side of the page. VFF to finger wiggling, eyes unable to cross midline. Not using her left arm as much, required quite a bit of prompting. Did say that her left hand was her own. Exam improved with lying her flat, eyes did cross midline and she started to use her LUE more spontaneously. Pertinent Results: Labs on admission: Heme ___ 04:00PM BLOOD WBC-24.3* RBC-3.21* Hgb-8.2* Hct-26.4* MCV-82 MCH-25.5* MCHC-31.1* RDW-15.9* RDWSD-47.3* Plt Ct-54*# ___ 04:00PM BLOOD Neuts-47 Bands-0 ___ Monos-1* Eos-0 Baso-0 Atyps-2* ___ Myelos-0 AbsNeut-11.42* AbsLymp-12.64* AbsMono-0.24 AbsEos-0.00* AbsBaso-0.00* ___ 04:00PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-OCCASIONAL Microcy-1+ Polychr-NORMAL ___ 04:00PM BLOOD ___ PTT-23.8* ___ Chem ___ 04:00PM BLOOD Glucose-266* UreaN-20 Creat-0.8 Na-129* K-3.6 Cl-94* HCO3-21* AnGap-18 ___ 04:00PM BLOOD cTropnT-0.13* ___ 08:02PM BLOOD cTropnT-0.10* Imaging on admission: CXR Increased interstitial prominence due to mild to moderate pulmonary edema or potentially atypical infection. Small right pleural effusion. CTA chest 1. No evidence of pulmonary embolism to the segmental level or aortic abnormality. 2. Mild to moderate asymmetric pulmonary edema with bilateral small to moderate pleural effusions and moderate cardiomegaly. 3. Multiple prominent mediastinal lymph nodes, measuring up to 1.0 cm. Suspected but not well assessed subcarinal nodes which are likely enlarged. EKG on admission: Sinus tachycardia NANI no acute ischemic changes Relevant prior studies: TTE ___ Mild regional left ventricular dysfunction c/w CAD (multivessel), with overall preseved systolic function. Elevated left ventricular filling pressure. Normal right ventricular free wall systolic function. Mild mitral regurgitation. Mild pulmonary hypertension. Labs over hospital course and on discharge: Heme: ___ 07:25AM BLOOD WBC-18.9* RBC-3.20* Hgb-8.1* Hct-25.6* MCV-80* MCH-25.3* MCHC-31.6* RDW-15.8* RDWSD-45.4 Plt Ct-75* ___ 07:55AM BLOOD WBC-29.9*# RBC-3.49* Hgb-8.7* Hct-28.0* MCV-80* MCH-24.9* MCHC-31.1* RDW-15.8* RDWSD-45.6 Plt Ct-90* Chem: ___ 07:55AM BLOOD UreaN-23* Creat-0.8 Na-135 K-3.5 ___ 07:25AM BLOOD cTropnT-0.26* ___ 05:10PM BLOOD CK-MB-2 cTropnT-0.22* ___ 07:55AM BLOOD CK-MB-3 cTropnT-0.28* ___ 07:55AM BLOOD Triglyc-102 HDL-49 CHOL/HD-2.8 LDLcalc-70 ___ 07:55AM BLOOD TSH-1.3 ___ 07:55AM BLOOD %HbA1c-PND Radiology Report EXAMINATION: Chest radiograph INDICATION: ___ with hx of CLL, recent chemo infusion, no SOB. had hx of pleural effusion from blood transfusion// effusion? TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph from ___ FINDINGS: There is prominence of interstitial lung markings, particularly in the perihilar distribution, right greater than left. There is no pneumothorax or left pleural effusion. Small right pleural effusion is suspected. The cardiomediastinal silhouette and hilar contours appear stable. IMPRESSION: Increased interstitial prominence due to mild to moderate pulmonary edema or potentially atypical infection. Small right pleural effusion. Radiology Report EXAMINATION: CTA CHEST WITH CONTRAST INDICATION: ___ with CLL, presented with SOB, xray shows mild pulm edema, and possible infiltrates, doesn't explain her SOB and increase O2 requirement// PE? TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of intravenous contrast. Reformatted coronal, sagittal, thin slice axial images, and oblique maximal intensity projection images were submitted to PACS and reviewed. DOSE: Total DLP (Body) = 156 mGy-cm. COMPARISON: Chest radiograph from ___ FINDINGS: HEART AND VASCULATURE: Of note, the study is suboptimal due to respiratory motion artifact. Within these limitations, the pulmonary vasculature is well opacified to the segmental level without filling defect to indicate a pulmonary embolus. The thoracic aorta is normal in caliber without evidence of dissection or intramural hematoma. The heart, pericardium, and great vessels are within normal limits. No pericardial effusion is seen. AXILLA, HILA, AND MEDIASTINUM: There are multiple prominent appearing mediastinal lymph nodes, measuring up to 1.0 cm (series 3: Image 72) in the prevascular region. In the subcarinal region there is suggestion of underlying adenopathy measuring 1.5 cm by 2.4 cm (2:53) though exact measurements is difficult given similar attenuation of the adjacent pleural effusion with this density. 8 mm lymph node seen adjacent to the upper esophagus. No axillary or hilar lymphadenopathy is present. No mediastinal mass. PLEURAL SPACES: There are bilateral dependent, layering, nonhemorrhagic pleural effusions, moderate on the right and small on the left. There is no evidence of pneumothorax. LUNGS/AIRWAYS: The diffuse ground-glass opacities in the bilateral lungs, right-greater-than-left, which are concerning for asymmetric mild-to-moderate pulmonary edema. The airways are patent to the level of the segmental bronchi bilaterally. BASE OF NECK: Visualized portions of the base of the neck show no abnormality. ABDOMEN: Included portion of the upper abdomen is unremarkable. BONES: Mild degenerative changes are seen in the thoracic spine. No suspicious osseous abnormality is seen.? There is no acute fracture. IMPRESSION: 1. No evidence of pulmonary embolism to the segmental level or aortic abnormality. 2. Mild to moderate asymmetric pulmonary edema with bilateral small to moderate pleural effusions and moderate cardiomegaly. 3. Multiple prominent mediastinal lymph nodes, measuring up to 1.0 cm. Suspected but not well assessed subcarinal nodes which are likely enlarged. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Dyspnea Diagnosed with Hypoxemia temperature: 98.1 heartrate: 110.0 resprate: 16.0 o2sat: 90.0 sbp: 132.0 dbp: 48.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, You were admitted to ___ for shortness of breath due to extra fluid in the lungs after your recent Rituximab dose. You improved with several dose of a diuretic by IV. While here, you developed new left-sided weakness concerning for possible stroke. You are being transferred to the Neurologic service at the ___ for further evaluation and management. Your vascular surgeon will also be seeing you at the ___. It was a pleasure caring for you.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: morphine / linezolid / Heparin Analogues Attending: ___. Chief Complaint: Fever, emesis Major Surgical or Invasive Procedure: none History of Present Illness: ___ hx of multiple UTIs and neurogenic bladder, seizure disorder, and chronic constipation on standing bowel regimen presents from nursing home with 1 day of fever to 101.8 on ___. Of note, patient reported eating impressive ___ meal on ___ with eggs ___ and some dairy, and endorse emesis thereafter associated with meal. She reprots since then she has felt well, with no abdominal pain, chills, chest pain, shortness of breath, or back pain or dysuria. Yesterday, she felt a little warm, and temperature was 101.7. She was brought to the ED given her history of recurrent UTIs, including history VRE. Per patient, she spoke gibberish yesterday night, which "usually happens with my UTI's". In the ED, initial vitals were: 99.5 94 115/47 21 98. CBC showed W 12.9 H/H 11.2/31.3 BUN/cr of 46:1.1 Her lactate was 1.4, and her initial U/A in ED showed > 182 WBC, + leuk, and was cloudy appearing. She had urine and blood cultures drawn at 1 am. She recieved. She recieved 1 gm of ceftriaxone at 200 am and 1 g vanc at 4 am. 1000 ml NS and 2.5 mg oxycodone at 2 am. On the floor, patient reports no complaints save for feeling hungry and wishing to eat. She reports standing consitpation, and again denies any dysuria. She confirms that she does not have a foley, and is straight cathed at rehab, and had straight cath in ED for urine culture above. She self reprots feeling better after abx in ED. Past Medical History: PAST MEDICAL HISTORY: - Seizure disorder - Neurogenic bladder with recurrent urinary tract infections including VRE, though most recently Vancomycin sensitive enterococcus - Hypertension - Anemia - Hyperlipidemia - Paroxysmal atrial fibrillation - Gastroesophageal reflux disease - Severe osteoarthritis of her left hip - Small bowel obstruction s/p laparotomy in ___ - Lumbar discectomy in ___. T6-9 laminectomy done in ___ done due to residual fluid left in spinal canal. Sister reports second cervical spine operation ___ at ___ and not ambulatory and with neurogenic bladder since then. - UGIB ___ duodenal ulcer ___ - History of HIT Social History: ___ Family History: Father deceased at age ___ from a heart virus. Her brother is alive but had leukemia as well as complications of a brain bleed and he also had coronary artery disease, status-post MI. Physical Exam: ON ADMISSION Vitals: bp 137/54 T 98 HR 74 RR 18 97 % RA. General: Alert, oriented, no acute distress. Lying in bed. HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL. Slight frontal maxilary sinus tenderness. No rhinorrhea. Oropharynx cl;ear without exudates. Neck: Supple, JVP not elevated, no cervical LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops. Lungs: Clear to auscultation bilaterally over anterior chest, no wheezes, rales, rhonchi. Slight psoterior B/L bibasilar crackles aucsulted on deep inspiration. Abdomen: Soft, non tender, slightly distended. GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Cotton inbetween toes B/L. Some evidence onchymycosis. ON D/C Vitals: T:97.___.6 BP: 101-136/46-71 P: 51-61 R: 18 O2: 98-99%RA General: Alert, oriented, no acute distress, lying in bed, sleeping. comfortable appearing with fewer covers HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI Neck: Supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2 Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No CVA tenderness, no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: EOMI, palate elevation symmetric, sensation grossly intact, able to move all extremities Pertinent Results: ON ADMISSION ___ 01:15AM URINE COLOR-Yellow APPEAR-Cloudy SP ___ ___ 01:15AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-300 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-LG ___ 01:15AM URINE RBC-14* WBC->182* BACTERIA-MANY YEAST-NONE EPI-2 TRANS EPI-5 ___ 01:15AM URINE HYALINE-38* ___ 01:15AM URINE MUCOUS-MANY ___ 12:47AM LACTATE-1.7 ___ 12:20AM GLUCOSE-126* UREA N-46* CREAT-1.1 SODIUM-140 POTASSIUM-4.2 CHLORIDE-109* TOTAL CO2-21* ANION GAP-14 ___ 12:20AM estGFR-Using this ___ 12:20AM ALT(SGPT)-8 AST(SGOT)-21 LD(LDH)-178 ALK PHOS-75 TOT BILI-0.4 DIR BILI-0.2 INDIR BIL-0.2 ___ 12:20AM LIPASE-21 ___ 12:20AM ALBUMIN-3.4* ___ 12:20AM WBC-12.9*# RBC-3.37* HGB-11.2* HCT-31.3* MCV-93 MCH-33.2* MCHC-35.7*# RDW-13.8 ___ 12:20AM NEUTS-88.3* LYMPHS-6.9* MONOS-4.0 EOS-0.7 BASOS-0.1 ___ 12:20AM PLT SMR-LOW PLT COUNT-91* CXR ___ FINDINGS: Evaluation is somewhat limited by the patient's body habitus. At the right base, there is localized pleural and parenchymal scarring with volume loss, which appears similar to prior exams. No new consolidation is identified. There is no pulmonary edema, pleural effusion, or pneumothorax. The mediastinal contours are normal. The heart size is at the upper limits of normal. IMPRESSION: No definite pneumonia, though given the baseline abnormality in the right lung base, an acute process is difficult to exclude. If indicated, short term followup chest radiographs or CT could be obtained. DISCHARGE LABS ___ 04:15AM BLOOD WBC-5.3 RBC-3.15* Hgb-10.4* Hct-29.5* MCV-94 MCH-32.9* MCHC-35.1* RDW-13.7 Plt ___ ___ 04:15AM BLOOD Glucose-74 UreaN-30* Creat-1.0 Na-142 K-4.3 Cl-114* HCO3-19* AnGap-13 ___ 04:15AM BLOOD Calcium-8.6 Phos-2.7 Mg-2.1 MICROBIOLOGY __________________________________________________________ ___ 1:15 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. __________________________________________________________ ___ 12:40 am BLOOD CULTURE Blood Culture, Routine (Pending): __________________________________________________________ ___ 12:20 am BLOOD CULTURE Blood Culture, Routine (Pending): Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Prochlorperazine 10 mg PO Q8H:PRN nausea 2. Bisacodyl 10 mg PR QAM 3. Lorazepam 0.5 mg PO Q6H:PRN anxiety 4. Fleet Enema ___AILY:PRN no bm during day 5. Acetaminophen 650 mg PO Q4H:PRN pain 6. Ipratropium-Albuterol Neb 1 NEB NEB Q2H:PRN sob 7. RISperidone 0.5 mg PO BID:PRN agitation 8. Milk of Magnesia 30 mL PO DAILY:PRN constipation 9. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain 10. Guaifenesin ___ mL PO Q4H:PRN nasal congestion 11. Senna 17.2 mg PO QHS 12. Calcium Carbonate 500 mg PO QHS 13. Ranitidine 150 mg PO QHS 14. Atorvastatin 10 mg PO QPM 15. Aspirin 81 mg PO DAILY 16. FoLIC Acid 1 mg PO DAILY 17. Acidophilus (L.acidoph & ___ acidophilus) 175 mg oral BID 18. RISperidone 1 mg PO BID 19. Juven (arginine-glutamine-calcium Hmb) unknown oral Other unkown 20. Gabapentin 100 mg PO BID 21. LACOSamide 100 mg PO BID 22. OxycoDONE (Immediate Release) 2.5 mg PO DAILY 23. OxycoDONE (Immediate Release) 2.5 mg PO BID Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN pain 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 10 mg PO QPM 4. Bisacodyl 10 mg PR QAM 5. Calcium Carbonate 500 mg PO QHS 6. Fleet Enema ___AILY:PRN no bm during day 7. FoLIC Acid 1 mg PO DAILY 8. Gabapentin 100 mg PO BID 9. Guaifenesin ___ mL PO Q4H:PRN nasal congestion 10. Ipratropium-Albuterol Neb 1 NEB NEB Q2H:PRN sob 11. LACOSamide 100 mg PO BID 12. Lorazepam 0.5 mg PO Q6H:PRN anxiety 13. Milk of Magnesia 30 mL PO DAILY:PRN constipation 14. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain 15. OxycoDONE (Immediate Release) 2.5 mg PO DAILY 16. OxycoDONE (Immediate Release) 2.5 mg PO BID 17. Prochlorperazine 10 mg PO Q8H:PRN nausea 18. Ranitidine 150 mg PO QHS 19. RISperidone 0.5 mg PO BID:PRN agitation 20. RISperidone 1 mg PO BID 21. Senna 17.2 mg PO QHS 22. Ciprofloxacin HCl 250 mg PO Q12H Duration: 4 Days D1 = ___, please finish on ___. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN nasal congestion 24. Acidophilus (L.acidoph & ___ acidophilus) 175 mg oral BID 25. Juven (arginine-glutamine-calcium Hmb) 0 unknown ORAL Frequency is Unknown unkown Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS UTI 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: Fever. Evaluate for pneumonia. TECHNIQUE: AP and lateral views of the chest. COMPARISON: Chest radiograph from ___. Chest radiograph from ___. FINDINGS: Evaluation is somewhat limited by the patient's body habitus. At the right base, there is localized pleural and parenchymal scarring with volume loss, which appears similar to prior exams. No new consolidation is identified. There is no pulmonary edema, pleural effusion, or pneumothorax. The mediastinal contours are normal. The heart size is at the upper limits of normal. IMPRESSION: No definite pneumonia, though given the baseline abnormality in the right lung base, an acute process is difficult to exclude. If indicated, short term followup chest radiographs or CT could be obtained. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Fever Diagnosed with URIN TRACT INFECTION NOS temperature: 99.5 heartrate: 94.0 resprate: 21.0 o2sat: 98.0 sbp: 115.0 dbp: 47.0 level of pain: 13 level of acuity: 3.0

Dear Ms. ___, You came to the hospital because you felt unwell and had a fever. At the hospital, it was determined you had a urinary tract infection. Our doctors started ___ on IV antibiotics, and later switched you to oral antibiotics. Please stop your antibiotics on the evening of ___. during your hospital stay, you started to feel better, and we discharged you back to your nursing home.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: TBI, L frontal IPH, IVH, ___ Major Surgical or Invasive Procedure: None. History of Present Illness: ___ is a ___ year old female who presents to ___ on ___ with a mild TBI. Mechanism of trauma: Per the patient and her husband, the patient sustained a mechanical fall at approximately noon on ___. They report that they were exiting their home, walked down the back stairs, and the patient slipped and fell on ice at the bottom portion of the stairs. She was initially well, and without any complaint - therefore they continued with their usual day's plans. Later on in the evening, the patient's daughter felt that the patient was "off" and called for an ambulance to take the patient to the ED for evaluation. She was initially examined at ___ and underwent a ___ that revealed a large left frontal IPH with edema, IVH, SDH. Past Medical History: Hypertension Migraines Social History: ___ Family History: non-contributory Physical Exam: Exam on Admission GCS at the scene: 14 GCS upon Neurosurgery Evaluation: 15 Airway: [ ]Intubated [x]Not intubated Eye Opening: [x]4 Opens eyes spontaneously Verbal: [x]5 Oriented Motor: [x]6 Obeys commands Gen: WD/WN, comfortable, NAD. HEENT: Pupils: ___ bilaterally EOMs: Intact Extrem: warm and well perfused Neuro: Mental Status: Awake, alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech is fluent with good comprehension. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Intact to light touch =================== Discharge Exam: =================== Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Orientation: [x]Person [x]Place [x]Time Follows commands: [ ]Simple [x]Complex [ ]None Pupils: Right ___ Left ___ EOM: [x]Full [ ]Restricted Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No Pronator Drift [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No Comprehension intact [x]Yes [ ]No Motor: TrapDeltoidBicepTricepGrip ___ IPQuadHamATEHLGast Right55___ Left5 5 5 5 5 5 [ ]Clonus [ ___ [x]Sensation intact to light touch [x]Propioception intact Pertinent Results: Please see OMR for pertinent lab and imaging results. Recent lab and imaging results: Labs: ___ 04:50AM BLOOD WBC-9.5 RBC-3.81* Hgb-11.0* Hct-34.2 MCV-90 MCH-28.9 MCHC-32.2 RDW-13.7 RDWSD-44.5 Plt ___ ___ 11:00PM BLOOD Neuts-90.4* Lymphs-4.3* Monos-4.4* Eos-0.0* Baso-0.2 Im ___ AbsNeut-12.84* AbsLymp-0.61* AbsMono-0.63 AbsEos-0.00* AbsBaso-0.03 ___ 04:50AM BLOOD ___ PTT-26.7 ___ ___ 04:50AM BLOOD Glucose-113* UreaN-19 Creat-0.7 Na-140 K-3.7 Cl-102 HCO3-26 AnGap-12 ___ 09:26AM BLOOD CK(CPK)-75 ___ 09:26AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 04:50AM BLOOD Calcium-8.0* Phos-2.5* Mg-2.1 ___ 06:30AM BLOOD Osmolal-291 Imaging: MR HEAD W & W/O CONTRAST Study Date of ___ 1:02 ___ IMPRESSION: 1. 5.9 cm left frontal intraparenchymal hematoma appears slightly increased in size compared to 1 day ago. No definitive underlying enhancing mass lesion is identified. Recommend repeat examination after resolution of hematoma for better evaluation of any underlying lesion. 2. Ventricular size similar. Rightward midline shift of the left frontal lobe is also similar. 3. Additional findings as described above. RECOMMENDATION(S): Consider follow-up imaging after resolution of hematoma for better evaluation of any underlying lesion. CHEST (PORTABLE AP) Study Date of ___ 4:10 ___ IMPRESSION: No previous images. There are low lung volumes that accentuate the prominence of the transverse diameter of the heart. The minimal if any vascular congestion. No evidence of pleural effusion or acute focal pneumonia. CTA HEAD W&W/O C & RECONS Study Date of ___ 5:27 AM IMPRESSION: 1. Unchanged findings of a large frontal intraparenchymal hemorrhage with surrounding edema, local mass effect, and rightward bowing of the anterior falx. 2. New, layering intraventricular hemorrhage within the bilateral occipital horns. 3. Stable appearance of a small subdural hematoma along the anterior left temporal and frontal lobes. 4. No new or additional sites of acute intracranial hemorrhage. No evidence for acute vascular territorial infarction by CT. 5. Patent intracranial vasculature without high-grade stenosis, occlusion, or aneurysm greater than 3 mm. 6. Additional findings, as above. Medications on Admission: 25mg atenolol daily Imitrex ___ PRN: migraine Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. Bisacodyl 10 mg PO DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID 4. Heparin 5000 UNIT SC BID 5. LevETIRAcetam 1000 mg PO Q12H Duration: 2 Days For a total of 7 days from your injury 6. Metoprolol Tartrate 25 mg PO BID ___ transition back to home Atenolol 25mg daily as patient's BP tolerates 7. Senna 8.6 mg PO BID:PRN constipation Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: intraparenchymal hemorrhage with surrounding edema intraventricular hemorrhage subdural hematoma 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 WANDW/O C AND RECONS INDICATION: ___ year old woman with large left IPH (? traumatic)// underlying vascular abnormality 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 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 802.7 mGy-cm. 2) Stationary Acquisition 2.5 s, 0.5 cm; CTDIvol = 27.2 mGy (Head) DLP = 13.6 mGy-cm. 3) Spiral Acquisition 2.7 s, 21.2 cm; CTDIvol = 30.0 mGy (Head) DLP = 637.3 mGy-cm. Total DLP (Head) = 1,454 mGy-cm. COMPARISON: Outside hospital CT head ___. FINDINGS: CT HEAD: Again seen is a large, left frontal intraparenchymal hematoma which appears grossly unchanged from the previous examination, allowing for mild interval evolution and differences in patient positioning. Again, there is surrounding vasogenic edema with mass effect and partial effacement of the anterior horn of the left lateral greater than right lateral ventricles. Additionally, there is rightward bowing of the anterior falx by approximately 5 mm, similar to the previous examination. Layering intraventricular hemorrhage is noted within the bilateral occipital horns. Additionally, there is a 5 mm thick focus of subdural hematoma along the anterior left temporal lobe extending superiorly overlying the frontal lobe, also similar from the previous examination. No new sites of acute intracranial hemorrhage are identified. No evidence for acute vascular territorial infarction. The remainder of the ventricles and sulci are grossly unremarkable in appearance. The basal cisterns are patent. There is no evidence for impending downward herniation at this time. The paranasal sinuses, middle ear cavities, and mastoid air cells are clear. The orbits are grossly unremarkable bilaterally. CTA HEAD: There is a left sided dominant vertebrobasilar system, with the right V4 segment terminating in the ___, a normal variant. Allowing for this, the visualized vertebral arteries are patent bilaterally. The basilar artery is patent and unremarkable. The visualized portions of the internal carotid arteries are patent bilaterally. Mild right and moderate left calcifications are seen within the cavernous segments of the ICAs. There are bilateral fetal origins of the posterior cerebral arteries, also a normal variant. No evidence for high-grade stenosis or vessel occlusion. No sites of aneurysm formation greater than 3 mm. The anterior cerebral arteries are mildly displaced towards the right secondary to the patient's large intraparenchymal hematoma. No evidence for focal stenosis or occlusion. The dural venous sinuses remain patent. IMPRESSION: 1. Unchanged findings of a large frontal intraparenchymal hemorrhage with surrounding edema, local mass effect, and rightward bowing of the anterior falx. 2. New, layering intraventricular hemorrhage within the bilateral occipital horns. 3. Stable appearance of a small subdural hematoma along the anterior left temporal and frontal lobes. 4. No new or additional sites of acute intracranial hemorrhage. No evidence for acute vascular territorial infarction by CT. 5. Patent intracranial vasculature without high-grade stenosis, occlusion, or aneurysm greater than 3 mm. 6. Additional findings, as above. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST ___ MR HEAD INDICATION: ___ year old woman with IPH, concern for tumor vs trauma// r/o tumor TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: CTA head ___ FINDINGS: 5.9 x 3.8 cm the left frontal intraparenchymal hemorrhage is again demonstrated causing effacement of frontal horns of the lateral ventricles bilaterally. The hemorrhage may have slightly increased in size from the CT examination of 1 day prior. Postcontrast examination demonstrates mild peripheral scattered curvilinear and rounded foci within the periphery of the hematoma, likely reactive in nature without evidence of definitive underlying mass. Hemorrhage product in the occipital horns of the lateral ventricles are re-identified. The superimposed periventricular and subcortical mild T2/FLAIR white matter hyperintensities are nonspecific, but compatible with chronic microangiopathy in a patient of this age. The major intracranial flow voids are preserved. No evidence for interval acute infarct. The dural venous sinuses are patent. Mild mucosal thickening of the ethmoid air cells. The remainder the paranasal sinuses are essentially clear. The orbits are unremarkable. The mastoid air cells appear clear. IMPRESSION: 1. 5.9 cm left frontal intraparenchymal hematoma appears slightly increased in size compared to 1 day ago. No definitive underlying enhancing mass lesion is identified. Recommend repeat examination after resolution of hematoma for better evaluation of any underlying lesion. 2. Ventricular size similar. Rightward midline shift of the left frontal lobe is also similar. 3. Additional findings as described above. RECOMMENDATION(S): Consider follow-up imaging after resolution of hematoma for better evaluation of any underlying lesion. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with IPH, baseline CXR// baseline CXR IMPRESSION: No previous images. There are low lung volumes that accentuate the prominence of the transverse diameter of the heart. The minimal if any vascular congestion. No evidence of pleural effusion or acute focal pneumonia. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: ICH, s/p Fall, Transfer Diagnosed with Traum subrac hem w/o loss of consciousness, init, Fall on same level due to ice and snow, initial encounter temperature: 97.9 heartrate: 80.0 resprate: 16.0 o2sat: 99.0 sbp: 141.0 dbp: 86.0 level of pain: 0 level of acuity: 2.0

Discharge Instructions Brain Hemorrhage without Surgery Activity •We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. •You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. •No driving while taking any narcotic or sedating medication. •If you experienced a seizure while admitted, you are NOT allowed to drive by law. •No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications •Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. •You have been discharged on Keppra (Levetiracetam). This medication helps to prevent seizures. Please continue this medication as indicated on your discharge instruction. It is important that you take this medication consistently and on time. •You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: •You may have difficulty paying attention, concentrating, and remembering new information. •Emotional and/or behavioral difficulties are common. •Feeling more tired, restlessness, irritability, and mood swings are also common. •Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Headaches: •Headache is one of the most common symptom after a brain bleed. •Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. •Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. •There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. When to Call Your Doctor at ___ for: •Severe pain, swelling, redness or drainage from the incision site. •Fever greater than 101.5 degrees Fahrenheit •Nausea and/or vomiting •Extreme sleepiness and not being able to stay awake •Severe headaches not relieved by pain relievers •Seizures •Any new problems with your vision or ability to speak •Weakness or changes in sensation in your face, arms, or leg Call ___ and go to the nearest Emergency Room if you experience any of the following: •Sudden numbness or weakness in the face, arm, or leg •Sudden confusion or trouble speaking or understanding •Sudden trouble walking, dizziness, or loss of balance or coordination •Sudden severe headaches with no known reason

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: morphine Attending: ___. Chief Complaint: Left ear fullness and headache s/p left posterior fossa craniotomy for trigeminal neuralgia Major Surgical or Invasive Procedure: None History of Present Illness: ___ year-old female with h/o migraines and left trigeminal neuralgia who underwent a left posterior fossa craniotomy for decompression on ___. The procedure was uncomplicated and she was discharged home on POD#3 in stable condition after a routine post-operative course. Decadron was tapered and discontinued on ___. She was seen in outpatient clinic on ___ for suture removal with complaints of left ear fullness, which has been persistent since that time. Also admits to muffled hearing and a crackling sensation. Denies pulsating pain or ringing in ears. No drainage from ear. No inner ear pain. She does admit to left-sided facial pain since yesterday, different from her pre-operative TGN pain, and headache since this morning. Also complains of dizziness and a feeling of "leaning to the left". Denies fever/chills, redness/drainage from her surgical wound. Past Medical History: Trigeminal Neuralgia, s/p left posterior fossa craniotomy for decompression Migraine headaches Social History: ___ Family History: NC. Physical Exam: ADMISSION EXAM: O: T 97.0 HR 81 BP 123/89 O2sat 99% on RA Gen: Awake, alert. Appears uncomfortable. HEENT: No significant perioribtal erythema or edema. No significant erythema or edema surrounding left ear. No tenderness with manipulation of outer ear. Canal clear without drainage or blockage. TM easily visualized, good light reflex, no significant erythema. No bulging of TM. Incision well-healed with no significant surrounding erythema or edema. Mild tenderness to palpation at the mastoid as well as along the length of the incision. No fluctuance. No wound dehiscience. Unable to express fluid upon palpation. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension. No dysarthria or paraphasic errors. Cranial Nerves: I: Not assessed II: Pupils equally round and reactive to light, to mm bilaterally. No ptosis or proptosis. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength intact and symmetric. Decreased sensation to light touch in V1, V2, V3 on left. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Grossly intact to light touch throughout. Coordination: No dysmetria as tested by finger-nose-finger DISCHARGE EXAM: Neurologically intact, with slightly decreased sensation in left V1-V3 distributions. Pertinent Results: ___ 08:10PM BLOOD WBC-8.8 RBC-3.89* Hgb-12.9 Hct-36.5 MCV-94 MCH-33.0* MCHC-35.2* RDW-14.6 Plt ___ ___ 08:10PM BLOOD Neuts-58.2 ___ Monos-5.2 Eos-2.3 Baso-0.3 ___ 08:10PM BLOOD ___ PTT-32.9 ___ ___ 08:10PM BLOOD Glucose-97 UreaN-10 Creat-0.7 Na-140 K-4.0 Cl-108 HCO3-21* AnGap-15 ___ 08:10PM BLOOD CRP-11.2* CT Head ___: Post-operative changes s/p left suboccipital craniotomy, without acute intracranial hemorrhage or edema. Fluid in the left mastoid air cells possibly reflecting inflammation. MRI HEAD W/ & W/O CONTRAST ___: 1. Posterior fossa craniectomy and cranioplasty with fluid subjacent to the craniotomy site. This may represent postoperative change although all pseudomeningocele is not excluded. 2. Left mastoid effusion. The bony margins are better delineated on prior CT dated ___ when there was no evidence of focal dehiscence at the floor of the middle cranial fossa. Medications on Admission: Zomig 5 mg nasal spray as needed Gabapentin 600 mg PO TID Topiramate (Topamax) 100 mg PO DAILY Venlafaxine 150 mg PO DAILY Omeprazole 20mg QD Discharge Medications: Zomig 5 mg nasal spray as needed Gabapentin 600 mg PO TID Topiramate (Topamax) 100 mg PO DAILY Venlafaxine 150 mg PO DAILY Omeprazole 20mg QD OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*40 Tablet ___ MEDrol (Pak) (methylPREDNISolone) 4 mg oral ASDIR RX *methylprednisolone [Medrol (Pak)] 4 mg 1 tablets(s) by mouth AS DIRECTED Disp #*1 Dose Pack Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Mastoid effusion Migraine TMJ Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD WITHOUT CONTRAST INDICATION: ___ year old woman with s/p Left microvascular decompression // Please evaluate for interval changes TECHNIQUE: Axial images of the head were obtained without contrast with sagittal and coronal reformats. DOSE: DLP:8 ___ MGy-cm CTDI: 5 6 mGy COMPARISON: MRI ___. FINDINGS: There is no acute hemorrhage mass effect midline shift or hydrocephalus. Gray-white matter differentiation is maintained. There is a coil pack in the right paraclinoid region from prior aneurysm embolization. A small high density area is seen adjacent to the left trigeminal nerve rootlet in the neural vascular decompression. Posterior fossa craniotomy and cranioplasty are visualized. The visualized paranasal sinuses are clear. No skull fracture is seen. IMPRESSION: No acute intracranial abnormalities are identified. Changes from prior no velocity compression are identified on the left side. Scratch previous embolization is noted. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST INDICATION: ___ year old woman with recent L suboccipital crani p/w L ear fullness, fluid in mastoid, ?CSF leak // Evaluate for CSF leak; please extend through posterior fossa TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of 8 mL of Gadavist intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations COMPARISON: CT head ___. FINDINGS: The examination is limited secondary to a artifact from patient motion. There is no evidence of acute intracranial hemorrhage or mass effect. The ventricles and basal cisterns appear normal. There are normal vascular flow voids. There is no evidence of acute infarct based on diffusion-weighted imaging. There is minimal T2/FLAIR signal hyperintensity within the subcortical white matter which is nonspecific though presumably on of chronic small vessel ischemic disease. There are postoperative changes of a root paraclinoid aneurysm embolization, posterior fossa craniectomy, and cranioplasty. There is T2 signal hyperintensity/ fluid subjacent to the cranioplasty site which may represent postoperative change although pseudomeningocele is not excluded. The bony margins are better delineated on prior CT dated ___ where there was no evidence of focal dehiscence of the floor of the middle cranial fossa. There is fluid within the bilateral mastoid air cells, left greater than right. The orbits, skull base, and paranasal sinuses are unremarkable. IMPRESSION: 1. Posterior fossa craniectomy and cranioplasty with fluid subjacent to the craniotomy site. This may represent postoperative change although all pseudomeningocele is not excluded. 2. Left mastoid effusion.The bony margins are better delineated on prior CT dated ___ when there was no evidence of focal dehiscence at the floor of the middle cranial fossa Gender: F Race: PORTUGUESE Arrive by WALK IN Chief complaint: Headache, L Ear pain Diagnosed with HEADACHE, TINNITUS NOS temperature: 97.0 heartrate: 81.0 resprate: 16.0 o2sat: 99.0 sbp: 123.0 dbp: 89.0 level of pain: 10 level of acuity: 2.0

Discharge Instructions: Call your neurosurgeon’s office and speak to the Nurse Practitioner if you experience: - Any neurological issues, such as change in vision, speech or movement - Any problems with medications, such as nausea vomiting or lethargy - Fever greater than 101.5 degrees Fahrenheit - Headaches not relieved with prescribed medications Activity: - Start to resume all activities as you tolerate – but start slowly and increase at your own pace. - Do not operate any motorized vehicle while you are taking narcotic medications. For migraine: -Please continue taking your home migraine medication as instructed. For temporomandibular joint dysfunction, we recommend the following: - Soft diet for two weeks - Ibuprofen up to 800mg three times daily for 1 week - Massage of jaw muscles three times daily - Follow up with dentist or oral surgeon

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Percocet / hydrochlorothiazide / Dilaudid Attending: ___ Chief Complaint: nausea and vomiting Major Surgical or Invasive Procedure: Sigmoidoscopy (___) History of Present Illness: ___ with history of HTN and vasovagal syncope as well as prior constipation and N/V following prior non-abdominal surgeries who presents with constipation, N/V, and abdominal pain following L thumb surgery on ___. Pt fell in the setting of increasing pain following surgery, but daughter was present and denies LOC. Pt reoprts history of vasovagal syncope in past. Pt reports that she has become constipated and not had BM since surgery 5 days ago. During that time has developed nausea and frequent vomiting (green color), with poor po intake. Has also developed abdominal pain. She reports these symptoms are similar to her course following knee surgeries last year (pt was in rehab at the time), although did not have abdominal pain in the past. Per daughter, pt's 'GI system completely shuts down' and may take weeks to recover. At home, she has been on scopolamine patch and zofran. Began taking vidocine after fall, and then tramadol. No known recent antibiotics or sick contacts. Pt denies fevers, SOB, cp. She was seen at ___ where she was given an enema for constipation and discharged. Daughter reports she was leaking blood per rectum following enema. In the ED, initial vital signs were: 99.4 98 149/79 14 99%. Labs were notable for WBC 13, Cr 1.2. CT abd showing diffuse bowel wall thickening throughout the colon with adjacent fat stranding, consistent with pancolitis. Patient was given ondansetron, lorazepam, and flagyl in ED, as well as 2L NS. On Transfer Vitals were:97.4 105 171/97 18 96% RA Past Medical History: Past Medical History: -Vasovagal syncope. -Hypertension (dx ___ -Carotid stenosis: <40% bilaterally (6.12 u/s). -Dilated ascending aorta: 3.6cm- TTE ___. -Aortic regurgitation: 1+ ___. -Post-op DVT after L TKR, 2.13, on warfarin from ___ Past Surgical History: -L thumb surgery at ___ ___ -bilateral knee replacement in ___ -R hand surgery Social History: ___ Family History: Mother ___ ___ HYPERTENSION Father ___ ___ STROKE Sister ___ ___ BREAST CANCER Brother ___ MELANOMA Brother ___ ___ COMPLICATIONS OF OBESITY Physical Exam: On admission: Vitals- 98.4 132/62 91 24 95%RA General- Alert, oriented x3, no acute distress HEENT- Sclera anicteric, mildly dry MM, oropharynx clear Lungs- Clear to auscultation bilaterally, no wheezes, rales, ronchi CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, non-distended, bowel sounds present, tender to palpation in lower mid abdomen, no rebound tenderness or guarding GU- no foley Ext- warm, well perfused, no clubbing, cyanosis or edema On discharge: Vitals- 98.1 119/50 78 18 96%RA General- Alert, oriented, no acute distress HEENT- Sclera anicteric, mildly dry MM, oropharynx clear Lungs- CTA bl CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, non-distended, bowel sounds present, mildly tender to palpation diffusely, no rebound tenderness or guarding GU- no foley Ext- cast on L hand; 1+ ___ edema bilaterally Pertinent Results: ================== Labs: ================== ___ 11:25AM BLOOD WBC-13.3*# RBC-4.44 Hgb-13.9 Hct-41.9 MCV-95 MCH-31.4 MCHC-33.2 RDW-13.2 Plt ___ ___ 07:45AM BLOOD WBC-7.4 RBC-3.84* Hgb-12.0 Hct-35.9* MCV-94 MCH-31.3 MCHC-33.4 RDW-12.8 Plt ___ ___ 11:25AM BLOOD Neuts-82.1* Lymphs-10.1* Monos-7.1 Eos-0.2 Baso-0.5 ___ 11:25AM BLOOD ___ PTT-23.8* ___ ___ 07:45AM BLOOD ___ PTT-24.4* ___ ___ 07:50AM BLOOD ESR-46* ___ 11:25AM BLOOD Glucose-124* UreaN-43* Creat-1.2* Na-132* K-4.8 Cl-93* HCO3-23 AnGap-21* ___ 07:45AM BLOOD Glucose-96 UreaN-13 Creat-0.8 Na-133 K-3.5 Cl-98 HCO3-25 AnGap-14 ___ 11:25AM BLOOD ALT-12 AST-20 AlkPhos-60 TotBili-0.7 ___ 11:25AM BLOOD Lipase-12 ___ 11:25AM BLOOD Albumin-3.7 ___ 07:50AM BLOOD Calcium-7.3* Phos-2.2* Mg-2.3 ___ 07:45AM BLOOD Calcium-7.9* Phos-2.2* Mg-2.2 ___ 11:25AM BLOOD CRP-281.3* ___ 12:55PM BLOOD Lactate-1.2 ___ 11:54AM BLOOD Lactate-1.0 ================== Micro: ================== ___ 7:04 am STOOL CONSISTENCY: WATERY Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). FECAL CULTURE (Final ___: NO ENTERIC GRAM NEGATIVE RODS FOUND. NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. ================== Imaging/Procedures: ================== CT ABD & PELVIS WITH CONTRAST Study Date of ___ 2:53 ___ IMPRESSION: 1. Diffuse bowel wall thickening throughout the colon with adjacent fat stranding, with sparing of the distal sigmoid colon and rectum, consistent with pancolitis, either infectious or inflammatory in etiology. 2. Small amount of ascites in the abdomen and pelvis. Sigmoidoscopy Report ___ Findings: Mucosa: Segmental discontinuous severe ulceration with exudates, friability, erythema and congestion without spontaneous bleeding were noted in the splenic flexure and transverse colon. Findings were at times asymmetric within the bowel. There was evidence of reperfusion injury with dilated blood vessel within the mucosal wall. These findings are compatible with ischemic colitis. Cold forceps biopsies were performed for histology. Normal mucosa was noted in the rectum and sigmoid colon. Protruding Lesions Internal & external hemorrhoids were noted. Excavated Lesions Several diverticula were seen in the sigmoid colon. Diverticulosis appeared to be of mild severity. Impression: Internal & external hemorrhoids Normal mucosa in the rectum and sigmoid colon Diverticulosis of the sigmoid colon Ulceration, friability, erythema and congestion in the splenic flexure and transverse colon compatible with ischemic colitis (biopsy) Otherwise normal sigmoidoscopy to transverse Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 50 mg PO DAILY 2. Amlodipine 2.5 mg PO DAILY 3. Oxybutynin 5 mg PO DAILY 4. Pravastatin 10 mg PO DAILY 5. Lisinopril 40 mg PO DAILY 6. Aspirin 325 mg PO DAILY 7. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain 8. Vitamin D 1000 UNIT PO DAILY 9. Glucosamine (glucosamine sulfate) 3000 mg oral unknown 10. Caltrate-600 + D Vit D3 (800) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -800 unit oral unknown 11. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-6-150 mg-unit-mg-mg oral unknown Discharge Medications: 1. Caltrate-600 + D Vit D3 (800) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -800 unit oral unknown 2. Glucosamine (glucosamine sulfate) 3000 mg oral unknown 3. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-6-150 mg-unit-mg-mg oral unknown 4. Oxybutynin 5 mg PO DAILY 5. Aspirin 325 mg PO DAILY 6. Lisinopril 40 mg PO DAILY 7. Metoprolol Succinate XL 50 mg PO DAILY 8. Pravastatin 10 mg PO DAILY 9. Vitamin D 1000 UNIT PO DAILY 10. Docusate Sodium 100 mg PO BID:PRN constipation RX *docusate sodium 100 mg 100 mg by mouth twice daily Disp #*60 Capsule Refills:*0 11. Polyethylene Glycol 17 g PO DAILY:PRN constipation RX *polyethylene glycol 3350 17 gram 17 g by mouth once daily Disp #*30 Packet Refills:*0 12. Ondansetron 4 mg PO Q8H:PRN nausea RX *ondansetron 4 mg 1 tablet,disintegrating(s) by mouth every 4 hours Disp #*21 Tablet Refills:*0 13. Lorazepam 0.5 mg PO Q4H:PRN severe nausea not responding to ondansetron/zofran RX *lorazepam 0.5 mg 1 tablet(s) by mouth every 4 hours Disp #*3 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Ischemic colitis ___, likely pre-renal HTN HLD Overactive bladder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Abdominal pain post wrist surgery. TECHNIQUE: MDCT imaging of the abdomen and pelvis with intravenous contrast was performed. Multiplanar reformats were prepared and reviewed. COMPARISON: Comparison is made with CT abdomen and pelvis from ___. FINDINGS: ABDOMEN: There is mild bibasilar atelectasis. There is a 9-mm hypodensity in the right lobe of the liver near the dome that is too small to characterize, but which is unchanged from prior exam and likely represents a hepatic cyst. The liver is otherwise homogeneous with no focal lesions. There is no biliary ductal dilatation. The gallbladder is normal. The spleen, pancreas, and adrenal glands are normal. The kidneys are unremarkable. The stomach, duodenum, and intra-abdominal loops of small bowel are normal in caliber and unremarkable. There is diffuse bowel wall thickening throughout the colon with adjacent fat stranding, with sparing of the distal sigmoid colon and rectum, consistent with pancolitis. The intra-abdominal aorta demonstrates atherosclerotic disease but is otherwise normal in appearance. A small amount of ascites is seen in the perihepatic region and pelvis. No free air is present. No pathologically enlarged mesenteric or retroperitoneal lymph nodes are seen. PELVIS: The rectum is normal in appearance. The distal ureters and bladder are normal. Small amount of ascites is noted in the pelvis. Prostate is unremarkable. BONE WINDOWS: No focal lytic or sclerotic osseous lesion suspicious for infection or malignancy is seen. Superior endplate scalloping of L2 is new from the prior exam. Mild grade 1 L4 on L5 anterolisthesis is unchanged. IMPRESSION: 1. Diffuse bowel wall thickening throughout the colon with adjacent fat stranding, with sparing of the distal sigmoid colon and rectum, consistent with pancolitis, either infectious or inflammatory in etiology. 2. Small amount of ascites in the abdomen and pelvis. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: N/V, Weakness Diagnosed with ABDOMINAL PAIN UNSPEC SITE, NAUSEA WITH VOMITING, UNSPECIFIED CONSTIPATION, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA temperature: 99.4 heartrate: 98.0 resprate: 14.0 o2sat: 99.0 sbp: 149.0 dbp: 79.0 level of pain: 0 level of acuity: 3.0

Dear Ms. ___, It was a pleasure to care for you. You were hospitalized due to your symptoms of nausea, vomiting, and abdominal pain. A CT scan showed inflammation of your large intestine. Based on the sigmoidoscopy (looking at your large intestine with a camera), we believe you have ischemic colitis, which is inflammation of your large intestine due to decreased blood supply, which may have been caused by a drop in blood pressure during your recent surgery. Please drink plenty of fluids to stay well hydrated, avoid NSAIDs (such as Advil/ibuprofen and Aleve/naproxen) and continue a low residue diet. If you are concerned about dehydration, you can use pedialyte for hydration. Please follow up with GI for a colonoscopy to evaluate healing of the large intestine.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ___ Attending: ___ Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Coronary angiography ___ with placement of bare metal stent to OM1 History of Present Illness: ___ year old man with h/o hyperlipidemia, bipolar disorder, and hypothyroidism who presents with chest pain. Patient reports acute onset of substernal chest pain waking him from sleep at 2 AM the morning of presentation. Pain felt like a constant pressure rated ___ in severity. It radiated down both arms Right>Left and to his jaw. Pain was associated with diaphoresis. He denied nausea or shortness of breath. At 545 am he called his nephew to bring him to the ED. Initially upon questioning, patient denied prior episodes of chest pain; however, on further reflection, he says at times he has fleeting pain associated with shortness of breath on exertion. He reportedly had chest pain before in ___ that occurred while walking and associated with some shortness of breath and diaphoresis. At that time, he underwent a nuclear stress (exercised 7 mins on modified ___, ___ METS) with no anginal symptoms, no ECG changes, and normal perfusion imaging. In the ED, initial vitals were T 98 HR 70 BP 182/84 RR 18 SaO2 100%. He was given ASA 324 mg and SL nitro. ECG showed normal sinus rhytm with ST depressions in V2-V4. Troponin was 0.10. CXR showed no acute process. He was started on a heparin drip and taken directly to the catheterization laboratory due to concern for a posterior STEMI. In the cath lab, he was also loaded with prasugrel and received a bare metal stent to OM1. He was also noted to have left main disease, felt not to be clinically significant currently. ECG after PCI showed resolution of ST depressions. On arrival to the floor, patient was chest pain free. He was requesting food. REVIEW OF SYSTEMS On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery. He denies current myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: Bipolar disorder Colon polyps Crohn's disease Diverticulitis Hypercholesterolemia Hypothyroidism Osteoarthritis Parkinsonism Status post tonsillectomy Status post anal fistulectomy Social History: ___ Family History: Father died from MI at ___. Brother with MI at ___, later CABG, died at ___. Mother with CVA in ___. Nephew with colon cancer. Sister with hypothyroid. No other family history of arrhythmia, cardiomyopathies. Physical Exam: On Admission: GENERAL: WDWN elderly Caucasian man in NAD. Oriented x3. Mood, affect appropriate. VS: T: 97.3 BP: 107/58 HR: 60 RR: 20 O2 sat: 99% on RA HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, OP clear. NECK: Supple without elevated JVP. CARDIAC: PMI located in ___ intercostal space, midclavicular line. RR, normal S1, S2. No murmurs, rubs or gallops. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: +BS. Soft, NTND EXTREMITIES: No clubbing, cyanosis or edema. Right groin without hematoma or bruit. PULSES: Right: Carotid 2+ Femoral 2+ DP 2+ ___ 2+ Left: Carotid 2+ Femoral 2+ DP 2+ ___ 2+ NEURO: A&Ox3. CN II-XII grossly intact. Strength ___ in upper and lower extemities. Resting tremor noted on Right. Prior to discharge: T 97.9 BP 131/80 HR 55 RR 18 SaO2 97% on RA EXTREMITIES: No clubbing, cyanosis or edema. Groin cath site clean, dressing intact. No hematoma or bruit. PULSES: Right: Femoral 2+ DP 2+ ___ 2+ Left: Femoral 2+ DP 2+ ___ 2+ Pertinent Results: Admission Labs: ___ 07:30AM BLOOD WBC-11.7* RBC-4.43* Hgb-14.0 Hct-40.9 MCV-92 MCH-31.5 MCHC-34.1 RDW-13.2 Plt ___ ___ 07:30AM BLOOD ___ PTT-27.0 ___ ___ 07:30AM BLOOD Glucose-119* UreaN-9 Creat-0.7 Na-142 K-4.0 Cl-106 HCO3-26 AnGap-14 ___ 07:30AM BLOOD cTropnT-0.10* Cardiac Enzymes: ___ 07:30AM BLOOD cTropnT-0.10* ___ 03:40PM BLOOD CK-MB-89* cTropnT-2.00* ___ 06:20AM BLOOD CK-MB-34* MB Indx-6.1* cTropnT-1.09* Discharge Labs: ___ 06:15AM BLOOD WBC-8.8 RBC-3.96* Hgb-12.8* Hct-36.7* MCV-93 MCH-32.2* MCHC-34.8 RDW-13.2 Plt ___ ___ 06:15AM BLOOD Glucose-84 UreaN-16 Creat-0.9 Na-142 K-4.4 Cl-104 HCO3-35* AnGap-7* ___ 06:15AM BLOOD CK-MB-7 cTropnT-0.80* ECG ___ 7:19:42 AM Sinus rhythm with ventricular premature beats. ST segment depression in the anterolateral leads. Compared to the previous tracing of ___ ventricular ectopy and ST segment depression are new and may be due to myocardial ischemia. ECG ___ 8:56:26 AM Normal sinus with one ventricular premature complex. Non-specific anterolateral T wave inversions and non-specific ST segment abnormalities in the inferior leads. Abnormal tracing. Compared to the previous tracing of ___ there is no significant change. Cardiac catheterization ___ 1. Selective coronary angiography of this right-dominant system demonstrated severe 2 vessel CAD. The LMCA had 40% stenosis in the distal vessel segment. The LAD had adjacent ostial and proximal 70-80% stenoses. The LCX had diffuse disease proximally followed by total occlusion of a large OM1. There was an additional 80% ostial lesion of a large branch coming off the proximal OM1. The dominant RCA had minimal luminal irregularities throughout. 2. Limited resting hemodynamics revealed normal systemic arterial pressures with a measured central aortic pressure of 120/62/86. 3. Successful PTCA and stenting of the upper pole of the first major obtuse marginal branch with a 2.25 x 18 mm Integrity BMS (see ___ comments). 4. Successful RFA AngioSeal (see PTCA comments). FINAL DIAGNOSIS: 1. Two vessel CAD. 2. Acute posterior MI. 3. Successful PCI of the upper pole of the major obtuse marginal branch with a 2.25 x 18 mm Integrity BMS. 4. Successful RFA AngioSeal. Echocardiogram ___: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of the inferolateral and anterolateral segments. The remaining segments contract normally (LVEF = 50 %). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Mild symmetric left ventricular hypertrophy with normal cavity size. Mildly reduced left ventricular systolic function with regional wall motion abnormalities as described above. No clinically significant valvular disease. Normal pulmonary artery systolic pressure. Medications on Admission: Divalproex ER 750 mg po qhs Levothyroxine 75 mcg po daily Lovastatin 20 mg po daily Quetiapine 25 mg po qhs Discharge Medications: 1. prasugrel 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* 4. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 5. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. valproic acid Oral 7. divalproex ___ mg Tablet Extended Release 24 hr Sig: Three (3) Tablet Extended Release 24 hr PO QHS (once a day (at bedtime)). 8. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 9. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: - ST Elevation Myocardial Infarction, posterior Secondary: - Coronary artery disease - Hyperlipidemia - Hypothyroidism - Bipolar disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Chest pain. COMPARISON: Radiograph available from ___. FRONTAL CHEST RADIOGRAPH: The heart size is top normal. The hilar and mediastinal contours are within normal limits and unchanged since ___ when taking into account differences in technique. There is no pneumothorax, focal consolidation, or pleural effusion. No bony abnormalities are seen. IMPRESSION: No acute intrathoracic process. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: CP/ARM PAIN Diagnosed with INTERMED CORONARY SYND temperature: 98.0 heartrate: 70.0 resprate: 18.0 o2sat: 100.0 sbp: 182.0 dbp: 84.0 level of pain: 9 level of acuity: 2.0

Mr. ___, it was a pleasure taking care of you here at ___. You were admitted to the hospital because you were having a heart attack (myocardial infarction). A cardiac catheterization was performed and a stent was placed to open up the corononary artery that was blocked. It is VERY important that you take Aspirin and Prasugrel every day. These medications help keep the stent open. Do NOT stop taking these medications without talking to your cardiologist first. You were also started on several other medications to help decrease your risk of having another heart attack. The following changes were made to your medications: - STOP lovastatin - START Atorvastatin 80mg daily at bedtime - START Metoprolol Succinate (Toprol XL) 25mg Daily - START Lisinopril 2.5mg Daily - START Prasugrel 10mg Daily - START Aspirin 325mg Daily You should continue all of your other meds as you were previously

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Incarcerated incisional hernia Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ M w/ PMH cholangiocarcinoma s/p R hepatectomy, extraehaptic bile duct rsxn w/ RNY HJ ___ for cholanagiocarcinoma p/w incisional hernia, pain, nausea and obstipation x 12 hrs. He reports that he saw Dr. ___ in clinic ___ and had begun to develop obstipation, nausea the day prior to clinic visit that self-resolved. Planned for elective incisional hernia repair, and was going to hear from surgical services this week re: timing of surgery. By ___ was feeling great. ___ am, however, he developed abdominal pain at his hernia, the hernia was "popping out" and he also developed nausea, burping, obstipation. He had no emesis yet. In ED, received IVF, antiemetic and pain control and is now feeling better, but hernia still bothering him and is "stuck out." No other complaints on ROS. Past Medical History: 1. Hyperlipidemia. 2. Benign prostatic hypertrophy. 3. Diverticulosis. 4. Hemorrhoids. 5. History of left shoulder surgery for traumatic dislocation. 6. Status post right inguinal hernia repair. 7. History of guaiac-positive stools with colonoscopy showing diverticulosis and EGD showing mild gastritis. 8. Cholangiocarcinoma, s/p resection and chemotherapy Social History: Has two siblings, two grown children and five grandchildren. He is not married, but has a partner, ___. He is not working presently, but for many years worked in a small ___ and had a lot of exposure to various solvents. He drinks alcohol approximately once a week. Smoked from age of ___. Physical Exam: On admission: Vitals: 96.7 56 127/63 15 100%RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, mildly distended, tender around ventral hernia, no rebound or guarding, normoactive bowel sounds, no palpable masses Ext: No ___ edema, ___ warm and well perfused Pertinent Results: ___ 02:30AM BLOOD WBC-8.6 RBC-3.65* Hgb-10.6* Hct-33.3* MCV-91 MCH-29.0 MCHC-31.8* RDW-15.3 RDWSD-51.0* Plt ___ ___ 02:30AM BLOOD Glucose-141* UreaN-20 Creat-1.0 Na-139 K-4.1 Cl-106 HCO3-22 AnGap-15 ___ 02:30AM BLOOD ALT-32 AST-45* AlkPhos-167* TotBili-0.7 ___ 02:30AM BLOOD Albumin-3.0* ___ ABDOMINAL US: IMPRESSION: 1. Small volume ascites. No evidence of varices. 2. A small amount of pneumobilia is consistent with prior hepaticojejunostomy. 3. Splenomegaly is mild. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Docusate Sodium 100 mg PO DAILY 2. Multivitamins 1 TAB PO DAILY 3. Cyanocobalamin 500 mcg PO DAILY 4. Finasteride 5 mg PO QHS 5. Lidocaine-Prilocaine 1 Appl TP PRN pain 6. Nadolol 20 mg PO DAILY 7. Pantoprazole 40 mg PO Q12H 8. promethazine 6.25 mg/5 mL oral DAILY:PRN nausea 9. Furosemide 40 mg PO BID:PRN leg swelling Discharge Medications: 1. Docusate Sodium 100 mg PO DAILY 2. Finasteride 5 mg PO QHS 3. Furosemide 40 mg PO BID:PRN leg swelling 4. Multivitamins 1 TAB PO DAILY 5. Nadolol 20 mg PO DAILY 6. Pantoprazole 40 mg PO Q12H 7. promethazine 6.25 mg/5 mL oral DAILY:PRN nausea 8. Cyanocobalamin 500 mcg PO DAILY 9. Lidocaine-Prilocaine 1 Appl TP PRN pain Discharge Disposition: Home Discharge Diagnosis: Incarcerated incisional hernia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: ABDOMEN US (COMPLETE STUDY) INDICATION: ___ s/p R hepatectomy, extraehaptic bile duct rsxn w/ RNY HJ ___ for cholanagiocarcinoma p/w incisional hernia (also h/o portal hypertensive gastropathy and GAVE) // assess ascites and varices TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: CT ___, ultrasound ___. FINDINGS: LIVER: The patient is status post right partial hepatectomy and resection of the common hepatic and common bile duct. A small amount of pneumobilia is again seen consistent with prior hepaticojejunostomy. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is small volume ascites. GALLBLADDER: The patient is status post cholecystectomy. PANCREAS: The pancreas is not well visualized, largely obscured by overlying bowel gas. SPLEEN: Normal echogenicity, measuring 13.7 cm. IMPRESSION: 1. Small volume ascites. No evidence of varices. 2. A small amount of pneumobilia is consistent with prior hepaticojejunostomy. 3. Splenomegaly is mild. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abd pain, Nausea Diagnosed with Other and unsp ventral hernia with obstruction, w/o gangrene temperature: 96.7 heartrate: 56.0 resprate: 15.0 o2sat: 100.0 sbp: 121.0 dbp: 71.0 level of pain: 7 level of acuity: 3.0

You were admitted to the surgery service at ___ for observation after you incarcerated incisional hernia was reduced in ED. You are now safe to return home to complete your recovery with the following instructions: Please return in ED if you will have severe abdominal pain, obstipation, severe nausea with emesis. Please wear abdominal binder for comfort. Please call your doctor or nurse practitioner if you experience the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you.