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Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Lisinopril / oxycodone / desmopressin Attending: ___. Chief Complaint: Chest pain/LUQ pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ with h/o GERD, a fib, HTN, HLD who presents for chest pain. In the ED, ___ reported having left chest sided chest pain last night that woke her up from sleep. Reported felt her BP was high, and reports 213/11. Reported pain felt like it was going through to her back but was a pressure, ___ that started 11 ___ but was "on and off". Reported took Tylenol for the pain. Had difficulty sleeping ___ pain. Denied numbness or weakness in the legs or abdominal pain, swelling in LEs but endorsed feeling weak and dizzy. Reported the pain is not exertional or change with movement. Reportd felt very weak. Daughter reports she seemed lethargic and was shaking and had a little bit of chills; denied fever. On arrival, pain improved. Denied fever. Endorsed + mild cough, nonproductive after a cold she had the last few days. Reported occasional nausea with cough, but no other nausea or vomiting. Reported 2 episodes of diarrhea, last night, NB. Denied dysuria. Past Medical History: HTN Hyperlipidemia Atrial fibrillation Anxiety Arthralgias h/o colonic polyps h/o cystocoele Social History: ___ Family History: Mom had stroke at age ___, brother had stroke at age ___. Physical Exam: ======================= ADMISSION PHYSICAL EXAM ======================= ADMISSION PHYSICAL EXAM: VS: 2214 97.3 PO 124 / 60 61 16 96 Ra GENERAL: NAD, appears comfortable, speech clear and interactive with interpreter HEENT: AT/NC, EOMI grossly, 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: nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema NEURO: A&Ox3, moving all 4 extremities with purpose, strength ___ in UE and ___ bilaterally, CN II-XII grossly intact SKIN: warm and well perfused, no excoriations or lesions, no rashes ======================= DISCHARGE PHYSICAL EXAM ======================= VS: 97.8, 98/58, 60, 18, 97% RA GENERAL: NAD, appears comfortable, speech clear and interactive HEENT: AT/NC, EOMI grossly, PERRL 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: nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema NEURO: A&Ox3, moving all 4 extremities with purpose, strength ___ in UE and ___ bilaterally, CN II-XII grossly intact SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: =============== ADMISSION LABS: =============== ___ 12:00PM BLOOD WBC-5.1 RBC-3.61* Hgb-11.2 Hct-31.9* MCV-88 MCH-31.0 MCHC-35.1 RDW-13.2 RDWSD-43.1 Plt ___ ___ 12:00PM BLOOD ___ PTT-36.3 ___ ___ 12:00PM BLOOD Glucose-131* UreaN-22* Creat-0.5 Na-121* K-4.2 Cl-86* HCO3-26 AnGap-12 ___ 12:00PM BLOOD Calcium-9.0 Phos-3.0 Mg-1.5* ___ 06:13PM BLOOD Osmolal-258* ___ 06:17PM BLOOD Glucose-130* Na-121* K-3.6 Cl-90* calHCO3-25 ___ 06:17PM BLOOD Hgb-11.8* calcHCT-35 ======================== PERTINENT INTERVAL LABS: ======================== ___ 12:00PM BLOOD cTropnT-<0.01 ___ 06:13PM BLOOD cTropnT-<0.01 ___ 12:00AM BLOOD CK-MB-2 cTropnT-<0.01 =============== DISCHARGE LABS: =============== ___ 07:00AM BLOOD WBC-3.8* RBC-3.52* Hgb-10.6* Hct-32.6* MCV-93 MCH-30.1 MCHC-32.5 RDW-13.9 RDWSD-47.2* Plt ___ ___ 07:00AM BLOOD Neuts-53.8 ___ Monos-19.7* Eos-2.1 Baso-0.5 Im ___ AbsNeut-2.04 AbsLymp-0.89* AbsMono-0.75 AbsEos-0.08 AbsBaso-0.02 ___ 07:00AM BLOOD Glucose-137* UreaN-16 Creat-0.6 Na-141 K-4.8 Cl-103 HCO3-26 AnGap-12 ___ 07:00AM BLOOD Calcium-9.6 Phos-3.2 Mg-1.9 ================ IMAGING STUDIES: ================ CXR (___): No acute cardiopulmonary process. EKG (___): Normal sinus rhythm at 67bpm, NA, first degree AV block with PR interval of 250, no ischemic changes ============= MICROBIOLOGY: ============= ___ 12:49 pm URINE Site: CLEAN CATCH **FINAL REPORT ___ URINE CULTURE (Final ___: KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Radiology Report INDICATION: History: ___ with chest pain// acute process? TECHNIQUE: AP and lateral chest radiograph. COMPARISON: Chest x-ray ___. FINDINGS: EKG leads overlie the chest. The cardiomediastinal silhouette is likely accentuated due to AP technique. The hila are unremarkable. The lungs are clear without focal consolidation. There is no pulmonary vascular congestion or pulmonary edema. There is no pneumothorax or pleural effusion. Severe bilateral glenohumeral and moderate to severe AC degenerative changes are incidentally noted, likely with intra-articular bodies seen on the left. IMPRESSION: No acute cardiopulmonary process. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Chest pain, LUQ abd pain Diagnosed with Hyperosmolality and hypernatremia temperature: 97.7 heartrate: 68.0 resprate: 18.0 o2sat: 100.0 sbp: 143.0 dbp: 75.0 level of pain: 7 level of acuity: 2.0

Dear Ms. ___, It was a pleasure taking care of you at the ___ ___! Why was I admitted to the hospital? -You were admitted because you had high blood pressure and chest pain. What happened while I was in the hospital? - Because you had chest pain, we did blood tests and an EKG to look at your heart. Both of these tests looked normal which is reassuring. You should follow up with your outpatient cardiologist, Dr. ___ 3 weeks after leaving the hospital. *** Please call ___ to schedule an appointment. *** - You were also found to have high blood pressure, so we started you on your home blood pressure medication (carvedilol). We also started another medication called Losartan. Your blood pressure is now back to normal. - You were also found to have low sodium in your blood. We gave you fluid through your veins to correct this, and your sodium level returned to normal. We also stopped your home medication (Hyzaar) because this can cause low sodium in your blood. Please stop taking this medication at home. What should I do after leaving the hospital? - Please take your medications as listed in discharge summary and follow up at the listed appointments. Thank you for allowing us to be involved in your care, we wish you all the best! Sincerely, Your ___ Healthcare Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Tetracycline Attending: ___. Chief Complaint: Left leg pain Major Surgical or Invasive Procedure: L tibia IMN History of Present Illness: ___ presents s/p fall with left tib/fib fracture. Patient reports on the day of presentation she was walking over a slippery area near the beach and slipped and fell. She noted immediate onset of pain in her left lower extremity. She was taken to an outside hospital where she underwent plain films which demonstrated a middle third tib-fib fracture of the left lower extremity. She additionally obtain some abrasions of the bilateral lower extremities. She has no focal numbness or weakness distal to her injury. She is otherwise well. Past Medical History: PMH/PSH: Depression and osteoarthritis Social History: ___ Family History: Non contributory Physical Exam: AFVSS Gen: A&Ox3, no actue distress Ext: LLE ___, SILT ___, WWP Pertinent Results: ___ AP of tib/fib in O.R.:Total fluoroscopy time of 115.2 seconds was recorded. The 10 spot images obtained during fluoroscopy were brought to our review. Note is made that the radiologist was not attending the procedure. The findings demonstrated the process of open reduction internal fixation of the tibia. Note is made of the presence of comminuted fracture of the fibula as well. ___ 07:35AM BLOOD Glucose-139* UreaN-11 Creat-0.8 Na-138 K-3.7 Cl-98 HCO3-33* AnGap-11 ___ 07:35AM BLOOD WBC-9.5# RBC-3.41* Hgb-10.2* Hct-29.6*# MCV-87# MCH-29.9 MCHC-34.4# RDW-12.6 Plt ___ ___ 08:25AM BLOOD WBC-6.7 RBC-3.29* Hgb-10.1* Hct-28.9* MCV-88 MCH-30.7 MCHC-34.9 RDW-13.2 Plt ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. CloniDINE 0.1 mg PO DAILY 2. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q6H:PRN pain 3. desvenlafaxine succinate 100 mg Oral QD Discharge Medications: 1. CloniDINE 0.1 mg PO DAILY 2. Acetaminophen 650 mg PO Q6H 3. Calcium Carbonate 500 mg PO TID 4. Docusate Sodium 100 mg PO BID 5. Enoxaparin Sodium 40 mg SC DAILY Duration: 10 Days Start: ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 40 mg sub-q Daily for 10 days following d/c to rehab Disp #*10 Syringe Refills:*0 6. Milk of Magnesia 30 ml PO BID:PRN Constipation 7. Multivitamins 1 CAP PO DAILY 8. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN Pain RX *oxycodone 5 mg ___ tablet(s) by mouth Every 4 hours as needed for pain control Disp #*70 Tablet Refills:*0 9. Senna 2 TAB PO HS 10. Vitamin D 400 UNIT PO DAILY 11. desvenlafaxine succinate 100 mg Oral QD Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left tib/fib 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 REASON FOR EXAMINATION: Open reduction internal fixation of the tibial fracture. Total fluoroscopy time of 115.2 seconds was recorded. The 10 spot images obtained during fluoroscopy were brought to our review. Note is made that the radiologist was not attending the procedure. The findings demonstrated the process of open reduction internal fixation of the tibia. Note is made of the presence of comminuted fracture of the fibula as well. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: L LEG INJURY Diagnosed with FX TIBIA W FIBULA NOS-CL, FALL FROM OTHER SLIPPING,TRIPPING,STUMBLING, TETANUS-DIPHT. TD DT temperature: 98.9 heartrate: 90.0 resprate: 16.0 o2sat: 98.0 sbp: 166.0 dbp: 88.0 level of pain: 7 level of acuity: 2.0

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: - 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 ACTIVITY AND WEIGHT BEARING: - Weight bearing as tolerated left lower extremity Physical Therapy: Weight bearing as tolerated in left lower extremity Treatments Frequency: Dressing changes as needed for comfort only. Dressings are not needed as long as wound continues to be non draining. Staples will be removed at follow up appointment.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: Penicillins Attending: ___. Chief Complaint: Headache Major Surgical or Invasive Procedure: ___ Left craniotomy for ___ Dr. ___ ___ of Present Illness: Patient is a ___ year old female who had a mechanical fall 203 weeks ago striking the left side of her head. She did not lose consciousness at that time. She had been doing well until recently when she developed left frontal headaches and tremulousness of her extremities left greater than right. She went to the ER at ___ today at the urging of her family and friends as they felt she had been not acting herself. While there a Head CT was performed which showed a left SDH 1.5cm in greatest diameter with 1.4cm of midline shift. She was subsequently sent to ___ for further management and care. She had been taking asa and naproxen for her headaches. Upon arrival she complained of left frontal headaches, mild lethargy. She denies dizziness, nausea, changes in bowel or bladder habits,difficulty ambulating, or changes in vision, hearing, or speech Past Medical History: HLD, DM2 Social History: ___ ___ History: ___ Physical Exam: On Admission: Gen: slightly lethargic, WD/WN, comfortable, NAD. HEENT: Pupils: PERRL EOMs intact without nystagmus 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. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4mm to 3mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Some delayed response to commands at times Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Intact to light touch and proprioception bilaterally Toes downgoing bilaterally Coordination: tremulous on FNF L>R but hits target Upon Discharge: Awake, alert, aphasic but improving, says her name, "hospital", month and year. MAE, follows commands. Incision C/D/I. Pertinent Results: ___ 07:37PM ___ PTT-29.9 ___ ___ 07:37PM PLT COUNT-267 ___ 07:37PM NEUTS-66.6 ___ MONOS-5.4 EOS-1.9 BASOS-0.5 ___ 07:37PM WBC-7.0 RBC-4.02* HGB-11.4* HCT-34.4* MCV-86 MCH-28.3 MCHC-33.1 RDW-13.3 ___ 07:37PM estGFR-Using this ___ 07:37PM GLUCOSE-198* UREA N-17 CREAT-0.6 SODIUM-138 POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-27 ANION GAP-15 ___ CT head 1. No evidence for fracture or dislocation. Slight subluxations can probably be explained by substantial facet joint degenerative changes. 2. Rightward shift of the mid brain associated with uncal herniation and mass effect from a large left-sided subdural hematoma, difficult to precisely compare for change compared to the prior CT. ___ CT head Post-surgical changes involving the left frontal, temporal, and parietal regions with small amount of hemorrhage, pneumocephalus, catheter in place, and effacement of the adjacent sulci. There is a decreased rightward shift of normally midline structures to 8 mm compared to 10 mm previously. Continued followup is recommended ___ CT head Postsurgical changes along the left convexity with small amounts of blood products and pneumocephalus, similar in extent to prior study; followup imaging as clinically indicated MR HEAD W & W/O CONTRAST ___ Status post left frontoparietal craniotomy, in comparison with the prior head CT, there is a persistent subdural collection, causing mild effacement of the sulci and midline shifting towards the right as described above, followup with head CT is recommended. Small locules of intracranial gas are redemonstrated. No diffusion abnormalities are detected to suggest acute or subacute ischemic changes. There is mild dural enhancement, likely consistent with the surgical approach CT head ___: Improvement of midline shift and L SDH, L hemispheric vasogenic edema. No acute infarct. Medications on Admission: glipizide, metformin, lovastatin, asa 81 Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever 2. Docusate Sodium 100 mg PO BID 3. Famotidine 20 mg PO BID 4. Phenytoin Sodium Extended 100 mg PO TID 5. Senna 1 TAB PO HS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Subdural hemorrhage Cerebral edema Altered mental status Dysphagia Aphasia Metabolic Acidosis 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 CT OF THE CERVICAL SPINE HISTORY: Trauma with subdural hematoma. COMPARISONS: Prior head CT from earlier on the same day from outside hospital as scanned into the ___ pacs system. TECHNIQUE: Multidetector CT images of the cervical spine were obtained without intravenous contrast. Sagittal and coronal reformations were also performed. FINDINGS: From C3-C4 through C7-T1, there are moderate facet joint degenerative changes. These are milder on the right side, noting mild leftward convex curvature centered along the lower cervical spine, although moderate facet joint degenerative changes are noted from C5-C6 through C7-T1 on the right side as well. This appearance may explain why there is mild spondylolisthesis of C5 on C6 and C7 on T1. There is moderate narrowing of the C6-C7 interspaces with subchondral sclerosis and small marginal osteophytes. There are also small anterior osteophytes at the C5-C6 level anteriorly. The C1-C2 articulation is moderately narrowed as well. Although facet hypertrophy is prominent along the lower levels as described above, there is no evidence for substantial bony neural foraminal narrowing. There is no evidence for fracture, dislocation, or prevertebral soft tissue swelling. There is a large partly visualized left-sided subdural hematoma, which is difficult to compare directly to the prior imaging for any potential small changes owing to differences in technique including orientation, uncal herniation with substantial rightward shift of the brainstem by 6 mm can be visualized. The partly visualized right lateral ventricle is also dilated up to 20 mm suggesting a trapped ventricle owing to midline shift. Interlobular septal thickening at the lung apices and ground glass suggests mild fluid overload. IMPRESSION: 1. No evidence for fracture or dislocation. Slight subluxations can probably be explained by substantial facet joint degenerative changes. 2. Rightward shift of the mid brain associated with uncal herniation and mass effect from a large left-sided subdural hematoma, difficult to precisely compare for change compared to the prior CT. This was discussed at 9:10 p.m. with Dr. ___ immediately after discovery time by telephone. Radiology Report INDICATION: Evaluation of patient status post left subdural hematoma evacuation. COMPARISON: Outside hospital head CT from ___. FINDINGS: Post-surgical changes are noted along the left frontotemporoparietal region with pneumocephalus, small amount of hyperdense material suggestive of blood, and hyperdense fluid, and catheter which terminates at the level of the inferior left temporal lobe. There is continued mass effect on the adjacent left frontotemporal parietal region with effacement of the sulci. Additionally, there is a rightward shift of normally midline structures by 8 mm, decreased in comparison to prior study from yesterday when it measured 10 mm. The right lateral ventricle appears dilated. No other new foci of hemorrhage are identified. The patient is status post left frontal and parietal craniotomy. The visualized mastoid air cells and paranasal sinuses are clear. IMPRESSION: Post-surgical changes involving the left frontal, temporal, and parietal regions with small amount of hemorrhage, pneumocephalus, catheter in place, and effacement of the adjacent sulci. There is a decreased rightward shift of normally midline structures to 8 mm compared to 10 mm previously. Continued followup is recommended. Radiology Report HISTORY: ___ female with a history of subdural hemorrhage, status post craniotomy, now in need of followup. STUDY: CT of the head without contrast. COMPARISON: ___ at 3:56 a.m. and outside hospital head CT from ___. FINDINGS: Again are seen post-craniotomy changes. On the left, the skin staple line and a drain in place in the subdural space. Collection demonstrated on outside hospital CT. There is still persist locules of gas and scattered areas of blood products which appear similar in extent to the prior exam. There is 6 mm of left-to-right shift of midline structures which is slightly decreased from prior exam. There continues to be sulcal and left lateral ventricle effacement on the left. There is no evidence of ventricular entrapment. The basilar cisterns are patent. The visualized paranasal sinuses and mastoid air cells are clear. IMPRESSION: Postsurgical changes along the left convexity with small amounts of blood products and pneumocephalus, similar in extent to prior study; followup imaging as clinically indicated. Radiology Report INDICATION: ___ female status post craniotomy for evacuation of subdural hemorrhage. Evaluate for interval change. COMPARISON: NECTs on ___ and ___. TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without administration of IV contrast. FINDINGS: Again are seen post-craniotomy changes in the left frontoparietal bones, with skin staples and a drain placed in the subdural space of the left frontoparietal convexity. There is persistence of locules of gas and scattered areas of blood products which appear similar in extent to the prior exam. There is a 6.3 mm left to right shift in the midline structures which is not significantly changed compared with prior exam. There continues to be sulcal and left lateral ventricle effacement in the left. There is no evidence of ventricular entrapment. The basal cisterns are patent. The visualized paranasal sinuses and mastoid air cells are clear. IMPRESSION: Post-surgical changes along the left convexity with small amount of blood products and pneumocephalus, similar to prior study. Radiology Report STUDY: MRI of the head with and without contrast. CLINICAL INDICATION: ___ woman with dysphagia, status post craniotomy. COMPARISON: Prior head CT dated ___. TECHNIQUE: Pre-contrast axial and sagittal T1-weighted images were obtained, axial FLAIR, axial T2, axial magnetic susceptibility and axial diffusion-weighted sequences. The T1-weighted images were repeated after the administration of gadolinium contrast in axial T1, sagittal MP-RAGE and multiplanar reconstructions were provided. FINDINGS: The patient is status post left frontoparietal craniotomy and evacuation of subdural hematoma. There is a drain in place in the subdural space. Subdural collection remains similar in extension in comparison with the prior head CT dated ___. Small locules of gas are present. There is persistent effacement of the sulci and minimal shifting of the normally midline structures towards the right with approximately 7.5 mm of rightward deviation. The perimesencephalic cisterns are patent and there is no evidence of uncal herniation. The maximum thickening of the subdural collection is approximately 6.9 mm. No diffusion abnormalities are detected to suggest acute or subacute ischemic changes. The major vascular flow voids are present with normal distribution. The orbits are unremarkable. The paranasal sinuses again demonstrate bilateral mucus retention cysts. The mastoid air cells are clear. IMPRESSION: Status post left frontoparietal craniotomy, in comparison with the prior head CT, there is a persistent subdural collection, causing mild effacement of the sulci and midline shifting towards the right as described above, followup with head CT is recommended. Small locules of intracranial gas are redemonstrated. No diffusion abnormalities are detected to suggest acute or subacute ischemic changes. There is mild dural enhancement, likely consistent with the surgical approach. Radiology Report INDICATION: ___ woman status post NG tube placement, assess for tube placement. COMPARISONS: None. Portable AP upright radiograph of the chest was obtained. Nasogastric tube courses into the stomach, terminating at the level of pylorus. The lungs are well expanded and clear. There is no pleural effusion or pneumothorax. The heart is normal in size. Normal cardiomediastinal contours. Radiology Report INDICATION: ___ woman with left subdural, assess NG tube placement. COMPARISONS: ___. FINDINGS: Nasogastric tube courses into the stomach, terminating in the region of pylorus. The lungs are otherwise clear. No pleural effusion or pneumothorax. The heart is normal in size with normal cardiomediastinal contours. Radiology Report HISTORY: ___ female with subdural hematoma and NG tube placement. COMPARISON: ___ and ___. FINDINGS: The lungs are well expanded and clear. There is no pleural effusion or pneumothorax. Cardiac silhouette and mediastinal contours are normal. An NG tube is in place, the tip projects over the expected location of the first portion of the duodenum. IMPRESSION: No acute chest abnormality. Radiology Report INDICATION: Left subdural hematoma. Evaluate for change. COMPARISONS: CT head ___. CT head ___. TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without the administration of IV contrast. FINDINGS: There is a hyperdense subdural collection layering over the left cerebral convexity. The transcalvarial drain has been removed from the collection, but the collection is unchanged in size and appearance from the prior exam. Specifically, the distribution of the blood products is unchanged. The associated mass effect is stable with effacement of the adjacent sulci and 6 mm of rightward shift of the normal midline structures. There is mild compression of the right lateral ventricle and effacement of the left lateral ventricle, but no evidence of entrapment. There has been a slight decrease in the amount of pneumocephalus. There is no evidence of new hemorrhage. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. An NG tube is present. IMPRESSION: Unchanged appearance of left subdural hematoma and its associated mass effect, s/p drain removal. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: SDH Diagnosed with SUBDURAL HEM W/O COMA, FALL ON STAIR/STEP NEC, DIABETES UNCOMPL ADULT, HYPERCHOLESTEROLEMIA temperature: 97.8 heartrate: 76.0 resprate: 16.0 o2sat: 99.0 sbp: 155.0 dbp: 91.0 level of pain: 5 level of acuity: 2.0

Craniotomy for Hemorrhage •Have a friend/family member check your incision daily for signs of infection. •Take your pain medicine as prescribed. •Exercise should be limited to walking; no lifting, straining, or excessive bending. •You may shower. •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, and Ibuprofen etc. •If you were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin, prior to your injury, you may safely resume taking this only after clearance from your neurosurgeon. • You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP’s office, but please have the results faxed to ___. •Clearance to drive and return to work will be addressed at your post-operative office visit. •Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING •New onset of tremors or seizures. •Any confusion 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. •Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. •Fever greater than or equal to 101.5° F.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: hyperkalemia Major Surgical or Invasive Procedure: none History of Present Illness: ___ with hx of bladder cancer since ___, prostate cancer, TCC,left nephroureterectomy with PERC nephrostomy, right renal pelvic tumor presents from clinic for hyperkalemia and frequent PVCs on EGK. Preop appointment for ureteroscopy and ablation next week. He denies chest pain, shortness of breath, decreased or change in output from PERC nephrostomy tube, abdominal pain, nausea, vomiting, diarrhea, fevers or chills. Does endorse some constipation, sacral pain, PERC nephrostomy discomfort. Last bowel movement was today and was not black or bloody. He endorses occasional red tinge to his PERC neph drain output, but no clots, thick or other abnormal drainage. In the ED, initial VS were: 99.0 76 124/62 18 98% RA Exam notable for: Red tinged clear output from PERC nephrostomy tube. No erythema around the tube site. Mild tenderness to palpation over the tube site, no CVA tenderness, NTND abd. RRR. CTAB. AAOx3. No c/c/e Labs showed: K 5.6, 12.5>11.___/36.5<448 Positive UA Imaging showed: CT chest: IMPRESSION: 1. Foci of sclerosis involving the left lateral sixth rib and T7 vertebral body are new from ___, concerning for osseous metastatic disease. 2. Unchanged bilateral pulmonary nodules measuring up to 4 mm. 3. Moderate to severe centrilobular emphysema. CT abdomen: 1. 3.7 x 4.1 cm soft tissue mass likely arising from the prostate, and obliterating the right seminal vesicles, with possible early invasion into the adjacent rectum, concerning for progression of prostate carcinoma in the setting of markedly elevated PSA. 2. New osseous metastases within L2, L4, L5, left ilium, sacrum, and right aspect of the pubic symphysis. 3. New bilateral external iliac and right obturator lymphadenopathy. 4. New prominent para-aortic and paracaval nodes do not meet strict criteria for adenopathy, but are also concerning for metastatic involvement. 5. Mild right hydronephrosis. Percutaneous nephrostomy tube and nephroureteral stent in situ. Right peripelvic stranding may reflect underlying pyelitis. 6. Post left nephroureterectomy. No recurrent mass at the nephrectomy bed. 7. Please refer to the separate chest CT dictation regarding intrathoracic findings. Patient received: ___ 21:09 IV CefTRIAXone ___ 22:32 IV CefTRIAXone 1 g ___ 23:15 PO Acetaminophen 1000 mg Urology was consulted and will continue to follow. No urgent interventions done given good UOP and no significant change in baseline GFR. Transfer VS were: 97.6 71 132/60 20 96% RA REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as per HPI Past Medical History: 1. Bladder cancer since ___, several TURBTs. 2. ___, TURBT low-grade TCC, T1 (microscopic), PNLMP in urethra. 4. ___, CT chest, multiple bilateral pulmonary nodules sub-5-mm, nonspecific T8 vertebral body abnormality. 5. ___, CT abdomen, multifocal urothelial CA with thickened bladder and left renal pelvis with hydronephrosis. 6. ___,, left percutaneous nephroscopy, renal pelvic biopsy of low-grade TCC. Ureteroscopy negative, bladder biopsy C/W low-grade TCC. 7. ___: Robotic left nephroureterectomy: pTa, low grade TCC. 8. ___: Cystoscopy/ureteroscopy, right renal pelvic tumor ablation, right JJ stent placement. 9. ___, admitted OSH, ___ - Cr 4.3, UTI, hydronephrosis/ureter - right perc NT placed, ___. Social History: ___ Family History: Diabetes; no GU malignancy Physical Exam: ================================ ADMISSION PHYSICAL EXAM: ================================ VS: 97.5PO 118 / 69R Sitting 65 18 97 RA GENERAL: sleepy, NAD, very pleasant HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD HEART:distant heart sounds LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly. right nephrostomy tube in place, dressing CDI, right sided positive CVAT 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: ==================================== VS: 97.4, 132 / 77, 71, 18, 95 Ra GENERAL: WD male in bed in NAD, very pleasant HEENT: AT/NC, EOMI, anicteric sclera NECK: supple HEART: distant heart sounds, RRR, no m/r/g LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly. right nephrostomy tube in place, dressing CDI, no erythema or tenderness at the site. no CVAT EXTREMITIES: no cyanosis, clubbing, or edema NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ======================== ADMISSION LABS: ======================== ___ 12:40PM BLOOD WBC-12.5* RBC-4.30*# Hgb-11.9*# Hct-36.5*# MCV-85 MCH-27.7 MCHC-32.6 RDW-14.3 RDWSD-43.8 Plt ___ ___ 06:00PM BLOOD Neuts-75.5* Lymphs-11.7* Monos-7.3 Eos-4.2 Baso-0.8 Im ___ AbsNeut-7.91* AbsLymp-1.22 AbsMono-0.76 AbsEos-0.44 AbsBaso-0.08 HEMOLYZED: ___ 12:40PM BLOOD UreaN-42* Creat-2.6* Na-138 K-6.3* Cl-98 HCO3-21* AnGap-19* ___ 12:40PM BLOOD PSA-388* ======================== RELEVANT LABS: ======================== ___ 06:00PM BLOOD K-4.4 ___ 03:05AM BLOOD K-4.9 ======================== DISCHARGE LABS: ======================== ___ 02:39AM BLOOD WBC-10.9* RBC-4.03* Hgb-11.2* Hct-34.4* MCV-85 MCH-27.8 MCHC-32.6 RDW-14.2 RDWSD-43.7 Plt ___ ___ 02:39AM BLOOD Neuts-75.4* Lymphs-11.8* Monos-7.0 Eos-4.8 Baso-0.6 Im ___ AbsNeut-8.21* AbsLymp-1.29 AbsMono-0.76 AbsEos-0.52 AbsBaso-0.07 ___ 02:39AM BLOOD ___ PTT-28.5 ___ ___ 02:39AM BLOOD Glucose-92 UreaN-41* Creat-2.4* Na-139 K-5.2* Cl-103 HCO3-21* AnGap-15 ___ 02:39AM BLOOD ALT-8 AST-12 LD(LDH)-166 AlkPhos-113 TotBili-0.3 ___ 02:39AM BLOOD Albumin-3.6 Calcium-8.8 Phos-3.7 Mg-2.3 ========================= IMAGING ========================= CT CHEST W/O CONTRAST ___ 1. Foci of sclerosis involving the left lateral sixth rib and T7 vertebral body are new from ___, concerning for osseous metastatic disease. 2. Unchanged bilateral pulmonary nodules measuring up to 4 mm. 3. Moderate to severe centrilobular emphysema. 4. Please refer to separate report for same day CT abdomen pelvis study for discussion of findings below the diaphragm. CT ABD & PELVIS W/O CONTRAST ___ 1. 3.7 x 4.1 cm soft tissue mass likely arising from the prostate, and obliterating the right seminal vesicles, with possible early invasion into the adjacent rectum, concerning for progression of prostate carcinoma in the setting of markedly elevated PSA. 2. New osseous metastases within L2, L4, L5, left ilium, sacrum, and right aspect of the pubic symphysis. 3. New bilateral external iliac and right obturator lymphadenopathy. 4. New prominent para-aortic and paracaval nodes do not meet strict criteria for adenopathy, but are also concerning for metastatic involvement. 5. Mild right hydronephrosis. Percutaneous nephrostomy tube and nephroureteral stent in situ. Right peripelvic stranding may reflect underlying pyelitis. 6. Post left nephroureterectomy. No recurrent mass at the nephrectomy bed. 7. Please refer to the separate chest CT dictation regarding intrathoracic findings. Radiology Report INDICATION: ___ year old man with h/o prostate ca, bladder ca, s/p nephroureterectomy, elevated PSA// please evaluate for mets, any abnormalities TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 10.1 s, 65.9 cm; CTDIvol = 7.4 mGy (Body) DLP = 485.1 mGy-cm. Total DLP (Body) = 485 mGy-cm. COMPARISON: CT from ___. Reference CT from ___. Abdominopelvic CT from ___. FINDINGS: Please refer to the separate chest CT dictation regarding intrathoracic findings. The liver density is within normal limits. There is a lobulated 1.4 x 1.2 cm likely cyst within segment II (series 2, image 47). 6 mm, 8 mm, 10 mm, and 4 mm hypodensities within segments II (series 2, image 49), ___ (series 2, image 50), VI (series 2, image 51), and VI (series 2, image 66), respectively, are less specific, but appear unchanged in comparison to the ___ study, and are likely benign cysts. No new hepatic lesion is detected. There is no definite intra extrahepatic bile duct dilation. The gallbladder is normal. No radiopaque ductal stones are detected. The pancreas demonstrates normal density and bulk, without duct dilation or focal lesion. The spleen size is within normal limits. The adrenal glands appear normal. Patient is post left nephroureterectomy. There is mild right hydronephrosis. A percutaneous nephrostomy tube and nephroureteral stent are present. There is mild stranding along the right renal pelvis (series 2, image 67). No stone is identified. There are enlarged bilateral external iliac lymph nodes, measuring up to 1.5 x 1.2 cm on the left (series 2, image 95) and a 2.1 x 1.7 cm on the right (series 2, image 97, 88). These are enlarged in comparison to the ___ study. There is a newly enlarged 10 mm obturator node on the right (series 2, image 101). Prominent para-aortic and paracaval nodes are new since ___, not meeting strict criteria for adenopathy, but concerning for disease involvement (series 2, image 77, 70). The stomach and intra-abdominal and intrapelvic loops of small and large bowel are normal in caliber. There is no focal gastrointestinal lesion. The appendix is normal (series 2, image 92). The bladder is collapsed, and difficult to assess. Arising from the right pelvis, between the bladder and the rectum, is a 3.7 x 4.1 cm soft tissue mass, new since the ___ examination, replacing or encasing the right seminal vesicles (series 2, image 104). This lesion appears contiguous with the prostate (series 2, image 1017). There is loss of the fat plane against the adjacent rectum (series 2, image 104, 105), and early invasion cannot be excluded. A 8 mm right mesorectal node is concerning for tumor involvement (series 2, image 106). The abdominal aorta, celiac trunk, SMA, and iliac branches appear normal in caliber. There is minimal atherosclerotic calcification. There are multiple sclerotic lesions within the pelvic bones, sacrum, and lumbar spine are suspicious for metastases, all new since ___: Anterior L2 vertebral body, 9 mm, series 2, image 61 Anterior L4 vertebral body, 1 mm, series 2, image 74 Left anterior L5 vertebral body, 4 mm, series 2, image 80 6 mm left iliac, series 2, image 81 9 mm and 8 mm right hemi sacrum, series 2, image 86, 88 8 mm, left hemi sacrum, series 2, image 88 16 mm, right aspect of the pubic symphysis series 2, image 109, series 6, image 27 A moderate left inguinal hernia contains a short segment of the sigmoid colon (series 2, image 106), without obstruction. There are multiple small supraumbilical ventral hernias containing fat (series 7, image 34), the largest protruding through a fascial defect measuring 2.5 cm (series 2, image 60). IMPRESSION: 1. 3.7 x 4.1 cm soft tissue mass likely arising from the prostate, and obliterating the right seminal vesicles, with possible early invasion into the adjacent rectum, concerning for progression of prostate carcinoma in the setting of markedly elevated PSA. 2. New osseous metastases within L2, L4, L5, left ilium, sacrum, and right aspect of the pubic symphysis. 3. New bilateral external iliac and right obturator lymphadenopathy. 4. New prominent para-aortic and paracaval nodes do not meet strict criteria for adenopathy, but are also concerning for metastatic involvement. 5. Mild right hydronephrosis. Percutaneous nephrostomy tube and nephroureteral stent in situ. Right peripelvic stranding may reflect underlying pyelitis. 6. Post left nephroureterectomy. No recurrent mass at the nephrectomy bed. 7. Please refer to the separate chest CT dictation regarding intrathoracic findings. NOTIFICATION: The impression and recommendation above was entered by Dr. ___ ___ on ___ at 17:53 into the Department of Radiology critical communications system for direct communication to the referring provider. Radiology Report EXAMINATION: CT CHEST W/O CONTRAST INDICATION: ___ man with history of prostate cancer, bladder cancer, status post nephroureterectomy with elevated PSA. Evaluate for metastatic disease. TECHNIQUE: Multi-detector helical scanning of the chest was performed without intravenous iodinated contrast agent and reconstructed as 5 and 1.25 mm thick axial, 2.5 mm thick coronal and sagittal, and 8 mm MIP axial images. DOSE: Acquisition sequence: 1) Spiral Acquisition 10.1 s, 65.9 cm; CTDIvol = 7.4 mGy (Body) DLP = 485.1 mGy-cm. Total DLP (Body) = 485 mGy-cm. ** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND PELVIS W/O CONTRAST) COMPARISON: Same day CT abdomen pelvis. Chest CT from ___ FINDINGS: NECK, THORACIC INLET, AXILLAE, CHEST WALL: The imaged thyroid is unremarkable. There is no supraclavicular or axillary lymphadenopathy. The esophagus is unremarkable. UPPER ABDOMEN: There is a small hiatal hernia. Please refer to separate report for same day CT abdomen pelvis study for discussion of findings below the diaphragm. MEDIASTINUM: There is no mediastinal mass or lymphadenopathy. HILA: There is no hilar mass or lymphadenopathy. HEART and PERICARDIUM: Heart size is normal. Coronary artery and aortic annular calcifications are mild. The thoracic aorta is normal in caliber. There is no pericardial effusion. PLEURA: No pleural effusion or pneumothorax. LUNG: 1. PARENCHYMA: The left lung apex is incompletely imaged. Small bilateral pulmonary nodules measuring up to 4 mm in the right middle lobe (3:179) are unchanged, and are as follows (3: 106, 156, 84, 142). Biapical scarring is noted. Moderate to severe centrilobular emphysematous changes are again seen, worse in the upper lobes. Small bilateral calcified granulomas are again noted. 2. AIRWAYS: The airways are patent to the level of the segmental bronchi bilaterally. There is mild-to-moderate diffuse bronchial wall thickening. 3. VESSELS: Main pulmonary artery diameter is within normal limits. CHEST CAGE: Sclerosis of the left lateral sixth rib (3:106) and a sclerotic focus in the T7 vertebral body (7:34) are new from ___. There is no acute fracture. A hemangioma is again seen in the T8 vertebral body. IMPRESSION: 1. Foci of sclerosis involving the left lateral sixth rib and T7 vertebral body are new from ___, concerning for osseous metastatic disease. 2. Unchanged bilateral pulmonary nodules measuring up to 4 mm. 3. Moderate to severe centrilobular emphysema. 4. Please refer to separate report for same day CT abdomen pelvis study for discussion of findings below the diaphragm. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abnormal labs Diagnosed with Acute kidney failure, unspecified, Urinary tract infection, site not specified temperature: 99.0 heartrate: 76.0 resprate: 18.0 o2sat: 98.0 sbp: 124.0 dbp: 62.0 level of pain: 0 level of acuity: 3.0

Dear Mr. ___, It was a pleasure to care for you at the ___ ___. Please find detailed discharge instructions below: WHY WERE YOU ADMITTED TO THE HOSPITAL? - You were admitted because you appeared to have elevated potassium levels in your blood, and you had some premature heart beats, noted at your outpatient urology appointment. WHAT HAPPENED TO YOU IN THE HOSPITAL? - Your blood potassium levels were rechecked and found to be within the normal range. The first potassium level at your outpatient appointment was falsely elevated because the blood had deteriorated in the collection tube. - You had occasional premature heart beats, as seen on the heart monitor, but you did not have any symptoms from it. Occasional premature heart beats are very common and not dangerous. - Your urine was examined in the lab and sent for a culture. Your urine looks like it may have an infection, but it is difficult to tell because of your complicated kidney history with the PCN tube (percutaneous nephrostomy tube) and ureter stent. You also did not seem to have obvious symptoms of a urine infection. However, because of your complicated medical history, we felt it was best to be safe and treat you with antibiotics for a possible urinary tract infection. - You received IV antibiotics while you were in the hospital for a urinary tract infection. - You were transitioned to oral antibiotics to take as an outpatient. - CT scan of your chest and abdomen showed that you had a prostate mass, with lesions in the bone that were concerning for metastatic cancer. WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL? - Please follow up with your urologist and oncologist outpatient to discuss further cancer testing and options. - Please follow up with your PCP. - Please take all your medications as prescribed. - In particular, please complete a total 7-day course of antibiotics. You last day of antibiotics will be on ___. We wish you the best! - Your ___ treatment team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Percocet Attending: ___. Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ w/ PMHx of HTN, HLD, cholecystectomy who was transferred from OSH for concern for ischemic colitis. Pt was well until ___ afternoon when she developed sudden onset of sharp, cramping, severe lower abdominal pain. Pain was so severe that pt collapsed and briefly lost consciousness. She then presented to OSH ED where CT scan showed collpase and thickening of the colon c/w ischemic colitis. Pt was then transferred to ___ for possible surgical management. In ED initial vitals were 98.6 66 113/64 20 98%RA. Lactate was 1.0 and WBC was normal. Surgery was consulted and recommended medical management. Pt given morphine for pain control, cipro/flagyl for empiric coverage, 2L NS, and was transfered to floor. On floor, repeat lactate was 2.1. VS remained stable. This morning, pt says that her pain was greatly improved and is ___ at rest. She reports three large bowel movements yesterday that were blood streaked, but not bowel movements since. Denies nausea, emesis, back pain, CP, SOB, fevers, chills, HA. Past Medical History: Lichen Sclerosis Osteoporosis HTN vitiligo/sundamaged skin polyps found on ___ colonoscopy GERD pancreatitis Social History: ___ Family History: ___ Cancer, HTN died age ___ MGM- died age ___ MGF- died age ___ Hemorrhage Father-DM, HTN, Heart Disease died age ___ Sister-HTN, one with cancer Physical Exam: VITALS: 100.7, 126/64, 70, 20, 97%RA GENERAL: Sleepy, but in NAD HEENT: PERRL, EOMI NECK: no carotid bruits, JVD LUNGS: CTAB HEART: RRR, normal S1 S2, no MRG ABDOMEN: Soft, but extremely tender to palpation in LLQ and around epigastric region no rebound tenderness. BS+ EXTREMITIES: No c/c/e NEUROLOGIC: A+OX3 DISCHARGE: VS 98-98.7 ___ 100-104/48-54 ___ 96-97%RA GEN Alert, oriented, no acute distress. thin elderly woman. HEENT NCAT MMM EOMI sclera anicteric, OP clear NECK supple, no JVD, no LAD PULM Good aeration, CTAB no wheezes, rales, ronchi CV RRR normal S1/S2, no mrg ABD soft ND normoactive bowel sounds, no r/g. Minimal TTP in lower abdomen. EXT WWP 2+ pulses palpable bilaterally, no c/c/e NEURO motor function grossly normal SKIN no ulcers or lesions Pertinent Results: ___ 07:00AM BLOOD WBC-5.6 RBC-3.10* Hgb-10.0* Hct-29.9* MCV-96 MCH-32.1* MCHC-33.3 RDW-13.1 Plt ___ ___ 09:03PM BLOOD WBC-9.0 RBC-3.91* Hgb-12.4 Hct-37.7 MCV-97 MCH-31.8 MCHC-32.9 RDW-12.9 Plt ___ ___ 07:00AM BLOOD WBC-6.3 RBC-3.02* Hgb-9.5* Hct-29.4* MCV-97 MCH-31.4 MCHC-32.3 RDW-13.0 Plt ___ ___ 09:03PM BLOOD Neuts-89.9* Lymphs-6.5* Monos-3.4 Eos-0.2 Baso-0.1 ___ 07:00AM BLOOD Glucose-102* UreaN-5* Creat-0.5 Na-137 K-3.0* Cl-108 HCO3-22 AnGap-10 ___ 09:03PM BLOOD Glucose-103* UreaN-26* Creat-0.8 Na-143 K-3.6 Cl-109* HCO3-24 AnGap-14 ___ 07:00AM BLOOD ALT-27 AST-22 LD(LDH)-151 AlkPhos-32* TotBili-0.3 ___ 09:03PM BLOOD ALT-36 AST-38 AlkPhos-37 TotBili-0.5 ___ 09:03PM BLOOD Albumin-4.1 ___ 07:20AM BLOOD Calcium-8.1* Phos-3.3 Mg-1.6 ___ 09:08PM BLOOD Lactate-1.0 ___ 02:51AM BLOOD Lactate-2.1* ___ 08:36AM BLOOD Lactate-1.3 CTA abdomen/pelvis ___: IMPRESSION: 1. Large bowel wall-thickening and submucosal edema in the vascular distribution of the ___. While there is no apparent stenosis or thrombosis of the ___, proximally, a more distal arterial occlusion cannot be excluded; however, this overall appearance of bowel may also be seen with "low-flow" venous ischemia. Inflammatory and infectious processes also remain differential diagnostic considerations, that might be assessed by colonoscopy. 2. Periportal edema and small ascites, particularly perihepatic. This may relate to the process, #1, above and/or to volume overload with "third-spacing." 3. Bilateral simple-appearing renal cysts. Medications on Admission: Preadmissions medications listed are incomplete and require futher investigation. Information was obtained from webOMR. 1. Clobetasol Propionate 0.05% Ointment 1 Appl TP DAILY apply to affected area once daily 2. Lisinopril 10 mg PO DAILY 3. Omeprazole 20 mg PO BID 4. Simvastatin 20 mg PO DAILY Discharge Medications: 1. Omeprazole 20 mg PO BID 2. Simvastatin 20 mg PO DAILY 3. Clobetasol Propionate 0.05% Ointment 1 Appl TP DAILY apply to affected area once daily Discharge Disposition: Home Discharge Diagnosis: Colitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ woman with history of hypertension and hyperlipidemia, presents with intermittent severe abdominal pain, and colonic thickening seen on OSH NECT; rule out ischemic colitis. COMPARISON: ___ abdomen and pelvis, ___. TECHNIQUE: Axial helical MDCT images were obtained of the abdomen and pelvis after the administration of oral and IV contrast. Multiplanar reformatted images were generated in the sagittal and coronal planes. DLP: 418.80 mGy-cm. FINDINGS: There is minimal bibasilar dependent atelectasis. Otherwise, the visualized lung bases are clear with no nodules, pleural effusions, or pneumothorax. The visualized portions of the heart and pericardium are unremarkable in appearance. CT ABDOMEN: The liver enhances homogeneously without focal lesion or intrahepatic biliary duct dilatation. There is moderate periportal "lymphatic tracking" edema, probably not much changed since the previous study. The gallbladder is surgically absent with surgical clips in place. The spleen, pancreas, and adrenal glands are unremarkable in appearance. There is a left renal upper pole subcentimeter hypodensity, too small to fully characterize by CT, but likely representing a simple renal cyst. There is a 1.7 x 0.9 cm right renal interpolar simple-appearing cyst. Otherwise, both kidneys present symmetric nephrograms and excretion of contrast without focal solid lesion, pelvicaliceal dilatation, or perinephric abnormalities. The stomach is distended but unremarkable in appearance. The duodenum and small bowel are unremarkable in appearance with no focal wall thickening or obstruction. Again seen is moderate bowel wall thickening in the ___ vascular territory, starting proximally from the splenic flexure, and extending distally to the proximal sigmoid colon. There is a "targetoid" cross-sectional appearance of the thickened colon, indicative of circumferential submucosal edema. However, the degree of mural enhancement in this segment appears quite similar in comparison to the more normal-appearing remainder of the large bowel. There is no pneumatosis or mesenteric or portal venous gas. Overall, the appearance of the bowel is unchanged from previous study. Of note is interval development of larger amount of ascites, in particular, perihepatic. There is moderate calcification of the abdominal aorta and its branches. The celiac axis, SMA, and bilateral renal arteries appear patent at their origins. Specifically, the origin and proximal portion of the ___ are visualized and appear patent; however, its mid- and distal portions are not well-visualized, due to scanning technique and contrast bolus timing. There is no intraabdominal free air or hernia noted. There are no enlarged mesenteric or retroperitoneal lymph nodes by CT size criteria. CT PELVIS: The bladder is distended but unremarkable in appearance. The uterus and bilateral ovaries are unremarkable in appearance. There is a small amount of fluid in the cul-de-sac, unchanged from previous exam. The rectum is unremarkable in appearance. There are no enlarged inguinal or pelvic wall lymph nodes by CT size criteria. OSSEOUS STRUCTURES: Degenerative changes of thoracolumbar spine, with most severe disc space loss at L5/S1. There are no -blastic or -lytic lesions in the visualized osseous structures concerning for malignancy. IMPRESSION: 1. Large bowel wall-thickening and submucosal edema in the vascular distribution of the ___. While there is no apparent stenosis or thrombosis of the ___, proximally, a more distal arterial occlusion cannot be excluded; however, this overall appearance of bowel may also be seen with "low-flow" venous ischemia. Inflammatory and infectious processes also remain differential diagnostic considerations, that might be assessed by colonoscopy. 2. Periportal edema and small ascites, particularly perihepatic. This may relate to the process, #1, above and/or to volume overload with "third-spacing." 3. Bilateral simple-appearing renal cysts. COMMENT: A "wet read" was entered into RIS-web by Dr. ___ discussed with Dr. ___, ___ at 9:40 p.m. on ___. His preliminary findings are concordant with the final interpretation. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: ISCHEMIC CHOLITIS Diagnosed with NONINF GASTROENTERIT NEC, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA temperature: 98.6 heartrate: 66.0 resprate: 20.0 o2sat: 98.0 sbp: 113.0 dbp: 64.0 level of pain: 8 level of acuity: 2.0

Dear Ms. ___, You were transferred to ___ for evaluation of your abdominal pain. A CT scan of your abdomen done at ___ ___ showed inflammation of your colon. The doctors at ___ were concerned that you may have had ischemic colitis, which is a condition in which the colon does not get enough blood supply and is damaged. This can occur because of very low blood pressure or because of a clot in the vessels that supply the colon. The doctors at ___ were concerned that you may have needed surgery, so you were sent to ___. The surgeons here did not believe that you needed surgery because you were feeling better. We got another CT scan of your abdomen, which showed that your colon had not suffered more damage; it was unchanged from your CT scan in ___. It also did not show any clots or blockages in the blood vessels that supply your colon. It is also possible that the inflammation in your colon is due to infection (infectious colitis), so we gave you antibiotics while you were in the hospital. We also tested your stool for bacteria. The results of your stool tests have not yet returned. We will contact you with these results when they are available. You no longer need to take antibiotics. When the inflammation in your colon has resolved, we recommend that you get a colonoscopy. Please discuss the timing of this procedure with your primary care doctor and with the surgeon at your follow-up appointment. While you were in the hospital, your blood pressure was lower than it normally is, so we stopped your blood pressure medication (lisinopril). You should not restart this medication until talking with your primary care doctor. You should also drink lots of fluids to help keep your blood pressure up. We made the following changes to your medications: 1. lisinopril - we stopped this medication. We have scheduled follow-up appointments for you with your primary care physician and with acute care surgery. If you cannot keep your appointments, please call to reschedule. It was a pleasure taking part in your care. We wish you a quick recovery and good health.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Neck pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ s/p C6/C7 anterior discectomy/fusion on ___ for syrinx and C6/7 disc herniation who was recently discharged on ___ and now presents with return of neck pain which she describes as pulsatile and worse than any pain she had after the surgery. She was actually off of pain medication from ___ - ___, however the pain returned yesterday and has gotten progressively worse since. She was taking PO dilaudid w/o relief. Had nausea w/3 episodes nbnb vomiting. No fevers/chills. Feels fatigued from not eating/drinking, but no focal weakness. No UE numbness or tingling. Of note, she was admitted from ___ for her elective surgery, as she wished to have decompression to avoid further injury in the future. She also needed neurosurgery clearance for her police academy given her cervical syrinx found on prior imaging. Post-operatively, her pain had been controlled with oxycodone and IV dilaudid that was switched to po dilaudid. She also complained of numbness on the R side of her body. Her symptoms improved by the time of discharge and she was discharged on po dilaudid ___ mg q4hr:prn as well as bisacodyl. She was scheduled to f/u with Dr. ___ on ___. In the ED, initial vitals were: 99.6 78 128/83 18 100%. Labs significant for a Hct 34.9 (was 38 on ___. Was given IV zofran and dilaudid 1mg which improved pain temporarily. She later received po dilaudid 4 mg and tizanidine with litting improvement in her pain. On exam, she had neck pain and back pain radiating down the R leg. Neurosurgery was consulted, and after review of her C-spine imaging, did not feel that surgical intervention was necessary. She was therefore admitted to medicine for pain control. VS upon transfer: 98.0 71 101/69 18. On the floor, Ms. ___ was very frustrated that she had experienced no pain prior to surgery, essentially no pain immediately after surgery, and now is in severe pain. She had even requested to return to work early because she felt so well. She complained of nausea, photophobia, shock-like sensations down her neck, pain in her low back, "stabbing" pain in her R leg, subjective L arm weakness, and subjective L leg weakness. She also experienced significant itching from the dilaudid. After admission to the floor, she was given dilaudid IV 2mg q2 and ondansetron. Her pain was poorly controlled and she required an additional 2mg at 2:30. She also was nauseous after 8mg of ondansetron and required compazine and lorazepam. Her itching became severe and she required po and IV benadryl. Review of systems: (+) Per HPI, all other ROS negative Past Medical History: C6/7 disc herniation and syrinx that is causing central stenosis, s/p formal decompression to avoid further injury, s/p C6/7 anterior cerivcal discectomy/fusion on ___. Social History: ___ Family History: NC Physical Exam: PHYSICAL EXAM ON ADMISSION: ==================== Temp 97.8, BP 137/60, HR 71, RR 18, 100% RA General: Alert, oriented, in significant distress from pain, unable to lie flat on back HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL. Healing anterior incision covered in steri-strips, no erythema, crepitus, or purulence. Neck: difficulty moving neck due to pain CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Patient fully oriented. + photophobia, ___ strength in right upper extremity, ___ strenght in left upper extremity. Strength symmetric and ___ in lower extremities (limited by pain.) Intact fine touch sensation in all extremities. CN II-XII intact. MSK: tenderness to palpation along spinous processes from the T10-sacral region. Tenderness to palpation over the paraspinal muscles on the right over the T10 to sacral distribution. Positive straight leg raise. PHYSICAL EXAM DISCHARGE: ================== Temp 97.7, BP 101/53, HR 67, RR 18, 97% RA General: Alert, oriented HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL. Healing anterior incision covered in steri-strips, no erythema, crepitus, or purulence. Neck: normal teck range of motion CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Patient fully oriented. CN II-XII intact. ___ strength in right upper extremity and left upper extremity. Strength symmetric ___ in lower extremities (previously limited by pain.) Intact fine touch sensation in all extremities. MSK: Mild tenderness to palpation over the paraspinal muscles on the right over the T10 to sacral distribution. Positive straight leg raise. Pertinent Results: PERTINENT LABS: ============== ___ 02:28PM BLOOD WBC-5.3 RBC-3.85* Hgb-12.3 Hct-34.9* MCV-91 MCH-32.0 MCHC-35.3* RDW-12.2 Plt ___ ___ 06:10AM BLOOD Plt ___ ___ 06:10AM BLOOD Glucose-80 UreaN-8 Creat-0.7 Na-140 K-3.9 Cl-103 HCO3-29 AnGap-12 ___ 06:10AM BLOOD Calcium-9.3 Phos-4.8* Mg-1.9 ___ 06:40AM BLOOD Ferritn-64 ___ 06:40AM BLOOD Calcium-8.6 Phos-3.8 Mg-1.9 Iron-121 IMAGING: ====== IMPRESSION: Status post C6/7 anterior fusion without evidence of hardware complications or change in alignment. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain 2. Bisacodyl 10 mg PO DAILY 3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain 4. Sarna Lotion 1 Appl TP TID:PRN Itchyness Discharge Medications: 1. Acetaminophen 650 mg PO Q4H 2. Cyclobenzaprine 5 mg PO TID:PRN back pain/muscle spasm RX *cyclobenzaprine 5 mg 1 tablet(s) by mouth three times a day Disp #*30 Tablet Refills:*0 3. Ibuprofen 600 mg PO Q8H:PRN back pain Duration: 10 Days RX *ibuprofen 600 mg 1 tablet(s) by mouth every eight (8) hours Disp #*30 Tablet Refills:*0 4. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*10 Capsule Refills:*0 5. Gabapentin 300 mg PO TID RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day Disp #*30 Capsule Refills:*0 6. TraMADOL (Ultram) 50 mg PO Q6H:PRN severe pain Duration: 3 Days RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp #*12 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary: Radiculopathy/Muscle Spasm Nausea Headache Secondary: C6/7 disc herniation and syrinx s/p C6/7 anterior cerivcal discectomy/fusion on ___. Secondary: 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 diskectomy / anterior fusion TECHNIQUE: Two views of the cervical spine COMPARISON: ___ FINDINGS: The patient is status post C6/C7 anterior fusion accomplished by an anterior plate with 2 pairs of screws and intervertebral disc spacer device. No evidence of hardware complications or change in alignment. No new fracture or subluxation. Minimal prevertebral soft tissue swelling persists, and likely reflective of recent surgery. Previously noted subcutaneous emphysema appears improved. Visualized lung apices are clear. IMPRESSION: Status post C6/7 anterior fusion without evidence of hardware complications or change in alignment. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Neck pain Diagnosed with CERVICALGIA, ABN REACT-PROCEDURE NOS temperature: 99.6 heartrate: 78.0 resprate: 18.0 o2sat: 100.0 sbp: 128.0 dbp: 83.0 level of pain: 9 level of acuity: 3.0

Dear Ms. ___, It was a pleasure being involved in your care. You were admitted to the hospital for worsening neck pain and nausea. Your neck was evaluated by the neurosurgery service who felt that there were no complications from your surgery. You developed lower back pain likely from a muscle spasm while here. We started you on medications to help with the pain and recommended continued physical therapy. Sincerely, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ otherwise healthy woman who presents with 2 days of severe abdominal pain. She reports that the pain started about 2 days ago and was mostly in her left lower quadrant, radiates to the back. It became more severe over the next few days she also had intermittent diarrhea. Her last bowel movement was yesterday evening, described as nonbloody. She has been able to tolerate p.o., and denies nausea or vomiting. She does endorse subjective fevers and chills at home. She has not had any urinary symptoms. Of note, she states that she had similar pain about 6 weeks ago that improved without any intervention over the course of the week. She has not had any prior episodes other than these 2. Review of systems is negative other than noted in HPI. Past Medical History: None Social History: ___ Family History: Non contributory Physical Exam: Physical examination upon admission: T: 98.0, HR 81, BP 98/55, RR 18, 98% RA GEN: Appears in no acute distress, alert and oriented ×3, uncomfortable laying in bed CV: Regular rate and rhythm Pulm: Clear to auscultation Abdomen: Soft, mildly distended, tender to palpation most significantly in left lower quadrant, no rebound or guarding Extremities: Warm and well perfused, no edema Physical examination upon discharge T: 97.6, BP 96 / 63, HR 77, RR 18, 99 % RA GEN: Appears in no acute distress, alert and oriented ×3, uncomfortable laying in bed CV: Regular rate and rhythm Pulm: Clear to auscultation Abdomen: Soft, non distended, non tender to palpation, no rebound or guarding Extremities: Warm and well perfused, no edema Pertinent Results: Laboratory results: ___ 02:45AM BLOOD WBC-19.7* RBC-4.76 Hgb-13.6 Hct-41.3 MCV-87 MCH-28.6 MCHC-32.9 RDW-13.3 RDWSD-42.1 Plt ___ ___ 07:52AM BLOOD WBC-16.3* RBC-4.62 Hgb-13.4 Hct-41.2 MCV-89 MCH-29.0 MCHC-32.5 RDW-13.4 RDWSD-44.0 Plt ___ ___ 07:55AM BLOOD WBC-11.2* RBC-4.26 Hgb-12.2 Hct-37.5 MCV-88 MCH-28.6 MCHC-32.5 RDW-13.2 RDWSD-42.8 Plt ___ ___ 07:30AM BLOOD WBC-9.6 RBC-4.04 Hgb-11.6 Hct-35.0 MCV-87 MCH-28.7 MCHC-33.1 RDW-13.2 RDWSD-42.3 Plt ___ Imaging: CTU (ABD/PEL) W/O CONTRAST (___): Impression: Diverticulitis with phlegmon and mild scattered pneumoperitoneum, but no fluid collection. Radiology Report INDICATION: NO_PO contrast; History: ___ with llq ttpNO_PO contrast// eval diverticulitis, stone TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired without intravenous contrast. Non-contrast scan has several limitations in detecting vascular and parenchymal organ abnormalities, including tumor detection. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.1 s, 56.4 cm; CTDIvol = 15.0 mGy (Body) DLP = 848.1 mGy-cm. Total DLP (Body) = 848 mGy-cm. COMPARISON: None available. FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: Evaluation is somewhat limited by respiratory motion artifact. HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout. There is no evidence of focal lesions within the limitations of an unenhanced scan. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions within the limitations of an unenhanced scan. There is no pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size. There is no evidence of focal renal lesions within the limitations of an unenhanced scan. There is no hydronephrosis. There is no nephrolithiasis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber and wall thickness throughout. There is diverticulosis of the proximal sigmoid colon in the left lower quadrant with significant surrounding fat stranding, moderate surrounding mesenteric haziness, and peritoneal thickening. There is mild scattered pneumoperitoneum. No fluid collection. The appendix is normal. PELVIS: The urinary bladder and distal ureters are unremarkable. There is trace 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. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: An umbilical hernia containing fat is noted. IMPRESSION: Diverticulitis with phlegmon and mild scattered pneumoperitoneum, but no fluid collection. Gender: F Race: OTHER Arrive by WALK IN Chief complaint: Abd pain Diagnosed with Dvtrcli of lg int w/o perforation or abscess w/o bleeding temperature: 98.9 heartrate: 104.0 resprate: 20.0 o2sat: 100.0 sbp: 134.0 dbp: 73.0 level of pain: 10 level of acuity: 3.0

Dear ___- ___ were admitted to the Acute Care Surgery Unit at ___ and ___ were treated for an acute episode of diverticulitis. Please continue your antibiotics for a total of two weeks. Please call your doctor or nurse practitioner or return to the Emergency Department for any of 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 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. ___ 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 ___. 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 driving or operating heavy machinery while taking pain medications.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: codeine Attending: ___. Chief Complaint: dyspnea Major Surgical or Invasive Procedure: placement of IVC filter ___ History of Present Illness: ___ yo M h/o NSCLC with mets to brain p/w one week of dyspnea. Pt reports one week of dyspnea with cough productive of blood clots. Denies CP/abd pain. +mild nausea without vomiting. . Pt dx'd with lung CA in ___. He has declined chemotherapy in the past due to negative experiences when wife had chemotherapy for lung CA. Pt is now s/p whole brain XRT for mets. . In the ED: T 98.4, 90/52, hr 80, 24, 89% ra. cxr showed large r opacity and large pleural effusion. cta showed numerous large segmental and lobar PEs with R-sided necrotic mass. LENIs showed L DVT and R superficial clot. CT head showed multiple mets with ? internal hemorrhage. Pt given asa 325 mg po, levofloxacin 750 mg iv, morphine 15 mg po. Dr. ___ with oncology service had GOC discussion with patient in the ED: Pt is now DNR/DNI and given the risks for bleeding has declined heparin treatment of DVT/PEs. Pt was amenable to IVC filter placement, which occured via ___ prior to transfer to the floor. . ROS: as above. o/w complete ROS negative. Past Medical History: PAST ONCOLOGIC HISTORY: He had acute onset of hemoptysis and cough in early ___. He initially presented to ___ where he was given a course of antibiotics; hemoptysis persisted and he presented to ___ ___ on ___. Mr. ___ had a bronchoscopy with bronchial washings and brushings in the right lower lobe on ___. The pathology noted atypical cells in the washings; however, the brushings were negative for malignant cells. No micro samples were sent. A CT scan of the chest was performed on ___ with note of a heterogeneous ~6 cm mass in the RLL. He had a CT-guided biopsy of mass on ___. The pathology report from that procedure notes "acute and organizing pneumonia with abundant lymphoplasmacytic chronic inflammation, reactive pneumocyte atypia, and frequent hemosiderin-laden macrophages in the alveolar spaces." Bug stains were negative and no malignancy was identified in that sample. Repeat CT-guided biopsy of the right lower lobe mass was done on ___ which showed "lung tissue with organizing pneumonia with areas of necrosis and atypical type 2 pneumocyte hyperplasia." Bug stains were again negative. On ___ he uderwent transbronchial biopsy at ___ which yielded a sample that showed non-small cell lung cancer, facor adenocarcinoma type. PAST MEDICAL HISTORY: 1. Emphysema/COPD. 2. Hyperlipidemia. 3. GERD. 4. Prostate cancer (___) status post brachytherapy. 5. Status post back surgery (___). 6. Status post AAA repair (___). 7. Status post cholecystectomy (___). 8. Status post carotid artery endarterectomy on the left (___). Social History: ___ Family History: Mother - lymphoma (died at age ___. Father - emphysema (died at age ___. Brother - coronary artery disease. Children - all healthy. Physical Exam: t 97.2 bp 120/70 hr 80 rr 24 sat 96% 6L FM gen: nad, speaking in full sentences eomi, perrl no ___ neck supple chest: clear irreg irreg abd benign ext w/wp, trace pedal edema neuro: non-focal skin: no rash ivc filter site: no hematoma/bruit, non-ttp Pertinent Results: ___ 09:28PM ___ ___ 03:05PM ___ COMMENTS-GREEN TOP ___ 03:05PM LACTATE-3.3* ___ 02:55PM GLUCOSE-141* UREA N-13 CREAT-0.8 SODIUM-136 POTASSIUM-5.1 CHLORIDE-98 TOTAL CO2-23 ANION GAP-20 ___ 02:55PM estGFR-Using this ___ 02:55PM cTropnT-<0.01 ___ 02:55PM WBC-12.9*# RBC-3.83* HGB-9.9* HCT-32.4* MCV-85 MCH-25.9* MCHC-30.6* RDW-16.1* ___ 02:55PM NEUTS-88* BANDS-1 LYMPHS-6* MONOS-4 EOS-0 BASOS-0 ___ MYELOS-1* ___ 02:55PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-2+ MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-2+ PENCIL-1+ TEARDROP-OCCASIONAL ___ 02:55PM PLT SMR-HIGH PLT COUNT-546* Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation 2 puffs bid 2. Metoclopramide 10 mg PO QIDACHS 3. Morphine Sulfate ___ 15 mg PO Q6H:PRN pain 4. Ranitidine 150 mg PO DAILY 5. Simvastatin 40 mg PO DAILY 6. Tiotropium Bromide 1 CAP IH DAILY 7. Aspirin 81 mg PO DAILY 8. Bisacodyl 10 mg PO DAILY:PRN constipation 9. Polyethylene Glycol 17 g PO DAILY:PRN constipation 10. Senna 1 TAB PO BID:PRN constipation Discharge Medications: 1. Bisacodyl 10 mg PO DAILY:PRN constipation 2. Morphine Sulfate ___ 15 mg PO Q6H:PRN pain 3. Polyethylene Glycol 17 g PO DAILY:PRN constipation 4. Ranitidine 150 mg PO DAILY 5. Senna 1 TAB PO BID:PRN constipation 6. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation 2 puffs bid 7. Tiotropium Bromide 1 CAP IH DAILY 8. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*3 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: ___ Secondary: pulmonary embolism 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: History of lung cancer with hypoxia and tachycardia. COMPARISON: Chest radiograph from ___ and CTA chest from ___. FINDINGS: Single portable chest radiograph was provided. Again seen is a large right lower lobe opacity, representing known mass. Superinfection cannot be excluded. A small small-to-moderate right pleural effusion is seen and appears increased since the prior exam. Hyperlucency of the upper lung zones and hyperinflation is consistent with known emphysema. There is no pneumothorax. No left pleural effusion is identified. The cardiomediastinal silhouette is normal. A VP shunt catheter courses along the right hemithorax and is incompletely imaged. IMPRESSION: 1. Large opacity within the right lower lobe representing known mass. Superinfection cannot be excluded with subtle suggestio of associated air bronchograms. 2. Increasing right pleural effusion. Radiology Report INDICATION: ___ with SOB, hypoxia, active cancer COMPARISON: CTA chest ___. TECHNIQUE: Contiguous helical MDCT images were obtained through the chest after administration of 100 cc of Omnipaque IV contrast. Multiplanar axial, coronal, sagittal and oblique maximum intensity projection images were generated. TOTAL BODY DLP: 314.67 mGy-cm. FINDINGS: CT CHEST WITH CONTRAST: There is no axillary, mediastinal, or hilar lymphadenopathy. The partially visualized thyroid is unremarkable. The airways are patent to the subsegmental level. The large mass in the right lower lobe is larger now, approximately 7.9 x 8 cm and contains areas of central hypodensity and locules of gas compatible with necrosis and increasing liquefaction, more prominent since the prior study. There are adjacent opacities, which may represent infection versus spread of malignancy. Additionally, there is atelectasis and a small right pleural effusion. There are several scattered calcified pleural plaques throughout the thorax. There is a severe background of centrilobular emphysema. Although this study is not designed for evaluation of intra-abdominal structures, the visualized solid organs and stomach are unremarkable. CTA OF THE CHEST: There are numerous lobar and segmental PEs bilaterally involving the bilateral upper lobes, right middle and lingular lobes, and left lower lobe. There is no evidence of parenchymal infarct. The heart shows evidence of subtle flattening of the intraventricular septum, which may represent early heart failure. There is no pericardial effusion. The aorta and main thoracic vessels are well opacified. The aorta demonstrates normal caliber throughout the thorax without intramural hematoma or dissection. OSSEOUS STRUCTURES: There are no concerning blastic or lytic lesions. IMPRESSION: 1. Numerous lobar and segmental PEs bilaterally as detailed above. Subtle flattening of the interventricular septum of the heart may suggest early heart failure. This can be further evaluated for on echocardiogram. There is no evidence of parenchymal infarct. 2. Growing mass in the right lower lobe with liquefaction and locules of gas. Opacities adjacent to the large mass may represent infection versus spread of malignancy. 3. Severe background of centrilobular emphysema. Radiology Report EXAM: Bilateral lower extremity Doppler ultrasound. CLINICAL INFORMATION: Metastatic lung cancer and new pulmonary embolism. COMPARISON: None. FINDINGS: Realtime grayscale, color and spectral sonographic evaluation of bilateral common femoral, superficial femoral, and popliteal veins was performed. On the right, thrombus is seen in the lesser saphenous vein with close proximity to the popliteal vein, approximately within 1 cm. Otherwise, there is normal compressibility and wall-to-wall color flow of the right common femoral, superficial femoral, and popliteal veins. There is normal compressibility and color flow seen in the right posterior tibial and peroneal veins. On the left, there is evidence of deep venous thrombosis involving the distal popliteal vein extending into at least one of the posterior tibial veins. The peroneal veins appear compressible. There is normal compressibility, wall-to-wall color flow in the left common femoral and superficial femoral veins. Some subcutaneous edema is seen in the left calf. IMPRESSION: 1. Deep venous thrombosis involving the distal left popliteal vein with extension into at least one of the left posterior tibial veins. 2. Thrombus in the lesser saphenous vein, which is a superficial vein, however, comes in close proximity to the popliteal vein, approximately within 1 cm. Radiology Report EXAM: Non-contrast-enhanced CT of the head. CLINICAL INFORMATION: Brain mets, need heparin for PE, question new mets. COMPARISON: Head CT from ___ and ___, and brain MRI from ___. TECHNIQUE: Non-contrast-enhanced CT images of the head were obtained. Reformatted coronal and sagittal images were also obtained. FINDINGS: A right frontal approach ventricular shunt catheter is again seen, terminating in the right lateral ventricle, near the midline. Prominence of the ventricles and sulci is stable. Multiple hyperdense metastatic lesions are seen, including involving the right midbrain, which grossly appears smaller compared to the prior study, today measuring 0.9 x 0.7 cm compared to the today's measurement of the prior study of 1.3 x 1.1 cm. However, full extent is better assessed on MRI. Right temporal lobe lesion, which was previously seen to be partially hyperdense, has now increased region of hyperdensity, with the region of hyperdensity measuring approximately 0.8 x 0.3 cm with possible internal calcification. While the increase in hyperdensity may relate to increase in cell content, hemorrhagic component is not excluded. Hemorrhage could be better evaluated for/or excluded on susceptibility sequences on MRI. Additional mets seen on prior MRI, including in the right post-central gyrus, in the inferior right parietal lobe, and in the right occipital lobe are better seen on MRI. Gray-white matter differentiation is preserved. The visualized paranasal sinuses and the mastoid air cells are clear. Right frontal burr hole is seen. No acute fracture is seen. IMPRESSION: Multiple metastatic lesions, as above, most of which are better assessed on MRI. Right temporal lobe lesion has increased region of hyperdensity on the current study, which may be due to increase in size of the lesion/increase in cell content, however, hemorrhagic component is not entirely excluded and could be excluded on MRI susceptibility sequence. Radiology Report HISTORY: Metastatic lung cancer with new bilateral pulmonary emboli and left lower lobe extremity DVT with guaic positive stools. COMPARISON: ___ PET CT from ___. TECHNIQUE: OPERATORS: Dr. ___ radiology fellow) and Dr. ___ radiology attending) performed the procedure. The attending, Dr. ___ was present and supervising throughout the procedure. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 75 mcg of fentanyl and 0.5 mg of Versed throughout the total intra-service time of 23 minutes during which the patient's hemodynamic parameters were continuously monitored. MEDICATIONS: None. CONTRAST: 50 ml of Optiray contrast FLUOROSCOPY TIME AND DOSE: 4.6 min, 63 mGy PROCEDURE: 1. Left common iliac vein and IVC venogram. 2. Infrarenal permanent Venentech IVC filter deployment. 3. Post filter placement venogram. PROCEDURE DETAILS: Following the explanation of the risks, benefits and alternatives to the procedure, written informed consent was obtained. The patient was brought to the angiography suite and placed supine on the imaging table. Both groins were prepped and draped in the usual sterile fashion. A pre-procedure timeout was performed using three patient identifiers. Under ultrasound and fluoroscopic guidance, the right common femoral vein was punctured using a 19 guage needle. A ___ wire was advanced through the needle into the inferior vena cava. Next, an Omniflush catheter was advanced over the wire into the IVC. The ___ wire was exchanged for an angled Glidewire, which was advanced into the left common iliac vein and the catheter tip was advanced into the left common iliac vein. A left common iliac and inferior vena cava venogram was performed. Based on the results of the venogram, detailed below, a decision was made to place a permanent Venatech filter. The catheter and sheath were removed over the wire and the sheath of an Venentech filter was advanced over the wire into the IVC past the take off of the renal vessels. An Venentech inferior vena cava filter was advanced over the wire until the cranial tip was at the level of the inferior margin of the right renal vein. The sheath was then withdrawn until the filter was deployed. The wire and loading device were then removed through the sheath and a repeat contrast injection was performed, confirming appropriate filter positioning. The sheath was removed and pressure was held for 10 minutes, at which point stasis was achieved. A sterile dressing was applied. The patient tolerated the procedure well and there was no immediate post procedure complications. FINDINGS: 1. Patent normal sized, non-duplicated IVC with single bilateral renal veins and no evidence of a clot. 2. Successful deployment of an infra-renal permanent Venatech IVC filter. IMPRESSION: Successful deployment of permanent Venatech IVC filter. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Dyspnea, Chest pain Diagnosed with PULM EMBOLISM/INFARCT temperature: 98.4 heartrate: 80.0 resprate: 24.0 o2sat: 89.0 sbp: 90.0 dbp: 52.0 level of pain: 4 level of acuity: 1.0

You were admitted to ___ with worsened shorntess of breath and coughing up blood. While you were here you were evaluated by Radiation Oncology and it was not thought that you tumor could be treated by radiation. Due to the risk of bleeding with blood thinners and your goals of focusing more on quality of life and symptom management, you were not started on a blood thinner. You did have an IVC filter placed. While you were in the hospital we treated your symptoms with medications and after a conversation with your family and palliative care, we decided that we could provide you with the best care by adding hospice services to your team.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Penicillins / Ultram / Motrin Attending: ___. Chief Complaint: ___ s/p L-S fusion by Dr. ___ on ___ complains of fevers, chills, and pain. Patient states he has been having pain in his right buttocks and RLE since before his surgery. He states it has never improved and has in fact gotten worse. He also reports fevers to 103 at home as well as chills. His physical therapist noted drainage from the wound. He was started on bactrim by his pcp which he finished yesterday. He denies focal weakness, saddle anesthesia, urinary incontinence, cough, shortness of breath, dysuria. He does report intermittent tingling in his RLE which he had prior to the surgery. Major Surgical or Invasive Procedure: None Past Medical History: R shoulde surgery ORIF R ankle ___ R L5-S1 discectomy Social History: ___ Family History: N/C Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. OxyCODONE SR (OxyconTIN) 80 mg PO Q8H 2. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain Discharge Medications: 1. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth q4hours Disp #*60 Tablet Refills:*0 2. OxyCODONE SR (OxyconTIN) 80 mg PO Q8H RX *oxycodone [OxyContin] 80 mg 1 tablet extended release 12 hr(s) by mouth q8hours Disp #*60 Tablet Refills:*0 3. Acetaminophen 650 mg PO Q6H:PRN headache 4. Docusate Sodium 100 mg PO BID 5. Gabapentin 900 mg PO TID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Postoperative fever Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAM: Chest frontal and lateral views. CLINICAL INFORMATION: Fever. COMPARISON: None. FINDINGS: Frontal and lateral views of the chest were obtained. There is right middle lobe opacity. There is eventration of the anterior right diaphragm. Findings may in part relate to atelectasis, findings are concerning for pneumonia given clinical scenario. The left lung is clear. There is no pleural effusion or pneumothorax. The cardiac and mediastinal silhouettes are unremarkable. IMPRESSION: Right middle lobe consolidation worrisome for pneumonia. Radiology Report EXAM: Lumbar spine, AP and lateral views and coned-down lateral views, three views. CLINICAL INFORMATION: History of spinal fusion, now with severe lower back pain and fever. ___ as well as spot fluoroscopic intraoperative images from ___. FINDINGS: Patient is status post posterior metallic fusion of L5 and S1. Interbody disc spacer is also seen. Grossly anatomic alignment is maintained. No definite cortical destruction is seen. There is no evidence of acute fracture or dislocation. The pubic symphysis and sacroiliac joints are intact. IMPRESSION: Status post posterior metallic fusion of L5 and S1 in anatomic alignment without evidence of acute fracture or dislocation. Please note that CT may be more sensitive in evaluating for infection. Radiology Report LUMBAR SPINE CT WITHOUT CONTRAST, ___ INDICATION: History of two prior L5-S1 decompressions, now status post L5-S1 posterior interbody fusion and posterolateral fusion on ___. Patient presents with worsening pain and reported history of fever, though afebrile in the hospital. Concern for hardware shift. COMPARISON: Intraoperative lumbar spine radiographs from ___ and post-operative lumbar spine radiographs from ___. ___ lumbar spine MRI from ___. TECHNIQUE: Axial non-contrast multidetector CT images of the lumbar spine with sagittal and coronal reformatted images. FINDINGS: Caudal to the most inferior rib-bearing vertebra, four lumbar-type vertebrae are identified. The most caudal lumbar-type vertebra has been labeled L5 on prior imaging studies and in the ___ surgical note. The same numbering is continued in this report, with the lumbar vertebrae labeled L2 through L5. The numbering is documented on series 7B, image 18. At L5-S1, the interbody device is located to the right of midline, extending to the ventral margin of the right neural foramen. It appears appropriately centered in the anterior-posterior dimension. There is erosion of the right inferior endplate of L5 overlying the device, concerning for loosening as well as infection, given the history of fever. Alignment of L5 and S1 vertebral bodies is normal. There is evidence of partial right facetectomy at L5-S1. There is instrumented posterior fusion of L5 and S1 with paired pedicle screws, which appear well positioned, as well as two posterior plates. Evaluation for an epidural collection on CT is markedly limited. There is edema in the posterior paravertebral muscles and subcutaneous fat at the level of the surgery. Evaluation for an associated fluid collection is limited, but none is definitively identified. Cranial to L5, vertebral body heights and disc space heights are preserved. Alignment is normal. There is a mild disc bulge at L4-5, similar to the prior MRI, without significant spinal canal or neural foraminal narrowing. The imaged intra-abdominal soft tissues are grossly unremarkable on limited non-contrast assessment. IMPRESSION: 1. There are four lumbar-type vertebrae, labeled L2 through L5, congruent with the numbering on prior imaging studies and the ___ operative note. 2. The intervertebral device at L5-S1 is located to the right of midline, extending to the ventral margin of the right neural foramen. There is no other post-operative CT for comparison. 3. Erosion of the right inferior endplate of L5 overlying the interbody device, suggesting loosening and the possibility of infection, given the history of fever. MRI would be more sensitive for evaluating extend of infection, as well as detecting an epidural collection or paravertebral collection, if clinically warranted. 4. Posterior fusion hardware at L5 and S1 appears unremarkable without evidence for complications. Findings were discussed by Dr. ___ with Dr. ___ over the telephone on ___ at 4:30 pm. Gender: M Race: OTHER Arrive by WALK IN Chief complaint: FEVER,CHILLS PAIN Diagnosed with FEVER, UNSPECIFIED temperature: 99.0 heartrate: 108.0 resprate: 20.0 o2sat: 94.0 sbp: 130.0 dbp: 66.0 level of pain: 10 level of acuity: 2.0

• Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand 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. ___ Limit any kind of lifting. • Diet: Eat a normal healthy diet. You may have some constipation after surgery. You have been given medication to help with this issue. • 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 please 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 or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your 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. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: Gait training, lower extremity strengthening, balance Treatments Frequency: Wound assessments

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: left-sided weakness, left visual field cut, headache Major Surgical or Invasive Procedure: ___ angiogram with R ICA stenting ___ angiogram with clot aspiriation History of Present Illness: HPI: The patient is an ___ year old right handed woman who presents with about 18 hours of headache, lightheadedness, intermittent dysarthria, left lower face weakness, and difficulty using the left side. She only has a known history of hypertension (on two medications and aspirin) and possibly hyperlipidemia (not on medications). She has been feeling well recently with no recent injury or illness. She was doing ___ cleaning in her house yesterday but did not think she overexerted herself. She has been eating and drinking okay. Last evening around 19:30 ___, she developed a right temporal pulsatile headache; she has no history of migraines and does not usually have unilateral or pounding headaches. She typically has bifrontal dull achy headaches once or twice per month that resolve with acetaminophen. She took two acetaminophen and felt somewhat better. She went to bed at 21:30 ___. She awoke at 06:30 AM and felt lightheaded. There was no vertigo or gait imbalance. Her husband (who has hearing loss) thought she may or may not have been harder to understand in terms of her enunciation. She reports feeling "odd" but denied any other symptoms including neck pain, palpitations, chest pain, nausea, dyspnea on exertion, vision changes, or difficulty moving her arms and legs. Nonetheless, she and her husband went to ___ in the morning where some basic studies were performed, and she was sent back home. When her son took her home, he noticed as she was getting out of the car that her left arm and leg didn't seem to be moving in a coordinated fashion, and when she gave her something to drink some of it spilled out of the left side of her mouth. He thought that she seemed "not herself" and had asymmetry of her face on the left. This prompted him to bring her to our Emergency Department. Here, due to an unknown time of onset of symptoms, a Code Stroke was not called, but Neurology was consulted after it was discovered on examination that she had a left-sided visual field cut. The patient herself is only aware of the lightheadedness and headache from last night. She denies any other symptoms and is unaware of her deficits which include a left homonymous hemianopia, mild left lower face weakness, and left sided sensory neglect. Her CT did not reveal a hypodensity to explain her symptoms but the impression was for a small choroidal territory stroke from hypoperfusion or embolization. A CTA revealed a very stenotic right ICA origin. We discussed the case with Vascular Surgery for possible carotid endarterectomy and were planning to admit her to the Neurology service with efforts to maintain perfusion and on a heparin infusion. However, in the ED, she suddenly became less alert, had a right gaze deviation, and stopped moving her left arm with her right arm raised above her head. Her SBP was in the 140s (she presented in the 190s-200s). This only lasted a minute or so but raised concern for seizure activity from the EM team. When the EM physician evaluated her, she was already improving and these symptoms had resolved by the time we returned. A repeat NCHCT did not show hemorrhage but did show more established mild hypodensities in a watershed territory in the right cerebral hemisphere. She did have left hemineglect (did not initially recognize her hand) and brisker reflexes on the left. In this setting Vascular Surgery decided that carotid endarterectomy may be too risky and asked Neurosurgery to consult for possible stenting; our Neurosurgery colleagues evaluated her and are planning to take her to the Neurointerventional suite for carotid angiography and possible carotid artery stenting. On review of systems, the patient endorses: lightheadedness (only), recent mild-moderate headache. On review of systems, the patient denies the following: - Neurologic: confusion, difficulty producing speech, difficulty understanding speech, vision loss, diplopia, vertigo, dysarthria, dysphagia, focal limb weakness, sensory loss, gait imbalance. - Constitutional: fever, rigors, night sweats, unintentional weight loss. - Cardiovascular: chest pain, palpitations. - Gastrointestinal: nausea, emesis, diarrhea, constipation. - Genitourinary: dysuria, urinary urgency, urinary incontinence. - Ear, Nose, Throat: tinnitus, hearing loss, rhinorrhea, odynophagia. - Hematologic: bleeding, easy bruising. - Musculoskeletal: arthralgia, myalgia. - Psychiatric: anxiety, depression. - Respiratory: dyspnea, cough, hematemesis. - Skin: rash, new skin lesions. Past Medical History: HTN, HL Social History: ___ Family History: No known neurologic diseases including no strokes. No MIs. Some hypertension in the family. Physical Exam: Physical Examination: VS T: 99 HR: 75 BP: ___ RR: 20 SaO2: 99% RA - General/Constitutional: Lying in bed comfortably, well-appearing elderly woman. - Eyes: Round, regular pupils. No conjunctival icterus, no injection. - Ear, Nose, Throat: Poor dentition, artificial upper teeth. No oropharyngeal lesions. No external auditory canal lesions. - Neck: No meningismus. No carotid, vertebral, or subclavian bruits appreciated. No lymphadenopathy. - Musculoskeletal: Range of motion with neck rotation full bilaterally. No focal spinal tenderness. - Skin: No rashes. No concerning lesions appreciated. - Cardiovascular: Regular rate. Regular rhythm. No murmurs, rubs, or gallops appreciated. Normal distal pulses. - Respiratory: Lungs clear to auscultation bilaterally. No crackles. No wheezes. - Gastrointestinal: Soft. Nontender. Nondistended. - Psychiatric: Mood congruent with affect. Intact insight. Neurologic Examination (around 1330): - Mental Status - Awake, alert. Oriented to name, birth place, current location, year. Attention to examiner easily attained and maintained. Recalls a coherent history, but not aware of any deficits. Speech is fluent with full sentences. Follows midline and appendicular commands. Intact repetition. Intact high frequency and low frequency naming. No paraphasias. Normal prosody. No dysarthria. No ideomotor apraxia. Tactile hemineglect to DSS only. - Cranial Nerves - [II] Pupils 2->1 brisk, right oblong and left round (both post-surgical for cataracts). Left homonymonus hemianopia. [III, IV, VI] EOMI, no nystagmus, saccadic intrusions with horizontal gaze bilaterally. [V] V1-V3 without deficits to light touch bilaterally. [VII] No facial movement asymmetry. [VIII] Hearing intact to finger rub bilaterally. [IX, X] Palate elevation symmetric. [XI] SCM/Trapezius strength ___ bilaterally. [XII] Tongue midline. - Motor - Diminished bulk of the small muscles of the hands, normal tone. No pronation, left parietal drift (upwards). No tremor, asterixis, or myoclonus. =[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas] [___] [C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1] [L5] L 5 5 5 5 5- 5 5 5 5 5 5- R 5 5 5 5 5- 5 5 5 5 5 5- - Sensory - No deficits to cold temperature or proprioception (at the feet) bilaterally. Extinction to double simultaneous tactile stimulation on the left. Misses nose as target when retracting hand from outstretched position with eyes closed. - Reflexes =[Bic] [Tri] [___] [Quad] [Gastroc] L 2 2 2 2 0 R 2 2 2 2 0 Plantar response obscured by withdrawal bilaterally. - Coordination - No dysmetria with finger to nose testing bilaterally. Intact cadence and accuracy with rapid alternating movements (finger tap). - Gait - Normal initiation. Stable stance with narrow base. Romberg sign is absent. Normal stride length. Normal arm swing. No sway with standard gait. No sway with turns. DISCHARGE EXAM: MS - knows she is in a hospital, can sometimes say ___ as an answer, knows the year the month, but not the date. Can follow simple commands, can say ___ word sentences, occasionally getting up to 5 words in a row, but has not yet been 7 (fluent). CN - left facial droop, right gaze preference MOTOR - moves everything antigravity, but is weaker on the left side. SENSORY - mildly decreased sensation on the left side GAIT - deferred Pertinent Results: Admission Labs: ___ 12:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 12:30PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 12:30PM ___ PTT-27.5 ___ ___ 12:30PM PLT COUNT-221 ___ 12:30PM NEUTS-76.6* LYMPHS-16.2* MONOS-5.0 EOS-1.2 BASOS-1.0 ___ 12:30PM WBC-7.3 RBC-3.90* HGB-12.6 HCT-38.1 MCV-98 MCH-32.2* MCHC-33.1 RDW-13.0 ___ 12:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 12:30PM URINE GR HOLD-HOLD ___ 12:30PM URINE HOURS-RANDOM ___ 12:30PM URINE HOURS-RANDOM ___ 12:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-6* bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 12:30PM ALBUMIN-4.1 CALCIUM-9.3 PHOSPHATE-3.1 MAGNESIUM-2.1 ___ 12:30PM cTropnT-<0.01 ___ 12:30PM LIPASE-27 ___ 12:30PM ALT(SGPT)-16 AST(SGOT)-28 ALK PHOS-63 TOT BILI-0.4 ___ 12:30PM estGFR-Using this ___ 12:30PM GLUCOSE-99 UREA N-11 CREAT-0.7 SODIUM-135 POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-22 ANION GAP-16 ___ 12:50PM LACTATE-1.6 ___ 08:50PM ___ PTT-30.0 ___ ___ 08:50PM PLT COUNT-209 ___ 08:50PM WBC-6.7 RBC-3.63* HGB-11.5* HCT-35.1* MCV-97 MCH-31.6 MCHC-32.7 RDW-13.1 ___ 08:50PM CALCIUM-7.6* PHOSPHATE-3.1 MAGNESIUM-1.6 ___ 08:50PM CK-MB-4 cTropnT-<0.01 ___ 08:50PM CK(CPK)-152 ___ 08:50PM GLUCOSE-131* UREA N-9 CREAT-0.6 SODIUM-127* POTASSIUM-3.3 CHLORIDE-100 TOTAL CO2-17* ANION GAP-13 ___ 10:45PM freeCa-1.08* ___ 10:45PM HGB-10.9* calcHCT-33 ___ 10:45PM GLUCOSE-133* LACTATE-1.1 NA+-131* K+-3.5 CL--100 ___ 10:45PM PO2-315* PCO2-43 PH-7.36 TOTAL CO2-25 BASE XS--1. . Dishcarge Labs: ___ 05:17AM BLOOD WBC-9.8 RBC-2.96* Hgb-9.1* Hct-28.1* MCV-95 MCH-30.6 MCHC-32.2 RDW-14.9 Plt ___ ___ 05:17AM BLOOD Glucose-128* UreaN-14 Creat-1.1 Na-137 K-4.3 Cl-103 HCO3-24 AnGap-14 ___ 05:17AM BLOOD Calcium-7.9* Phos-2.8 Mg-2.0 ___ 05:17AM BLOOD Vanco-17.9 . Microbiology: # Blood Culture x2 (___): Coag Negative Staph # Urine Culture (___): No growth. # Urine Culture (___): No growth. # Blood Culture x2 (___): No growth. . Pathology: None. . Imaging/Studies : # CTA Neck (___): High-grade stenosis (70-80%) at the bifurcation the right internal carotid artery that extends approximately 1 cm into the internal carotid artery. The 3D reformations are pending. Once the 3D reformations are obtained an addendum will be issued if any changes are identified. # CXR (___): 1. No evidence of acute cardiopulmonary process. 2. Moderately severe compression fracture at thoracolumbar junction of uncertain chronicity. Correlate clinically for acuity. # CT Head W/O contrast (___): No evidence of acute hemorrhage or infarct. 2. Interval placement of right internal carotid artery metallic stent with complete occlusion of the entire internal carotid artery. Minimal collateral retrograde flow is seen at the most distal aspect of the supra clinoid segment. The right MCA demonstrates markedly decreased flow. The left-sided vasculature for is well patent with adequate arterial flow. # CT abd/pelvis (___): 1. No retroperitoneal hematoma. Mild stranding in the right inguinal region and pelvis with a local rectus sheeth expansion, compatible with a small amount hematoma in this area. 2. 1.3 cm heavily calcified splenic artery aneurysm, located at the hilum. 3. 2 hypodense lesions within the pancreas, likely representing cystic lesions. Further evaluation with MRI is recommended non emergently if clinically indicated. 4. Indeterminate left renal hypodensity measuring 2.8 cm, which may represent a cyst. This can be further evaluated at the time of pancreatic MRI. # Trans-Thoracic ECHO (___): No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Normal LV wall thickness, cavity size, and global systolic function (biplane LVEF = 75 %). The estimated cardiac index is high (>4.0L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Doppler parameters are most consistent with Grade I (mild) left ventricular diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. 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 to moderate (___) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is mild pulmonary artery systolic hypertension. IMPRESSION: Normal biventricular regional/global systolic function. Hyperdynamic left ventricle with high cardiac index. Grade I diastolic dysfunction with elevated left ventricular enddiastolic pressure. Mild to moderate mitral and mild aortic regurgitation. # MRI Head (___): Restricted diffusion in the right basal ganglia, right insula and throughout the right parietal and temporal lobes consistent with acute ischemia in the territory of the M1 segment of the right middle cerebral artery. # CXR (___): New nasogastric drainage tube ends low in nondistended stomach. # CXR (___): Endotracheal tube has been removed. A feeding tube is again seen. Heart size is within normal limits. There has been interval development of increased pulmonary interstitial markings suggestive of pulmonary edema. There is no focal consolidation, although there are more confluent densities at the right base. There are no pneumothoraces identified. # CXR (___): Mild pulmonary edema developed between ___ and ___. Subsequently, the edema has improved somewhat, but there is more consolidation at the right lung base that could be due either to atelectasis or new pneumonia. The heart size is top normal. Nasogastric tube passes into the stomach and out of view. Pleural effusions are small. No pneumothorax. Dr. ___ was paged at 12:30 as soon as the study was reviewed. # Video Swallow Eval (___): Gross aspiration of nectar thickened barium and inability to form bolus with pureed barium. # CXR (___): As compared to the previous radiograph, the patient has received a right-sided PICC line. The tip of the line projects over the lower SVC. The course of the line is unremarkable, no evidence of complications, notably no pneumothorax. Otherwise, the radiograph is unchanged, including the presence of a nasogastric tube. # CT abd/pelvis (___): 1. Small right pelvic hematoma, likely related to prior arterial puncture for cerebral angiography. 2. Right colic venous gas as well as venous gas in the left hepatic lobe, without associated pneumatosis, likely benign in nature. Correlation with serum lactate and serial physical exam is recommended. 3. New moderate right and small left nonhemorrhagic pleural effusions. 4. 1.8 cm pancreatic cystic lesion. If serial CT imaging is planned for this patient, this lesion could be followed up on these studies. Otherwise, the standard recommendation for followup would be an MRCP in 6 months. 5. Unchanged benign appearing left renal cysts. 6. Extensive diverticulosis, without evidence of diverticulitis. Rectal fecal loading. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Losartan Potassium 50 mg PO DAILY 3. Atenolol 50 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. ALPRAZolam 0.25 mg PO BID:PRN anxiety Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. Losartan Potassium 50 mg PO DAILY 3. Acetaminophen 650 mg PR Q6H:PRN pain, fever 4. Atorvastatin 80 mg PO DAILY 5. Bisacodyl 10 mg PR HS:PRN constipation 6. Clopidogrel 75 mg PO DAILY 7. Docusate Sodium 100 mg PO BID 8. Fluconazole 200 mg PO Q24H 9. Metoprolol Tartrate 50 mg PO BID Hold for HR < 60 or SBP < 110 10. Piperacillin-Tazobactam 4.5 g IV Q8H 11. Senna 8.6 mg PO BID 12. Vancomycin 1000 mg IV Q 12H 13. Amlodipine 10 mg PO DAILY 14. Omeprazole 40 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Right MCA infarct resulting from Right Carotid Stenosis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: MR HEAD W/O CONTRAST INDICATION: ___ year old woman with HTN p/w left lower face weakness, homonymous hemianopia,tactile hemineglect; tight right ICA stenosis // assess for cerebral infarction (embolic versus hypoperfusion), other pathology TECHNIQUE: MRI of the brain is performed and includes the following sequences: sagittal T1-weighted, axial fast spin echo T2-weighted,axial flair, axial diffusion weighted and axial gradient echo images . COMPARISON: CTA head of ___. FINDINGS: There is restricted diffusion in the right basal ganglia, right insula and throughout much of the right parietal and temporal lobes consistent with acute ischemia. There is corresponding FLAIR and T2 hyperintensity. There is no evidence of intracranial hemorrhage or hemorrhagic conversion. A flow voids in the M1 segment of the right middle cerebral artery appears attenuated compared to the left M1 segment but patent. Prominence of the ventricles and sulci likely represents age-related involutional changes. Subcortical and periventricular FLAIR and T2 hyperintensities most likely the sequela of chronic small vessel ischemic disease. IMPRESSION: Restricted diffusion in the right basal ganglia, right insula and throughout the right parietal and temporal lobes consistent with acute ischemia in the territory of the M1 segment of the right middle cerebral artery. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 3:13 ___, minutes after discovery of the findings. Radiology Report EXAMINATION: CTA HEAD WANDW/O C AND RECONS INDICATION: ___ year old woman with stroke and just got an intervention now with worseningexam // eval for bleeding or extension of the stroke TECHNIQUE: Using a multi detector CT scanner, volumetric data was acquired through the head and collimated at 5 mm slice thickness. In addition, contrast-enhanced volumetric data was acquired through the head following the uncomplicated administration of intravenous contrast and collimated at 1.25 mm slice thickness. Sagittal, coronal and axial maximum intensity projections were also generated. Images were processed on a separate workstation with display 3D volume rendered images, and maximum intensity projection images. DOSE: DLP: 1721.28 mGy.cm COMPARISON: CTA head and neck with and without contrast ___ at 14:19. FINDINGS: CT Head: There is no evidence of hemorrhage, midline shift, mass, mass effect, or acute infarction. The ventricles, sulci and basal cisterns are normal in caliber and configuration. No fractures are identified. There is mild mucosal thickening of the maxillary and sphenoid sinuses. CTA Head: A partially visualized right internal carotid artery metallic stent has been placed in the interval. There is complete occlusion of the visualized extracranial internal carotid artery including cervical, petrosal, cavernous and supraclinoid segments. There is minimal contrast enhancement of the most distal supra clinoid right ICA, from collateral flow. There is mild opacification of the right MCA, which is markedly diminished compared to prior study performed several hr earlier on the same date, as well as decreased flow compared to the left-sided vasculature. The right A1 segment is not opacified, although prior examination showed a hypoplastic right A1 segment. The other vessels, including the left internal carotid artery, left middle cerebral and anterior cerebral arteries and posterior circulation demonstrates unchanged and adequate opacification, compared to earlier study. Again seen is moderate atherosclerotic calcification of the bilateral carotid siphons. There is adequate opacification of the right anterior cerebral artery distal to the Acom. The posterior communicating arteries are not seen. There is no evidence of aneurysm formation. IMPRESSION: 1. No evidence of acute hemorrhage or infarct. 2. Interval placement of right internal carotid artery metallic stent with complete occlusion of the entire internal carotid artery. Minimal collateral retrograde flow is seen at the most distal aspect of the supra clinoid segment. The right MCA demonstrates markedly decreased flow. The left-sided vasculature for is well patent with adequate arterial flow. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 8:35 ___, 5 minutes after discovery of the findings. Radiology Report INDICATION: ___ year old woman with recent interventional procedure with groin access ; evaluate for retroperitoneal hematoma TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis without contrast. Coronal and sagittal reformations were performed. DOSE: DLP: 669 mGy-cm. COMPARISON: None. FINDINGS: ABDOMEN: LUNG BASES: Clear. Normal heart size. LIVER: Homogenous attenuation with no evidence of solid mass. There is no evidence of intrahepatic or extrahepatic biliary dilatation. GALLBLADDER: Normal. PANCREAS: 0.9 cm hypodensity in the tail of the pancreas. A second hypodense lesion is present at the neck of the pancreas measure 1.3 cm 7. There is no ductal dilatation. The pancreas is otherwise normal in appearance. SPLEEN: Normal. ADRENALS: Normal. KIDNEYS: Normal. There is no evidence of stones, solid mass, or hydronephrosis. Two left renal hypodense lesions are present, larger measuring 2.8 cm and the smaller measuring 1.7 cm. The smaller lesion is compatible with a cyst, the larger is indeterminate. BOWEL: Normal in caliber without evidence of obstruction. RETROPERITONEUM: There is no enlarged retroperitoneal or mesenteric lymphadenopathy. VASCULAR: The abdominal aorta demonstrates significant atherosclerosis throughout the aorta with atherosclerosis at the origin of the branch vessels. The right groin catheter sheath is present and terminates in the infrarenal abdominal aorta. There is a 1.3 cm heavily calcified splenic artery aneurysm located at the hilum. PELVIS: URINARY BLADDER: Full contrast, likely due to recent procedure. There is a small amount of urine within the bladder, despite the presence of a Foley catheter. LYMPHADENOPATHY: There are no enlarged pelvic or inguinal lymphadenopathy. FREE FLUID: Small amount of stranding in the right pelvis near the groin, likely representing a small amount of hemorrhage. Small hematoma in the rectus musculature on the right at the inguinal canal, measuring 1.8 x 2.6 cm (2: 71). There is no retroperitoneal hematoma. BONES: There are no suspicious osseous lesions. Moderate to severe compression fracture of the T12 vertebral body. There is mild compression of L1 vertebral body as well. Degenerative disc disease at L5-S1. IMPRESSION: 1. No retroperitoneal hematoma. Mild stranding in the right inguinal region and pelvis with a local rectus sheeth expansion, compatible with a small amount hematoma in this area. 2. 1.3 cm heavily calcified splenic artery aneurysm, located at the hilum. 3. 2 hypodense lesions within the pancreas, likely representing cystic lesions. Further evaluation with MRI is recommended non emergently if clinically indicated. 4. Indeterminate left renal hypodensity measuring 2.8 cm, which may represent a cyst. This can be further evaluated at the time of pancreatic MRI. Radiology Report RADIOLOGY PROCEDURE NOTE SERVICE: Neurosurgery. PROCEDURE PERFORMED: Diagnostic cerebral angiography with acute right ICA clot thrombolysis and aspiration. INDICATIONS: Ms. ___ is an ___ white female who presented with acutely symptomatic stroke and critical right ICA stenosis of 90% or greater. She underwent uncomplicated carotid stenting and received aspirin and Plavix. Postoperatively, she had done well initially and her exam was the same. However, she became more somnolent and less interactive, so CT was done demonstrating no flow to the carotid stent. After a long discussion with the family regarding implications of retreatment, potential for thrombus or thrombolysis, as well as the risk for reperfusion hemorrhage, decision was made to give her IV Integrilin at a loading dose and then bring her down to the angio suite for possible thrombo aspiration. ATTENDING: Dr. ___. ASSISTANT: Dr. ___, Dr. ___. ANESTHESIA: General endotracheal anesthesia. DESCRIPTION OF THE PROCEDURE: Ms. ___ was brought to the neuroangio suite, immediately intubated, and placed on the neuroangio table. Bilateral groins were prepped and draped in the usual sterile fashion. The sheath from the previous procedure had been left in and an exchange for the ___ wire was used to place a new 8 ___ sheath and then a 9 ___ sheath. A 5 ___ ___ 2 catheter was then connected to an RSV, contrast power injector and continuous heparinized saline flush, and used to in ___ configuration access the right common carotid artery. Runs were used to demonstrate occlusion of the stent. Next, under roadmap guidance, an exchange length 0.038 Terumo Glidewire was used to remove the ___ 2 for a 9 ___ ___ balloon guide catheter after the balloon had been prepped. This was placed within the distal common carotid artery. 4MAX reperfusion catheter was then brought up to the proximal face of the clot and then balloon catheter was inflated and mechanical aspiration was used on the clock for roughly two minutes. After this, the catheter was brought back with aspiration and then the balloon was deflated. Intracranial runs were then performed and the catheter was removed and the sheath was left sutured in place. IMAGING FINDINGS: 1. Initial angiography demonstrates injection within the common carotid artery with good filling down into the external carotid artery as well as reflux down into the subclavian and vertebral artery. There is evidence of in-stent thrombosis with complete occlusion in the mid stent with no filling of the ICA distally. Intracranial runs demonstrate this further with preserved external carotid artery filling and slow reflux and reperfusion of the ICA and MCA distribution through collaterals through the external carotid artery and the ophthalmic artery. Final post clot aspiration imaging demonstrates good filling through the common carotid artery and the external carotid artery with open flow through the ICA. There remains stenosis within the actual stent and residual stenosis per NASCET criteria measures 49%. Flow is seen at good timing through the internal carotid artery through the ICA and out into the MCA distribution with no obvious complete cut-off in the distal MCA distribution. There is a plaque and thrombus seen within the internal carotid artery, both within the cervical ICA as well as higher at the ICA bifurcation at the end of the procedure. Due to the risk of bleeding and significant reperfusion hemorrhage, feeling was that adding any further antiplatelet agent or anticoagulant at this point would lead to increased reperfusion hemorrhage risk. CONCLUSIONS: 1. Complete occlusion in her right ICA stent, status post thrombo aspiration with recanalization of the ICA to 49% stenosis with some distal thrombus seen within the ICA. Radiology Report AP CHEST, 12:43 P.M., ___ HISTORY: ___ woman with stroke and nasogastric tube placement. IMPRESSION: AP chest compared to ___: New nasogastric drainage tube ends low in nondistended stomach. Lungs are fully expanded and clear. Pleural effusion is small, if any. ET tube in standard placement. Heart size normal. Radiology Report STUDY: AP chest, ___. HISTORY: ___ woman with stroke. Status post extubation. FINDINGS: Comparison is made to previous study from ___. Endotracheal tube has been removed. A feeding tube is again seen. Heart size is within normal limits. There has been interval development of increased pulmonary interstitial markings suggestive of pulmonary edema. There is no focal consolidation, although there are more confluent densities at the right base. There are no pneumothoraces identified. Radiology Report AP CHEST, 9:36 A.M., ___ HISTORY: An ___ woman with stroke. Rule out pneumonia. IMPRESSION: AP chest compared to ___ and ___: Mild pulmonary edema developed between ___ and ___. Subsequently, the edema has improved somewhat, but there is more consolidation at the right lung base that could be due either to atelectasis or new pneumonia. The heart size is top normal. Nasogastric tube passes into the stomach and out of view. Pleural effusions are small. No pneumothorax. Dr. ___ was paged at 12:30 as soon as the study was reviewed. Radiology Report EXAMINATION: Video oropharyngeal swallowing examination INDICATION: Episodes of dysphagia and possible aspiration. TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in conjunction with the speech and swallow division. Multiple consistencies of barium were administered. COMPARISON: None FINDINGS: Limited examination was performed due to patient's clinical status. There is gross aspiration of nectar with inadequate bolus formation attempted swallowing of purees/thickened barium. Exam was halted at this point and the residual barium was suctioned from the patient's oropharynx. Transferred images are slightly limited due to degraded image quality injure in transferring to the speech and language pathologist's workstation and then to PACS. Original images, viewed at the fluoroscopy machine during the study were of greater quality and satisfactory for diagnosis. IMPRESSION: Gross aspiration of nectar thickened barium and inability to form bolus with pureed barium. Please refer to the speech and swallow division note in OMR for full details, assessment, and recommendations. Radiology Report PICC line placement. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, the patient has received a right-sided PICC line. The tip of the line projects over the lower SVC. The course of the line is unremarkable, no evidence of complications, notably no pneumothorax. Otherwise, the radiograph is unchanged, including the presence of a nasogastric tube. Radiology Report INDICATION: Recent stroke with decreasing hematocrit, status post cerebral angiogram. Assess for pelvic bleed. TECHNIQUE: Helical axial CT imaging was performed through the abdomen and pelvis without the administration of either intravenous or oral contrast material. Multiplanar formats were performed. DOSE: DLP: 662 mGy-cm. COMPARISON: CT abdomen and pelvis from ___. FINDINGS: Abdomen CT: There are new moderate right and small left nonhemorrhagic pleural effusions. Mild associated bilateral lower lobe compressive atelectasis is noted. Lack of intravenous contrast limits assessment of the abdominal organs. There is portal venous gas within the left hepatic lobe (02:20). The liver is otherwise unremarkable. Layering high density material in the gallbladder could be due to vicarious excretion of intravenous contrast related to the prior contrast enhanced CT from ___. The gallbladder is otherwise unremarkable. The spleen is normal. Benign appearing left renal cysts are not significantly changed in size compared to the recent CT from ___, measuring up to 3.3 x 1.7 cm (02:19). The kidneys are otherwise unremarkable. The adrenal glands are normal. There is a 1.8 x 1.7 cm cystic lesion within the pancreatic neck, not significantly changed (02:20). The remainder of the pancreas is unremarkable. There is a small hiatal hernia. An enteric catheter ends within the lower aspect of the stomach. The stomach is otherwise unremarkable. The small bowel is normal limits. There is extensive colonic diverticulosis, without evidence of diverticulitis. Oral contrast material within the colon relates to prior contrast administration for a video oropharyngeal swallow from ___. There is new gas within branches of the right colic vein, likely originating from near the level of the ileocecal valve. There is no associated pneumatosis. There are no pathologically enlarged abdominal lymph nodes. The abdominal aorta is normal in caliber. Marked aortic calcifications are seen. There is a 1.2 cm heavily calcified splenic artery aneurysm, not significantly changed. Pelvis CT: There is a 5.3 x 2.4 cm right groin hematoma, new compared to the prior CT from ___ (02:55). A previously seen right common femoral/external iliac arterial catheter has been removed. A Foley catheter is seen within the bladder. Air within the nondependent aspect of the bladder relates to aforementioned catheterization. There is no free fluid in the pelvis. No pathologically enlarged pelvic lymph nodes are seen. There is extensive rectal fecal loading. Bone windows: No suspicious lytic or blastic lesions are identified. Compression deformities of the T12 and L1 vertebral bodies are not significantly changed, age indeterminate. IMPRESSION: 1. Small right pelvic hematoma, likely related to prior arterial puncture for cerebral angiography. 2. Right colic venous gas as well as venous gas in the left hepatic lobe, without associated pneumatosis, likely benign in nature. Correlation with serum lactate and serial physical exam is recommended. 3. New moderate right and small left nonhemorrhagic pleural effusions. 4. 1.8 cm pancreatic cystic lesion. If serial CT imaging is planned for this patient, this lesion could be followed up on these studies. Otherwise, the standard recommendation for followup would be an MRCP in 6 months. 5. Unchanged benign appearing left renal cysts. 6. Extensive diverticulosis, without evidence of diverticulitis. Rectal fecal loading. NOTIFICATION: Findings were discussed with Dr. ___ by Dr. ___ at 15:55 via telephone on the day of the study, 5 minutes after discovery. Radiology Report INDICATION: Altered mental status. Assess for pneumonia. COMPARISONS: CTA head and neck of ___. FINDINGS: AP and lateral views of the chest demonstrate hyperexpanded lungs. There is no pleural effusion, focal consolidation or pneumothorax. Hilar and mediastinal silhouettes are unremarkable. Heart size is normal is size. There is no pulmonary edema. Moderately severe compression fracture at thoracolumbar junction is of uncertain chronicity. IMPRESSION: 1. No evidence of acute cardiopulmonary process. 2. Moderately severe compression fracture at thoracolumbar junction of uncertain chronicity. Correlate clinically for acuity. Radiology Report EXAMINATION: CTA HEAD AND CTA NECK INDICATION: History: ___ with field cut on left and dizzy // CVA? TECHNIQUE: Contiguous axial images were obtained through the brain without contrast. Subsequently, rapid axial imaging was performed from the aortic arch through the brain during infusion of Omnipaque intravenous contrast material. Three dimensional images were generated on a separate workstation. DOSE: DLP: 1393.86 mGy-cm; CTDI: 54.45 mGy COMPARISON: None. FINDINGS: Head CT: There is no evidence of hemorrhage, edema, masses, mass effect, or infarction. The ventricles and sulci are minimally prominent consistent with age-related atrophy. No fractures are identified. Head CTA: The intracranial carotid and vertebral arteries and their major branches are patent with no evidence of stenoses, occlusions or aneurysm formation. The right anterior communicating artery is hypoplastic. There are calcifications in the cavernous portion of the internal carotid arteries. Neck CTA: There is high-grade stenosis (70 80%) at the bifurcation of the right internal carotid artery that extends approximately 1 cm into the internal carotid artery. There is atherosclerotic calcification at the bifurcation of the left carotid artery, however, there is no flow-limiting stenosis. The right vertebral artery is congenitally small and has a calcified plaque at its origin. The left vertebral artery is without flow-limiting stenosis. No aneurysm or vascular malformation identified. IMPRESSION: High-grade stenosis (70-80%) at the bifurcation the right internal carotid artery that extends approximately 1 cm into the internal carotid artery. The 3D reformations are pending. Once the 3D reformations are obtained an addendum will be issued if any changes are identified. Radiology Report INDICATION: Left-sided weakness and possible seizure. COMPARISONS: CTA of ___. TECHNIQUE: MDCT-acquired contiguous images through the head were obtained without intravenous contrast at 5-mm slice thickness. Coronally and sagittally reformatted images are provided. FINDINGS: There is no evidence of acute intracranial hemorrhage, mass effect or shift of normally midline structures. Linear hyperdensity in right frontal region (2A:25) is felt to be artifactual. No vascular territorial infarction. The sulci and ventricles are prominent, likely age-related involutional changes. The basal cisterns are patent. There is no evidence of herniation. No acute fracture is seen. The imaged paranasal sinuses and mastoid air cells are well aerated. The orbits are unremarkable. There is rotatory orientation of C1 and C2, which is new since study obtained two hours prior. IMPRESSION: 1. No evidence of acute intracranial process. 2. Rotatory orientation of C1 and C2 is most likely positional, however, clinical correlation is recommended to exclude underlying ligamentous injury. Radiology Report RADIOLOGY PROCEDURE NOTE SERVICE: Neurosurgery. PROCEDURE PERFORMED: Diagnostic cerebral angiography with injections of the right common carotid artery, right internal carotid artery stenting for acute symptomatic carotid stenosis and stroke, in-stent balloon angioplasty. INDICATIONS: Ms. ___ is an ___ white female who presented to the emergency department with significant right-sided ICA stenosis. Her symptoms initially started five hours ago; however, she improved back to her baseline. Over the last hour, she has developed significant left-sided weakness and neglect, indicative of a right parietal stroke syndrome and an ___ stroke scale of 10. Her CTA demonstrates critical right ICA stenosis, indicative of likely stroke. After discussion with the family, plan was made to bring the patient to the neuroangio suite for potential intra-arterial stroke therapy. ATTENDING: Dr. ___. ASSISTANT: Dr. ___, Dr. ___. ANESTHESIA: General endotracheal anesthesia. MEDICATIONS EMPLOYED: The patient was brought to the angio suite after having been loaded with 325 mg of aspirin rectally as well as 600 mg of Plavix rectally in the emergency department. She had previously been on aspirin. She was also on heparin drip at time of the procedure. DESCRIPTION OF PROCEDURE: The patient was emergently brought to the neuroangio suite and quickly intubated while a very brief timeout was performed. Her bilateral groins were prepped and draped in the usual sterile fashion and her right femoral artery was accessed using anatomic landmarks. Using a micropuncture needle kit and Seldinger technique, an 8 ___ sheath was placed in the right femoral artery, sutured in place and connected to a continuous heparinized saline flush. Next, a 5 ___ ___ 2 catheter was connected to an RHV, continuous heparinized saline flush, and a contrast power injector and brought over the aortic arch using an 0.038 Terumo Glidewire. A ___ configuration was performed and the right common carotid artery was accessed. Cervical and intracranial AP and lateral angiography was then performed. Next, under roadmap guidance, the ___ 2 was brought into the external carotid artery and exchanged with a 0.035 Amplatz exchange wire for a 6 ___ Cook shuttle; was used to place the Cook shuttle in the distal common carotid artery. Next, under roadmap guidance, carefully an Emboshield NAV6 was placed within the distal internal carotid artery and deployed successfully, and then over the Monorail system, an Xact carotid stent was placed within the internal carotid artery and deployed without any problems. AP and lateral angiography then followed. Next, a 5 x 30 ___ balloon was brought up within the stent and inflated and then deflated. Final intracranial AP and lateral angiography then followed and the patient was allowed to wake up and she was found to be extubated at her largely same preoperative exam with an ___ stroke scale of ___. IMAGING FINDINGS: 1. RIGHT COMMON CAROTID ARTERY: Injection is seen with the catheter in the proximal common carotid artery with some reflux down into the subclavian and the vertebral artery. Common carotid artery demonstrates good filling to the common carotid and the external carotid artery, but sluggish flow through the internal carotid artery. There is an obvious ulcerated and stenotic plaque at the ICA bifurcation with thrombus associated with it, and significant stenosis of the artery, measuring 91% per NASCET criteria. The distal flow through the ICA is quite sluggish and fills in a delayed fashion. Intracranial AP and lateral angiography demonstrates good rapid filling of the external carotid artery branches and very slow sluggish filling through a normally contoured distal ICA. The origins of the ophthalmic and anterior choroidal arteries appear normal through this injection; however, there is no evidence of a PCom. There is no communication with an ACA from this side and there is an isolated right MCA distribution hemisphere. Subsequent imaging demonstrates guide catheter position within the common carotid artery and stent deployment across the ICA stenosis with improved flow through the ICA. Post-balloon angioplasty demonstrates good position of the stent within the ICA down into the common carotid artery and a smoothly contoured appearance of the ICA. The residual stenosis measures 10% after procedure. Final intracranial AP and lateral angiography demonstrates rapid filling of the ICA with no filling of the ACA distribution and minimal PCom communication, but completely preserved and intact appearance of the MCA vasculature with no appearance of cut-off and good parenchymal filling and venous egress. CONCLUSIONS: 1. Symptomatic right ICA stenosis with 91% degree of stenosis status post carotid stenting with resolution of the ulcerated plaque and stenosis down to 9%. Markedly improved flow is seen distally within the ICA to the isolated right MCA filling with no distal evidence of thromboembolic complications. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: R/O STROKE Diagnosed with CEREBRAL ART OCCLUS W/INFARCT temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: nan

Dear ___, ___ were hospitalized due to symptoms of headache, lightheadedness, intermittent dysarthria, left lower face weakness, and difficulty using the left side 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. 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 - High Cholesterol We are changing your medications as follows: - We are STARTING ___ on ATORVASTATIN 80mg daily - We are STARTING ___ on TYLENOL ___ every 6 hours as need for pain or fever - We are INCREASING your ASPIRIN to 325mg daily - We are STARTING ___ on AMLODIPINE 10mg dailhy - We are STARTING ___ on BISACODYL 10mg as needed for constipation - We are STARTING ___ on CLOPIDOGREL 75mg daily - We are STARTING ___ on DOCUSATE 100mg two times daily - We are STARTING ___ on FLUCONAZOLE 200mg daily - We are STARTING ___ on METOPROLOL 50mg BID - We are STARTING ___ on PIPERACILLIN-TAZOBACTAM 4.5g IV every eight hours - We are STARTING ___ on SENNA 8.6mg two times daily - We are STARTING ___ on VANCOMYCIN 1000mg IV two times daily - We are INCREASING your OMEPRAZOLE to 40mg once a day. - We are STOPPING ATENOLOL 50mg daily - We are STOPPING ALPRAZOLAM 0.25mg BID as needed Please take your other medications as prescribed. Please followup with Neurology and your primary care physician as listed below. It was a pleasure providing ___ with care during this hospitalization.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Oxycodone Attending: ___. Chief Complaint: possible seizure, AMS Major Surgical or Invasive Procedure: Lumbar puncture ___ History of Present Illness: ___ female with h/o HTN, COPD, and PAD, presenting with question of new seizure. Per husband, pt was feeling fine and mentating at baseline yesterday afternoon. Husband noted yesterday 5:30pm that the patient had gentle constant shaking of her upper and lower extremities lasting approximately ___ with dry heaving for ___. During that time the patient had a decreased level of responsiveness, did not recognize her husband, and would not answer the husband's questions, speaking "gibberish." No bleeding from tongue. Husband noticed diaper was soaked with urine after shaking was over (has fecal and urinary incontinence at baseline). Afterwards she seemed very sleepy and slept for approximately 3 hours. Pt's husband and son woke pt up and she had difficulty expressing that her chronic leg pain was bothering her and spoke in broken sentences; also c/o HA. Pt was given home Dilaudid and went to sleep. This am, pt still not oriented and didn't recognize husband and had trouble finding words. Pt received another dose of Dilaudid and husband called PCP who recommended transfer to ___. She was complaining of some lower abdominal pain. No shortness breath, cough, chest pain. No weakness in her upper or lower extremities, headache. L midline in for IVF ___ due to poor PO intake for past 2 months. 15# weight loss in past 2 months. Last BM yesterday. In the ___, initial vitals 7.9 95 124/62 16 93% Had mild improvement of mental status per husband in ___ initially- 1pm- became agitated and had worsening of slurred speech. Received Dilaudid and pt improved in terms of speech. Exam notable for A&O to person Labs notable for fs-123 The pt underwent an LP, traumatic after low-grade fever of 100.7 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: PMH: Hypertension, emphysema, peripheral arterial disease, 4.5 cm thoracic aneurysm with ulcerative plaque, juxta renal aneurysm ~ 4.9 cm, old cerebellar infarct, vitamin B12 deficiency, chronic back pain, gait instability, macrocytosis, lung mass. PSH: - ___ Left common femoral artery to above-knee popliteal artery bypass using 6-mm supported Maquet graft - ___ Right femoral to popliteal bypass graft. - "throat surgery", Social History: ___ Family History: FH: Non-contributory Physical Exam: On admission: VS - 98.3 95 148/75 18 96% RA GENERAL - NAD, comfortable, confused, thin HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear, no facial asymmetry. NECK - supple, no LAD LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - hypoactive BS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - atrophic L calf, no calf tenderness bilaterally SKIN - no rashes or lesions, no cyanosis of feet NEURO - awake, A&Ox1 (not oriented to place or time), CNs II-XII grossly intact, muscle strength ___ throughout, ___ strenght in L foot plantar/dorsiflexion, sensation grossly intact throughout, gait deferred, no Babinski's sign On discharge: Afebrile, BP 150s-160s, non-tachycardic, non-tachypneic, saturating high ___ on RA GA: NAD, comfortable, thin, pleasant, interacting appropriately HEENT: PERRLA, EOMI, sclerae anicteric, MMM, OP clear, no facial asymmetry. NECK - supple, no LAD LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - normoactive BS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - atrophic L calf, no calf tenderness bilaterally SKIN - no rashes or lesions, no cyanosis of feet NEURO - awake, A&Ox2 (not oriented to time), CNs II-XII grossly intact, muscle strength ___ throughout, ___ strenght in L foot plantar/dorsiflexion, sensation grossly intact throughout, gait deferred Pertinent Results: On admission: ___ 11:57AM BLOOD WBC-13.0*# RBC-3.49* Hgb-11.0* Hct-34.3* MCV-98 MCH-31.6 MCHC-32.2 RDW-14.0 Plt ___ ___ 11:57AM BLOOD Neuts-85.5* Lymphs-9.8* Monos-3.7 Eos-0.9 Baso-0.2 ___ 11:57AM BLOOD ___ PTT-35.2 ___ ___ 11:57AM BLOOD Glucose-103* UreaN-19 Creat-0.6 Na-141 K-4.2 Cl-104 HCO3-30 AnGap-11 ___ 11:57AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.2 ___ 11:57AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 12:10PM BLOOD Glucose-91 Lactate-1.8 K-4.1 ___ 02:30PM URINE Color-Yellow Appear-Clear Sp ___ ___ 09:49PM URINE Color-Yellow Appear-Clear Sp ___ ___ 09:49PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 02:30PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM ___ 09:49PM URINE RBC-2 WBC-3 Bacteri-FEW Yeast-NONE Epi-0 ___ 02:30PM URINE RBC-1 WBC-8* Bacteri-FEW Yeast-NONE Epi-0 On discharge: ___ 05:30AM BLOOD WBC-6.2 RBC-3.55* Hgb-10.8* Hct-34.6* MCV-98 MCH-30.4 MCHC-31.1 RDW-13.8 Plt ___ ___ 05:30AM BLOOD ___ PTT-39.4* ___ ___ 05:30AM BLOOD Glucose-94 UreaN-9 Creat-0.5 Na-144 K-4.1 Cl-108 HCO3-24 AnGap-16 ___ 05:30AM BLOOD Calcium-8.9 Phos-4.3 Mg-2.0 Radiology: ___ CT head FINDINGS: There is no acute hemorrhage, edema, mass effect, or large territorial infarction. Hypodense areas within the left cerebellar hemisphere, left occipital lobe, and within the right pons are consistent with prior infarcts. There are multiple lacunar infarcts within the basal ganglia bilaterally. There is extensive periventricular white matter hypodensity consistent with chronic small vessel ischemic disease. The ventricles and sulci are prominent, likely due to age-related atrophy. Carotid siphon calcifications are noted. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. There is no fracture. IMPRESSION: 1. No acute intracranial process. However, if there is clinical concern for acute infarction, MRI is more sensitive. 2. Multiple areas of old infarction. 3. Chronic small vessel ischemic disease and atrophy. Micro: **FINAL REPORT ___ URINE CULTURE (Final ___: ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ 1 S ___ MRI head FINDINGS: Motion degrades the quality of this study. There is no evidence of recne t infarct. There are extensive T2/FLAIR hyperintensities in the periventricular and subcortical white matter, which is nonspecific but is likely related to small vessel ischemic changes. There are two old infarcts in the left occipital and left cerebellar hemisphere. There are also multiple deep white matter lacunes. There is a focus of old hemorrhage lateral to the atrium of the left lateral ventricle. There is no evidence of abnormal enhancement. There is prominence of the extra-axial CSF spaces and ventricles suggesting global cerebral volume loss. IMPRESSION: No acute infarct. Extensive small vessel ischemic changes with lacunar infarcts and two larger infarcts in the left occipital and left cerebellum as described. No abnormal enhancement. Neuro: ___ EEG 20 minute: slow background, sharps in L temporal lobe. FINDINGS: CONTINUOUS EEG RECORDING: Began at 7:01 on the morning of ___ ___ and continued for 24 hours. At the beginning, it showed a normal-appearing 8 Hz alpha frequency background bilaterally in wakefulness. There were also bursts of mixed frequency slowing in the left temporal region on a few left temporal spike discharges, primarily at T3. T here were also occasional or subtle generalized slowing, some with mildly sharp features. Less frequently, there were single generalized high voltage sharp waves with a frontal maximum. SPIKE DETECTION PROGRAMS: Showed the same fairly frequent left temporal spikes plus less frequent generalized sharp waves. There were no repetitive discharges. SEIZURE DETECTION PROGRAMS: Showed no electrographic seizures. PUSHBUTTON ACTIVATIONS: There were none. SLEEP: The patient progressed from wakefulness to sleep without additional findings. CARDIAC MONITOR: Showed a generally regular rhythm. IMPRESSION: This telemetry captured no pushbutton activations. The recording showed a normal background in wakefulness and sleep. There were frequent isolated and non-repetitive spike discharges in the left mid temporal region, and there were several generalized sharp waves. There were no repetitive discharges or electrographic seizures. There was some focal slowing in the left temporal region, as well. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. B-12 DOTS *NF* (cyanocobalamin (vitamin B-12)) 200 MCG Oral 1 daily anemia 2. Multivitamins 1 TAB PO DAILY 3. Gabapentin 300 mg PO TID pain 4. Clopidogrel 75 mg PO DAILY blood clot 5. Ranitidine (Liquid) 150 mg PO BID acid reducer 6. Docusate Sodium (Liquid) 100 mg PO BID stool softner 7. Acetaminophen (Liquid) 650 mg PO Q8H:PRN pain 8. HYDROmorphone (Dilaudid) 4 mg PO Q3H:PRN pain 9. Warfarin 1 mg PO DAILY16 blood clot 10. Pravastatin 20 mg PO DAILY cholesterol 11. Mirtazapine 7.5 mg PO HS mood 12. Polyethylene Glycol 17 g PO DAILY constipation Discharge Medications: 1. Lorazepam 0.5-1 mg PO Q6H:PRN agitation RX *lorazepam 0.5 mg ___ tablet(s) by mouth every six (6) hours Disp #*56 Tablet Refills:*0 2. B-12 DOTS *NF* (cyanocobalamin (vitamin B-12)) 200 MCG Oral 1 daily anemia 3. Warfarin 1 mg PO DAILY16 4. Ranitidine (Liquid) 150 mg PO BID acid reducer 5. Pravastatin 20 mg PO DAILY 6. Polyethylene Glycol 17 g PO DAILY constipation 7. Multivitamins 1 TAB PO DAILY 8. Mirtazapine 7.5 mg PO HS 9. HYDROmorphone (Dilaudid) 4 mg PO Q3H:PRN pain 10. Gabapentin 300 mg PO TID pain 11. Docusate Sodium (Liquid) 100 mg PO BID 12. Clopidogrel 75 mg PO DAILY 13. Acetaminophen (Liquid) 650 mg PO Q8H:PRN pain 14. Ampicillin 500 mg PO Q6H RX *ampicillin 500 mg 1 capsule(s) by mouth every six (6) hours Disp #*36 Capsule Refills:*0 15. Normal saline Please administer 1L NS via IV three times a week (MWF) 16. Saline Flush 10cc saline flushes after each access from midline. Discharge Disposition: Home With Service Facility: ___ ___: Seizure of unknown origin Urinary tract infection, complicated Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Followup Instructions: ___ Radiology Report INDICATION: ___ woman with likely new onset seizure, evaluate for intracranial hemorrhage or mass. COMPARISONS: None. TECHNIQUE: MDCT axial images were obtained through the brain without the administration of intravenous contrast material. Coronal and sagittal reformats were completed. FINDINGS: There is no acute hemorrhage, edema, mass effect, or large territorial infarction. Hypodense areas within the left cerebellar hemisphere, left occipital lobe, and within the right pons are consistent with prior infarcts. There are multiple lacunar infarcts within the basal ganglia bilaterally. There is extensive periventricular white matter hypodensity consistent with chronic small vessel ischemic disease. The ventricles and sulci are prominent, likely due to age-related atrophy. Carotid siphon calcifications are noted. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. There is no fracture. IMPRESSION: 1. No acute intracranial process. However, if there is clinical concern for acute infarction, MRI is more sensitive. 2. Multiple areas of old infarction. 3. Chronic small vessel ischemic disease and atrophy. These findings were discussed with Dr. ___ by Dr. ___ telephone at 3:10 p.m, ___. Radiology Report HISTORY: New seizure. TECHNIQUE: Upright AP and lateral views of the chest. COMPARISON: Chest radiograph ___. Chest CTA ___. FINDINGS: The heart size is normal. Aorta is tortuous with enlargement of the aortic knob and displaced intimal calcifications compatible with known aortic arch aneurysm, unchanged. The pulmonary vascularity is not engorged. The lungs are hyperinflated with emphysematous changes again noted. Increased streaky opacity in the right lung base may reflect atelectasis though infection cannot be excluded. 15 mm lingular nodule is unchanged. No pleural effusion or pneumothorax. A mid thoracic vertebral body compression deformity is re- demonstrated. IMPRESSION: 1. Increased streaky opacity within the right lung base which could reflect atelectasis but infection cannot be excluded. 2. Emphysema. 3. Unchanged 15 mm nodule within the lingula. As noted on the prior PET CT from ___, continued imaging followup of this lesion is recommended, and a chest CT should be obtained at this time. 4. Aortic arch aneurysm, unchanged. Radiology Report INDICATION: ___ woman with hypertension, peripheral artery disease, with aphasia and altered mental status, status post possible seizure, evaluate for infarct or mass. TECHNIQUE: Multiplanar, multisequence MRI of the brain was obtained before and after the administration of IV gadolinium as per departmental protocol. 5 mL of Gadovist was administered. COMPARISON: CT head of ___. FINDINGS: Motion degrades the quality of this study. There is no evidence of recne t infarct. There are extensive T2/FLAIR hyperintensities in the periventricular and subcortical white matter, which is nonspecific but is likely related to small vessel ischemic changes. There are two old infarcts in the left occipital and left cerebellar hemisphere. There are also multiple deep white matter lacunes. There is a focus of old hemorrhage lateral to the atrium of the left lateral ventricle. There is no evidence of abnormal enhancement. There is prominence of the extra-axial CSF spaces and ventricles suggesting global cerebral volume loss. IMPRESSION: No acute infarct. Extensive small vessel ischemic changes with lacunar infarcts and two larger infarcts in the left occipital and left cerebellum as described. No abnormal enhancement. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: ? SZ YESTERDAY Diagnosed with OTHER CONVULSIONS, FEVER, UNSPECIFIED, OTHER MALAISE AND FATIGUE, HX VENOUS THROMBOSIS/EMBOLISM, LONG TERM USE ANTIGOAGULANT temperature: 97.9 heartrate: 95.0 resprate: 16.0 o2sat: 93.0 sbp: 124.0 dbp: 62.0 level of pain: 0 level of acuity: 3.0

Dear ___ was our pleasure caring for you at the ___. You were admitted to the hospital for concerns of a possible seizure you endured the night before admission which caused you to have confusion and agitation thereafter. We did a CT and MRI scan of your head and worked with the neurology team to investigate the cause of your confusion. The images of your brain showed old lesions which indicate past strokes. We could not find any brain infection which could have also been the cause of your seizure. We are treating you with an antibiotic for a urinary tract infection which you are to complete at home (total of 10 day course). You expressed your wish to return home and have comfort-focused care. You will have visiting nurses and physical therapy to care for you at home. The palliative care team will also continue to see you and further discuss your goals of care. Since you are possibly at risk for future seizures, we also recommend you follow-up with a neurologist (their office will call you).

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Codeine / Zosyn / Penicillins / Indomethacin / epinephrine / Versed Attending: ___. Chief Complaint: falls Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ with a history significant for CF with MAC, temporal lobe epilepsy, stable carotid stenosis, depression, and anxiety disorder, who was referred in from PCP after patient reports 2 week history of increased falls and lower extremity weakness. PCP is requesting coordination of care through psychiatry and neurology. He presented today reporting falling 5 times PTA with report that legs feel weak and will not support him. The patient stated that this has been going on for about 3 months. He also reports that he has ongoing vertigo but this symptom does not always precede weakness in his legs. He denies any vision changes, headaches, N/V, paresthesias/decreased sensation, myalgias/arthralgias, and endorses normal appetite recently. He has not had loss of consciousness, or had any focal neurological deficits. He does not feel lightheaded, and denies chest pain, worsening shortness of breath, dyspnea on exertion or worsening cough. Denies any shaking movements or stiffening. He notes that he has become less active within the last year, but cannot contribute his lack of activity to anything specifically. He has a history of steatosis, chronic diarrhea, and pancreatitis secondary to CF which he was diagnosed with in ___. However, he currently does not endorse any changes in bowel habits or increase in diarrhea. He does note he has a history of anxiety and depression, and is being followed by psychiatry but is not on any SSRIs. He only takes trazadone QHS. When asked about his mood and what activities he enjoys, the patient notes he has depressed mood, does not have much social or family support, and endorses work stressors. He also is noted to be perserverating on his diagnosis and consequences of his diagnosis. Per report from ED staff, patient is also suicidal - has intermittently gone to the roof and thought about jumping off. No actual suicide attempts, sees a therapist and psychiatrist but takes no medications for depression currently. Misunderstood directions about taking citalopram and has not taken it correctly. In the ED, initial vital signs were: - Exam was notable for: normal neurologic examination - Labs were notable for Cr 1.3 (baseline 0.9-1), MCV 99 - Head imaging showed no acute intracranial process. - Psychiatry was consulted, and recommended continuing 1:1 sitter at this point Past Medical History: - Cystic Fibrosis and diffuse bronchiectasis (___) - followed by ___ at ___ Clinic - Hepatic/Splenic steatosis (___) - ?Chronic pancreatitis, chronic diarrhea - Mitral valve prolapse (___) - SVT s/p Cardiac ablation ___ - left temporal lobe epilepsy (___) - followed by Dr. ___ - ___ disorder, Insomnia - Depression - tried various SSRIs without success - Eczema - GERD, esophageal spasm s/p fundoplication (___) - Hypertension - BPH s/p TURP (___) - Primary nocturnal diuresis (___) - chronic ___ pulmonary infection - Carotid Stenosis - Strabismus Social History: ___ Family History: - siblings heterozygous for cystic fibrosis gene (Delta 508) - father died of esophageal cancer. h/o alcoholism - 2 sisters with lung cancer (both smokers) - paternal aunt with cystic fibrosis, died at age ___ Physical Exam: PHYSICAL EXAM ON ADMISSION VITALS - T 98.9, BP 122/61, HR 69, R 18, SpO2 96%/RA GENERAL - pleasant, well-appearing, in no apparent distress HEENT - normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear; no end gaze nystagmus NECK - JVP not elevated CARDIAC - regular rate & rhythm, normal S1/S2, audible systolic click PULMONARY - clear to auscultation bilaterally, without wheezes or rhonchi ABDOMEN - normal bowel sounds, soft, non-tender, non-distended, no organomegaly EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or edema SKIN - without rash GU - dark urine in urinal at bedside NEUROLOGIC - A&Ox3, CN II-XII grossly normal, normal sensation, with strength ___ in both proximal and distal upper and lower extremities. Gait WNL. Heel walk and toe walk intact. Able to stand from squatting position without difficulty. PSYCHIATRIC - listen & responds to questions appropriately, calm, perseverating on CF DX; occasionally losing train of thought though redirectable PHYSICAL EXAM ON DISCHARGE VITALS - T 98.9, BP 120s-140s/60s, HR 69, R 18, SpO2 96%/RA GENERAL - pleasant, well-appearing, in no apparent distress HEENT - normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear; no end gaze nystagmus NECK - JVP not elevated CARDIAC - regular rate & rhythm, normal S1/S2, audible systolic click PULMONARY - clear to auscultation bilaterally, without wheezes or rhonchi ABDOMEN - normal bowel sounds, soft, non-tender, non-distended, no organomegaly EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or edema SKIN - without rash GU - dark urine in urinal at bedside NEUROLOGIC - A&Ox3, CN II-XII grossly normal, normal sensation, with strength ___ in both proximal and distal upper and lower extremities. Gait WNL. Heel walk and toe walk intact. Able to stand from squatting position without difficulty. PSYCHIATRIC - listen & responds to questions appropriately, calm, perseverating on CF DX; occasionally losing train of thought though redirectable Pertinent Results: LABS ON ADMISSION ___ 02:13PM BLOOD ___-6.2 RBC-4.70 Hgb-15.4 Hct-46.6 MCV-99* MCH-32.8* MCHC-33.0 RDW-13.4 RDWSD-48.5* Plt ___ ___ 02:13PM BLOOD ___ PTT-30.1 ___ ___ 02:13PM BLOOD Glucose-119* UreaN-16 Creat-1.3* Na-140 K-4.7 Cl-100 HCO3-27 AnGap-18 ___ 02:13PM BLOOD ALT-40 AST-88* AlkPhos-141* TotBili-1.4 ___ 02:13PM BLOOD Albumin-4.0 ___ 02:20PM BLOOD Lactate-1.7 LABS ON DISCHARGE ___ 06:41AM BLOOD WBC-5.2 RBC-4.27* Hgb-13.6* Hct-41.9 MCV-98 MCH-31.9 MCHC-32.5 RDW-13.5 RDWSD-48.3* Plt ___ ___ 06:10AM BLOOD Glucose-93 UreaN-17 Creat-1.1 Na-141 K-4.2 Cl-102 HCO3-27 AnGap-16 ___ 06:41AM BLOOD LD(LDH)-150 CK(CPK)-59 ___ 06:10AM BLOOD Calcium-9.7 Phos-3.7 Mg-1.8 IMAGING ___ CT scan head IMPRESSION: No acute intracranial process. ___ CXR IMPRESSION: No acute cardiopulmonary process. ___ EKG Sinus rhythm at the upper limits of normal rate. Single atrial premature beat. Q waves in leads V1-V3. Consider anteroseptal myocardial infarction. There is generalized low voltage. Compared to the previous tracing of ___ no significant change. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Valsartan 160 mg PO DAILY 2. Fluocinolone Acetonide 0.025% Ointment 1 Appl TP DAILY 3. Diphenoxylate-Atropine 2 TAB PO BID 4. DiCYCLOmine 10 mg PO TID 5. Hyoscyamine SO4 (Time Release) 0.375 mg PO BID 6. ClonazePAM 1 mg PO BID 7. ClonazePAM 0.5 mg PO QAFTERNOON 8. Ranitidine 150 mg PO QHS 9. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 10. Desmopressin Acetate 0.2 mg PO QHS 11. Pantoprazole 40 mg PO Q12H 12. Aspirin 325 mg PO DAILY 13. Levalbuterol Neb 0.63 mg NEB TID 14. Cyanocobalamin 1000 mcg PO DAILY 15. Vitamin D ___ UNIT PO DAILY 16. dornase alfa 2.5 mg inhalation BID Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. ClonazePAM 1 mg PO BID 3. ClonazePAM 0.5 mg PO QAFTERNOON 4. Cyanocobalamin 1000 mcg PO DAILY 5. Desmopressin Acetate 0.2 mg PO QHS 6. DiCYCLOmine 10 mg PO TID 7. Diphenoxylate-Atropine 2 TAB PO BID 8. Fluocinolone Acetonide 0.025% Ointment 1 Appl TP DAILY 9. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 10. Hyoscyamine SO4 (Time Release) 0.375 mg PO BID 11. Levalbuterol Neb 0.63 mg NEB TID 12. Pantoprazole 40 mg PO Q12H 13. Ranitidine 150 mg PO QHS 14. Valsartan 160 mg PO DAILY 15. Vitamin D ___ UNIT PO DAILY 16. dornase alfa 2.5 mg inhalation BID Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ================= Weakness Cystic Fibrosis Depression Acute Kidney Injury SECONDARY DIAGNOSIS =================== Gastroesophageal Reflux Disease Temporal lobe epilepsy Primary nocturnal enuresis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with progressive cognitive decline, unsteady gait w/recent falls // eval for PNA TECHNIQUE: Frontal and lateral views of the chest. COMPARISON: ___ chest x-ray and ___ chest CT. FINDINGS: Right middle lobe bronchiectasis and calcified granulomas explain the linear and nodular opacities projecting over the right lung base. The lungs are otherwise clear. There is no consolidation, effusion, or edema. The cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ with frequent falls // r/o acute process TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained without intravenous contrast. Coronal and sagittal reformats were also performed. DOSE: Total DLP (Head) = 903 mGy-cm. COMPARISON: Brain MRI from ___. Head CT from ___. FINDINGS: There is no intra-axial or extra-axial hemorrhage, mass, midline shift, or acute major vascular territorial infarct. Gray-white matter differentiation is preserved. Ventricles and sulci are prominent compatible with global volume loss. Basilar cisterns are patent. Included paranasal sinuses and mastoids are essentially clear besides mild mucosal thickening in the ethmoids and right maxillary sinus. Patient is status post apparent endoscopic sinus surgery on the left. Stranding within the posterior subcutaneous tissues is unchanged from prior exams. Skull and extracranial soft tissues are otherwise unremarkable. IMPRESSION: No acute intracranial process. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: s/p Fall Diagnosed with Major depressive disorder, single episode, unspecified, Low self-esteem temperature: 96.8 heartrate: 74.0 resprate: 18.0 o2sat: 99.0 sbp: 128.0 dbp: 69.0 level of pain: 0 level of acuity: 3.0

Mr. ___, You were admitted to ___ because of some falls you have been having at home. Your medical work up for the cause of your falls was negative. You were also seen by physical therapy and psychiatry. Please make sure you follow up with your primary care physician, ___, Dr. ___ your neurologist at your earliest convenience. It was a pleasure taking part in your care Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: doxycycline / lisinopril Attending: ___ ___ Complaint: Dyspnea Major Surgical or Invasive Procedure: Intubation ___ Extubation ___ History of Present Illness: This is a ___ with past medical history of hypertension, chronic back pain attributed to lumbar disc disease, Diabetes type 2 complicated by Diabetic neuropathy, chronic opiates for above issues complicated by constipation requiring movantik, GERD with chronic reflux, COPD, ongoing tobacco abuse, schizoaffective disorder with a prior suicide attempt, who presents with progressive cough and dyspnea x 10 days. Patient reports that 10 days prior to presentation, she noticed symptoms of cough productive of green sputum. Denies chest pain, palpitations, lower extremity edema. Patient initially presented to ___, but was transferred to ___ ED due to concern about her respiratory status and reported question of confusion. In the ___ ED, initial VS were 96.7 ___ 20 90% Nasal Cannula ___ 323; exam was reported as "exp wheezing throughout and rhonchi". labs were notable for WBC 10.4, Hgb 14.5, Plt 224; Cr 0.6, HCO3 27, lactate 2.0, VBG 7.34/56 --> 7.33/60; CXR without acute cardiopulmonary abnormality. Patient was given albuterol, ipratropium, Dilaudid, clonazepam, IV mag sulfate, 6 units insulin, metoprolol and was admitted to medicine for further management. On arrival to the floor, patient confirmed above. Reported feeling safe. Also reported she thinks she may have a periumbilical hernia. Full 10 point review of systems positive where noted, otherwise negative. Past Medical History: Hypertension Hyperlipemia Chronic back pain attributed to lumbar disc disease Diabetes type 2 complicated by Diabetic neuropathy Colon polyps COPD Schizoaffective disorder, bipolar type, with prior suicide attempt Social History: ___ Family History: Mother had pulmonary embolism Father had lung cancer Physical Exam: ADMISSION EXAM VS: 98.1PO 141 / 92 107 22 95 4LNC Gen: sitting up in bed, comfortable Eyes - EOMI ENT - OP clear, MMM Heart - RRR no mrg Lungs - expiratory wheezing throughout, good air movement; no ronchi no crackles; Abd - soft nontender, normoactive bowel sounds; on coughing, has small reducible periumbilical hernia, nontender; no rebound/guarding Ext - no edema Skin - cool, no rashes Vasc - 2+ DP/radial pulses Neuro - AOx3, tangential with pressured speech, but redirectable; ___ in extremities; Psych - tangential as above; DISCHARGE EXAM VITALS: SATTING 92% ON RA; HR 100S SINUS GENERAL: confused but calm, AO x name only ___ anicteric, MMM NECK: JVP not elevated, no LAD LUNGS: Wheezes throughout, poor air movement B/L CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: No rashes NEURO: sedated Pertinent Results: LABS ON ADMISSION ___ 11:00AM BLOOD WBC-10.4* RBC-5.45* Hgb-14.5 Hct-43.9 MCV-81* MCH-26.6 MCHC-33.0 RDW-14.2 RDWSD-41.2 Plt ___ ___ 11:00AM BLOOD Neuts-85.6* Lymphs-8.4* Monos-5.5 Eos-0.0* Baso-0.2 Im ___ AbsNeut-8.94* AbsLymp-0.88* AbsMono-0.57 AbsEos-0.00* AbsBaso-0.02 ___ 04:55AM BLOOD ___ PTT-30.2 ___ ___ 11:00AM BLOOD Glucose-387* UreaN-11 Creat-0.6 Na-140 K-3.9 Cl-97 HCO3-27 AnGap-16 ___ 04:55AM BLOOD ALT-22 AST-22 LD(LDH)-246 AlkPhos-88 TotBili-0.4 ___ 05:56AM BLOOD cTropnT-<0.01 proBNP-97 ___ 04:55AM BLOOD cTropnT-<0.01 proBNP-90 ___ 11:00AM BLOOD Calcium-9.8 Phos-1.7* Mg-1.9 ___ 05:56AM BLOOD TSH-0.08* ___ 05:58AM BLOOD T4-6.9 ___ 11:12AM BLOOD Lactate-2.0 ___ 11:44AM BLOOD ___ O2 Flow-4 pO2-27* pCO2-56* pH-7.34* calTCO2-32* Base XS-1 Intubat-NOT INTUBA LABS ON DISCHARGE ___ 04:17AM BLOOD WBC-7.7 RBC-4.75 Hgb-12.7 Hct-40.0 MCV-84 MCH-26.7 MCHC-31.8* RDW-14.4 RDWSD-44.2 Plt ___ ___ 04:17AM BLOOD Neuts-56.4 ___ Monos-8.7 Eos-1.2 Baso-0.3 Im ___ AbsNeut-4.34 AbsLymp-2.50 AbsMono-0.67 AbsEos-0.09 AbsBaso-0.02 ___ 04:17AM BLOOD ___ PTT-28.0 ___ ___ 04:17AM BLOOD Glucose-85 UreaN-13 Creat-0.4 Na-141 K-3.7 Cl-93* HCO3-39* AnGap-9* ___ 03:20AM BLOOD ALT-15 AST-18 AlkPhos-64 TotBili-0.2 ___ 04:17AM BLOOD Calcium-8.8 Phos-4.4 Mg-2.1 ___ 03:27AM BLOOD ___ Temp-37.1 ___ Tidal V-500 PEEP-5 FiO2-40 pO2-54* pCO2-66* pH-7.43 calTCO2-45* Base XS-15 As/Ctrl-ASSIST/CON Intubat-INTUBATED ___ 04:57AM BLOOD Lactate-0.8 CULTURES BCx ___ NGTD UCx ___ NGTD ET sputum ___ 12:12 am SPUTUM Source: Endotracheal. GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Preliminary): IMAGING ECHO ___ The left atrium is normal in size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). There is a mild resting left ventricular outflow tract obstruction. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal biventricular function. Mild aortic stenosis. CXR ___ EXAMINATION: Chest portable radiograph INDICATION: ___ year old woman with COPD, intubated for AMS/delirium and hypoxia// edema, consolidations TECHNIQUE: Chest portable radiograph COMPARISON: Chest radiograph most recently done on ___ FINDINGS: Stable, mild interstitial edema. Unchanged position of endotracheal tube and nasogastric tube. Cardiomediastinal silhouette is stable. There is bibasilar atelectasis. No pneumothorax. IMPRESSION: Stable mild interstitial edema. Unchanged position of supportive and monitoring devices. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation PRN 2. Amitriptyline 125 mg PO QHS 3. Aspirin 81 mg PO DAILY 4. HYDROmorphone (Dilaudid) 2 mg PO Q4-6HR pain 5. Losartan Potassium 100 mg PO DAILY 6. Metoprolol Succinate XL 100 mg PO DAILY 7. QUEtiapine Fumarate 300 mg PO QHS 8. Rosuvastatin Calcium 40 mg PO QPM 9. ClonazePAM 1 mg PO Q6-8H:PRN anxiety 10. varenicline 1 mg oral BID 11. Nicotine Patch 21 mg TD DAILY 12. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID 13. Cyclobenzaprine 10 mg PO HS:PRN back pain 14. Omeprazole 40 mg PO DAILY 15. Glargine 50 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 16. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 17. Movantik (naloxegol) 25 mg oral DAILY Discharge Medications: 1. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 2. Ipratropium-Albuterol Neb 1 NEB NEB Q4H 3. Thiamine 500 mg IV Q24H Duration: 5 Days 4. Amitriptyline 50 mg PO QHS 5. ClonazePAM 1 mg PO TID 6. Glargine 35 Units Bedtime 7. QUEtiapine Fumarate 75 mg PO TID 8. Aspirin 81 mg PO DAILY 9. HYDROmorphone (Dilaudid) 2 mg PO Q4-6HR pain 10. Nicotine Patch 21 mg TD DAILY 11. Omeprazole 40 mg PO DAILY 12. Rosuvastatin Calcium 40 mg PO QPM Discharge Disposition: Extended Care Discharge Diagnosis: COPD Exacerbation Toxic metabolic encephalopathy Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with COPD here with hypoxia and shortness of breath//pneumonia? TECHNIQUE: Chest PA and lateral COMPARISON: None. FINDINGS: Heart size is normal. Mediastinal contours are unremarkable. Prominence of the hila bilaterally may suggest dilated pulmonary arteries. Lungs are hyperinflated. No pulmonary edema is seen. No focal consolidation, pleural effusion or pneumothorax is present. No acute osseous abnormalities visualized. IMPRESSION: 1. No acute cardiopulmonary abnormality. 2. Prominent hila bilaterally may reflect dilated pulmonary arteries and be suggestive of pulmonary arterial hypertension. 3. Hyperinflated lungs compatible with history of COPD. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with COPD, here for COPD exacerbation. Now with worsening hypoxia// please eval for interval change please eval for interval change IMPRESSION: Comparison to ___. There is an interval increase in interstitial and vascular markings, suggesting the presence of mild pulmonary edema. Borderline size of the cardiac silhouette persists. No larger pleural effusions. No pneumonia. Radiology Report EXAMINATION: Chest x-ray INDICATION: ___ year old woman with COPD and possible CHF with acute hypoxia// ? evidence of volume overload TECHNIQUE: Portable chest x-ray COMPARISON: Chest x-ray ___ FINDINGS: The lungs are hyperaerated. There is stable mild pulmonary edema. The heart is normal in size. The trachea is midline. There are no large pleural effusions. IMPRESSION: Hyperaeration. Mild pulmonary edema, similar to previous. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with intubation // ?tube place/ interval change ?tube place/ interval change IMPRESSION: ET tube tip is 7.5 cm above the carinal. Heart size and mediastinum are stable. There is interval enlargement of the hila and development of bibasal opacities potentially aspirations or progression of infectious process. It might be in part exaggerated by low lung volumes compared to previous examination but true progression of bibasal abnormality CIS breast an. No definitive pleural effusion is seen. No pneumothorax is present. No definitive evidence of pulmonary edema is noted. Radiology Report INDICATION: ___ year old woman with OG tube placed// ?placement TECHNIQUE: Chest AP COMPARISON: ___ IMPRESSION: Lungs are low volume with bibasilar atelectasis. A NG tube has been placed in the interim with its tip projecting below the diaphragm over the stomach. The ET tube is unchanged. Cardiomediastinal silhouette is stable. No pneumothorax is seen. Radiology Report INDICATION: ___ year old woman who was reintubated// tube in correct position? TECHNIQUE: Chest AP COMPARISON: ___ IMPRESSION: Lungs are low volume with mild interstitial edema the ET tube, NG tube are unchanged. There is bibasilar atelectasis. Cardiomediastinal silhouette is stable. No pneumothorax is seen Radiology Report EXAMINATION: Chest portable radiograph INDICATION: ___ year old woman with COPD, intubated for AMS/delirium and hypoxia// edema, consolidations TECHNIQUE: Chest portable radiograph COMPARISON: Chest radiograph most recently done on ___ FINDINGS: Stable, mild interstitial edema. Unchanged position of endotracheal tube and nasogastric tube. Cardiomediastinal silhouette is stable. There is bibasilar atelectasis. No pneumothorax. IMPRESSION: Stable mild interstitial edema. Unchanged position of supportive and monitoring devices. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Dyspnea, Transfer Diagnosed with Chronic obstructive pulmonary disease w (acute) exacerbation, Dyspnea, unspecified temperature: 96.7 heartrate: 116.0 resprate: 20.0 o2sat: 90.0 sbp: 179.0 dbp: 101.0 level of pain: 0 level of acuity: 2.0

Mrs. ___, ___ were hospitalized with shortness of breath. ___ have a severe COPD exacerbation that is likely related to the amount of sedating medications ___ take at home. Per ___ family request, ___ are being transferred to ___ for further care. It was a pleasure taking care of ___! Your ___ team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: gabapentin Attending: ___. Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: None History of Present Illness: Mrs. ___ is a ___ year-old lady with a history of MCTD complicated by ILD, esophageal dysmotility, atypical chest pain, asthma presenting with chest pain. Patient reports that over the ~1 week she has been having intermittent exertional precordial pain without radiation which responded to SL nitroglycerin. Of note, she intermittently has short episodes of palpitations (<1min) that follow mild-moderate exertion, sometimes coinciding with chest pain. One day prior to admission, while driving, she experienced ___ precordial chest pain without exertion which did not respond to SL nitro but resolved spontaneously. This AM she woke up to the same pain, which resolved with sitting forward and taking SL nitroglycerin; she decided to seek care for this in the ED. In the ED initial vitals were: 98.4 | 79 | 135/77 | 18 | 100% RA EKG: RBBB, but non-ischemic, no STTW changes or PR depression Labs/studies notable for: * Leukopenia 3.1, N57%, anemia 10.6, nl plt * Chem: Phos 4.6 *Trop-T: <0.01 x2 (0605->1045) *proBNP: <5 *Cardiology was consulted and recommended stress MIBI or echo in AM * Patient was given: ___ 05:53 PO Aspirin 324 mg ___ 06:06 SL Nitroglycerin SL .4 mg ___ 08:09 PO Aluminum-Magnesium Hydrox.-Simethicone 30 mL ___ 08:09 PO Donnatal 5 mL ___ 08:09 PO Lidocaine Viscous 2% 10 mL ___ 12:22 PO Omeprazole 40 mg Vitals on transfer: 98.3 | 90 | 109/59 | 19 | 97% RA On the floor, patient reports that her chest discomfort has remained at ___ down from ___ when he came to the ED. She does not feel uncomfortable. She complains of intermittent cramping in her lower extremities but also in her abdominal wall. ROS: Cardiac review of systems is notable for dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, 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, 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. CARDIAC RISK FACTORS: none 2. CARDIAC HISTORY: - Bifasicular block (RBBB & LAFB) - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: None - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: - mixed connective tissue disease (___) - Interstitial lung disease - Esophageal dysmotility - GERD - Peripheral neuropathy Social History: ___ Family History: Mother with MI and sister with hypertension Physical Exam: Exam at Admission ================= VS: 98.4 | 125/70 | 98 | 16 | 100 RA GENERAL: WDWN lady in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple without JVD. CARDIAC: RR, normal S1, S2. No murmurs/rubs/gallops. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Bibasilar dry crackles. No wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. Mild bilateral calf pain. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Distal pulses palpable and symmetric ` Exam at Discharge ================= 98.3 114-123/57-60 99-104 ___ 99 ra GENERAL: WDWN F in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with JVP <8 cm. CARDIAC: rapid rhythm, regular rhythm. no murmurs, rubs, gallops. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: 2+ b/l Pertinent Results: Labs at Admission ================= ___ 06:05AM BLOOD WBC-3.1*# RBC-3.86* Hgb-10.6* Hct-34.6 MCV-90 MCH-27.5 MCHC-30.6* RDW-13.7 RDWSD-44.1 Plt ___ ___ 06:05AM BLOOD Neuts-57.1 ___ Monos-14.3* Eos-2.3 Baso-0.3 Im ___ AbsNeut-1.76# AbsLymp-0.77* AbsMono-0.44 AbsEos-0.07 AbsBaso-0.01 ___ 06:05AM BLOOD Glucose-102* UreaN-14 Creat-0.7 Na-135 K-4.3 Cl-96 HCO3-22 AnGap-21* ___ 06:05AM BLOOD ALT-30 AST-22 LD(LDH)-234 AlkPhos-77 TotBili-0.2 ___ 06:05AM BLOOD cTropnT-<0.01 proBNP-<5 ___ 10:45AM BLOOD cTropnT-<0.01 ___ 01:36AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 07:34AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 06:05AM BLOOD Albumin-4.6 Calcium-9.8 Phos-5.6* Mg-2.2 Cholest-285* ___ 06:05AM BLOOD Triglyc-205* HDL-71 CHOL/HD-4.0 LDLcalc-173* Labs at Discharge ================= ___ 07:34AM BLOOD WBC-3.4* RBC-4.03 Hgb-11.1* Hct-35.6 MCV-88 MCH-27.5 MCHC-31.2* RDW-13.3 RDWSD-43.1 Plt ___ ___ 07:34AM BLOOD Glucose-108* UreaN-12 Creat-0.7 Na-138 K-4.8 Cl-99 HCO3-28 AnGap-16 ___ 07:34AM BLOOD Calcium-9.4 Phos-4.6* Mg-2.1 ___ 03:56AM BLOOD %HbA1c-5.5 eAG-111 Important Studies ================= CXR ___ Bibasilar interstitial lung disease has been more fully characterized by a recent CT. No definite superimposed secondary process such as pneumonia, although subtle new abnormalities may be difficult to detect in the setting of chronic lung disease. Stress ___ INTERPRETATION: ___ yo woman with hx of SLE complicated by ILD referred to evaluate an atypical chest discomfort and dyspnea. The patient was administered 0.142 mg/kg/min of Persantine over 4 minutes. No chest, back, neck or arm discomforts were reported. No significant ST segment changes were noted. The rhythm was sinus with no ectopy noted. The hemodynamic response to the Persantine infusion was appropriate. Post-infusion, the patient was administered 125 mg Aminophylline IV. IMPRESSION: No anginal symptoms or ischemic ST segment changes. Nuclear report sent separately. Cardiac Perfusion Scan ___ The image quality is adequate but limited due to soft tissue and breast attenuation. There is activity adjacent to the heart in the rest and stress images. Left ventricular cavity size is normal. Rest and stress perfusion images reveal uniform tracer uptake throughout the left ventricular myocardium. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction is 73% with an EDV of 69 ml. IMPRESSION: 1. Normal myocardial perfusion. 2. Normal left ventricular cavity size and systolic function. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Mycophenolate Mofetil 1000 mg PO BID 2. Nitroglycerin SL 0.3 mg SL QID:PRN chest pain 3. Omeprazole 40 mg PO DAILY 4. PredniSONE 10 mg PO QAM 5. Sulfameth/Trimethoprim DS 1 TAB PO DAILY 6. Cyanocobalamin 500 mcg PO DAILY 7. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Atorvastatin 40 mg PO QPM RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Pyridoxine 50 mg PO DAILY 3. Omeprazole 40 mg PO BID 4. Cyanocobalamin 500 mcg PO DAILY 5. Mycophenolate Mofetil 1000 mg PO BID 6. Nitroglycerin SL 0.3 mg SL QID:PRN chest pain 7. PredniSONE 10 mg PO QAM 8. Sulfameth/Trimethoprim DS 1 TAB 3x/week. 9. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Chest pain 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: ___ woman with lupus, interstitial lung disease, and esophageal dysmotility presenting with ___ chest pain radiating to the back as well as shortness of breath. Evaluate for cardiopulmonary process causing the patient's chest pain. TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph dated ___. CT chest dated ___. FINDINGS: Persistent basilar predominant interstitial lung disease as evaluated on recent chest CT. No focal consolidation, effusion, edema, or pneumothorax. The heart remains mildly enlarged. Enlarged mediastinal lymph nodes on the recent chest CT are not as well appreciated on this radiograph. A hiatal hernia is small. No acute osseous abnormality. Multilevel degenerative changes in the thoracic spine are mild. IMPRESSION: Bibasilar interstitial lung disease has been more fully characterized by a recent CT. No definite superimposed secondary process such as pneumonia, although subtle new abnormalities may be difficult to detect in the setting of chronic lung disease. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Chest pain Diagnosed with Chest pain, unspecified temperature: 98.4 heartrate: 79.0 resprate: 18.0 o2sat: 100.0 sbp: 135.0 dbp: 77.0 level of pain: 8 level of acuity: 3.0

Dear Ms. ___ ___ were admitted to ___ because ___ had severe and sudden chest pain. As such, we were concerned about your heart. We did an EKG to look at your heart and it was found to be unchanged. We checked enzymes, which inform us if ___ have heart damage, and they were found to be normal. Given that ___ were complaining of chest pain, ___ underwent a stress test, which did not reveal abnormalities in your heart. ___ were started on atorvastatin to help control your cholesterol. ___ were seen by your pulmonologist, who recommended changes to your medication regimen. He discussed decreasing your ___ to 3 times a week, changing Omeprazole 40 mg twice a day, and recommended Vitamin B6 for your muscle cramps. He recommended continuing your current CellCept dosing. Your pulmonary appointment was also moved to ___. ___ were scheduled for a cardiology appointment on ___. ___ are also scheduled to see your primary care physician on ___ ___. It was a pleasure to take care of ___. We wish ___ the best with your health! Your ___ Cardiac Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Transient L vision loss Major Surgical or Invasive Procedure: None History of Present Illness: HPI: Ms. ___ is a ___ RH woman with a history of significant psychiatric illness, hypothyroidism and right retinal microaneurysm who presents with monocular left visual changes. The patient was doing eye exercises with a chart yesterday when she suddenly noticed that the vision in her left eye "blacked out" suddenly and completely, lasting several seconds. The vision then returned to normal and she denied blurriness, changes in color saturation, diplopia or eye pain. She again had a similar episode at 10am this morning, afterward she did feel faint and light-headed so laid down. Her vision then returned to normal, though while we were testing her vision today, she noted she had a circumferential "tire like ring of black" around her vision in her left eye. She otherwise denies vertigo, changes in strength, changes in hearing, trouble swallowing, headaches, numbness/tingling and has otherwise been feeling normal. She does endorse a significant increase in personal stress, including her mother being in the hospital in the last few days and her husband recently stopping his job. After the second episode today, she spoke with her PCP and her retinal specialist who recommended taking an aspirin and evaluation in the hospital today. Past Medical History: Depression. Schizoaffective disorder/Bipolar disorder. Multiple psychiatric hospitalizations, the last in ___. Drug toxicities: Elevated prolactin attributed to psychiatric medication; mild CRI due to lithium now improved; hypercalcemia due to lithium ___, now resolved. Hypothyroidism and thyroid nodules Benign positional vertigo. Tremor: mostly affecting the UE, thought to be secondary to psychiatric medications Right retinal microaneursym, reportedly picked-up on routine exam Appendectomy in ___. Deviated septum and turbinate extraction in the 1980s. Ankle fracture (___): requiring surgery with placement of plate and screws; reports that she was in the subway station, caught her foot in her shopping cart and fell. Tubal ligation Social History: ___ Family History: No thyroid disease or osteoporosis in the family. Father died of MI at age ___, aunt died of CVA in her ___. Physical Exam: General: Awake, cooperative, NAD. HEENT: NC/AT Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: CTABL Cardiac: RRR, no murmurs. Dr. ___ a gallop on exhalation. Abdomen: soft, nontender, nondistended Extremities: mild non-pitting edema through ankles, pulses palpated 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. Prosody was quite varibale. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt. was able to register 3 objects and recall ___ at 5 minutes. The pt. had good knowledge of current events. There was no evidence of apraxia or neglect. Calculation was intact thoug slow (answers seven quarters in $1.75). There was no evidence of left-right confusion as the patient was able to accurately follow the instruction to tough left ear with right hand. -Cranial Nerves: I: Olfaction not tested. II: PERRL 5 to 4mm and brisk. Acuity approximately ___ -1 bilaterally though patient took many attempts to achieve this. On VF testing, in the left eye only, there was a lower nasal field cut (R inferior quadrant) but remainder of fields were intact including entirely so on left. Funduscopic exam revealed no papilledema, exudates, or hemorrhages and microaneurysm was not visualized. 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 asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 5 R 5 ___ 4+ ___ 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, proprioception throughout. Vibration diminished bilaterally. 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: There was a small amplitude postural tremor in the LUE, no dysdiadochokinesia noted. There was some dysmetria on FNF in the left hand but no rebound or past-pointing. The dysmetria waxed and waned through the exam with the tremor. -Gait: Deferred. Pertinent Results: ON ADMISSION: ___ 01:10PM BLOOD WBC-5.2 RBC-4.80 Hgb-13.4 Hct-40.4 MCV-84 MCH-27.9 MCHC-33.2 RDW-13.1 Plt ___ ___ 01:10PM BLOOD Neuts-55.0 ___ Monos-7.1 Eos-1.2 Baso-0.7 ___ 01:10PM BLOOD Plt ___ ___ 01:16AM BLOOD ___ PTT-45.3* ___ ___ 06:40AM BLOOD ESR-2 ___ 01:10PM BLOOD Glucose-78 UreaN-27* Creat-1.3* Na-139 K-4.0 Cl-100 HCO3-33* AnGap-10 ___ 07:03PM BLOOD cTropnT-<0.01 ___ 01:10PM BLOOD cTropnT-<0.01 ___ 06:40AM BLOOD TSH-0.99 ___ 06:40AM BLOOD CRP-0.6 ___ 06:40AM BLOOD Triglyc-87 HDL-65 CHOL/HD-2.6 LDLcalc-89 ___ 06:40AM BLOOD %HbA1c-5.4 eAG-108 ___ 06:40AM BLOOD Cholest-171 URINE CULTURE (Final ___: NO GROWTH. CT head w/o contrast ___ No acute intracranial process. CTA head and neck ___. Non-opacification of the left sigmoid sinus, new, with apparent collateral vessels in this venous drainage pathway. When correlated with the concurrent cranial MRI/MRV, the constellation of findings most likely represents partial thrombosis of the left sigmoid sinus. 2. No evidence of intra-orbital sequelae of cerebral venous disease. 3. No intracranial hemorrhage, edema or mass effect. 4. No hemodynamically significant stenosis of the cervical carotid arteries, by NASCET criteria. MRI and MRV head ___. Hypoplastic left venous sinus system with diminished flow-related enhancement. However, when correlated with the concurrent CTA, there is non-opacification of the left sigmoid sinus and venous collaterals are present along this venous drainage pathway. The constellation of findings is most consistent with partial thrombosis of the left sigmoid sinus, new since ___. 2. No acute infarct, edema or intracranial hemorrhage. ECHO ___ The left atrium and right atrium are normal in cavity size. A patent foramen ovale is present with premature appearance of agitated saline in the left heart post-Valsalva release. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. IMPRESSION: Patent foramen ovale. Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. No pathologic flow identified.. =========== ON DISCHARGE: ___ 06:30AM BLOOD Glucose-92 UreaN-23* Creat-1.3* Na-143 K-4.4 Cl-107 HCO3-32 AnGap-8 ___ 06:30AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.0 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Benztropine Mesylate 0.5 mg PO DAILY 2. ChlorproMAZINE 50 mg PO QHS 3. Divalproex (DELayed Release) 1250 mg PO QHS 4. Levothyroxine Sodium 75 mcg PO DAILY 5. Paroxetine 20 mg PO DAILY 6. RISperidone 6 mg PO HS 7. Calcium Carbonate 600 mg PO DAILY 8. Ferrous GLUCONATE 324 mg PO DAILY 9. Fish Oil (Omega 3) ___ mg PO DAILY 10. ChlorproMAZINE 25 mg PO DAILY:PRN agitation Discharge Medications: 1. Benztropine Mesylate 0.5 mg PO DAILY 2. Calcium Carbonate 600 mg PO DAILY 3. ChlorproMAZINE 50 mg PO QHS 4. ChlorproMAZINE 25 mg PO DAILY:PRN agitation 5. Divalproex (DELayed Release) 1250 mg PO QHS 6. Ferrous GLUCONATE 324 mg PO DAILY 7. Fish Oil (Omega 3) ___ mg PO DAILY 8. Levothyroxine Sodium 75 mcg PO DAILY 9. Paroxetine 20 mg PO DAILY 10. RISperidone 6 mg PO HS 11. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis 1. left eye monocular vision changes 2. hypoplastic left sigmoid and transverse venous sinuses, possible partially occlusive thrombus Secondary diagnosis 1. Schizoaffective disorder/Bipolar disorder 2. Right retinal microaneursym Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Neurologic: no deficits Followup Instructions: ___ Radiology Report HISTORY: Sudden vision loss in right eye. COMPARISON: Comparison is made with head MR from ___. TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without administration of IV contrast. Reformatted coronal and sagittal and thin section bone algorithm reconstructed images were acquired. FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or infarction. The ventricles and sulci are normal in size and configuration. The basal cisterns appear patent and there is preservation of gray-white matter differentiation. No fracture is identified. Minimal mucosal thickening is seen in the left maxillary sinus. Otherwise, the visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The globes are intact. IMPRESSION: No acute intracranial process. Radiology Report HISTORY: ___ female with left eye vision loss. TECHNIQUE: Multidetector axial CT images were obtained through the head without intravenous contrast. Following the administration of intravenous contrast, CT angiogram of the head and neck was performed. Coronal and sagittal images were reformatted from the source data. At a separate workstation, 3D images were constructed. COMPARISON: MRI IAC ___. FINDINGS: NECT: No intracranial hemorrhage is identified. There is no mass, mass effect or midline shift. There is no evidence for a territorial infarct. The gray-white matter differentiation is well preserved. The ventricular system is normal in size and configuration. CTA head: The major intracranial vessels are patent. There is no evidence for hemodynamically significant stenosis or occlusion. No aneurysm or arterial venous malformation is present. The basilar tip is patulous, a normal variant. Non opacification of the a left sigmoid sinus and the left jugular vein is present. The left transverse sinus is hypoplastic. Collateral vessels are present along this venous drainage pathway. There is no evidence of intra-orbital sequelae of venous disease. No stranding is present in the orbital fat. The superior and inferior ophthalmic veins are symmetric and normal in caliber, and demonstrate normal enhancement. The cavernous sinuses are symmetric. CT angiogram neck: The bilateral common carotid, internal carotid, and external carotid arteries are patent. Both vertebral arteries are patent. The left vertebral artery is dominant. Measurements of minimal diameters as follows: Right ICA: Proximal: 6.0 mm Distal: 3.5 mm Left ICA: Proximal: 6.5 mm Distal: 4.0 mm Therefore, there is no evidence for hemodynamically significant stenosis by NASCET criteria. Multiple small to borderline in size cervical lymph nodes are present. Mild scarring and atelectasis is present in the lung apices. There are cervical spine degenerative changes most notable at C5-C6 and C6-7 where there is mild to moderate left neural foraminal narrowing secondary to uncinate and facet hypertrophy. IMPRESSION: 1. Non-opacification of the left sigmoid sinus, new, with apparent collateral vessels in this venous drainage pathway. When correlated with the concurrent cranial MRI/MRV, the constellation of findings most likely represents partial thrombosis of the left sigmoid sinus. 2. No evidence of intra-orbital sequelae of cerebral venous disease. 3. No intracranial hemorrhage, edema or mass effect. 4. No hemodynamically significant stenosis of the cervical carotid arteries, by NASCET criteria. COMMENT: Discussed with Dr. ___ (Neurology service) by Dr. ___ ___ at 11:30 hours on ___, at the time of discovery. Radiology Report HISTORY: ___ woman with sudden left vision loss and inferior temporal quadrantanopia of the left eye now with possible occlusion of the left sigmoid sinus. TECHNIQUE: Sagittal T1, axial FLAIR, axial T2, axial susceptibility and axial diffusion weighted images were obtained. An MRV was obtained using a 2D time-of-flight technique (no gadolinium).. COMPARISON: CT angiogram head and neck ___ and MR ___ ___. FINDINGS: MRI brain: There is no acute infarct or intracranial hemorrhage. No mass, mass effect or midline shift is present. The ventricular system is normal in size and configuration. Coarctation of the frontal horn of the left laterla ventricle is present with a stable appearance dating back to examinations from ___. MR venogram: The left transverse and sigmoid sinuses are hypoplastic with diminished flow related enhancement. There was a normal caliber and enhancement of the left sigmoid sinus on MRI ___ from ___. The superior sagittal sinus, right transverse sinus, right sigmoid sinus, visualized right jugular vein, straight sinus and vein ___ and are patent. IMPRESSION: 1. Hypoplastic left venous sinus system with diminished flow-related enhancement. However, when correlated with the concurrent CTA, there is non-opacification of the left sigmoid sinus and venous collaterals are present along this venous drainage pathway. The constellation of findings is most consistent with partial thrombosis of the left sigmoid sinus, new since ___. 2. No acute infarct, edema or intracranial hemorrhage. COMMENT: Discussed with Dr. ___ (Neurology service) by Dr. ___ ___ at 1130H on ___, at the time of discovery. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: L VISION CHANGES Diagnosed with CHEST PAIN NOS, VISUAL DISTURBANCES NEC temperature: 97.8 heartrate: 80.0 resprate: 18.0 o2sat: 100.0 sbp: 139.0 dbp: 81.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, It was a pleasure caring for you at ___ ___. You were admitted for some transient vision changes in your left eye. You had an MRI of your brain which showed no evidence of a stroke. An MR venogram showed that the veins draining the left side of your brain are smaller than the right. This is likely something you were born with and is unlikely to be related to your visual complaints. You should have a repeat MRV in ___ months to re-evaluate this. You also had an echocardiogram to rule out the possibility of a blood clot in your heart, and this showed no blood clot on prelim report. You were evaluated by opthalmology who did not find any abnormality inside your eye to explain your symptoms. You will need to follow up in their clinic for a repeat evaluation as well as formal visual field testing. You will also need to follow up with your primary care doctor as well as Dr. ___ in neurology clinic (see details below). We started you on a baby aspirin to reduce your risk of future strokes. We did not make any changes in the rest of your medications. It is important that you take all medications as prescribed, and keep all follow up appointments.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Subdural hematoma Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old female who is s/p an MVC this morning with + LOC and +SB. There was no air bag deployment. She was driving in a parking lot at low speed when another vehicle struck her car at approximately 30mph. She was initially transported to ___ ___ for evalaution and workup revealed a small right parietal SDH. She was neurologically intact and trasnferred to ___ for further management and care. She reports of a mild ___ headache. She denies nasuea, vomiting, dizziness, difficulty ambulating, changes in vision, hearing, or speech. Past Medical History: Borderline DM, HTN, chronic LBP, depression Social History: ___ Family History: Non-contributory Physical Exam: Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL EOMs intact without nystagmus 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. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4mm to 3mm bilaterally. Visual fields are grossly full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Intact to light touch bilaterally Coordination: normal on finger-nose-finger Discharge exam: Neurologically intact Pertinent Results: CT HEAD ___ (Preliminary Report) FINDINGS: There is interval increase in size of the acute right cerebral subdural hematoma, previously 4mm in thickness, now 10mm in thickness. No significant mass effect or shift of midline structures. Ventricles and sulci are normal in overall size and configuration. The imaged paranasal sinuses are clear. Mastoid air cells and middle ear cavities are well aerated. The bony calvarium is intact. IMPRESSION: Right cerebral subdural hematoma, increased in size, now 10mm. CT HEAD ___ (Preliminary Report) FINDINGS: A stable acute right frontoparietal subdural hematoma which extends along the temporal convexity, measuring 9 mm in thickness (previously 9 mm in thickness). There is no evidence of infarction, new hemorrhage, edema, or mass. The ventricles and sulci are normal in size and configuration. No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are unremarkable. Calcification of cavernous portions of bilateral internal carotid arteries are noted. IMPRESSION: Stable acute right subdural hematoma, measuring 9 mm in thickness. No shift of midline structures. Medications on Admission: Lisinopril, Celexa Discharge Medications: Lisinopril, Celexa, Keppra 500mg BID Discharge Disposition: Home Discharge Diagnosis: Right parietal subdural hematoma 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: Status post MVA, question internal injury COMPARISON: Outside hospital chest radiograph from earlier today. FINDINGS: AP portable supine view of the chest. There is no focal consolidation or supine evidence for effusion or pneumothorax. The cardiomediastinal silhouette is normal. Imaged osseous structures are intact. IMPRESSION: No acute intrathoracic process Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ with MVC, Rt SDH, followup. TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain, intermediate and bone windows. Coronal and sagittal reformats were also performed. DOSE: DLP: 892 mGy-cm COMPARISON: OSH HEAD CT from earlier today. FINDINGS: There is interval increase in size of the acute right cerebral subdural hematoma, previously 4mm in thickness, now 10mm in thickness. No significant mass effect or shift of midline structures. Ventricles and sulci are normal in overall size and configuration. The imaged paranasal sinuses are clear. Mastoid air cells and middle ear cavities are well aerated. The bony calvarium is intact. IMPRESSION: Right cerebral subdural hematoma, increased in size, now 10mm. No significant mass effect or midline shift. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old woman with minor MVC, expansion of right parietal SDH on repeat imaging. Assess stability of subdural hematoma. TECHNIQUE: Contiguous axial images images of the brain were obtained without contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed images were obtained. DOSE: DLP: 1014 mGy-cm CTDI: 54.21 mGy COMPARISON: Noncontrast head CT ___. FINDINGS: The hyperdense subdural hematoma along the right convexity is stable compared to 1 day earlier. There is no significant sulcal effacement and no shift of midline structures. There is no new hemorrhage or edema. The ventricles and basal cisterns remain normal in size. The partially paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: Stable right subdural hematoma compared to 1 day earlier, without sulcal effacement. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Transfer, MVC Diagnosed with SUBARACHNOID HEM-NO COMA, MV COLLISION NOS-DRIVER temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: 1.0

Discharge Instructions 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 until your follow up appointment with Dr. ___. 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.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Shellfish Derived Attending: ___. Chief Complaint: Bilateral lower abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ G3P3 with a PMH significant for AML s/p treatment, now in remission, presents to the ED with 1 day of bilateral lower abdominal pain. Pain started last night (___) around 2200. Is constant and aching, rated initially ___, throughout the lower abdomen but slightly more right than left-sided. She tried OTC meds at home with little relief. She was seen in ___ clinic this morning for routine follow-up and was sent to the ED given her significant pain. She denies any fevers, chills, vomiting, dysuria, vaginal discharge or bleeding, diarrhea, constipation. She has nausea with the pain. She did have intercourse on ___ with her partner (of one week), and the condom did break. The intercourse was only uncomfortable in that it was with a relatively new partner but described as non-painful. She does not believe her partner has had any sexually transmitted infections. Past Medical History: OB/GYN: G3P3, s/p LTCS x ___ s/p Bilateral tubal ligation History of latent syphilis diagnosed ___, s/p PCN tx x 14d and w/ f/u negative LP. No other h/o STIs. Regular menses, heavy ___ days of bleeding Does not remember last pap - prob w/in last ___ years ? h/o HSV but denies genital outbreaks - had rash on back (pt says the rash comes when she has eaten nuts) PMH: Acute myelogenous leukemia in remission with last cycle of chemo completed in ___ also part of experimental vaccine trial. H/o shingles on back (pt believes this to be due to nut allergy, not shingles). PSH: LTCS x 3; tubal ligation; vein stripping in L leg Social History: ___ Family History: noncontributory Physical Exam: on admission, by Dr. ___: VS initially in ED: T 99.6 HR 80 BP 111/95 O2 sat 100% on RA NAD, sleeping in stretcher curled on side RRR CTAB Abdomen significantly tender to both light and deep touch. Voluntary guarding present. No rebound. Abdomen warm to touch. No distinct masses palpated. +BS. Pelvic: Normal external genitalia, normal vaginal mucosa. Cervix appears normal. There is some milky white discharge in the posterior fornix and coming from the os, but this does not appear prurulent and could be consistent with recent intercourse/condom breakage. Bimanual exam: No cervical motion tenderness when internal hand used to manipulate cervix. Additionally no right or left adnexal tenderness with only internal palpation. Significant abdominal tenderness elicited with use of external hand to palpate, worse on right compared to left. on day of discharge: 98.2, 94/55, 96, 16, 100%RA Gen: NAD, AxO Abd: normoactive bowel sounds, soft, nondistended, minimally tender to palpation diffusely, no rebound or guarding Pertinent Results: ___ 06:50AM BLOOD WBC-12.4* RBC-3.37* Hgb-10.6* Hct-31.4* MCV-93 MCH-31.5 MCHC-33.9 RDW-12.5 Plt ___ ___ 09:59PM BLOOD WBC-17.3* RBC-3.33* Hgb-10.9* Hct-30.7* MCV-92 MCH-32.7* MCHC-35.3* RDW-12.4 Plt ___ ___ 06:55AM BLOOD WBC-18.4* RBC-3.49* Hgb-11.2* Hct-32.5* MCV-93 MCH-32.1* MCHC-34.5 RDW-12.5 Plt ___ ___ 11:00PM BLOOD WBC-17.5* RBC-3.65* Hgb-11.4* Hct-33.5* MCV-92 MCH-31.3 MCHC-34.1 RDW-12.6 Plt ___ ___ 11:58AM BLOOD WBC-19.7* RBC-3.74* Hgb-11.8* Hct-33.9* MCV-91 MCH-31.5 MCHC-34.7 RDW-12.5 Plt ___ ___ 09:30AM BLOOD WBC-17.5*# RBC-3.78* Hgb-11.7* Hct-35.1* MCV-93 MCH-31.1 MCHC-33.5 RDW-12.5 Plt ___ ___ 06:50AM BLOOD Neuts-92.9* Lymphs-3.7* Monos-3.1 Eos-0.2 Baso-0.1 ___ 09:59PM BLOOD Neuts-91.4* Lymphs-5.3* Monos-3.0 Eos-0.2 Baso-0.1 ___ 06:55AM BLOOD Neuts-90.0* Lymphs-5.9* Monos-3.5 Eos-0.4 Baso-0.2 ___ 11:00PM BLOOD Neuts-87.8* Lymphs-9.7* Monos-2.0 Eos-0.3 Baso-0.1 ___ 11:58AM BLOOD Neuts-90.3* Lymphs-7.7* Monos-1.8* Eos-0.1 Baso-0.2 ___ 09:30AM BLOOD Neuts-91.3* Lymphs-5.0* Monos-3.3 Eos-0.2 Baso-0.2 ___ 09:20AM BLOOD ___ PTT-26.5 ___ ___ 09:59PM BLOOD ___ PTT-28.3 ___ ___ 09:20AM BLOOD ___ ___ 09:59PM BLOOD ___ ___ 11:58AM BLOOD ESR-25* ___ 09:30AM BLOOD ___ ___ 06:50AM BLOOD Glucose-146* UreaN-6 Creat-0.4 Na-135 K-3.5 Cl-102 HCO3-26 AnGap-11 ___ 09:59PM BLOOD Glucose-131* UreaN-7 Creat-0.6 Na-136 K-3.5 Cl-101 HCO3-29 AnGap-10 ___ 06:55AM BLOOD Glucose-121* UreaN-10 Creat-0.4 Na-135 K-3.6 Cl-101 HCO3-27 AnGap-11 ___ 11:00PM BLOOD Glucose-119* UreaN-9 Creat-0.5 Na-137 K-3.8 Cl-99 HCO3-29 AnGap-13 ___ 11:58AM BLOOD Glucose-116* UreaN-10 Creat-0.5 Na-136 K-3.8 Cl-100 HCO3-26 AnGap-14 ___ 09:30AM BLOOD UreaN-11 Creat-0.6 Na-136 K-3.9 Cl-99 HCO3-30 AnGap-11 ___ 06:50AM BLOOD ALT-8 AST-11 TotBili-0.4 ___ 09:30AM BLOOD ALT-11 AST-14 LD(LDH)-176 AlkPhos-62 TotBili-0.7 ___ 06:50AM BLOOD Albumin-3.8 Calcium-8.7 Phos-1.9* Mg-1.8 ___ 09:59PM BLOOD Calcium-8.8 Phos-3.4 Mg-1.9 ___ 06:55AM BLOOD Calcium-8.7 Phos-2.1* Mg-1.9 ___ 09:30AM BLOOD Calcium-9.4 Phos-3.0 Mg-1.8 ___ 09:30AM BLOOD HCG-<5 ___ 11:58AM BLOOD CRP-89.7* ___ 12:13PM BLOOD Lactate-2.1* ___ 05:32PM URINE Color-Yellow Appear-Clear Sp ___ ___ 11:58AM URINE Color-Straw Appear-Clear Sp ___ ___ 05:32PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 11:58AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG ___ 05:32PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-<1 TransE-<1 GC/Ch cultures negative (final) Urine culture ___ and ___ no growth (final) blood culture ___ no growth (final) blood cultures ___, and ___ no growth to date Pelvic US ___: The ultrasound shows a dilated tube on the left with a slightly thick wall and debris. The ovary is seen adjacent to this. This is not a classic ___ since the ovary is seen separate from the tube, and but the amount of debris in the tube is compatible with a pyosalpinx. This tube measures 5.2 x 2.3 cm on the images where it appears the largest. This change in diagnosis from hydrosalpinx to pyosalpinx is compatible with the patient's clinical history of PID. CT A/P ___: 1. Bilateral fluid-filled tubular structures within the pelvis most likely represent bilateral hydrosalpinges including suggestion of bilateral inflammatory changes. Although an inflamed appendix intermingled with the right adnexa is hard to exclude, a small inflammed tube seems much more likely. Active pelvic inflammatory disease is a likely etiology and further evaluation with ultrasound is suggested. 2. Cholelithiasis without evidence of cholecystitis. CT A/P ___: 1. Fluid-filled rim-enhancing tubular structures in both adnexa are most consistent with pyosalpinx as noted on the recent ultrasound. 2. 9 mm fluid filled appendix without ___ stranding to suggest appendicitis. Medications on Admission: acyclovir Discharge Medications: 1. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 2. metronidazole 500 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 7 days: do not consume alcohol while on this medication. Disp:*21 Tablet(s)* Refills:*0* 3. Percocet ___ mg Tablet Sig: ___ Tablets PO every six (6) hours as needed for pain. Disp:*10 Tablet(s)* Refills:*0* 4. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. Disp:*20 Tablet, Rapid Dissolve(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: bilateral pyosalpinx Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report CLINICAL HISTORY: ___ woman with marked bilateral abdominal pain and rebound tenderness. COMPARISON: ___ examination. TECHNIQUE: Multidetector helical CT scan of the abdomen and pelvis was obtained after administration of 130 cc of Omnipaque intravenous contrast. Axial, coronal, and sagittal reformats were prepared. FINDINGS: Within the lung bases, no concerning lesions or pleural effusions are seen. The mediastinum is unremarkable. CT OF THE ABDOMEN: A hypodense lesion in the right lobe of the liver measures 16 x 12 mm in axial ___ (2:17), similar to decreased; although indeterminant stability suggests benignity. The spleen, pancreas, bilateral kidneys, and bilateral adrenal glands are unremarkable. The gallbladder shows several dependent calcified gallstones. The stomach, duodenum, and small bowel loops within the abdomen are unremarkable. Portions of the colon within the abdomen are unremarkable. CT OF THE PELVIS: Within the pelvis, the adnexa show evidence of calcifications followed by a fluid-filled tubular structures on the right as well as the left (image 2:64 and image 2:65 as well as image 601B:17 and image 601B:18). On the right the tubular structure is small but with mural enhancement. Although the cecum closely approaches it, it appears more likely adnexal suggesting a small probably inflammed fallopian tube. On the left there is clearly a moderate convoluted tube consistent with a hydrosalpinx and its fluid content is perhaps slightly hyperdense. The appendix is not clearly visualized as a separate entity (although it is also not clearly seen on earlier examinations) so it is difficult to completely exclude that the right-sided structure could potentially represent an inflammed appendix, although doubted. The loops of small bowel within the pelvis as well as the rectum and uterus are unremarkable. The bladder is distended and unremarkable. No pelvic lymphadenopathy is seen. OSSEOUS STRUCTURES: The osseous structures show no concerning sclerotic or lytic bone lesions. IMPRESSION: 1. Bilateral fluid-filled tubular structures within the pelvis most likely represent bilateral hydrosalpinges including suggestion of bilateral inflammatory changes. Although an inflamed appendix intermingled with the right adnexa is hard to exclude, a small inflammed tube seems much more likely. Active pelvic inflammatory disease is a likely etiology and further evaluation with ultrasound is suggested. 2. Cholelithiasis without evidence of cholecystitis. Radiology Report INDICATION: ___ woman with clinical PID, evaluate for tubo-ovarian abscess. COMPARISON: CT abdomen and pelvis with contrast ___. PELVIC ULTRASOUND: LMP: ___. Transabdominal and transvaginal ultrasound examinations were performed, the latter for better visualization of the endometrium and adnexa. The uterus measures 9.3 x 5.4 x 7.5 cm. The endometrium measures 6 mm and is within normal limits. The right ovary measures 4.4 x 2.5 x 3.3 cm. A follicle is noted within the right ovary. The left ovary measures 3.5 x 2.8 x 2.4 cm. A predominantly anechoic tubular structure within the left adnexa appears consistent with hydrosalpinx. C-section scar with possible fibroid measuring 1.1 x 1.4 x 1.4 cm within the C-section scar is noted in the lower uterine segment. There is fluid in the cervix. IMPRESSION: 1. C-section scar with possible small fibroid at the C-section scar. 2. Fluid within the cervix. 3. Left hydrosalpinx. Addendum: This study was discussed with Dr. ___ at 845 AM on ___ by Dr. ___. The ultrasound shows a dilated tube on the left with a slightly thick wall and debris. The ovary is seen adjacent to this. This is not a classic ___ since the ovary is seen separate from the tube, and but the amount of debris in the tube is compatible with a pyosalpinx. This tube measures 5.2 x 2.3 cm on the images where it appears the largest. This change in diagnosis from hydrosalpinx to pyosalpinx is compatible with the patient's clinical history of PID. Radiology Report INDICATION: ___ woman with likely PID versus appe, now with worsening pain and continued to be febrile. COMPARISON: Pelvic ultrasound from ___, CT of the abdomen and pelvis from ___. TECHNIQUE: MDCT images were acquired through the abdomen and pelvis with IV and oral contrast. Multiplanar reformations were obtained and reviewed. DLP: 503.24 mGy-cm. FINDINGS: The partially imaged lungs show minimal bibasilar atelectasis. The partially imaged heart is unremarkable. The topmost dome of the right lobe of the liver is not imaged on the current exam. CT OF THE ABDOMEN WITH IV CONTRAST: The liver shows a focal hypodensity adjacent to the IVC, likely representing a simple cyst. The portal vein is patent. The spleen, both adrenals, both kidneys, pancreas are unremarkable. The gallbladder contains vicariously excreted contrast. A stone is noted in the neck of the gallbladder measuring 12 x 15 mm. No abdominal free fluid or free air is present. No abdominal, retroperitoneal or mesenteric lymphadenopathy by CT size criteria is present. The small bowel loops are unremarkable. The appendix measures up to 9 mm and is fluid filled, although no significant periappendiceal stranding is noted. CT OF THE PELVIS WITH IV CONTRAST: The rectum, sigmoid colon, bladder, and uterus are unremarkable. Both adnexa show tubular rim-enhancing structures which are most consistent with pyosalpinx as noted on the recent pelvic ultrasound. There is a small amount of pelvic free fluid. A Foley catheter terminates within the bladder. No pelvic or inguinal lymphadenopathy is present. OSSEOUS STRUCTURES: The visible osseous structures show no suspicious lytic or blastic lesions or fractures. IMPRESSION: 1. Fluid-filled rim-enhancing tubular structures in both adnexa are most consistent with pyosalpinx as noted on the recent ultrasound. 2. 9 mm fluid filled appendix without ___ stranding to suggest appendicitis. Gender: F Race: HISPANIC OR LATINO Arrive by AMBULANCE Chief complaint: RLQ ABD PAIN Diagnosed with ABDOMINAL PAIN RLQ, ACUTE MYELOID LEUK-IN REMISS temperature: 99.6 heartrate: 80.0 resprate: 16.0 o2sat: 100.0 sbp: 111.0 dbp: 65.0 level of pain: 10 level of acuity: 3.0

You left the hospital against medical advice. We strongly recommend that you continue to stay here and receive IV antibiotics for at least the next day but you decided to leave. YOU MUST RETURN TO THE EMERGENCY ROOM IF YOU HAVE A FEVER OR ABDOMINAL PAIN THAT IS WORSE. These things could be a sign of an under-treated infection. You could die if you have an infection that is not properly treated. General instructions: * Take your medications as prescribed. Continue to take both oral antibiotics and complete a ___o not consume alcohol while on these antibiotics, as this will cause severe nausea/discomfort. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * You may eat a regular diet To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: dyspnea on exertion, early satiety Major Surgical or Invasive Procedure: Upper and lower endoscopy, ___ History of Present Illness: ___ with a PMH of non-ischemic cardiomyopathy with EF 35-40% p/w several weeks of DOE which worsened yesterday. He states his symptoms started around 2 weeks ago while he was in ___ and were stable to mildly worsening until yesterday he had significant worsening of his SOB. He notes the SOB is present mainly with exertion and has been limiting his activity but resolves with rest. He has no accompanied wheezing. He has not any symptoms like this before. He denies any chest pain or pressure, PND, and orthopnea. He notes intermittent ankle swelling which he attributed to gout and which has currently resolved. He flew in to ___ where he recieves his medical care on ___ and underwent prostate biopsy on ___ which was uncomplicated. He has noted no changes in his urination since the biopsy including hematuria, dysuria, frequency, or changes in his stream. He had an associated occasionally productive cough but denies fevers and chills. In the ED initial vitals were: 99.5 108 141/87 20 96% RA - Labs were significant for BNP 7500, Cr 1.9 (baseline 1.0), Trop negative x1, VGB 7.38/40 with lactate of 3.4. CXR without infiltrate or edema and bedside u/s without pericardial effusion. - Patient was given: ___ 18:04 PO Acetaminophen 650 mg ___ 18:04 PO Acetaminophen 650 mg ___ 18:04 IVF 1000 mL NS ___ 20:42 IV Heparin 5000 UNIT ___ 20:42 IV Heparin gtt This AM he denies CP, PND, orthopnea. He feels that his breathing is improved. He does note red urine. No other complaints. Review of Systems: (+) per HPI Past Medical History: HTN DM2 Cardiomyopathy CHF EF 35-40% Sickle cell disease Hyperlipidemia h/o osteomyelitis in right femur h/o elevated PSA h/o iron deficiency anemia Social History: ___ Family History: No family history of colon cancer or IBD. Mother died of old age, father passed away when he was young. Unremarkable, specifically no history of prostate cancer. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals - 97.9 ___ on 2L. 93 RA GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, good dentition NECK: nontender supple neck, moderately elevated JVP CARDIAC: Tachycardic, regular, S1, split S2, LUNG: Bibasilar crackles R>L, no increased work of breathing ABDOMEN: Mild distention, no detectable ascites, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused with good cap refill, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: Vitals - 97.7 ___ 20 100RA Weight: 85.5kg from 88 admission. GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, good dentition NECK: nontender supple neck, JVP 1cm above the clavicle at 90 deg. CARDIAC: regular rhythm, normal rhythm, S1, S2 split, no rubs or murmurs. LUNG: CTAB nonlabored. + expiratory wheeze. No appreciable RV heave or PA tap. Good air movement. ABDOMEN: Mild distention, no detectable ascites, +BS, nontender in all quadrants, no rebound/guarding, EXTREMITIES: no cyanosis, clubbing. No sacral or lower extremity edema. PULSES: 2+ DP pulses bilaterally SKIN: warm and well perfused with good cap refill, no excoriations or lesions, no rashes Pertinent Results: ================================================================ LABS 7.7 > 10.2 (MCV 85) < 247 ___ Hb baseline ~12, retics 5%, hx Sickle Cell, Fe studies pending BUN/Cr: ___ -> ___ BNP 7,500 (___) D-Dimer: 5,045 (nl < 500) (___) PSA: 7.6 (___) VBG: 7.38/42; lactate 3.3 (___) UA: 106 RBCs, 17 WBCs, otherwise neg FeNa: 6.84%; FeUrea: 48% ================================================================ MICRO: UCx: ___ pending (UA w/ 17 WBCs) BCx: ___ - pending x 2 RPR: ___ - pending Lyme serology: ___ - pending ================================================================ STUDIES: C-SCOPE (___): Normal colon to cecum, good prep. EGD (___): Normal esophagus. Irregular Z-line (path pending) Erythema and friability with few superficial erosions in the duodenum compatible w/ duodenitis (path pending) Otherwise nl EGD to ___ part of duodenum. Recommend PPI BID for at least 8 weeks, then daily. V/Q Scan (___): Definite, unmatched segmental perfusion defects involving the right apex and RML, with a possible lingular subsegmental defect. These findings are consistent with a high likelihood for pulmonary embolism CT A/P (non-con) (___): - Liver, pancreas unremarkable - Auto-infarction of the spleen with residual calcified soft tissue mass - Assesment of the gastric lumen precluded by PO intake - Markedly enlarged prostate (unchanged); no pathologic lymph nodes - Bones demonstrate appearance classic for sickle cell w/ endplate infarction - Fullness of L. adrenal gland (chronic, unchanged) CT Chest (non-con) ___: No suspicious pulmonary nodules. Non-characteristic scarrning at the bases of the lingula. Old left rib fracture. No evidence of malignancy on the current examination. CXR (PA/Lat): ___ - mild cardiomegaly, otherwise clear TTE (___): 35-40%; non-dilated. Moderate LV hypokinesis. Nl RV. No significant valvular disease. ================================================================ PRIOR STUDIES: EGD (___): Inflammation at GE junction, chronic active gastritis (H. pylori +ve). C-scope (___): 3 x <5mm sessile polyps; serrated adenomas ================================================================ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Tartrate 100 mg PO BID 2. MetFORMIN (Glucophage) 1000 mg PO BID 3. Simvastatin 40 mg PO DAILY 4. Hydrochlorothiazide 12.5 mg PO DAILY Discharge Medications: 1. Metoprolol Tartrate 100 mg PO BID 2. Simvastatin 40 mg PO DAILY 3. Rivaroxaban 15 mg PO BID RX *rivaroxaban [Xarelto] 15 mg 1 tablet(s) by mouth twice a day Disp #*42 Tablet Refills:*0 4. TraZODone 100 mg PO HS:PRN insomnia RX *trazodone 50 mg 1 tablet(s) by mouth at night Disp #*30 Tablet Refills:*0 5. Hydrochlorothiazide 12.5 mg PO DAILY 6. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Unprovoked, pulmonary embolism. Duodenitis, hematuria SECONDARY DIAGNOSIS: Sickle Cell. Hypertension, Diabetes, Systolic Heart Failure, 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 several weeks of dyspnea with recent worsening, productive cough. TECHNIQUE: Chest PA and lateral COMPARISON: ___ chest radiograph and ___ chest CTA FINDINGS: The heart size remains mildly enlarged. The mediastinal and hilar contours are within normal limits. Pulmonary vasculature is normal. Linear opacities in the left lung base likely reflect atelectasis or scarring. No focal consolidation, pleural effusion or pneumothorax is present. Remote left-sided rib fractures are demonstrated. IMPRESSION: No radiographic evidence for pneumonia. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man with dyspnea. // interval change, pulmonary vascular congestion interval change, pulmonary vascular congestion IMPRESSION: In comparison with the study of ___, there is little interval change. The cardiac silhouette is at the upper limits of normal in size and there is no evidence of acute pneumonia, vascular congestion, or pleural effusion. Streak of atelectasis is seen at the left base. Radiology Report INDICATION: ___ year old man with unprovoked PE and history of early satiety. ORAL CONTRAST ONLY. MARGINAL RENAL FUNCTION // malignancy, specifically gastric or pancreatic TECHNIQUE: CT of the Abdomen and Pelvis WITHOUT IV contrast and with oral contrast DOSE: DLP: 876. COMPARISON: ABDOMINAL CT FROM ___ FINDINGS: LOWER CHEST: Please see the CT chest report from the same day for full details CT OF THE ABDOMEN WITHOUT CONTRAST: LIVER SHOWS NO DEFINITE MASS LESIONS, PORTAL VASCULATURE CANNOT BE ASSESSED, GALLBLADDER IS UNREMARKABLE OTHER THAN SIMPLE AND UNCHANGED CHOLELITHIASIS. MILD PROMINENCE OF THE LEFT ADRENAL GLAND UNCHANGED, THE RIGHT ADRENAL GLAND IS UNREMARKABLE AS ARE BOTH KIDNEYS OTHER THAN SIMPLE CYSTS INVOLVING THE LEFT KIDNEY. THERE IS NO FREE FLUID, NO PATHOLOGICALLY ENLARGED ADENOPATHY, THE PANCREAS APPEARS UNREMARKABLE. THERE IS AUTO INFARCTION OF THE SPLEEN WITH A RESIDUAL CALCIFIED SOFT TISSUE MASS, UNCHANGED. THERE IS MARKED A P.O. INTAKE WITHIN THE GASTRIC LUMEN, EXCLUDING ANY ASSESSMENT OF THE AND GASTRIC LUMEN. MILD ATHEROSCLEROTIC DISEASE AT THE ORIGIN OF THE CELIAC AXIS. CT OF THE PELVIS WITHOUT CONTRAST: VISUALIZED LOOPS OF LARGE SMALL BOWEL APPEAR UNREMARKABLE, SIMPLE MIDLINE FAT CONTAINING UMBILICAL HERNIA, MARKEDLY ENLARGED BUT UNCHANGED PROSTATE, NO FREE FLUID, NO PATHOLOGICALLY ENLARGED NODES. BONES DEMONSTRATE APPEARANCE CLASSIC FOR SICKLE CELL WITH ENDPLATE INFARCTION IMPRESSION: 1. No specific evidence of malignancy on this non contrast CT 2. FINDINGS CONSISTENT WITH SICKLE CELL DISEASE INCLUDING AUTO INFARCTION OF THE SPLEEN, VERTEBRAL ENDPLATE INFARCTION. 3. CHRONIC FINDINGS INCLUDING A FULLNESS OF THE LEFT ADRENAL GLAND, SIMPLE CHOLELITHIASIS. Radiology Report COMPUTED TOMOGRAPHY OF THE THORAX INDICATION: Search for malignancy. COMPARISON: ___. TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration, no administration of intravenous contrast material. FINDINGS: 12 mm hypodense right thyroid nodule. No supraclavicular, infraclavicular or axillary lymphadenopathy. No lymphadenopathy in the mediastinum. No substantial coronary calcifications. Mild mitral valve calcifications. No pericardial effusion. The abdominal findings are reported in detail in the abdominal CT examination performed today. Diffuse bony changes, not different from previous examination from ___. Minimal subpleural bulla on the left. Non-characteristic subpleural micronodules, none of which is suspicious for malignancy. No suspicious pulmonary nodules. No pleural effusions. No pneumonia. Non-characteristic scarring at the bases of the lingula. Pleural thickening and scarring at the right lung base (4, 258). Old left rib fracture. IMPRESSION: No evidence of malignancy on the current examination. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Dyspnea Diagnosed with RESPIRATORY ABNORM NEC temperature: 99.5 heartrate: 108.0 resprate: 20.0 o2sat: 96.0 sbp: 141.0 dbp: 87.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, It was a pleasure taking care of you during your hospitalization. You were admitted when you developed an acute onset of shortness of breath. We were worried that this could have been due to your heart not functioning as well or from a problem with your lungs. We obtained a scan of your lungs that showed that you had blood clots in your lungs. We kept you on a blood thinner and started you on a medication called Rivaroxaban that you should continue taking for at least six months. You also reported poor appetite so we performed a endoscopy and colonoscopy to make sure that there were no anatomical problems with your gastrointestinal system. This showed mild irritation for which you should take a medication called pantoprazole twice a day. We also gave a you a medication for your sleep. We have followup with Dr. ___ you next ___. We wish you the best, Your ___ team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Bactrim DS Attending: ___ Chief Complaint: Fatigue Major Surgical or Invasive Procedure: DC Cardioversion ___ History of Present Illness: Mr. ___ is a ___ year old M with newly diagnosed HFrEF (EF 28% ___, persistent Afib, HTN, HLD, recently admitted for CHF exacerbation and rapid AF, now re-presenting with one day of profound fatigue as well as transient disequilibrium and garbled speech. Patient was very recently admitted to the ___ Cardiology service for CHF exacerbation and rapid AFib. He was diuresed to euvolemia, started on amiodarone, and successfully electrically cardioverted on ___. He discharged home the following day in sinus rhythm. He felt well for the two days and was able to go to work and go out to dinner. However, ___ evening he began feeling fatigued. He attributed this initially to a cold. However, his fatigue persisted despite his runny nose and chills resolving. Yesterday evening (___) he nearly fell asleep sitting at the dinner table. When he awoke he felt transiently off balance; no dizziness or unilateral weakness, just disequilibrium; this resolved quickly. His wife also reported his speech was transiently garbled. He thought this was due to being half asleep, but she was worried and insisted he seek medical attention so they drove to the ED. In the ED: - Initial VS: 99.9 107 177/97 18 RA - Labs notable for: WBC 6.4 Cr 1.1 (at baseline), K 4.5, Mg 1.9 Trop <0.01 proBNP 904 (___ last admission) - EKG: AF at 114, normal axis, QTc 457/501, TWI. - CXR: stable cardiomegaly, no edema or pneumonia. - CT head found subacute/chronic bilateral infarcts. - CTA head/neck negative. - Neuro was consulted and believed his symptoms were more related to his rapid AF rather than his strokes and recommended admission to Medicine vs. Cardiology for further management, as well as non-urgent MRI. On the floor, patient reports ongoing fatigue and palpitations. No chest pain, dyspnea, or dizziness. No recurrence of neurologic symptoms since Of note, patient reports good adherence to apixiban, amiodarone, lasix, and all other medications. He weighs himself daily and his weight has been stable since discharge. He follows a low-salt diet. He denies any exertional dyspnea (just fatigue), orthopnea, PND, or recurrent edema. Regarding his neuro symptoms, he denies any headache, vision changes, unilateral weakness, paresthesias, or dysarthria. No convulsions, urinary incontinence, or confusion. His cold symptoms were limited to rhinorrhea and chills. He has not had any fevers, sinus pain, cough, N/V/D/abdominal pain, dysuria, or rashes. Past Medical History: 1. CARDIAC RISK FACTORS - Hypertension - Hyperlipidemia 2. CARDIAC HISTORY - A-fib 3. OTHER PAST MEDICAL HISTORY Motor vehicle crash ___: Whiplash, low back and knee injuries History of recurrent MRSA infections: Sees dermatology p.r.n. Hypertension Hyperlipidemia Hearing loss b/l wears hearing aids f/up by ENT, Erectile Dysfunction on viagra Ca Prostate followed by ___, s/p radiation and hormonal therapy colonosocpy done ___ rec repeat in ___ yrs ___ persistant rash: face/neck abscess ___ Social History: ___ Family History: Negative for premature CAD, arrhythmias, heart failure, cardiomyopathy, sudden or unexpected death. No family history of HTN, DM, or cancers. Physical Exam: ADMISSION EXAM: =============== VS: 97.6 129/94 124 18 95%RA GEN: Lying comfortably flat in bed. HEENT: NC/AT. No icterus or injection. MMM. CV: JVP ~7cm. Tachycardic, irregularly irregular, no murmurs. Normal distal pulses. RESP: Normal work of breathing. Transmitted coarse upper airway sounds but no crackles or wheezes. ABD: Soft, NDNT. No HSM. EXTR: Warm, trace edema beneath compression stockings. NEURO: Alert, oriented, normal attention, memory, and speech. PERRL, EOMI, CN ___ intact. Strength ___ throughout. No dysmetria. DISCHARGE EXAM: =============== Temp: 97.2 (Tm 98.9), BP: 127/57 (107-144/57-80), HR: 62 (62-86), RR: 18 (___), O2 sat: 100% (94-100), O2 delivery: Ra, Wt: 140.43 lb/63.7 kg GEN: Lying comfortably flat in bed. HEENT: NC/AT. No icterus or injection. MMM. CV: JVP not visible. RRR, no murmurs. Normal distal pulses. RESP: Normal work of breathing. Minimal wheeze throughout. ABD: Soft, NDNT. No HSM. EXTR: Warm, no edema. NEURO: Alert, oriented, normal attention, memory, and speech. PERRL, EOMI, CN ___ intact. Strength ___ throughout. No dysmetria. Sensation grossly intact. Pertinent Results: ADMISSION LABS: =============== ___ 09:00PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE ___ 10:55AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 10:55AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 07:16AM GLUCOSE-60* UREA N-13 CREAT-0.8 SODIUM-137 POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-24 ANION GAP-16 ___ 07:16AM CALCIUM-9.2 PHOSPHATE-2.9 MAGNESIUM-1.9 ___:16AM WBC-7.1 RBC-5.52 HGB-17.5 HCT-51.5* MCV-93 MCH-31.7 MCHC-34.0 RDW-13.7 RDWSD-47.5* ___ 07:16AM PLT COUNT-150 ___ 07:16AM ___ PTT-31.0 ___ ___ 08:40PM GLUCOSE-88 UREA N-17 CREAT-1.1 SODIUM-140 POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-29 ANION GAP-10 ___ 08:40PM ALT(SGPT)-73* AST(SGOT)-58* ALK PHOS-119 TOT BILI-0.8 ___ 08:40PM cTropnT-<0.01 ___ 08:40PM proBNP-904* ___ 08:40PM ALBUMIN-3.7 CALCIUM-9.0 PHOSPHATE-2.5* MAGNESIUM-1.9 CHOLEST-210* ___ 08:40PM %HbA1c-6.0 eAG-126 ___ 08:40PM TRIGLYCER-162* HDL CHOL-47 CHOL/HDL-4.5 LDL(CALC)-131* ___ 08:40PM TSH-2.1 ___ 08:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 08:40PM WBC-6.4 RBC-5.35 HGB-16.7 HCT-49.7 MCV-93 MCH-31.2 MCHC-33.6 RDW-13.6 RDWSD-47.1* ___ 08:40PM NEUTS-78.2* LYMPHS-6.7* MONOS-12.9 EOS-1.4 BASOS-0.5 IM ___ AbsNeut-5.01 AbsLymp-0.43* AbsMono-0.83* AbsEos-0.09 AbsBaso-0.03 ___ 08:40PM PLT COUNT-153 DISCHARGE LABS: =============== ___ 07:10AM BLOOD WBC-6.7 RBC-4.86 Hgb-15.0 Hct-45.0 MCV-93 MCH-30.9 MCHC-33.3 RDW-13.6 RDWSD-46.7* Plt ___ ___ 07:10AM BLOOD Glucose-105* UreaN-15 Creat-0.9 Na-143 K-4.5 Cl-101 HCO3-26 AnGap-16 ___ 07:10AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.0 CXR ___: ============== FINDINGS: Cardiac silhouette size remains moderately enlarged. The aorta is tortuous with atherosclerotic calcifications noted at the aortic knob. Pulmonary vasculature is not engorged. Lungs are clear. No pleural effusion or pneumothorax is demonstrated. Mild degenerative changes are seen in the thoracic spine. IMPRESSION: No acute cardiopulmonary abnormality. CT HEAD WITHOUT CONTRAST ___: =================================== IMPRESSION: Findings suggestive of subacute/chronic infarctions within the left occipital lobe, right posterior parietal lobe, and right cerebellum. If clinical concern remains high for an acute infarction, MRI would be more sensitive for evaluation. No evidence of intracranial hemorrhage. RECOMMENDATION(S): If clinical concern remains high for an acute infarction, MRI would be more sensitive for evaluation. CTA HEAD AND CTA NECK ___: ================================ FINDINGS: CTA HEAD: The vessels of the circle of ___ and their principal intracranial branches appear normal without stenosis, occlusion, or aneurysm formation. The dural venous sinuses are patent. There are small bilateral mucous retention cysts, otherwise remaining paranasal sinuses middle ear canals and mastoid air cells are clear. Left occipital, right parietal and right cerebellar chronic infarcts are better assessed on noncontrast head CT from ___. CTA NECK: There is a predominantly noncalcified atherosclerotic plaque at the origin of the right internal carotid artery. This mildly encroaches on the carotid bulb. Otherwise 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: Partially imaged portions of the lung apices demonstrate stable pleural scarring with a stable 5 mm left apical subpleural nodule, unchanged since ___. There are 2 potential hypodensities in the right thyroid lobe measuring up to 8 mm, however may be artifactual (2:107, 2:112). Otherwise, the visualized portion of the thyroid gland is within normal limits. There is no lymphadenopathy by CT size criteria. There is moderate calcification of the aortic arch. IMPRESSION: 1. Noncalcified plaque at the origin of the right internal carotid artery with no evidence of stenosis. 2. The remainder of the vessels appear normal 3. Possible subcentimeter right thyroid lobe nodules, however not definitive and may be artifactual. RECOMMENDATION(S): Thyroid nodule. No follow up recommended. Absent suspicious imaging features, unless there is additional clinical concern, ___ College of Radiology guidelines do not recommend further evaluation for incidental thyroid nodules less than 1.0 cm in patients under age ___ or less than 1.5 cm in patients age ___ or ___. Suspicious findings include: Abnormal lymph nodes (those displaying enlargement, calcification, cystic components and/or increased enhancement) or invasion of local tissues by the thyroid nodule. ___, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White Paper of the ACR Incidental Findings Committee". J ___ ___ 12:143-150. MRI HEAD ___: ============== FINDINGS: There is no acute infarction. There are small chronic infarcts involving the left occipital lobe, right posterior parietal lobe and right posterior cerebellar hemisphere. Moderately extensive subcortical, deep and periventricular white matter T2/FLAIR hyperintensities are nonspecific but compatible with chronic small vessel ischemic disease given the patient's age. No evidence for edema, mass effect, or blood products. There is mild global parenchymal volume loss with prominent ventricles and sulci. The major intracranial vascular flow voids are maintained. There are mucous retention cysts in the maxillary sinuses and mild mucosal thickening in the ethmoid air cells. There is trace fluid signal in bilateral mastoid tip air cells. There are degenerative changes in the included upper cervical spine, including mild retrolisthesis of C3 on C4 with posterior endplate osteophytes, previously seen on the ___ cervical spine MRI. IMPRESSION: 1. No acute infarction. 2. Small chronic infarcts involving the left occipital lobe, right posterior parietal lobe and right posterior cerebellar hemisphere. 3. Moderately extensive supratentorial white matter signal abnormality nonspecific, but likely sequela of chronic small vessel ischemic disease. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 5 mg PO BID 2. Lisinopril 20 mg PO DAILY 3. TraZODone 50 mg PO QHS:PRN Insomnia 4. Sildenafil 100 mg PO ONCE:PRN Erectile Dysfunction 5. Amiodarone 200 mg PO BID 6. Furosemide 20 mg PO DAILY Discharge Medications: 1. Amiodarone 400 mg PO BID RX *amiodarone 400 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. Apixaban 5 mg PO BID 3. Furosemide 20 mg PO DAILY 4. Lisinopril 20 mg PO DAILY 5. Sildenafil 100 mg PO ONCE:PRN Erectile Dysfunction 6. TraZODone 50 mg PO QHS:PRN Insomnia Discharge Disposition: Home Discharge Diagnosis: PRIMARY: ======== Atrial fibrillation Hypertension CHF exacerbation Subacute/Chronic CVAs SECONDARY: ========== Hyperlipidemia Transaminitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK INDICATION: History: ___ with AF, found to have sub-acute to chronic ischemic changes// Aneurysms, carotid artery stenosis? TECHNIQUE: Contiguous MDCT axial images were obtained through the brain with contrast material. Helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of 70 mL of Omnipaque350 intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 59.9 mGy (Head) DLP = 30.0 mGy-cm. 2) Spiral Acquisition 5.4 s, 42.4 cm; CTDIvol = 31.1 mGy (Head) DLP = 1,319.1 mGy-cm. Total DLP (Head) = 1,349 mGy-cm. COMPARISON: Noncontrast head CT ___. CT neck ___ FINDINGS: CTA HEAD: The vessels of the circle of ___ and their principal intracranial branches appear normal without stenosis, occlusion, or aneurysm formation. The dural venous sinuses are patent. There are small bilateral mucous retention cysts, otherwise remaining paranasal sinuses middle ear canals and mastoid air cells are clear. Left occipital, right parietal and right cerebellar chronic infarcts are better assessed on noncontrast head CT from ___. CTA NECK: There is a predominantly noncalcified atherosclerotic plaque at the origin of the right internal carotid artery. This mildly encroaches on the carotid bulb. Otherwise 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: Partially imaged portions of the lung apices demonstrate stable pleural scarring with a stable 5 mm left apical subpleural nodule, unchanged since ___. There are 2 potential hypodensities in the right thyroid lobe measuring up to 8 mm, however may be artifactual (2:107, 2:112). Otherwise, the visualized portion of the thyroid gland is within normal limits. There is no lymphadenopathy by CT size criteria. There is moderate calcification of the aortic arch. IMPRESSION: 1. Noncalcified plaque at the origin of the right internal carotid artery with no evidence of stenosis. 2. The remainder of the vessels appear normal 3. Possible subcentimeter right thyroid lobe nodules, however not definitive and may be artifactual. RECOMMENDATION(S): Thyroid nodule. No follow up recommended. Absent suspicious imaging features, unless there is additional clinical concern, ___ College of Radiology guidelines do not recommend further evaluation for incidental thyroid nodules less than 1.0 cm in patients under age ___ or less than 1.5 cm in patients age ___ or ___. Suspicious findings include: Abnormal lymph nodes (those displaying enlargement, calcification, cystic components and/or increased enhancement) or invasion of local tissues by the thyroid nodule. ___, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White Paper of the ACR Incidental Findings Committee". J ___ ___ 12:143-150. Radiology Report EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD INDICATION: ___ year old man with subacute/chronic strokes on CT. Evaluate location and chronicity of strokes. TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was performed with gradient echo, FLAIR, diffusion, and T2 technique were then obtained. COMPARISON CT head without contrast ___ at 21:53 (approximately 12 hours earlier). FINDINGS: There is no acute infarction. There are small chronic infarcts involving the left occipital lobe, right posterior parietal lobe and right posterior cerebellar hemisphere. Moderately extensive subcortical, deep and periventricular white matter T2/FLAIR hyperintensities are nonspecific but compatible with chronic small vessel ischemic disease given the patient's age. No evidence for edema, mass effect, or blood products. There is mild global parenchymal volume loss with prominent ventricles and sulci. The major intracranial vascular flow voids are maintained. There are mucous retention cysts in the maxillary sinuses and mild mucosal thickening in the ethmoid air cells. There is trace fluid signal in bilateral mastoid tip air cells. There are degenerative changes in the included upper cervical spine, including mild retrolisthesis of C3 on C4 with posterior endplate osteophytes, previously seen on the ___ cervical spine MRI. IMPRESSION: 1. No acute infarction. 2. Small chronic infarcts involving the left occipital lobe, right posterior parietal lobe and right posterior cerebellar hemisphere. 3. Moderately extensive supratentorial white matter signal abnormality nonspecific, but likely sequela of chronic small vessel ischemic disease. Radiology Report INDICATION: ___ year old man with new fevers, cough// Assess for pneumonia, cause of fevers/cough TECHNIQUE: Chest PA and lateral COMPARISON: ___ IMPRESSION: Lungs are clear. Heart size is normal. There is no pleural effusion. No pneumothorax is seen Gender: M Race: BLACK/CAPE VERDEAN Arrive by WALK IN Chief complaint: Altered mental status, Weakness Diagnosed with Dizziness and giddiness, Other fatigue, Altered mental status, unspecified, Unspecified atrial fibrillation temperature: 99.9 heartrate: 107.0 resprate: 18.0 o2sat: nan sbp: 177.0 dbp: 97.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, It was a pleasure taking care of you at ___. WHY WERE YOU IN THE HOSPITAL? - You were recently in the hospital because of heart failure and atrial fibrillation. You came back to the hospital because of fatigue and garbled speech. - Because of these symptoms, you were concerned that you were back in atrial fibrillation. WHAT HAPPENED IN THE HOSPITAL? - Because of the garbled speech, you had imaging of the brain. This showed old strokes but nothing new. - Your amiodarone dose was increased. - You went for another cardioversion procedure. This was successful and you went back in to a normal rhythm. WHAT SHOULD YOU DO AFTER LEAVING THE HOSPITAL? - You should take all of your medications as prescribed, including the increased dose of amiodarone. You should take the 400 mg twice a day for 1 week, then 400 mg per day thereafter. - You should take it easy at work. - You should follow up with your cardiologist on ___. - You should follow up with your primary care doctor on ___, ___. We wish you the best, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Toprol XL / Univasc / Sulfa (Sulfonamide Antibiotics) / nitrofurantoin Attending: ___. Chief Complaint: AMS Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ with h/o dementia, bipolar disorder, T2DM, hypothyroidism, CVA, recurrent UTIs, and recent admission from ___ for confusion and worsening tardive dyskinesia attributed to E coli UTI, who re-presents to the ED with worsening mental status, agitation, and tardive dyskinesia. Briefly, the patient was admitted from ___ for altered mental status and worsening tardive dyskinesia ultimately attributed to E coli UTI, with improvement of her symptoms following treatment of her infection. She was initially treated with linezolid given history of MDR enterococcus UTI and was subsequently narrowed to ceftriaxone and was discharged on a course of augmentin to be completed on ___. Hospital course was complicated by hypernatremia attributed to decreased free water intake, underlying partial nephrogenic DI in the setting of chronic lithium, and multiple falls. She was discharged from the hospital on ___ to home with her daughters, who are with her ___. Of note there was discussion about rehab at the time of discharge per ___ recommendations, however the family at that time felt their ultimate goal was to get the patient home and decision was made with medical team that patient may be safer at home under ___ care. On arrival to the ED on admission her daughters report that the patient has not returned to her baseline mobility (still using a wheelchair), and over the past few days has become increasingly agitated and frequently tries to get out of her chair or bed without assistance. Unfortunately there seems to have been inadequate support from ___ and ___. In this setting they are concerned that she is not safe at home. Her daughters additionally note that she has had worsening symptoms of insomnia, paranoia, visual hallucinations after recent discharge from the hospital for treatment of recurrent UTIs. They deny any fevers, falls at home. Per discussion with outpatient psychiatrist Dr. ___ by the ED: Pt's baseline is some irritability, but family has able to care for her adequately in the past. In recent weeks-months, she has been intermittently far form her baseline in the setting of frequent UTI. In the ED: - Initial vital signs were notable for: T97.3 HR77 BP127/95 RR17 O2-96 on RA - Exam notable for: - Labs were notable for: H/H 9.1/30.6 Troponin-T 0.06 UA: >183 WBC, few bacteria, neg nitrites - Patient was given: ___ 15:20 IM OLANZapine 5 mg - Consults: Psychiatry Upon arrival to the floor, she is lying peacefully in bed but becomes agitated with interaction. She is unable to provide any history or reliably answer questions but denies pain. REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise negative. Past Medical History: Schizoaffective disorder, bipolar type Hypothyroidism Type 2 diabetes Tardive dyskinesia Recurrent UTIs Recurrent falls of unclear etiology Status post CVA History of C1 fracture/cervical spondylolysis Vitamin B12 deficiency Anemia Osteoarthritis Osteoporosis Constipation Seizures - undetermined type, with aura, ?every month Social History: ___ Family History: Mother - died from MI in ___ Father - died from MI in ___ Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: T97.9 BP112/66 HR72 RR17 O2-95 GENERAL: Agitated, cachectic. HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without injection. MMM. Frequent repetitive mouth and tongue movements. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. Normal work of breathing. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No palpable organomegaly. No suprapubic tenderness. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. No rashes. NEUROLOGIC: Oriented to self and to hospital in ___. Agitated, crying out intermittently. Difficult to understand speech in setting of tardive dyskinesa. Squeezes finger on command. DISCHARGE PHYSICAL EXAM: VITALS: 24 HR Data (last updated ___ @ 815) Temp: 98.1 (Tm 98.1), BP: 103/45 (103-146/45-92), HR: 76 (67-76), RR: 18, O2 sat: 95% (94-95), O2 delivery: RA GENERAL: lying on her side in bed, awake and alert, speaking clearly HEENT: Very dry lips and tongue, frequent repetitive mouth and tongue movements. LUNGS: no respiratory distress ABDOMEN: non distended NEUROLOGIC: Frequent limb movement without purpose Pertinent Results: ADMISSION LABS: ================ ___ 01:29PM BLOOD WBC-7.9 RBC-2.81* Hgb-9.1* Hct-30.6* MCV-109* MCH-32.4* MCHC-29.7* RDW-16.8* RDWSD-67.2* Plt ___ ___ 01:29PM BLOOD Glucose-107* UreaN-28* Creat-0.9 Na-145 K-4.4 Cl-109* HCO3-23 AnGap-13 ___ 01:29PM BLOOD ALT-22 AST-43* CK(CPK)-128 AlkPhos-64 TotBili-0.4 ___ 01:29PM BLOOD cTropnT-0.06* ___ 07:50PM BLOOD CK-MB-3 cTropnT-0.06* ___ 04:47AM BLOOD cTropnT-0.05* ___ 01:29PM BLOOD Albumin-4.2 Calcium-10.5* Phos-3.4 Mg-2.4 ___ 04:47AM BLOOD Folate-12 ___ 06:03AM BLOOD %HbA1c-4.6 eAG-85 ___ 06:03AM BLOOD Triglyc-140 HDL-54 CHOL/HD-2.4 LDLcalc-46 ___ 06:10AM BLOOD TSH-2.0 LATEST LABS PRIOR TO DISCHARGE: ___ 11:03AM BLOOD WBC-10.2* RBC-2.66* Hgb-8.9* Hct-32.6* MCV-123* MCH-33.5* MCHC-27.3* RDW-17.1* RDWSD-77.2* Plt ___ ___ 05:52AM BLOOD Glucose-88 UreaN-21* Creat-0.6 Na-156* K-3.8 Cl-124* HCO3-24 AnGap-8* ___ 05:52AM BLOOD LD(LDH)-308* ___ 09:01AM BLOOD Calcium-9.0 Phos-2.6* Mg-2.2 MICROBIOLOGY: ================ ___ 6:29 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: IDENTIFICATION AND Susceptibility testing requested per ___ ON ___ AT 11:52. ___ ALBICANS. >100,000 CFU/mL. Yeast Susceptibility:. Fluconazole MIC OF 0.5 MCG/ML SUSCEPTIBLE. Results were read after 24 hours of incubation. test result performed by Sensititre. ___ - STOOL CDIFF PCR POSITIVE, TOXIN NEGATIVE IMAGING: ========== ___ MRI head without contrast IMPRESSION: 1. Please note the study is suboptimal due to extensive motion artifact which limits evaluation of intracranial structures. 2. Within these limitations, several areas of high signal on the diffusion weighted images are seen in the left cerebellum are seen without definite correlate on the ADC sequences. While these lesions could represent subacute infarcts, other lesions are not excluded given degree of motion and a repeat study may be helpful for further characterization. RECOMMENDATION(S): A repeat study when patient is more cooperative would be helpful to better characterize the left cerebellar lesions. ___ ECHO: The left atrial volume index is normal. The interatrial septum is dynamic, but not frankly aneurysmal. There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is suboptimal image quality to assess regional left ventricular function. Overall left ventricular systolic function is hyperdynamic. The visually estimated left ventricular ejection fraction is 75%. There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets are mildly thickened. There is trivial mitral regurgitation. The tricuspid valve leaflets are mildly thickened with systolic prolapse. There is physiologic tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the prior TTE (images not available for review) of ___, the findings are similar. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. ClonazePAM 0.25 mg PO AM 3. ClonazePAM 0.5 mg PO QHS 4. ClonazePAM 0.25 mg PO AFTERNOON:PRN agitation 5. Cyanocobalamin ___ mcg PO DAILY 6. Docusate Sodium 100 mg PO BID 7. Levothyroxine Sodium 50 mcg PO DAILY 8. Lithium Carbonate 150 mg PO QHS 9. Omeprazole 20 mg PO BID 10. Polyethylene Glycol 17 g PO DAILY 11. Pyridoxine 100 mg PO DAILY 12. QUEtiapine Fumarate 100 mg PO QHS 13. Senna 8.6 mg PO BID:PRN Constipation 14. Simvastatin 20 mg PO DAILY 15. Vitamin D 1000 UNIT PO DAILY 16. Multivitamins W/minerals 1 TAB PO DAILY 17. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain - Moderate 18. QUEtiapine Fumarate 25 mg PO DAILY PRN paranoia 19. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 20. Dipyridamole-Aspirin 1 CAP PO BID Discharge Medications: 1. Atorvastatin 40 mg PO QPM RX *atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*7 Tablet Refills:*0 2. Fluconazole 100 mg PO Q24H Duration: 14 Days RX *fluconazole 40 mg/mL 2.5 mL(s) by mouth daily Refills:*0 3. ClonazePAM 0.25 mg PO BID RX *clonazepam 0.25 mg 1 tablet(s) by mouth twice daily at 8AM and noon Disp #*14 Tablet Refills:*0 4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line RX *polyethylene glycol 3350 17 gram 1 packet by mouth daily Disp #*14 Packet Refills:*0 5. QUEtiapine Fumarate 50 mg PO QHS RX *quetiapine 50 mg 1 tablet(s) by mouth at bedtime Disp #*7 Tablet Refills:*0 6. QUEtiapine Fumarate 25 mg PO BID:PRN agitation RX *quetiapine 25 mg 1 tablet(s) by mouth twice daily Disp #*14 Tablet Refills:*0 7. ClonazePAM 0.5 mg PO QHS RX *clonazepam 0.5 mg 1 tablet(s) by mouth at bedtime Disp #*7 Tablet Refills:*0 8. Dipyridamole-Aspirin 1 CAP PO BID RX *aspirin-dipyridamole 25 mg-200 mg 1 capsule(s) by mouth twice daily Disp #*14 Capsule Refills:*0 9. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY RX *lansoprazole 30 mg 1 tablet(s) by mouth daily Disp #*7 Tablet Refills:*0 10. Levothyroxine Sodium 50 mcg PO DAILY RX *levothyroxine 50 mcg 1 tablet(s) by mouth daily Disp #*7 Tablet Refills:*0 11. Lithium Carbonate 150 mg PO QHS RX *lithium carbonate 150 mg 1 capsule(s) by mouth at bedtime Disp #*7 Capsule Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY: ================== Subacute encephalopathy in the setting of dementia Cerebral vascular accident Failure to thrive Severe malnutrition SECONDARY: ================== Tardive dyskinesia Schizophrenia vs bipolar disorder Hypernatremia Recurrent urinary tract infection, ___ Oropharyngeal dysphagia GERD Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman with unequal pupils concern for intracranial process, stroke// unequal pupils concern for intracranial process, stroke TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 6.6 s, 22.0 cm; CTDIvol = 53.0 mGy (Head) DLP = 1,166.0 mGy-cm. 2) Sequenced Acquisition 6.6 s, 22.0 cm; CTDIvol = 53.0 mGy (Head) DLP = 1,166.0 mGy-cm. Total DLP (Head) = 2,332 mGy-cm. COMPARISON: CT head ___ FINDINGS: Examination is significantly limited by patient positioning, motion and beam hardening artifact. Evaluation of the skull brain interfaces particularly suboptimal. Within these confines: There is an approximately 3.2 cm hypodensity in the left cerebellum demonstrating mass effect, not previously seen on CT head ___, consistent with an late acute to subacute infarct. There is no large hemorrhage, however, small hemorrhage cannot be excluded on this limited study. There is no midline shift. The ventricles and sulci are prominent, consistent with age related atrophy. The known bilateral C1 anterior and posterior arch fractures are partially imaged. There is mild mucosal thickening of the sphenoid and ethmoid sinuses. Patient is status post bilateral lens replacement; the visualized portion of the orbits are otherwise unremarkable. IMPRESSION: 1. Findings compatible with late acute to subacute left cerebellar infarct. 2. No large hemorrhage or midline shift. Examination is significantly limited by patient positioning, motion and beam hardening artifact. 3. Additional findings described above. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 9:06 am, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD INDICATION: ___ year old woman with history of dementia, bipolardisorder/schizoaffective disorder, tardive dyskinesia (thoughtto be due to olanzapine, stelazine) that presented to the hospital for change in mental status found to have late acute to subacute cerebellar stroke// evaluate 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 CT head without contrast from ___ FINDINGS: Please note that the study is suboptimal due to extensive motion artifact which limits evaluation of intracranial structures. Within these limitations, there are several areas of high signal on the diffusion-weighted images in the left cerebellar hemisphere corresponding to the abnormalities seen on the CT head study from ___. However, the apparent diffusion coefficient images are so degraded by motion artifact that it is not clear whether there are corresponding regions of slow diffusion. Prominence of ventricles and sulci are compatible with age related involutional changes. Ill-defined T2/FLAIR hyperintensities are nonspecific but likely due to chronic sequela of small-vessel ischemic disease. The paranasal sinuses are grossly clear without obvious opacification. The orbits are unremarkable. IMPRESSION: 1. Please note the study is suboptimal due to extensive motion artifact which limits evaluation of intracranial structures. 2. Within these limitations, several areas of high signal on the diffusion weighted images are seen in the left cerebral hemisphere are seen without definite correlate on the ADC sequences. While these lesions could represent subacute infarcts, other lesions are not excluded given degree of motion and a repeat study may be helpful for further characterization. RECOMMENDATION(S): A repeat study when patient is more cooperative would be helpful to better characterize the left cerebellar lesions. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 3:21 pm, 1 minutes after discovery of the findings. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Altered mental status, Dehydration Diagnosed with Altered mental status, unspecified temperature: 97.3 heartrate: 88.0 resprate: 17.0 o2sat: nan sbp: 127.0 dbp: 95.0 level of pain: u level of acuity: 2.0

Dear ___, You were admitted to ___ because you were confused. While you were here, you had a cat scan of your head which showed that you had a stroke. We gave you medicines to help make you feel better. Your family and your doctors decided that ___ be happiest at home with home ___. These doctors and ___ help manage any symptoms that you have. It was a pleasure taking part in your care. We wish you all the best. Sincerely, The team at ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: C. Diff Colitis Major Surgical or Invasive Procedure: None History of Present Illness: This is a ___ yo man w PMHx significant for DMII, HTN, HLD, GERD presents with 5 weeks of watery diarrhea (24x/day) associated with abdominal cramps. Patient reports significant decreased appetite, with 25lb weight loss in the past two weeks. The patient had planned a 2 week trip to ___, and prior to leaving had started experiencing symptoms of bloating, loose stools, and abdominal pain. While on vacation, the diarrhea worsened, increasing in frequency and becoming watery. Patient visited PCP ___ ___ (one day after returning from ___ when her returned from the ___ ___ stool analysis and lab tests that were unremarkable. Patient presented to the ED (___ ___ on ___ where he had a an abdominal CT that showed pancolitis, but both stool and blood samples were unrevealing. Patient was discharged on ciprofloxacin. Patient was then seen by outpatient GI on ___ who ordered a new stool analysis, added flagyl to his treatment, and scheduled him for a colonoscopy. Once the stool came back positive for C. diff (___), the patient was started on PO vancomycin. His GI physician suggested the patient should visit the ED given his dehydration and weight loss. Patient denies recent antibiotic use or hospitalization. In the ED, initial vital signs were: T=97.8 HR=100 BP=142/80 RR=20 SpO2=98% RA Labs were notable for Na of 132, glucose of 302. KUB showed normal bowel gas pattern without evidence of obstruction or free intraperitoneal air. Patient was given 2L of NS and Vancomycin Oral Liquid ___ mg PO On transfer the patient's vitals were: T=98.2, HR=83, BP=122/84, RR=20, and SpO2=97%RA Past Medical History: Poorly Controlled DMII HTN HLD Asthma GERD Left Hip Replacement in ___ Facial reconstructive surgery after MVA at age ___ Hernia repair Vasectomy Social History: ___ Family History: Father has DM2, HTN, HLD Mother died of breast cancer Physical Exam: ADMISSION PHYSICAL EXAM: ======================== Vitals: T=98.2, HR=83, BP=122/84, RR=20, and SpO2=97%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry MM Neck: Supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, mildly distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNs2-12 intact, motor function grossly normal DISCHARGE PHYSICAL EXAM: ======================== Vitals: T=98.0 BP=138/75 HR=94 RR=18 SpO2=100% on RA General: Well appearing, comfortable HEENT: NC/AT, EOMI, MMM Lungs: CTAB, no r/r/w CV: RR, +S1/S2, no m/r/g Abdomen: Soft, ND, non-tender, no rebound or guarding Ext: WWP, no edema Neuro: AAO x3, non-focal Pertinent Results: ADMISSION LABS: =============== ___ 04:15PM WBC-9.3 RBC-4.85 HGB-13.8 HCT-40.5 MCV-84 MCH-28.5 MCHC-34.1 RDW-13.2 RDWSD-40.0 ___ 04:15PM NEUTS-66.7 LYMPHS-17.6* MONOS-9.2 EOS-4.5 BASOS-0.6 IM ___ AbsNeut-6.19* AbsLymp-1.63 AbsMono-0.85* AbsEos-0.42 AbsBaso-0.06 ___ 04:15PM PLT COUNT-396 ___ 04:15PM GLUCOSE-302* UREA N-13 CREAT-1.0 SODIUM-132* POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-23 ANION GAP-17 ___ 04:16PM LACTATE-1.5 DISCHARGE LABS: =============== ___ 06:09AM BLOOD WBC-7.9 RBC-4.17* Hgb-11.8* Hct-36.0* MCV-86 MCH-28.3 MCHC-32.8 RDW-13.5 RDWSD-42.1 Plt ___ ___ 06:09AM BLOOD Plt ___ ___ 06:09AM BLOOD Glucose-296* UreaN-9 Creat-0.9 Na-132* K-4.7 Cl-96 HCO3-24 AnGap-17 ___ 06:09AM BLOOD Calcium-8.1* Phos-3.1 Mg-2.0 MICROBIOLOGY: ============= Blood Culture, Routine (Final ___: NO GROWTH. PERTINENT IMAGING: ================== ABD XRAY SUPINE/ERECT (___) Nonobstructive bowel gas pattern is demonstrated. No free intraperitoneal air, pneumatosis, or differential air-fluid levels are seen. There are no concerning soft tissue calcifications. Mild degenerative changes are noted in the lower thoracic and lower lumbar spine. Patient is status post left hip arthroplasty. Marked degenerative changes are noted in the right femoral acetabular joint. Radiology Report INDICATION: ___ yoM with DMII, HTN,HLD presenting with 5 weeks of watery diarrhea, C Diff positive. TECHNIQUE: Supine and upright AP views of the abdomen COMPARISON: None. FINDINGS: Nonobstructive bowel gas pattern is demonstrated. No free intraperitoneal air, pneumatosis, or differential air-fluid levels are seen. There are no concerning soft tissue calcifications. Mild degenerative changes are noted in the lower thoracic and lower lumbar spine. Patient is status post left hip arthroplasty. Marked degenerative changes are noted in the right femoral acetabular joint. IMPRESSION: Normal bowel gas pattern without evidence for obstruction or free intraperitoneal air. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abd pain, Diarrhea Diagnosed with Enterocolitis due to Clostridium difficile temperature: 97.8 heartrate: 100.0 resprate: 20.0 o2sat: 98.0 sbp: 142.0 dbp: 80.0 level of pain: 6 level of acuity: 3.0

Dear Mr. ___, It was a pleasure taking care of you. You were admitted to the ___ because you had severe diarrhea with dehydration and weight loss from a bacteria in your large intestine known as Clostridium difficile. In the hospital, we continued your antibiotics and gave you intravenous fluids to rehydrate you. Your diarrhea has decreased in frequency, but you will need to continue your antibiotic for another 10 days after you leave the hospital (total of 14 days - last day ___. You should follow-up with your primary care physician ___ ___ days of discharge and your GI specialist after you finish your antibiotic course. In some cases, the infection may recur. If your diarrhea increases in frequency or recurs after it has completely resolved, please see your GI specialist. We wish you a speedy recovery, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: CARDIOTHORACIC Allergies: ACE Inhibitors / adhesive tape / Statins-Hmg-Coa Reductase Inhibitors Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: ___ Cardiac cath with Impella insertion and 2 DES ___ Impella repositioning, unsuccessful impella removal ___ 1. Coronary artery bypass grafting x1 with left internal mammary artery to the left anterior descending artery. 2. Removal of Impella device with aortotomy. History of Present Illness: ___ with hx of HTN and high cholesterol who is presenting as a transfer from ___ with NSTEMI on heparin and nitro. She started having exertional chest pain for 2 days. Pain progressed to severe rest pain on morning (___). Pain was described as constant, heavy, and in the ___ her chest that radiated up to her neck. She presented to ___ ED and was transferred to BI ED. She has no cardiac history and has never had this chest pain before. She denies shortness of breath, fever, chills, abdominal pain, nausea, vomiting, diarrhea or other symptoms. In the ED initial vitals were: 98.8, 75, 136/70, 14, 97% Nasal Cannula EKG:STE in II, III, aVF, STD in V1-V3 with T wave inversions Labs/studies notable for: CBC: 9.3/12.7/39.5/280 BMP: ___ Trop: 0.11 CK-MB: 21 CK:211 Patient was given: ___ 18:55 IV Heparin Started 12 units/hr ___ 18:55 IV DRIP Nitroglycerin (0.35-3.5 mcg/kg/min ordered)Started 0.4 mcg/kg/min ___ 18:55 PO/NG TiCAGRELOR 180 mg She was taken to the cath lab found 90% occlusion of proximal LAD which was not thought to be culprit lesion so was not revascularized. Proximal RCA was totally occluded and was revascularized with DES x2. Patient became hypotensive and dopamine was started, she went into complete heart block with bradycardia and a RV temp wire was placed. Temp wire was subsequently pulled. She remained hypotensive (SBP 85 mmHg) so IABP was inserted. She then developed polymorphic VT requiring Lidocaine, Amiodarone, 3 shocks, and ~5min CPR. Hemodynamic support was escalated to Impella. Was in SVT, and then a fib with RVR (rates in 120s). On arrival to the CCU patient on levo 0.03 and heparin drip, alert and oriented breathing comfortably on NC. Initially patient was in a fib but converted to NSR with rates in ___. Right sided cordis, swan, and a line were placed. Per family, patient has no cardiac history and only takes medication for hypertension and hyperlipidemia. They do not remember the names of her medications. Past Medical History: 1. CARDIAC RISK FACTORS - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - Coronaries CAD: unknown - Pump ECHO CHF: unknown - Rhythm: LBBB (new) 3. OTHER PAST MEDICAL HISTORY - Osteoporosis - Basal cell carcinoma Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: ADMISSION EXAM VS: T HR 59 BP 108/77 RR 12 O2 SAT 99% on NC GENERAL: Well developed, well nourished in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. Cordis in place on right side, dressing in place is clean. NECK: Supple. JVP of ____ cm. CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. 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 EXAM Vital Signs and Intake/Output: Tmax: 98.9 Tcurrent: 98.3 B/P: 112/63 HR/Rhythm: 86 RR: 18 SaO2:92 Oxygen: RA FSBG: n/a Date: 73.1 (74 kg) In Out: ___ Physical Examination: General/Neuro: NAD [x] A/O x3 [x] non-focal [x] Cardiac: RRR [x] Irregular [] Nl S1 S2 [x] Lungs: CTA [x] No resp distress [x] Abd: NBS [x]Soft [x] ND [x] NT [x] Extremities: 1+ CCE[x] Pulses doppler [x] palpable [], r foot paresthesias continue Wounds: Sternal: CDI [x] no erythema or drainage [x] Sternum stable [] Prevena [x] R groin: Staples intact Pertinent Results: ___ 04:50AM BLOOD WBC-8.3 RBC-3.23* Hgb-9.6* Hct-28.6* MCV-89 MCH-29.7 MCHC-33.6 RDW-15.5 RDWSD-49.5* Plt ___ ___ 04:50AM BLOOD Glucose-98 UreaN-26* Creat-0.7 Na-141 K-3.7 Cl-101 HCO3-27 AnGap-13 TTE ___ The left atrium is elongated. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is mildly depressed (LVEF= 50 %). Right ventricular chamber size and free wall motion are normal. There is abnormal septal motion/position. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Mildly reduced left ventricular systolic function. Unable to assess for regional dysfunction. Mild aortic and tricuspid regurgitation. Borderline pulmonary hypertension. PA and Lateral ___ -Trace bilateral pleural effusions, otherwise good aeration Medications on Admission: Asa 81' Losartan 50' Discharge Medications: 1. Bisacodyl ___AILY:PRN constipation 2. Clopidogrel 75 mg PO DAILY 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Furosemide 40 mg PO DAILY Duration: 10 Days 5. Metoprolol Tartrate 25 mg PO BID 6. Pantoprazole 40 mg PO Q24H Duration: 30 Days 7. Polyethylene Glycol 17 g PO DAILY:PRN constipation 8. Potassium Chloride 20 mEq PO DAILY Duration: 10 Days 9. Tamsulosin 0.4 mg PO QHS 10. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 11. Aspirin EC 81 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Myocardial infarction, coronary artery disease s/p Coronary artery bypass graft x 1, drug-eluting stent placement x 2 Past medical history: Hypertension LBBB Osteoporosis Hyperlipidemia Basal cell carcinoma of skin b/l total knee replacement Cataract extraction Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage 1+ Edema Followup Instructions: ___ Radiology Report INDICATION: ___ year old woman with impella, and swan placed// interval changes IMPRESSION: Fluoroscopic images demonstrate placement of a Swan-Ganz catheter. Please note that the superior portion of the catheter tip is not included on the field of view. Please refer to the operative note for additional details.There is gaseous distention of the stomach. Radiology Report INDICATION: ___ year old woman with impella and Swan// need stat CXR to confirm impella placement COMPARISON: Intra procedural study from 1 hour earlier. IMPRESSION: There is a Swan-Ganz catheter with the distal tip projecting over the main pulmonary artery in good position. Impella catheter is seen within the aorta. Heart size is within normal limits. There is no focal consolidation, large pleural effusions, pulmonary edema, or pneumothoraces. Radiology Report INDICATION: Adjustment of Impella catheter. COMPARISON: Compared to radiographs from ___ IMPRESSION: Fluoroscopic images demonstrate placement of a Swan-Ganz catheter. On the last image, the distal tip appears to terminate within a distal right main pulmonary arterial branch. This could be pulled back 4-5 cm for more optimal placement. Please refer to the procedure note for additional details. Radiology Report INDICATION: ___ year old woman with Impella removal; CABG// eval tube position COMPARISON: Radiographs from ___ IMPRESSION: The Impella device has been removed. There is a Swan-Ganz catheter, endotracheal tube, feeding tube, and chest tubes which are in standard position. Heart size is upper limits of normal. There remains some prominence of the upper left mediastinum, unchanged. There is minimal blunting of the right CP angle. Lungs are relatively clear. There is no pneumothoraces. Radiology Report EXAMINATION: Lower extremity arterial duplex US. INDICATION: ___ year old woman s/p cabg/impella pre-op, right side cannulation// assess flow right leg TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound imaging of the right lower extremity arteries was obtained. FINDINGS: On the right, the common femoral artery is patent with a peak velocity of 0 with impella device in place. The SFA is patent with velocities of 37, 18, and 17 cm/sec. There is no velocity elevation to suggest stenosis. The popliteal artery is patent with a velocity of 11 cm/sec. The and anterior tibial artery is patent with a velocity of 15 cm/sec but the peronal, poterior tibial and dorsalis pedis arteries do not have flow. IMPRPRESSION: Patent right femoral and popliteal arteries with severely decreased flows. No flow seen in distal tibial arteries. Radiology Report INDICATION: ___ year old woman s/p CABG-had Impella pre-op with in right side cannulation// assess right ___ TECHNIQUE: Non-invasive evaluation of the arterial system in the lower extremities was performed with Doppler signal recording, pulse volume recordings and segmental limb pressure measurements. FINDINGS: On the right side, no Doppler waveforms are seen at the ankle. The toe PPG waveform is flat. On the left side, triphasic Doppler waveforms are seen at the posterior tibial and dorsalis pedis arteries. The left ABI was 1.19. The digit PPG waveform is barely pulsatile. Pulse volume recordings are severely dampened on the right. They are normally pulsatile at the left calf, ankle, and metatarsal levels. IMPRESSION: Evidence of severe right lower extremity ischemia. No evidence ischemia on the left. Radiology Report EXAMINATION: KNEE (AP, LAT AND OBLIQUE) RIGHT INDICATION: ___ year old woman with knee pain/after impella removal// assess for mass/trauma/ assess for mass/trauma/ TECHNIQUE: Right knee, three views. COMPARISON: None. FINDINGS: Right total knee arthroplasty hardware is in place without periprosthetic fracture, or hardware complication. Alignment is preserved. There is a moderate joint effusion. There is no fracture or dislocation. IMPRESSION: Moderate joint effusion. Right TKR without fracture or dislocation. Radiology Report EXAMINATION: Portable chest INDICATION: ___ year old woman with POD 2 from Impella removal and CABGx1.// Post chest tube removal TECHNIQUE: Portable AP chest COMPARISON: Chest radiograph ___ FINDINGS: There is a large right-sided pneumothorax. There is increased opacification of the right lower lung which is likely due to layering pleural effusion. In the left midlung there is a focal area of opacification which may be due to central pulmonary vascular congestion or aspiration/pneumonia in the appropriate clinical setting. The cardiomediastinal silhouette is mildly enlarged and appears stable. There are medial sternotomy wires which appear intact and aligned. There has been interval removal of a left-sided chest tube, a Swan-Ganz catheter, endotracheal tube, and nasogastric tube. A right central venous catheter is seen with its tip in the mid SVC. IMPRESSION: There is a new large right-sided pneumothorax and right-sided pleural effusion. New area of focal opacification in the left midlung which may be due to pulmonary vascular congestion or aspiration/pneumonia in the appropriate clinical setting. NOTIFICATION: The findings were discussed with Dr. ___. by ___, M.D. on the telephone on ___ at 5:10 pm, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: Chest radiograph INDICATION: ___ year old woman post pigtail placement.// Expansion of right lung. TECHNIQUE: Portable frontal view of the chest. COMPARISON: ___ 16:09 IMPRESSION: Compared to the examination from 2 hours prior, a right upper pleural pigtail catheter has been placed, with decrease of the right apical lateral pneumothorax, though with small residual apical component and residual partial collapse of the right upper lobe. No other interval changes seen. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with PTX// ___ year old woman with PTX ___ year old woman with PTX IMPRESSION: Comparison to ___. The right internal jugular vein catheter and the right chest tube are in stable position. On the current radiograph, there is no evidence of pneumothorax. Moderate cardiomegaly. Mild retrocardiac atelectasis. No larger pleural effusions. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with s/p cabg// chest tube on water seal- please do xray around 1200 thank you IMPRESSION: In comparison with the earlier study of this date, with the right chest tube on water seal, there is no evidence of appreciable pneumothorax. Otherwise no change. Radiology Report EXAMINATION: Chest radiograph INDICATION: ___ year old woman s/p Line exchange// ___ year old woman s/p Line exchange Contact name: ___: ___ TECHNIQUE: Portable frontal view of the chest. COMPARISON: ___ 12:06 IMPRESSION: Compared to the earlier same day examination, there has been exchange of the right internal jugular central venous catheter with the tip now terminating at the cavoatrial junction, satisfactory. There is no associated pneumothorax. There is otherwise no significant change compared to the earlier same day examination. The right pigtail pleural catheter remains in place and there is no gross pneumothorax. There are likely small bilateral pleural effusions with bibasilar atelectasis and linear lingular atelectasis. There is no worsening or new consolidation. Radiology Report EXAMINATION: Chest AP view. INDICATION: ___ year old woman s/p clamp trial, perform at 1130// ___ year old woman s/p clamp trial, perform at 1130 TECHNIQUE: Chest PA and lateral COMPARISON: ___ IMPRESSION: Chest AP view is compared to a prior done ___. Right-sided pigtail catheter and right IJ line are unchanged in position. Small bilateral effusions right greater than left have slightly increased in volume. Cardiomediastinal silhouette is stable. No pneumothorax is seen. Lungs are low volume. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman s/p chest tube removal// ___ year old woman s/p chest tube removal ___ year old woman s/p chest tube removal IMPRESSION: Compared to chest radiographs ___, through 11:33. Small right pleural effusion stable, no detectable right pneumothorax, following removal of the right pigtail pleural drainage catheter. Previous mild cardiomegaly has resolved and small pleural effusions are smaller. Moderate left lower lobe atelectasis unchanged. No pulmonary edema. Right jugular line ends in the low SVC. Radiology Report EXAMINATION: Chest radiograph PA and lateral INDICATION: ___ year old woman s/p CABG// ___ year old woman s/p CABG TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph from ___ FINDINGS: Small bilateral pleural effusions. There is left basilar atelectasis. There is no focal consolidation or definite evidence of pneumothorax. The cardiac silhouette is mildly enlarged. There has been interval removal of right-sided chest tube and a right central venous catheter. There are medial sternotomy wires which appear aligned and intact. IMPRESSION: No definite evidence of pneumothorax. Stable small pleural effusions. Gender: F Race: PATIENT DECLINED TO ANSWER Arrive by UNKNOWN Chief complaint: NSTEMI, Transfer Diagnosed with ST elevation (STEMI) myocardial infarction of unsp site temperature: 98.8 heartrate: 75.0 resprate: 14.0 o2sat: 97.0 sbp: 136.0 dbp: 70.0 level of pain: 0 level of acuity: 2.0

Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments 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, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns ___ Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **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: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fall at home Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ male with a history of A. fib on apixaban, type 2 diabetes, MVR, mental disability with developmental delay who presented after an unwitnessed fall. Patient was found at his assisted living facility wedged between the door and toilet. Patiend denies remembering a fall. When EMS arrived, patient's blood glucose was 23. Had no complaints per report. Reported takes his medications. ___ recently made adjustments to diabetes medications in ___, and it appears that he may be being prescribed glimerpide from 2 different prescribers. Patient also had recent ED visit at ___ ___ for slurred speech and confusion found to be hypoglycemic to 63, improved with food. Also, sister reports an episode of symptomatic hypoglycemia on ___ for which he did not go to the hospital. On arrival to the ED, patient was seen by ortho spine and ACS, and had a CT cervical spine was notable for teardrop fracture. Ortho spine team and ACS recommending non-surgical management. On ___, patient transferred to medicine through the ___ pathway. At time of transfer, patient feeling rather well. Denies pain anywhere including his neck. No neuro symptoms. No chest pain or dyspnea. A 10 point ROS [was] obtained and negative except for HPI. Past Medical History: Atrial fibrillation Type 2 diabetes mellitus, on insulin Essential hypertension Hyperlipidemia Intellectual functioning disability Mitral regurgitation Bladder Mass Social History: ___ Family History: - Mother alive - Father deceased, COPD (age ___ Physical Exam: DISCHARGE PHYSICAL EXAM ======================= Vitals: 24 HR Data (last updated ___ @ 819) Temp: 97.6 (Tm 99.7), BP: 120/75 (86-138/50 Manual-85), HR: 107 (80-117), RR: 16 (___), O2 sat: 93% (92-94), O2 delivery: Ra, Wt: 145.94 lb/66.2 kg GENERAL: Alert and interactive. In no acute distress. HEENT: MMM, no obvious trauma. NECK: C-collar in place CARDIAC: Irregularly irregular rate, tachycardic, II/VI holosystolic murmur best heard at apex LUNGS: CTAB, non-labored breathing ABDOMEN: Normal bowels sounds, non distended EXTREMITIES: No ___ edema, warm SKIN: Warm. No rash. NEUROLOGIC: AOx3, facial symmetry Pertinent Results: ADMISSION LABS ============== ___ 01:10PM BLOOD ___ PTT-24.3* ___ ___ 11:00AM BLOOD Glucose-105* UreaN-22* Creat-0.8 Na-141 K-4.6 Cl-103 HCO3-23 AnGap-15 ___ 06:13AM BLOOD Calcium-8.7 Phos-2.2* Mg-1.7 DISCHARGE LABS ============== ___ 04:17AM BLOOD WBC-12.7* RBC-4.96 Hgb-14.7 Hct-44.5 MCV-90 MCH-29.6 MCHC-33.0 RDW-13.2 RDWSD-43.7 Plt ___ ___ 04:17AM BLOOD Plt ___ ___ 04:17AM BLOOD Glucose-149* UreaN-19 Creat-0.9 Na-140 K-4.1 Cl-102 HCO3-28 AnGap-10 NOTABLE IMAGING =============== ___ NCHCT IMPRESSION: 1. No intracranial hemorrhage or calvarial fracture. 2. Global age-related involutional changes. 3. Mild paranasal sinus disease. ___ C-SPINE XR IMPRESSION: Acute avulsion fracture of the anteroinferior corner of the C3 vertebra, likely due to hyperextension. ___ C-SPINE XR FINDINGS: C1-C6 visualized on the lateral projection. There is straightening of the normal cervical lordosis, likely positional as the patient was imaged in a hard collar. There is persistent visualization of a C3 fracture involving the anterior inferior endplate. This is minimally displaced but unchanged in appearance when compared to the prior study. Severe degenerative disc disease at C5-6. No prevertebral soft tissue swelling seen. IMPRESSION: Unchanged appearances of the known C3 fracture. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 5 mg PO BID 2. Metoprolol Succinate XL 50 mg PO DAILY 3. glimepiride 4 mg oral BID 4. Glargine 34 Units Breakfast 5. Atorvastatin 80 mg PO QPM 6. amLODIPine 10 mg PO BID Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Glargine 18 Units Dinner Insulin SC Sliding Scale using HUM Insulin 3. Metoprolol Succinate XL 100 mg PO DAILY 4. Apixaban 5 mg PO BID 5. Atorvastatin 80 mg PO QPM Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Primary diagnosis - C3 fractures Secondary diagnoses - Atrial fibrillation - Type II diabetes Discharge Condition: Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ with hypoglycemia// pna COMPARISON: Prior chest radiograph is dated ___ and CT of the chest dated ___ FINDINGS: AP portable upright view of the chest. Lung volumes remain low though the lungs are clear. An unfolded thoracic aorta accounts for prominence of the mediastinum. The heart size is normal. No large effusion or pneumothorax. Imaged bony structures are intact. IMPRESSION: No acute intrathoracic process. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ with fall on apixaban// eval for hemorrhage or bleed TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Total DLP (Head) = 903 mGy-cm. COMPARISON: CT head ___ FINDINGS: There is no evidence of large territory infarction,hemorrhage,edema,or discrete mass. There is prominence of the ventricles and sulci suggestive of involutional changes. Asymmetry of the lateral ventricles is unchanged since ___. There are dense atherosclerotic calcifications within the bilateral carotid siphons and proximal intracranial vertebral arteries. There is no evidence of fracture. Other than a small mucous retention cyst in the right maxillary sinus, the visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. No intracranial hemorrhage or calvarial fracture. 2. Global age-related involutional changes. 3. Mild paranasal sinus disease. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: ___ with fall on apixaban// eval for hemorrhage or bleed TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue and bone algorithm images were generated. Coronal and sagittal reformations were then constructed. DOSE: Total DLP (Body) = 566 mGy-cm. COMPARISON: CT C-spine ___ FINDINGS: There is an acute avulsion fracture at the anterior-inferior corner of C3 vertebral body, likely due to hyperextension. No significant prevertebral soft tissue swelling. Alignment is unchanged. Multilevel degenerative changes most notable at the C3-4 and C5-6 with intervertebral disc height loss, anterior and posterior osteophytosis, and uncovertebral joint hypertrophy appear grossly similar. As with the prior study, there is mild-to-moderate spinal canal narrowing at these levels. There is moderate right and mild-to-moderate left foraminal narrowing at the C5-6 level. IMPRESSION: Acute avulsion fracture of the anteroinferior corner of the C3 vertebra, likely due to hyperextension. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 12:08 pm, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: C-SPINE NON-TRAUMA ___ VIEWS INDICATION: ___ year old man with cervical fracture// Position to compare w/ follow up radiographs. In collar TECHNIQUE: AP and lateral views of the cervical spine COMPARISON: CT cervical spine ___ FINDINGS: C1-C6 visualized on the lateral projection. There is straightening of the normal cervical lordosis, likely positional as the patient was imaged in a hard collar. There is persistent visualization of a C3 fracture involving the anterior inferior endplate. This is minimally displaced but unchanged in appearance when compared to the prior study. Severe degenerative disc disease at C5-6. No prevertebral soft tissue swelling seen. IMPRESSION: Unchanged appearances of the known C3 fracture. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Hypoglycemia, s/p Fall Diagnosed with Type 2 diabetes mellitus with hypoglycemia without coma, Long term (current) use of insulin temperature: 98.6 heartrate: 104.0 resprate: 16.0 o2sat: 97.0 sbp: 164.0 dbp: 88.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, You were admitted to the hospital after falling at home. You likely fell because your blood sugar was so low. When you fell you broke a bone in your neck. This should heal without surgery, but you will need to wear a collar for quite a while. You will see the spine surgeons in clinic. We decreased your insulin dose to prevent your blood sugar from going so low. It was a privilege to care for you in the hospital, and we wish you all the best. Sincerely, Your ___ Health 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: shortness of breath Major Surgical or Invasive Procedure: ___ - Cardiac catheterization with right coronary artery stenting History of Present Illness: Mr. ___ is a ___ year old gentleman with a PMH of atrial fibrillation on warfarin, CAD s/p CABGx2, systolic heart failure with an LVEF of 25%, carotid stenosis s/p CEA, and recent admission for mechanical fall c/b multiple bruises and liver laceration (___), now being readmitted with increased dyspnea on exertion, a few episodes of acute SOB and continued right-sided abomdinal pain. Patient is being admitted for observation, pain control and serial hematocrit monitoring. Patient notes that he felt fine when he left the hospital on ___. The next day, "things went South," and the following day "things went farther South." The patient developed increasing dyspnea on exertion, just after walking 2 steps up the stairs, so that he had to go up the stairs on his bottom one step at a time. Additionally, he had 9 episodes of right-sided, lower chest pain over the past three days; these episodes responded to nitroglycerin. These episodes were accompanied by shortness of breath. He has a dry cough at baseline, as this cough increased in frequency, but is not productive. He denies any orthopnea, PND, weight gain, central chest pain or peripheral edema. He also notes more anxiety than usual. . In the ED, initial vs were: T 98.4 BP 133/76 HR 108 RR 16 SaO2 98%RA. Physical exam with ecchmosis around R eye stable; AOx3, although slightly more confused; lungs CTAB no crackles; heart irregular no S3, no elevation of JVD, abd firm, slightly distended and tympanitic, no chest wall tenderness, no ___ edema. Labs were remarkable for BNP 2485, differential with neutrophilic predominance of 77.8%, INR 2.7. Troponin <0.01. CT abdomen and pelvis with contrast showed no evidence of liver laceration or evolution of ascites, with a decrease in the amount of ascites since imaging on ___. Vitals on Transfer: Temp: 97.8 °F (36.6 °C), Pulse: 82, RR: 24, BP: 152/68, O2Sat: 96 on RA. . On arrival to the floor, the patient developed an acute episode of chest pain and shortness of breath on transfer from the stretcher to his bed. His vitals on arrival were 97.3 184/109 58 98%RA. He received one nitroglycerin 0.4 mg SL, which resulted in decrease in BP to 140/80. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History: - Diabetes - Dyslipidemia - Hypertension - CAD s/p anterior and inferior MIs s/p CABG ___ - Ischemic Cardiomyopathy and CHF ___ EF 28%) s/p ICD in ___ - Afib on warfarin - PACING/ICD: dual chamber ICD ___ - s/p bilateral carotid endarterectomy - Restrictive lung disease (asbestos exposure) - h/o Frontal lobe CVA - CKD (baseline Cr 1.1-1.4) - h/o PUD - Benign abdominal tumor s/p resection - Restless leg syndrome - Obstructive sleep apnea on CPAP - Depression on lamotrigine and lithium - Prostate cancer, s/p radiation, c/b radiation proctitis - Gout - Arthritis Social History: ___ Family History: Maternal aunt may have had Alzheimer's disease. Father died of complications related to a football injury at a young age. Mother lived to be ___ and died following a rapidly progressive course of pancreatic cancer. One sister died in early ___ possibly related to malnutrition. 4 adult siblings are all in good health. Brother with HTN. Physical Exam: ADMISSION EXAM: VS 97.3 184/109 (-> 140/80) 58 20 98%RA General: Alert, oriented, initially in distress with chest pain and SOB, but lwess anxious after getting nitroglycerin HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Very good air movement. Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Irregular rhythm, controlled rate, normal S1 + S2, I/VI holosystolic murmur at LLSB with radiation to apex Abdomen: soft, non-tender, slightly distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Back: No CVA tenderness, +TTP over right lower flank Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: no rashes Neuro: alert, awake and oriented x3, no asterixis. CNs II-XII intact and symmetric. Moving all extremities. DISCHARGE EXAM: VS- 97.7 ___ 74 20 97% RA Lungs clear to auscultation CV- irregularly irregular HR, normal S1/S2, I/VI holosystolic murmur unchanged Abd- +BS, soft, nontender, nondistended Neuro- alert, agitated, oriented x 1 (person), unable to attend, nonlinear thought process Pertinent Results: ADMISSION LABS: ___ 01:00PM BLOOD WBC-6.9 RBC-3.40* Hgb-8.2* Hct-27.4* MCV-80* MCH-24.2* MCHC-30.0* RDW-19.6* Plt ___ ___ 01:00PM BLOOD Neuts-77.8* Lymphs-15.8* Monos-5.0 Eos-1.1 Baso-0.2 ___ 01:00PM BLOOD ___ PTT-41.1* ___ ___ 05:40AM BLOOD Ret Aut-2.8 ___ 01:00PM BLOOD Glucose-334* UreaN-24* Creat-1.2 Na-137 K-4.5 Cl-107 HCO3-17* AnGap-18 ___ 01:00PM BLOOD proBNP-2485* ___ 01:00PM BLOOD cTropnT-<0.01 ___ 05:50AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 05:05PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 11:49PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 05:50AM BLOOD Calcium-9.9 Phos-2.7 Mg-2.3 ___ 05:40AM BLOOD calTIBC-520* Ferritn-35 TRF-400* ___ 05:40AM BLOOD %HbA1c-7.4* eAG-166* DISCHARGE LABS: Hct 30.1 WBC 7.7 Creatinine 1.5 MICROBIOLOGY DATA: ___ Urine culture - mixed bacterial flora ___ Blood culture - no growth ___ Stool culture- c.difficile DNA amplification assay negative ___ Urine culture- <10,000 org/ul IMAGING: ___ CT ABDOMEN & PELVIS - No evidence of acute intra-abdominal pathology. Amount of ascites since the examination of ___ has decreased. ___ CHEST (PORTABLE AP) - Again seen is a dual-lead pacemaker, moderate cardiomegaly, sternal wires, mediastinal clips, patchy areas of volume loss and bilateral small effusions, small pulmonary vascular redistribution. Compared to the study from five days prior, the effusions are slightly smaller and the aeration of the right lower lung is slightly larger, but the vascular plethora is more pronounced. The overall impression is that of persistent CHF. ___ CHEST (PORTABLE AP) - Lower lung volumes with persistent bilateral pleural effusions and bibasilar atelectasis. Retrocardiac air-bronchograms and hazy right lower lung field could be secondary to atelectasis, but infection cannot be excluded. ___ Cardiac cath- 1. Severe native 3 vessel CAD. 2. Patent LIMA-LAD, SVG-RPDA, and SVG-D. 3. Totally occluded SVG-OM. 4. Elevated right and left-sided filling pressures. 5. Moderate-severe pulmonary arterial hypertension. 6. Successful PCI of 99% stenosis of SVG-PDA with excellent result. 7. Bare metal stent (Integrity 2.5 x 12 mm BMS) used given Warfarin use. 8. Angioseal closure of RFA. ___ CT head w/o contrast - No CT evidence for acute intracranial hemorrhage. Bifrontal areas of encephalomalacia unchanged from ___. Medications on Admission: Acetaminophen 1000 mg PO/NG TID Aspirin 81 mg PO/NG DAILY ALPRAZolam 0.25 mg PO/NG TID:PRN anxiety Citalopram 20 mg PO/NG DAILY Docusate Sodium 100 mg PO/NG BID Donepezil 10 mg PO/NG HS Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Furosemide 40 mg PO/NG DAILY Start: In am hold for SBP < 90 Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Insulin SC (per Insulin Flowsheet) Sliding Scale Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY hold for SBP < 90 LaMOTrigine 400 mg PO/NG HS Lisinopril 2.5 mg PO/NG DAILY Start: In am hold for SBP < 90 Lidocaine 5% Patch 1 PTCH TD DAILY Metoprolol Tartrate 50 mg PO/NG BID hold for SBP < 90 or HR < 60 Morphine Sulfate ___ mg IV ONCE Duration: 1 Doses Morphine Sulfate ___ mg IV Q4H:PRN breakthrough pain Nitroglycerin SL 0.4 mg SL PRN chest pain OxycoDONE (Immediate Release) 5 mg PO/NG Q4H:PRN breakthrough pain hold for AMS, sedation or RR < 12 Simvastatin 20 mg PO/NG HS Spironolactone 25 mg PO/NG DAILY Start: In am hold for SBP < 90, or K > 5 Warfarin 4 mg PO/NG 5X/WEEK (___) Warfarin 2 mg PO/NG 2X/WEEK (WE,SA) ranolazine *NF* 500 mg Oral BID Reason for Ordering: Wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. traZODONE 200 mg PO/NG HS Discharge Medications: 1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. insulin lispro 100 unit/mL Solution Sig: Sliding scale unit Subcutaneous ASDIR (AS DIRECTED). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 4. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain: take 1 for chest pain, wait 5 min, take another, if call ambulance. Disp:*30 Tablet, Sublingual(s)* Refills:*0* 5. warfarin 2 mg Tablet Sig: as directed Tablet PO once a day: please discuss with Dr. ___ prior to taking dose. 6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for pain: do not drink alcohol while taking. 7. lamotrigine 200 mg Tablet Sig: Two (2) Tablet PO once a day. 8. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 9. ranolazine 1,000 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO twice a day. Disp:*60 Tablet Extended Release 12 hr(s)* Refills:*2* 10. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 11. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: Three (3) Tablet Extended Release 24 hr PO DAILY (Daily). 12. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gas, bloating. Disp:*30 Tablet, Chewable(s)* Refills:*0* 13. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 14. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 15. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Flomax 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO once a day. 17. Seroquel 25 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*60 Tablet(s)* Refills:*0* 18. Seroquel 25 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for agitation. 19. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnosis- # CHF exacerbation # Right PDA stenting with bare metal stent # Acute delerium Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report CHEST RADIOGRAPH PERFORMED ON ___ ___. CLINICAL HISTORY: DOE, question pulmonary edema. FINDINGS: PA and lateral views of the chest obtained. AICD is again seen with lead tips extending into the right atrium and right ventricle. Midline sternotomy wires and mediastinal clips are again noted. There are bilateral small pleural effusions with fluid tracking along the minor fissure. Mild pulmonary interstitial edema is likely present. Cardiomediastinal silhouette is stable. Bony structures are intact. IMPRESSION: Mild interstitial edema with bilateral small pleural effusions. Radiology Report HISTORY: ___ man with questionable liver laceration now with worsening abdominal pain and decreased hematocrit. Question worsening abdominal pathology. COMPARISON: ___ as well as ___ CT of the abdomen and pelvis. TECHNIQUE: CT of the abdomen and pelvis was performed with the administration of IV contrast. No oral contrast was administered. FINDINGS: LUNG BASES: There is a stable appearing rounded consolidation in the right lower lobe most consistent with rounded atelectasis. There is calcified pleural plaques consistent with prior asbestos exposure. Apex of the heart is unremarkable with ventricular lead terminating in the right ventricle. ABDOMEN: Liver is of normal contour with no focal masses or evidence of laceration. Gallbladder is unremarkable. Spleen and pancreas are unremarkable. Bilateral kidneys are unremarkable; they enhance and excrete contrast symmetrically. There is trace perihepatic ascites (2:23); however, this is decreased since the prior examination. Other areas of ascites from the prior examination such as the left paracolic gutter as well as pelvic free fluid has mostly resolved with the exception of trace amounts of pelvic free fluid (2:69). Overall, the amount of fluid has decreased. Loops of small and large bowel are unremarkable. Aortic calcifications are once again noted. These extend through the iliacs. PELVIS: Large bowel is unremarkable. Bladder is normal. Prostate is enlarged with multiple prostatic seeds. No pelvic lymphadenopathy. Trace ascites in the pelvis again is mildly decreased since the prior examination. OSSEOUS STRUCTURES: No concerning lytic or sclerotic lesions. No fracture is identified. Significant degenerative changes within the thoracolumbar spine are again noted and unchanged. IMPRESSION: 1. No evidence of acute intra-abdominal pathology. 2. Amount of ascites since the examination of ___ has decreased. Radiology Report CHEST ON ___ HISTORY: Chest pain. REFERENCE EXAM: ___. FINDINGS: Again seen is a dual-lead pacemaker, moderate cardiomegaly, sternal wires, mediastinal clips, patchy areas of volume loss and bilateral small effusions, small pulmonary vascular redistribution. Compared to the study from five days prior, the effusions are slightly smaller and the aeration of the right lower lung is slightly larger, but the vascular plethora is more pronounced. The overall impression is that of persistent CHF. Radiology Report HISTORY: CHF with acute delirium. FINDINGS: In comparison with study of ___, there are continued low lung volumes with enlargement of the cardiac silhouette and blunting of the costophrenic angles consistent with pleural effusions and bibasilar atelectasis. Pacemaker device remains in place. No convincing evidence of pulmonary vascular congestion. Radiology Report INDICATION: Abdominal pain and distention. Concern for obstruction or megacolon. COMPARISON: CT abdomen and pelvis, ___. FINDINGS: There is bibasilar atelectasis. Median sternotomy wires and pacer leads are partially visualized. There is a large amount of gas within the stomach. The bowel gas pattern is otherwise within normal limits. Radiopaque brachytherapy seeds are visualized in the region of the prostate. There is no evidence of free intraperitoneal air. The osseous structures are unremarkable. Radiology Report INDICATION: ___ male with confusion status post fall with head strike. COMPARISON: ___. TECHNIQUE: Axial CT images through the head were acquired without intravenous contrast. Coronal, sagittal, and thin slice bone reconstructed images were created and reviewed. FINDINGS: Images of the skull base are degraded by motion artifact, limiting evaluation. Within this limitation, there is no evidence for acute intracranial hemorrhage, large mass, mass effect, or hydrocephalus. Bifrontal encephalomalacia appears similar compared to prior. Arterial calcifications are noted. Prominent ventricles and sulci suggest age-related involutional changes. White matter hypodensity is likely secondary to sequela of chronic small vessel ischemic disease. The basal cisterns appear patent. Muscosal thickening is seen in the ethmoid air cells. IMPRESSION: No CT evidence for acute intracranial hemorrhage. Bifrontal areas of encephalomalacia unchanged from ___. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: DOE Diagnosed with SHORTNESS OF BREATH, ATRIAL FIBRILLATION temperature: 98.4 heartrate: 108.0 resprate: 16.0 o2sat: 98.0 sbp: 133.0 dbp: 76.0 level of pain: 5 level of acuity: 2.0

It was a pleasure taking care of you during your recent admission. You were admitted because of worsening shortness of breath. You were given lasix to help get excess fluid off of your lungs, and you improved. You had no ongoing shortness of breath. You had a cardiac catheterization and a stent was placed. You had no ongoing chest pain for the remainder of admission. You were very delerious throughout the admission, requiring lots of medication to help you calm down. For help sleeping at night, please take seroquel, and do not take trazodone or alprazolam. If you are more confused or agitated after taking 1 dose of seroquel, you may take a second tab. You also had difficulty urinating on your own, and need to have a catheter placed in your bladder. You were started on a medication to help you urinate, but for now should keep the catheter in place until you see a urologist. The following changes were made to your medication regimen: - START plavix daily - INCREASE aspirin to 325mg daily - INCREASE metoprolol to 100mg twice a day - STOP spironolactone - STOP donepezil - STOP alprazolam as this will cause confusion - STOP trazodone as this will cause confusion - START seroquel at night to help with sleep and decrease confusion. For increasing agitation, may give an extra dose of seroquel. - START tamsulosin once daily at night for help with urinary retention Please continue the remainder of medications as prescribed prior to admission

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Lipitor / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Fall Major Surgical or Invasive Procedure: ___ - Left calf fasciotomies and tibial plateau ex-fix History of Present Illness: ___ mechanical fall down three stairs, landed on her left side. Did not hit her head, denies LOC. No preceding light headedness, SOB, CXP, dizziness. C/O left shoulder and left knee/calf pain. Specifically denies left hip or groin pain. Denies numbness or tingling. No neck or back pain. Fall occured at 18:00. NPO since ___. Patient is currently under treatment for bilateral lower extremity cellulitis and is on day ___ of doxycycline. The doxycycline resulted in oral thrush and she is currently on nystatin swish and spit. Has also had diarrhea on doxycycline. Past Medical History: Hypothyroid, Alcoholism (Denies and gets angry when discussed), osteopenia (denies and says it is improving), depression, cellulitis BLE PSH: Left intertrochanteric femur fracture ___ s/p TFN, removal of TFN ___ for back pain Social History: ___ Family History: NC Physical Exam: In general, the patient is a somewhat confused female who appears uncomfortable. She is AAOx3. Vitals: BP 164/82 Right upper extremity: Skin intact Soft, non-tender arm and forearm Full, painless AROM/PROM of shoulder, elbow, wrist, and digits +EPL/FPL/DIO (index) fire +SILT axillary/radial/median/ulnar nerve distributions +Radial pulse Left upper extremity: Skin intact TTP at shoulder and pain with ROM there Full, painless AROM/PROM of elbow, wrist, and digits +EPL/FPL/DIO (index) fire +SILT axillary/radial/median/ulnar nerve distributions +Radial pulse Right lower extremity: Skin intact, erythema over foot, reportedly improved Shiny skin from knee down Soft, non-tender thigh and leg Full, painless AROM/PROM of hip, knee, and ankle ___ fire +SILT SPN/DPN/TN/saphenous/sural distributions ___ pulses, foot warm and well-perfused Left lower extremity: Skin intact, erythema over foot, reportedly improved Edema of leg and foot TTP in calf and firm compartments TTP at knee and will not allow ROM No pain with ___ at hip ___ fire +SILT SPN/DPN/TN/saphenous/sural distributions +DP pulse, foot warm and well-perfused COMPARTMENT PRESSURE: After discussion of risks and benefit of compartment interrogation the patient agreed to proceed. DBP - 82 Deep posterior - 80 Superficial posterior - 88 Lateral - 85 Anterior - 79 Pertinent Results: ___ 10:00AM BLOOD WBC-12.7* RBC-2.40*# Hgb-6.2*# Hct-20.3*# MCV-85 MCH-25.9* MCHC-30.6* RDW-14.6 Plt ___ ___ 12:50AM BLOOD Glucose-123* UreaN-14 Creat-0.6 Na-139 K-4.1 Cl-104 HCO3-23 AnGap-16 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 150 mcg PO DAILY 2. Pravastatin 10 mg PO DAILY 3. Ascorbic Acid ___ mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Omeprazole 20 mg PO DAILY 7. LaMOTrigine 50 mg PO BID 8. ClonazePAM 0.5 mg PO QHS:PRN insomnia 9. Doxycycline Hyclate 100 mg PO Q12H 10. Nystatin Oral Suspension 5 mL PO QID thrush Discharge Medications: 1. Ascorbic Acid ___ mg PO DAILY 2. ClonazePAM 0.5 mg PO QAM 3. ClonazePAM 1 mg PO QHS 4. Docusate Sodium 100 mg PO BID 5. LaMOTrigine 50 mg PO DAILY 6. Levothyroxine Sodium 150 mcg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Nystatin Oral Suspension 5 mL PO QID thrush 9. Omeprazole 20 mg PO DAILY 10. Pravastatin 10 mg PO DAILY 11. Cyclobenzaprine 5 mg PO BID:PRN spasm 12. Enoxaparin Sodium 40 mg SC DAILY Start: Today - ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 40 mg SC Daily Disp #*14 Syringe Refills:*0 13. Milk of Magnesia 30 mL PO Q6H:PRN constipation 14. Senna 8.6 mg PO BID 15. TraZODone 25 mg PO HS:PRN insomnia 16. Vitamin D 400 UNIT PO DAILY 17. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Tibial plateau fracture and compartment syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report HISTORY: ___ with s/p fall, pain, headache. TECHNIQUE: Multi detector CT scan of the head without IV contrast. Reformatted images were provided. DLP: 891.93 mGy-cm. CTDIvol: 55.75 mGy. COMPARISON: None. FINDINGS: There is no acute hemorrhage, edema, mass, mass effect or acute large vascular territorial infarction. The ventricles and sulci are normal in size and configuration. There is preservation of gray-white matter differentiation. The basal cisterns are patent. Periventricular white matter hypodensities likely represent the sequela of chronic small vessel ischemic disease. No fracture is identified. The globes appear normal. The paranasal sinuses and mastoid air cells are clear. IMPRESSION: No acute intracranial process. Radiology Report HISTORY: ___ with s/p fall, pain, headache. TECHNIQUE: Multi detector CT scan of the cervical spine without IV contrast. Reformatted images were provided. DLP: 1,537.19 mGy-cm. CTDIvol: 36.89 mGy. COMPARISON: None. FINDINGS: No acute fracture or traumatic malalignment is seen. There is multilevel degenerative changes from the C3 to the C7 level including disc space narrowing and tiny anterior osteophytes. There is no prevertebral soft tissue swelling. The aerodigestive tract is clear. The thyroid appears normal. The lung apices are scarred. There is no pathologic lymphadenopathy by CT size criteria. IMPRESSION: No acute fracture or traumatic malalignment. Radiology Report CLINICAL INDICATION: Fasciotomy. Left tib/fib fractures. COMPARISON: Outside hospital knee and hip radiographs. 17 intraoperative fluoroscopic spot images show placement of external fixation pins in the distal femur and proximal tibia. Radiology Report INDICATION: Left tibial plateau fracture, status post fasciotomy and ex-fix placement. TECHNIQUE: Axial MDCT images were acquired through the left knee without intravenous contrast. Coronal and sagittal reformats were produced and reviewed. COMPARISON: Left knee radiographs, ___ and intraoperative images, ___. FINDINGS: There has been placement of an external fixator device with proximal fixation through the distal femur and distal fixation through the distal tibia. There has also been fasciotomy with skin defects evident along the medial and lateral aspects of the calf. There is a small amount of subcutaneous air, some of which tracks into the fascial planes (3:277). This is presumed to be related to the recent surgery. There is also a small amount of air in the medullary cavity of the tibia (3:223). There is a split and depressed fracture of the lateral tibial plateau (401B:40) with depression of the articular surface by approximately 1.1 cm. There is a spiral component of this fracture which extends down to the mid tibial diaphysis (401B:35). There is minimal displacement of this fracture line. There is an additional comminuted fracture of the proximal fibula (401B:44). This is angulated but not displaced. A moderate-sized lipohemarthrosis is seen. There is mild diffuse subcutaneous edema throughout the visualized lower extremity. Assessment of the soft tissue structures of the knee is limited; nonetheless, the anterior and posterior cruciate ligaments appear to be intact. The extensor mechanism is intact. Multifocal areas of increased attenuation within the medulla of both the femur and the proximal tibia are presumed to be blood related to the fracture at the placement of the ex-fix device (3:100). No ___ cyst is seen. IMPRESSION: 1. Split and depressed-type fracture of the lateral tibial plateau, Schatzker type 2, with 1.1 cm depression of the articular surface. A spiral component to the fracture extends down to the mid tibial diaphysis. 2. Moderate lipohemarthrosis. 3. Status post fasciotomy. Radiology Report HISTORY: Three intraoperative radiographs of the left leg. Since preoperative exam ___ (5 days ago) the lateral tibial plateau fracture has been fixated by a lateral plate extending to the mid portion of the tibia with multiple associated horizontal screws. There is poorly visualized associated fracture of the proximal fibula. Radiology Report HISTORY: Status post multiple surgeries now with increasing white blood cell count and platelet count. Evaluate for pneumonia or consolidation. COMPARISON: Chest radiograph ___. FRONTAL SUPINE CHEST RADIOGRAPH: The lungs are hyperinflated. There is no pleural effusion, pneumothorax or focal airspace consolidation worrisome for pneumonia. A right nipple shadow is noted and should not be mistaken for an intraparenchymal lesion. The heart is normal in size. Mediastinal structures are unremarkable. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: S/P FALL Diagnosed with FX UPPER END TIBIA-CLOSE, TRAUMATIC COMPARTMENT SYNDROME OF LOWER EXTREMITY, FALL ON STAIR/STEP NEC temperature: 98.2 heartrate: 76.0 resprate: 18.0 o2sat: 96.0 sbp: 176.0 dbp: 93.0 level of pain: 10 level of acuity: 2.0

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: - 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. - Keep your donor graft site open to air. The area will form a scab and can be left dry. - Daily dressing changes with xeroform and gauze over skin graft site for 5 days. ACTIVITY AND WEIGHT BEARING: - touch down weight bearing left lower extremity in unlocked ___. ROM as tolerated. Physical Therapy: Touch down weight bearing in unlocked ___. Treatments Frequency: WOUND CARE: - 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. - Keep your donor graft site open to air. The area will form a scab and can be left dry. - Daily dressing changes with xeroform and gauze over skin graft site for 5 days.

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: epinephrine Attending: ___ ___ Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: Flexible Sigmoidoscopy ___ Endoscopy ___ History of Present Illness: Ms. ___ is an ___ year female with history significant for hemorrhoids, diverticulitis, and polyps who presents with 2 day history of colicky abdominal pain, constipation, followed by 2 loose stools with "mucousy" blood in the toilet. In the ED, initial vitals were: Temp. 97.9, HR 66, BP 136/93, RR 18, 100% RA Labs in the ED were notable for elevated lactate 2.5, Hg/Hct 15.8/45.4, and WBC of 11.7. UA negative for nitrites and leukocytes. CTA was significant for no evidence of mesenteric ischemia, hyperenhancing 5mm focus along the wall of the jejunum that may represent polyp or extravasation and hiatal hernia. The patient was given 1L NS. She was noted to be anxious in the ED and received her AM dose of ativan at that time. On the floor, the patient notes that starting last night she noted diffuse colickly abdominal pain. She notes that she is constipated at baseline and that she noted feeling constipated in the setting of her abdominal discomfort. She denies any correlation of her colicky abdominal pain to food. She had 2 hard bowel movements both of which were associated with straining and bright red blood per rectum. Her abdominal pain did not resolve however and continued this morning at which time she came to the ED. She denies any associated nausea, vomiting, fever, or chills. She does endorse previous mid-epigastric discomfort that has resolved with prilosec. She does endorse a recent fall last while tripping over a rug and fell on her tail bone. In addition she notes "blurred, half vision" currently in the setting of resolving migraine on ___. She notes that this is usually how she feels prior getting a migraine. She denies any splurred speech, facial droop, or weakness in her arms or legs. Review of systems: (+) 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, or diahrea. She denies any dysuria or frequency. Denies arthralgias or myalgias. Past Medical History: Anxiety Skin cancer s/p Mohs Cataracts Constipation GERD Migraine headaches GERD Hypercholesterolemia Hypertension Hypothyroidism Neck pain Osteopenia Recurrent urinary tract infections Pedal Edema Hemorrhoids Social History: ___ Family History: History of colon cancer on father's side predominately. Notes she has paternal grandmother, aunt, and uncle all with colon cancer she believes at ages over ___ years old. She notes her father had "heart disease." Mother with uterine cancer Physical Exam: EXAM ON ADMISSION: ==================== Vitals: T: 99.2 BP: 150/70 P: 61 R: 18 O2: 100% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present though hypoactive, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: No rash Neuro: CN II-XII intact, ___ strength in upper and lower extremities EXAM ON DISCHARGE: ================== VItals: Temp. 99.2 BP 124/68 53 18 99% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present though hypoactive, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: No rash Neuro: CN II-XII intact, ___ strength in upper and lower extremities Pertinent Results: PERTINENT LABS: ================== ___ 07:00AM BLOOD WBC-11.7*# RBC-5.37 Hgb-15.8 Hct-45.4 MCV-85 MCH-29.4 MCHC-34.8 RDW-14.5 Plt ___ ___ 12:58PM BLOOD Hgb-14.9 Hct-44.9 ___ 07:00AM BLOOD Glucose-116* UreaN-16 Creat-1.0 Na-139 K-5.9* Cl-107 HCO3-19* AnGap-19 ___ 10:12AM BLOOD K-4.7 PERTINENT STUDIES: ================== CTA Abdomen ___: IMPRESSION: 1. No evidence of mesenteric ischemia. 2. Hyperenhancing 5 mm focus along the wall of the jejunum seen only on portal venous phase may represent a polyp or venous extravasation. No arterial extravasation identified. 3. Hiatal hernia. 4. Trace pleural effusions. Flex sigmoidoscopy ___: Mucosa: Localized erythema and ulceration were noted in the proximal descending colon. These findings are compatible with mild colitis (? ischemic). Cold forceps biopsies were performed for histology at the sigmoid erythema. Protruding Lesions Small internal hemorrhoids were noted. Excavated Lesions A few diverticula with small openings were seen.Diverticulosis appeared to be of mild severity. Impression: Diverticulosis of the colon Internal hemorrhoids Erythema and ulceration in the proximal descending colon compatible with mild colitis (? ischemic) (biopsy) Otherwise normal sigmoidoscopy to descending colon Recommendations: We will contact you with the results of the biopsy Stay hydrated Prevent constipation by taking daily colace and miralax if you have not had a bowel movement after 2 days Endoscopy ___: Esophagus: Normal esophagus. Stomach: Lumen: A large size hiatal hernia was seen. Mucosa: Normal mucosa was noted. Duodenum/Jejunum: Normal. Other findings: Nothing seen in the proximal jejunum to explain the CTA findings. Impression: Large hiatal hernia Normal mucosa in the stomach Nothing seen in the proximal jejunum to explain the CTA findings. Otherwise normal EGD to mid jejunum Recommendations: Nothing on this exam to explain the CTA findings Hiatal hernia is the likely cause of acid reflux Daily PPI Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 25 mg PO DAILY 2. isometh-dichloral-acetaminophn 65-100-325 mg oral PRN headache 3. Levothyroxine Sodium 25 mcg PO DAILY 4. Lovastatin 40 mg oral QHS 5. Mirtazapine 15 mg PO QHS 6. Aspirin 81 mg PO DAILY 7. Vitamin D 1000 UNIT PO DAILY 8. Omeprazole 20 mg PO DAILY 9. Lorazepam 0.5 mg PO QHS 10. Lorazepam 0.25 mg PO QAM Discharge Medications: 1. Atenolol 25 mg PO DAILY 2. isometh-dichloral-acetaminophn 65-100-325 mg oral PRN headache 3. Levothyroxine Sodium 25 mcg PO DAILY 4. Lorazepam 0.5 mg PO QHS 5. Lorazepam 0.25 mg PO QAM 6. Lovastatin 40 mg oral QHS 7. Mirtazapine 15 mg PO QHS 8. Omeprazole 20 mg PO DAILY 9. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*3 10. Aspirin 81 mg PO DAILY 11. Vitamin D 1000 UNIT PO DAILY 12. Polyethylene Glycol 17 g PO DAILY:PRN constipation RX *polyethylene glycol 3350 [ClearLax] 17 gram/dose 17 powder(s) by mouth once a day Disp #*510 Gram Gram Refills:*3 Discharge Disposition: Home Discharge Diagnosis: Primary: Gastrointestinal bleeding Colitis Hiatal Hernia Secondary: Anxiety Skin cancer s/p Mohs Cataracts Constipation GERD Migraine headaches GERD Hypercholesterolemia Hypertension Hypothyroidism Neck pain Osteopenia Recurrent urinary tract infections Pedal Edema Hemorrhoids Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CTA ABD AND PELVIS INDICATION: ___ woman with bright red blood per rectum, intermittent abdominal pain, question mesenteric ischemia. TECHNIQUE: Multidetector CT of the abdomen and pelvis was performed utilizing mesenteric CTA protocol. IV contrast was administered. Multiplanar reformations were provided. DOSE: DLP: 2495.2mGy-cm COMPARISON: Chest CT from ___. FINDINGS: Lung Bases: Emphysema is noted at the imaged lung bases with areas of scarring and mild atelectasis. There is a moderate in size hiatal hernia. Trace pleural effusions noted bilaterally. CTA: The abdominal aorta is normal in course and caliber with mild atherosclerotic calcifications. The major aortic branches appearing patent with a normal branching pattern. No dissection is identified. Abdomen: A tiny hypodensity within segment 7 of the liver near the dome is seen on series 4b, image 207, too small to characterize. Otherwise, the liver appears normal. Main portal vein is patent. The gallbladder is not fully distended. The pancreas appears normal. This spleen is unremarkable. Mild nodular thickening is seen at the apex of the left adrenal gland measuring approximately 11 mm, stable from the prior noncontrast CT chest from ___, suggesting a benign entity. The right adrenal gland appears normal. There is a cortical hypodense lesion measuring approximately 1 cm in diameter arising from the interpolar left kidney on series 4b, image 236 without significant difference in central attenuation on arterial and portal venous phase suggesting a hemorrhagic cyst. No hydronephrosis or definite renal lesion of concern. The distal aspect of the stomach and duodenum appear normal. Pelvis: There is abnormal hyperdensity along the wall of the proximal jejunum on series 4b image 259 which matches blood pool and may represent a polyp or venous extravasation. Loops of small bowel demonstrate no signs of ileus or obstruction. The appendix is not visualized though there are no secondary signs of appendicitis. Scattered colonic diverticulosis without diverticulitis is noted. The colon is not fully distended though there is no evidence of active arterial extravasation or bowel wall thickening. The sigmoid colon is decompressed limiting assessment for mild colitis. The urinary bladder is decompressed. The uterus and adnexal regions appear unremarkable. No free pelvic fluid is seen. Bones: No worrisome lytic or blastic osseous lesion is seen. Degenerative changes are noted in the lumbar spine with loss of disc space most pronounced at L3-4 and L4-5. IMPRESSION: 1. No evidence of mesenteric ischemia. 2. Hyperenhancing 5 mm focus along the wall of the jejunum seen only on portal venous phase may represent a polyp or venous extravasation. No arterial extravasation identified. 3. Hiatal hernia. 4. Trace pleural effusions. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: BRBPR Diagnosed with RECTAL & ANAL HEMORRHAGE temperature: 97.9 heartrate: 66.0 resprate: 18.0 o2sat: 100.0 sbp: 136.0 dbp: 93.0 level of pain: 10 level of acuity: 3.0

Dear Ms. ___, It was a pleasure being involved in your care. You were admitted to the hospital because you had bright red blood in your stool. We were concerned that you were having bleeding from your gastrointestinal tract. You had a sigmoidoscopy that looked at the lower part of your gastrointestinal tract that showed showed inflammation or colitis. This was thought to most likely be due to constipation. We started you on a medication called colace and miralax that you should take daily to help with constipation. It is also important for you to drink fluids daily to help prevent constipation. You also had a scope of your upper gastrointestinal tract that showed your hiatal hernia. It was recommended that you continue to take prilosec. Sincerely, Your ___ 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: RUE weakness Major Surgical or Invasive Procedure: tPA at ___ on ___ History of Present Illness: Neurology at bedside for evaluation after code stroke activation within: 5 minutes Time (and date) the patient was last known well: 0500 on ___ clock) ___ Stroke Scale Score: 2 t-PA given: No Reason t-PA was not given or considered: already given at OSH ___ Stroke Scale score was 0: 1a. Level of Consciousness: 0 1b. LOC Question: 0 1c. LOC Commands: 0 2. Best gaze: 0 3. Visual fields: 0 4. Facial palsy: 0 5a. Motor arm, left: 0 5b. Motor arm, right: 1 6a. Motor leg, left: 0 6b. Motor leg, right: 0 7. Limb Ataxia: 0 8. Sensory: 1 9. Language: 0 10. Dysarthria: 0 11. Extinction and Neglect: 0 HPI: Mr. ___ is a ___ RHM h/o HTN p/w sudden onset RUE weakness at 5am today. He has recently been in his USOH w/o med changes. Typically wakes early and woke today at 4:30 am. While tying shoes at 5am, noted clumsiness of the hand. Was able to drive to his daughter's who brought him to ___ where acute stroke identified (NIHSS unclear but findings limited to RUE) and pt given tPA at 7:06am. Transferred here for further care. In the ED, NIHSS 2 for weakness and sensory in the RUE. CTA was done to ensure that there was no need for further intervention; demonstrated carotid atherosclerosis. Subjectively pt feels slightly improved from prior. ROS: Positive for weak/numb as above, no other weakness or numbness. Denies any productive/receptive/articulation difficulty. No clumsiness RUE aside. No incontinence. General ROS negative for F/C/sweats, head/neck/back pain, chest pain, SOB, cough, abd pain, N/V/C/D, myalgias, arthralgias, rash. Past Medical History: - HTN on lisinopril and atenolol - Cataract s/p surgery OS - s/p b/l knee surgery Social History: ___ Family History: Negative for stroke in the young, recurrent miscarriage, bleeding issues. Physical Exam: Admission Physical Examination 98 86 153/88 16 99% RA General: NAD NT ND Heent: NC/AT Neck: No bruits Card: Faint sounds, regular Pulm: Clear Abd:S oft normal sounds Extrem: Thin Neurologic - MS: A&Ox3. DOWIR nl. Names normally with intact fluency, repetition, comprehension. No dysarthria. No neglect. - CN: 3.5 -> 3 OS (post surgical), 3 -> 2 OD. VFFTC without neglect. Eyes ortho, EOMI. Face symmetric to pin and activates equally. Symmetric audition, tongue, palate, shrug. - Motor: Right delt 4, tric/bic 5-, no movement of right wrist or intrinsic muscles of the hand. The EHLs are 4+ bilaterally but otherwise he is full strength. Cannot relax making tone difficult but no clonus at ankles; ? upgoing R toe (weakly). j - Sensory: Diminished to pin glove-like distribution R hand extending to forearm. R thumb proprioception impaired; halluces normal. Otherwise sensitive to pin. Does not extinguish to double. Romberg deferred. - Reflexes: Difficult to relax; no apparent asymmetry between arms. Surgical knees, present at ankles. - Cerebellar: FNF abnl in RUE but not out of proportion to weakness, L FNF and heel/shin b/l nl. - Gait; Deferred Discharge Physical Examination Most significant for a right cortical hand with ___ delt, ___ tri/biceps, no movement of right wrist or intrinsic muscles of the hand Pertinent Results: ___ 08:35AM BLOOD WBC-12.1* RBC-4.62 Hgb-14.5 Hct-38.6* MCV-84 MCH-31.3 MCHC-37.5* RDW-13.2 Plt ___ ___ 02:40AM BLOOD WBC-7.6 RBC-4.28* Hgb-13.5* Hct-36.0* MCV-84 MCH-31.4 MCHC-37.3* RDW-13.2 Plt ___ ___ 06:30AM BLOOD WBC-8.5 RBC-4.53* Hgb-14.2 Hct-38.8* MCV-86 MCH-31.4 MCHC-36.6* RDW-13.2 Plt ___ ___ 02:40AM BLOOD Neuts-49.2* ___ Monos-8.8 Eos-2.8 Baso-0.9 ___ 06:30AM BLOOD Neuts-64.6 ___ Monos-8.0 Eos-2.1 Baso-0.7 ___ 08:35AM BLOOD ___ PTT-27.6 ___ ___ 02:40AM BLOOD Glucose-104* UreaN-15 Creat-0.7 Na-134 K-3.8 Cl-99 HCO3-23 AnGap-16 ___ 06:30AM BLOOD Glucose-113* UreaN-23* Creat-0.8 Na-137 K-4.5 Cl-102 HCO3-26 AnGap-14 ___ 08:35AM BLOOD ALT-15 AST-21 AlkPhos-35* TotBili-0.4 ___ 08:35AM BLOOD Lipase-51 ___ 08:35AM BLOOD cTropnT-<0.01 ___ 02:40AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 06:30AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 02:40AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.1 Cholest-147 ___ 06:30AM BLOOD %HbA1c-5.6 eAG-114 ___ 02:40AM BLOOD Triglyc-161* HDL-37 CHOL/HD-4.0 LDLcalc-78 ___ 08:35AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 08:52AM BLOOD Glucose-124* Na-130* K-4.6 Cl-93* calHCO3-27 ___ 10:03AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 10:03AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG ___ CTA Head/Neck 1. No acute intracranial hemorrhage or mass effect. Please see MRI of the head performed subsequently regarding multiple small acute infarcts in the left cerebral hemisphere. 2. Patent major intra and extracranial arteries as described above. Extensive atherosclerotic disease with calcified and noncalcified plaques in the aortic arch, arch vessels, common carotid arteries and the bifurcations and cervical internal carotid arteries as described above. Approximately 50% stenosis in the right common carotid artery, less than 20% in the left common carotid artery and approximately 55% stenosis at the left common carotid bifurcation. Left Cervical ICA: Prominent calcified and noncalcified plaques in the left proximal cervical internal carotid artery extending from the common carotid bifurcation, causing approximately 60-65% luminal narrowing, based on European criteria, though 30% based on NASCET criteria, over a length of approximately 2.1cm; the difference can be attributed to tortuous course and expanded vessel contour. Tiny hypodense focus within-? thrombus or volume averaging. Right cervical ICA: Less than 20% stenosis Intracranial ICA: Mild-moderate narrowing of the cavernous carotid segments on both sides. 3. Multilevel, multifactorial degenerative changes are noted, with mild canal moderate to severe foraminal narrowing with deformity on the nerves from C3-C7 levels. A small sclerotic focus in the T4 vertebral body question bone island or a sclerotic neoplastic lesion. Correlate clinically to decide on the need for further workup or followup. 4. Periapical lucencies noted around the left mandibular third molar- correlate with dental examination. ___ MRI Head w/o 1. Several foci of acute-subacute infarction in primarily the left MCA territory as detailed above, likely embolic; no evidence of hemorrhagic transformation, significant edema or mass effect. 2. T2/FLAIR signal hyperintensity in the periventricular, subcortical, and deep white matter which is nonspecific but likely on the basis of chronic small vessel ischemic disease. ___ CT head w/o 1. No evidence of acute hemorrhage. 2. Unchanged appearance of left frontal lobe subcortical hypodensity. 3. Age-related involutional changes and likely sequela of chronic small vessel ischemic disease. ___ ECHO The left atrium is normal in size. No thrombus/mass is seen in the body of the left atrium. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. ___ Carotid Dopplers Less than 40% stenosis of the bilateral internal carotid arteries. Doppler suggests that the left ICA stenosis is less severe than suggested by CTA ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 25 mg PO DAILY 2. Lisinopril 20 mg PO DAILY Discharge Medications: 1. Atenolol 25 mg PO DAILY 2. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*5 3. Atorvastatin 80 mg PO DAILY RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*5 4. Lisinopril 20 mg PO DAILY 5. Outpatient Occupational Therapy Dx: Stroke To Evaluate and Treat Discharge Disposition: Home Discharge Diagnosis: Left MCA Stroke Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: History: ___ with RUE weakness, numbness // Eval for clot/lesion TECHNIQUE: CT of the head without IV contrast; CT angiogram of the head and neck with IV contrast; 2D and 3D reformations of the intra and extracranial arteries. Report based on all the images provided. COMPARISON: CT head from ___, on ___. FINDINGS: CT HEAD: No acute intracranial hemorrhage or mass effect. Dense calcifications in the basal ganglia and cerebellar hemispheres, similar to the prior study. Scattered hypodense foci in the cerebral white matter in the frontal and the parietal lobes on both sides. Limited assessment for small acute infarcts. Moderately prominent ventricles, mildly prominent extra-axial CSF spaces and sulci, likely relates to volume loss. No suspicious osseous lytic or sclerotic lesions are noted. Mild ethmoidal mucosal thickening. The mastoid air cells are clear. CT ANGIOGRAM HEAD: The major intracranial arteries of the anterior and the posterior circulation are patent, without focal flow-limiting stenosis or occlusion. There is fetal PCA pattern on the left side, with diminutive or absent P1 segment and posterior communicating artery continuing as the posterior cerebral artery. Vascular calcifications are noted in the cavernous carotid segments on both sides, with mild to moderate narrowing. The anterior and the middle cerebral arteries are patent. CT ANGIOGRAM NECK: The origins of the arch vessels are patent. Calcifications are noted at the aortic arch and the arch vessels. The included portions of the subclavian arteries on patent, the left not well seen distally-? Artifactual. Calcified and noncalcified plaques are noted in right common carotid artery proximally, causing approximately 50% stenosis series 3, image 132 and less than 20% in the left common carotid artery- se 3, im 124. Calcified and noncalcified plaques are noted at the common carotid bifurcations, extending into the proximal cervical internal carotid arteries on both sides, more on the left. In the left common carotid bifurcation, there is approximately 55% stenosis series 3, image 157 by calcified and noncalcified plaques. In the left proximal cervical internal carotid artery, though there is approximately 30% stenosis by NASCET criteria, there is mild expansion of the vessel contour, with peripheral calcifications and noncalcified plaques laterally, over a length of approximately 2.1 cm series 602b, image 47, resulting in approximately atleast 60-65% stenosis by European criteria- series 3, image 167. Accurate assessment is somewhat limited due to the tortuous course and eccentric location of the plaques. There is also likely tiny hypodense focus, that can relate to filling defect within or volume averaging -series 3, image 173. The vertebral arteries are patent throughout their course, without focal flow-limiting stenosis or occlusion. Calcifications are noted at the vertebral artery origins right more than left and in the left V2 and V4 segments. CT NECK: A few small nodes are noted in both sides of the neck, not abnormally enlarged by size criteria. Prominent adenoids and palatine tonsils with punctate calcifications in the palatine tonsils likely from prior inflammation. Thyroid is normal. Periapical lucencies noted around the left mandibular third molar, series 3, image 179-193. Multilevel, multifactorial degenerative changes are noted, with mild canal moderate to severe foraminal narrowing with deformity on the nerves from C3-C7 levels. A small sclerotic focus in the T4 vertebral body question bone island or a sclerotic neoplastic lesion. The included lung the pieces are clear. Scattered emphysematous changes are noted. IMPRESSION: 1. No acute intracranial hemorrhage or mass effect. Please see MRI of the head performed subsequently regarding multiple small acute infarcts in the left cerebral hemisphere. 2. Patent major intra and extracranial arteries as described above. Extensive atherosclerotic disease with calcified and noncalcified plaques in the aortic arch, arch vessels, common carotid arteries and the bifurcations and cervical internal carotid arteries as described above. Approximately 50% stenosis in the right common carotid artery, less than 20% in the left common carotid artery and approximately 55% stenosis at the left common carotid bifurcation. Left Cervical ICA: Prominent calcified and noncalcified plaques in the left proximal cervical internal carotid artery extending from the common carotid bifurcation, causing approximately 60-65% luminal narrowing, based on European criteria, though 30% based on NASCET criteria, over a length of approximately 2.1cm; the difference can be attributed to tortuous course and expanded vessel contour. Tiny hypodense focus within-? thrombus or volume averaging. Right cervical ICA: Less than 20% stenosis Intracranial ICA: Mild-moderate narrowing of the cavernous carotid segments on both sides. 3. Multilevel, multifactorial degenerative changes are noted, with mild canal moderate to severe foraminal narrowing with deformity on the nerves from C3-C7 levels. A small sclerotic focus in the T4 vertebral body question bone island or a sclerotic neoplastic lesion. Correlate clinically to decide on the need for further workup or followup. 4. Periapical lucencies noted around the left mandibular third molar- correlate with dental examination. Radiology Report INDICATION: ___ year old man with stroke // ? Intrathoracic process COMPARISON: Outside hospital radiograph from ___ at 06:10. IMPRESSION: Heart size is within normal limits. There is mild tortuosity of the thoracic aorta. There are no focal consolidations, pleural effusion, or pulmonary edema. There are no pneumothoraces. Radiology Report EXAMINATION: MR HEAD W/O CONTRAST INDICATION: ___ year old man with right cortical hand // define stroke characteristics TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was performed with gradient echo, FLAIR, diffusion, and T2 technique. COMPARISON: No prior MRI. Prior CT and CTA study dated ___ FINDINGS: There are several small scattered regions of slow diffusion in the left frontal lobe, left parietal lobe, and a few in the inferior left temporal lobe and left occipital lobe. This diffusion abnormality is particularly evident in the left pre and postcentral gyri. T2/FLAIR signal abnormality is seen within these regions. Findings are consistent with acute-subacute infarction in primarily MCA territory. There is no evidence of hemorrhagic transformation. The ventricles and sulci are prominent likely reflecting age-related parenchymal volume loss. There is additional periventricular, subcortical, and deep white matter T2/FLAIR signal hyperintensity likely reflecting chronic small vessel ischemic disease. Susceptibility artifact noted in the bilateral cerebellar hemispheres corresponds to calcification as seen on prior CT scan. Major vascular flow voids are patent. Patient is status post bilateral lens replacement. There is mucosal thickening within the ethmoid air cells. The remaining paranasal sinuses and mastoid air cells are clear. IMPRESSION: 1. Several foci of acute-subacute infarction in primarily the left MCA territory as detailed above, likely embolic; no evidence of hemorrhagic transformation, significant edema or mass effect. 2. T2/FLAIR signal hyperintensity in the periventricular, subcortical, and deep white matter which is nonspecific but likely on the basis of chronic small vessel ischemic disease. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: 24 hour followup in a patient with a left MCA stroke, status post TPA at 07:00 on ___. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: DLP: 897.1 mGy-cm CTDI: 53.8 mGy COMPARISON: CTA head and neck from ___. FINDINGS: The patient is status post administration of tPA 24 hours prior, without evidence of acute hemorrhage. Again seen is a prominent area of subcortical hypodensity in the left frontal lobe, similar in appearance compared to the most recent CT head. Additional foci of hypodensity in the left thalamus and periventricular regions are consistent with sequela of chronic small vessel ischemic disease. There is no evidence of mass. The ventricles sulci and extra-axial CSF spaces are mildly prominent, consistent with age-related involutional changes. Calcifications of the bilateral basal ganglia and cerebellum are unchanged. No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: 1. No evidence of acute hemorrhage. 2. Unchanged appearance of left frontal lobe subcortical hypodensity. 3. Age-related involutional changes and likely sequela of chronic small vessel ischemic disease. Radiology Report EXAMINATION: CAROTID DOPPLER ULTRASOUND INDICATION: ___ year old man with L MCA stroke, L ICA 60% stenosis on CTA - further evaluation with carotid U/S // degreee of L ICA stenosis - do bilateral carotid US with dopplers TECHNIQUE: Real-time grayscale and color and spectral Doppler ultrasound imaging of the carotid arteries was obtained. COMPARISON: Head and neck CTA ___ FINDINGS: RIGHT: The right carotid vasculature has mild heterogeneous atherosclerotic plaque. The right internal carotid artery has peak systolic/diastolic velocities of 47/12 cm/sec in its proximal portion, 56/21 cm/sec in its mid portion, and 42/12 cm/sec in its distal portion. The right common carotid artery has peak systolic/diastolic velocities of 71/9 cm/sec. The external carotid artery has peak systolic velocity of 34 cm/sec. The vertebral artery has peak systolic velocity of 39 cm/sec with normal antegrade flow. The right ICA/CCA ratio is 0.79. LEFT: The left carotid vasculature has mild heterogeneous atherosclerotic plaque. The left internal carotid artery has peak systolic/diastolic velocities of 78/27 cm/sec in its proximal portion, 53/17 cm/sec in its mid portion, and 41/15 cm/sec in its distal portion. The left common carotid artery has peak systolic/diastolic velocities of 65/11 cm/sec. The external carotid artery has peak systolic velocity of 65 cm/sec. The vertebral artery has peak systolic velocity of 62 cm/sec with normal antegrade flow. The left ICA/CCA ratio is 1.2. IMPRESSION: Less than 40% stenosis of the bilateral internal carotid arteries. Doppler suggests that the left ICA stenosis is less severe than suggested by CTA ___. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Transfer Diagnosed with CEREBRAL ART OCCLUS W/INFARCT, HYPERTENSION NOS temperature: 98.0 heartrate: 86.0 resprate: 16.0 o2sat: 99.0 sbp: 153.0 dbp: 88.0 level of pain: 0 level of acuity: 1.0

Dear Mr ___, You were hospitalized due to symptoms of right hand 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. 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: Hypertension High Cholesterol We are changing your medications as follows: Aspirin 81 daily Atorvastatin 80 daily Please take your other medications as prescribed. Please follow up 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 Sincerely, Your ___ Neurology Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Tylenol-Codeine #3 Attending: ___. Chief Complaint: L wrist fracture Major Surgical or Invasive Procedure: external fixation and splinting of L wrist fracture History of Present Illness: This is a ___ year-old Female with PMH significant for hypertension, atrial fibrillation (not on anticoagulation), adjustment disorder, anxiety, prior left breast cancer (invasive lobular adenocarcinoma, s/p XRT and tamoxifen), osteopenia, presenting to the ED with a L wrist fracture (comminuted displaced left distal radius fx with ulnar styloid fx). The patient fractured her wrist on ___, when she was walking into a casino and lost her footing on an uneven entryway. Denies fever, chills, weight loss, nausea, vomiting, diarrhea, dysuria. On ___ she went to a Dr ___, who wrapped her hand and only let her leave when she promised to see her Dr ___ ___ soon. On ___ she saw her PCP in ___, who "did not like the color of the hand" and sent her to the ___ ED. Per the patient the hand has felt numb and been dusky in color ever since the fall. She is no able to move her ___ finger, she can wiggle her other fingers. In the ED, initial VS 98.8 70 154/49 18 96% RA. Seen by hand-palstic surgery in the ED. They attempted closed reduction in the ED. She was requiring escalating doses of pain medications and required admission to medicine. She received Morphine 5 mg IV x 3, then Oxycodone 5 mg PO x 1. Following this she became somnolent and had oxygen desaturations to 78% on RA and recieved Naloxone 0.4 mg IV x 2 with improvement. She then recieved Ibuprofen 800 mg PO x 1, Oxycodone 5 mg PO x 1, Toradol 30 mg IV x 1 and Dilaudid 1 mg IV x 1. She was then transferred to the medicine floor. Past Medical History: 1. adjustment disorder 2. atrial fibrillation (cardiologist - Dr. ___, ___ 3. anxiety and depression 4. vitamin B12 deficiency 5. breast cancer (T1N0M0 invasive lobular adenocarcinoma s/p RTX/implant/tamoxifen for ___ years) 6. colonic polyps (___) 7. constipation 8. hypertension 9. osteopenia 10. seasonal affective disorder 11. gastric bypass ___ Social History: ___ Family History: Mother deceased from recurrent non-Hodgkin's lymphoma. Multiple family members with ovarian and breast ca at early ages (mother with ovarian ca in her ___, 2 aunts with breast ca) Physical Exam: PHYSICAL EXAM: Vitals: 98.0 123/47 85 16 93%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: L arm braced and wrapped. L fingers dusky in color with cap refill ~ 3 seconds. Sensation decrased in L hand, feels "numb". Not able to wiggle ___ finger. Pertinent Results: ___ 01:20PM BLOOD WBC-5.7 RBC-3.69* Hgb-11.9* Hct-38.0 MCV-103* MCH-32.1* MCHC-31.2 RDW-13.6 Plt ___ ___ 01:20PM BLOOD Plt ___ ___ 01:20PM BLOOD ___ PTT-34.5 ___ EKG without ischemic changes Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ALPRAZolam 0.5 mg PO BID:PRN anxiety hold for sedation, RR < 12 2. Cyanocobalamin Dose is Unknown PO DAILY 3. Lisinopril 20 mg PO HS hold for SBP < 100 4. Meclizine 12.5 mg PO TID:PRN dizziness hold for sedation, RR < 12 5. Metoprolol Tartrate 12.5 mg PO BID hold for SBP < 100, HR < 60 6. Mirtazapine 15 mg PO HS 7. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN pain 8. Paroxetine 40 mg PO DAILY 9. Aspirin 81 mg PO DAILY 10. Docusate Sodium 100 mg PO BID:PRN constipation hold for loose stool 11. Senna 1 TAB PO BID:PRN constipation 12. Ferrous Sulfate 325 mg PO BID Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Docusate Sodium 100 mg PO BID 3. Ferrous Sulfate 325 mg PO BID 4. Lisinopril 20 mg PO HS 5. Meclizine 12.5 mg PO TID:PRN dizziness 6. Metoprolol Tartrate 12.5 mg PO BID 7. Mirtazapine 15 mg PO HS 8. Paroxetine 40 mg PO DAILY 9. Senna 1 TAB PO BID 10. Acetaminophen 1000 mg PO Q8H RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours (three times a day) Disp #*30 Tablet Refills:*0 11. Calcium Carbonate 500 mg PO BID RX *calcium carbonate [Calcium 500] 500 mg calcium (1,250 mg) 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 12. Naproxen 250 mg PO Q12H RX *naproxen 250 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 13. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours as needed Disp #*30 Tablet Refills:*0 14. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 [Gavilax] 17 gram/dose 1 dose by mouth daily Disp #*20 Packet Refills:*0 15. Vitamin D 1000 UNIT PO DAILY RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 16. ALPRAZolam 0.5 mg PO BID:PRN anxiety 17. Cyanocobalamin 0 mcg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis 1. comminuted displaced left distal radius fx with ulnar styloid fx 2. altered mental status from narcosis Secondary Diagnosis 1. osteopenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Left wrist fracture with severe pain. TECHNIQUE: Left wrist, 3 views. COMPARISON: Reference wrist radiographs ___. FINDINGS: Overlying cast limits fine osseous detail. Comminuted fracture of the distal radius is re- demonstrated with intra-articular extension, mild impaction, and volar displacement of the dominant distal fracture fragments by approximately 1 shaft width. Displaced ulnar styloid fracture is also again seen and similar in appearance. There is diffuse soft tissue swelling. The osseous structures are diffusely demineralized. IMPRESSION: Comminuted distal radial fracture with intra-articular extension, displacement, and slight impaction. Displaced ulnar styloid fracture, unchanged. Radiology Report HISTORY: Distal radial fracture status post reduction. TECHNIQUE: 3 views of the left wrist. COMPARISON: ___ at 17:18. FINDINGS: Evaluation of the osseous structures is limited due to overlying splint. Again seen is a comminuted, mildly impacted distal radial fracture with intra-articular extension. The alignment of the fracture fragments appears slightly improved with less volar displacement of the dominant distal fracture fragment. Ulnar styloid fracture remains mildly displaced and unchanged. No other fractures or dislocation is identified. IMPRESSION: Slight interval improvement in alignment of the comminuted distal radial fracture. Persistent mildly displaced ulnar styloid fracture. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: LEFT WRIST INJURY Diagnosed with JOINT EFFUSION-L/LEG, POPLITEAL SYNOVIAL CYST temperature: 98.8 heartrate: 70.0 resprate: 18.0 o2sat: 96.0 sbp: 154.0 dbp: 49.0 level of pain: 12 level of acuity: 3.0

Dear Ms. ___, It was a pleasure caring for you at ___ ___. You were admitted with a left wrist fracture after a fall. You were seen by hand surgery, who partially externally fixed the fracture. You will need to follow up in hand clinic on ___ for likely surgery later in the week. It is important that you avoid driving or operating heavy machinery while taking oxycodone for pain. Please take all medications as prescribed, and keep all follow up appointments.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Anemia Major Surgical or Invasive Procedure: EGD Blood transfusion History of Present Illness: Mr. ___ is a ___ y/o gentleman without any significant medical history who presented to the ED from his PCP's office for a Hgb of 6. He was in his normal state of health until five months ago when he started to feel as if his 'stomach was bubbling'. He attributed the sensation to excessive caffeine use, as he was drinking several soft and energy drinks every day. As a result, he stopped drinking caffeine and experienced severe caffeine withdrawal headaches. To self-treat his withdrawal headaches he was taking approximately 9 regular aspirin a day for about a week, and then continued to take numerous aspirin after that weeks. In the setting of his excessive aspirin intake, he began to notice dark tarry stools and increasing fatigue. He appoximates that he's had about one melanic stool per day, although in the past few days it has been more frequent. No other symptoms of diarrhea or bright red blood in his stool. He had a couple episodes of nonbilious, nonbloody vomiting approximately two weeks ago. As the month progressed, he noted increasing fatigue, especially as his job as the ___ ___ requires a great deal of energy. He notes increasing muscle weakness, a heart that 'was working hard' and the sensation of 'seeing bright lights' with exertion. A few weeks ago, he had a episode of left arm and chest pain that resolved over the day, was not associated with exertion, and changed with movement, which the patient attributed to an uncomfortable sleeping position. He also noted that his skin appeared more pale. He initially attributed his symptoms to dehydration and thus, drank a great deal of gatorade and water to compensate. When this did not relieve his symptoms, he visited his PCP. Labs done by his primary care physician ___ ___ were notable for severe ___ deficiency anemia with Hg 6.0, Hct 19.9, MCV 68.3, Plt 446, Serum Fe 27, TIBC 479, Tfn ___ 5.6 and Transferrin 342. Due to his severe anemia and suggestive symptoms, his PCP suggested he present to the ___ ED. At the advice of his PCP, he presented to the ___ ED. He does not report any fevers, chills, dyspnea, pain, chemical exposures, travel history or trauma. In the ED, initial vitals: 98.8 98 131/58 16 100% RA. He had guiaic positive stools and GI was consulted. They suggested an EGD tomorrow morning, and starting a PPI tonight. Vitals prior to transfer: 98.1 79 93/61 18 100%RA Currently, he feels slightly fatigued, but has no other symptoms, including no pain, no dizziness, no lightheadedness and no palpitations. He is comfortable laying in bed. ROS: No fevers, chills, night sweats. Has gained 3 lbs over the last month. No changes in hearing, no changes in balance. No cough, no shortness of breath. No chest pain. No dysuria or hematuria. No numbness or weakness, no focal deficits. Past Medical History: Oral surgery when a teenager. Social History: ___ Family History: Maternal grandmother- multiple brain aneurysms Maternal grandfather- ___ disease Paternal grandmother- throat cancer ___ grandfather- throat and stomach cancer Mother- ___ deficiency anemia Father- hyperlipidemia Brother- ___ years old in good health Physical Exam: ADMISSION PHYSICAL EXAM Vitals- 98.3 106/58 78 20 100% RA General- Alert, oriented, no acute distress HEENT- Sclerae anicteric/pale, MMM, oropharynx clear Neck- Supple, JVP at 8cm, no LAD Lungs- CTAB no wheezes, rales, rhonchi CV- RRR, Nl S1, S2, No MRG Abdomen- Soft, normoactive bowel sounds, NT/ND, no rebound tenderness or guarding, no organomegaly, liver felt 1cm below the rib cage. GU- no foley Ext- Warm, well perfused, 2+ radial and DP pulses, no clubbing, cyanosis or edema, 2x 18G IVs, one in each arm. Neuro- CNs2-12 intact, motor function grossly normal Skin- Extremely pale. DISCHARGE PHYSICAL EXAM Vitals: 98.1 99/51(80-100/40-60s) 77(50-80s) 20 100%RA Exam: General- Alert, oriented, no acute distress HEENT- No conjunctiva pallor, MMM, oropharynx clear Neck- Supple Lungs- CTAB no wheezes, rales, rhonchi CV- RRR, Nl S1, S2, No MRG Abdomen- Soft, normoactive bowel sounds, NT/ND, no rebound tenderness or guarding, no organomegaly. GU- no foley Ext- Warm, well perfused, 2+ DP pulses, no clubbing, cyanosis or edema, 2x 18G IVs, one in each arm. Neuro- CNs2-12 intact, motor function grossly normal Skin- pale. Pertinent Results: ADMISSION LABS: ___ 02:05PM BLOOD WBC-4.0 RBC-2.65* Hgb-5.1* Hct-20.1* MCV-76* MCH-19.4* MCHC-25.5* RDW-18.5* Plt ___ ___ 02:05PM BLOOD Neuts-68.6 ___ Monos-6.4 Eos-0.9 Baso-0.4 ___ 02:05PM BLOOD Plt ___ ___ 02:05PM BLOOD ___ PTT-30.0 ___ ___ 02:05PM BLOOD Ret Man-5.2* ___ 12:25PM BLOOD Glucose-88 UreaN-16 Creat-1.1 Na-138 K-3.7 Cl-106 HCO3-24 AnGap-12 DISCHARGE LABS: ___ 07:55AM BLOOD WBC-6.5 RBC-3.67* Hgb-8.7* Hct-28.7* MCV-78* MCH-23.8* MCHC-30.4* RDW-19.2* Plt ___ RELEVANT INTERIM LABS: H.pylori negative EGD ___ Irregular z-line (biopsy) Mild gastritis and erosion of the antrum. This does not necessarily explain the patients severe anemia. (biopsy) Normal mucosa in the whole duodenum (biopsy) Otherwise normal EGD to third part of the duodenum IMAGING: CT A/P ___ IMPRESSION: 1. No imaging features to suggest small bowel lymphoma. 2. Multiple abnormal appearing segments of small bowel are identified, some with apparent wall thickening and other with fecalization as described above which may be related to processes such as Crohn disease. Assessment is limited given the static nature of CT enterography, and as the majority of enteric contrast was in the colon. MR-Enterography is recommended for further evaluation. PATHOLOGY -Upper GI biopsy pending at time of discharge Medications on Admission: None. Some aspirin use, as detailed in the HPI. Discharge Medications: 1. Ferrous Sulfate 325 mg PO BID RX *ferrous sulfate 325 mg (65 mg ___ 1 tablet(s) by mouth twice daily Disp #*60 Tablet Refills:*0 2. Omeprazole 40 mg PO DAILY RX *omeprazole 40 mg 1 capsule,delayed ___ by mouth daily Disp #*60 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: ___ deficiency anemia. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Gastrointestinal bleeding. Rule out lymphoma. COMPARISON: No prior studies available for comparison. TECHNIQUE: MDCT imaging of the abdomen and pelvis with intravenous and oral contrast was performed (CT enterography). Multiplanar reformats were prepared and reviewed. DLP: 358 mGy-cm FINDINGS: ABDOMEN: The liver is homogeneous in texture with no focal lesion. There is no intra- or extra-hepatic biliary tree dilatation. The spleen, pancreas and adrenal glands are normal. The gallbladder is unremarkable without any gallstones. The aorta is of normal caliber. There are multiple small intra-mesenteric lymph nodes which are not size significant. The stomach, duodenum and colon are unremarkable. However, there is fecalization of a small bowel loop in the right hemi-abdomen (5;36 and 6b; 17) which is slightly distended up to 3.2 cm. Two additional segments of small bowel appear slightly circumferentially thickened and enhancing in the mid abdomen (6b;13) measuring 7 cm and left hemi-abdomen (6b;21) measuring 6 cm. The terminal ileum is difficult to identify but appears unremarkable. No free fluid or fluid collection. The lung bases are clear. BONE WINDOWS: No focal lytic or sclerotic osseous lesions suspicious for infection or malignancy is seen. IMPRESSION: 1. No imaging features to suggest small bowel lymphoma. 2. Multiple abnormal appearing segments of small bowel are identified, some with apparent wall thickening and other with fecalization as described above which may be related to processes such as Crohn disease. Assessment is limited given the static nature of CT enterography, and as the majority of enteric contrast was in the colon. MR-Enterography is recommended for further evaluation. The findings were discussed with the treating team at 6:15 p.m. on ___. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Anemia Diagnosed with GASTROINTEST HEMORR NOS temperature: 98.6 heartrate: 98.0 resprate: 16.0 o2sat: 100.0 sbp: 131.0 dbp: 58.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, It was a pleasure to take part in your care during your stay at the ___. As you know, you were admitted to the hospital to receive a blood transfusion and investigate the cause of your anemia (low blood counts). You received a Esophagogastroduodenoscopy or EGD in which a camera took pictures of your esophagus, stomach and the upper part of your small intestine. There was no site of bleeding identified during the EGD. You also received a CT scan to look for changes in your intestine that might be bleeding and could also result in a low blood count. The results of this test were pending at the time of discharge. We have made you an appointment with your primary doctor who you should ___ with so that he can help get you scheduled for an outpatient colonoscopy. You may also need a capsule study (which looks at your small intestine), but only if the other tests are negative. We wish you good health in the future.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Traumatic brain injury Major Surgical or Invasive Procedure: ___ - Right Neurovent placement ___ - Right decompressive hemicraniectomy, subdural hematoma evacuation, removal of right Neurovent ___ - Trach and PEG ___ - Cranioplasty ___: Trach decannulated History of Present Illness: ___ is a ___ year old male who presented to the Emergency Department on ___ as a transfer from an outside facility status post fall off the back of a moving pick-up truck with a severe traumatic brain injury. The patient was transferred to ___ for escalation of care. The Neurosurgery Service was consulted for evaluation and management recommendations. Past Medical History: - hyperlipidemia - hypertension - status post appendectomy as a child Social History: ___ Family History: Noncontributory. Physical Exam: On Admission: ------------- ___ Physical Examination: GCS at the Scene: 3 GCS on Neurosurgical Evaluation: 7T Time of Neurosurgical Evaluation: ___ 11:15 Airway: [x]Intubated [ ]Not intubated Eye Opening: [x]1 Does not open eyes [ ]2 Opens eyes to painful stimuli [ ]3 Opens eyes to voice [ ]4 Opens eyes spontaneously Verbal: [x]1 Makes no sounds [ ]2 Incomprehensible sounds [ ]3 Inappropriate words [ ]4 Confused, disoriented [ ]5 Oriented Motor: [ ]1 No movement [ ]2 Extension to painful stimuli (decerebrate response) [ ]3 Abnormal flexion to painful stimuli (decorticate response) [ ___ Flexion/withdrawal to painful stimuli [x]5 Localizes to painful stimuli [ ]6 Obeys commands Exam: General: Well nourished adult male. Intubated. Sedation held for 5 minutes prior to examination. HEENT: Normocephalic. Large, approximately 3cm, laceration to left parietal scalp, poorly approximated. Extremities: Warm and well perfused. Neurologic: Mental Status: Intubated. Sedation held prior to examination. No eye opening. Does not follow commands. Orientation: Unable to assess, patient intubated, unresponsive. Language: Unable to assess, patient intubated, unresponsive. Cranial Nerves: I: Not tested. II: Pupils equally round and reactive to light, 2.5-2mm, bilaterally. Unable to test visual fields, patient intubated, unresponsive. III, IV, VI: Unable to test, patient intubated, unresponsive. V, VII: Unable to test, patient intubated, unresponsive. VIII: Unable to test, patient intubated, unresponsive. IX, X: Unable to test, patient intubated, unresponsive. XI: Unable to test, patient intubated, unresponsive. XII: Unable to test, patient intubated, unresponsive. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Left upper extremity localizes to noxious, but otherwise no movement in other extremities. Unable to test drift, patient intubated, unresponsive. Sensation: Unable to test, patient intubated, unresponsive. On Discharge: ------------- General: Vital Signs: ___ 0551 Temp: 98.4 PO BP: 139/95 L Lying HR: 84 RR: 20 O2 sat: 93% O2 delivery: RA Bowel Regimen: [x]Yes [ ]No BM: ___ Exam: Opens Eyes: [x]Spontaneous [ ]To voice [ ]To noxious [ ]None Follows Commands: [X]Simple [ ]Complex []None Pupils: PERRL, 4-3mm, bilaterally EOMs: [x]Crosses midline, tracks examiner Face Symmetric: [x]No - right NL flattening at rest Tongue Midline: [ ]Yes [ ]No [x]Unable to assess - Difficulty with complex commands Speech Fluent: [ ]Yes [x]No - Nonverbal Comprehension Intact: [ ]Yes [x]No Motor: MAEx4 spontaneously at least antigravity. Purposeful & spontaneous. Surgical Incisions: [x]Clean, dry, intact [x]Well healing Pertinent Results: Please see OMR for relevant laboratory and imaging results. Medications on Admission: - amlodipine 10mg PO once daily - hydrochlorothiazide unknown dose PO once daily - metoprolol tartrate unknown dose PO BID - pravastatin 10mg PO once daily Discharge Medications: *** 1. Acetaminophen 1000 mg PO Q8H 2. BusPIRone 15 mg PO TID 3. Labetalol 200 mg PO Q8H 4. LACOSamide 200 mg PO BID 5. LamoTRIgine 150 mg PO BID 6. LevETIRAcetam Oral Solution 1000 mg PO BID Duration: 7 Days 7. LevETIRAcetam Oral Solution 500 mg PO BID 8. QUEtiapine Fumarate 12.5 mg PO DAILY 9. QUEtiapine Fumarate 25 mg PO QHS 10. Ramelteon 8 mg PO QHS 11. TraZODone 37.5 mg PO QHS Discharge Disposition: Extended Care Facility: ___ - Discharge Diagnosis: Traumatic brain injury Epidural hematom Subdural hematoma Traumatic subarachnoid hemorrhage Intraparenchymal hemorrhage Brain compression/Mass effect Nondisplaced fractures of left zygomatic, left sphenoid, left temporal bones Multiple rib fractures Seizures Pneumonia Dysphagia Hypertension Tachycardia Oral thrush 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 (PORTABLE AP) INDICATION: History: ___ with major trauma//ptx, rib fx TECHNIQUE: Supine AP view of the chest COMPARISON: None. Patient is currently listed as EU critical. FINDINGS: Lung volumes are low. Endotracheal tube tip terminates approximately 3.8 cm from the carina. Cardiac silhouette size is moderately enlarged, accentuated by low lung volumes. There is pulmonary vascular congestion without frank pulmonary edema. Patchy ill-defined opacities are seen within the upper lobes bilaterally and to a lesser extent within the lower lobes, potentially areas of atelectasis, with contusion not excluded. No large pleural effusion or pneumothorax is seen on this supine exam. Fractures of the left third, fourth, and fifth ribs are demonstrated. There is massive gastric distension. IMPRESSION: 1. Endotracheal tube in standard position. 2. Low lung volumes with patchy ill-defined opacities in both upper lobes as well as to a lesser extent in both lower lobes which could reflect atelectasis and/or contusion. 3. Multiple left-sided rib fractures without large pneumothorax or pleural effusion. 4. Marked gastric distension for which enteric tube placement is recommended. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: History: ___ with trauma, fall from moving truck, +head strike and injury, trauma TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 18.0 s, 18.8 cm; CTDIvol = 48.1 mGy (Head) DLP = 903.1 mGy-cm. Total DLP (Head) = 903 mGy-cm. COMPARISON: No prior studies available for comparison. FINDINGS: Multiple acute intracranial hemorrhages are demonstrated including: 1. A 9 mm subdural hematoma along the right cerebral convexity and adjacent subarachnoid hemorrhage seen within the sylvian fissure and right temporal lobe sulci with mass effect resulting in effacement of the right lateral ventricle and 5 mm of leftward midline shift. No subfalcine herniation. 2. A 2.7 x 1.7 x 5.2 cm left parietotemporal intraparenchymal hematoma with adjacent diffuse subarachnoid hemorrhage extending the sylvian fissure and inferiorly into the anterior temporal lobe. An overlying temporal bone fracture noted as described below and thus an epidural component to this hemorrhage cannot be excluded. 3. A 2.2 x 1.0 cm lentiform hematoma along the greater wing of the left sphenoid (series 2, image 11), likely an epidural hematoma. The basal cisterns are patent. No evidence of hydrocephalus or acute large territorial infarction. There are three nondisplaced hairline calvarial fractures involving the left zygomatic bone (series 3, image 10), the greater wing of the left sphenoid bone (series 3, image 20), and the squamous portion of the left temporal bone (series 601, image 67) overlying the above-described intraparenchymal hemorrhage. Partial opacification of the bilateral maxillary sinuses and ethmoid air cells, and complete opacification of the sphenoid sinus and nasopharynx may represent sequelae of intubation. The mastoid air cells, and middle ear cavities are clear. A small locule of air is noted in the extraconal left orbit adjacent to the lateral rectus muscle, likely sequela of adjacent sphenoid bone fracture. Otherwise, the visualized portion the orbits are unremarkable. IMPRESSION: 1. Extensive traumatic right-sided subdural, bilateral subarachnoid, left parietotemporal intraparenchymal, and left-sided epidural hematomas as described above. 2. Right-sided mass effect with effacement of the right lateral ventricle and 5 mm of right to left midline shift. No hydrocephalus, or subfalcine or uncal herniation. 3. Nondisplaced fractures of the left zygomatic, greater wing of the left sphenoid, and squamous portion of the left temporal bones as described above. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE INDICATION: History: ___ with trauma, fall from moving truck, +head strike*** WARNING *** Multiple patients with same last name!// trauma trauma TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue and bone algorithm images were generated. Coronal and sagittal reformations were then constructed. DOSE: Acquisition sequence: 1) Spiral Acquisition 6.5 s, 25.5 cm; CTDIvol = 22.9 mGy (Body) DLP = 585.7 mGy-cm. Total DLP (Body) = 586 mGy-cm. COMPARISON: No prior studies available for comparison. FINDINGS: Alignment is normal. No fractures are identified.Mild degenerative changes of the cervical spine are most pronounced at C4-5 and C5-6 with intervertebral disc space narrowing and posterior osteophyte formation resulting in mild central canal narrowing. No evidence of high-grade spinal canal or neural foraminal stenosis. There is no prevertebral soft tissue swelling, but assessment is somewhat limited to the presence of enteric and endotracheal tubes seen in the esophagus and trachea, respectively.There is no evidence of infection or neoplasm. Visualized aspect of the thyroid gland is unremarkable. Visualized lung apices demonstrate atelectatic changes. IMPRESSION: 1. No fracture or traumatic malalignment. 2. Mild degenerative change of the cervical spine. Radiology Report EXAMINATION: CT chest abdomen and pelvis INDICATION: History: ___ with trauma, fall from moving truck, +head strike, history of CP are//trauma TECHNIQUE: MDCT axial images were acquired through the chest, abdomen and pelvis following intravenous contrast administration. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 8.8 s, 69.6 cm; CTDIvol = 23.8 mGy (Body) DLP = 1,656.2 mGy-cm. Total DLP (Body) = 1,656 mGy-cm. COMPARISON: No similar prior studies available for comparison. FINDINGS: CHEST: HEART AND VASCULATURE: The thoracic aorta is normal in caliber without evidence of acute injury. Main pulmonary artery is dilated to 3.6 cm. No central pulmonary embolism. The heart appears mildly enlarged. 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: Trace left-sided hemothorax. No pneumothorax. LUNGS/AIRWAYS: Mild to moderate atelectasis is seen in the upper and lower lobes dependently. The airways are patent to the level of the segmental bronchi bilaterally. Endotracheal tube terminates approximately 2.5 cm above the carina. BASE OF NECK: Visualized portions of the base of the neck show no abnormality. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. 0.6 cm hypodense lesion within the hepatic dome is too small to characterize (series 2, image 61). There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder contains gallstones without wall thickening or surrounding inflammation. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesion or laceration. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. No evidence of hydronephrosis. Bilateral subcentimeter hypodense lesions are too small to characterize, but likely represent renal cysts. There is no perinephric abnormality. GASTROINTESTINAL: Enteric tube terminates in the pylorus. Otherwise, the stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is not visualized. There is no evidence of mesenteric injury. There is no free fluid or free air in the abdomen. PELVIS: Foley catheter is visualized within the urinary bladder. 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. Mild atherosclerotic disease is noted. BONES: Acute bilateral rib fractures including the anterolateral second through seventh ribs on the left, the anterolateral first through eighth ribs on the right, and the posterior fourth through seventh ribs on the left. No focal suspicious osseous abnormality. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Acute bilateral rib fractures including the anterior left second through seventh ribs, the posterior left fourth through seventh ribs, and the anterior right first through eighth ribs. No pneumothorax. 2. Bilateral dependent atelectasis in the upper and lower lobes with trace left-sided hemothorax. 3. No solid organ injury within the abdomen or pelvis. Radiology Report EXAMINATION: DX ELBOW AND FOREARM INDICATION: ___ year old man with trauma// Fx TECHNIQUE: Four portable views of the left elbow were obtained COMPARISON: None FINDINGS: There is no acute fracture or dislocation identified. Fragmented enthesophytes are noted along the olecranon at the attachment of the triceps tendon. There is no evidence of a joint effusion however the lateral view suboptimal. A peripheral intravenous catheter seen over the antecubital fossa. IMPRESSION: No acute osseous injury of the left elbow. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with multiple rib Fx// interval changes IMPRESSION: In comparison with the study ___, the tip of the the subclavian base central line of is about at the level of the cavoatrial junction. Endotracheal tube has been somewhat withdrawn with the tip at the clavicular level, approximately 6.5 cm above the carina. Continued low lung volumes accentuates the enlargement of the cardiac silhouette. Retrocardiac opacification has decreased and there is no evidence of vascular congestion or acute focal pneumonia. The left rib fractures are much better seen on the recent CT. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old man with head trauma. Evaluate for interval change. TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain window. DOSE: Acquisition sequence: 1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 934.3 mGy-cm. Total DLP (Head) = 934 mGy-cm. COMPARISON: CT head ___ 12:28 FINDINGS: There has been interval placement of a right frontal presumed ventriculostomy drainage catheter which terminates in the deep white matter of the right frontal lobe, outside of the ventricular system. There is an acute subdural hematoma abutting the right cerebral convexity measuring up to 1.0 cm across maximal width(2:20), mildly increased in size as compared to most recent CT previously measuring up to 0.8 cm at the same level. Subdural blood is also seen extending along the tentorium and falx. There is a lenticular hyperdense collection abutting the right temporal lobe measuring up to 1.3 cm across maximal width (2:12), which is new or increased in size and could represent an epidural hematoma. Re-demonstrated is a lenticular hyperdense extra-axial collection abutting the left temporal lobe measuring up to 2.2 cm across maximal with (2:15), unchanged. There is intraparenchymal hemorrhage in the left parietooccipital region measuring 3.9 x 2.7 cm (2:22), grossly unchanged. Diffuse subarachnoid hemorrhage, most prominent along the bilateral sylvian fissures and tentorial leaflets, is grossly unchanged. There is mass effect with right to left midline shift of 5 mm (2:21), grossly unchanged. Basal cisterns are patent. Nondisplaced left calvarial fractures are better assessed on comparison CT. There is no evidence of a new or worsening fracture. There is partial opacification of the maxillary and bilateral ethmoid air cells. Sphenoid sinuses are completely opacified. IMPRESSION: 1. Right-sided acute subdural hematoma is mildly increased in size from most recent head CT, now measuring 1.0 cm across maximal with, previously measuring up to 0.8 cm, and extending to the tentorium and falx. 2. There is a lenticular shaped hyperdense extra-axial collection abutting the right temporal lobe measuring up to 1.3 cm, which is new or increased in size from most recent head CT and given the shape likely represents an epidural hematoma. 3. There has been interval placement of a right-sided intraparenchymal drainage catheter which terminates in the deep white matter of the right frontal lobe. The presence of placement of a intraparenchymal drainage catheter was confirmed by conversation with Dr. ___. 4. Diffuse subarachnoid hemorrhage, left parieto-occipital intraparenchymal hemorrhage, and left temporal epidural hemorrhage with mass effect and right to leftward midline shift of 5 mm are all unchanged. 5. Nondisplaced calvarial fractures are better assessed on recent head CT with bone algorithm. There is no evidence of a new or worsening fracture. NOTIFICATION: The findings were discussed by Dr. ___ with Dr ___, ___ on the telephone on ___ at 5:45 pm, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old man with trauma// line placemen t Contact name: ___: ___ TECHNIQUE: AP portable chest radiograph COMPARISON: CT chest from earlier today FINDINGS: The tip of the endotracheal tube projects over the midthoracic trachea and a feeding tube extends to the stomach. The tip of a left subclavian central line projects over the upper right atrium, approximately 1 cm beyond the cavoatrial junction. There are low bilateral lung volumes. Opacities throughout the left hemithorax likely reflect atelectasis. No pleural effusion or pneumothorax. The size of the cardiac silhouette is mildly enlarged but is likely magnified secondary to low lung volumes and AP technique. Multiple bilateral rib fractures are again seen but were better evaluated on the CT chest from earlier today. IMPRESSION: The tip of a left subclavian central line projects over the upper right atrium, approximately 1 cm beyond the cavoatrial junction. Opacities within the left hemithorax likely reflect atelectasis, better evaluated on the CT chest from earlier today. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with TBI now s/p right craniectomy// interval changes TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 934.5 mGy-cm. Total DLP (Head) = 935 mGy-cm. COMPARISON: CT head with the same date. FINDINGS: Interval removal of the right frontal ICP monitor. The patient is status post right hemi craniectomy and evacuation of an acute right subdural hematoma. Surgical drain is seen within the right extra-axial space. There are multiple small foci of pneumocephalus overlying the right frontal and temporal lobes, expected. The large left parietal intraparenchymal hemorrhage with surrounding edema is unchanged measuring 3.9 x 2.7 cm in maximum axial ___ (series 2, image 23). The extent of subarachnoid hemorrhage throughout the left hemisphere is unchanged. There is also an unchanged acute epidural hematoma along the left temporal lobe measuring 10 mm. Small amount of remaining subarachnoid hemorrhage overlying the right temporal lobe. Additional extra-axial hemorrhage overlying the right temporal lobe has also decreased in size, either subdural or epidural in location (series 2, image 13). Small subdural along the tentorium and falx is unchanged. There is no evidence of acute territorial infarction. No evidence of significant mass, mass effect, or midline shift. The ventricles and sulci are normal in size and configuration. Basal cisterns are patent. There is a large subgaleal hematoma overlying the left parietal lobe. Known calvarial fractures are better demonstrated on the prior head CT. Complete opacification of the bilateral sphenoid sinuses. Air-fluid levels within the posterior ethmoids and maxillary sinuses bilaterally. The visualized portion of the mastoid air cells and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. Endotracheal and orogastric tubes are partially imaged. Fluid filling the nasopharynx and oropharynx is likely due to intubation. IMPRESSION: 1. Interval right hemicraniectomy and evacuation of an acute right subdural hematoma. Small residual right temporal extra-axial collection, either epidural or subdural. 2. Unchanged large left parietal intraparenchymal, left temporal epidural, and bilateral subarachnoid hemorrhage. Unchanged small subdural hemorrhage along the tentorium and falx. 3. No evidence of new hemorrhage. Resolution of prior midline shift. The basilar cisterns are patent. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with ETT// eval PNA TECHNIQUE: 2 frontal views of the chest COMPARISON: None. FINDINGS: The ET tube is position below the thoracic inlet, approximately 6.1 cm above the carina, within normal limits for position. The left-sided subclavian central line is at the cavoatrial junction. Prominent cardiomegaly again noted. Retrocardiac opacification is stable. Possible slight interval increased hazy opacity left upper lobe. No pneumothorax or effusion. The left rib fractures are better seen on prior chest CT. IMPRESSION: Retrocardiac opacity, which may reflect pneumonia, stable. Mild increased left upper lobe hazy opacity could reflect developing pneumonia in this region. Radiology Report EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Q116 CT HEADSINUS INDICATION: ___ s/p fall from moving truck, w/ L IPH/SAH, L EDH, R SDH, bilateral multiple rib fx// Left temporal bone fracture 1. involvement of otic capsule2. course of facial nerve3. skull base4. involvement of carotid canal 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 6.0 s, 12.3 cm; CTDIvol = 123.5 mGy (Head) DLP = 1,521.8 mGy-cm. Total DLP (Head) = 1,522 mGy-cm. COMPARISON: CTs head ___ and ___ FINDINGS: Surgical changes from right hemi craniectomy are noted with a displaced bony fragment(301:75) noted and overlying edema, hemorrhage, and foci of air. There is overlying swelling, high-density fluid likely representing blood products, and foci of air in the overlying soft tissues of the scalp. There is no evidence of a right temporal bone fracture. There is no left temporal bone fracture included in the field of view of this study. The previously noted non-displaced fracture involving the squamous portion of the left temporal bone, characterized on CT head ___, is not included in the field of view of this study. Re-demonstrated is diffuse subarachnoid hemorrhage, intraventricular hemorrhage noted in the occipital horn of the left lateral ventricle, acute temporal subdural hematoma, acute left temporal epidural hematoma, and hemorrhage in both sphenoid and posterior ethmoid air cells are unchanged from CT head ___. Basal cisterns are patent. The ossicles are unremarkable. Minimal opacity in each right middle ear canal, right greater than left, is doubtful in significance. Inner ear structures are unremarkable. Orogastric and endotracheal tube are partially visualized in the oropharynx. IMPRESSION: 1. No evidence of a temporal bone fracture on the study. Please note that the nondisplaced fracture involving the squamous portion of the left temporal bone, characterized on CT head ___, is not included in the field of view of this study (too cranial). 2. Partially visualized diffuse subarachnoid hemorrhage, intraventricular hemorrhage, right temporal subdural hemorrhage, and left temporal epidural hemorrhage are unchanged from CT head ___. 3. Postsurgical changes from right hemi-craniectomy with overlying swelling, high-density fluid, likely representing blood products, and foci of air in the scalp, all unchanged from ___. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with s/p fall from truck with subdural, subarachnoid intraparenchymal hemorrhages. Evaluate for changes in hemorrhage. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Found no primary dose record and no dose record stored with the sibling of a split exam. !If this Fluency report was activated before the completion of the dose transmission, please reinsert the token called CT DLP Dose to load new data. COMPARISON: CT maxillofacial ___. Head CT ___. FINDINGS: The patient is status post right hemicraniectomy. A surgical drain is again seen within the craniectomy site. There has been interval expansion of the right cerebral hemisphere into the craniectomy site. While pneumocephalus overlying the right frontal and temporal lobes has resolved, soft tissue thickening near the craniectomy site has increased. A subgaleal hematoma overlying left parietal lobe is again seen. There has been expected evolution of the left parietal intraparenchymal hemorrhage with surrounding edema, with interval mild decrease in size of the hyperdense component. Subarachnoid blood within the left cerebral hemisphere is not significantly changed. Epidural hematoma along the left temporal lobe (03:12) measures 9 mm in greatest axial ___, previously 10 mm. Extra-axial hemorrhage along the right temporal lobe measures 7 mm, decreased in size from prior. Subarachnoid blood along the right temporal lobe has not significantly changed. Subdural blood tracking along the falx and tentorium is again seen. No definite areas of new hemorrhage identified. There is mild effacement of the left lateral ventricle, with approximately 4 mm of rightward shift of normally midline structures. Question interval increase in size of right lateral ventricle compared to ___ prior exam. The basilar cisterns are grossly patent. Approximately 3 mm new parafalcine hygroma is noted (see 03:32 on current study and 02:30 on ___ prior exam). Partial opacification of the ethmoid air cells, with an air-fluid level in the maxillary sinuses. Complete opacification of the bilateral sphenoid sinuses is unchanged. Otherwise, the visualized portion of the mastoid air cells and middle ear cavities are clear. The visualized portion of the orbits are preserved. IMPRESSION: 1. No evidence of new hemorrhage. 2. Interval expansion of the right cerebral hemisphere into craniectomy site, with approximately 4 mm rightward shift of normally midline structures. 3. Question interval increase in size of right lateral ventricle compared to ___ prior exam. Recommend attention on follow-up imaging. 4. Approximately 3 mm new interhemispheric hygroma. 5. Grossly stable right temporal extra-axial hemorrhage, along with left parietal intraparenchymal, left temporal epidural, and bilateral subarachnoid hemorrhage. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 4:35 pm, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with TBI with bleeds now intubated and having thick secretions from his lungs// infiltrate in lungs? TECHNIQUE: Chest AP COMPARISON: ___ IMPRESSION: Left-sided PICC line, ET and NG tube are unchanged. Cardiomediastinal silhouette is stable. There is subsegmental atelectasis in the left lung base. No pneumothorax is seen there is no pleural effusion Radiology Report EXAMINATION: CT of the temporal bones. INDICATION: ___ year old man with multiple trauma. now s/p right craniectomy with possible CSF leak// temporal bone CT with fine cuts to better delineate the course of the fracture- On temporal bone CT, please evaluate specifically involvementof: (1) otic capsule (2) facial nerve (3) skull base/tegmen (4) carotid canal TECHNIQUE: Multidetector CT images of the left of the temporal bones were obtained without intravenous contrast. Sagittal and coronal reformations were also performed. DOSE: Acquisition sequence: 1) Spiral Acquisition 8.9 s, 18.3 cm; CTDIvol = 123.5 mGy (Head) DLP = 2,263.0 mGy-cm. Total DLP (Head) = 2,263 mGy-cm. COMPARISON: Recent prior studies from ___ and ___. FINDINGS: Multiple intracranial hemorrhages show no short-term change. There is re-demonstration of subarachnoid hemorrhage overlying bilateral hemispheres, not significantly changed in extent. An acute extra-axial hematoma along the left temporal lobe measures 9 mm similar to prior. An acute extra-axial hematoma along the right temporal lobe measures 7 mm, similar to prior. There is a stable large intraparenchymal hemorrhage in the left parietal lobe with evidence of a fluid-fluid level concerning for increased risk of expansion. There is surrounding edema exerting mass effect on the left lateral ventricle. There is 4 mm of rightward midline shift. The basal cisterns are patent. Hemorrhage is seen within the occipital horn of the right lateral ventricle. There has been right hemicraniectomy and evacuation of a right subdural hematoma. There has been interval removal of a surgical drain. There is persistent hyperdense extra-axial hemorrhage seen layering along the falx and tentorium and along the anterior right frontal lobe. There is unchanged complete opacification of the sphenoid sinuses. There is partial opacification of several ethmoid air cells with air-fluid level seen in the maxillary sinuses. Left zygomatic and left sphenoid fractures are again seen. Similar to prior findings, there is hairline nondisplaced fracture which begins superiorly along the left parietal bone, not fully imaged, and which courses anteriorly and inferior ___ into the squamous part of the left temporal bone. However, there is no evidence for involvement of the petrous bone. There is trace opacity in the left middle ear cavity, similar to recent prior findings, but no fluid. There are small quantities of new fluid within the left mastoid air cells, however. However, there is no evidence for fracture involving the petrous part of the temporal bone, and middle and inner ear structures appear intact. On the right, there is similar to perhaps mildly increased opacity within the right middle ear cavity as well as some new fluid within the mastoid air cells. Again, however, middle and inner ear structures appear intact without evidence for fracture involving the petrous bone. IMPRESSION: 1. Nondisplaced left parietal fracture extending into the left squamous temporal bone. However, no evidence for fracture involving petrous temporal bones on either side. No evidence for fracture small quantity of new fluid within mastoid air cells bilaterally. 2. Unchanged findings associated with extensive intracranial hemorrhages. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with head trauma and brain bleeds// interval changes. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 934.6 mGy-cm. Total DLP (Head) = 935 mGy-cm. COMPARISON: CT head ___. FINDINGS: Again, patient is status post right hemicraniectomy. Interval removal of surgical drain is noted. There is increased expansion of the right cerebral hemisphere into the craniotomy site with increased hypodense subdural fluid collection measuring up to 6 mm in thickness. There is re-demonstration of soft tissue thickening superficial to the craniectomy site, similar to prior. Interval evolution of the left frontoparietal and temporal intraparenchymal hemorrhage with surrounding edema, similar in extent compared to prior, with increased effacement of the left occipital horn which demonstrates evolving layering posterior intraventricular hemorrhage. There is also continued evolution of the subarachnoid blood in the left cerebral hemisphere. Left temporal epidural hematoma measures 6 mm in thickness, previously measuring 9 mm in thickness. Right temporal extra-axial hemorrhage measuring 8 mm in thickness is similar to prior. Left parafalcine subdural hematoma measures 4 mm in thickness, similar to prior. Right parafalcine subdural hematoma measures 4 mm in greatest thickness also similar to prior. There is rightward midline shift measuring 5 mm, similar to prior. The size the increased effacement of the left occipital horn, the size and configuration of the ventricles and sulci are similar to prior. Again, the basilar cisterns are grossly patent. Re-demonstration 3 mm right parafalcine hygroma noted. Small left parietal subgaleal hematoma has decreased in size compared to prior with overlying skin staples. Partial opacification of bilateral mastoid air cells have increased compared to prior. There is new fluid within bilateral middle ear cavities. There is increased opacification of the ethmoid sinuses and complete opacification of the sphenoid sinus with hyperdense material, likely blood. Increased opacification of bilateral maxillary sinuses with air-fluid levels are again demonstrated. Visualized bilateral orbits appear unremarkable. IMPRESSION: 1. Status post right hemi craniectomy with interval removal of surgical drain with slightly increased expansion of the right cerebral hemisphere into the craniotomy site and increased hemispheric hypodense subdural fluid collection measuring up to 6 mm in thickness. 2. Interval evolution of left frontoparietal temporal intraparenchymal hemorrhage, left frontal subarachnoid hemorrhage, left temporal epidural hemorrhage, and right extra-axial hemorrhage. Re-demonstration of left and right parafalcine subdural hematoma with right parafalcine subdural hygroma. Right word 5 mm midline shift similar to prior. Increased effacement of the left occipital horn. 3. Interval decrease in size of small left parietal scalp hematoma. 4. Increased opacification of the ethmoid sinuses, and bilateral maxillary sinuses with complete opacification of the sphenoid sinus. Increased partial opacification of bilateral mastoid air cells with new fluid in the bilateral middle ear cavities. These findings do not necessarily imply an infectious process in the setting of endotracheal intubation, however. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with suspected PNA// please eval for interval changes please eval for interval changes IMPRESSION: Comparison to ___. The lung volumes have slightly decreased. As a consequence, areas of basilar atelectasis are visualized. No pleural effusions. No new focal parenchymal changes suggestive of pneumonia. No pulmonary edema. The feeding tube and the endotracheal tube are in stable correct position. Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old man with new picc// R picc 47cm Contact name: sal, ___: ___ R picc 47cm IMPRESSION: Comparison to ___. The patient has received a right-sided PICC line. The course of the line is unremarkable, the tip projects over the lower aspect of the right atrium, to be at the cavoatrial junction, the line needs to be pulled back by approximately 9-10 cm. No complications, notably no pneumothorax. Otherwise unchanged radiograph. Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old man with picc repo// picc repo Contact name: sal, ___: ___ IMPRESSION: In comparison with the earlier study of this date, the right subclavian PICC line is been pulled back so that the tip is in the mid to lower SVC. Otherwise, little change. Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old man with picc line placement// ? picc line placement Contact name: ___, Phone: 3 ? picc line placement IMPRESSION: Compared to chest radiographs ___ through ___. New tracheostomy tube is midline. No appreciable mediastinal widening. No pneumothorax. Mild cardiomegaly stable. Lungs clear. No pleural effusion. Right PIC line has been partially withdrawn and now ends in the upper SVC, Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD. INDICATION: ___ year old man with TBI s/p hemicraniectomy, assess for interval change, not following commands. 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 = 747.6 mGy-cm. Total DLP (Head) = 748 mGy-cm. COMPARISON: Noncontrast head CTs between ___ and ___. FINDINGS: A left frontal intraparenchymal hematoma has decreased in size since 5 day prior, now measuring approximately 4.5 x 3.3 cm, previously 6.5 x 3.5 cm. Vasogenic edema is unchanged to minimally decreased. Midline shift is minimally decreased, now measuring 3 mm toward the right. Previously seen subarachnoid hemorrhage is less conspicuous. Right and left parafalcine subdural hematomas are minimally decreased. Patient is status-post right hemi craniectomy and subdural hematoma evacuation. A large right subdural hygroma measuring approximately 1.5 cm from the dura is unchanged. Right temporal lobe edema/encephalomalacia is unchanged. A small amount of adjacent extra-axial blood products are less conspicuous. No evidence of new intracranial hemorrhage or acute, large territorial infarction. The ventricles are not enlarged. Interval decrease in paranasal sinus opacification. There is partial opacification of the left sphenoid sinus and a posterior left ethmoid air cell, though the sphenoid ostium is patent. mastoid air cells and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. Continued evolution of a large left frontal intraparenchymal hemorrhage and bilateral extra-axial hemorrhages as detailed in the findings. No evidence of a new intracranial hemorrhage. 2. Status-post right hemi craniectomy with a persistent subdural hygroma. 3. Improved, partially imaged paranasal sinus disease. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with fever and leukocytosis// eval for pneumonia eval for pneumonia IMPRESSION: Compared to chest radiographs ___ through ___. Pulmonary vasculature is more engorged and mediastinal veins are more distended and moderate cardiomegaly has worsened, indicating interval progression of cardiac decompensation.. Basal lung consolidation has worsened, either atelectasis or pneumonia. No pneumothorax. Right PIC line ends at the origin of the SVC. Tracheostomy tube midline. Radiology Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ year old man with TBI s/p hemicraniectomy with tachycardia and low grade fevers, r/o DVT// r/o DVT. TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, flow, and augmentation of the bilateral common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: No evidence of deep venous thrombosis in the right or left lower extremity veins. Radiology Report EXAMINATION: CT HEAD W/ CONTRAST Q1211 CT HEAD INDICATION: ___ year old man febrile to 103, s/p decompressive hemicraniectomy. Evaluate for empyema. TECHNIQUE: Contiguous axial images of the brain were obtained after the intravenous administration of 90 cc Omnipaque 350 contrast agent. Thin bone-algorithm reconstructed images and coronal and sagittal reformatted images were then produced. DOSE: Acquisition sequence: 1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 934.6 mGy-cm. Total DLP (Head) = 935 mGy-cm. COMPARISON: Noncontrast head CT from ___ and multiple earlier CTs dating back to ___. FINDINGS: Patient is status post right hemi-craniectomy. There is a stable hypodense extra-axial fluid collection at the craniectomy site without rim enhancement. Resolved left parietal parenchymal hematoma and surrounding edema are stable compared to ___. Previously seen subarachnoid hemorrhage is not well assessed on this exam due to intravascular contrast. Hypodensity in the right temporal lobe is unchanged compared to ___, with decreased mass effect compared to ___. No change in minimal parenchymal herniation through right hemicraniectomy defect. The ventricles appear stable in size and configuration compared to ___, though slightly larger compared to ___, in part due to decreased compression of the left atrium by the left parietal hematoma. Basal cisterns are preserved. Dural venous sinuses are patent. There is expected opacification of the major intracranial arteries, which are not assessed in angiographic detail. Carotid and vertebral artery calcifications are again seen. Nondisplaced left squamous temporal bone fracture is again seen. Again seen is fluid in the left sphenoid sinus. There is fluid and mucosal thickening and mucosal retention cyst in the left maxillary sinus, not included in the field of view on ___, and with decreased overall opacification compared to ___. There is trace fluid in the bilateral mastoid air cells. IMPRESSION: 1. No rim enhancement of the extra-axial fluid collection at the right craniectomy site to suggest empyema. However, superimposed infection cannot be definitively excluded on the basis of imaging. 2. Resolving left parietal parenchyma hematoma is stable compared to ___. Known subarachnoid hemorrhage is not adequately reassessed due to the presence of intravascular contrast. 3. The ventricles are stable in size and configuration compared to ___, though slightly increased in size compared to ___. 4. Nondisplaced left squamous temporal bone fracture is again seen. Radiology Report EXAMINATION: CT CHEST W/O CONTRAST INDICATION: ___ year old man with consistent fevers. Chest xray with congestion and atelectasis vs pna// eval for infectious process/ effusion/empyema TECHNIQUE: Multidetector helical scanning of the chest was reconstructed as contiguous 5- and 1.25-mm thick axial, 2.5-mm thick coronal and parasagittal, and 8 x 8 mm MIPs axial images. DOSE: Acquisition sequence: 1) Spiral Acquisition 2.2 s, 34.7 cm; CTDIvol = 20.3 mGy (Body) DLP = 702.2 mGy-cm. Total DLP (Body) = 702 mGy-cm. COMPARISON: Previous CT chest from ___. FINDINGS: NECK, THORACIC INLET, AXILLAE, CHEST WALL: There is a tracheostomy tube present. The visualized portion of the thyroid is unremarkable. There is no axillary adenopathy. MEDIASTINUM: There is no mediastinal fluid, gas or lymphadenopathy. Right upper extremity PICC line tip terminates in the mid SVC. HILA: Unremarkable within the limits of unenhanced CT. HEART and PERICARDIUM: Trace pericardial fluid. PLEURA: No pleural effusion or pneumothorax. LUNG: PARENCHYMA: There is segmental atelectasis in both lower lobes. This has slightly improved overall from ___. There is a linear opacity in the lateral basal right lower lobe associated with mild surrounding ground-glass opacity. This is likely related to atelectasis although superimposed inflammation or early infection is not excluded. Otherwise there is no evidence of airspace consolidation to suggest pneumonia. AIRWAYS: There is multifocal segmental/subsegmental bronchial plugging associated with atelectasis in the lower lobes. VESSELS: The pulmonary trunk is mildly dilated at 3.2 cm. This can be associated with pulmonary hypertension. MUSCULOSKELETAL: Bilateral posterior rib fractures are again demonstrated. Notably these include segmental fractures of the left ___ to ___ and right ___ to 6th ribs. UPPER ABDOMEN: There is a G-tube in the stomach. Limited images of the upper abdomen are otherwise unremarkable. IMPRESSION: 1. Mild improvement in the atelectasis of the bilateral lower lobes with component of aspiration changes not excluded. Superimposed infection is difficult to exclude radiographically and clinical correlation is recommended. 2. Multiple bilateral segmental rib fractures are again noted. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with PICC, partially withdrawn// check PICC placement TECHNIQUE: Portable supine frontal chest radiograph. COMPARISON: ___ chest CT. FINDINGS: Distal tip of the right PICC now terminates in the confluence of the right subclavian and right brachiocephalic vein. The endotracheal tube tip terminates in the mid trachea. The lung volumes are low bilaterally. There is no focal consolidation, large pleural effusion or pneumothorax. Prominence of the cardiomediastinal silhouette is likely secondary to low lung volumes. No acute osseous abnormality IMPRESSION: 1. Distal tip of the right PICC now terminates in the confluence of the right subclavian and right brachiocephalic vein. 2. No pneumothorax. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 10:11 am, 1 minutes after discovery of the findings. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with TBI, s/p unwitnessed fall// Evaluate for hemorrhage TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 934.6 mGy-cm. 2) Sequenced Acquisition 2.0 s, 8.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 373.8 mGy-cm. Total DLP (Head) = 1,308 mGy-cm. COMPARISON: ___ FINDINGS: Status post right hemicraniectomy. Evolution of blood products at the right hemi craniectomy site with a minimal interval increase in fluid volume. Minimal herniation through the craniotomy site appears stable. No acute intracranial hemorrhage is demonstrated. A intraparenchymal hematoma within the left parietal lobe is decreased in prominence from prior without high-density products identified. There is residual edema at the bleed site. 3 mm of rightward midline shift is unchanged. The ventricles are stable in size and configuration compared to ___. The basal cisterns are preserved. The previously characterized left squamous temporal bone fracture is nondisplaced and appears grossly unchanged from the prior study. No significant thickening or abnormal findings within the paranasal sinuses. The bilateral mastoid air cells demonstrate partial opacification on the right which is unchanged from prior, otherwise unremarkable. The orbits are unremarkable. IMPRESSION: 1. Status post right hemi craniectomy with evolution of a right subdural hygroma. No acute intracranial hemorrhage. 2. Resolving left parietal parenchymal hematoma without acute component, minimally decreased associated edema. 3. Stable size and configuration of the ventricles compared to ___. 4. Nondisplaced left squamous temporal bone fracture which is unchanged. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with severe TBI s/p right decompressive craniectomy// Pre-op assessment for OR on ___ Surg: ___ (Right cranioplasty) TECHNIQUE: Chest AP view COMPARISON: ___ IMPRESSION: Lungs are low volume. No new consolidations. Old healed posterior third rib fracture on the right. There are no pleural effusions. No pneumothorax is seen. Tracheostomy tube in place. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with severe TBI s/p decompressive craniotomy and cranioplasty// S/p bone cranioplasty, eval for bleeding and hydrocephalus TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 934.6 mGy-cm. Total DLP (Head) = 935 mGy-cm. COMPARISON: Head CT ___ FINDINGS: Since prior, right frontoparietal cranioplasty has been performed. Surgical drain. Previously seen right hemispheric extra-axial fluid collection at the cranioplasty level is no longer present. Trace extra-axial fluid overlies posterior right occipital lobe, stable. Areas of encephalomalacia, volume loss right temporal lobe, stable. Left MCA distribution subacute infarct stable. No acute hemorrhage. Suggestion of trace low-density fluid collection overlying left temporal lobe. No hydrocephalus.. Mild opacification right mastoids, similar. Clear paranasal sinuses. IMPRESSION: 1. Interval right cranioplasty, no acute hemorrhage. 2. Left MCA distribution subacute infarct, stable. 3. Suggestion of trace extra-axial fluid collection overlying left temporal lobe. 4. Right temporal lobe encephalomalacia, volume loss. 5. Remainder as above. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with severe TBI (day ___), s/p decompressive hemicrani (___), now ___ s/p cranioplasty. Now with increased periorbital edema.// please eval for fluid accumulation TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 934.6 mGy-cm. Total DLP (Head) = 935 mGy-cm. COMPARISON: CT head ___ FINDINGS: Status post right hemicraniectomy. There is a right hemispheric extra-axial collection representing a postoperative hygroma versus subacute/chronic blood at the cranioplasty level measuring up to 0.9 cm in maximal thickness, new from CT head ___. Trace extra-axial fluid overlies the posterior right occipital lobe, decreased in size from prior. There is up to 0.3 cm of leftward midline shift, previously up to 0.3 cm of rightward midline shift. The basal cisterns are patent. The ventricles are stable in size. Right temporal lobe encephalomalacia with ex vacuo dilation of the left lateral ventricle temporal horn is unchanged. The left MCA distribution subacute infarct/evolving intraparenchymal hemorrhage is grossly stable in size without evidence of mass effect or hemorrhagic transformation. There is a nondisplaced left zygomatic arch fracture is again noted, unchanged. There is unchanged mild opacification of the right mastoid. Visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavitiesare otherwise clear. The visualized portion of the orbits are preserved. IMPRESSION: 1. Interval development of right hemispheric extra-axial collection at the cranioplasty level measuring up to 0.9 cm in maximal thickness. Differential considerations include postoperative hygroma versus subacute/chronic subdural blood products. 2. Grossly stable ventricle size as described. 3. Additional grossly stable findings as described. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with severe TBI// Assess interval changes. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 934.7 mGy-cm. 2) Sequenced Acquisition 2.0 s, 8.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 373.9 mGy-cm. Total DLP (Head) = 1,309 mGy-cm. COMPARISON: CT head ___. FINDINGS: There are stable expected postoperative findings from large right craniotomy. There is trace right subgaleal fluid just inferior and superficial to the craniotomy, unchanged (02:12). The 8 mm wide hypoattenuating right subdural collection is unchanged. The hypodensity likely corresponding to subacute infarction in the left frontoparietal region is unchanged. Hypodensity in the right temporal pole is unchanged, and may reflect evolving contusion/sequelae of recent trauma. There is stable lateral and third ventriculomegaly the fourth ventricle is also mildly prominent, unchanged. No obstructing mass. Minimal leftward midline shift is unchanged. There is no evidence of new hemorrhage, infarction, edema, or mass effect. Right mastoid effusion is unchanged. Left mastoid is clear. The visualized paranasal sinuses are clear. Globes are intact. IMPRESSION: 1. Stable examination. No new acute infarction or new hemorrhage. 2. Unchanged 8 mm hypoattenuating right subdural collection. 3. Unchanged evolving left frontoparietal subacute infarction. 4. Unchanged ventriculomegaly. 5. Expected postoperative findings from large right craniotomy, unchanged. 6. Right mastoid effusion, unchanged. Radiology Report EXAMINATION: RF - GI TUBE CHECK INDICATION: ___ year old man with severe TBI, PEG placement ___, pulled out// With water soluble contrast- confirm placement of foley tip in stomach (in tract of previous PEG) TECHNIQUE: Two portable supine radiographs of the abdomen before and after administration of contrast through Foley tube. COMPARISON: CT chest, abdomen and pelvis ___. FINDINGS: There is a Foley tube projecting over the body of the stomach. Water-soluble contrast was administered through the tube and appears within the body of the stomach and proximal duodenum. There is no evidence of contrast leak, although evaluation is limited by the small volume of contrast administered. IMPRESSION: The Foley tube is located within the body of the stomach. No definite evidence of contrast leak. Radiology Report EXAMINATION: G tube placement check (optiray ordered) INDICATION: ___ year old man with severe TBI, s/p PEG replacement// G tube placement check (optiray ordered) TECHNIQUE: Portable radiographs of the abdomen. COMPARISON: None FINDINGS: Water-soluble contrast (Optiray) was administered through the gastrostomy tube. Injected contrast opacifies the stomach, indicating appropriate placement of the gastrostomy tube. There is no evidence of extraluminal contrast. Note is made of spina bifida occulta (a normal variant) involving S1. IMPRESSION: Gastrostomy tube appropriately positioned within the body of stomach. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with TBI// evolutionary changes of TBI TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 934.8 mGy-cm. Total DLP (Head) = 935 mGy-cm. COMPARISON: CT head without contrast from ___, ___ FINDINGS: Patient is status post right frontotemporal craniotomy. Again seen are hypodensities in the right temporal lobe and left frontoparietal region compatible with evolving infarcts. There is persistent enlargement the lateral ventricles, third ventricle, and fourth ventricle, which appears increased in size since ___ although similar to ___. There is no obvious midline shift. No evidence of intracranial hemorrhage or new major acute infarct. There is again partial opacification of the right mastoid air cells. Otherwise, the visualized portion of the paranasal sinuses, left mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. Postsurgical changes seen following right frontotemporal craniotomy. There are evolving infarcts in the right temporal lobe and left frontoparietal regions. No evidence of hemorrhagic transformation or new major acute infarct. 2. Persistent enlargement of the lateral ventricles, third ventricle, and fourth ventricle, which appears increased in size since ___ although similar to ___. Gender: M Race: UNKNOWN Arrive by UNKNOWN Chief complaint: s/p Fall, Transfer Diagnosed with Multiple fractures of ribs, unsp side, init for clos fx, Prsn outsd pk-up/van inj in clsn w nonmtr veh in traf, init temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: UA level of acuity: 1.0

Surgery: • You underwent a surgery called a craniectomy. A portion of your skull was removed to allow your brain to swell. You then underwent a cranioplasty and the skull was replaced. • You had a thin catheter in your brain that helped the neurosurgeon monitor the pressure and oxygen level in your brain. This was removed on ___. • It is best to keep your incision open to air but it is ok to cover it when outside. • Call your surgeon if there are any signs of infection like redness, fever, or drainage. 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. • You make shower. • 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 symptoms after traumatic brain injury. Headaches can be long-lasting. • 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. More Information about Brain Injuries: • You were given information about headaches after TBI and the impact that TBI can have on your family. • If you would like to read more about other topics such as: sleeping, driving, cognitive problems, emotional problems, fatigue, seizures, return to school, depression, balance, or/and sexuality after TBI, please ask our staff for this information or visit ___ 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: SURGERY Allergies: Tylenol Attending: ___. Chief Complaint: bile duct stricture Major Surgical or Invasive Procedure: ERCP and biliary stent placement ___ Cholecystectomy, choledochojejunostomy and intraoperative ultrasound of the pancreas ___ History of Present Illness: ___ with history of cholelithiasis & cholangitis ___ s/p ERCP with stent placement and subsequent stent change x2 with CBD stricture thought to be inflammatory in nature. She had a CT abdomen ___ which demonstrated a hypoenhancing area in the head of the pancreas which was consistent with pancreatitis/necrosis but could not rule out pancreatic head mass. The plan was for her to f/u with West2a in clinic with a repeat CT abdomen prior to operative intervention (likely cholecystectomy with biliary bypass). She did not keep many outpatient appointments and refused an outpatient CT scan because she had "personal issues" going on involving her apartment and her kids. She presented to her PCP today complaining of increasing right sided abdominal pain x 1 week. She reports long term poor appetite and nausea which has not changed recently. She reports that her eyes turned yellow 2 days ago and this is what prompted her to go to her PCP. Also endorses darkened urine and lighter color stools. No fevers, no emesis. Past Medical History: Past Medical History: -asthma -h/o seizures Past Surgical History: -C-section x ___ -s/p tonsillectomy Social History: ___ Family History: Mother with HTN, asthma, and arthritis. Physical Exam: At time of discharge: 99.9, 82, 90/52, 18. 96% on room air no acute distress, ambulating independently clear to auscultation bilaterally regular rate and rhythm abdomen soft, minimally distended, appropriately tender periincisionally incision with healing ridge, no erythema, no drainage, staples in place, clean no peripheral edema Pertinent Results: ___ 06:15PM BLOOD ALT-234* AST-228* AlkPhos-1863* TotBili-8.4* ___ 07:15AM BLOOD ALT-143* AST-67* AlkPhos-1361* Amylase-39 TotBili-2.9* ___ 07:00AM BLOOD ALT-115* AST-39 AlkPhos-1195* TotBili-2.9* ___ 07:35AM BLOOD ALT-71* AST-32 AlkPhos-881* TotBili-2.1* ___ 04:55AM BLOOD ALT-127* AST-139* AlkPhos-692* TotBili-2.1* ___ 09:14AM BLOOD ALT-93* AST-49* AlkPhos-514* TotBili-1.7* ___ 06:15PM BLOOD Lipase-11 ___ 07:00AM BLOOD Lipase-13 Time Taken Not Noted Log-In Date/Time: ___ 3:14 pm SWAB BILE. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). WOUND CULTURE (Final ___: This culture contains mixed bacterial types (>=3) so an abbreviated workup is performed. Any growth of P.aeruginosa, S.aureus and beta hemolytic streptococci will be reported. IF THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT PRESENT in this culture.. ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. ERCP ___: The ampulla was s/p previous sphincterotomy. The old stent was partially migrated distally. It was removed with a snare and sent for cytology. Cannulation of the biliary duct was successful and deep with a balloon catheter using a free-hand technique. Contrast medium was injected resulting in complete opacification. A straight tip .035in guidewire was placed. A single stricture that was 1 cm long was seen at the distal CBD. The proximal CBD was severely dilated to 2.5 cm. The left intrahepatic ducts were mildly dilated. Cytology samples were obtained for histology using a brush in the stricture. A 7cm by ___ Cotton ___ biliary stent was placed successfully. The bile flow was good. Otherwise normal ercp to third part of the duodenum. Medications on Admission: albuterol prn Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *Augmentin 500 mg-125 mg twice a day Disp #*9 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID RX *Colace 100 mg twice a day Disp #*30 Capsule Refills:*1 3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg q4-6 hours Disp #*30 Tablet Refills:*0 4. Polyethylene Glycol 17 g PO DAILY:PRN constipation RX *Miralax 17 gram daily Disp #*30 Packet Refills:*1 5. Senna 1 TAB PO BID RX *senna 8.6 mg twice a day Disp #*30 Tablet Refills:*1 6. ketorolac *NF* 10 mg Oral q6 Duration: 3 Days RX *ketorolac 10 mg q6 Disp #*12 Tablet Refills:*0 7. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing Discharge Disposition: Home Discharge Diagnosis: Bile duct stricture in the setting of chronic pancreatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report CLINICAL HISTORY: ___ man with history of cholangitis and pancreatitis and multiple ERCP stents, now with likely stent obstruction. COMPARISON: ___ study. TECHNIQUE: CTA of the abdomen was performed in multiple phases. IV contrast was administered. FINDINGS: The lung bases show dependent atelectasis; however, no nodules or effusions are identified. Pericardium is unremarkable. Within the abdomen, there is arterial enhancement of a portion of segment V of the liver (3A:25) which is not seen on subsequent scans and likely a perfusional abnormality. No focal liver lesions are noted. There is extensive intra- and extra-hepatic ductal dilatation extending from the common bile duct to intrahepatic ducts in both the left and right lobe (3A:23 through 3A:50). The cystic duct is also low inserting (3A:49) and is dilated. CBD stent is seen at the distal aspect of the CBD, 3A:49, but does appear to be in a backward configuration as compared to normal. Within the pancreas, there is mild pancreatic ductal prominence, however, decreased from the prior study. There is also again noted hypoattenuating area in the head of the pancreas (3B:153). This is completely unchanged from the prior study and perhaps which is due to the transversing common bile duct stent. At the tail of the pancreas, a stable 2.6 x 2.5 cm cystic lesion is noted indenting the stomach. The appearance is most likely a pancreatic tail pseudocyst. Bilateral kidneys enhance and excrete contrast symmetrically with no evidence of hydronephrosis or masses. Spleen, aorta, and small and large bowel are unremarkable. There are at least two enlarged portacaval lymph nodes (2:37 1.1 x 1.9 cm and 2:30, 1.2 x 1.4 cm) unchanged in size. BONES: No suspicious bony lesions are noted. IMPRESSION: 1. Intra- or extra-hepatic ductal dilatation with the common bile duct measuring up to 3 cm. CBD stent appears to have migrated in a reverse configuration. 2. Perfusional defects noted in segment V of the liver, but no focal lesions. 3. Stable hypodensity in the pancreatic head and stable pancreatic tail pseudocyst. Stable portacaval lymph nodes. Radiology Report HISTORY: ___ female with cholangitis, pancreatitis, and biliary obstruction, for preoperative evaluation. COMPARISON: ___. FINDINGS: AP and lateral chest radiographs demonstrate clear lungs without effusion, or pneumothorax. The cardiac silhouette and mediastinal contours are normal. The pulmonary vasculature is normal. A Silastic CBD stent is unchanged in position in the right upper quadrant. A left IJ central venous catheter has been removed in the interim. IMPRESSION: No acute chest abnormality. Radiology Report INTRAOPERATIVE ULTRASOUND OF THE PANCREAS INDICATION: ___ female with known chronic pancreatitis and intermittent cholangitis and jaundice due to biliary obstruction. OR plan for cholecystectomy and bile duct exploration and bypass. Transgastric and retrogastric imaging of the pancreas was performed, demonstrating extensive parenchymal calcifications throughout the somewhat atrophic pancreas as well as multiple intraductal stones. The pancreatic duct is dilated from the head to the tail with a maximum diameter of 5-6 mm. There appears to be a structured narrowing of the pancreatic duct in the low head of the pancreas within 1-2 cm of the ampulla. Markedly dilated common bile duct is seen with an indwelling stent as well as sludge within the lumen of the duct. CONCLUSION: Findings indicate chronic pancreatitis with parenchymal atrophy and calcifications and pancreatic duct dilatation up to 6 mm., with a short stricture in the pancreatic head as described. Bile duct dilatation was also noted with sludge in the duct and an indwelling ERCP-placed stent. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: RLQ PAIN Diagnosed with ABDOMINAL PAIN RUQ, JAUNDICE NOS temperature: 99.9 heartrate: 110.0 resprate: 16.0 o2sat: 99.0 sbp: 118.0 dbp: 72.0 level of pain: 10 level of acuity: 3.0

You were admitted to the hospital for evaluation and treatment of your biliary stricture. You underwent ERCP with stent placement, as well as cholecystectomy and a biliary bypass. You tolerated these well and are ready to continue your recovery at home. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. You will complete a course of oral antibiotics as prescribed. You should continue stool softeners and a bowel regimen. Please take toradol for pain control and try to slowly decrease the amount of oxycodone that you are needing for pain control. 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.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Aspirin / Penicillins / Codeine / Inderal / Isordil Titradose / Iodine-Iodine Containing / Celexa / Glucophage / Atorvastatin / Dilaudid (PF) / Vioxx / Levofloxacin / Hydralazine And Derivatives / Ondansetron / Carbapenem / Lidocaine / Nortriptyline / Fosfomycin / Morphine / Trimethoprim / Latex / Aloe ___ ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ year-old female with history of CAD, DVT s/p IVC filter, HTN, HLD and who presented to the ED complaining of worsening frequency of presyncopal symptoms and chest pain. Describes pain as burning x7 days and unrelieved with Maalox. Associated with nausea but no vomiting. Has woken up with diaphoresis at night. No relieving symptoms. Presyncopal symptoms worse on sitting up. Has fainted at table before, but has not struck head or lost consciousness (of note, family denies that patient has lost consciousness). Patient is largely wheelchair dependent but can use walker with seat for up to 3 minutes, does not say she is dizzy while standing. In the ED, initial vital signs were T 97.6 P 68 BP 164/79 R 18 O2 sat 96%. EKG was performed for chest pain, but no change from prior EKGs noted. Patient was given 1g ceftriaxone for suspected UTI. Foley was inserted which put out 1L clear urine. Past Medical History: Coronary artery disease (___ ___ with 50% lesion in mid LAD, 50% lesion in OM1). Hypertension. Hyperlipidemia. Valvular heart disease ___ MR, 2+ TR). ?Symptomatic bradycardia. Presyncope/?Syncope. insulin-dependent diabetes GERD chronic kidney disease (Cr0.9-1.2) recurrent UTIs urinary retention osteoporosis status post CVA with residual left-sided weakness status post DVT status post IVC filter L1-L2 discectomy, L5-S1 fusion cervical stenosis and cervical spondylosis arthritis status post appendectomy status post laparoscopic cholecystectomy status post hysterectomy cataract surgery x2 Social History: ___ Family History: Parents both died of CAD in their ___. She had two brothers die of CAD in their ___. One sister with ___ disease and one with lung cancer. Physical Exam: ADMISSION EXAM Vitals- T99 BP 157/64 P 89 R 18 SpO2 97 BS 214 General- Alert, oriented, anxious 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. Pain produced on palpation, but not the same as reported. Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding. GU- No CVA tenderness. foley to gravity. Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal DISCHARGE EXAM Physical Exam: Vitals- T97.8 BP 140/70 P 74 R 18 SpO2 97 Urine output 800cc General- Alert, oriented, in no acute distress, mildly anxious HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- Clear to auscultation bilaterally, no wheezes, rales, ronchi CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops. Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding. GU- No CVA tenderness. foley to gravity. Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal Pertinent Results: CXR (___): The lungs are clear. No confluent opacity is identified. There is no pulmonary edema or pleural effusions. Cardiomediastinal and hilar contours are within normal limits. Aortic knob calcifications are again noted. Surgical clips are redemonstrated in the right upper quadrant. IVC filter projects over the thoracolumbar spine. STRESS ECHO (___): 3D echocardiographic evidence of prior distal LAD-territory myocardial infarction without inducible ischemia to achieved workload. Mild to moderate mitral regurgitation at rest. EKG: (___): Sinus rhythm. Left anterior fascicular block. Atrio-ventricular conduction delay. Probable prior inferior myocardial infarction. Possible prior anteroseptal myocardial infarction. Left ventricular hypertrophy. Low voltage in the limb leads. Compared to the previous tracing of ___ the findings are similar. CTA (___): Wet Read: ___ ___ 10:18 AM No acute process of the chest including no evidence of acute aortic syndrome or pulmonary embolism. ___ 07:10AM BLOOD WBC-6.2 RBC-3.70* Hgb-11.2* Hct-34.9* MCV-94 MCH-30.2 MCHC-32.0 RDW-13.2 Plt ___ ___ 07:10AM BLOOD Glucose-277* UreaN-22* Creat-1.2* Na-134 K-5.2* Cl-102 HCO3-23 AnGap-14 ___ 02:00AM BLOOD Glucose-232* UreaN-25* Creat-1.5* Na-139 K-4.7 Cl-104 HCO3-25 AnGap-15 ___ 02:00AM BLOOD cTropnT-<0.01 ___ 07:10AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.2 ___ 07:30AM BLOOD WBC-7.6 RBC-3.71* Hgb-11.5* Hct-34.9* MCV-94 MCH-30.9 MCHC-32.9 RDW-13.4 Plt ___ ___ 07:30AM BLOOD Plt ___ ___ 07:30AM BLOOD Glucose-133* UreaN-22* Creat-1.1 Na-140 K-4.4 Cl-105 HCO3-26 AnGap-13 ___ 07:30AM BLOOD Calcium-8.4 Phos-4.3 Mg-2.1 Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Pharmacy. 1. Ticlopidine HCl 250 mg PO BID 2. Gabapentin 300 mg PO DAILY 3. Gabapentin 100 mg PO HS 4. Simvastatin 40 mg PO DAILY 5. Glargine 15 Units Breakfast Discharge Medications: 1. Gabapentin 100 mg PO HS 2. Gabapentin 300 mg PO DAILY 3. Glargine 15 Units Bedtime 4. Simvastatin 40 mg PO DAILY 5. Ticlopidine HCl 250 mg PO BID 6. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 Capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 7. Nitrofurantoin (Macrodantin) 50 mg PO Q6H RX *nitrofurantoin macrocrystal 50 mg 1 Capsule(s) by mouth every 6 hours Disp #*36 Capsule Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Chronic atypical chest pain Urinary retension Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report HISTORY: ___ female with chest pain. COMPARISON: Chest radiograph from ___. FRONTAL AND LATERAL CHEST RADIOGRAPH: The lungs are clear. No confluent opacity is identified. There is no pulmonary edema or pleural effusions. Cardiomediastinal and hilar contours are within normal limits. Aortic knob calcifications are again noted. Surgical clips are redemonstrated in the right upper quadrant. IVC filter projects over the thoracolumbar spine. IMPRESSION: No acute cardiopulmonary process. Radiology Report INDICATION: Patient with elevated creatinine. Assess for hydronephrosis. COMPARISONS: CTU of ___. FINDINGS: The right kidney measures 9.5 cm and the left kidney measures 9.7 cm. There is no evidence of hydronephrosis, nephrolithiasis, or renal masses bilaterally. Corticomedullary differentiation is well preserved. The bladder is collapsed around the Foley catheter. IMPRESSION: No evidence of hydronephrosis. Radiology Report INDICATION: ___ woman with iodine allergy running with chest and back pain. Rule out aortic dissection. TECHNIQUE: Contiguous MDCT images through the chest were obtained per CT angiography protocol with initial non-enhanced and subsequently enhanced imaging. Coronal and sagittal reformats were acquired. Reported iodine allergy, pretreated with steroids. No complications. COMPARISON: CTU from ___, the abdomen and pelvis from ___, chest radiograph from ___. FINDINGS: CTA OF THE CHEST: The thyroid gland is normal. There is no axillary, hilar or mediastinal lymphadenopathy. There is no pneumomediastinum or mediastinal hemorrhage. Normal heart size. No pericardial fluid. No pleural fluid. The airways are patent to subsegmental level. Unchanged right lower lobe basilar pulmonary nodule (2;36). Minimal bibasilar atelectasis. Subsegmental atelectasis versus scar in the lower anterior right upper lobe. There are moderate-to-severe atherosclerotic calcifications of the aortic arch, mild atherosclerotic calcifications of the descending and ascending thoracic aorta. There are moderate atherosclerotic calcifications of the coronary arteries and mild atherosclerotic calcifications of the mitral valve and aortic valve. There is no acute aortic syndrome including no evidence of aortic aneurysm or aortic dissection. The origins of the supraaortic vessels are normal.There is no pulmonary embolism. The main pulmoary artery is of normal caliber. Partially visualized upper abdomen shows that the patient is status post cholecystectomy. There is a small hiatal hernia and a large duodenal diverticulum. BONES: There are no suspicious lytic or sclerotic bony lesions. IMPRESSION: No acute process of the chest including no evidence of acute aortic syndrome or pulmonary embolism. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: NAUSEA ABD PAIN Diagnosed with SYNCOPE AND COLLAPSE, CHEST PAIN NOS, URIN TRACT INFECTION NOS, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERCHOLESTEROLEMIA temperature: 97.6 heartrate: 68.0 resprate: 18.0 o2sat: 96.0 sbp: 164.0 dbp: 79.0 level of pain: 8 level of acuity: 2.0

Dear Ms. ___, Thank you for choosing us for your care. You were admitted for chest pain in conjunction with feelings of lightheadedness. There are many reasons for chest pain. You previously had a filter placed in one of your body's large veins to prevent pulmonary embolism. This time, we have done testing to rule out dangerous conditions such as heart attack and aortic dissection. When you arrived in the ER, one of your blood tests showed that your kidneys were not working optimally. We placed a catheter in your bladder to help measure your urine output. When placed, it drained a large amount of urine, suggesting that your bladder is not emptying properly. We ruled out a physical obstruction by kidney stone using ultrasound. Since we've been draining your urine with a foley, your kidney function has returned to normal. Please see your urologist to follow up this issue of urinary retention on an outpatient basis. When we looked at your urine, we found that it contained bacteria. This can happen if urine is retained for a long time. However, without a fever and without a rise in your immune response, this was more likely to be a benign bacterial colonization of your bladder than an invasive infection. We have started the following medication: Omeprazole 20mg by mouth daily - for treatment of your heartburn

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: nausea, vomiting, anorexia, weight loss, jaundice Major Surgical or Invasive Procedure: (___): Percutaneous liver biopsy History of Present Illness: ___ previously healthy who presented with a 2 week history of nausea, anorexia, 10lb weight loss, tea-colored urine, and pruritus. Patient's family told him that he was jaundiced. Today, the patient denied abdominal pain or discomfort but did note that recently he has been gassy and taking pepto-bismuth for his symptoms. He has had an almost constant, dull, and diffuse discomfort of his abdomen. He reported no fever, chills, UTI symptoms or abnormal stool. He has no recent travel or food poisoning. He denies taking any medications or acetaminophen. He has been consuming dry beef that his mother brought from ___, but many other family members have been eating the same food and are asymptomatic. In the ED, initial vitals: ED physical exam: -- 134/78 79 17 100%RA Physical exam: alert, not in distress HEENT: scleral icterus, PERLA, EOM intact Lung: cta ___: rrr, normal s1,s2 Abdomen: soft, lax, non tender, no ascites or fluid thrill, normal bowel sounds Skin: slightly jaundice LL: no ankle edema or calf pain Labs were significant for ___ 13.3, INR 1.2, ALT 1868, AST 939, TBili 7.9, Dbili 5.5, lipase 102, cholesterol 225 Imaging showed hepatic steatosis Patient was given 2L NS bolus. Patient was seen by Hepatology/ Decision made to admit for further workup. Vitals prior to transfer: ___ 115/68 79 18 99%RA On arrival to the floor, the patient stated he was hungry with some mild epigastric discomfort he believed was related to hunger. ROS: No fevers, chills, night sweats, or weight changes. No changes in vision or hearing, no changes in balance. No cough, no shortness of breath, no dyspnea on exertion. No chest pain or palpitations. No nausea or vomiting. No diarrhea or constipation. No dysuria or hematuria. No hematochezia, no melena. No numbness or weakness, no focal deficits. Past Medical History: Hepatic steatosis (noted on U/S ___ Retinal detachment Hemorrhoids Social History: ___ Family History: Father with type ___ diabetes, HTN Coronary artery disease No known history of liver disorders, blood disorders, or cancer Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: 97.8 146/79 61 18 96%RA GEN: Alert, lying in bed, no acute distress, comfortable appearing HEENT: dry MM, icteric sclerae, no conjunctival pallor, palatal jaundice NECK: Supple without LAD PULM: Generally CTA b/l without wheeze or rhonchi COR: RRR (+)S1/S2 no m/r/g ABD: +BS, soft, non-tender, non-distended, no hepatomegaly appreciated EXTREM: Warm, well-perfused, no edema NEURO: AAOx3, CN ___ grossly intact, motor function grossly normal DISCHARGE PHYSICAL EXAM: ======================== Vitals: 97.7 108/67 60 20 94%RA GEN: Alert, walking around room, no acute distress, comfortable appearing HEENT: dry MM, icteric sclerae, no conjunctival pallor, palatal jaundice NECK: Supple without LAD PULM: Generally CTA b/l without wheeze or rhonchi COR: RRR (+)S1/S2 no m/r/g ABD: +BS, soft, non-tender, non-distended, hepatomegaly appreciated, no masses palpated EXTREM: Warm, well-perfused, no edema NEURO: AAOx3, CN ___ grossly intact, motor function grossly normal Pertinent Results: ADMISSION LABS: ================ ___ 08:58AM BLOOD WBC-3.1* RBC-4.94 Hgb-15.2 Hct-47.0 MCV-95 MCH-30.8 MCHC-32.3 RDW-14.0 RDWSD-49.5* Plt ___ ___ 02:00PM BLOOD Neuts-39.5 ___ Monos-10.6 Eos-3.3 Baso-1.3* Im ___ AbsNeut-1.19* AbsLymp-1.36 AbsMono-0.32 AbsEos-0.10 AbsBaso-0.04 ___ 02:00PM BLOOD Glucose-86 UreaN-12 Creat-0.9 Na-137 K-4.0 Cl-98 HCO3-27 AnGap-16 ___ 02:22PM BLOOD Lactate-1.4 ___ 08:58AM BLOOD ALT-1848* AST-903* AlkPhos-129 TotBili-7.3* DirBili-5.2* IndBili-2.1 ___ 02:00PM BLOOD Lipase-102* ___ 08:58AM BLOOD Albumin-4.4 Cholest-225* ___ 08:58AM BLOOD Triglyc-243* HDL-18 CHOL/HD-12.5 LDLcalc-158* ___ 02:12PM BLOOD ___ PTT-36.3 ___ ___ 08:58AM BLOOD HBsAg-Negative HBsAb-Negative HBcAb-Negative HAV Ab-Positive IgM HAV-NEGATIVE DISCHARGE LABS: ================ ___ 06:35AM BLOOD WBC-2.8* RBC-4.47* Hgb-14.0 Hct-42.6 MCV-95 MCH-31.3 MCHC-32.9 RDW-14.6 RDWSD-52.0* Plt ___ ___ 06:35AM BLOOD Neuts-38.8 ___ Monos-11.0 Eos-5.3 Baso-1.4* Im ___ AbsNeut-1.09* AbsLymp-1.21 AbsMono-0.31 AbsEos-0.15 AbsBaso-0.04 ___ 06:35AM BLOOD ___ PTT-34.1 ___ ___ 06:35AM BLOOD Glucose-94 UreaN-12 Creat-1.0 Na-138 K-4.4 Cl-103 HCO3-26 AnGap-13 ___ 06:35AM BLOOD Albumin-3.7 Calcium-9.0 Phos-3.9 Mg-2.0 ___ 06:35AM BLOOD ALT-1654* AST-895* LD(LDH)-361* AlkPhos-103 TotBili-7.3* OTHER PERTINENT LABS: ====================== ___ 06:13AM BLOOD Lipase-110* ___ 06:13AM BLOOD Smooth-NEGATIVE ___ 06:13AM BLOOD ___ ___ 06:13AM BLOOD HIV Ab-Negative ___ 02:00PM BLOOD Acetmnp-NEG ___ 08:58AM BLOOD HCV Ab-Negative ___ 06:13AM BLOOD HCV VL-NOT DETECT ___ 06:13AM BLOOD CMV VL-NOT DETECT ___ 06:13AM BLOOD HBV VL-NOT DETECT ___ 06:13AM BLOOD HIV1 VL-NOT DETECT URINE STUDIES: =============== ___ 02:15PM URINE Color-Yellow Appear-Clear Sp ___ ___ 02:15PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-MOD Urobiln-2* pH-6.0 Leuks-NEG MICROBIOLOGY: ============== ___ 2:15 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: < 10,000 CFU/mL. ___ 2:15 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 2:00 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. IMAGING: ================ ___ LIVER/GB ULTRASOUND IMPRESSION: 1. Echogenic liver consistent with steatosis. Other forms of liver disease and more advanced liver disease including steatohepatitis or significant hepatic fibrosis/cirrhosis cannot be excluded on this study. 2. Adenomyomatosis of the gallbladder. 3. No cholelithiasis or cholecystitis. ___ PATHOLOGIC DIAGNOSIS: Liver, needle core biopsy: - Portal areas with moderate, predominantly mononuclear inflammation comprised of lymphocytes and macrophages along with focally prominent eosinophils. - Bile ducts with dystrophic change and intraductal lymphocytes. -Lobules with moderate lymphohistiocytic inflammation, including within sinusoids, and scattered eosinophils along with prominent apoptotic hepatocytes and focal canalicular cholestasis. -No features of toxic/metabolic injury (steatosis, ballooning degeneration) are seen prominently in this biopsy. -Trichrome stain demonstrates no increase in fibrosis. -Iron stain shows no stainable iron. -EBV in-situ and latent membrane protein immunostains are in progress and will be reported in a revised report. Note: Overall, the features of those of a moderately active hepatitis with associated cholestasis as well as bile duct damage. The differential diagnosis includes an acute viral hepatitis (negative serologies thus far with few pending results), a drug/supplement/toxin-related liver injury, or least likely given lack of prominent plasma cells and negative serologies, an autoimmune hepatitis. Clinical correlation with special consideration to the patient's medication (including herbals and OTC drugs) and ingestion history is recommended. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ with ___// eval for PVT, hepatic architecture TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: ___ abdominal ultrasound FINDINGS: LIVER: The liver is diffusely echogenic. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 3 mm. GALLBLADDER: There is no evidence of stones. Focal mural thickening of the gall bladder fundus is consistent with fundal adenomyomatosis. PANCREAS: The pancreas is incompletely visualized and assessed due to overlying bowel gas. SPLEEN: Normal echogenicity, measuring 9.8 cm. KIDNEYS: Limited views of the right kidney show no hydronephrosis. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. Echogenic liver consistent with steatosis. Other forms of liver disease and more advanced liver disease including steatohepatitis or significant hepatic fibrosis/cirrhosis cannot be excluded on this study. 2. Adenomyomatosis of the gallbladder. 3. No cholelithiasis or cholecystitis. Radiology Report EXAMINATION: Ultrasound-guided liver biopsy INDICATION: ___ year old previously healthy man with sudden onset nausea, anorexia, 10lb weight loss, jaundice, and pruritus. Labs notable to be stably elevated: ALT 1848, AST 903, Tbili 7.3, lipase 102. Hepatic steatosis was seen ___. Workup so far has been negative.// Etiology for acute hepatitis COMPARISON: Abdominal ultrasound from ___ PROCEDURE: Ultrasound-guided non-targeted liver biopsy. OPERATORS: Dr. ___, radiology trainee and Dr. ___, attending 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. The liver is diffusely echogenic. 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 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 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 15 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. IMPRESSION: Uncomplicated non-targeted liver biopsy. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Abnormal labs Diagnosed with Acute viral hepatitis, unspecified temperature: nan heartrate: 79.0 resprate: 17.0 o2sat: 100.0 sbp: 134.0 dbp: 78.0 level of pain: 0 level of acuity: 3.0

Dear Mr. ___, You were admitted to ___ (___) due to your nausea, jaundice, and pruritus. Your labs showed that you had an acute hepatitis. We did an extensive laboratory workup to understand the cause of your hepatitis. Additionally, we performed a biopsy for which we will call your doctor with the results. While inpatient, we continued to monitor your progress and saw that you had a low neutrophil count (immune cells that help to fight infections). You had no signs of infection while in the hospital, but please follow-up with your primary care doctor about this issue. Please follow up with your outpatient providers and all your scheduled appointments. Thank you for allowing us to be involved in your care. Sincerely, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Keflex / Penicillins / Dicloxacillin / Morphine / Compazine / Reglan / Amicar / Verapamil / Ambien / Valtrex / Percocet / Vibramycin / doxycycline / Demerol / adhesive / Creon / Geodon / Amitiza / Neurontin / dronabinol / lactulose Attending: ___ Chief Complaint: Vertigo, diplopia Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ old woman with a history of antiphospholipid antibody syndrome on warfarin, epilepsy on Lamictal, migraine headaches and end-stage renal disease on hemodialysis who presents with gait unsteadiness, vertigo, oscillopsia and diplopia. Patient is followed very closely by Dr. ___ her history of antiphospholipid antibody syndrome. She has multiple neurologic complaints and has been seen in the emergency room numerous times for variants of the above symptoms. Today, she reports waking up and feeling well at 6:30 AM. Around 730, she noticed gradual onset unsteadiness when walking around getting ready for work. She also noted vertiginous symptoms like things are moving around her. This has happened in the past so she took meclizine which did not help her symptoms. Her eyes "jumping around" and she felt confused, like she could not complete tasks. For example, she tried turning off the computer could not think of the steps in order to do it. She also felt like she had problems with her memory. She felt like her right hand was shaking and had difficulty typing, hitting a key she wanted to hit multiple times. Her symptoms continued to progress over the course in the morning though she was able to go to work. At some point, she noticed horizontal double vision and closed one eye and things improved. She did note that the vertiginous symptoms continued throughout the day, would worsen with head movement but still be present when standing still. Her last episode of vertigo was a few months ago. She does note that she tends to get vertiginous symptoms on days of dialysis. She was supposed to go to dialysis this afternoon, but instead she called her nephrologist reporting that her symptoms are unmanageable and she had to go to the emergency department. She was hospitalized last week for a vulvar infection, for which she was started on initially vancomycin and then levofloxacin. Otherwise there have been no new medications. Regarding her neurologic history, she is seen by somebody from neurology either inpatient or outpatient at least once every 2 months for various complaints. Most recently, she was evaluated by Dr. ___ on ___ for visual disturbances, headache and neck pain. The neck pain was felt to be musculoskeletal in origin and she was advised to wear a soft collar. It was thought that the neck pain was triggering her migraines. Given the history of images jumping around, the etiology of her visual disturbances was thought to be oscillopsia from an underlying vestibular disorder. Currently, patient feels "way off my baseline." On neuro ROS, the pt denies headache, loss of vision, dysarthria, dysphagia, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. On general review of systems, the pt denies recent fever or chills. Past Medical History: - Migraine headaches - SLE with antiphospholipid antibody syndrome - history of DVT - depression and anxiety - seizure disorder - Raynaud's phenomenon - gastritis, GERD - glaucoma - Thrombotic microangiopathy s/p failed renal transplant in ___ - ___ deficiency - OSA on CPAP (auto CPAP ___ with 50 mL EERS and 2L NC) - bipolar disorder - H/o malignant HTN c/b hypertensive encephalopathy and PRES - Hyperlipidemia - s/p TAH-BSO at 43 for heavy menses and bleeding ovarian cysts - H/o tardive dyskinesia Social History: Per last ___ summary "No alcohol, tobacco or drug use. Works as ___ ___ 3 hr/day. Lives alone, has help with grocery shopping, cleaning. Cooks for herself, self bathes, self dresses. Sister, ___, is HCP." - 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 [x] 3: Moderate disability: requires some help but able to walk unassisted [] 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: Father with anti-phospholipid syndrome, HTN, DM. Sister with MS. ___ siblings with asthma, HTN. Physical Exam: ============== ADMISSION EXAM ============== Physical Exam: Vitals: T: 97.7 P: 68 R: 16 BP: 136/72 SaO2: 96% General: Awake, cooperative, NAD, she has backed multiple bags for the possibility of admission. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple. No nuchal rigidity 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. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus, though reports horizontal diplopia with near vision. She also reports horizontal diplopia L > R extremes. The inside image disappears when she closes her right eye. VFF to confrontation. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Decreased hearing on the right ear 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: 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, proprioception throughout. No extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 0 R 2 2 2 2 0 Plantar response was withdrawal bilaterally. -Coordination: L > R end intention tremor versus mild dysmetria. Normal finger-tap bilaterally. -Gait: Needs assistance getting out of bed. Takes a few narrow based steps, but very hesitant, will not walk without 1 person assist. ============== DISCHARGE EXAM ============== -GEN: Awake in bed, NAD -HEENT: NC/AT -NECK: Supple -CV: Well perfused. -PULM: Breathing comfortably on room air. -ABD: Soft, NT/ND. -EXT: Warm, well-perfused. No clubbing, cyanosis, or edema. Jaundiced. -MS: A&Ox4. Language fluent. Able to recount entire history without difficulty. -CN: PERRL ___. EOMI. Complains of diplopia on left, right, and upgaze. No diplopia in primary position, or downgaze. No dysarthria. Face symmetric. -MOT: No drift, no rebound. No asterexis. Delt Bic Tri WrE FE IP Quad Ham TA ___ ___ L 5 ___ ___ 5 5 5 5 R 5 ___ ___ 5 5 5 5 -___: Symmetric on arms and legs. -COORD: FNF intact and with good speed. Rapid finger tapping with good speed bilaterally. -GAIT: Narrow-based, small steps, stable. Able to walk comfortably. Pertinent Results: ==== LABS ==== ___ 02:59PM BLOOD WBC-3.9* RBC-2.82* Hgb-8.9* Hct-29.3* MCV-104* MCH-31.6 MCHC-30.4* RDW-17.1* RDWSD-62.8* Plt ___ ___ 06:06AM BLOOD WBC-3.6* RBC-2.98* Hgb-9.2* Hct-30.4* MCV-102* MCH-30.9 MCHC-30.3* RDW-17.0* RDWSD-61.8* Plt ___ ___ 07:49AM BLOOD WBC-4.1 RBC-2.93* Hgb-9.5* Hct-29.6* MCV-101* MCH-32.4* MCHC-32.1 RDW-16.9* RDWSD-62.2* Plt ___ ___ 02:59PM BLOOD Neuts-69 Bands-0 Lymphs-14* Monos-8 Eos-6 Baso-0 ___ Metas-3* Myelos-0 AbsNeut-2.69 AbsLymp-0.55* AbsMono-0.31 AbsEos-0.23 AbsBaso-0.00* ___ 07:49AM BLOOD Neuts-66 Bands-1 ___ Monos-5 Eos-4 Baso-1 ___ Myelos-1* AbsNeut-2.75 AbsLymp-0.90* AbsMono-0.21 AbsEos-0.16 AbsBaso-0.04 ___ 02:59PM BLOOD Hypochr-1+ Anisocy-OCCASIONAL Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL ___ 07:49AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Spheroc-OCCASIONAL Tear ___ ___ 10:25PM BLOOD ___ PTT-45.7* ___ ___ 06:06AM BLOOD ___ PTT-44.8* ___ ___ 07:49AM BLOOD ___ PTT-46.4* ___ ___ 02:59PM BLOOD Glucose-85 UreaN-61* Creat-6.8*# Na-133 K-5.9* Cl-96 HCO3-19* AnGap-24* ___ 10:25PM BLOOD Glucose-68* UreaN-67* Creat-7.4* Na-131* K-6.0* Cl-96 HCO3-19* AnGap-22* ___ 06:06AM BLOOD Glucose-68* UreaN-75* Creat-7.7* Na-131* K-5.7* Cl-95* HCO3-18* AnGap-24* ___ 07:49AM BLOOD Glucose-80 UreaN-75* Creat-8.2* Na-131* K-5.6* Cl-94* HCO3-20* AnGap-23* ___ 02:59PM BLOOD ALT-12 AST-26 AlkPhos-175* TotBili-0.3 ___ 06:06AM BLOOD CK-MB-<1 cTropnT-0.02* ___ 02:59PM BLOOD Albumin-3.2* Calcium-9.0 Phos-4.3 Mg-3.6* ___ 06:06AM BLOOD Calcium-8.8 Phos-4.7* Mg-3.7* Cholest-86 ___ 07:49AM BLOOD Calcium-8.7 Phos-4.9* Mg-3.6* ___ 06:06AM BLOOD %HbA1c-4.2 eAG-74 ___ 06:06AM BLOOD Triglyc-184* HDL-25 CHOL/HD-3.4 LDLcalc-24 ___ 02:59PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 05:00PM BLOOD K-5.5* ___ 10:42PM BLOOD K-5.9* ======= IMAGING ======= - ___ CTA Head & Neck 1. No evidence for acute intracranial abnormalities. 2. Chronic bilateral sphenoid sinusitis and chronic small mucous retention cyst in the right posterior ethmoid. Chronic near complete opacification of the right mastoid air cells and partial opacification of the right middle ear cavity. Please correlate with any associated active symptoms. 3. No evidence for flow-limiting stenosis in the cervical or major intracranial arteries. 4. Partially visualized small bilateral pleural effusions with adjacent atelectasis. Partially visualized ground-glass opacities with perihilar predominance in the upper lobes are suggestive of pulmonary edema, but infectious etiology is not excluded. Small peripheral ground-glass opacities in the anterior right lower lobe are nonspecific. These abnormalities are new compared to the ___. Extensive mediastinal and hilar lymphadenopathy is again partially visualized. Prominent supraclavicular and bilateral cervical lymph nodes are not significantly changed compared to the ___tiology of lymphadenopathy cannot be determined on this exam. RECOMMENDATION(S): 1. MRI would be more sensitive for an acute infarction, if clinically warranted. 2. Consider follow-up chest CT in 3 months, if clinically warranted. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Aspirin 81 mg PO DAILY 3. Calcitriol 1 mcg PO 3X/WEEK (___) 4. Docusate Sodium 300 mg PO BID 5. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN Pain - Severe 6. LamoTRIgine 200 mg PO BID 7. Levofloxacin 500 mg PO Q48H 8. macitentan 10 mg oral DAILY 9. Meclizine 12.5 mg PO Q12H:PRN dizziness 10. Mupirocin Ointment 2% 1 Appl TP QID:PRN rash 11. Ondansetron 8 mg PO BID nausea 12. Ranitidine 300 mg PO QHS 13. RESTASIS 1 drop ophthalmic BID 14. Senna 17.2 mg PO BID:PRN constipation 15. sevelamer CARBONATE 2400 mg PO TID W/MEALS 16. sevelamer CARBONATE 1600 mg PO ONCE DAILY W/ SNACK 17. Sildenafil 20 mg PO TID 18. Sucralfate 1 gm PO QID 19. TraZODone 200 mg PO 3X/WEEK (___) 20. TraZODone 100 mg PO 4X/WEEK (___) 21. Warfarin 3 mg PO DAILY16 Discharge Medications: 1. Levofloxacin 500 mg PO Q48H 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 3. Aspirin 81 mg PO DAILY 4. Calcitriol 1 mcg PO 3X/WEEK (___) 5. Docusate Sodium 300 mg PO BID 6. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN Pain - Severe 7. LamoTRIgine 200 mg PO BID 8. macitentan 10 mg oral DAILY 9. Meclizine 12.5 mg PO Q12H:PRN dizziness 10. Mupirocin Ointment 2% 1 Appl TP QID:PRN rash 11. Ondansetron 8 mg PO BID nausea 12. Ranitidine 300 mg PO QHS 13. RESTASIS 1 drop ophthalmic BID 14. Senna 17.2 mg PO BID:PRN constipation 15. sevelamer CARBONATE 2400 mg PO TID W/MEALS 16. sevelamer CARBONATE 1600 mg PO ONCE DAILY W/ SNACK 17. Sildenafil 20 mg PO TID 18. Sucralfate 1 gm PO QID 19. TraZODone 200 mg PO 3X/WEEK (___) 20. TraZODone 100 mg PO 4X/WEEK (___) 21. Warfarin 3 mg PO DAILY16 22.Outpatient Physical Therapy Discharge Disposition: Home Discharge Diagnosis: Diplopia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK INDICATION: History: ___ with dizziness, vision changes. Evaluate for stroke. The patient has chronic renal failure on hemodialysis. TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of 70 mL of Omnipaque350 intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 934.2 mGy-cm. 2) Spiral Acquisition 4.8 s, 37.8 cm; CTDIvol = 11.4 mGy (Body) DLP = 430.0 mGy-cm. 3) Spiral Acquisition 5.0 s, 39.0 cm; CTDIvol = 11.4 mGy (Body) DLP = 442.6 mGy-cm. 4) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 15.2 mGy (Body) DLP = 7.6 mGy-cm. 5) Stationary Acquisition 6.6 s, 0.5 cm; CTDIvol = 33.0 mGy (Body) DLP = 16.5 mGy-cm. Total DLP (Body) = 897 mGy-cm. Total DLP (Head) = 934 mGy-cm. COMPARISON: ___ brain MRI. ___ head CT. ___ brain MRI/brain MRA/neck MRA. ___ chest CT. ___ neck CT. FINDINGS: CT HEAD WITHOUT CONTRAST: There is no acute hemorrhage, edema, mass effect, or CT evidence for an acute major vascular territorial infarction. Mild to moderate periventricular and deep white matter hypodensities are nonspecific but likely sequela of chronic small vessel ischemic disease in this age group. There is mild global parenchymal volume loss with associated prominence of the ventricles and sulci. There is an unchanged mucous retention cyst in the air right posterior ethmoid air cell on image 3:230. There is dependent polypoid material an bilateral sphenoid sinuses, which is unchanged on the left compared to ___, suggesting combination of mucous retention cysts and secretions, but shifted in location since ___ on the right, suggesting secretions. Thickening of the sphenoid sinus walls and sphenoid septum indicates sequela of chronic inflammation. There is near complete opacification of right mastoid air cells, unchanged since ___. Partial opacification of the right middle ear cavity was probably present previously, but is better seen currently due to thinner slices. Left mastoid air cells and left middle ear cavity appear well-aerated. CTA NECK: There is a 3 vessel aortic arch. There is calcified plaque in bilateral proximal subclavian arteries without evidence for significant narrowing. There is minimal calcified plaque in bilateral proximal internal carotid arteries without stenosis by NASCET criteria. Streak artifact from dental amalgam limits evaluation of mid to distal cervical internal carotid and distal cervical vertebral arteries bilaterally. Vertebral arteries otherwise demonstrate no evidence for flow-limiting stenosis. CTA HEAD: There is calcified plaque in bilateral carotid siphons without evidence for flow-limiting stenosis. There is no evidence for flow-limiting stenosis or aneurysm elsewhere in the major intracranial arteries. The dural venous sinuses are patent. OTHER: Small bilateral pleural effusions are partially visualized, new since the ___ chest CT. There is mild dependent atelectasis, mostly in the included superior segments of the lower lobes. Ground-glass opacities with perihilar predominance in the included upper lobes are suggestive of pulmonary edema, though infectious etiology is not excluded. Small peripheral ground-glass opacities in the anterior right lower lobe, 9 mm on image 4:1 and 10 mm on image 4:8, are new compared to the ___ chest CT; they are nonspecific and could be related to pulmonary edema or infection. 3.5 mm nodule in the right minor fissure on image 4:12 is unchanged compared to the prior chest CT. There is extensive mediastinal and hilar lymphadenopathy, as seen on the prior chest CT. Supraclavicular lymph nodes measure up to 8 mm in long axis on the right and 7 mm on the left (images 4:132, 4:139), not dramatically changed compared to the ___ neck CT. Cervical lymph nodes are prominent bilaterally, up to 15 mm at level 2a on the left (top-normal, image 4:167), 10 mm at level 2b on the left (top-normal, image 4:161), and 11 mm at level 5 on the left (minimally enlarged, image 4:165), minimally changed compared to the ___ neck CT. No focal thyroid lesions are detected. IMPRESSION: 1. No evidence for acute intracranial abnormalities. 2. Chronic bilateral sphenoid sinusitis and chronic small mucous retention cyst in the right posterior ethmoid. Chronic near complete opacification of the right mastoid air cells and partial opacification of the right middle ear cavity. Please correlate with any associated active symptoms. 3. No evidence for flow-limiting stenosis in the cervical or major intracranial arteries. 4. Partially visualized small bilateral pleural effusions with adjacent atelectasis. Partially visualized ground-glass opacities with perihilar predominance in the upper lobes are suggestive of pulmonary edema, but infectious etiology is not excluded. Small peripheral ground-glass opacities in the anterior right lower lobe are nonspecific. These abnormalities are new compared to the ___ chest CT. 5. Extensive mediastinal and hilar lymphadenopathy is again partially visualized. Prominent supraclavicular and bilateral cervical lymph nodes are not significantly changed compared to the ___ neck CT. Etiology of lymphadenopathy cannot be determined on this exam. RECOMMENDATION(S): 1. MRI would be more sensitive for an acute infarction, if clinically warranted. 2. Consider follow-up chest CT in 3 months, if clinically warranted. NOTIFICATION: Impression items 1 and 3 were included in a wet read by a radiology resident at the time of the exam. The entire impression and recommendations above were entered by Dr. ___ on ___ at 15:04 into the Department of Radiology critical communications system for direct communication to the referring provider. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Dizziness, Visual changes Diagnosed with Dizziness and giddiness temperature: 97.7 heartrate: 68.0 resprate: 19.0 o2sat: 96.0 sbp: 136.0 dbp: 72.0 level of pain: 0 level of acuity: 1.0

Dear Ms. ___, You were admitted to the hospital for symptoms of dizziness, gait instability, and double vision that were concerning for stroke. Your brain CT was normal. Your symptoms improved to baseline after you received dialysis. The likely cause of your problems was electrolyte abnormalities or drug clearance problems due to your renal disease, not stroke. You were cleared by ___ to go home. We made a follow-up appointment with Dr. ___ ___ neurology) for you. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Continue taking your home medications. Best, Your ___ Neurology Team

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Bactrim / Flaxseed Attending: ___ Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ___: Laparascopic cholecystectomy History of Present Illness: Ms. ___ is a ___ year old female with history of gallstones and DM type 2 who presents with right upper quadrant pain radiating to her back. The pain began the evening of ___ ___ an hour after eating a meal of rice and cheese cake. The pain persisted through the night, preventing her from sleeping. She vomited 6 times on ___ at which point the pain subsided, and she was pain free until ___. She reported no blood in her vomit. ___ evening she at a meal consisting of fish at 6 ___ and her RUQ abdominal pain started at 7 ___. She rated the pain ___ at that time and could not find any position that relieved the pain. She took Motrin for the pain that mildly reduced the pain, which was a ___ upon arrival to ED. She denies any diarrhea, dizziness, fever or chills in the past 3 days. Past Medical History: Past Medical History: -Reactive follicular hyperplasia and progressive transformation of germinal centers (PTGC). Dx ___ -Type 2 Diabetes Mellitus -Hypertension -Cholelithiasis Past Surgical History: -Right axillary lymph node biopsy ___ Social History: ___ Family History: Mother - ___ and HTN Father - HTN Physical ___: On admission: Vitals: Temp 97, HR 96, BP 157/94, RR 14, SpO2 100% RA GEN: A&O, NAD, shifted position multiple times due to pain HEENT: No scleral icterus, mucus membranes moist, PERRL CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R, resonant to percussion bilaterally ABD: Soft, distended. TTP in RUQ without rebound or guarding. Negative ___ sign. Normoactive bowel sounds, no palpable masses. Ext: No ___ edema, ___ warm and well perfused, 3+ dorsalis pedis pulses bilaterally. Pertinent Results: ___ 02:37AM BLOOD WBC-8.1 RBC-4.96 Hgb-10.7* Hct-36.4 MCV-73* MCH-21.6* MCHC-29.4* RDW-15.7* Plt ___ Neuts-63.3 ___ Monos-2.3 Eos-1.7 Baso-0.6 Glucose-135* UreaN-20 Creat-0.8 Na-140 K-3.4 Cl-104 HCO3-24 AnGap-15 ALT-12 AST-26 AlkPhos-92 TotBili-0.5 Lipase-22 Albumin-4.4 Lactate-0.8 ___ LIVER OR GALLBLADDER US (SINGLE ORGAN): IMPRESSION: Preliminary Report1. Tensely distended gallbladder with two stones, one of which may be impacted the gallbladder neck. Findings are equivocal for cholecystitis and correlation with lab evaluation and exam findings is recommended. If clinically indicated, HIDA can be obtained for further assessment. Echogenic liver compatible with fatty deposition. Other forms of liver disease including advanced hepatic fibrosis/cirrhosis cannot be excluded on this study. Medications on Admission: lisinopril 20', metformin ER 500', aspirin 81' Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for loose bowel movements. 2. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain: may cause increased drowsiness, avoid driving while on this medication. Disp:*20 Tablet(s)* Refills:*0* 3. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain. 4. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. metformin 500 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Acute cholecystitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ female with known gallstones and right upper quadrant pain without fever, assess for symptomatic cholelithiasis versus cholecystitis. COMPARISONS: ___. RIGHT UPPER QUADRANT ULTRASOUND: The liver is mildly echogenic, which may reflect fatty deposition. There is no intra- or extra-hepatic biliary ductal dilatation. The main portal vein is patent with hepatopetal flow. The common duct measures 4 mm. The gallbladder is tensely distended without mural edema or pericholecystic fluid. Two gallstones are seen measuring up to 1.7 cm. One may be impacted in the gallbladder neck. Sonographic ___ sign was unreliable in the setting of pain medication. The pancreas appears unremarkable, though the distal body and tail are not well seen. IMPRESSION: 1. Tensely distended gallbladder with two stones, one of which may be impacted in the gallbladder neck. Findings are equivocal for cholecystitis and correlation with lab evaluation and exam findings is recommended. If clinically indicated, HIDA can be obtained for further assessment. 2. Echogenic liver compatible with fatty deposition. Other forms of liver disease including advanced hepatic fibrosis/cirrhosis cannot be excluded on this study. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: ABDOMINAL PAIN Diagnosed with CHOLELITH W AC CHOLECYST, DIABETES UNCOMPL ADULT, HYPERTENSION NOS temperature: 97.0 heartrate: 96.0 resprate: 14.0 o2sat: 100.0 sbp: 157.0 dbp: 94.0 level of pain: 7 level of acuity: 3.0

You were admitted to the hospital with abdominal pain related to acute cholecystitis. You subsequently underwent a laparascopic cholecystectomy and recovered in the hospital. You are now preparing for discharge to home with the following 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. 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. 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.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Lipitor / Deodorized Tincture of Opium Attending: ___. Chief Complaint: Vomiting Major Surgical or Invasive Procedure: None History of Present Illness: ___ PMH of Metastatic colon cancer (s/p right colectomy, right heparin lobectomy, chemoradiation, w/ recurrence, s/p LAR, loop ileostomy, hysterectomy/BSO , on ___ until ___, Rectal Wall dehiscence (c/b presacral abscess s/p ___ drain then upsizing, on prolonged Abx), Right leg DVT (s/p IVC filter, on lovenox), who presents with vomiting found to have SBO As per review of notes, patient recently with rectal wall dehiscence with presacral abscess s/p ___ drain (___) and upsizing x2 (___). She has been on vanc/cipro/flagyl at home, followed by OPAT, with plan to hold chemotherapy until she is off antibiotics (scheduled to stop ___. On this admission, patient was very tired and refused to speak at length about her presentation. She noted that she was tired and wanted to go to sleep so would not speak in depth. She did however note that she had vomiting and no ostomy output at home, without any abdominal pain, so presented to ED. She noted that she felt slightly improved s/p NGT. She noted that sacral drain has not had significant output. She noted that she was without fever or chills. She noted that she had been tolerating her antibiotics without issue. In the ED, initial vitals: 98.1 103 123/84 18 100% RA. CBC with WBC 7.6, Hgb 9.5, plt 1215, CHEM with HCO# 19 lactate wnl, AP 384 other LFTS ok, Alb 2.8. Lower extremity duplex of left was negative for DVT. CT A/P revealed: 1. Small-bowel obstruction with transition point in ileal loops in the right lower quadrant. No evidence of perforation or ischemia. Small amount of free fluid. 2. Persistent dehiscence of the posterior rectal wall with slight interval decrease in associated presacral air and fluid collection containing a percutaneous drain. 3. Moderate to severe right-sided hydronephrosis and hydroureter which extends the level of the presacral collection. Degree of hydroureter appears similar compared to the previous exams. 4. Interval increase in size of pulmonary metastases. Change in the size of hepatic metastases is difficult to assess. 5. Small right greater than left pleural effusions. Colorectal surgery was consulted, NGT was placed with feculent material which came out. They noted that given malignant progression documented in pulm metastases, that obstruction was likely malignant and rec'd goals of care, medical management, with possible venting GTube if it didn't resolve. They noted that surgical mgmt would only further delay chemotherapy and therefore would not be useful to patient. She was then given morphine, Zofran, cipro, lovenox, Compazine and admitted to oncology. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: PAST ONCOLOGIC HISTORY: Stage IV colon cancer (liver mets) s/p 3 cycles of FOLFOX neoadjuvant chemotherapy followed by hepatic/colonic resection at ___ on ___ and then completed adjuvant FOLFOX for a total of 12 cycles ___. On ___, Dr. ___ reported she had a CT scan at ___, small old met noted and portal vv thrombosis noted. He recommends RFA after chemo completed since resection will be difficult. She underwent RFA ___ at ___. CEA was normal preop but then started to rise once recurrence noted. PET ___ shows FDG avid at liver resection margin and the pelvic mass - maybe resectable but would be extensive surgery including vagina. Repeat ___ scan confirm response to chemotherapy. She received C10 FOLFIRI/neulasta on ___ then admitted for fever/Cdiff/neutorpenia so surgery postponed. In ___, the rectosigmoid mass is stable and resectable and Dr ___ not want to subject her to a big surgery if her small lung nodules are mets that growing. They are too small to biopsy and PET likely will be unhelpful due to the small size. She ultimately underwent extensive resection with close margin. CT abd/pelvis ___ was neg for mets and CEA is normal and started xeloda/RT. Cont xeloda/RT - finishes ___ and then have boost to vag. In ___, her PET showed recurrent disease. She has multiple liver mets and likely lung mets. She has been on ___ since then. PAST MEDICAL HISTORY: - Metastatic Colon Cancer, as above - CAD s/p STEMI s/p ___ with stent placement - Hypothyroidism - Osteoporosis - ___ Syndrome - Eosinophilic Esophagitis - Dysphagia with distal esophageal stricture which is periodically dilated - Hypertension - Hyperlipidemia - Fatty Liver Disease - Toe Fracture - s/p right hemicolectomy and R hepatic lobectomy ___ (Drs. ___ ___ - s/p right port-a-cath placement - s/p right Colles' fracture repair ___ Social History: ___ Family History: Grandmother had leukemia and urethral cancer. Mother had skin cancer. Great aunt had colon cancer. Uncle had bladder cancer. Physical Exam: Exam on Admission ===================== Vitals: 24 HR Data (last updated ___ @ 2205) Temp: 98.5 (Tm 98.5), BP: 117/75, HR: 99, RR: 16, O2 sat: 98%, O2 delivery: RA, Wt: 112 lb/50.8 kg GENERAL: laying in bed, appears very tired, awakens to voice but then closes her eyes and attempts to refuse answering questions EYES: patient would not participate with exam HEENT: OP clear, NGT in nare with feculent material in tubing NECK: supple LUNGS: CTA anteriorly as would not sit up, no wheezes/rales/rhonchi, normal RR CV: RRR normal distal perfusion, no murmurs heard ABD: Soft, Has mild diffuse tenderness, was noted to have liquid in ostomy bag, and when I palpated her abdomen a significant amount of formed stool started emanating from ostomy, hypoactive BS, NGT with feculent material being suctioned, sacral drain with small amt of green fluid GENITOURINARY: no foley EXT: warm, dry, thin extremities with poor muscle bulk SKIN: warm, dry, no rash NEURO: AOx3, fluent speech ACCESS: PORT in right chest, dressing c/d/I . Exam on discharge: ====================== 24 HR Data (last updated ___ @ 938) Temp: 98.3 (Tm 99.2), BP: 97/63 (92-104/58-65), HR: 89 (89-102), RR: 18 (___), O2 sat: 96% (96-98), O2 delivery: Ra, Wt: 117.5 lb/53.3 kg GENERAL: laying in bed, in NAD EYES: No scleral icterus, PERRL bilaterally HEENT: OP clear. MMM. NECK: supple LUNGS: CTAB, no wheezes/rales/rhonchi, normal RR CV: RRR normal s1 and s2, no murmurs ABD: Soft, minimally tender, liquid/formed green/brown stool in ostomy bag EXT: warm, dry, thin extremities with poor muscle bulk SKIN: warm, dry, no rash NEURO: AOx3, fluent speech ACCESS: PORT in right chest, dressing c/d/i Pertinent Results: ADMISSION ========= ___ 11:40AM BLOOD WBC-7.6 RBC-3.35* Hgb-9.5* Hct-30.0* MCV-90 MCH-28.4 MCHC-31.7* RDW-18.4* RDWSD-59.9* Plt ___ ___ 11:40AM BLOOD Neuts-91.1* Lymphs-3.3* Monos-4.8* Eos-0.1* Baso-0.0 Im ___ AbsNeut-6.89* AbsLymp-0.25* AbsMono-0.36 AbsEos-0.01* AbsBaso-0.00* ___ 04:33AM BLOOD ___ PTT-40.4* ___ ___ 11:40AM BLOOD Glucose-91 UreaN-10 Creat-1.1 Na-135 K-4.5 Cl-101 HCO3-19* AnGap-15 ___ 11:40AM BLOOD ALT-11 AST-26 AlkPhos-384* TotBili-0.3 ___ 11:40AM BLOOD Albumin-2.8* Calcium-8.8 Phos-4.2 Mg-1.8 ___ 11:55AM BLOOD Lactate-1.3 . DISCHARGE ========= ___ 02:40PM BLOOD WBC-5.3 RBC-2.81* Hgb-8.0* Hct-25.1* MCV-89 MCH-28.5 MCHC-31.9* RDW-17.8* RDWSD-57.1* Plt ___ ___ 04:33AM BLOOD Neuts-81.6* Lymphs-8.7* Monos-8.2 Eos-0.6* Baso-0.2 Im ___ AbsNeut-4.40 AbsLymp-0.47* AbsMono-0.44 AbsEos-0.03* AbsBaso-0.01 ___ 02:40PM BLOOD Plt ___ ___ 05:07AM BLOOD Glucose-88 UreaN-6 Creat-0.9 Na-133* K-3.6 Cl-102 HCO3-19* AnGap-12 ___ 04:33AM BLOOD ALT-9 AST-20 CK(CPK)-39 AlkPhos-393* TotBili-0.2 ___ 05:07AM BLOOD Calcium-7.5* Phos-2.1* Mg-1.7 . MICRO ====== ___ BCx - pending . IMAGING ======== Duplex LLE ___: Negative for DVT . CT A/P w/ contrast ___. Small-bowel obstruction with transition point in ileal loops in the right lower quadrant. No evidence of perforation or ischemia. Small amount of free fluid. 2. Persistent dehiscence of the posterior rectal wall with slight interval decrease in associated presacral air and fluid collection containing a percutaneous drain. 3. Moderate to severe right-sided hydronephrosis and hydroureter which extends the level of the presacral collection. Degree of hydroureter appears similar compared to the previous exams. 4. Interval increase in size of pulmonary metastases. Change in the size of hepatic metastases is difficult to assess. 5. Small right greater than left pleural effusions. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ascorbic Acid ___ mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Cholestyramine 4 gm PO BID 4. Cyanocobalamin 1000 mcg PO DAILY 5. Levothyroxine Sodium 100 mcg PO 5X/WEEK (___) 6. Levothyroxine Sodium 200 mcg PO 2X/WEEK (___) 7. Omeprazole 20 mg PO DAILY 8. Rosuvastatin Calcium 40 mg PO QPM 9. Vitamin E 400 UNIT PO DAILY 10. Tamsulosin 0.4 mg PO DAILY 11. Morphine SR (MS ___ 30 mg PO Q12H 12. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral DAILY 13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 14. Enoxaparin Sodium 80 mg SC DAILY Start: ___, First Dose: First Routine Administration Time 15. MetroNIDAZOLE 500 mg PO Q8H 16. Ciprofloxacin HCl 500 mg PO Q12H 17. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate 18. Potassium Chloride 20 mEq PO DAILY 19. Magnesium Oxide 400 mg PO BID 20. Ondansetron ODT 8 mg PO Q8H:PRN nausea/vomiting 21. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting 22. Daptomycin 600 mg IV Q24H Discharge Medications: 1. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 2. MetroNIDAZOLE 500 mg PO Q8H 3. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 [ClearLax] 17 gram/dose 1 powder(s) by mouth daily Disp #*1 Package Refills:*0 4. Senna 8.6 mg PO BID:PRN Constipation - First Line 5. Daptomycin 300 mg IV Q24H RX *daptomycin 500 mg 0.6 bag IV daily Disp #*14 Vial Refills:*0 6. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg ___ tablet(s) by mouth every four hours Disp #*30 Tablet Refills:*0 7. Ascorbic Acid ___ mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral DAILY 10. Cholestyramine 4 gm PO BID 11. Ciprofloxacin HCl 500 mg PO Q12H 12. Cyanocobalamin 1000 mcg PO DAILY 13. Enoxaparin Sodium 80 mg SC DAILY 14. Levothyroxine Sodium 100 mcg PO 5X/WEEK (___) 15. Levothyroxine Sodium 200 mcg PO 2X/WEEK (___) 16. Magnesium Oxide 400 mg PO BID 17. Morphine SR (MS ___ 30 mg PO Q12H 18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 19. Omeprazole 20 mg PO DAILY 20. Ondansetron ODT 8 mg PO Q8H:PRN nausea/vomiting 21. Potassium Chloride 20 mEq PO DAILY 22. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting 23. Rosuvastatin Calcium 40 mg PO QPM 24. Tamsulosin 0.4 mg PO DAILY 25. Vitamin E 400 UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Small bowel obstruction Secondary Metastatic colorectal cancer DVT rectal wall dehiscence Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: UNILAT LOWER EXT VEINS LEFT INDICATION: ___ with LLE swelling// evaluate for DVT TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the left lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, flow, and augmentation of the left common femoral, femoral, and popliteal veins. Normal color flow is demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. Small amount of soft tissue edema is seen in the leg. IMPRESSION: No evidence of deep venous thrombosis in the left lower extremity veins. Radiology Report EXAMINATION: CT abdomen pelvis INDICATION: NO_PO contrast; History: ___ with history of rectal cancer, status post colostomy, also with intra-abdominal abscess now with abdominal pain and no output from colostomy to for the last 1.5 days NO_PO contrast// Elevated for abscess, obstruction TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 24.1 mGy (Body) DLP = 12.0 mGy-cm. 2) Spiral Acquisition 6.4 s, 50.6 cm; CTDIvol = 9.4 mGy (Body) DLP = 473.8 mGy-cm. Total DLP (Body) = 486 mGy-cm. COMPARISON: CT pelvis ___ CT abdomen pelvis ___ Chest CT ___ PET-CT ___ FINDINGS: LOWER CHEST: Small left greater than right bilateral pleural effusions. Mild compressive atelectasis at the left base. There are several pulmonary nodules in the right lower lobe measuring up to 11 mm (2:1, 2:7, 2:16), larger compared to prior PET-CT. Tip of the catheter is seen terminating in the right atrium. Moderate coronary artery atherosclerotic calcifications are noted. Trace pericardial fluid likely physiologic. ABDOMEN: HEPATOBILIARY: Status post right hepatectomy. A 1.6 cm hypoenhancing lesion in the caudate lobe (02:22) and a 1.5 cm hypoenhancing lesion in segment 2 (02:20) as well as a 2.1 cm hypoenhancing lesion in segment 3 (02:31) are present on prior PET-CT, though size comparison is difficult given absence of contrast on that study. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is surgically absent. Small amount of perihepatic fluid is new in the interval. 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. Few calcifications within spleen are suggestive of prior granulomatous disease. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: There is moderate to severe right-sided hydronephrosis and hydroureter which extends to the level of the presacral collection described below. Moderate right hydroureter is similar to that seen on prior CT pelvis. There is delayed nephrogram on the right side. No evidence of focal lesions. No perinephric abnormality. GASTROINTESTINAL: Small hiatal hernia. Stomach is otherwise unremarkable. Proximal small bowel loops are diffusely dilated and fluid-filled measuring up to 4.0 cm. There is transition to decompressed small bowel in ileal loops in the right hemipelvis (601:30) compatible with a small bowel obstruction. Loop ileostomy is noted in the right lower quadrant of the abdomen in a patient status post right colectomy. Loss of definition and enhancement of the posterior rectal wall is similar to prior exam and consistent with history of dehiscence. An adjacent curvilinear collection containing air and fluid in the presacral space is difficult to measure wall, but measures approximately 7.9 x 1.6 cm, and appears slightly decreased in size compared to the prior exam. A right gluteal approach terminates in unchanged position in this collection. There is trace mesenteric free-fluid. PELVIS: The urinary bladder and distal ureters are unremarkable. REPRODUCTIVE ORGANS: The uterus is not visualized. There is 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. Moderate atherosclerotic disease is noted. IVC filter is noted in place. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Sacroplasty material is noted. SOFT TISSUES: Right lower quadrant loop ileostomy is noted. There is mild diffuse subcutaneous edema. IMPRESSION: 1. Small-bowel obstruction with transition point in ileal loops in the right lower quadrant. No evidence of perforation or ischemia. Small amount of free fluid. 2. Persistent dehiscence of the posterior rectal wall with slight interval decrease in associated presacral air and fluid collection containing a percutaneous drain. 3. Moderate to severe right-sided hydronephrosis and hydroureter which extends the level of the presacral collection. Degree of hydroureter appears similar compared to the previous exams. 4. Interval increase in size of pulmonary metastases. Change in the size of hepatic metastases is difficult to assess. 5. Small right greater than left pleural effusions. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with NG tube placed for ?SBO// please confirm placement of NG tube please confirm placement of NG tube IMPRESSION: Comparison to ___. The patient has received a feeding tube. The course of the tube is unremarkable, the tip of the tube projects over the central stomach. No complications, notably no pneumothorax. Stable position of the right Port-A-Cath. Visualization of a vena cava filter. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Abd pain, N/V Diagnosed with Other intestnl obst unsp as to partial versus complete obst, Other specified soft tissue disorders, Unspecified abdominal pain temperature: 98.1 heartrate: 103.0 resprate: 18.0 o2sat: 100.0 sbp: 123.0 dbp: 84.0 level of pain: 5 level of acuity: 2.0

Dear Ms. ___, It was a pleasure taking care of you at ___. WHY DID YOU COME TO THE HOSPITAL? -You were having nausea and vomiting. WHAT HAPPENED WHILE YOU WERE HERE? - You were diagnosed with a small bowel obstruction - You had a tube placed into your stomach and you did not eat for 24 hours to give your bowel rest. - Your nausea improved and you were able to tolerate eating, and your ostomy output improved. - It is possible that some of your symptoms may be due to opiates, which slow down the gut's movement. WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL? - Please continue to take all of your medications as directed, and follow up with all of your doctors. Again, it was a pleasure taking care of you! Sincerely, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: chest pain Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ year old woman with a h/o provoked post-surgical PE in ___ (negative thrombophilia w/u, anti-coagulated for 6 mo), presenting with 2 days of worsening substernal chest pain. One week prior to admission, she underwent superficial venectomy for painful veins. She did well post-operatively, but this ___, two days prior to admission, she followed up in clinic where she had LENIs that showed 3 DVTs in her LLE (operative leg). Per the patient, she was sent home on asa 325 po qd despite her positive history for PE. On ___, after returning home from clinic, she then noticed the gradual onset of substernal chest pain that felt somewhat like heartburn. This progressed and though she does not subjectively endorse SOB, her family feels like she has been panting when walking. She otherwise denies leg swelling or tenderness, low grade fever, chills, abd pain or dysuria. On arrival to the ED: - Initial vitals were 99 82 128/68 20 100% RA - Labs revealed nl lytes, CBC and coags - CTA Chest demonstrated RML, RLL and LLL segmental partially occlusive PEs. No signs of right heart strain. - She was given 70 mg SC Lovenox per weight based protocol and admitted to the floor for further management. Currently, is comfortable, complaining of mild chest discomfort without SOB. ROS: See HPI. Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: # h/o of DVTs and PE in ___ - ___ s/p c-section - Chest CT scan showed multiples bilateral segmental and sub-segmental pulmonary emboli - Negative w/u for Factor V Leiden, prothrombin gene mutation, proteins C and S, AT3, the lupus anticoagulant, anticardiolipin antibodies - Anti-coagulated for 6 months # Raynaud's Social History: ___ Family History: Unclear Physical Exam: ADMISSION EXAM: VS - 98.4 67 132/76 18 100%RA General: NAD HEENT: Sclera anicteria, MMM, no OP lesions Neck: Supple, no JVD, no LAD CV: RRR, no heave, no m/r/g Lungs: CTAB Abdomen: Soft, ND, +BS, NT to palpation, no hepatosplenomegaly GU: Deferred Ext: WWP, well-healing, non-purelent surgical scar extending from knee to upper left leg; no tenderness, redness or swelling Neuro: Alert and oriented, CN II-XII intact, no focal weakness, sensation intact to light touch Skin: No rash, abrasions or ulcers DISCHARGE EXAM: VS - 98.4 97.9 60-67 ___ 18 99-100%RA General: NAD HEENT: Sclera anicteria, MMM, no OP lesions Neck: Supple, no JVD, no LAD CV: RRR, no heave, no m/r/g Lungs: CTAB Abdomen: Soft, ND, +BS, NT to palpation, no hepatosplenomegaly GU: Deferred Ext: 1x0.5cm superficial mobile, tender nodule over L inguinal area, WWP, well-healing, non-purelent surgical scar extending from knee to upper left leg; no redness or swelling Neuro: Alert and oriented, CN II-XII intact, no focal weakness, sensation intact to light touch Skin: No rash, abrasions or ulcers Pertinent Results: ADMISSION LABS: ___ 12:45PM BLOOD WBC-7.2 RBC-4.52# Hgb-14.7# Hct-42.1# MCV-93 MCH-32.6* MCHC-35.0 RDW-13.0 Plt ___ ___ 12:45PM BLOOD Neuts-73.1* Lymphs-17.9* Monos-5.6 Eos-3.0 Baso-0.4 ___ 12:45PM BLOOD Glucose-76 UreaN-16 Creat-0.7 Na-139 K-3.9 Cl-99 HCO3-28 AnGap-16 ___ 01:17PM BLOOD ___ PTT-34.5 ___ PERTINENT LABS: ___ 07:00AM BLOOD cTropnT-<0.01 proBNP-24 ___ 01:17PM BLOOD ___ PTT-34.5 ___ ___ 07:00AM BLOOD ___ PTT-100.7* ___ ___ 01:45PM BLOOD PTT-86.9* DISCHARGE LABS: ___ 07:00AM BLOOD WBC-5.6 RBC-4.35 Hgb-14.4 Hct-41.2 MCV-95 MCH-33.2* MCHC-35.1* RDW-12.8 Plt ___ ___ 01:45PM BLOOD PTT-86.9* ___ 07:00AM BLOOD Glucose-95 UreaN-13 Creat-0.7 Na-137 K-4.1 Cl-100 HCO3-26 AnGap-15 ___ 07:00AM BLOOD Calcium-9.5 Phos-3.8 Mg-2.1 RADIOLOGY: ___ CTA CHEST WITH AND WITHOUT CONTRAST: FINDINGS: Pulmonary arteries are well opacified to the subsegmental level. Nonocclusive filling defects are seen in the lobar, segmental and subsegmental pulmonary artery branches involving the right middle and right lower lobes as well as segmental branches of the left lower lobe. While some of these filling defects, particularly in the left lower lobe, were present in the study of ___, others are new. There is no sign of right heart strain. Thoracic aorta is of normal caliber without evidence of aneurysm or dissection. There is no axillary, mediastinal or hilar adenopathy. Heart is normal in size. There is no pericardial effusion. Trachea is midline and airways are patent to the subsegmental level. Lungs are clear. There is no pleural effusion. There is no pneumothorax. Limited view of the upper abdomen is unremarkable. Bones do not show suspicious lytic or sclerotic lesions and no acute fractures. IMPRESSION: Partially occlusive RML and RLL lobar, segmental, and subsegmental pulmonary emboli and partially occlusive LLL segmental and subsegmental pulmonary emboli are demonstrated. No CT evidence of right heart strain ___ ULTRASOUND OF BILAT LOWER EXT VEINS WITH DOPPLER (LENIS): FINDINGS: Gray scale, color, and spectral Doppler ultrasound examination of the bilateral common femoral, femoral, popliteal, posterior tibial, and peroneal veins was conducted. There is a large, expansile, occlusive thrombus in the left greater saphenous vein leading to the confluence with the femoral vein. All other imaged vessels showed normal compressibility, flow, and augmentation. IMPRESSION: Large occlusive expansile thrombus in the left greater saphenous vein at its confluence with the femoral vein. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 325 mg PO DAILY Discharge Medications: 1. Warfarin 5 mg PO DAILY16 RX *warfarin 5 mg 1 tablet(s) by mouth qday Disp #*30 Tablet Refills:*0 2. Enoxaparin Sodium 70 mg SC Q12H pulmonary embolus You will stop these injections once your INR reaches goal. RX *enoxaparin 80 mg/0.8 mL 70 mg IM every 12 hours Disp #*30 Syringe Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: - acute Pulmonary embolus SECONDARY DIAGNOSIS: - acute lower extremity Deep venous thrombosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: History of DVT and PE, documented DVT today, chest pain, shortness of breath; evaluate for pulmonary emboli. COMPARISON: ___. TECHNIQUE: Contiguous MDCT images were obtained through the chest with IV contrast. Axial images were reviewed in conjunction with coronal and sagittal reformats. FINDINGS: Pulmonary arteries are well opacified to the subsegmental level. Nonocclusive filling defects are seen in the lobar, segmental and subsegmental pulmonary artery branches involving the right middle and right lower lobes as well as segmental branches of the left lower lobe. While some of these filling defects, particularly in the left lower lobe, were present in the study of ___, others are new. There is no sign of right heart strain. Thoracic aorta is of normal caliber without evidence of aneurysm or dissection. There is no axillary, mediastinal or hilar adenopathy. Heart is normal in size. There is no pericardial effusion. Trachea is midline and airways are patent to the subsegmental level. Lungs are clear. There is no pleural effusion. There is no pneumothorax. Limited view of the upper abdomen is unremarkable. Bones do not show suspicious lytic or sclerotic lesions and no acute fractures. IMPRESSION: Partially occlusive RML and RLL lobar, segmental, and subsegmental pulmonary emboli and partially occlusive LLL segmental and subsegmental pulmonary emboli are demonstrated. No CT evidence of right heart strain Radiology Report HISTORY: Evaluate for DVT in a patient with known pulmonary embolism. COMPARISON: None available. FINDINGS: Gray scale, color, and spectral Doppler ultrasound examination of the bilateral common femoral, femoral, popliteal, posterior tibial, and peroneal veins was conducted. There is a large, expansile, occlusive thrombus in the left greater saphenous vein leading to the confluence with the femoral vein. All other imaged vessels showed normal compressibility, flow, and augmentation. IMPRESSION: Large occlusive expansile thrombus in the left greater saphenous vein at its confluence with the femoral vein. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Dyspnea, Chest pain Diagnosed with PULM EMBOLISM/INFARCT, ACUTE VENOUS EMBOLISM AND THROMBOSIS OF UNSPECIFIED DEEP VESSELS OF LOWER EXTREMITY temperature: 99.0 heartrate: 82.0 resprate: 20.0 o2sat: 100.0 sbp: 128.0 dbp: 68.0 level of pain: 5 level of acuity: 2.0

Dear Ms. ___, It was a pleasure taking care of you in the hospital. You were admitted with chest pain due to a pulmonary embolus which originated from a vein in your leg. You were started on a heparin drip with the plan to transition to warfarin as an outpatient. Because it will not be therapeutic for a few days, you will need to take lovenox for a short period of time as a bridge. During your admission, you did not have shortness of breath, fever or evidence of heart damage. This is your second pulmonary embolus occurring in the post-operative period, which may indicate that you need a longer course of warfarin. Please follow up with a hematologist to discuss further.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: fever, new weakness Major Surgical or Invasive Procedure: None History of Present Illness: ___ man with past medical history of idiopathic pulmonary fibrosis, hypertension, hyperlipidemia, depression, and dysphagia who presents with about 4 days of fever to a high of 102, increased nonproductive cough, mild epigastric abdominal pain, decreased appetite, and general weakness. Starting on ___ he found he was unable to get himself out of bed due to weakness, and states he has been very shaky. He denies dysuria or hematuria but states that his urine has been darker than usual. At baseline he ambulates unassisted. He and his son also note that around the time of onset of his symptoms, he had a fall at home, and his wife was unable to get him up off the floor, so he was down for about 1 hour. He denies head strike or loss of consciousness at that time. Denies headaches, neck stiffness or vision changes. Denies vomiting or diarrhea. Denies blood in his stool. His son believes his mental status is at his baseline. HE ___ any sick contacts, chest pain, dyspnea. In the ED, initial VS were: 99.4 80 142/56 16 94% RA Tmax 102.8 Exam notable for: AOx3. Breathing comfortably on room air. On auscultation, there are crackles throughout, worse on the right than the left. Mild epigastric tenderness to palpation. Neuro exam nonfocal. Labs showed: Cr 1.5 H/H 10.9/32.7, lactate 2.2. Flu is negative and UA negative for infection Imaging showed: Liver Or Gallbladder Us (Single Organ) 1. Slight interval increase in size of right complex right hepatic lobe cyst,unlikely to be retracting internal hemorrhage considering time interval since ___. Nonurgent, outpatient multiphasic liver MR (___) or CT is recommended for further evaluation. 2. Stable left hepatic lobe simple appearing cyst. 3. No evidence of cholelithiasis or acute cholecystitis. CT ___ W/O Contrast No evidence of acute fracture or traumatic malalignment. CT Head W/O Contrast No acute intracranial process. No evidence of intracranial hemorrhage or fracture. CXR: IMPRESSION: Diffuse abnormalities in the lungs compatible with underlying interstitial lung disease. No definite superimposed acute process given stability compared to prior. Patient received: APAP, ceftriaxone, and IVF Transfer VS were: 99.6 85 125/47 16 98% RA On arrival to the floor, patient reports the above story and reports feeling much better with only complaint of cough. He said initially he came into the hospital because of profound chills and aches which have dramatically improved since coming in. Past Medical History: Parotid tumor s/p resection ___ unclear neoplasm BPH and overactive bladder GERD History of PPD+ in ___ (by online documents, CXR obtained which showed apical capping but no other abnormality - patient not believed to have active TB and not treated) hypercholesterolemia Hypertension Hyperlipidemia History of interstitial lung disease (UIP/IPF) Syncope History of Aspiration History of PE no on anticoagulation Social History: ___ Family History: ___ Physical Exam: ADMISSION PHYSICAL EXAM: VS: 97.6 PO 138 / 64 72 18 96 ra GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: Inspiratory crackles throughout lung fields. ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly 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: VS: 99.3PO 135 / 70 83 18 96 Ra GENERAL: Pleasant, alert, and interactive. NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM. No pharyngeal erythema. NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: Diffuse faint inspiratory crackles, most pronounced at right base posteriorly. ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally. 2+ radial pulses bilaterally. NEURO: A&Ox3, moving all 4 extremities with purpose. CN ___ intact. SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS: =============== ___ 04:32PM ___ ___ ___ 04:32PM ___ ___ IM ___ ___ ___ 03:54PM URINE ___ SP ___ ___ 03:54PM URINE ___ ___ ___ ___ 03:54PM URINE ___ ___ ___ 03:54PM URINE ___ ___ 03:54PM URINE ___ ___ 04:32PM ___ ___ 04:32PM ___ ___ 04:32PM ALT(SGPT)-28 AST(SGOT)-39 ALK ___ TOT ___ ___ 04:32PM ___ UREA ___ ___ TOTAL ___ ANION ___ ___ 04:38PM ___ DISCHARGE LABS ============== ___ 07:00AM BLOOD ___ ___ Plt ___ ___ 07:00AM BLOOD ___ ___ ___ 07:00AM BLOOD ___ IMAGING: ======== CXR (___): Lung volumes remain low. Bilateral increased interstitial markings are seen throughout the lungs. These are unchanged from prior and compatible with known underlying interstitial process. No definite superimposed consolidation identified. The cardiomediastinal silhouette is stable. No acute osseous abnormalities. CT HEAD W/O CONTRAST (___): There is no evidence of infarction, hemorrhage, edema, or mass. There is prominence of the ventricles and sulci suggestive of ___ cerebral volume loss. Periventricular and subcortical white matter hypodensities are nonspecific, though likely sequelae of chronic small vessel ischemic disease. Atherosclerotic vascular calcifications are noted of bilateral vertebral and cavernous portions of internal carotid arteries. No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are unremarkable. CT ___ W/O CONTRAST (___:) Alignment is normal. No fractures are identified. Multilevel degenerative changes are seen, most extensive at ___ and notable for uncovertebral hypertrophy, osteophytes and facet arthropathy causing severe right neural foraminal stenosis at ___ and ___ and severe left neural foraminal stenosis at ___. There is no prevertebral edema. There are fibrotic changes at the lung apices, unchanged compared to prior. Thyroid is unremarkable. LIVER/GALLBLADDER U/S (___): 1. Slight interval increase in size of right complex right hepatic lobe cystic lesion with internal avascular echogenic contents. Nonurgent, multiphasic liver MR is recommended for further evaluation. If contraindication to MR, CT could be considered. 2. Stable left hepatic lobe simple appearing cyst. 3. No evidence of cholelithiasis or acute cholecystitis. RECOMMENDATION(S): Nonurgent, multiphasic liver MR is recommended for further evaluation. If contraindication to MR, CT could be considered. CT CHEST W/O CONTRAST (___): FINDINGS: The thyroid is unremarkable. There are no enlarged axillary lymph nodes. There is stable 7 mm hypodense lesion in the right upper posterior back (image 6 series 2. This could represent a sebaceous cyst. The left axillary lymph node measuring 18 mm has decreased in size it previously measured 24 mm. There is stable mild to moderate cardiomegaly. There are no enlargedmediastinal hilar lymph nodes. There is no pericardial effusion. There is coronary artery calcification. There is mild atherosclerotic calcification involving the aorta. There is no pleural effusion. Peripheral fibrosis and traction bronchiectasis in the right middle lobe and the lingula is unchanged. Mild bronchiectasis in both lower lobes with mild peribronchial thickening is also unchanged. The interstitial abnormality bilaterally is stable and is most likely related to age related fibrosis. No new nodules or consolidations. Review of bones shows degenerative changes involving the thoracic spine. Limited sections through the upper abdomen shows a large hypodense lesion within the right lobe of liver, could represent a cyst or hemangioma and is unchanged. IMPRESSION: No evidence of pneumonia. Stable interstitial abnormality which most likely represents age related fibrosis. Decrease in size of the left axillary lymph nodes which are most likely reactive. MICRO: ====== ___ 04:07PM OTHER BODY FLUID ___ ___ ___ BLOOD CULTURE: NGTD ___ BLOOD CULTURE: NGTD ___ URINE CULTURE: negative Radiology Report INDICATION: ___ with h/o pulmonary fibrosis p/w 4d fever, increased cough, general weakness// eval for PNA TECHNIQUE: AP and lateral views the chest. COMPARISON: Chest x-ray from ___. Chest CT from ___. FINDINGS: Lung volumes remain low. Bilateral increased interstitial markings are seen throughout the lungs. These are unchanged from prior and compatible with known underlying interstitial process. No definite superimposed consolidation identified. The cardiomediastinal silhouette is stable. No acute osseous abnormalities. IMPRESSION: Diffuse abnormalities in the lungs compatible with underlying interstitial lung disease. No definite superimposed acute process given stability compared to prior. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ with general weakness, s/p fall 4 days ago, now with neck pain/C-spine TTP// eval for intracranial bleed or fracture TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained without intravenous contrast. Coronal and sagittal reformations and bone algorithms reconstructions were also performed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 16.2 cm; CTDIvol = 49.6 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: Noncontrast head CT ___. FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. There is prominence of the ventricles and sulci suggestive of age-related cerebral volume loss. Periventricular and subcortical white matter hypodensities are nonspecific, though likely sequelae of chronic small vessel ischemic disease. Atherosclerotic vascular calcifications are noted of bilateral vertebral and cavernous portions of internal carotid arteries. No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: No acute intracranial process. No evidence of intracranial hemorrhage or fracture. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: ___ with general weakness, s/p fall 4 days ago, now with neck pain/C-spine TTP// eval for intracranial bleed or fracture TECHNIQUE: Contiguous axial images obtained through the cervical spine without intravenous contrast. Coronal and sagittal reformats were reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 6.0 s, 23.5 cm; CTDIvol = 22.8 mGy (Body) DLP = 535.7 mGy-cm. Total DLP (Body) = 536 mGy-cm. COMPARISON: CT C-spine ___. FINDINGS: Alignment is normal. No fractures are identified.Multilevel degenerative changes are seen, most extensive at C3-C4, C4-C5, C5-C6 and notable for uncovertebral hypertrophy, osteophytes and facet arthropathy causing severe right neural foraminal stenosis at C3-C4 and C4-C5 and severe left neural foraminal stenosis at C5-C6. There is no prevertebral edema. There are fibrotic changes at the lung apices, unchanged compared to prior. Thyroid is unremarkable. IMPRESSION: No evidence of acute fracture or traumatic malalignment. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ with fever, weakness, epigastric abdominal pain, decreased appetite// eval for gallbladder pathology TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: Ultrasound ___, CT abdomen pelvis ___. FINDINGS: LIVER: Again demonstrated, is a right hepatic lobe cystic lesion with echogenic internal debris slightly larger than prior currently measuring 8.0 x 8.3 x 6.9 cm, previously measuring 7.0 x 6.7 x 7.2 cm, without internal vascularity. In addition, there is a stable appearing simple cyst in the left hepatic lobe measuring approximately 3.8 x 2.0 x 2.4 cm. Echogenic shadowing focus is compatible with calcification. No additional focal lesions identified. The contour of the liver is smooth. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CBD was not identified. GALLBLADDER: There is no evidence of stones or gallbladder wall thickening. PANCREAS: The imaged portion of the pancreas appears within normal limits, without masses or pancreatic ductal dilation, with portions of the pancreatic tail obscured by overlying bowel gas. SPLEEN: The spleen was identified. KIDNEYS: Limited views of the right kidney show no hydronephrosis. IMPRESSION: 1. Slight interval increase in size of right complex right hepatic lobe cystic lesion with internal avascular echogenic contents. Nonurgent, multiphasic liver MR is recommended for further evaluation. If contraindication to MR, CT could be considered. 2. Stable left hepatic lobe simple appearing cyst. 3. No evidence of cholelithiasis or acute cholecystitis. RECOMMENDATION(S): Nonurgent, multiphasic liver MR is recommended for further evaluation. If contraindication to MR, CT could be considered. Radiology Report EXAMINATION: CT CHEST W/O CONTRAST INDICATION: ___ ___ man with past medical history of idiopathic pulmonary fibrosis, hypertension, hyperlipidemia, depression, and dysphagia who presents with about 4 days of fever to a high of 102, increased nonproductive cough// Pneumonia? Worsening IPF? TECHNIQUE: Multi detector CT of the chest was performed without the administration of Intravenous contrast. Axial coronal sagittal reconstructions were acquired. Maximum intensity projections were also acquired. DOSE: Acquisition sequence: 1) Spiral Acquisition 2.3 s, 35.7 cm; CTDIvol = 19.1 mGy (Body) DLP = 680.0 mGy-cm. Total DLP (Body) = 680 mGy-cm. COMPARISON: To a prior study done on ___ FINDINGS: The thyroid is unremarkable. There are no enlarged axillary lymph nodes. There is stable 7 mm hypodense lesion in the right upper posterior back (image 6 series 2. This could represent a sebaceous cyst. The left axillary lymph node measuring 18 mm has decreased in size it previously measured 24 mm. There is stable mild to moderate cardiomegaly. There are no enlarged mediastinal hilar lymph nodes. There is no pericardial effusion. There is coronary artery calcification. There is mild atherosclerotic calcification involving the aorta. There is no pleural effusion. Peripheral fibrosis and traction bronchiectasis in the right middle lobe and the lingula is unchanged. Mild bronchiectasis in both lower lobes with mild peribronchial thickening is also unchanged. The interstitial abnormality bilaterally is stable and is most likely related to age related fibrosis. No new nodules or consolidations. Review of bones shows degenerative changes involving the thoracic spine. Limited sections through the upper abdomen shows a large hypodense lesion within the right lobe of liver, could represent a cyst or hemangioma and is unchanged. IMPRESSION: No evidence of pneumonia. Stable interstitial abnormality which most likely represents age related fibrosis. Decrease in size of the left axillary lymph nodes which are most likely reactive. Gender: M Race: HISPANIC/LATINO - DOMINICAN Arrive by WALK IN Chief complaint: Fever Diagnosed with Fever, unspecified, Weakness temperature: 99.4 heartrate: 80.0 resprate: 16.0 o2sat: 94.0 sbp: 142.0 dbp: 56.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, It was a pleasure to participate in your care. WHY WAS I ADMITTED TO THE HOSPITAL? - You were admitted to the hospital because you were having fevers at home. Your family also noticed that you seemed more weak than usual, and you had a hard time getting up after you fell at home. WHAT HAPPENED WHILE I WAS HERE? - You were started on antibiotics to treat for a possible pneumonia. We did a CT scan of your chest which did not show any signs of pneumonia so the antibiotics were stopped. -You received IV fluids because we felt that you were dehydrated. WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL? - Please follow up with your PCP - ___ take all of your medications as prescribed We wish you the best! Sincerely, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Back Pain Major Surgical or Invasive Procedure: T7-8 laminectomy thoracotomy with drainage History of Present Illness: The patient is a ___ year old male with minimal PMH besides known T7-8 osteomyelitis, discitis, and epidural abcess s/p prior laminectomy who presented with worsening back pain. His MRI showed worsening anterior T7-8 collapse with increased prevertebral soft tissue edema and new paravertebral fluid collections concerning for discitis and osteomyelitis with prevertebral spread. MRI also noted new adjacent right lower lobe consolidations. He was treated for pneumonia in the ED with Levofloxacin and admitted to the Neurosurgery service. He underwent ___ guided bone biopsy of back ___, with gram stain showing GPCs in pairs and clusters. Of note, he had prior cultures with MSSA. He was transferred to Medicine for further medical management of his infection. On transfer to medicine, he endorsed a productive cough which started a week or two prior. He denied any fevers, chills, night sweats, or systemic symptoms. He denied any focal weakness, numbness, paresthesias, or bowel/bladder dysfunction. He denied any difficulty ambulating. He did note that his mid back pain occasionally radiates around his chest, and that the area is sometimes numb. His back pain is currently under reasonably good control, especially when he is not moving much. REVIEW OF SYSTEMS: (+) Per HPI. No BM in a few days. Reflux symptoms and dyspepsia. Occasional cramping sensation in his chest and mild SOB. (-) No fevers, chills, night sweats, fatigue, or malaise. No headache, sinus tenderness, rhinorrhea, or congestion. No vertigo, presyncope, syncope, vision changes, hearing changes, focal weakness, or paresthesias. No chest pain, palpitations, SOB, DOE, or hemoptysis. No abdominal pain, nausea, vomiting, diarrhea, melena, or BRBPR. No hematuria, dysuria, frequency, or urgency. No joint or muscle pain. No rashes or concerning skin lesions. No easy bleeding or bruising. Review of systems was otherwise negative. Past Medical History: - Chronic low back pain since ___ after multiple MVAs and construction - IVDU in his teens (confirms using only once when he was ___, none since) - Pain medication abuse PAST SURG HX: - Right knee surgery for tib-fib fracture in ___ with "fiberglass rods" Social History: ___ Family History: # Mother: died at ___ from lung cancer # Father: died at ___ from pancreatic cancer Physical Exam: PHYSICAL EXAM ON TRANSFER TO MEDICINE: VS: T 99.1, BP 146/89, HR 91, RR 18, SpO2 93% on RA Gen: Middle aged male in NAD. Oriented x3. HEENT: Sclera anicteric. PERRL, EOMI. MMM, OP benign. Neck: No cervical lymphadenopathy. CV: Exam limited by TLSO. RRR with normal S1, S2. No M/R/G. Chest: Respiration unlabored. Rhonchorous breath sounds and crackles on the right. Abd: Normal bowel sounds. Soft, NT, ND. No organomegaly or masses. 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. Sensation grossly intact to light touch. Normal speech. PHYSICAL EXAM ON DISCHARGE: AVSS A&Ox3 HEENT: atraumatic, normocephalic CV: RRR EXT: Digital cap refill <2 sec. No C/C/E. Distal pulses intact CN II-XII intact, strength ___ in all extremities. Sensation intact Incision: clean, dry, intact Pertinent Results: LABS ON ADMISSION: ___ 03:00PM BLOOD WBC-12.8* RBC-4.13* Hgb-14.0 Hct-40.0 MCV-97# MCH-33.8*# MCHC-35.0 RDW-14.3 Plt ___ ___ 03:00PM BLOOD Neuts-84.8* Lymphs-7.9* Monos-6.9 Eos-0.1 Baso-0.2 ___ 03:00PM BLOOD ___ PTT-27.3 ___ ___ 03:00PM BLOOD Glucose-96 UreaN-14 Creat-0.8 Na-128* K-3.7 Cl-89* HCO3-27 AnGap-16 ___ 05:58PM BLOOD Lactate-2.2* INFLAMMATORY MARKERS: ___ 03:00PM BLOOD ESR-97* ___ 03:00PM BLOOD CRP-237.6* MEDICATION MONITORING: ___ 06:15AM BLOOD Vanco-9.3* IMAGING / STUDIES: # MR THORACIC SPINE W/O CONTRAST ___ at 1:38 ___: FINDINGS: Since the ___ MRI examination there has been interval anterior collapse of the T7 and T8 vertebral bodies with focal kyphosis (2:5). Increased T2 signal intensity across the vertebral bodies and T7/8 disc has also progressed since the prior examination. There are new prevertebral well-circumscribed T2 hyperintense lesions (7:14, 11, 15), measuring up to 20 x 10 mm (7:14), which neighboring abnormal increased signal intensity throughout the prevertebral soft tissues and surrounding the aorta (7:12). New right lower lobe consolidations are present(7:10). Small bilateral pleural effusions are unchanged. A focus of signal intensity along the posterior aspect of T7 and T8 abuts the spinal cord. An adjacent epidural process is not seen, but cannot be excluded on this noncontrast examination. No definite cord signal abnormality is detected. There is chronic thickening of the ligamentum flavum at this level. The remaining thoracic vertebral bodies demonstrate normal heights and signal intensities. A right T2 hemangioma appears unchanged (6:6). IMPRESSION: Interval anterior collapse of T7 and T8 since ___, with increased prevertebral soft tissue edema and new paravertebral fluid collections, and new adjacent right lower lobe consolidations, concerning for discitis and osteomyelitis with prevertebral spread. # CHEST (PA & LAT) ___ at 4:10 ___: FINDINGS: The heart is at the upper limits of normal size. There is no pleural effusion or pneumothorax. An extensive opacity involving the right lower lobe is consistent with pneumonia, with lesser opacities noted along the right upper lobe and probably the lingula. This includes a nodular focus projecting over the right mid lung, new since the prior study also. There is destruction of a mid thoracic interspace with marked wedging of the adjoining vertebral bodies. This appearance is consistent with sequelae of known osteomyelitis/discitis. IMPRESSION: 1. New opacification in the right lower lobe, with left lesser opacities elsewhere, suggesting pneumonia. 2. Endplate destruction of a mid thoracic interspace, consistent with sequela of spinal infection, including increasing loss in height of adjoining vertebral bodies since the prior MR, but better assessed on the accompanying dedicated thoracic spine MR performed on the prior day. # CT TORSO W/CONTRAST ___ at 3:46 AM): FINDINGS: There are stable small bilateral pleural effusions with associated atelectasis and pleural thickening. In addition there are ___ opacities in the right middle and lower lobes, consistent with infection. There is no pneumothorax. The heart, pericardium, and great vessels are unremarkable. Again seen is evidence of known discitis-osteomyelitis with destructive change of the T7 and T8 vertebral bodies. There is no further loss of height of the T7-T8 complex since the study on ___. Patient has had laminectomies at these levels. Also noted is an irregular lucency consistent with non-acute fracture of the left articular facet of T7. Adjacent air-containing fluid collections are minimally progressed in the interval: a fluid collection and a collection posterior to the aorta are slightly larger, and there is a new small fluid collection medial to the aorta in the left paravertebral area (2:34) measuring 23 mm x 7.5 mm. There is scattered mediastinal lymphadenopathy. The liver enhances homogeneously without focal lesion or intrahepatic biliary ductal dilatation. The spleen is homogeneous and normal in size. The gallbladder is unremarkable, and the portal vein is patent. The pancreas is unremarkable without a focal lesion, peripancreatic stranding, or fluid collection. The bilateral adrenal glands unremarkable. The kidneys presents symmetric nephrograms and excretion of contrast without solid or cystic lesions. There is a duodenal diverticulum, and diverticula are also noted in the descending colon. There is no wall thickening or obstruction in the small or large bowel. There is no ascites. IMPRESSION: 1. Redemonstration of osteomyelitis-discitis at T7-T8 with slight increase in the previously seen paravertebral fluid collections and a new small paravertebral collection as described above. 2. ___ opacities in the right middle and lower lobes, consistent with infection. Stable bilateral pleural effusions. MRI T-Spine ___: 1. Allowing for the difference in technique between non-contrast and contrast-enhanced MR studies, there has been no significant short-interval change in the degree of osseous destruction at the T7-8 level since ___, but there is progressive osseous destruction since an earlier study of ___. 2. The current contrast-enhanced study better characterized\s the T7-8 spondylodiscitis and vertebral osteomyelitis, demonstrating an intervertebral rim-enhancing collection in direct communication with the large right-sided paraspinal/pleural collection, likely empyema. 3. Multiple additional smaller loculated pleural-based collections in the lung bases, compatible with additional empyemas. Extensive adjacent airspace consolidations in the lung bases representing with ongoing pneumonia. Clinical concern is raised for the proximity of the collections to the descending aorta, with potential for infectious aortitis. CT T-Spine ___: Re-demonstration of osteomyelitis-discitis at T7-T8. Bilateral paravertebral fluid collections, greatest on the right, are unchanged since MRI ___. CT Chest ___: Re- demonstration of osteomyelitis-discitis at T7 -T8 surrounded by bilateral paravertebral and pleural collections. There is no change since MRI of ___ and CT yesterday, ___. Medications on Admission: No current medications on admission. Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush 3. Senna 1 TAB PO BID Please hold for loose stools. 4. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush 5. Oxycodone SR (OxyconTIN) 40 mg PO Q8H pain RX *oxycodone [OxyContin] 40 mg 1 tablet(s) by mouth every eight (8) hours Disp #*42 Tablet Refills:*0 6. Ondansetron 4 mg IV Q8H:PRN nausea 7. Nicotine Patch 21 mg TD DAILY 8. Nafcillin 2 g IV Q4H 9. Methocarbamol 750 mg PO QID RX *methocarbamol 750 mg 1 tablet(s) by mouth four times a day Disp #*56 Tablet Refills:*0 10. Ibuprofen 400 mg PO Q8H 11. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth Q3H Disp #*224 Tablet Refills:*0 12. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 13. Gabapentin 300 mg PO TID 14. Heparin 5000 UNIT SC TID 15. Docusate Sodium 100 mg PO BID 16. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of breath, wheezing, or coughing 17. Bisacodyl 10 mg PO/PR DAILY 18. Cepacol (Menthol) 1 LOZ PO PRN throat irritation Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: T7-8 paraspinous abscesses pleural effusions Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Patient must wear his TLSO brace when at or above 30 degrees in bed. Followup Instructions: ___ Radiology Report CHEST RADIOGRAPHS HISTORY: Productive cough. COMPARISONS: Radiographs from ___ and MR studies from the prior day and ___. TECHNIQUE: Chest, PA and lateral. FINDINGS: The heart is at the upper limits of normal size. There is no pleural effusion or pneumothorax. An extensive opacity involving the right lower lobe is consistent with pneumonia, with lesser opacities noted along the right upper lobe and probably the lingula. This includes a nodular focus projecting over the right mid lung, new since the prior study also. There is destruction of a mid thoracic interspace with marked wedging of the adjoining vertebral bodies. This appearance is consistent with sequelae of known osteomyelitis/discitis. IMPRESSION: 1. New opacification in the right lower lobe, with left lesser opacities elsewhere, suggesting pneumonia. 2. Endplate destruction of a mid thoracic interspace, consistent with sequela of spinal infection, including increasing loss in height of adjoining vertebral bodies since the prior MR, but better assessed on the accompanying dedicated thoracic spine MR performed on the prior day. Radiology Report INDICATION: ___ year old man with prior T7/8 discitis/osteomyelitis status post laminectomy and washout in ___, with persistent pain and signal abnormality on MRI. PROCEDURE: T7-8 disc aspiration and T8 superior endplate core biopsy. PREPROCEDURE DIAGNOSIS: T7-8 discitis/osteomyelitis. POST-PROCEDURE DIAGNOSIS: T7-8 discitis/osteomyelitis. ANESTHESIA: Moderate sedation was provided by administering divided doses of fentanyl and midazolam throughout the total intra-service time of 37minutes during which the patients hemodynamic parameters were continuously monitored. In total, the patient received 100mcg of fentanyl and 2mg of midazolam. PHYSICIANS: Dr. ___ (attending physician), and Dr. ___ ___ (fellow). PROCEDURAL DETAILS AND FINDINGS: Prior to the procedure, written informed consent was obtained and the patient demonstrated good understanding of the indication, risks, benefits and alternatives. The patient was brought to the angiography suite and placed in a prone position on the angiography table. A preprocedural timeout was performed using standard ___ protocol. The skin was prepped and draped in typical sterile fashion. Fluoroscopic guidance was used to select the T7-T8 level. Confirmation of appropriate level was made by repeating counting from the ___ and 12th ribs by 3 independant observers. Local anesthetia was achieved with 1% lidocaine 3.5cm to the left of the midline. Thereafter, an 11-gauge ___ needle was carefully advanced under biplane fluoroscopic observation lateral to the left pedicle and into the intervertebral disc space. Multiple disc space aspirates taken. Thereafter, the ___ was used for guidance and an 11g ___ biopsy needle was advanced through it, into the T8 superior endplate under biplane fluoroscopic observation. This was used to take 3 core biopsy samples (1 of which was fixed in formalin for pathology, 2 of which were sent for requested microbiology evaluation). Finally, the Acerman needle was removed, the stylet of the ___ needle was replaced and then the ___ needle was carefully removed. Pressure was maintained at the dermatotomy site until good hemostasis was achieved. A dry sterile dressing was applied, and the patient was transferred from the angiography suite in stable condition. IMPRESSION: Successful 11g core needle biopsy of the T8 superior endplate (x 3) and T7-8 disc aspirate. Specimens were sent to pathology/microbiology for the requested laboratory analysis. Results are pending. Radiology Report HISTORY: Discitis osteomyelitis with right lower lobe pneumonia. TECHNIQUE: Contiguous axial MDCT images were obtained through the chest, abdomen, and pelvis after the administration of 130 cc of Omnipaque intravenous contrast using a split bolus technique. Coronal and sagittal reformats were also obtained, as well as reformats using bone algorithm. DLP: 399.76 mGy-cm. COMPARISON: MRI thoracic spine ___. Chest x-ray ___. FINDINGS: There are stable small bilateral pleural effusions with associated atelectasis and pleural thickening. In addition there are ___ opacities in the right middle and lower lobes, consistent with infection. There is no pneumothorax. The heart, pericardium, and great vessels are unremarkable. Again seen is evidence of known discitis-osteomyelitis with destructive change of the T7 and T8 vertebral bodies. There is no further loss of height of the T7-T8 complex since the study on ___. Patient has had laminectomies at these levels. Also noted is an irregular lucency consistent with non-acute fracture of the left articular facet of T7. Adjacent air-containing fluid collections are minimally progressed in the interval: a fluid collection and a collection posterior to the aorta are slightly larger, and there is a new small fluid collection medial to the aorta in the left paravertebral area (2:34) measuring 23 mm x 7.5 mm. There is scattered mediastinal lymphadenopathy. The liver enhances homogeneously without focal lesion or intrahepatic biliary ductal dilatation. The spleen is homogeneous and normal in size. The gallbladder is unremarkable, and the portal vein is patent. The pancreas is unremarkable without a focal lesion, peripancreatic stranding, or fluid collection. The bilateral adrenal glands unremarkable. The kidneys presents symmetric nephrograms and excretion of contrast without solid or cystic lesions. There is a duodenal diverticulum, and diverticula are also noted in the descending colon. There is no wall thickening or obstruction in the small or large bowel. There is no ascites. IMPRESSION: 1. Redemonstration of osteomyelitis-discitis at T7-T8 with slight increase in the previously seen paravertebral fluid collections and a new small paravertebral collection as described above. 2. ___ opacities in the right middle and lower lobes, consistent with infection. Stable bilateral pleural effusions. Radiology Report INDICATION: T7/T8 osteomyelitis/discitis with prevertebral fluid collection and treated for possible right lower lobe pneumonia, needs pre-operative evaluation prior to surgery. COMPARISON: ___. TECHNIQUE: PA and lateral chest radiograph, two views. FINDINGS: Heart size is top normal. Again appreciated is extensive opacity involving the right lower lobe, which is slightly improved compared to ___. Small amount of fluid is seen tracking along the right major fissure. Left lung is clear. There is no pneumothorax. Again noted is destruction of the T7/T8 interspace with marked wedging of adjoining vertebral bodies compatible with the given diagnosis of osteomyelitis/discitis. IMPRESSION: 1. Minimal improvement in right lower lobe pneumonia with persistent effusion tracking along the major fissure. 2. Endplate destruction of the T7/T8 interspace compatible with given diagnosis of osteomyelitis/discitis. Radiology Report CHEST RADIOGRAPH INDICATION: Spinal abscess, status post thoracotomy, evaluation for interval change. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, there is no relevant change. The right chest tube is in constant position. Unchanged small pleural effusion and atelectasis at the right lung bases. The plate-like atelectasis on the left is constant in appearance. Unchanged size of the cardiac silhouette. No pneumothorax. Radiology Report PORTABLE AP CHEST X-RAY INDICATION: Patient with spinal abscess T7-T8, thoracotomy, washout. Evaluate for right pneumothorax. COMPARISON: ___. FINDINGS: Moderate subcutaneous air is due to recent surgery. There is no pneumothorax and right chest tube projects at right lung base. Bibasilar consolidation presumed to be atelectasis, right more than left is unchanged. Cardiac contour is normal. There is no pleural effusion. CONCLUSION: Patient just had surgery for thoracic spine abscess. There is no pneumothorax. Moderate subcutaneous air is due to the surgery. Radiology Report CHEST RADIOGRAPH INDICATION: Chest tube, evaluation. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, there is no relevant change. The position of the chest tube at the bases of the right lung is constant. No relevant changes in extent and severity of the pleural effusion with an intrafissural component. The lung volumes remain overall low and no overt pulmonary edema is present. Unchanged size of the cardiac silhouette. Radiology Report PORTABLE CHEST OF ___ COMPARISON: ___ radiograph. FINDINGS: Status post removal of right-sided chest tube, with persistent small right pleural effusion and no visible pneumothorax. Cardiomediastinal contours are stable in appearance. Atelectatic changes in both lower lobes appear relatively similar compared to the prior radiograph except for slight worsening in the left retrocardiac region. Radiology Report HISTORY: ___ man, status post I&D of T7/T8 osteomyelitis and discitis. Evaluate for postoperative changes and residual collection. COMPARISON: Outside MRI thoracic spine on ___ and in-house MR thoracic spine on ___. Of note, two previous MRI thoracic spine was performed without contrast. CT chest and abdomen on ___. TECHNIQUE: Multiplanar, multisequence T1- and T2-weighted images were acquired through the thoracic spine before and after administration of IV gadolinium contrast. FINDINGS: Allowing for difference in technique between the previous non-contrast MRI studies and the current contrast-enhanced MRI study, again noted is the T7/T8 discitis osteomyelitis, with severe osseous destruction of both vertebral bodies, grossly unchanged compared to ___, but demonstrating progressive destruction since ___. There is similar diffuse marrow abnormality at T7 and T8 vertebral bodies. There are similar post-operative posterior decompression from T7 and T8 laminectomies. The rim-enhancing T7/T8 intervertebral disc collection measures up to 9 mm in maximum thickness. This collection is in direct communication with the large right-eccentric anterior paraspinal collection, which measures approximately 2.5 x 7.9 x 7.4 cm (AP x SI x TV). The collection extends to the right pleural space. There are additional, but smaller rim-enhancing pleural-based collections bilaterally, representing empyemas. Extensive adjacent air-space consolidations are noted in the lung bases, better assessed in the recent CT chest and abdomen on ___. There is exaggerated kyphosis centered at T7-8 level, but without significant alignment changes since ___. There is corresponding kyphotic curvature of the cord at T7/8, but without evidence of cord compression. The cord demonstrates no leptomeningeal enhancement. The corresponding anterior epidural space is thickening and enhancement. There is no evidence of interval dissemination of infection to the other vertebral levels. The remaining vertebral bodies are normal in height and signal intensity. Again incidentally noted is a T1- and T2- hyperintense lesion in the T2 vertebral body, compatible with a low-flow vascular malformation (formerly, "hemangioma"). No other focal vertebral bone marrow abnormality is seen IMPRESSION: 1. Allowing for the difference in technique between non-contrast and contrast-enhanced MR studies, there has been no significant short-interval change in the degree of osseous destruction at the T7-8 level since ___, but there is progressive osseous destruction since an earlier study of ___. 2. The current contrast-enhanced study better characterized\s the T7-8 spondylodiscitis and vertebral osteomyelitis, demonstrating an intervertebral rim-enhancing collection in direct communication with the large right-sided paraspinal/pleural collection, likely empyema. 3. Multiple additional smaller loculated pleural-based collections in the lung bases, compatible with additional empyemas. Extensive adjacent airspace consolidations in the lung bases representing with ongoing pneumonia. Clinical concern is raised for the proximity of the collections to the descending aorta, with potential for infectious aortitis. Radiology Report HISTORY: T7-T8 osteomyelitis discitis and para-vertebral abscess status post thoracotomy, drainage and debridement on ___. Now with recurrent fevers. TECHNIQUE: MDCT data were acquired through the thoracic spine after the uneventful administration of 90 cc of contrast. Images were displayed in multiple planes. COMPARISON: MRI ___. CT chest and abdomen ___. FINDINGS: Destructive changes of the T7 and T8 vertebral bodies are unchanged since ___. There are post-laminectomy changes at this these levels. A fracture through the left T7 articular facet is stable. Large paravertebral fluid collections are unchanged since MRI ___. The right pleural/paravertebral collection measures up to 7 cm transverse. The left-sided collection measures 3 cm AP (3:56. 3:69). There is an additional 2 cm collection within the collapsed left lower lobe (3:58), also stable. All the aforementioned fluid collections have rim enhancement. Bibasilar pulmonary volume loss is incompletely assessed. IMPRESSION: Re-demonstration of osteomyelitis-discitis at T7-T8. Bilateral paravertebral fluid collections, greatest on the right, are unchanged since MRI ___. Radiology Report HISTORY: T7-T8 osteomyelitis discitis. TECHNIQUE: MDCT data were acquired through the chest without intravenous contrast. Images were displayed in multiple planes. COMPARISON: CT thoracic spine yesterday and thoracic spine MRI ___. CT chest and abdomen ___. FINDINGS: There has been no change in the appearance of T7-T8 osteomyelitis-discitis and adjacent paraspinal and pleural fluid collections. There has been no new intervention since the prior exam. Bilateral paravertebral rim enhancing collections communicate with small bilateral pleural effusions. There is associated atelectasis, but no nodule, consolidation or pneumothorax. The thyroid gland enhances homogeneously. There is no supraclavicular or axillary adenopathy. Subcarinal and right hilar nodes are enlarged. Heart size is normal. There is no pericardial effusion. LAD and circumflex coronary artery calcifications are moderate. There is no pericardial effusion. The sizes of the aorta and pulmonary trunk are normal. Limited views of the upper abdomen show no abnormalities. Severe compression deformities and osteolyic destruction of the end plates of T7 and T8 are unchanged. IMPRESSION: Re- demonstration of osteomyelitis-discitis at T7 -T8 surrounded by bilateral paravertebral and pleural collections. There is no change since MRI of ___ and CT yesterday, ___. Radiology Report HISTORY: PICC placement. FINDINGS: In comparison with study of ___, there has been placement of a right subclavian PICC line that extends into the right atrium. It could be pulled back about 2.5 cm to be within the lower SVC. Although the patient has taken a slightly poor inspiration, the opacification at the right base have decreased. Atelectatic changes are still seen bilaterally. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: LOW BACK PAIN Diagnosed with BACKACHE NOS, PNEUMONIA,ORGANISM UNSPECIFIED temperature: 99.8 heartrate: 98.0 resprate: 18.0 o2sat: 100.0 sbp: 183.0 dbp: 102.0 level of pain: 8 level of acuity: 3.0

•If you have staples, keep your wound clean and dry until they are removed. • No tub baths or pool swimming for two weeks from your date of surgery. •Do not smoke. •No pulling up, lifting more than 10 lbs., or excessive bending or twisting. •Limit your use of stairs to ___ times per day. •Have a friend or family member check your incision daily for signs of infection. •Take your pain medication as instructed; you may find it best if taken in the morning when you wake-up for morning stiffness, and before bed for sleeping discomfort. Pain medication should be used as needed when you have pain. You do not need to take it if you do not have pain. •Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc. for two weeks. •Increase your intake of fluids and fiber, as pain medicine (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. •Loss of control of bowel or bladder functioning •You have to wear you TLSO brace at all times when you are at 30 degrees or more in bed. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: •Pain that is continually increasing or not relieved by pain medicine. •Any weakness, numbness, tingling in your extremities. •Any signs of infection at the wound site: redness, swelling, tenderness, and drainage. •Fever greater than or equal to 101.5° F. •Loss of control of bowel or bladder functioning

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Keflex Attending: ___. Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old female with diastolic dysfunction and COPD presenting with 1 week of dyspnea that acutely worsened today with associated mild swelling in the legs and generalized fatigue. On arrival to the ED the patient triggered for room air sat of 80% and became intermittently somnolent with noted bilateral crackles on exam. Given concern for somnolence ABG was obtained with pH 7.21/PCO2 85/PaO292/HCO3 36 with hypercapnea for which BIPAP was started. Initial concern for CHF exacerbation for which cardiology was consulted though ultimately determined that patient had a mixed picture and so recommended admission to the MICU. Per report patient has been exposed to sick contacts in her family with viral illness. Additionally patient noted to have fever to 100.4. In the ED initial vitals showed temp 97.9, HR 79, BP 125/41, RR 21. In the ED the patient was given 1000 mg IV vanco and levofloxacin. Labs in the ED were notable for WBC 10.0, Hg 12.4, Hct 41.6, platelets 213. Chem-7 notable for Na 134, K 5.0, Cl 95, bicarb 29, BUN 103, Cr 1.6, glucose 140. Trop elevated to 0.12 repeat 0.10. BNP 30788. EKG showed T wave inversions. UA negative for signs/symptoms of infection. In the ED the patient was evaluated by cardiology who felt patient's picture was mixed and not consistent with CHF exacerbation alone. For this reason it was determined that she should be admitted to the MICU team. On transfer, vitals were: Temp 99.9, BP 104/65, HR 72, RR 25, 98% RA On arrival to the MICU, the patient has BIPAP in place. She is able to nod yes/no to some questions though exam and interview is limited by BIPAP and patient's hearing impairment. The patient denies chest pain, fever, diarrhea, nasuea, or vomitting. Per discussion with her children the family notes that the patient has had ongoing dyspnea for 1 week after vacation in ___ and was exposed to grandchildren who were febrile reportedly. Per report she has not had any infectious symptoms as a result including fever, chills, cough, or wheezing. Per report mid-week her mental status declined at about the same time when she had reported worsening lower extremity pain and started taking higher doses of tramadol up to 200 mg three times per day. She additionally had a fall forward onto her knees while being moved out of a chair today and did not have a head strike. This entire episode was witnessed by her family. Past Medical History: - Lymphoma, in remisssion since ___ - ___ - Spinal stonsis, leg weakness and bowel/bladder incontinence at baseline - Atrial fibrillation s/p cardioversion - COPD - Glaucoma Social History: ___ Family History: No known history of cardiac disease. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: afebrile BP: 90/31 P: 62 CPAP FIO2 .36 PEEP 5 GENERAL: somnolent but awakens to voice and mild sternal rub. Follows simple commands. HEENT: Sclera anicteric, NECK: supple, JVP not elevated, no LAD LUNGS: Bilateral upper airway sounds secondary to ventilation CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no edema, bilateral lower extremity dressing in place. Left leg with dressing over posterior calf. SKIN: Back with dressing in place over wound from prior spinal stenosis surgery NEURO: grossly intact, able to follow simple commands DISCHARGE PHYSICAL EXAM: VS - 98.5 64 120/65 18 98%2L Weight: 83.7kg General: elderly female in NAD, lying comfortably in bed HEENT: MMM, EOMI, JVD to mid neck at 45 degrees, PEERL NEURO: AAOx3, CNII-XII intact, moving all extremnities, sensation grossly intact to light touch CV: Regular rate, no MRG, normal S1 and S2 Lungs: Bilateral crackles, no increased work of breathing Abdomen: soft, nontender, nondistended, no HSM appreciated Ext: WWP, trace edema below knees, trace edema in thighs bilaterally Pertinent Results: ADMISSION LABS: ___ 04:00PM BLOOD WBC-10.0# RBC-4.54 Hgb-12.4 Hct-41.6 MCV-92 MCH-27.3 MCHC-29.8* RDW-15.3 RDWSD-49.7* Plt ___ ___ 04:00PM BLOOD ___ PTT-24.8* ___ ___ 04:00PM BLOOD Glucose-140* UreaN-103* Creat-1.6* Na-139 K-5.0 Cl-95* HCO3-29 AnGap-20 ___ 04:00PM BLOOD cTropnT-0.12* ___ 02:00AM BLOOD Calcium-8.3* Phos-5.9*# Mg-2.6 ___ 04:17PM BLOOD Comment-GREEN TOP INTERVAL LABS, IMAGING: ___ 04:00PM BLOOD cTropnT-0.12* ___ 10:05PM BLOOD cTropnT-0.10* ___ 02:00AM BLOOD CK-MB-2 cTropnT-0.08* - ___ CXR No acute cardiopulmonary abnormality. - ___ BILATERAL KNEE XR Osteopenia. Status post right TKR. Severe left knee osteoarthritis. No fracture or dislocation detected in either knee on the available views. No right knee hardware loosening or failure detected. - ___ BILATERAL HIP XR Severe right and mild to moderate left hip osteoarthritis. No definite fracture detected involving either hip. If there is ongoing clinical suspicion for fracture, then CT or MRI could help further assessment. No displaced fracture detected about the pelvis. Microbiology ============================== ___ 5:00 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. SECOND MORPHOLOGY. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | KLEBSIELLA PNEUMONIAE | | AMPICILLIN/SULBACTAM-- <=2 S 4 S CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- 32 S 32 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S ___ 4:00 pm BLOOD CULTURE Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CLUSTERS. Reported to and read back by ___ ___ ___ 10:55AM. DISCHARGE LABS: ___ 06:55AM BLOOD WBC-4.9 RBC-3.61* Hgb-9.8* Hct-33.4* MCV-93 MCH-27.1 MCHC-29.3* RDW-14.6 RDWSD-48.4* Plt ___ ___ 06:55AM BLOOD Glucose-96 UreaN-69* Creat-1.2* Na-148* K-3.9 Cl-103 HCO3-39* AnGap-10 ___ 06:55AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.1 Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Metoprolol Succinate XL 25 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 5. Mirtazapine 7.5 mg PO QHS 6. Torsemide 40 mg PO DAILY 7. TraMADOL (Ultram) 25 mg PO Q8 HOURS PRN pain 8. Docusate Sodium 100 mg PO BID Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Docusate Sodium 100 mg PO BID 3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 5. Metoprolol Succinate XL 25 mg PO DAILY 6. Mirtazapine 15 mg PO QHS 7. Torsemide 40 mg PO DAILY 8. Duloxetine 20 mg PO DAILY 9. Acetaminophen 650 mg PO Q6H:PRN pain Discharge Disposition: Extended Care Facility: ___ ___ Discharge Diagnosis: Primary: Acute respiratory failure Secondary: ___ exacerbation Opioid overdose COPD exacerbation UTI Type II NSTEMI Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with dyspnea and history of congestive heart failure TECHNIQUE: Portable upright AP view of the chest COMPARISON: ___ FINDINGS: Moderate enlargement of the cardiac silhouette persists. The aorta remains tortuous. Hilar contours are relatively unchanged. There is no pulmonary edema. Minimal streaky atelectasis is noted lung bases without focal consolidation. No pleural effusion or pneumothorax is present. Clips from prior cholecystectomy are demonstrated in the right upper quadrant of the abdomen. Partially imaged is cervical spinal fusion hardware. Degenerative changes are noted throughout the imaged thoracolumbar spine as well as within the glenohumeral joints bilaterally. IMPRESSION: No acute cardiopulmonary abnormality. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with diastolic dysfunction and hypercarbia presenting with respiratory distress // evaluate for pulmonary edema COMPARISON: ___ at 16 16 FINDINGS: The patient's chin and mask overlie and obscure the upper portion of both lungs. Inspiratory volumes are lower than on the prior film and the patient appears more kyphotic. Allowing for this, the cardiomediastinal silhouette is grossly unchanged. Mild vascular plethora and bibasilar atelectasis is similar to the prior film. No frank consolidation or gross effusion. Incidental note made of bilateral severe glenohumeral osteoarthritis. IMPRESSION: As above. Radiology Report EXAMINATION: BILAT HIPS (AP,LAT AND AP PELVIS) INDICATION: ___ year old woman s/p fall w/ hip pain // r/o fracture TECHNIQUE: AP pelvis an AP and frog-leg lateral views of both hips. No cross-table lateral views available. COMPARISON: None. FINDINGS: Right hip: Severe osteoarthritis, with bone-on-bone narrowing of the joint and prominent surrounding osteophytes. Subchondral cyst or possible slight flattening along the superomedial femoral head is present . Probable subtle acetabular protrusio. Linear density across the neck is likely an artifact due to overlying osteophytes. No definite fracture is detected. Left hip: There are mild to moderate degenerative changes, with probable joint space narrowing inferomedially and with marginal osteophytes. Allowing for the use of the frog-leg lateral view, no fracture is detected. Pelvis: The pelvic girdle is grossly congruent. The sacrum is considerably obscured by overlying bowel gas. No displaced fracture is identified . Vascular calcification and injection granulomas noted. IMPRESSION: Severe right and mild to moderate left hip osteoarthritis. No definite fracture detected involving either hip. If there is ongoing clinical suspicion for fracture, then CT or MRI could help further assessment. No displaced fracture detected about the pelvis. Radiology Report EXAMINATION: KNEE (2 VIEWS) BILATERAL INDICATION: ___ year old woman s/p fall // r/o acute fracture TECHNIQUE: AP and lateral views of both knees. No oblique view available. COMPARISON: None. FINDINGS: Right knee: Severe diffuse osteopenia. Status post 3 component knee prosthesis, in overall anatomic alignment. No fracture or dislocation is detected. No hardware loosening or failure is identified. Possible joint effusion, but no lipohemarthrosis seen on the cross-table lateral view. Extensive heterotopic ossification is noted anterior to the distal femur. Left knee: There is diffuse osteopenia. There is severe osteoarthritis, with femorotibial joint space narrowing and tricompartmental spurring. Probable joint effusion, but no definite lipohemarthrosis is detected on the cross-table lateral view. A small amount of heterotopic ossification is seen anterior to the distal femur. If there is continuing concern for an occult fracture in the right knee, then CT could help for further assessment. IMPRESSION: Osteopenia. Status post right TKR. Severe left knee osteoarthritis. No fracture or dislocation detected in either knee on the available views. No right knee hardware loosening or failure detected. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with COPD, CHF exacerbations // Interval change Interval change COMPARISON: Chest radiographs ___. IMPRESSION: Mild interstitial edema has developed since ___. Mild cardiomegaly is long-standing. Pleural effusions are small if any. No pneumothorax. Band of atelectasis at the base of the right lung is the only focal pulmonary abnormality. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Dyspnea Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION temperature: 97.7 heartrate: 79.0 resprate: 21.0 o2sat: 97.0 sbp: 125.0 dbp: 41.0 level of pain: 0 level of acuity: 1.0

Dear ___, ___ were admitted to the hospital for severe difficulty with breathing. We feel this was due to taking too much tramadol, along with your COPD and congestive heart failure. We treated with a drug to reverse the tramadol, and antibiotics and ___ improved. The physical therapists saw ___ and recommended ___ go to an acute rehab facility to help with your care and improve your strength. Please continue to take your medications as directed. Also please weigh yourself every morning, and call MD if weight goes up more than 3 lbs. Finally, please stop taking your tramadol. We have replaced it with a medication called duloxetine which will not have the same side effects. It was a pleasure taking care of ___. Best of luck, Your ___ medical 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: Weakness and fall Major Surgical or Invasive Procedure: N/A History of Present Illness: Mr. ___ is an ___ with a h/o HTN and DM2 who presented with a fall. History obtained from medical record as patient is not reliable. Per ED and SW notes: According to his wife, the patient fell last night while walking to the door when he tripped and fell to the right. He was on the floor for 13 hours before EMS was called; per wife he is stubborn and she thought he could get up. SW was involved in the ED and called Elder Protective services as his wife appeared confused. Daughter also lives at home. In the ED pt deined LOC, cp/sob, f/c/s, presyncope, but was feeling weak prior to fall. When EMS arrived he was prone in the bedroom, cool, confused, slow to answer questions, FSG was 467. Per wife has had multiple falls recently but usually gets up. In the ED, initial VS were T: 97.9, HR: 100, BP: 116/79, RR: 14, O2%: 94%, FSBG: 402. Exam was notable for abrasions on the bilateral knees and R elbow. He also had a normal rectal tone initially with guaiac negative stools. Had maroon colored emesis in the ED and guaiac positive one hour after arrival, NG tube placed. KUB shot, read pending, per report not c/w obstruction. Labs: BUN 88 and creatinine of 3.0 (unknown baseline), CK of 1808, Trop-T of 0.04, WBC of 18.4 (86%N), and lactate of 3.2. Glu 513. Ca ___ alb 3.8. Repeat lactate 2.4. Urine >186 Wbc's, mod bacteria, no epis. CXR without acute cardiopulmonary processes or signs of infection. C-spine showed no evidence of acute fracture or prevertebral soft tissue abnormality. CT head showed no acute hemorrhage or fracture. GI was consulted in the ED for occult positive gastric contents on NG lavage and maroon vomitus, they recommended 40mg bid po ppi. Patient received 3L of NS, 40 mg of IV pantoprazole, 8 units of insulin (regular), ceftriaxone Transfer VS were Today 19:27 0 98.2 104 135/83 23 95% RA FSBG: 499. On arrival to the floor, patient says he feels well in spite of everything that's happened. After arrival to floor, ED resident paged that NG tube needed to be advanced. Tip was not clearly visible on CXR but it was at 60cm with some dark material present in tube. Given no recent vomiting and likelihood that it was coiled, it was removed. Past Medical History: Stage 3 CKD Diverticulosis Diabetes type 2 Hyperlipidemia HTN Cognitive impairment Obesity Social History: ___ Family History: Noncontributory Physical Exam: ADMISSION VS - 98.8 159/86, 78, 22 General: Sleepy, AOx3 but difficulty maintaining attention during interview HEENT: Dry MM, EOMI, NG tube draining dark fluid Neck: beard obscures neck veins CV: ___ systolic murmur loudest RUSB Lungs: CTAB Abdomen: Obese, nt/nd Ext: no c/c/e Neuro: MAE Skin: no rashes DISCHARGE VS (stable except as noted): 98.3 178/90 78 20 94/ra General: More awake compared to yesterday, NAD, lying in bed comfortably. HEENT: Dry MM, EOMI Cardiac: Normocardic, regular, ___ systolic murmur loudest RUSB Vasc: extr wwp without ___ edema Lungs: CTAB Abdomen: Obese, nt/nd Neuro: AOx3, maew Skin: no rashes Pertinent Results: ================================ LABS ================================ Admission labs: 134 | 99 | 88 AGap=19 ---------------<513 4.5 | 21 | 3.0 Ca: 10.4 Mg: 2.1 P: 4.1 18.4 > 15.3/44.6 < 264 N:86.1 L:7.5 M:6.0 E:0.2 Bas:0.2 Lactate:3.2 CK: 1808 Trop-T: 0.04 UA: Urine >186 Wbc's, mod bacteria, no epis ================================ STUDIES ================================ CXR (___): NO acute cardiopulmonary processes or signs of infection. C-spine (___): no evidence of acute fracture or prevertebral soft tissue abnormality. CT head (___): showed no acute hemorrhage or fracture KUB (___): Nonobstructive bowel gas pattern without evidence of free intraperitoneal air. EKG ___: sinus with pac's rate 96bpm, q waves in III and aVF suggest old inf MI Echo ___: Conclusions The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF = 70%). There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. There are focal calcifications in the aortic arch. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (valve area = 1.1cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a prominent fat pad. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Hydrochlorothiazide 12.5 mg PO DAILY 2. Losartan Potassium 100 mg PO DAILY 3. Simvastatin 40 mg PO QPM 4. Glargine 50 Units Breakfast Glargine 42 Units Dinner Humalog 15 Units Breakfast Humalog 50 Units Lunch Discharge Medications: 1. Losartan Potassium 100 mg PO DAILY 2. Simvastatin 40 mg PO QPM 3. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days Day 1 = ___. Should be continued for 10 day course for complicated UTI. 4. Docusate Sodium 100 mg PO BID:PRN constipation 5. Polyethylene Glycol 17 g PO DAILY:PRN constipation 6. Senna 8.6 mg PO BID:PRN constipation 7. Glargine 50 Units Bedtime NPH 15 Units Breakfast Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Enterococcus UTI, hyperglycemia due to poorly controlled T2DM, ___ and hypernatremia caused by hyperglycemia. Code status: Full Discharge follow-up with Dr. ___ (PCP) (___) Discharge Condition: Ambulating comfortably off O2 and taking a full diet without difficulty. Mentating at baseline. Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. 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: Status post fall with confusion. Evaluate for hemorrhage or fracture. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed images were obtained. CTDIvol: 53.6 mGy DLP: 1003.4 mGy-cm COMPARISON: None available. FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles and sulci are prominent, likely related to age-related involutional changes. Periventricular white matter hypodensities are consistent with chronic small vessel ischemic disease. No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: No acute hemorrhage or fracture identified. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: Status post fall with confusion. Evaluate for fracture. TECHNIQUE: Contiguous axial images were obtained. Sagittal and coronal reformatted images were generated. No contrast was administered. CTDIvol: 66.9 mGy DLP: 829.7 mGy-cm COMPARISON: None available. FINDINGS: Mild anterolisthesis of the C3 and C4 vertebral bodies is likely degenerative. Alignment is otherwise normal. No fractures are identified. Multilevel degenerative changes are noted, most notable for intervertebral disc height loss, posterior osteophyte formation and uncovertebral joint hypertrophy. These changes result in up to moderate canal narrowing at C4-C5 and severe left foraminal narrowing at C5-C6. There is no prevertebral soft tissue abnormality. Thyroid and lung apices are unremarkable. Atherosclerotic calcifications noted at the carotid bulbs and proximal ICAs bilaterally. IMPRESSION: 1. No acute fracture or prevertebral soft tissue abnormality of the cervical spine. 2. Mild anterolisthesis of the C3 on C4 vertebral bodies is likely degenerative. Radiology Report INDICATION: ___ with fall, weakness // eval for PNA TECHNIQUE: Single supine view of the chest. COMPARISON: Correlation made to same day CT of the cervical spine. FINDINGS: Relatively low lung volumes are noted. The lungs are grossly clear without confluent consolidation or evidence of pneumothorax on this supine film. Cardiac silhouette is within normal limits for technique. There is widened upper mediastinum compatible with prominent mediastinal fat seen on concurrent chest CT. No displaced fractures identified. IMPRESSION: The lung volumes without acute cardiopulmonary process. Radiology Report EXAMINATION: CHEST (AP AND LATERAL) INDICATION: History: ___ with emesis, maroon positive, // please eval for obstruction and ng tube placement TECHNIQUE: Upright AP and lateral views of the chest COMPARISON: ___ at 14:44 FINDINGS: There has been interval placement of a nasogastric tube with the tip not visualized beyond the upper esophagus on the frontal view. While the lateral view demonstrates a catheter which courses in the expected region of the esophagus and into the upper abdomen, this cannot be confirmed on the frontal view. The heart size is mildly enlarged. Mediastinal and hilar contours are unchanged. Pulmonary vasculature is not engorged. No focal consolidation, pleural effusion or pneumothorax is detected. Streaky atelectasis is noted in the lung bases. Compression fracture of a vertebral body at the thoracolumbar junction is noted, of indeterminate age. No subdiaphragmatic free air is present. IMPRESSION: Nasogastric tube tip can only be traced to the proximal esophagus on the frontal view. Recommend advancement. Radiology Report INDICATION: History: ___ with emesis maroon positive, // please eval for obstruction and ng tube placement TECHNIQUE: Supine and upright AP views of the abdomen COMPARISON: Chest radiograph obtained at 20:17, ___ FINDINGS: No enteric tube is identified. The bowel gas pattern is nonobstructive. Moderate amount of stool is seen in the rectum. There are no dilated loops of small bowel, free intraperitoneal air, or concerning soft tissue calcifications demonstrated. Mild degenerative changes are noted in the imaged thoracolumbar spine. IMPRESSION: 1. No enteric tube identified. 2. Nonobstructive bowel gas pattern without evidence of free intraperitoneal air. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Weakness, Hyperglycemia, s/p Fall Diagnosed with OTHER MALAISE AND FATIGUE, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN temperature: 97.9 heartrate: 100.0 resprate: 14.0 o2sat: 94.0 sbp: 116.0 dbp: 79.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, You were hospitalized at ___ after a fall at home. We think that fall was due to high blood sugars and a urine infection. Unfortunately, because you were on the ground for such a long time, you developed high sodium (blood salt levels) and a mild injury to your kidney from dehydration. Your blood sugars, urine infection, sodium level, and kidney injury are all getting better. If you fall again and cannot get up, please promptly call Emergency Medical Services for assistance. Please see appointments and medications below. Sincerely, Your ___ Internal Medicine Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Biaxin / Shellfish Attending: ___. Chief Complaint: ___ pain and weakness Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ yo RHW with h/o chronic LBP s/p L4-5 fusion, fibromyalgia, anxiety, depression, who presents with progressive distal lower extremity numbness and weakness for the past 3 months. The patient initially presented on ___ ___. She had awoken that morning with severe numbness below the knees bilaterally. Her legs were weak and she collapsed on attempting to stand. She had a recent stomach flu a few days prior. Examination demonstrated distal lower extremity weakness and decreased sensation to pin and vibration, with diminished lower extremity reflexes. There was concern for GBS. CSF was normal (0 cells, glucose 59, protein 24, neg CSF Lyme, neg bands). However it was thought there was still benefit to treating empirically, so patient received 3 doses IVIG. She developed fever to ___ F after 3rd dose so no more were given. She also underwent MRI C, T and L spine, and MRI/A brain which were all unrevealing. Labs were initially notable for CK almost 20K, attributed to fall, but this was mild and there was not prolonged down time. CRP 50, ESR 16, WBC 18.3. CK trended down with IVF and has been normal on repeat checks since. The pt was discharged to rehab and was then discharged home with ___. Neurologic work-up continued as an outpatient under care of Dr. ___. EMG ___ showed acute length dependent polyneuropathy with mixed axonal and demyelinating features. Motor neuropathy and paraneoplastic Abs sent to ___ were negative (GM1, GD1b, MAG, ___, CV2, amiphiphysin). Autoimmune labs neg ___, ANCA, SSa/b). On ___, CRP was down to 25, ESR 12. The patient complains of severe pain, that was not part of the initial presentation but began after returning home from rehab and doing ___. It has become more severe and refractory to medications in the past month. Pain includes R foot cramps, sharp pains at L posterior calf and feet, burning pain on soles of feet, hypersensitivity to touch that is painful on L foot. Pain is worse when putting pressure on the legs to stand, and on touching the L foot. There are no paresthesias. She will sometimes feel extreme cold but then legs are not cold to the touch. Pt also c/o losing muscle mass and bulk all over, including upper extremities, though there are no other symptoms in the upper extremities (no weakness, numbness, tingling in hands/fingers). She feels her health going downhill in general and is very discouraged. She reports her L leg bends backwards on walking. She had been using cane, but is now using a wheelchair. Of note, the patient reports that her pain medications were stolen from her 5 days ago. Since then she experienced severe withdrawal symptoms (N/V/D and extreme pain). She had not slept or ate well in days. She presented to ___ ED today, and her neurologist felt she warranted additional workup since diagnosis is unclear, and sent her to ___ ED. The patient reports she was supposed to have nerve and muscle biopsy tomorrow at ___. ___. Past Medical History: -fibromyalgia -chronic LBP on narcotics -s/p L4-5 fusion few years ago, "failed" -GAD -depression -PTSD -SBO s/p LOA -COPD vs BOOP Social History: ___ Family History: negative for neurologic disease Physical Exam: At admission: Vitals: T: 97.6 P:56 R: 14 BP:96/68 SaO2:100/ra 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. Language is fluent with naming, intact repetition and comprehension. Speech was not dysarthric. Able to follow both midline and appendicular commands. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. There was initially horizontal diplopia on far right gaze but this resolved after a few seconds and did not return on repeat testing. V: Facial sensation intact to light touch. VII: No facial droop, upper and lower facial musculature full strength and 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 with normal quick lateral movements. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. neck flexion and extension full strength Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5- 4 3 4 3 3 R 5 ___ ___ 5 5 5 5 5 4 5- There is element of giveway and poor effort in all above where weakness is noted. -Sensory: No deficits to light touch or cold. Decreased pinprick (50%) on left lower medial leg and medial and dorsal foot. Pin on left lateral foot causes severe burning. Decreased vibratory sense at L>R great toes. Intact proprioception to large amplitude movements at bilateral great toes and DIPs. No extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L 2+ 2 2+ 1 0 R 2+ 2 2+ 1 0 Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF bilaterally, cannot perform HKS. No overshoot or rebound on horizontal or vertical saccades -Gait: deferred due to pain Discharge Physical Exam: As above, except notable for normal strength in upper and lower extremities, with notable giveway weakness in the lower left extremity. Normal positioning of the left leg/foot, improved from admission. The patient was able to ambulate with a very mildly antalgic gait with a cane. Her sensation testing was notable for persistent pain and burning across the dorsum of her ___ in non dermatomal, non radicular patterns. Pertinent Results: ___ 06:50PM BLOOD WBC-18.8* RBC-6.18* Hgb-17.3* Hct-52.6* MCV-85 MCH-28.0 MCHC-32.8 RDW-14.1 Plt ___ ___ 06:50PM BLOOD Neuts-51.1 ___ Monos-5.2 Eos-0.9 Baso-1.6 ___ 06:50PM BLOOD Plt ___ ___ 06:50PM BLOOD ESR-4 ___ 06:50PM BLOOD Glucose-82 UreaN-39* Creat-0.9 Na-136 K-4.2 Cl-95* HCO3-26 AnGap-19 ___ 06:50PM BLOOD ALT-7 AST-23 AlkPhos-112* TotBili-0.4 ___ 06:50PM BLOOD Albumin-4.5 Calcium-9.9 Phos-4.2 Mg-2.3 ___ 04:10PM BLOOD CEA-5.2* ___ 06:50PM BLOOD CRP-7.7* ___ 04:10PM BLOOD HIV Ab-NEGATIVE ___ 06:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 04:10PM BLOOD CA ___ -PND CXR: IMPRESSION: No acute cardiopulmonary process. CT torso with contrast: IMPRESSION: 1. Innumerable bilateral sub-2mm pulmonary nodules some of which are calcified and shotty mediastinal lymphadenopathy. Differential includes tuberculosis/fungal infection/sarcoidosis or less likely hematogenous mets with calcification, ie osteogenic, mucinous, thyroid, breast origin. Calcification suggests a chronic granulomatous infection (TB) should be considered. Comparison with any old CT imaging is recommended. 2. Dilated CBD measuring up to 11-mm which abruptly terminates at the pancreatic head with no stone seen. Possible thickening of the duodenum at the ampulla is suspicious for malignancy. Followup ERCP/MRCP is strongly recommended. 3. 5mm indeterminate hepatic hypodensity. MRI C-T-L-spine IMPRESSION: Mild degenerative changes of the cervical, thoracic, and lumbar spine as described above. Post-surgical changes, status post disc spacers at L4-5 and L5-S1 levels. No evidence of abnormal enhancement or abnormal signal in the spinal cord. MRI head with and without contrast: IMPRESSION: Unremarkable MRI of the head with and without contrast. Medications on Admission: Morphine SR (MS ___ 100 mg PO Q12H Morphine Sulfate ___ 30 mg PO/NG Q6H:PRN pain Order date: ___ Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB/wheezing Albuterol Inhaler 2 PUFF IH Q6H:PRN sob/wheezing Order date: Potassium Chloride 20 mEq PO DAILY Duration: 24 Aspirin 81 mg PO/NG DAILY Polyethylene Glycol 17 g PO/NG DAILY:PRN Amitriptyline 100 mg PO/NG HS Pantoprazole 40 mg PO Q24H Soma *NF* (carisoprodol) 350 mg Oral q8 pain Fluticasone Propionate NASAL 1 SPRY NU DAILY traZODONE 100 mg PO/NG HS:PRN insomnia Lorazepam 1 mg PO/NG Q6H:PRN anxiety Discharge Medications: 1. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for stomach upset. 2. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 4. morphine 30 mg Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours). Disp:*30 Tablet Extended Release(s)* Refills:*0* 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. amitriptyline 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:*60 Tablet(s)* Refills:*2* 7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB/wheezing. 8. trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:*60 Tablet(s)* Refills:*2* 9. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. Disp:*30 Tablet(s)* Refills:*0* 10. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 11. carisoprodol 350 mg Tablet Sig: One (1) Tablet PO q8 (). 12. gabapentin 300 mg Capsule Sig: Instructions Capsule PO BID (2 times a day): Take 600 mg in AM and afternoon. Take 900 mg at bedtime. Disp:*200 Capsule(s)* Refills:*0* 13. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for sob/wheezing. 14. morphine 15 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*21 Tablet(s)* Refills:*0* 15. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) PO once a day. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: 1. Compression polyneuropathy, 2. Fibromyalgia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Neuro Exam: AOx3, full strength in upper extremities. Largely full strength in lower extremities with some giveway strength, likely related to pain at the left ankle. Followup Instructions: ___ Radiology Report CHEST, TWO VIEWS: ___ HISTORY: ___ female with elevated white blood cell count. Question pneumonia. FINDINGS: PA and lateral views of the chest. No prior. Small calcified granulomas are identified at the upper lungs, more numerous on the right than on the left. The lungs are otherwise clear without consolidation or effusion. The cardiomediastinal silhouette is normal. Osseous and soft tissue structures are unremarkable. IMPRESSION: No acute cardiopulmonary process. Radiology Report INDICATION: ___ female with polyradiculopathy, fevers and weight loss, here to evaluate for occult malignancy. COMPARISON: No prior studies available. TECHNIQUE: MDCT-acquired axial images were obtained from the thoracic inlet to the pubic symphysis following the uneventful administration of 100 cc Omnipaque intravenous contrast and oral contrast per oncology protocol. Coronally and sagittally reformatted images were generated and reviewed. DLP: 708 mGy-cm FINDINGS: The thyroid gland is unremarkable. No axillary, hilar, or supraclavicular lymphadenopathy is seen. Several prominent paratracheal lymph nodes measuring up to 9 mm in short axis are noted. The pulmonary arterial trunk is patent and normal in caliber. The thoracic aorta is also normal in caliber without evidence of acute aortic syndrome. There is a normal three-vessel takeoff from the aortic arch. The heart is normal in size without pericardial effusion. The esophagus is normal in appearance with a small amount of oral contrast retained in the mid-to-lower esophagus. The central tracheobronchial tree is patent to subsegmental levels. Within the pulmonary parenchyma, there are centrilobular emphysematous changes predominantly affecting the lung apices. Bibasilar atelectasis is noted. There are no pleural effusions, focal consolidations or pneumothoraces. Innumerable sub-2-mm pulmonary nodules are present bilaterally with a random distribution, but predominantly located in the right lung, some of which are calcified (for example, 3:9, 10, 22, 26, 29). No other pulmonary nodules or masses are seen. CT ABDOMEN WITH CONTRAST: The liver enhances homogeneously without perfusion defect. A focal 5-mm hypodensity is noted in the right lobe of the liver (3:47), which is too small to fully characterize by CT. No other focal liver lesion is detected. The portal venous system opacifies satisfactorily with intravenous contrast. There is mild-to-moderate central intrahepatic biliary dilatation and extrahepatic biliary dilatation with the common bile duct measuring up to 11 mm within the head of the pancreas. There is an abrupt termination of the CBD at the pancreatic head with no calcified gallstones seen. There is associated thickened appearance of the duodenum at the ampulla concerning for underlying malignancy (3:68). The gallbladder is contracted with a thick enhancing wall. The pancreatic parenchyma enhances normally, with mild atrophy of the gland noted. The spleen, bilateral adrenal glands and kidneys are unremarkable. Two splenules are incidentally noted at the splenic hilum. The stomach and duodenal bulb are distended. The intra-abdominal loops of small and large bowel are unremarkable without evidence of wall thickening or obstruction. The appendix is normal in appearance. No free air or ascites is present. There is no retroperitoneal or mesenteric lymphadenopathy. The abdominal aorta is normal in caliber with minimal calcified atherosclerosis of the distal abdominal aorta extending into the bilateral common iliac arteries proximally. CT PELVIS WITH CONTRAST: The urinary bladder, prostate, seminal vesicles, rectum, and sigmoid colon are unremarkable. There is no free pelvic fluid or inguinal/pelvic lymphadenopathy. OSSEOUS STRUCTURES: Intervertebral disc spacers are noted at the L4-L5 and L5-S1 levels. A small sclerotic area in the left paramedian sacrum (3:86) may represent a bone island. There is deformity at the right posterior superior iliac spine at the right SI joint (3:87). IMPRESSION: 1. Innumerable bilateral sub-2mm pulmonary nodules some of which are calcified and shotty mediastinal lymphadenopathy. Differential includes tuberculosis/fungal infection/sarcoidosis or less likely hematogenous mets with calcification, ie osteogenic, mucinous, thyroid, breast origin. Calcification suggests a chronic granulomatous infection (TB) should be considered. Comparison with any old CT imaging is recommended. 2. Dilated CBD measuring up to 11-mm which abruptly terminates at the pancreatic head with no stone seen. Possible thickening of the duodenum at the ampulla is suspicious for malignancy. Followup ERCP/MRCP is strongly recommended. 3. 5mm indeterminate hepatic hypodensity. Radiology Report INDICATION: ___ woman with diffuse weakness involving multiple motor and sensory nerves. COMPARISON: None. TECHNIQUE: Multiplanar, multisequence images of the head were performed with and without contrast. FINDINGS: There is no evidence of acute infarct or hemorrhage. There is no abnormal enhancement. The ventricles and sulci are age appropriate. No mass effect or midline shift. The major intracranial flow voids are preserved. The orbits are unremarkable. The paranasal sinuses are clear. IMPRESSION: Unremarkable MRI of the head with and without contrast. Radiology Report INDICATION: ___ woman with diffuse weakness involving multiple motor and sensory nerves. COMPARISON: None. TECHNIQUE: Multiplanar multisequence images of the cervical, thoracic, and lumbar spine were performed with and without contrast. FINDINGS: CERVICAL SPINE: There is normal anatomic alignment, vertebral body height, and bone marrow signal intensity. The posterior fossa is unremarkable. The spinal cord demonstrates normal signal intensity. The paraspinal soft tissues are unremarkable. At C2-3 level, there is a disc bulge, asymmetric to the left, causing mild narrowing of the left neural foramen. At C3-4 level, there is a mild disc bulge indenting the thecal sac but no significant spinal canal stenosis or neural foraminal narrowing. At C4-5 level, there is a mild disc bulge indenting the thecal sac but no significant spinal canal stenosis or neural foraminal narrowing. At C5-6 level, there is a disc bulge slightly flattening the spinal cord and causing mild narrowing of the bilateral neural foramina. At C6-7 level, there is a mild disc bulge, asymmetric to the right, indenting the thecal sac and causing mild narrowing of the right neural foramen. At C7-T1 level, there is no significant disc bulge, spinal canal stenosis, or neural foraminal narrowing. Note is made that images are degraded by motion. THORACIC SPINE: There is normal anatomic alignment, vertebral body height, and bone marrow signal intensity. The spinal cord demonstrates no abnormal signal intensity. At T6-7 level, there is a central disc protrusion indenting the spinal cord but no significant spinal canal stenosis or neural foraminal narrowing. At T7-8 level, there is a central disc protrusion indenting the spinal cord, but no significant spinal canal stenosis or neural foraminal narrowing. At T8-9 level, there is a disc bulge indenting the thecal sac but no significant spinal canal stenosis or neural foraminal narrowing. LUMBAR SPINE: There are post-surgical changes, status post disc spacer at L4-5 and L5-S1 levels. There is normal anatomic alignment, vertebral body height, and bone marrow signal intensity. The spinal cord terminates at L1-2 level with normal signal of the cauda equina nerve roots without enhancement. The paraspinal soft tissues are grossly unremarkable. Please refer to same day CT of the torso. There is no significant disc bulge, spinal canal stenosis, or neural foraminal narrowing. There is no evidence of abnormal enhancement in the cervical, thoracic, and lumbar spine. IMPRESSION: Mild degenerative changes of the cervical, thoracic, and lumbar spine as described above. Post-surgical changes, status post disc spacers at L4-5 and L5-S1 levels. No evidence of abnormal enhancement or abnormal signal in the spinal cord. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: WORSENING NEUROPATHY Diagnosed with MUSCSKEL SYMPT LIMB NEC, LEUKOCYTOSIS, UNSPECIFIED , MYALGIA AND MYOSITIS NOS temperature: 97.6 heartrate: 56.0 resprate: 14.0 o2sat: 100.0 sbp: 96.0 dbp: 68.0 level of pain: 10 level of acuity: 3.0

Ms. ___ you were admitted for further evaluation of your pain and weakness. Your weakness improved dramatically with time, nutrtional supplementation and B12. Your pain medications were adjusted a bit as whenever these medications were increased to your home regiment you became unarousable and your oxygen level would drop down. This is an indication of over medication and is dangerous. Therefore we will provide you prescriptions of the medication doses that you were on here, as detailed in the discharge medications. Please contact your regular neurologist.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ y/o male with no significant pmh who presents with left sided chest pain, found to have left upper lobe anterolateral lung abscess and pneumomediastinum. He was in his usual state of health until 3 weeks ago when he developed gradually worsening, sharp, persistent, left-sided chest pain, worse with inspiration. He also has had a mild nonproductive cough. He denies fevers, chills, chest trauma. He denies abdominal pain, joint pain, joint swelling. He denies sore throat. He has never been incarcerated, works as a ___, and has no known TB exposure or significant healthcare exposures. He initially presented to ___ on ___ following an abnormal CXR at urgent care. Because urgent care xray revealed a left upper lobe opacity, he underwent a CT scan which showed a 3.6 x 4.3cm abscess vs mass. He was discharged home with a diagnosis of PNA, and given Levaquin x4 days. Since then he has had resolution of the chest pain, but continues to have an intermittent cough. A repeat CT scan was performed ___, ordered by his PCP, which showed evolution of the mass, now with possible involvement of the pleura, as well as pneumomediastinum. Because of this he was referred to the ED at ___, and given the findings, he was transferred to ___ for further evaluation and thoracics consult. In the ___ ED, he was given IV Vancomycin. Thoracics was consulted who recommended admission to medicine with ID consult and IV Antibiotics. Regarding prior antibiotic exposures, he reports a prior 7 day course of PO Abx in ___ for a R axillary abscess. Other than this and the recent Levofloxacin, no other recent ABx. REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as per HPI Past Medical History: - left inguinal hernia repair - prior R axillary abscess treated ___ Social History: ___ Family History: Father - DM2 Grandmother - ___, breast cancer Physical Exam: ADMISSION PHYSICAL EXAM: =============================== VS: T 98.4, HR 77, BP 100/58, RR 16, 96% RA GENERAL: NAD, well appearing HEENT: AT/NC, EOMI, anicteric sclera, MMM, oropharynx clear w/o lesion or exudate NECK: supple, no LAD HEART: RRR LUNGS: CTAB, no wheezes, breathing comfortably on RA ABDOMEN: nondistended, nontender EXTREMITIES: no cyanosis, clubbing, or edema. No joint effusion or swelling. PULSES: 2+ radial 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: ============================= VS: 98.0PO 128 / 85 74 18 99 Ra GENERAL: NAD, well appearing HEENT: EOMI, anicteric sclera, MMM HEART: RRR, no murmurs LUNGS: CTAB, no wheezes/crackles, breathing comfortably on RA ABDOMEN: Soft, nondistended, nontender, +BS EXTREMITIES: WWP, no edema. NEURO: A&Ox3, moving all 4 extremities with purpose == Pertinent Results: ADMISSION LABS: ==================== ___ 07:52PM BLOOD WBC-10.4* RBC-4.25* Hgb-12.8* Hct-37.7* MCV-89 MCH-30.1 MCHC-34.0 RDW-12.2 RDWSD-39.9 Plt ___ ___ 07:52PM BLOOD Neuts-61.9 ___ Monos-8.7 Eos-1.4 Baso-0.5 Im ___ AbsNeut-6.45* AbsLymp-2.80 AbsMono-0.91* AbsEos-0.15 AbsBaso-0.05 ___ 07:52PM BLOOD Glucose-111* UreaN-13 Creat-0.9 Na-142 K-4.3 Cl-101 HCO3-28 AnGap-13 ___ 07:30AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.4 ___ 03:57PM URINE Color-Straw Appear-Clear Sp ___ ___ 03:57PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG ___ 03:57PM URINE barbitr-NEG opiates-NEG cocaine-POS* amphetm-NEG oxycodn-NEG mthdone-NEG ___ 07:30AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG PERTINENT LABS: ==================== ___ 07:30AM BLOOD TSH-5.3* ___ 03:30PM BLOOD T3-95 Free T4-1.2 ___ 08:10AM BLOOD ANCA-NEGATIVE B ___ 08:10AM BLOOD ___ CRP-29.6* ___ 07:30AM BLOOD HIV Ab-NEGATIVE ___ 07:30AM BLOOD Vanco-19.4 ___ 11:44PM URINE Hours-RANDOM Creat-62 Na-56 ___ 11:44PM URINE Osmolal-197 DISCHARGE LABS: ==================== ___ 05:54AM BLOOD WBC-9.6 RBC-4.33* Hgb-12.6* Hct-38.4* MCV-89 MCH-29.1 MCHC-32.8 RDW-12.0 RDWSD-39.2 Plt ___ ___ 05:54AM BLOOD Glucose-93 UreaN-11 Creat-1.3* Na-142 K-4.4 Cl-102 HCO3-29 AnGap-11 ___ 07:30AM BLOOD ALT-10 AST-14 LD(LDH)-141 AlkPhos-53 TotBili-0.2 ___ 05:54AM BLOOD Calcium-9.5 Phos-4.3 Mg-2.0 IMAGING: ==================== ECHO ___ The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild global left ventricular hypokinesis (LVEF = 45 %). 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 number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. JUGULAR VEIN ULTRASOUND ___ No evidence of deep vein thrombosis in the bilateral internal and external jugular veins. CHEST XRAY ___ 1. Right-sided PICC line ends at the cavoatrial junction. No evidence of pneumothorax. 2. Focal opacification located laterally within the left hemithorax likely represents infarct, secondary to adjacent pulmonary embolus as seen on CT from ___. However in a patient of this age, vasculitis cannot be entirely excluded. 3. Persistent pneumomediastinum. MICROBIOLOGY: ==================== __________________________________________________________ ___ 7:03 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. __________________________________________________________ ___ 8:21 pm BLOOD CULTURE Blood Culture, Routine (Pending): __________________________________________________________ ___ 7:52 pm BLOOD CULTURE Blood Culture, Routine (Pending): ___ 08:10AM BLOOD B-GLUCAN-PND ___ 08:10AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-PND Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Ertapenem Sodium 1 g IV DAILY RX *ertapenem [Invanz] 1 gram 1 g IV Daily Disp #*30 Vial Refills:*0 3.Outpatient Lab Work ICD-9: 513.0 Lung Abscess LABS:WEEKLY CBC with differential, BUN, Cr, AST, ALT, Total Bili, ALK PHOS FAX TO: ATTN: ___ CLINIC FAX: ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Left upper lobe mass, presumed abscess Pneumomediastinum Reduced ejection fraction Acute Kidney Injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: BILATERAL UP EXT VEINS US INDICATION: ___ yo man without significant PMHx presents with progressive lung mass and mid non-productive cough.// eval internal/external jugular veins for thrombus TECHNIQUE: Grey scale and Doppler evaluation was performed on the bilateral upper extremity veins. COMPARISON: CT from ___. FINDINGS: There is normal flow with respiratory variation in the bilateral subclavian veins. The bilateral internal and external jugular veins are patent, show normal color flow and compressibility. IMPRESSION: No evidence of deep vein thrombosis in the bilateral internal and external jugular veins. Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old man with right PICC. Evaluation for placement of right PICC. TECHNIQUE: Chest portable AP COMPARISON: CT chest from ___. FINDINGS: Right-sided PICC line ends at the cavoatrial junction. Cardiomediastinal silhouette is within normal limits. The pulmonary vasculature is normal. Focal opacification located laterally within the left hemithorax likely represents infarct, secondary to adjacent pulmonary embolus as seen on CT from ___. However in a patient of this age, vasculitis cannot be entirely excluded. There is persistent pneumomediastinum. No pleural effusion or pneumothorax is seen. There are no acute osseous abnormalities. IMPRESSION: 1. Right-sided PICC line ends at the cavoatrial junction. No evidence of pneumothorax. 2. Focal opacification located laterally within the left hemithorax likely represents infarct, secondary to adjacent pulmonary embolus as seen on CT from ___. However in a patient of this age, vasculitis cannot be entirely excluded. 3. Persistent pneumomediastinum. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Abscess, Transfer Diagnosed with Abscess of lung without pneumonia temperature: 98.6 heartrate: 68.0 resprate: 18.0 o2sat: 100.0 sbp: 90.0 dbp: 68.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, You were admitted to the hospital because you were having chest pain and the CAT scan of your chest showed a mass. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? - You were treated with antibiotics, because the mass in your lung is most likely an infection/abscess. - You were evaluated by the infectious disease team, who recommended a long course of antibiotics. - You were evaluated by the thoracic surgeons and interventional pulmonologists (lung specialists). They did not recommend biopsy or other procedures at this time because they felt the antibiotics alone should treat the infection. - You had an echo (an ultrasound of your heart) and an ultrasound of the veins in your neck. There was no evidence that the infection in your lungs had spread to those areas. - You had a PICC line placed so that you could get IV antibiotics at home. - Your blood tests showed some kidney injury. This may be from one of the antibiotics you got in the hospital. You will be taking a different antibiotic at home. Your primary care doctor ___ continue to monitor this to ensure it improves. WHAT SHOULD I DO WHEN I GO HOME? - You will need to complete at least 4 weeks of IV antibiotics. The infectious disease doctors ___ be in touch with you regarding the exact duration. - ***You will need to get blood tests each week while on antibiotics, starting on ___. *** This is to monitor for side effects. - Please keep all your follow up appointments as listed below. - You will see the infectious disease, interventional pulmonology, and thoracic surgery doctors as ___ outpatient. - You will get a repeat CAT scan of your chest in ___ as listed below to make sure the mass in your lungs improved with antibiotics. If the mass is still there, you will likely need additional testing and treatment. - It is very important not to drink alcohol or use any other recreational drugs while you are on antibiotics. WHEN SHOULD I COME BACK TO THE HOSPITAL? - If you have fevers/chills, chest pain, difficulty breathing, nausea/vomiting. - If you have pain, redness, swelling around your PICC line. It was a pleasure caring for you, and we wish you all the best. Sincerely, Your ___ 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: Unresponsive episode Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old woman with signficant PMH ESRD and Afib on coumadin with history of CVA in ___ who presents to the ED after being found unresponsive at her ECF. Per report, patient was seen normal eating breakfast at 8am. She was then found by staff unresponsive by staff sometime later, between 9am and noon, although reports are conflicting. EMS was activated and per report FSBG was normal. Her finger stick blood glucose was normal per report and without complaint. In the ED, initial VS were T 96.8 °F, P ___, RR 22, BP 136/58, O2Sat: 95 3LNC. She was was unresponsive to vocal stimulation but would withdraw all four extremities to painful stimuli. She had no apparent posturing or seizure activity. Eyes were not deviated nor had patterned movement. Gag reflex was intact and she was breathing comfortably. NCHCT and CXR showed no acute process. Initial bloodwork was remarkable for subtherapeutic INR of 1.6 and Cr of 3.5 (c/w prior). She was given narcanx2 without apparent effect. Patient was being prepared for intubation when she apparently awoke spontaneously after the ED staff left to gather supplies. She was not post ictal and was AAOx3. She had no complaints. On arrival to the floor, patient is comfortable. She notes rememberign ride in the ambulance and being in the CT scanner. She also notes someone 'pushing on my chest with their thumb'. When asked why she didn't respond, she says 'I'm not sure'. She denies SOB, cough, abominal pain, nausea or vomiting. She has no dysuria and has been moving her bowels well. She denies recent fevers or chills. She denies new weakness or numbness. She does note increased blurriness of her vision and does not like the artificial tears recently started. Of note, she has had multiple recent admissions. She was admitted with initiation of HD for ESRD from ___ to ___. She was then readmitted with SOB contributed to under UF and mild COPD exacerbation from ___ to ___. During this last admission, zyprexa was started qhs for sundowning. Past Medical History: - CVA ___ when temporarily off coumadin, cannot fully extend left arm. Strength mostly regained following ___. - Afib on coumadin, goal INR ___ - ESRD ___ Polycystic kidney disease diagnosed ___ years ago. Also hypertensive nephrosclerosis. Initiated on hemodialys ___ - Colon cancer s/p right hemicolectomy and chemotherapy in ___. - Diverticulosis with numerous GI bleeds requiring transfusion - Abdominal aortic aneurysm s/p surgery in ___ at ___. - Chronic anemia - Hypertension - Arthritis - S/p right hip replacement, inferior pubic ramus fracture Social History: ___ Family History: Positive for arthritis, throat cancer in her father, and ___ dementia in her mother. Physical Exam: PHYSICAL EXAM ON ADMISSION: VS - Temp 98.2 F, BP 140/72, HR 96, RR 20, O2-sat 99% RA GENERAL - Thin elderly woman in NAD, comfortable, appropriate HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - Mildly labored on room air and speaking in short sentences. Fair air movment. No wheeze noted. Soft crackles at bases. HEART - PMI non-displaced, RRR, no MRG, soft S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ left deltoid, sensation grossly intact throughout, cerebellar exam notable for intention tremor of left arm on FTN, gait deferred NEUROLOGY CONSULT PHYSICAL EXAM: Tm 98.3 Tc 98.3 HR 70 BP 130/75 RR 18 O2Sat 94% RA Physical Exam Gen: lying comfortably on dialysis bed, interactive and in NAD, cachectic HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity. Pulmonary: Crackles heard bilaterally anteriorly in bases. Not in respiratory distress. Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, no masses or organomegaly noted. No rebound or guarding. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: some bruises in lower extremities. No other lesions noted. Neurologic: -Mental Status: Patient is alert and oriented to ___, date and her name, and able to follow complex and appendicular commands. Patient is interactive with attention intact (able to spell WORLD backwards). Patient is able to calculate. No tactile neglect to DSS. Speech is fluent with intact prosody. Naming intact to high and low frequency words. Repetition and comprehension are intact. Memory and recall are intact. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. Fundoscopic exam w/ no papilledema. III, IV, VI: EOM intact, normal saccades. V: Facial sensation intact to touch. VII: No facial droop, facial musculature symmetric. VIII: some hearing loss in left ear, but able to hear bilaterally. IX, X: Palate elevates symmetrically. XI: Able to shrug shoulders XII: Good tongue strength in both directions. Able to move tongue without difficulty. -Motor: Normal bulk for her age, normal tone. No rigidity, or adventitious movements noted. Left arm pronator drift. Able to move all 4 extremities, and is able to follow commands. ___ strength in left arm in UMN pattern. Patient has a mild tremor on exam. -Sensory: intact to touch -DTRs: Bi Tri ___ Pat Ach L 2 2 2 0 1 R - - - 0 1 Plantar response was downgoing bilaterally -Coordination: Slow on rapid alternating movements. Exhibits past pointing on finger to nose exam along with an intention tremor. -Gait: Deferred PHYSICAL EXAM ON DISCHARGE: VS - Tm 98.3 BP 138/76 HR 68 RR 18 O2 97%RA GENERAL - Thin elderly woman in NAD, comfortable, appropriate, sitting up in chair HEENT - PERRL, sclerae anicteric, MMM, OP clear NECK - supple, JVD not appreciated LUNGS - Overall comfortable on room air but does use accessory muslces. Fair air movement with crackles at bases bilaterally more prominent on left. HEART - Regular rate, irregularly irregular rhythm, no MRG, soft S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, strength grossly unchagned since admission Pertinent Results: ADMISSION LABS: ___ 01:45PM BLOOD WBC-5.9 RBC-3.05* Hgb-8.5* Hct-30.0* MCV-98 MCH-28.0 MCHC-28.5* RDW-18.5* Plt ___ ___ 01:45PM BLOOD ___ PTT-37.6* ___ ___ 01:45PM BLOOD Glucose-86 UreaN-38* Creat-3.5* Na-142 K-4.4 Cl-102 HCO3-30 AnGap-14 ___ 01:45PM BLOOD ALT-23 AST-22 AlkPhos-110* TotBili-0.4 ___ 01:45PM BLOOD Lipase-104* ___ 01:45PM BLOOD cTropnT-0.06* ___ 09:25PM BLOOD cTropnT-0.06* ___ 01:45PM BLOOD Albumin-3.1* ___ 01:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 09:34PM BLOOD ___ pO2-76* pCO2-53* pH-7.37 calTCO2-32* Base XS-3 Comment-GREEN TOP ___ 01:54PM BLOOD Lactate-1.3 DISCHARGE LABS: ___ 07:20AM BLOOD WBC-6.8 RBC-3.52* Hgb-9.6* Hct-34.6* MCV-98 MCH-27.2 MCHC-27.7* RDW-19.1* Plt ___ ___ 07:20AM BLOOD ___ PTT-36.2 ___ ___ 07:20AM BLOOD Glucose-86 UreaN-20 Creat-2.2*# Na-140 K-3.6 Cl-98 HCO3-29 AnGap-17 ___ 07:20AM BLOOD Calcium-9.1 Phos-2.8# Mg-2.1 URINE: ___ 06:20PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 06:20PM URINE Blood-TR Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD ___ 06:20PM URINE RBC-2 WBC-35* Bacteri-FEW Yeast-NONE Epi-17 ___ 06:20PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG PERTINENT MICROBIOLOGY ___ 2:00 pm BLOOD CULTURE 2 OF 2. **FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CLUSTERS. Reported to and read back by ___ ___ ___. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CLUSTERS. ___ 6:20 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. ___ MORPHOLOGY. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ R LINEZOLID------------- 1 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ =>32 R Add'l Blood cx from ___ and ___ No significant growth to date REPORTS: ___ Neurophysiology EEG This is an abnormal EEG because of mild diffuse background slowing. These findings are indicative of mild diffuse encephalopathy which is etiologically non-specific. There were no epileptiform features. ___ Radiology CT HEAD W/O CONTRAST 1. No acute intracranial process. 2. Chronic small vessel ischemic disease and age-related volume loss. ___ Radiology CHEST (PORTABLE AP) 1. No acute cardiopulmonary process. 2. Chronic left lower lobe opacitiy may be due to aspiration, atelectasis or scarring. Medications on Admission: 1. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) treatment Inhalation every six (6) hours. 3. ipratropium bromide 0.02 % Solution Sig: One (1) treatment Inhalation Q6H (every 6 hours). 4. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 ___. 5. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily). 9. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for intertrigo. 10. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One (1) Appl Ophthalmic Q 8H (Every 8 Hours). 11. polyvinyl alcohol-povidon(PF) 1.4-0.6 % Dropperette Sig: ___ Drops Ophthalmic Q2H (every 2 hours): Hold while sleeping. 12. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain. 13. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day): Until INR becomes therapeutic. 14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 16. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)) for 10 days Discharge Medications: 1. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. 3. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. 4. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily). 8. miconazole nitrate 2 % Powder Sig: One (1) application Topical four times a day as needed for intertrigo. 9. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain. 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 12. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 13. heparin (porcine) 5,000 unit/mL Cartridge Sig: One (1) Injection three times a day: Until therapeutic on coumadin. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: 1. Medication side effect 2. End stage renal disease 3. Atrial Fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report INDICATION: Unresponsiveness. Evaluate for pneumonia. COMPARISONS: Chest radiograph ___. Chest radiograph ___. FINDINGS: There is an unchanged linear opacification at the left base, most consistent with chronic atelectasis, aspiration or scarring. There is no pulmonary edema, pleural effusion or pneumothorax. Moderate enlargement of the cardiac silhouette is stable from the prior exam. Atherosclerotic calcification is noted within a torturous aorta. Clips are noted in the mediastinum. No definite fractures identified. IMPRESSION: 1. No acute cardiopulmonary process. 2. Chronic left lower lobe opacitiy may be due to aspiration, atelectasis or scarring. Radiology Report INDICATION: Unresponsiveness. COMPARISONS: CT head ___. 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 acute hemorrhage, edema, mass, mass effect, or infarction. The ventricles and sulci are prominent, suggesting age-related atrophy. The basal cisterns are patent. Periventricular confluent white matter hypodensities are consistent with chronic small vessel ischemic disease. The gray-white matter differentiation is preserved. No fracture is identified. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. There has been no significant change from the prior head CT on ___. IMPRESSION: 1. No acute intracranial process. 2. Chronic small vessel ischemic disease and age-related volume loss. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: UNRESPONSIVE Diagnosed with SEMICOMA/STUPOR, END STAGE RENAL DISEASE temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: nan

Dear Ms. ___, You were admitted to the hospital because you had an episode of unresponsiveness at your extended care facility. We did several studies including an EEG, a CT of your head, and blood work and did not see any concerning cause of this episode. We believe it may have been caused by a medication recently started called olanzapine (Zyprexa). We stopped this medication and you had no more episodes. We did have one blood culture grow some bacteria, and we started you on antibiotics. However, after further review, it appears the baceteria was contamination from your skin and you do not need to be on antiobiotics. Please note the following changes to your medications: INCREASE Coumadin (Warfarin) to 2.5 mg daily or as otherwise directed CONTINUE Heparin 5000 units SC until INR>2.0 STOP Olanzapine (Zyprexa) STOP Artificial tears No other changes were made to your medications. Please weigh yourself every morning, and call your MD if weight goes up more than 3 lbs. It has been a pleasure taking care of you.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: ciprofloxacin / Statins-Hmg-Coa Reductase Inhibitors Attending: ___ Chief Complaint: Stroke Major Surgical or Invasive Procedure: tPA History of Present Illness: ___ is a ___ male w/ hx of DM, HTN, prostate CA (currently opting for observation), colon CA s/p resection, CAD, and prior traumatic SDH who presents as OSH transfer for R arm weakness/sensory loss and aphasia. History obtained mostly from wife and OSH records d/t patient aphasia. Watching TV at ___ when developed acute onset right sided weakness and difficulty speaking. Wife called EMS who noted plegia on right and grunting. Significant improvement in ambulance w/ NIHSS 2 on arrival to OSH. Weakness worsened after CT scans. Telestroke consult w/ repeat NIHSS 5 (1- R superior quandrantanopsia, 1 L facial weakness (?chronic), 1 R arm weakness, 1 R sensory loss, and 1 dysarthria). BP 211/110 on arrival at OSH requiring IV metoprolol, IV labetalol, and nicardipine gtt. Received tPA at 0152 at OSH. CTA H/N at ___ did not show LVO, not thrombectomy candidate. Code Stroke on arrival to ___ for further care (no ICU beds at ___. ROS limited by inability of patient to answer questions but completed w/ wife to best of her knowledge. On neuro ROS, the pt denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies parasthesiae. No bowel or bladder incontinence or retention. On general review of systems, the pt denies recent fever or chills. 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: DM HTN Colorectal CA s/p resection BPH prostate CA (watchful waiting) GERD hx of traumatic SDH ___ years ago after MVA CAD (diagnostic cath 1.5 wks ago, possible need for CABG) Social History: ___ Family History: No family hx of stroke. Physical Exam: Physical Exam on admission =============== Vitals: Pain 0 Temp 97.8F HR 110 BP 151/80 RR 16 SpO2 97% RA General: Awake, cooperative, anxious but NAD HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no nuchal rigidity Pulmonary: breathing non labored on room air Cardiac: warm and well perfused Abdomen: soft, ND Extremities: No cyanosis, clubbing or edema bilaterally Skin: no rashes or lesions noted. Neurologic: -Mental Status: Awake, alert. Unable to answer orientation questions or relate history. Language is fluent but frequently nonsensical with intact repetition. Normal prosody. Pt was able to name occasional high frequency objects. Able to read without difficulty. Speech was not dysarthric. Inconsistently follows midline and appendicular commands. Able to read w/o difficulty. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to blink to threat. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: mild L NLFF (unclear if chronic), 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. RUE downward drift w/o pronation. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FE IP Quad Ham TA Gastroc L 5 ___ 5 5 5 5 5 5 R 4+ 5 4+ 4+ 4+ 5 5 5 5 5 -Sensory: Decreased light touch in throughout RUE/RLE. Unable to test further d/t aphasia. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 0 R 2 2 2 2 0 Plantar response was flexor bilaterally. -Coordination: No intention tremor. No dysmetria on FNF bilaterally. -Gait: deferred On Discharge: AF, HR 60-80s, 140-s170s/80s General: Awake, cooperative, NAD. HEENT: MMM Neck: Supple 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 ___ edema. Skin: no rashes or lesions noted. Neurologic: Alert and oriented, to hospital my month year and situation .Able to complete moyb without difficulty. Naming intact with the exception of a few low frequency objects like cuticle. Repetition intact. Able to complete multi step commands. No dyscalculia. CN - EOMI, VFF to finger counting, no agraphesthesia, subtle R. NLF Flattening Motor Delt Bic Tri WrE FFl FE IO IP Quad Ham TA L 5 5 5- ___ ___ 5 5 R 5 ___ ___ 5 5 5 5 -Sensory: No deficits to light touch -DTRs: ___ -___: no obvious dysmetria -Gait: deferred Pertinent Results: ___ 10:58AM BLOOD %HbA1c-8.3* eAG-192* ___ 10:58AM BLOOD Triglyc-99 HDL-45 CHOL/HD-3.9 LDLcalc-109 ___ 10:58AM BLOOD TSH-1.2 CT HEAD ___ No evidence of acute hemorrhage or acute large territory infarction. Please note that MR would be more sensitive for evaluation of infarction. MRI HEAD ___ Some of the images are degraded by movement artifact. There are multiple foci of restricted diffusion in the left frontal, parietal and occipital lobes, and a small focus of restricted diffusion adjacent to the trigone of the right lateral ventricle, with associated T2/FLAIR hyperintensity. On the gradient echo sequence, there is a small amount of susceptibility in the left parietal lobe, in keeping with a degree of hemorrhagic products. Susceptibility is also noted peripherally within the right temporal lobe, in keeping with old blood products. Note is made of encephalomalacia in the lateral aspect of the right temporal lobe. There is an old lacunar infarct in the head of the right caudate nucleus, and foci of T2 hyperintensity in the left basal ganglia, which may represent old lacunar infarcts or dilated perivascular spaces. There are nonspecific bilateral supratentorial T2/FLAIR hyperintensities, which may represent the sequelae of chronic microangiopathy. There is no mass, mass effect or midline shift. The ventricles and sulci are normal in caliber and configuration. IMPRESSION: Multiple foci of restricted diffusion in the left cerebellar hemisphere and adjacent to the trigone of the right lateral ventricle, in keeping with multiple focal acute/subacute infarcts, which are likely embolic in nature. Susceptibility within the left parietal lobe in a region of restricted diffusion, suggestive of hemorrhagic products. TTE Mild global left ventricular systolic dysfunction with ? focal hypokinesis of apex.Will recommend sonographer return and perform additional lumason enhanced images and thisreport will be ammended. No PFO identified. No clear LV thrombus, but will confirm withlumason images. CAROTID ULTRASOUND Right ICA <40% stenosis. Left ICA <40% stenosis. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 100 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. glimepiride 4 mg oral BID 4. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY 5. MetFORMIN (Glucophage) 1000 mg PO DAILY 6. Pantoprazole 40 mg PO BID 7. Tamsulosin 0.4 mg PO DAILY 8. Valsartan 80 mg PO DAILY Discharge Medications: 1. Apixaban 5 mg PO BID 2. Metoprolol Succinate XL 50 mg PO DAILY RX *metoprolol succinate 50 mg 1 tablet(s) by mouth Dao;y Disp #*30 Tablet Refills:*2 3. 70/30 50 Units Breakfast 70/30 40 Units Dinner 4. Praluent Pen (alirocumab) 150 mg/mL SC EVERY 2 WEEKS 5. Valsartan 160 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. glimepiride 4 mg oral BID 8. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY 9. MetFORMIN (Glucophage) 1000 mg PO DAILY 10. Pantoprazole 40 mg PO BID 11. Tamsulosin 0.4 mg PO DAILY 12.Outpatient Physical Therapy ___ Acute Ischemic stroke Physical therapy at least 3x weekly Discharge Disposition: Home Discharge Diagnosis: Acute ischemic stroke Non-ST elevation myocardial infarction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: History: ___ with s/p TPA with worsened exam // eval for acute bleed TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 18.0 s, 18.7 cm; CTDIvol = 48.2 mGy (Head) DLP = 903.1 mGy-cm. Total DLP (Head) = 903 mGy-cm. COMPARISON: None. FINDINGS: There is no evidence of fracture, acute large territory infarction,hemorrhage,edema,or mass effect. There appear to be chronic infarcts involving the right caudate head, the right internal capsule, the left basal ganglia. There is prominence of the ventricles and sulci suggestive of involutional changes. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. Patient is status post right lens surgery. IMPRESSION: No evidence of acute hemorrhage or acute large territory infarction. Please note that MR would be more sensitive for evaluation of infarction. Radiology Report EXAMINATION: MR HEAD W/O CONTRAST ___ MR HEAD INDICATION: ___ year old man with aphasia, right sided weakness // Eval for stroke. To be done ___ if possible TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was performed with gradient echo, FLAIR, diffusion, and T2 technique were then obtained. COMPARISON CT Head ___. FINDINGS: Some of the images are degraded by movement artifact. There are multiple foci of restricted diffusion in the left frontal, parietal and occipital lobes, and a small focus of restricted diffusion adjacent to the trigone of the right lateral ventricle, with associated T2/FLAIR hyperintensity. On the gradient echo sequence, there is a small amount of susceptibility in the left parietal lobe, in keeping with a degree of hemorrhagic products. Susceptibility is also noted peripherally within the right temporal lobe, in keeping with old blood products. Note is made of encephalomalacia in the lateral aspect of the right temporal lobe. There is an old lacunar infarct in the head of the right caudate nucleus, and foci of T2 hyperintensity in the left basal ganglia, which may represent old lacunar infarcts or dilated perivascular spaces. There are nonspecific bilateral supratentorial T2/FLAIR hyperintensities, which may represent the sequelae of chronic microangiopathy. There is no mass, mass effect or midline shift. The ventricles and sulci are normal in caliber and configuration. IMPRESSION: Multiple foci of restricted diffusion in the left cerebellar hemisphere and adjacent to the trigone of the right lateral ventricle, in keeping with multiple focal acute/subacute infarcts, which are likely embolic in nature. Susceptibility within the left parietal lobe in a region of restricted diffusion, suggestive of hemorrhagic products. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with stroke // Post tPA 24 hour non contrast CT scan. Please perform it on ___ at 0200 am. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 934.5 mGy-cm. Total DLP (Head) = 935 mGy-cm. COMPARISON: Head CT ___. Head MRI ___. FINDINGS: Infarcts of the left frontal and parietal lobes, along with the bilateral occipital lobes, are better assessed on prior MRI. There is no evidence of hemorrhage. Chronic infarcts of the right caudate and internal capsule and the left basal ganglia are again seen. There is prominence of the ventricles and sulci suggestive of involutional changes. Periventricular and subcortical white matter hypodensities are better assessed on prior MRI, likely sequela of chronic ischemic small vessel disease. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. Aside from a right lens replacement, the visualized portion of the orbits are normal. IMPRESSION: 1. No evidence of hemorrhage. 2. Infarcts of the left frontal and parietal lobes, along with the bilateral occipital lobes, are better assessed on prior MRI. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with stroke // EVal for bleed, s/p tPA on hep gttPLEASE PERFORM AT 0100 TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 11.0 s, 18.7 cm; CTDIvol = 48.8 mGy (Head) DLP = 911.9 mGy-cm. Total DLP (Head) = 927 mGy-cm. COMPARISON: Head CT dated ___. FINDINGS: There is no evidence of fracture, acute vascular territorial infarction,hemorrhage,edema,or mass. There is encephalomalacia in the right lateral temporal lobe as well as areas of evolving infarct in left frontal parietal region and left occipital lobe, corresponding to findings on MRI, more conspicuous than on previous CT. No hemorrhage. Chronic infarcts in the bilateral basal ganglia and the right internal capsule again seen. There is prominence of the ventricles and sulci suggestive of involutional changes. Hypoattenuation in the white matter is noted which is nonspecific but likely reflects chronic small vessel disease in this age group. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are normal, with right lens replacement noted. IMPRESSION: 1. Redemonstration of left frontal and parietal infarcts as well as left occipital infarct. No hemorrhage 2. Encephalomalacia in the lateral right temporal lobe is again seen likely reflecting old infarct. Chronic bilateral basal ganglia lacunar infarcts and right internal capsule lacunar infarct. Radiology Report EXAMINATION: Carotid Artery ultrasound INDICATION: ___ year old man with recent likely cardioembolic strokes, workup for CABG // ? eval carotid stenosis, CABG workup TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound imaging of the carotid arteries was obtained. COMPARISON: None FINDINGS: RIGHT: There is mild heterogenous atherosclerotic plaque in the right carotid artery. Segment: PSV (cm/s) / EDV (cm/s) ---------------------------------------------- CCA ___: 124 cm/s / 18.5 cm/s CCA Distal: 132 cm/s / 18 cm/s ICA ___: 105 cm/s / 24.4 cm/s ICA Mid: 104 cm/s / 16.8 cm/s ICA Distal: 90.4 cm/s / 20.3 cm/s ECA: 86.1 cm/s Vertebral: 54.9 cm/s ICA/CCA Ratio: 0.8 The right vertebral artery flow is antegrade with a normal spectral waveform. LEFT: There is mild heterogenous atherosclerotic plaque in the left carotid artery. Segment: PSV (cm/s) / EDV (cm/s) ---------------------------------------------- CCA ___: 93.7 cm/s / 16.4 cm/s CCA Distal: 153 cm/s / 29.5 cm/s ICA ___: 87.6 cm/s / 20.3 cm/s ICA Mid: 80.6 cm/s / 21.7 cm/s ICA Distal: 68.6 cm/s / 18.8 cm/s ECA: 158 cm/s Vertebral: 50.4 cm/s ICA/CCA Ratio: 0.57 The left vertebral artery flow is retrograde with a normal spectral waveform. IMPRESSION: Right ICA <40% stenosis. Left ICA <40% stenosis. Radiology Report EXAMINATION: CHEST (PRE-OP PA AND LAT) INDICATION: ___ year old man with recent stroke and NSTEMI // pre-op workup for CABG Surg: ___ (CABG ) IMPRESSION: In comparison with the outside study of ___, the cardiac silhouette is within normal limits and there is no vascular congestion, pleural effusion, or acute focal pneumonia. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: R Weakness, Slurred speech Diagnosed with Weakness temperature: 97.8 heartrate: 110.0 resprate: 16.0 o2sat: 97.0 sbp: 151.0 dbp: 80.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, You were hospitalized due to symptoms of trouble speaking, word 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. 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: Diabetes Hypertension Heart disease You were also noted to have had a minor heart attack this admission or NSTEMI. You were on a blood thinner for this and were seen by the cardiologists and cardiothoracic surgeons. You will see ___ as an outpatient and will follow-up with We are changing your medications as follows: - Starting Apixiban 5mg twice daily (this is a blood thinner, please take it every day) - Start Metoprolol - Increased Valsartan (blood pressure medication) - Stop atenolol 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: F Service: MEDICINE Allergies: Percocet / Morphine Attending: ___ Chief Complaint: diarrhea Major Surgical or Invasive Procedure: none History of Present Illness: This is a ___ woman with a deceased donor renal transplant in ___ c/b stage IV chronic kidney disease in the transplant ___ chronic allograft nephropathy, baseline Cr 3.7, as well as secondary hyperparathyroidism, recurrent PEs presenting with N/V/D and ___. Pt developed N/V/D, HA, malaise approximately 1 week ago with her children reporting similar symptoms. Vomiting resolved ~5 days ago but she has continued to have nausea and extensive non-bloody brown loose stool, with associated epigastric pain. Her stool is just now starting to have some form. No travel, new foods or uncooked meat. She has been taking APAP but no NSAIDS. She denies any pruritis or metallic taste. She has had GI side effects from MMF in the past necessitating dose reduction. She has not had any fevers or recent antibiotic or hospital exposure. She has continued to take her immunosuppresants and didnt see any pills in her vomitus. She also continued to take her lasix despite poor PO intake. She noticed decreased UOP and LH on standing 1 day PTA and presented for evaluation in the ED. Her transplant course was complicated by acute humoral rejection during her pregnancy in ___ and then acute cellular rejection in ___. She is inactive on the kidney transplant wait list, blood group O, with no potential live donors, with a plan to start evaluating the patient for a new transplant. Most recent PRA 0 with no identified anti-HLA antibodies. Her BMI has been >40. As an outpt, furosemide recently increased to 40 mg twice daily as well as an increased dose of vitamin D. Her prednisone dose was weaned to 10 mg ___. She had amlodipine resumed at that time as well. In the ED, VSS, labs notable for ___ with Cr 8.7 and associated AG metabolic acidosis (nml lactate), K 3.4, Mg 1.2, tacro 21. FeNa 0.62. Renal US nml. She received zofran, dilaudid, and 500 cc NS. Past Medical History: - CKD ___ hypertension and probably APOL1 genetic predisposition, s/p status post DD renal transplant with prior peripartum acute humoral and cellular rejection (s/p ATG and plasmapheresis, IVIG, and rituximab), now with transplant chronic rejection (stage IV CKD). - Secondary hyperparathyroidism - Iron deficiency (received feraheme as outpt) - Recurrent PEs on coumadin, goal INR 2.5-3.5 - Status post cholecystectomy - Status post ligation of AV fistula Social History: ___ Family History: Her family history is notable for a brother with end-stage kidney disease, and a mother with diabetes ___. Physical Exam: PHYSICAL EXAMINATION ON ADMISSION: VS: 98.1 121/76 lying 86/56 standing 87 16 100% RA General: NAD HEENT: Dry MM, no obvious oral lesions Neck: No JVD noted CV: RRR, no m/r/g Lungs: CTAB Abdomen: Soft, obese, NT/ND, NABS Ext: WWP, no edema. Non-functioning AVG on left. Neuro: A+Ox3, moving all extremities symmetrically Skin: Dry without obvious impairments PHYSICAL EXAM ON DISCHARGE: VS: 98.2 120/75 80 18 96% RA General: NAD HEENT: MMM, no obvious oral lesions Neck: No JVD noted CV: RRR, no m/r/g Lungs: CTAB Abdomen: Soft, obese, tender to palpation in upper quadrants, NABS Ext: WWP, no edema. Non-functioning AVG on left. Neuro: A+Ox3, moving all extremities symmetrically Skin: Dry without obvious impairments Pertinent Results: LABS ON ADMISSION: ___ 10:03PM ___ PO2-188* PCO2-30* PH-7.17* TOTAL CO2-12* BASE XS--16 ___ 08:44PM GLUCOSE-91 UREA N-65* CREAT-9.0* SODIUM-136 POTASSIUM-3.3 CHLORIDE-105 TOTAL CO2-10* ANION GAP-24* ___ 08:44PM CALCIUM-8.1* PHOSPHATE-6.1* MAGNESIUM-1.1* ___ 08:44PM ___ PTT-61.8* ___ ___ 11:58AM URINE HOURS-RANDOM CREAT-226 SODIUM-22 POTASSIUM-27 CHLORIDE-15 ___ 11:58AM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 11:58AM URINE BLOOD-SM NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 11:58AM URINE RBC-14* WBC-5 BACTERIA-FEW YEAST-NONE EPI-3 ___ 08:02AM LACTATE-1.6 K+-3.4 ___ 07:33AM ALT(SGPT)-27 AST(SGOT)-13 ALK PHOS-128* TOT BILI-0.1 ___ 07:33AM LIPASE-49 ___ 07:33AM ALBUMIN-4.0 CALCIUM-7.8* PHOSPHATE-6.2*# MAGNESIUM-1.2* ___ 07:33AM HCG-<5 ___ 07:33AM tacroFK-21.2* ___ 07:33AM WBC-10.3 RBC-5.70* HGB-12.2 HCT-40.9 MCV-72* MCH-21.3* MCHC-29.7* RDW-17.5* ___ 07:33AM NEUTS-60 BANDS-0 ___ MONOS-9 EOS-0 BASOS-1 ___ MYELOS-0 NUC RBCS-2* ___ 07:33AM HYPOCHROM-OCCASIONAL ANISOCYT-2+ POIKILOCY-3+ MACROCYT-1+ MICROCYT-OCCASIONAL POLYCHROM-OCCASIONAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL BURR-2+ PENCIL-1+ TEARDROP-OCCASIONAL ___ 07:33AM PLT SMR-NORMAL PLT COUNT-237 IMAGING: ___ RENAL TRANSPLANT ULTRASOUND IMPRESSION: Normal renal transplant ultrasound. ___ HEAD CT IMPRESSION: Mild paranasal sinus inflammatory changes. Otherwise normal study. ___ VENOUS DUPLEX UPPER EXTREMITIES IMPRESSION: 1. The brachial and radial arteries on both sides appear widely patent. No evidence of calcifications. 2. Right cephalic and basilic veins in as indicated above. 3. The the forearm loop graft is occluded and only the basilic vein is visualized on the left side. Measurements as indicated above. LABS ON DISCHARGE ___ 05:56AM BLOOD WBC-6.5 RBC-4.29 Hgb-9.2* Hct-30.0* MCV-70* MCH-21.5* MCHC-30.8* RDW-17.4* Plt ___ ___ 05:56AM BLOOD Glucose-99 UreaN-48* Creat-5.8* Na-139 K-3.4 Cl-109* HCO3-17* AnGap-16 ___ 05:56AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.6 ___ 05:56AM BLOOD tacroFK-5.7 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PredniSONE 10 mg PO DAILY 2. Acetaminophen Dose is Unknown PO Frequency is Unknown 3. Sodium Bicarbonate 1300 mg PO BID 4. Labetalol 300 mg PO BID 5. Warfarin 5 mg PO 5X/WEEK (___) 6. Warfarin 2.5 mg PO 2X/WEEK (___) 7. Amlodipine 10 mg PO HS 8. Mycophenolate Mofetil 500 mg PO TID 9. Tacrolimus 3 mg PO Q12H 10. Furosemide 40 mg PO BID 11. Magnesium Oxide 250 mg PO BID 12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 13. Calcitriol 0.25 mcg PO 6X/WEEK (___) 14. Vitamin D 50,000 UNIT PO 1X/WEEK (WE) Discharge Medications: 1. Azathioprine 100 mg PO DAILY RX *azathioprine 50 mg 2 tablet(s) by mouth Daily Disp #*60 Tablet Refills:*0 2. Acetaminophen 650 mg PO Q6H:PRN pain, fever 3. Amlodipine 10 mg PO HS 4. Calcitriol 0.25 mcg PO 6X/WEEK (___) 5. Labetalol 300 mg PO BID 6. Vitamin D 50,000 UNIT PO 1X/WEEK (WE) 7. Outpatient Lab Work Needs CBC, chem-10, INR, tacrolimus checked on ___, send results to Dr. ___, ___ Phone: ___ Fax: ___ ICD-9: V42.0 8. PredniSONE 10 mg PO DAILY 9. Sodium Bicarbonate 1300 mg PO BID 10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 11. Tacrolimus 2 mg PO Q12H 12. Warfarin 4 mg PO DAILY16 RX *warfarin [Coumadin] 1 mg 4 tablet(s) by mouth Daily Disp #*120 Tablet Refills:*0 13. LOPERamide 2 mg PO QID:PRN diarrhea RX *loperamide [Anti-Diarrheal (loperamide)] 2 mg 1 capsule by mouth four times a day Disp #*30 Capsule Refills:*0 14. Magnesium Oxide 250 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: ___ Infectious gastroenteritis Secondary diagnoses: S/p renal transplant Hypertension Hypercoaguability Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: RENAL TRANSPLANT U.S. INDICATION: History: ___ with epigastric pain. Evaluate for renal transplant thrombosis. 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 0.63 to 0.68, within the normal range. The main renal artery shows a normal waveform, with prompt systolic upstroke and continuous antegrade diastolic flow, with peak systolic velocity of 64 centimeter/second. Vascularity is symmetric throughout transplant. The transplant renal vein is patent and shows normal waveform. IMPRESSION: Normal renal transplant ultrasound. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ woman with a deceased donor renal transplant in ___ with worse headache of her life and INR of 11. Please assesss for acute intracranial process, evidence of hemorrhage. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed images were obtained. DOSE: DLP: 891 mGy-cm CTDI: 52 mGy COMPARISON: Head CT from ___ FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles and sulci are normal in size and configuration. No osseous abnormalities seen. Minimal mucosal thickening of the left maxillary sinus and right anterior ethmoid air cells are noted, otherwise the imaged paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: Mild paranasal sinus inflammatory changes. Otherwise normal study. Radiology Report EXAMINATION: VENOUS DUP UPPER EXT BILATERAL INDICATION: ___ year old woman s/p L sided fistula with need for dialysis soon // Please do vein mapping for possible dialysis TECHNIQUE: Grey scale and Doppler evaluation was performed on the bilateral upper extremity veins. COMPARISON: ___ FINDINGS: Right arm: The right brachial artery measures 4.7 mm the radial artery 2 mm. No calcifications noted. The cephalic vein is patent and measures 1.8-2.6 mm in the forearm, 4.5 mm at the elbow and 3.7-4.2 mm above the elbow. The basilic vein measures 1.5-1.9 mm in the forearm, 2.8 mm at the elbow and 3-3.7 mm above the elbow. Left arm: The distal forearm loop graft is occluded. The left brachial artery measures 5.7 mm in diameter the radial artery 1.8 mm. No obvious calcifications. Unfortunately the cephalic vein cannot be followed. The basilic vein measures 1.1-1.5 mm in the forearm, 2.9 mm at the elbow and 3.1-3.3 mm above the elbow. IMPRESSION: 1. The brachial and radial arteries on both sides appear widely patent. No evidence of calcifications. 2. Right cephalic and basilic veins in as indicated above. 3. The the forearm loop graft is occluded and only the basilic vein is visualized on the left side. Measurements as indicated above. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: N/V, Headache Diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED, KIDNEY TRANSPLANT STATUS temperature: 98.3 heartrate: 92.0 resprate: 18.0 o2sat: 100.0 sbp: 113.0 dbp: 65.0 level of pain: 6 level of acuity: 3.0

Dear Ms. ___, You were admitted with renal injury that improved with IVF. We have adjusted doses of several of your medications. Please keep all of your followup appointments. Eating a lactose free diet should help with your loose stool as your GI tract recovers from the infection. Please have labs checked on ___. These will be sent to the ___. Your INR should be checked at that time as well. Sincerely, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Lisinopril / IV Dye, Iodine Containing Contrast Media / vancomycin Attending: ___. Chief Complaint: Foot Ulcer Major Surgical or Invasive Procedure: Debridement of left foot first metatarsal and proximal phalanx History of Present Illness: Patietn seen and examined agree with house officer admission note by Dr. ___ ___ with additions below ___ year old Male with Type 2 diabetes complicated by diabetic retinopathy, diabetic neuropathy, and recurrent foot infections who presents with worsening of an ulcer on his Left foot. In ___ he underwent left foot surgery on his ___ metatarsal head with secondary closure of wound performed by Dr. ___. He has had slow wound healing since that time, although without fevers, frank discharge, pain or erythema. On the day prior to admission he noticed his left foot was more swollen and erythematous. He took some Keflex he had at home and went to bed. The morning of admission it continued to look worse. He reports no new drainage at the site, although he has yellow or bloody drainage on his bandages daily. He denies any pain on his foot, but noticed a malodorous smell around the area. He usualy changes the bandages on his foot each day and applies betadine. He currently is ambulating with crutches. In the ED, his exam was notable for ulceration on the left foot. Labs notable for WBC 9.6, neutrophils 79.8, and lactate 1.2 The patient underwent an xray which showed no evidence of osteomyelitis. The xray demonstrated: Post-surgical changes involving the left first metatarsal head and a large plantar soft tissue defect on the lateral view. He received zosyn and vancomycin in the ED. He noticed soon after the vancomycin infusion he began to feel very itchy and called the staff over. He was found to have welts/hives(?) on his arms, so the vancomycin infusion was stopped. He was seen by podiatry who recommened IV antibiotics and daily wound dressing changes with betadine. Currently, the patient denies any pain from his foot or ulcer. He reports minimal drainage from his ulcer/bandage site. He denies fevers, chills, nightsweats, changes in energy or appetite. Past Medical History: -Benign Hypertension -Hyperlipidemia -Type 2 Diabetes - retinopathy, neuropathy, and persistent difficulties with foot ulcerations -Anemia -Obesity -PVD ---Right BK POP-DP BPG and Rt ___ met head resection (___) ---I&D Rt ___ met head ulcer and balloon angioplasty of graft (___) ---Left BK pop-pedal and left toe amputation (___) ---suspected occlusion of left graft, with plan for angiogram Social History: ___ Family History: Pt does not know history of mother or father. Physical Exam: ADMISSION PHYSICAL EXAM: VSS: 98.1, 168/63, 74, 18, 96% GEN: NAD Pain: ___ HEENT: EOMI, MMM, - OP Lesions PUL: CTA B/L COR: RRR, S1/S2, - MRG ABD: NT/ND, +BS, - CVAT EXT: - CCE, 4cm erythematous incision on Left Foot, no eschar or frank pus NEURO: CAOx3, Motor ___ ___ Spread DISCHARGE PHYSICAL EXAM: VS - Tm/c 98.3 BP 146-172/57-64 HR 66 RR 16 99%RA GENERAL - well-appearing man in NAD, comfortable, appropriate HEENT - NC/AT, MMM, OP clear NECK - supple LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - RRR, no MRG ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - LLE with cast in place left foot to just below left knee SKIN - scattered seborhhic keratoses on back and cherry angiomas on chest NEURO - awake, A&Ox3 Pertinent Results: ADMISSION LABS ___ 06:25AM BLOOD WBC-8.5 RBC-3.89* Hgb-10.3* Hct-30.3* MCV-78* MCH-26.4* MCHC-33.8 RDW-16.4* Plt ___ ___ 11:10AM BLOOD WBC-9.6 RBC-4.13* Hgb-10.7* Hct-32.4* MCV-78* MCH-26.0* MCHC-33.1 RDW-16.6* Plt ___ ___ 11:10AM BLOOD Neuts-79.8* Lymphs-14.0* Monos-3.3 Eos-2.5 Baso-0.3 ___ 06:25AM BLOOD Glucose-199* UreaN-21* Creat-0.9# Na-140 K-3.3 Cl-98 HCO3-32 AnGap-13 ___ 11:20AM BLOOD Lactate-1.2 DISCHARGE LABS ___ 05:23AM BLOOD WBC-10.4 RBC-3.92* Hgb-10.3* Hct-31.0* MCV-79* MCH-26.3* MCHC-33.3 RDW-16.7* Plt ___ ___ 05:23AM BLOOD Glucose-231* UreaN-27* Creat-1.0 Na-137 K-3.7 Cl-97 HCO3-34* AnGap-10 MICROBIOLOGY ___ 2:20 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 12:35 pm SWAB Source: left foot woud. **FINAL REPORT ___ GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final ___: This culture contains mixed bacterial types (>=3) so an abbreviated workup is performed. Any growth of P.aeruginosa, S.aureus and beta hemolytic streptococci will be reported. IF THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT PRESENT in this culture.. BETA STREPTOCOCCUS GROUP B. SPARSE GROWTH. STAPH AUREUS COAG +. RARE GROWTH. OF TWO COLONIAL MORPHOLOGIES. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. ___ 1:10 pm TISSUE LEFT ___ METATARSAL HEAD. GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final ___: This culture contains mixed bacterial types (>=3) so an abbreviated workup is performed. Any growth of P.aeruginosa, S.aureus and beta hemolytic streptococci will be reported. IF THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT PRESENT in this culture.. STAPH AUREUS COAG +. RARE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # 350-2638N ___. BETA STREPTOCOCCUS GROUP B. SPARSE GROWTH. IDENTIFICATION PERFORMED ON CULTURE # ___ ___. ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. IMAGING FOOT AP,LAT & OBL LEFT Study Date of ___ 11:15 AM IMPRESSION: 1. Post-surgical changes involving the left first metatarsal head. Although post-operative radiographs since the last debridement are not available, indistinct bony borders, fragmentation, and focal demineralization are concerning for osteomyelitis. A large plantar soft tissue defect is depicted on the lateral view. 2. Linear opacity overlying the third toe proximal phalanx, likely a foreign body within the soft tissues, unchanged compared to the prior study from ___. MRI LEFT FOOT ___: IMPRESSION: Osteomyelitis of the first metatarsal as well as the base of the first proximal phalanx. Inflammation of the soft tissues surrounding the amputated metatarsal head as described above, with associated skin ulcer along the plantar aspect- of the foot. No drainable fluid collections to suggest abscess. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO DAILY 3. Ferrous Sulfate 325 mg PO DAILY 4. Carvedilol 25 mg PO BID 5. Torsemide 20 mg PO BID 6. Potassium Chloride (Powder) 10 mEq PO DAILY Hold for K >4.8 7. Lantus *NF* (insulin glargine) 43 units Subcutaneous qhs 8. NovoLOG *NF* (insulin aspart) SSI Subcutaneous daily Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO DAILY 3. Carvedilol 25 mg PO BID 4. Ferrous Sulfate 325 mg PO DAILY 5. Torsemide 20 mg PO BID 6. Potassium Chloride (Powder) 10 mEq PO DAILY Hold for K >4.8 7. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID apply to gluteal fold RX *clobetasol 0.05 % 1 application twice a day Disp #*1 Tube Refills:*0 8. Glargine 50 Units Bedtime Humalog 20 Units Breakfast Humalog 20 Units Lunch Humalog 20 Units Dinner Insulin SC Sliding Scale using HUM Insulin 9. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. RX *heparin lock flush 10 unit/mL 2mL Line flush Disp #*100 Unit Refills:*0 10. NovoLOG *NF* (insulin aspart) ___ UNITS SUBCUTANEOUS DAILY according to sliding scale as above 11. Lantus *NF* (insulin glargine) 50 units SUBCUTANEOUS QHS 12. Nafcillin 2 g IV Q4H Duration: 6 Weeks RX *nafcillin in D2.4W 2 gram/100 mL 2 grams every 4 hours Disp #*504 Gram Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Osteomyelitis Secondary: Diabetes mellitus, Congestive heart failure, hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance with crutches Followup Instructions: ___ Radiology Report INDICATION: History of diabetes and foot ulceration, with worsening redness/drainage. Assess for osteomyelitis versus a lytic lesion. COMPARISON: Left foot radiographs from ___. LEFT FOOT, THREE VIEWS: There is redemonstration of prior left first metatarsal head resection. A soft tissue defect is present along the plantar aspect subjacent to the first metatarsophalangeal joint region. A linear opacity overlying the third toe proximal phalanx is not significantly changed in appearance, likely a foreign body within the soft tissues. Degenerative changes are again seen throughout the midfoot. Superior and inferior calcaneal enthesophytes are again noted. Vascular calcifications are redemonstrated. Surgical clips are seen along the medial aspect of the distal tibia, as before. IMPRESSION: 1. Post-surgical changes involving the left first metatarsal head. Although post-operative radiographs since the last debridement are not available, indistinct bony borders, fragmentation, and focal demineralization are concerning for osteomyelitis. A large plantar soft tissue defect is depicted on the lateral view. 2. Linear opacity overlying the third toe proximal phalanx, likely a foreign body within the soft tissues, unchanged compared to the prior study from ___. Radiology Report MRI LEFT FOOT: CLINICAL INDICATION: ___ man with history of diabetic foot ulcer status post prior left first metatarsal head resection. Patient with worsening redness, drainage, concerning for underlying osteomyelitis. TECHNIQUE: Multiaxial, multiplanar MRI of the left foot was obtained without and with administration of intravenous contrast material. Comparison is made to radiograph dated ___. FINDINGS: Partial amputation of the first metatarsal head is noted, with marked edema involving the residual metatarsal bone, with sparing at the base, as well as edema in the base of the first proximal phalanx. Subtle indistinctness of lateral first proximal phalanx base articular surface. Skin and soft tissue defect along the plantar aspect of the first metatarsal-phalangeal joint extending into the surgical bed of prior metatarsal head surgery. Large amount of granulation tissue/phlegmon situated between first metatarsal and proximal phalanx. No drainable fluid collections are identified. Susceptibility artifact reflecting prior surgery. Following administration of contrast, there is enhancement in the first metatarsal and base of the proximal phalanx. Edema and enhancement is also seen involving the muscles of the fore- and mid foot, likely due to the diabetic denervation injury. Old amputation of the fifth toe is noted, without evidence of edema or osteomyelitis. Limited evaluation of the extensor and flexor tendons of the foot, as well as the peroneal tendons demonstrated no significant abnormality. Susceptibility artiface overlies third proximal phalanx and may represent a foreign body or post-surgical change and should be correlated. IMPRESSION: Osteomyelitis of the first metatarsal as well as the base of the first proximal phalanx. Inflammation of the soft tissues surrounding the amputated metatarsal head as described above, with associated skin ulcer along the plantar aspect- of the foot. No drainable fluid collections to suggest abscess. These critical findings were discussed with Dr. ___ at 12:01pm on ___ by Dr. ___ (fellow) Radiology Report EXAM: X-ray of the foot, AP, lateral, oblique. CLINICAL INDICATION: ___ man with left foot ulcer status post surgical debridement. COMMENTS: Frontal, lateral and oblique views of the left foot are compared to study from ___, and demonstrates overlying splint material around the foot. Compared to the prior exam, there has been further interval surgical debridement and osteotomy/washout of the first metatarsal head, with tiny residual bone fragment seen at the surgical site. Mild surrounding osteopenia is present. There is a linear (needle-like) radiopaque foreign body seen within the soft tissues adjacent to the the third metatarsophalangeal joint, measuring approximately 1.4 cm. Old resection of the left toe is again noted. There are scattered vascular calcifications. IMPRESSION: 1. Postoperative changes status post resection of the first metatarsal head as described above. 2. Linear (needle-like) foreign body seen along the soft tissues adjacent to to the third metatarsophalangeal joint. These may represent the foreign body, unchanged. Radiology Report SINGLE FRONTAL VIEW OF THE CHEST REASON FOR EXAM: Assess line. Left PICC tip is in the upper SVC. Cardiac size is top normal. The lungs are clear aside from minimal bibasilar atelectasis. There is no pleural effusion or pneumothorax. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: WOUND RED Diagnosed with OTHER POST-OP INFECTION, ABN REACT-SURG PROC NEC, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA temperature: 97.8 heartrate: 80.0 resprate: 20.0 o2sat: 97.0 sbp: 162.0 dbp: 57.0 level of pain: 0 level of acuity: 3.0

It was a pleasure to participate in your care at ___. You were admitted to the hospital because of your left foot ulcer. You were treated with antibiotics. A biopsy of your bone was performed by the podiatry service and a portion of infected bone was removed. Cultures were obtained from the deep tissues during surgery. Your wound continued to improve and was closed with sutures. A PICC line was placed so that you can receive IV antibiotics outside of the hospital. You remained stable and were discharged home. You will be treated with the IV antibiotic nafcillin through your PICC line for 6 weeks. A visiting nurse ___ show you how to set up the infusion. You will follow up with the Infectious Disease department as well as Podiatry for care of the ulcer.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: ruptured abdominal aortic aneursym Major Surgical or Invasive Procedure: open infrarenal AAA repair History of Present Illness: ___ xfer from ___ hemodynamic instability in setting of newly diagnosised ruptured AAA. Per OSH report, pt presented to ___ of severe abdominal pain radiating to back x ___ days. Has had associated anorexia w reported 15# weight loss in last one week. Endorses substantial increase in abdominal pain this ___ following episode of coughing. Reported to ___ for further evaluation. On arrival to ___ ED noted to have SBP ___ which improved w 1L resuscitation. CT I- performed which showed contained rupture of 7cm juxtarenal AAA. Arranged for emergent xfer to ___ for further management. Past Medical History: Hx ischemic CVA (multiple B/L cerebellar infarctions, L occipital infarction), HTN, HLD, PSH: Repair L-spine herniated disc Social History: ___ Family History: Possibly hypertension, no known stroke Physical Exam: Temp: Gen: lying in bed no distress HEENT: non icteric sclera CV: Regular rate, no m,r,g Resp: clear to ausculation bilaterally Abd: midline incision c/d/i with staples, non tender, non distended right groin small incision c/d/i wiht 2 staples no hematoma Ext: palapble distal pulses, no edema Pertinent Results: ___ 06:52AM BLOOD WBC-10.5 RBC-4.20* Hgb-13.2* Hct-40.0 MCV-95 MCH-31.5 MCHC-33.0 RDW-14.4 Plt ___ ___ 07:54AM BLOOD WBC-11.0 RBC-4.38* Hgb-13.6* Hct-41.0 MCV-94 MCH-31.1 MCHC-33.3 RDW-14.7 Plt ___ ___ 04:52AM BLOOD WBC-10.6 RBC-4.04* Hgb-12.5* Hct-37.1* MCV-92 MCH-30.8 MCHC-33.5 RDW-14.8 Plt ___ ___ 01:21AM BLOOD WBC-16.1* RBC-4.09* Hgb-12.6* Hct-37.3* MCV-91 MCH-30.8 MCHC-33.7 RDW-14.6 Plt ___ ___ 05:25PM BLOOD WBC-16.9* RBC-4.18* Hgb-13.2* Hct-37.7* MCV-90 MCH-31.6 MCHC-35.0 RDW-14.6 Plt ___ ___ 01:35AM BLOOD WBC-19.2* RBC-4.48* Hgb-14.2 Hct-40.7 MCV-91 MCH-31.6 MCHC-34.8 RDW-14.6 Plt ___ ___ 02:41AM BLOOD WBC-13.2* RBC-4.20*# Hgb-13.1*# Hct-37.9*# MCV-90 MCH-31.3 MCHC-34.7 RDW-14.3 Plt ___ ___ 12:00AM BLOOD WBC-15.9* RBC-3.24* Hgb-10.1* Hct-30.3* MCV-93 MCH-31.1 MCHC-33.3 RDW-14.2 Plt ___ ___ 09:30PM BLOOD WBC-14.6*# RBC-4.17* Hgb-12.8* Hct-38.2* MCV-92 MCH-30.6 MCHC-33.4 RDW-14.1 Plt ___ ___ 07:38PM BLOOD WBC-16.7* RBC-4.71 Hgb-14.7 Hct-42.7 MCV-91 MCH-31.2 MCHC-34.5 RDW-14.1 Plt ___ ___ 07:03AM BLOOD Glucose-117* UreaN-27* Creat-1.2 Na-139 K-3.9 Cl-101 HCO3-27 AnGap-15 ___ 06:52AM BLOOD Glucose-106* UreaN-34* Creat-1.3* Na-138 K-4.2 Cl-102 HCO3-28 AnGap-12 ___ 07:54AM BLOOD Glucose-114* UreaN-43* Creat-1.4* Na-140 K-4.0 Cl-103 HCO3-26 AnGap-15 ___ 04:00PM BLOOD Glucose-124* UreaN-42* Creat-1.4* Na-138 K-3.8 Cl-102 HCO3-25 AnGap-15 ___ 04:52AM BLOOD Glucose-116* UreaN-44* Creat-1.4* Na-141 K-3.3 Cl-104 HCO3-27 AnGap-13 ___ 03:56PM BLOOD Glucose-117* UreaN-43* Creat-1.5* Na-137 K-3.6 Cl-103 HCO3-23 AnGap-15 ___ 01:21AM BLOOD Glucose-118* UreaN-40* Creat-1.6* Na-140 K-3.7 Cl-107 HCO3-25 AnGap-12 ___ 05:25PM BLOOD UreaN-39* Creat-1.7* Na-139 K-3.4 Cl-105 HCO3-25 AnGap-12 ___ 01:35AM BLOOD Glucose-110* UreaN-34* Creat-1.8* Na-138 K-4.1 Cl-108 HCO3-23 AnGap-11 ___ 04:25PM BLOOD Glucose-118* UreaN-34* Creat-1.8* Na-138 K-3.8 Cl-105 HCO3-24 AnGap-13 ___ 02:41AM BLOOD Glucose-188* UreaN-32* Creat-1.5* Na-139 K-3.9 Cl-107 HCO3-21* AnGap-15 TA TORSO: Large infrarenal abdominal aortic aneurysm with evidence of recent rupture along its anterolateral left wall (05:34) with significant adjacent fat stranding and blood along the anterior para renal fascia, left greater than right. No active arterial extravasation. Rupture starts at the left renal artery. Just above the renal arteries the aorta measures 3.1 x 3.4 cm (3:123). Bilateral common iliac arteries measure 3.8 x 4 cm and 3.5 x 3.4 cm left and right respectively. The infra renal aortic aneurysm measures 6.3 x 5.3 cm at its maximal width. Just above the iliac bifurcation the distal aorta measures 5.0 x 4.9 cm (3:165). Dilated proximal patent bilateral internal iliac arteries measuring 0.9 and 1 cm right and left respectively. The celiac axis, SMA, and bilateral single renal arteries are patent. Circumferential atherosclerotic mural calcifications are seen throughout the aorta and its major branches. The hepatic arterial anatomy is conventional. Assessment of the venous vasculature is somewhat limited by the timing of contrast. CHEST: The thyroid is normal.No axillary, supraclavicular, mediastinal, or hilar lymph node enlargement. There are coronary as well aortic and mitral valvular calcifications. No pericardial effusion.The airways are patent to the subsegmental levels. No pleural effusion or pneumothorax. Lungs are notable for diffuse paraseptal emphysematous changes as well as areas of mild interstitial change most notable within the left lung base, where there is also probably coinciding superimposed atelectasis. Two 0.8 x 0.5 and 0.7 x 0.5 cm opacities within the right lower lobe may represent mucous plugging however given solid appearance findings are concerning for pulmonary nodules. (03:10 3 and 3:96). No additional pulmonary nodule identified. A 2 mm calcified granuloma is noted within the right upper lobe (3:60). ABDOMEN: A 0.7 x 0.5 cm (3:112) hypodensity within segment 8 of the liver is too small to characterize.The portal vein, SMA, and splenic vein are patent. No intra or extrahepatic biliary dilatation. The gallbladder, pancreas, spleen, and bilateral adrenal glands are normal.The kidneys enhance symmetrically and are without suspicious solid mass. A 0.8 x 0.8 cm (3: 126) right upper pole hypodensities too small to characterize. There is a small hiatal hernia. The appendix is normal without evidence of acute appendicitis. Sigmoid diverticulosis is moderate in severity. No retroperitoneal or mesenteric lymph node enlargement by CT size criteria. No pneumoperitoneum. No abdominal wall hernia. PELVIS: The bladder is unremarkable. No pelvic side-wall or inguinal lymph node enlargement.No free pelvic fluid is identified. The prostate and seminal vesicles are unremarkable. OSSEOUS STRUCTURES: Multilevel, multifactorial degenerative changes are seen within the visualized thoracolumbar spine. No focal lytic or sclerotic lesion concerning for malignancy. IMPRESSION: 1. Acute rupture of large infrarenal aortobi-iliac abdominal aortic aneurysm along its anterolateral left aortic wall with acute hemorrhage in the retroperitoneum. No evidence of active arterial extravasation. 2. Sigmoid diverticulosis without evidence of acute diverticulitis. 3. Chronic emphysematous changes of the lungs with interstitial changes and focal left lower lobe opacity suggesting superimposed atelectasis. 4. 0.8 and 0.7 cm pulmonary nodules. Followup CT in ___ months is recommended for surveillance. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Clopidogrel 75 mg PO DAILY 2. Escitalopram Oxalate 10 mg PO DAILY 3. Pravastatin 40 mg PO DAILY 4. Lisinopril 2.5 mg PO DAILY Discharge Medications: 1. Clopidogrel 75 mg PO DAILY 2. Escitalopram Oxalate 10 mg PO DAILY 3. Lisinopril 2.5 mg PO DAILY 4. Pravastatin 40 mg PO DAILY 5. Acetaminophen 1000 mg PO Q8H RX *acetaminophen 500 mg 2 tablet(s) by mouth 8 hours Disp #*30 Tablet Refills:*0 6. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 7. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth 4 hours Disp #*20 Tablet Refills:*0 8. Metoprolol Tartrate 50 mg PO TID RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth three times daily Disp #*90 Tablet Refills:*1 9. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*30 Capsule Refills:*0 10. Senna 8.6 mg PO BID RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*30 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: ruptured abdominal aortic aneursym 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: History: ___ with ruptured AAA. Ruptured AAA- anatomy TECHNIQUE: MDCT images were obtained through the torso, initially without contrast, and subsequently in the arterial phase after administration of IV Omnipaque contrast. Axial images were interpreted in conjunction with coronal, sagittal, and MIP reformats. DLP: ___ MGy-cm COMPARISON: None. FINDINGS: CTA TORSO: Large infrarenal abdominal aortic aneurysm with evidence of recent rupture along its anterolateral left wall (05:34) with significant adjacent fat stranding and blood along the anterior para renal fascia, left greater than right. No active arterial extravasation. Rupture starts at the left renal artery. Just above the renal arteries the aorta measures 3.1 x 3.4 cm (3:123). Bilateral common iliac arteries measure 3.8 x 4 cm and 3.5 x 3.4 cm left and right respectively. The infra renal aortic aneurysm measures 6.3 x 5.3 cm at its maximal width. Just above the iliac bifurcation the distal aorta measures 5.0 x 4.9 cm (3:165). Dilated proximal patent bilateral internal iliac arteries measuring 0.9 and 1 cm right and left respectively. The celiac axis, SMA, and bilateral single renal arteries are patent. Circumferential atherosclerotic mural calcifications are seen throughout the aorta and its major branches. The hepatic arterial anatomy is conventional. Assessment of the venous vasculature is somewhat limited by the timing of contrast. CHEST: The thyroid is normal.No axillary, supraclavicular, mediastinal, or hilar lymph node enlargement. There are coronary as well aortic and mitral valvular calcifications. No pericardial effusion.The airways are patent to the subsegmental levels. No pleural effusion or pneumothorax. Lungs are notable for diffuse paraseptal emphysematous changes as well as areas of mild interstitial change most notable within the left lung base, where there is also probably coinciding superimposed atelectasis. Two 0.8 x 0.5 and 0.7 x 0.5 cm opacities within the right lower lobe may represent mucous plugging however given solid appearance findings are concerning for pulmonary nodules. (03:10 3 and 3:96). No additional pulmonary nodule identified. A 2 mm calcified granuloma is noted within the right upper lobe (3:60). ABDOMEN: A 0.7 x 0.5 cm (3:112) hypodensity within segment 8 of the liver is too small to characterize.The portal vein, SMA, and splenic vein are patent. No intra or extrahepatic biliary dilatation. The gallbladder, pancreas, spleen, and bilateral adrenal glands are normal.The kidneys enhance symmetrically and are without suspicious solid mass. A 0.8 x 0.8 cm (3: 126) right upper pole hypodensities too small to characterize. There is a small hiatal hernia. The appendix is normal without evidence of acute appendicitis. Sigmoid diverticulosis is moderate in severity. No retroperitoneal or mesenteric lymph node enlargement by CT size criteria. No pneumoperitoneum. No abdominal wall hernia. PELVIS: The bladder is unremarkable. No pelvic side-wall or inguinal lymph node enlargement.No free pelvic fluid is identified. The prostate and seminal vesicles are unremarkable. OSSEOUS STRUCTURES: Multilevel, multifactorial degenerative changes are seen within the visualized thoracolumbar spine. No focal lytic or sclerotic lesion concerning for malignancy. IMPRESSION: 1. Acute rupture of large infrarenal aortobi-iliac abdominal aortic aneurysm along its anterolateral left aortic wall with acute hemorrhage in the retroperitoneum. No evidence of active arterial extravasation. 2. Sigmoid diverticulosis without evidence of acute diverticulitis. 3. Chronic emphysematous changes of the lungs with interstitial changes and focal left lower lobe opacity suggesting superimposed atelectasis. 4. 0.8 and 0.7 cm pulmonary nodules. Followup CT in ___ months is recommended for surveillance. NOTIFICATION: The findings were discussed by Dr. ___ with vascular surgery in person on ___ at time of discovery of findings. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old man with AAA // ptx TECHNIQUE: Single portable AP radiograph of the chest. COMPARISON: Prior chest CTA dated ___. FINDINGS: There has been interval placement of an endotracheal tube, with the tip ending 7.9 cm from the carina, this could be advanced 4 cm for optimal seating within the trachea. A right IJ Cordis line is in place. The enteric tube extends outside of the field of view but likely ends within the stomach. There is new mild atelectasis and a small-to-moderate left-sided plueral effusion. IMPRESSION: 1. Endotracheal tube tip ends 7.9 cm from the carina, and could be advanced 4 cm for optimal seating within the trachea. 2. New mild bibasilar atelectasis. 3. New small to moderate left-sided pleural effusion. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with as above // s/p AAA repair w/increased shortness of breath r/o PTX COMPARISON: ___ IMPRESSION: As compared to the previous radiograph, the patient has been extubated. And the nasogastric tube was removed. The venous introduction sheet in the right internal jugular vein remains in situ. Increasing left retrocardiac atelectasis. Slightly increasing left pleural effusion. No pulmonary edema. Unchanged appearance of the cardiac silhouette. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: AAA Diagnosed with ABDOM AORTIC ANEURYSM temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: nan

Dear Mr. ___ you were admitted to the hospital following surgery to repair the leak in your aorta. You have done amazingly well and are now ready for discharge. Please allow us to give you some general instructions regarding your discharge as well as a few specific to you. 1) we have started a new medication metoprolol to help control your blood pressure. You should continue to take this and follow up with your PCP ___ ___ weeks to have your blood pressure checked. 2) Because your aorta had an aneursym it is possible that other blood vessels in your body may be predisposed to aneursym. Accordingly we have scheduled you to have an ultrasound of the arteries in your knees next week. WHAT TO EXPECT: 1. It is normal to feel weak and tired, this will last for ___ weeks • You should get up out of bed every day and gradually increase your activity each day • You may walk and you may go up and down stairs • Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have incisional and leg swelling: • Wear loose fitting pants/clothing (this will be less irritating to incision) • Elevate your legs above the level of your heart with ___ pillows every ___ hours throughout the day and at night • Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time • You will probably lose your taste for food and lose some weight • Eat small frequent meals • It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing • To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication • • Take all the medications you were taking before surgery, unless otherwise directed • Take one aspirin daily. Continue to take your plavix. ACTIVITIES: • No driving until post-op visit and you are no longer taking pain medications • You should get up every day, get dressed and walk, gradually increasing your activity • You may up and down stairs, go outside and/or ride in a car • Increase your activities as you can tolerate- do not do too much right away! • No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit • You may shower (let the soapy water run over incision, rinse and pat dry) • Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area CALL THE OFFICE FOR : ___ • Redness that extends away from your incision • A sudden increase in pain that is not controlled with pain medication • A sudden change in the ability to move or use your leg or the ability to feel your leg • Temperature greater than 101.5F for 24 hours • Bleeding from incision • New or increased drainage from incision or white, yellow or green drainage from incisions

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Motrin / Codeine / Peanut / Rapamune / sodium bicarbonate Attending: ___ Chief Complaint: Right shoulder pain Major Surgical or Invasive Procedure: Placement of left IJ central line History of Present Illness: ___ year old woman with a history of renal transplant and prior shoulder effusions who presented with 3 days of shoulder pain. She reported "sleeping funny" on her shoulder and awaking with severe pain on ___. She went to her PCP and orthopedic surgeon on ___ who prescribed flexeril and suggested rest, ice, and NSAIDs. The night of ___ the pain significantly increased with swelling of the entire arm. She reported severe shooting pain down her arm with any motion of the shoulder, elbow, or wrist. No constitutional symptoms or other complaints elsewhere in her body. She has had weight loss for the past year associated with poor intake with intermittent N/V. There has been no acute change in these symptoms. In the ED, initial vitals: Pain ___, Temp 97.3, HR 74 BP 104/85 RR16 98RA Exam: right arm swollen and erythematous. Present brachial and radial pulses. Neuro exam limited ___ pain but has motion of all fingers and wrist. No active motion of elbow or shoulder--patient carried her arm with her other hand. ED labs showed Na 118, K 5.8 Bicarb 12, Creatinine 2.6, Uric Acid 12.6, Hgb 8.3, INR 1.2 Imaging: UE US without DVT, CXR without mass She wave given PO oxycodone 10 and Dilaudid 0.25 mg IV x2 On transfer, vitals were: Pain ___ HR 70 BP 144/71 RR20 93% RA Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: - CAD: ___ Stress test c large rev anterior defect s/p DES to LAD - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: ___ DES to LAD; 70% Lcx untreated - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: ESRD s/p live related transplant now stage IV CKD Focal segmental glomerulosclerosis Anemia Osteoporosis Proteinuria Tobacco abuse s/p tubal ligation ___ Social History: ___ Family History: Her father died at age ___ of pneumonia. He had a history of a "blood disease." Her mother died at age ___ from complications status post hip fracture, she had a history of hypertension. She has nine brothers, seven sisters and one son. One of her brothers has diabetes and several of her siblings have hypertension. There is no family history notable for stroke, hyperlipidemia, early coronary artery disease or sudden cardiac death. Physical Exam: ADMISSION PHYSICAL EXAM ======================= VITALS: 98.2 117/66 74 16 94RA GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: bibasilar rales, otherwise CTAB CV: regular, normal S1 S2, systolic murmur ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Multiple rheumatic nodules and deformity of small joints. RUE: nonpitting edema of RUE, limited AROM and PROM of shoulder ___ pain, sensation intact. R radial pulse thrill and bruit. SKIN: mild erythema over R upper arm and shoulder NEURO: Moves all extremities. Sensation intact. DISCHARGE PHYSICAL EXAM ======================= VITALS: 99.3 | 120/76 | 80 | 18 | 96%RA I&O: 1480 | 3150 GENERAL: Thin woman, non-diaphoretic, sitting in bed in no acute distress. HEENT: Moist mucous membranes. Oropharynx clear. 1 purpuric lesion on ___ each lip. None in mouth. NECK: Supple. L CVL in place. CV: Regular rate and rhythm. II/VI holosystolic murmur heard ___ at left midaxillary line. JVP at 9 cm. RESPIRATORY: L lower lung field crackles. Intermittent rhonci halfway up right lung field, decreased/absent lung sounds in right lower lung field; present w/ crackles in lateral right field. ABDOMEN: Soft, nontender, nondistended. Well-healed scars. Pelvic kidney non-tender. +BS. LYMPH: No right axillary lymph nodes appreciated on exam. 1 0.5 cm R epitrochlear lymph node, non-tender, mobile. EXTREMITIES: RIGHT SHOULDER: Minimally swollen, warm, mildly tender to palpation. RUE edema resolved. UPPER EXTREMITIES: Left radial artery with AV fistula + bruit + thrill (appreciable on palpation). Right radial artery with small thrill. MCP/PIP arthritis on several digits. LOWER EXTREMITIES: Warm, well-perfused, without cyanosis. SKIN: No rashes. Multiple facial and chest telangectasias. Multiple non-blanching purpura on both lower extremities below knee, L > R with ecchymosis on upper extremities and by site of shoulder tap. NEURO: Face symmetric. Moves all limbs against gravity. PSYCH: Pleasant. Answers questions appropriately. Pertinent Results: ADMISSION LABS ============== ___ 03:00PM BLOOD WBC-8.1 RBC-2.87* Hgb-8.3* Hct-25.0* MCV-87 MCH-28.9 MCHC-33.2 RDW-13.9 RDWSD-44.0 Plt ___ ___ 03:00PM BLOOD Neuts-84* Bands-1 Lymphs-3* Monos-9 Eos-0 Baso-0 ___ Myelos-0 Hyperse-3* AbsNeut-7.13* AbsLymp-0.24* AbsMono-0.73 AbsEos-0.00* AbsBaso-0.00* ___ 03:00PM BLOOD Neuts-84* Bands-1 Lymphs-3* Monos-9 Eos-0 Baso-0 ___ Myelos-0 Hyperse-3* AbsNeut-7.13* AbsLymp-0.24* AbsMono-0.73 AbsEos-0.00* AbsBaso-0.00* ___ 03:00PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-2+ Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-1+ Burr-1+ Tear Dr-1+ ___ 03:00PM BLOOD ___ PTT-30.0 ___ ___ 03:00PM BLOOD Glucose-89 UreaN-51* Creat-2.6* Na-118* K-5.8* Cl-96 HCO3-12* AnGap-16 ___ 11:14PM BLOOD ALT-12 AST-28 CK(CPK)-116 AlkPhos-101 TotBili-0.4 ___ 11:14PM BLOOD CK-MB-2 cTropnT-<0.01 ___ ___ 03:00PM BLOOD UricAcd-12.6* ___ 11:14PM BLOOD Albumin-3.6 Calcium-7.8* Phos-4.0 Mg-1.1* ___ 03:00PM BLOOD Osmolal-265* ___ 11:14PM BLOOD TSH-1.5 ___ 08:02AM BLOOD Cortsol-25.3* ___ 11:14PM BLOOD CRP-198.4* ___ 07:27PM BLOOD tacroFK-23.4* ___ 08:05PM URINE Type-RANDOM Color-Yellow Appear-Clear Sp ___ ___ 08:05PM URINE Blood-TR Nitrite-NEG Protein->300 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-5.5 Leuks-NEG ___ 08:05PM URINE RBC-2 WBC-<1 Bacteri-NONE Yeast-NONE Epi-<1 ___ 08:05PM URINE Hours-RANDOM Creat-102 Na-<20 K-28 Cl-LESS THAN TotProt-112 Prot/Cr-1.1* ___ 08:05PM URINE Osmolal-319 SELECT INTERVAL LABS ====================== Complete blood counts ___ 06:17AM BLOOD WBC-5.9 RBC-2.45* Hgb-6.9* Hct-21.2* MCV-87 MCH-28.2 MCHC-32.5 RDW-14.0 RDWSD-44.5 Plt ___ ___ 09:25AM BLOOD WBC-4.1 RBC-2.37* Hgb-6.8* Hct-21.0* MCV-89 MCH-28.7 MCHC-32.4 RDW-14.6 RDWSD-46.8* Plt ___ Coags ------ ___ 08:02AM BLOOD ___ PTT-45.9* ___ ___ 06:36AM BLOOD ___ PTT-24.7* ___ Chem-10 ------- ___ 04:30PM BLOOD Glucose-103* UreaN-56* Creat-2.5* Na-120* K-5.7* Cl-93* HCO3-14* AnGap-19 ___ 03:00PM BLOOD Glucose-179* UreaN-52* Creat-2.2* Na-128* K-4.5 Cl-92* HCO3-22 AnGap-19 ___ 02:14AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.5* Miscellaneous ------------- ___ 06:17AM BLOOD VitB12-250 ___ 06:30PM BLOOD CK-MB-3 cTropnT-0.03* ___ 02:14AM BLOOD CK-MB-3 cTropnT-0.06* ___ 06:30PM BLOOD CK(CPK)-69 ___ 09:00AM BLOOD Cortsol-10.3 ___ 10:00AM BLOOD Cortsol-12.4 ___ 12:35AM BLOOD Free T4-1.3 ___ 06:36AM BLOOD C3-85* C4-31 ___ 11:14PM BLOOD CRP-198.4* ___ 06:36AM BLOOD RheuFac-15* ___ 06:36AM BLOOD PEP-HYPOGAMMAG IgG-815 IgA-187 IgM-22* IFE-NO MONOCLO DISCHARGE LABS ============== ___ 05:50AM BLOOD WBC-5.7 RBC-2.82* Hgb-7.9* Hct-24.3* MCV-86 MCH-28.0 MCHC-32.5 RDW-14.6 RDWSD-45.4 Plt ___ ___ 05:50AM BLOOD Glucose-91 UreaN-66* Creat-2.2* Na-131* K-4.2 Cl-94* HCO3-29 AnGap-12 ___ 05:50AM BLOOD Calcium-8.5 Phos-2.9 Mg-2.5 ___ 05:50AM BLOOD tacroFK-4.6* MICRO ===== BLOOD CULTURES ___: FINAL REPORT: NO GROWTH URINE CULTURE ___: FINAL REPORT: NO GROWTH JOINT FLUID ___: GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Pending): LYME SEROLOGY ___: NO ANTIBODY TO B. ___ DETECTED BY EIA. IMAGING ======== ___ RUE U/S IMPRESSION: No evidence of deep vein thrombosis in the right upper extremity. ___ CXR IMPRESSION: Comparison to ___. In the interval, the patient has developed moderate pulmonary edema. The size of the cardiac silhouette is enlarged and there are signs of basal apical blood flow redistribution. In addition, the lateral radiograph shows signs of fissure oral fluid marking. Larger pleural effusions are not present. No evidence of pneumonia. No suspicious nodules or masses. ___ MR SHOULDER WITHOUT CONTRAST IMPRESSION: 1. The study is significantly degraded by patient motion. 2. Large complex glenohumeral joint effusion with intermediate/low T2 signal and subtle high T1 signal, significantly increased since ___, increased laxity of the glenohumeral joint, increased bone marrow edema in the proximal humerus, and new soft tissue edema about the shoulder. The differential includes some degree of hemorrhagic and/or proteinaceous content within the glenohumeral joint. Although the appearance is non-specific, glenohumeral joint infection should be excluded. A severe noninfectious inflammatory process of this extent would be unusual, but might also account for this appearance. 3. The significance of subtle cortical effacement about the glenoid, progressed slightly compared with ___, is dependent on the presence or absence of infection within the joint. Otherwise, no bone erosion detected. 4. Severe end-stage osteoarthritis of the glenohumeral joint with essentially complete loss of hyaline cartilage and of the glenoid labrum, similar to ___. 5. Severe tendinosis of the supraspinatus and subscapularis tendons with tendon attenuation and partial thickness tearing. The distal ubscapularis may be expanded by complex fluid within the tendon. Supraspinatus tendon is probably fenestrated, with intrasubstance tearing. These changes have both progressed considerably compared with ___. 6. Severe tenosynovitis and tendinosis of the biceps tendon. 7. Moderate subacromial subdeltoid bursitis. Fluid in the SA/SD bursa is much simpler than fluid seen within the joint. ___ MR ELBOW WITHOUT CONTRAST IMPRESSION: Trace elbow joint effusion. Marked dense and extensive subcutaneous edema. No bone marrow edema or bony erosion is detected. Ligaments, tendons and muscles are grossly unremarkable. Note made of prominent high-flow vessels in the subcutaneous soft tissues. ___: RIGHT UPPER EXTREMITY ARTERIAL DUPLEX IMPRESSION: patent right upper extremity arterial system ___: ECHOCARDIOGRAM IMPRESSION: Normal global and regional biventricular systolic function. Mild to moderate mitral regurgitation. ___: CHEST CT WITHOUT CONTRAST IMPRESSION: Diffuse ground-glass opacities, combined to small left pleural effusion, likely reflect infection. The absence of an interstitial component. Is not consistent with pulmonary edema. Small pleural effusion. Signs of pulmonary hypertension. ___ CHEST X-RAY PA AND LATERAL IMPRESSION: In comparison with the study of ___, there has been a substantial increase in asymmetric pulmonary edema, more prominent on the right. Blunting of the costophrenic angles is consistent with developing effusions and bibasilar atelectasis. This in the appropriate clinical setting, given the extensive pulmonary changes. The left IJ catheter extends to the lower SVC. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Atorvastatin 80 mg PO QPM 2. Acetaminophen 500 mg PO Q8H:PRN pain 3. Amlodipine 10 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Mycophenolate Mofetil 250 mg PO BID 6. PredniSONE 4 mg PO DAILY 7. Sodium Bicarbonate 650 mg PO BID 8. Tacrolimus 1.5 mg PO Q12H 9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 10. Carvedilol 6.25 mg PO BID 11. Lisinopril 2.5 mg PO DAILY 12. TiCAGRELOR 90 mg PO BID 13. darbepoetin alfa in polysorbat 40 mcg/0.4 mL injection EVERY 2 WEEKS 14. Ranitidine 150 mg PO BID Discharge Medications: 1. Cefpodoxime Proxetil 400 mg PO Q24H Duration: 9 Doses RX *cefpodoxime 200 mg 2 tablet(s) by mouth once per day Disp #*18 Tablet Refills:*0 2. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain - Moderate Duration: 6 Days RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth twice per day as needed Disp #*12 Tablet Refills:*0 3. sevelamer CARBONATE 800 mg PO TID W/MEALS RX *sevelamer carbonate [Renvela] 800 mg 1 tablet(s) by mouth three times per day Disp #*90 Tablet Refills:*0 4. Tacrolimus 1 mg PO QPM RX *tacrolimus 1 mg 1 capsule(s) by mouth QPM Disp #*28 Capsule Refills:*0 5. Tacrolimus 1.5 mg PO QAM RX *tacrolimus 0.5 mg 3 capsule(s) by mouth QAM Disp #*84 Capsule Refills:*0 6. Acetaminophen 500 mg PO Q8H:PRN pain 7. Amlodipine 10 mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Atorvastatin 80 mg PO QPM 10. Carvedilol 6.25 mg PO BID 11. darbepoetin alfa in polysorbat 40 mcg/0.4 mL injection EVERY 2 WEEKS 12. Lisinopril 2.5 mg PO DAILY 13. PredniSONE 4 mg PO DAILY 14. Ranitidine 150 mg PO BID 15. TiCAGRELOR 90 mg PO BID 16.Outpatient Lab Work Chem 10, CBC, tacro level End stage renal disease N18.6 ___ FAX: ___ Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES ================= SEPTIC ARTHRITIS HYPONATREMIA LOWER EXTREMITY EDEMA GROUND GLASS OPACITIES, RADIOGRAPHICALLY CONSISTENT WITH PNEUMONIA ATRIAL FIBRILLATION WITH RAPID VENTRICULAR RESPONSE HYPERKALEMIA ANEMIA SECONDARY DIAGNOSES =================== END STAGE RENAL DISEASE STATUS-POST KIDNEY TRANSPLANT CORONARY ARTERY DISEASE STATUS-POST DRUG ELUTING STENT ___ HYPERTENSION Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with right arm swelling // Please evaluate for DVT or signs of chest mass Please evaluate for DVT or signs of chest mass IMPRESSION: Comparison to ___. In the interval, the patient has developed moderate pulmonary edema. The size of the cardiac silhouette is enlarged and there are signs of basal apical blood flow redistribution. In addition, the lateral radiograph shows signs of fissure oral fluid marking. Larger pleural effusions are not present. No evidence of pneumonia. No suspicious nodules or masses. Radiology Report EXAMINATION: UNILAT UP EXT VEINS US RIGHT INDICATION: ___ with right arm swelling, evaluate for DVT or signs of chest mass TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper extremity veins. COMPARISON: None. FINDINGS: There is normal flow with respiratory variation in the bilateral subclavian veins. The right internal jugular and axillary veins are patent, show normal color flow and compressibility. The right brachial, basilic, and cephalic veins are patent, compressible and show normal color flow and augmentation. IMPRESSION: No evidence of deep vein thrombosis in the right upper extremity. Radiology Report EXAMINATION: MR ELBOW ___ CONTRAST RIGHT INDICATION: ___ year old woman with R shoulder pain, swelling and limited motion // R elbow effusion TECHNIQUE: Multiplanar multi sequence MRI of the right elbow performed on a 1.5 tesla magnet without IV contrast with the following sequences: Axial and coronal T1, axial and coronal T2 with fat sat, sagittal proton density with fat sat, sagittal T2, and coronal gradient echo. Motion suppression blade images were also attempted. COMPARISON: None available FINDINGS: The study is moderately degraded by patient motion. This exam was tailored to evaluation of Bone marrow signal: Within normal limits. No bone marrow edema detected to suggest contusion, fracture, or focal bone lesion. Joint effusion: Trace Radio-capitellar joint: Congruent. No gross osteoarthritis. Ulnar-trochlear joint: Congruent. No gross osteoarthritis. Radial collateral ligament: Grossly intact Ulnar collateral ligament: Grossly intact Lateral ulnar collateral ligament: Grossly intact. Common extensor tendon: Grossly normal. Common flexor tendon: Grossly normal Biceps tendon: Within normal limits. Brachialis tendon: Within normal limits. Triceps tendon:Within normal limits. Muscles: Muscle mass is grossly preserved, without muscle edema. Radio-bicipital bursa: No significant fluid. Olecranon bursa: No significant fluid. Cubital tunnel: No mass detected within the cubital tunnel. Assessment of the ulnar nerve is limited, but grossly unremarkable. There is profuse subcutaneous interstitial edema. Allowing for the absence of IV contrast, no focal fluid collection or mass is detected. Note is made of prominent subcutaneous vessels, with signal void suggestive of high flow. IMPRESSION: Trace elbow joint effusion. Marked dense and extensive subcutaneous edema. No bone marrow edema or bony erosion is detected. Ligaments, tendons and muscles are grossly unremarkable. Note made of prominent high-flow vessels in the subcutaneous soft tissues. Radiology Report EXAMINATION: MR SHOULDER ___ CONTRAST RIGHT INDICATION: ___ year old woman with R shoulder pain, swelling and limited motion // concern for septic arthritis effusions TECHNIQUE: Multiplanar multi sequence MRI of the right shoulder without IV contrast on a 1.5 Tesla magnet with the following sequences, sagittal T1, axial proton density with fat sat, coronal sagittal T2 BLADE with fat sat. COMPARISON: MR shoulder ___. Radiographs of the right shoulder ___. FINDINGS: The study is degraded by patient motion. There is marked soft tissue edema about the shoulder, including subcutaneous soft tissue edema and areas of intramuscular edema particularly about the scapula. . Acromio-clavicular joint: Mild degenerative change. Subacromial-subdeltoid bursa: Moderate effusion. Fluid in the subacromial/subdeltoid bursa appears relatively high T2 signal and simple. Supraspinatus tendon: The fibers of the supraspinatus tendon are severally attenuated and redundant with elevated signal (08:15). Intact fibers are present, though areas of intrasubstance partial tearing administration are likely present. Infraspinatus tendon: Grossly intact Teres minor tendon: Grossly intact Subscapularis tendon: Severely attenuated and redundant with increased signal (07:20) compatible with severe tendinosis. Alternatively, the outer in inner fibers of the subscapularis tendon may be separated in distended by fluid from the biceps tendon sheath/glenohumeral joint. Glenohumeral joint: The joint is distended with large complex intermediate signal fluid significantly increased since ___. Of note, this material is heterogeneously low signal on the fluid sensitive images, with subtle areas of increased signal on the T1 weighted images. The labrum is extensively markedly diminutive. No normal labrum is identified. There is full-thickness cartilage loss of both the humeral head and glenoid. There are subchondral cystic changes in the glenoid, which appears to progressed compared with ___ (08:16). There is no definite bony erosion. Of note, the glenohumeral joint is widened compared with ___. Biceps tendon: The biceps tendon is appropriately positioned within the intertubercular groove. A large amount of complex intermediate/low T2 signal fluid surrounds the intertubercular portion of the biceps tendon (07:19). The intra-articular portion of the biceps tendon is attenuated with increased signal. The biceps labral anchor is severely diminutive (08:16). Muscles: Probable mild atrophy of the supraspinatus, infraspinatus and subscapularis muscles, though this is difficult to assess due to displacement by the large glenohumeral joint effusion and extension of edema into the musculature surrounding the scapula. Background muscle mass appears grossly preserved. Bone marrow: There is extensive heterogeneous bone marrow edema in the visualized portions of the proximal humerus. This is more pronounced than the periarticular edema seen about the glenohumeral joint on ___. . However, on the sagittal T1 weighted images, most of this remains hyperintense compared to muscle, which is more suggestive of red marrow. IMPRESSION: 1. The study is significantly degraded by patient motion. 2. Large complex glenohumeral joint effusion with intermediate/low T2 signal and subtle high T1 signal, significantly increased since ___, increased laxity of the glenohumeral joint, increased bone marrow edema in the proximal humerus, and new soft tissue edema about the shoulder. The differential includes some degree of hemorrhagic and/or proteinaceous content within the glenohumeral joint. Although the appearance is non-specific, glenohumeral joint infection should be excluded. A severe noninfectious inflammatory process of this extent would be unusual, but might also account for this appearance. 3. The significance of subtle cortical effacement about the glenoid, progressed slightly compared with ___, is dependent on the presence or absence of infection within the joint. Otherwise, no bone erosion detected. 4. Severe end-stage osteoarthritis of the glenohumeral joint with essentially complete loss of hyaline cartilage and of the glenoid labrum, similar to ___. 5. Severe tendinosis of the supraspinatus and subscapularis tendons with tendon attenuation and partial thickness tearing. The distal subscapularis may be expanded by complex fluid within the tendon. Supraspinatus tendon is probably fenestrated, with intrasubstance tearing. These changes have both progressed considerably compared with ___. . 6. Severe tenosynovitis and tendinosis of the biceps tendon. 7. Moderate subacromial subdeltoid bursitis. Fluid in the SA/SD bursa is much simpler than fluid seen within the joint. NOTIFICATION: At the time of this dictation the primary team is aware of the patient's joint effusion and concern for infection. Imaging guided arthrocentesis is planned. Radiology Report Study arterial duplex upper extremity Reason pain Findings. The right subclavian, axillary, brachial, radial and ulnar arteries are patent with normal waveforms and velocities. Impression patent right upper extremity arterial system Radiology Report EXAMINATION: INJ/ASP MAJOR JT W/FLUORO INDICATION: ___ year old woman with right shoulder pain and swelling // please perform right shoulder arthrocentesis COMPARISON: MRI ___ PROCEDURE: The risks, benefits, and alternatives were explained to the patient and written informed consent obtained. It was noted that the patient is taking baby aspirin and has a higher risk of bleeding as well as bruising. A pre-procedure timeout confirmed three patient identifiers. Under fluoroscopic guidance, an appropriate spot was marked. The area was prepared and draped in standard sterile fashion. 10 cc 1% Lidocaine was used to achieve local anesthesia. Under intermittent fluoroscopic guidance, a 20-gauge spinal needle was advanced into the right glenohumeral joint. Appropriate position was confirmed by the injection of a small amount of water soluble contrast. 8 cc of bloody fluid was aspirated. The needle was removed, hemostasis achieved, and a sterile bandage applied. The patient tolerated the procedure well and left the department in stable condition. There were no immediate complications or complaints. FINDINGS: Nodular appearance at the joint space upon injection may be secondary to synovitis. IMPRESSION: 1. Imaging Findings - nodular synovium in the secondary to synovitis. 2. Procedure - Technically successful aspiration of the right glenohumeral joint. Requested laboratory examinations are pending. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ with a history of ESRD ___ FSGS s/p LRRT ___, on prograft/cellcept/prednisone, now with chronic scarring and CKD IV, CAD (s/p DES to LAD), with right shoulder presumed septic arthritis, RUE swelling, found to have severe hyponatremia and hyperkalemia and ICU monitoring course c/b afib with RVR (now in NSR), now on abx for septic arthritis and receiving electrolyte management. // Eval placement of L CVL Contact name: J.A. ___: ___ placement of L CVL IMPRESSION: Comparison to ___. Newly inserted left internal jugular vein catheter. The course of the catheter is unremarkable, the tip projects over the upper to mid SVC. No complications, notably no pneumothorax. Decrease in severity of the pre-existing pulmonary edema. Stable appearance of the cardiac silhouette. Radiology Report EXAMINATION: CT CHEST W/O CONTRAST INDICATION: ___ year old woman with CKD s/p renal transplant, new ___ edema, asymptomatic hyponatremia. // concern for siADH due to chest malignancy vs. lymph obstructing process TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration, no administration of intravenous contrast material, multiplanar reconstructions. DOSE: DLP: 167 mGy-cm COMPARISON: No comparison. FINDINGS: Given the lack of contrast material, the question of potential vascular obstruction cannot be addressed. Mild adenopathy in the axillary regions. The patient is asymmetrically positioned within the scanner. Severe aortic wall calcifications. Moderate to severe dilatation of the main pulmonary artery, indicative of pulmonary hypertension. Severe coronary calcifications, mild to moderate aortic valve calcifications, mild mitral valve calcifications, no pericardial effusion. Mild cardiomegaly. The posterior mediastinum is unremarkable. Diffuse calcifications in the left upper quadrant, combined to perisplenic and perihepatic acites. Minimal degenerative vertebral disease. No vertebral compression fractures. No osteolytic lesions at the level of the ribs, the sternum, or the vertebral bodies. The lung parenchyma shows, in relatively diffuse manner, stones of increased ground-glass like opacities located both in the periphery and in the central parts of the lung. These opacities are not associated with interstitial changes. Simultaneously, the diameter of the vascular structures is markedly dilated. The airways are patent. A small effusion is present on the left. The only other abnormality is as scar in the lingula as well as an atelectasis in the left upper lobe, at the level of the lateral portion of the aortic arch. IMPRESSION: Diffuse ground-glass opacities, combined to small left pleural effusion, likely reflect infection. The absence of an interstitial component. Is not consistent with pulmonary edema. Small pleural effusion. Signs of pulmonary hypertension. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with ESRD (s/p LRRT), with CKD-IV, here with R shoulder septic arthritis. Initially no respiratory symptoms, despite GGOs demonstrated on CT chest, though now with mild hypoxia (94% on RA) and cough. Initially on vanc/CTX, then mono-CTX, now PO cefpodoxime. // Eval for new infiltrate, volume overload? Eval for new infiltrate, volume overload? IMPRESSION: In comparison with the study of ___, there has been a substantial increase in asymmetric pulmonary edema, more prominent on the right. Blunting of the costophrenic angles is consistent with developing effusions and bibasilar atelectasis. This in the appropriate clinical setting, given the extensive pulmonary changes. The left IJ catheter extends to the lower SVC. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: R Arm pain, R Arm swelling Diagnosed with Other specified soft tissue disorders temperature: 97.3 heartrate: 74.0 resprate: 16.0 o2sat: 98.0 sbp: 104.0 dbp: 85.0 level of pain: 10 level of acuity: 3.0

Dear Ms. ___, You came to ___ with a swollen and painful right shoulder. While you were here, we noticed you had low sodium and high potassium, and you were admitted to the intensive care unit for monitoring. Your electrolytes improved. Infection of the shoulder joint is the most likely explanation of your shoulder pain, so please continue your antibiotic until ___, for a total of 2.5 weeks. We also did a chest catscan to see why your right arm was swollen. We saw evidence of a lung infection. However, you did not have symptoms. The most likely lung infections are also treated with the antibiotic (cefpodoxime) that you are taking. We recommend your PCP get ___ imaging in ___ weeks to see if the lung findings have improved. Your legs started swelling, so we treated you with medicine to help remove fluid from your body. We also restarted your lisinopril, which should help. You will follow up with your nephrologist as scheduled below. Please get labs drawn in one week (___). Please also weigh yourself every day. If your weights start to rise, or if you notice worsening swelling in your legs, call the renal transplant clinic at ___. It was a pleasure taking care of you! We wish you the ___. - Your Care Team at ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: CARDIOTHORACIC Allergies: latex Attending: ___. Chief Complaint: chest pain/SOB Major Surgical or Invasive Procedure: none History of Present Illness: ___ h/o COPD on home o2 p/w to OSH w dyspnea, CP, cyanosis. pt, visiting ___, says that she woke up this AM with a 2 coughing spell followed by chest pain and dyspnea. pt's spouse says she became cyanotic, which prompted them to OSH ED. Cardiac enzymes and EKG at OSH was negative. CXR shows R ptx 50% w slight medastinal left shift. A chest tube was place. Serial CXR shows resolution of ptx with mild R lung opacity. CT was done and reveals spontaneous ptx, blebs, and lung nodules. pt was transferred to ___ for further mgt. During the transfer, chest tube was clamped. At ___ ED, chest tube is put on suction and leakage was noted. CT had no o/p. Repeat CXR shows emphesymatic lungs with no clear evidence of ptx. Past Medical History: PAST MEDICAL HISTORY: Stage IV COPD HTN HLD Breast CA s/p lumpectomy s/p chemo Neuropathy ___ chemo Afib Osteoporosis PAST SURGICAL HISTORY: Lumpectomy Social History: ___ Family History: Mother - etoh abuse Father - CAD Physical ___: Temp 98 BP 105/57 HR 75 RR 18 O2 sat 99% on 2LPM Gen: AAOx3 NAD HEENT: wnl CV: rrr s1 s2 PULM: decrease breath sounds ___. GI: s/nt/nd. +bsx4 EXT/MS/SKIN: no c/c/e. +2 pulses NEURO: grossly intact Pertinent Results: ___ 05:00PM WBC-11.0* RBC-4.66 HGB-13.4 HCT-40.8 MCV-88 MCH-28.8 MCHC-32.8 RDW-14.6 RDWSD-46.7* ___ 05:00PM ___ PTT-25.9 ___ ___ 05:00PM PLT COUNT-242 ___ 05:00PM GLUCOSE-189* UREA N-14 CREAT-0.7 SODIUM-130* POTASSIUM-3.4 CHLORIDE-91* TOTAL CO2-26 ANION GAP-16 ___ CXR : Right apical opacity may be due to prominent apical thickening/scarring, correlate with more remote radiographs to ensure stability, if not, consider followup chest CT. Bibasilar reticular opacities suggest chronic lung disease. Relative lucency of the mid lungs likely relates to pulmonary emphysema. Blunting of the right costophrenic angle suggesting a small right pleural effusion. Right chest tube is seen. Subcutaneous emphysema along the right chest wall. ___ CXR with pneumostat in place : 1. Chest tube in appropriate positioning without evidence of pneumothorax. 2. Unchanged bilateral diffuse interstitial thickening representing chronic interstitial lung disease. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN wheezing 2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 3. Amlodipine 10 mg PO DAILY 4. Metoprolol Succinate XL 25 mg PO DAILY 5. Omeprazole 20 mg PO BID 6. Atorvastatin 80 mg PO QPM 7. Hydrochlorothiazide 25 mg PO DAILY 8. Potassium Chloride 20 mEq PO DAILY 9. Aspirin 325 mg PO DAILY 10. Temazepam 7.5 mg PO QHS:PRN insomnia Discharge Medications: 1. Omeprazole 20 mg PO BID 2. Acetaminophen 650 mg PO Q6H:PRN pain 3. DiphenhydrAMINE 25 mg PO Q6H:PRN pruritis RX *diphenhydramine HCl 25 mg 1 capsule(s) by mouth every six (6) hours Disp #*8 Capsule Refills:*0 4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 5. Sarna Lotion 1 Appl TP TID:PRN pruritis RX *camphor-menthol [Anti-Itch (menthol/camphor)] 0.5 %-0.5 % 1 application three times a day Refills:*0 6. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN wheezing 7. Amlodipine 10 mg PO DAILY 8. Aspirin 325 mg PO DAILY 9. Atorvastatin 80 mg PO QPM 10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 11. Hydrochlorothiazide 25 mg PO DAILY 12. Metoprolol Succinate XL 25 mg PO DAILY 13. Potassium Chloride 20 mEq PO DAILY 14. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*2 15. Milk of Magnesia 30 mL PO Q12H:PRN constipation Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Right spontaneous pneumothorax Left lower lobe lung nodule 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 pnuemo at OSH, chest tube placed, images getting uploaded of prior // residual pnuemothorax? TECHNIQUE: Single frontal view of the chest COMPARISON: ___ at 12:56 from ___. FINDINGS: Right apical opacity may be due to prominent apical thickening/scarring, correlate with more remote radiographs to ensure stability, if not, consider followup chest CT. Bibasilar reticular opacities suggest chronic lung disease. Relative lucency of the mid lungs likely relates to pulmonary emphysema. There is blunting of the right costophrenic angle suggesting a small right pleural effusion. Right chest tube is seen coursing into the right lower chest. Right chest wall subcutaneous emphysema is again seen. The cardiac and mediastinal silhouettes are stable. IMPRESSION: Right apical opacity may be due to prominent apical thickening/scarring, correlate with more remote radiographs to ensure stability, if not, consider followup chest CT. Bibasilar reticular opacities suggest chronic lung disease. Relative lucency of the mid lungs likely relates to pulmonary emphysema. Blunting of the right costophrenic angle suggesting a small right pleural effusion. Right chest tube is seen. Subcutaneous emphysema along the right chest wall. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with right pneumothorax, chest tube. // please assess for pneumo. please assess for pneumo. COMPARISON: Comparison to ___ at 16 57 FINDINGS: Portable upright chest radiograph ___ at 07:35 is submitted. IMPRESSION: There is some overlying motion artifact which limits the examination. A right basilar chest tube remains in place. There is air within the right lateral chest wall and neck soft tissues consistent with subcutaneous emphysema. Rounded lucency at the right apex likely represents a small pneumothorax. There is bilateral parenchymal distortion with fibrotic changes at the bases consistent with fibrotic lung disease. Multiple small nodular opacities with associated right apical pleural thickening are again seen and may reflect prior granulomatous infection. Clinical correlation is advised. Overall cardiac and mediastinal contours are stable. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with ptx // post water seal TECHNIQUE: CHEST (PORTABLE AP) COMPARISON: ___ IMPRESSION: Right chest tube is in place although more distally located than previously. Apical opacity on the right is unchanged. No definitive pneumothorax is seen. Interstitial changes and fibrosis in the lung bases is similar to previous study Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with spont ptx // interval change TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph dated ___. . FINDINGS: The right chest tube appears unchanged in comparison to the prior chest radiograph. There is small amount of subcutaneous emphysema. No pneumothorax. There is bilateral apical pleural thickening, worse on the right. There is bilateral diffuse interstitial thickening, worse at the bases which is unchanged. Heart size is normal. The mediastinal and hilar contours are normal. The pulmonary vasculature is normal. No pleural effusion is seen. There are no acute osseous abnormalities. IMPRESSION: 1. Chest tube in appropriate positioning without evidence of pneumothorax. 2. Unchanged bilateral diffuse interstitial thickening representing chronic interstitial lung disease. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with right ptx // R/O ptx with ct on pneumostat IMPRESSION: As compared to ___ radiograph from earlier the same date, a right chest tube remains in place, with persistent loculated hydro pneumothorax at right lung apex and small dependent pleural effusion at right lung base. Overall, allowing for differences in technique and projection, there has not been a substantial change in appearance of the chest since the recent study from several hr earlier. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Dyspnea, Pneumothorax, Transfer Diagnosed with OTHER AIR LEAK temperature: 97.8 heartrate: 100.0 resprate: 22.0 o2sat: 94.0 sbp: 127.0 dbp: 67.0 level of pain: 5 level of acuity: 2.0

* You were admitted to ___ for treatment of a pneumothorax. A chest tube was placed at ___ and you were transferred to ___ for further management. There is a persistent air leak from your lung which will need time to heal and seal over. Your chest xray shows full expansion of the lung which is good. You are ready to go home, but still need your chest tube. A small device, called an Atrium Pneumostat, has been placed on the end of your chest tube to help you get better. The ___ will help you manage this device. * Your oxygen has been reordered for you and you should wear it at ___ LPM as you were doing at home. * If you have any increased shortness of breath, fevers > 101 or any new concerns call Dr. ___ at ___. About The Atrium Pneumostat: The Atrium Pneumostat is made to allow air and a little fluid to escape from your chest until your lung heals. The device will hold 30ml of fluid. Empty the device as often as needed (see directions below) and keep track of how much you empty each day. Items Needed for Home Use: • Atrium Pneumostat Chest Drain Valve (provided by hospital) • ___ syringes to empty drainage, if needed (provided by hospital or ___ Nurse) • Wound dressings (provided by hospital or ___ Nurse) Securing the Pneumostat: Utilize the pre-attached garment clip to secure the Pneumostat to your clothes. It is small and light enough that you won't even feel it hanging at your side. Make sure to keep the Pneumostat in an upright position as much as possible. Before lying down to sleep or rest, empty the Pneumostat so there will be no fluid to potentially leak out. Wound Dressing: You have a dressing around your chest tube. This should be changed at least every other day or as prescribed by your doctor. Showering/Bathing: Showering with a chest tube is all right as long as you don't submerge the tube or device in water. Place the pneumostat in a zip lock bag for showering then remove. No baths, swimming, or hot tubs. Note: This device is very important and the tubing must stay attached to the end of your chest tube. • If it falls off, reconnect it immediately and tape it securely. • If it falls off and you can't get it back together, go to the closest hospital emergency room. Warnings: 1. Do not obstruct the air leak well. 2. Do not clamp the patient tube during use. 3. Do not use or puncture the needleless ___ port with a needle. 4. Do not leave a syringe attached to the needleless ___ port. 5. Do not connect any ___ connector to the needleless ___ port located on the bottom of the chest drain valve. 6. If at any time you have concerns or questions, contact your nurse or physician. Emptying the Pneumostat • Keep the Pneumostat in an upright position and make sure the tubing stays firmly attached to the end of your chest tube. Make sure the Pneumostat stays clean and dry. Do not allow the Pneumostat to completely fill with fluid or it may start to leak out. If fluid does leak out, clean off the Pneumostat and use a Q-tip to dry out the valve. • If the Pneumostat becomes full with fluid, empty it using a ___ syringe. Firmly screw the ___ onto the port located on the bottom of the Pneumostat. • Pull the plunger back on the syringe to empty the fluid. When the syringe is full, unscrew the syringe and empty the fluid into the nearest suitable receptacle. Repeat as necessary. If it becomes difficult to empty the fluid using a syringe, squirt water through the port to flush out the blockage or consult your nurse or physician. The Pneumostat may need to be changed out.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Leaking ostomy appliance Major Surgical or Invasive Procedure: Gastrograffin enema History of Present Illness: ___ recent sigmoid colectomy with diverting ileostomy on ___ with Dr. ___ divericulitis. Postop she recovered well and was discharged home on ___. Was re-admitted ___ for leaking appliance and midline wound infection. She was on vanco a few days, had her wound partially opened, and was discharged home on Bactrim. She presents again tonight with the same problem, that is, stool leaking out of the ostomy and contaminating the laparotomy incision. There was increased erythema around the incision today so she presented to an outside hospital and was subsequently transferred here for evaluation. Ostomy output has been normal, no change. Past Medical History: diverticulitis ___ hospitalized for 4 days at ___ for a 3cm abscess), high cholesterol, HTN, migraines, asthma, depression PSH: Bilateral tubal ligation; C-Section; Bilateral ___ Vein Stripping; ___ drainage of abcess ___ Social History: ___ Family History: Noncontributory Physical Exam: Upon presentation to ___: Vitals: T 99.5 P 96 BP 134/85 RR 18 O2 99% 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, nontender, no rebound or guarding, Incision: moderate erythema surrounding the length of the incision, more pronounced at each staple. Stoma pink, peristomal skin with excoriation but no cellulitis. Ext: 1+ ___ edema, ___ warm and well perfused Pertinent Results: GASTROGRAFIN ENEMA: Gastrografin contrast was instilled through an 18 ___ flexible catheter into the rectum. Contrast flowed freely into the rectum, past the colorectal anastomosis and into the distal colon. There is no evidence of leaks or strictures. The patient tolerated the procedure well. IMPRESSION: No evidence of leaks at the colorectal anastomosis. Medications on Admission: 1. levothyroxine 50 mcg Daily 2. atenolol 25 mg Daily 3. furosemide 80 mg Daily 4. simvastatin 80 mg Daily 5. aspirin 81 mg Daily 6. hydromorphone ___ mg Q4H as needed for pain 7. butalbital/acetaminophen/caffeine 50mg/325mg/40mg as needed for headache Discharge Medications: 1. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 7. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain. 8. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day). Disp:*1 bottle* Refills:*2* 9. Ostomy supplies ConvaTec Surfit Moldable Large Convex it ___: # ___ 10. Ostomy supplies ConvaTec Drainable Pouch ___: ___ ___ 11. Ostomy supplies Ostomy Belt: manf # ___ 12. Dressing/Wound supplies Aquacel AG rope Sig: Commercial wound cleanser, pat dry. Aquacel AG rope, dry gauze, change daily. Disp: 1 tube Refills: 4 Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: Leaking ostomy appliance Candidiasis skin infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Status post sigmoidectomy for diverticulitis. Evaluate colorectal anastomosis prior to ileostomy takedown. COMPARISONS: None. GASTROGRAFIN ENEMA: Gastrografin contrast was instilled through an 18 ___ flexible catheter into the rectum. Contrast flowed freely into the rectum, past the colorectal anastomosis and into the distal colon. There is no evidence of leaks or strictures. The patient tolerated the procedure well. IMPRESSION: No evidence of leaks at the colorectal anastomosis. Gender: F Race: HISPANIC OR LATINO Arrive by WALK IN Chief complaint: WOUND EVAL Diagnosed with OTHER SPEC COMPL S/P SURGERY, ACCIDENT NOS temperature: 99.5 heartrate: 96.0 resprate: 18.0 o2sat: 99.0 sbp: 134.0 dbp: 85.0 level of pain: 0 level of acuity: 3.0

You were admitted to the hospital with non adherent ostomy due to leaking. As a result you developed a fungal skin rash that is beingtreated with an anti-fungal powder. A new ostomy appliance has been used - you will be given prescriptions for the new supplies. DO NOT use the old ostomy appliance that you have at home. You may resume your home medications as prescribed. Return to the Emergency room if your ostomy appliance leaks again.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Naprosyn / Nsaids / Statins-Hmg-Coa Reductase Inhibitors / Niaspan Starter Pack / Lisinopril / Biaxin / Fosamax / adhesive tape / Bactrim / doxycycline / Ditropan / General Anesthesia / latex Attending: ___. Chief Complaint: Dyspnea on Exertion Major Surgical or Invasive Procedure: 1) EGD (___) 2) Colonoscopy (___) 3) Capsule endoscopy (___) History of Present Illness: ___ female with a past medical history notable for polycythemia ___, systolic heart failure s/p bioprosthetic mitral valve replacement in ___, recent hospitalization requiring ICU admission for GI bleed (___), who presented with 1 week of weakness. The patient additionally reports several episodes of dark stools over the past week. The patient was seen by her PCP earlier on the day of admission and found to be profoundly anemic and was sent to the ED for further evaluation. The patient also reported significant dyspnea on exertion, which had been steadily worsening. Despite her history of CHF, she had not been taking her home lasix for some time. She denied any fever/chills, chest pain, abdominal pain, and dysuria. Rectal exam showed guaiac positive stools. Of note, patient had been recently admitted from ___ for hematochezia. At that time, patient had a CTA abdomen/pelvis with and without contrast which showed "linear area of hyperdensity at level of right anus on arterial phase, best seen on the coronal views, which disseminates and enlarges on the delayed phases." Anoscopy showed thrombosed internal hemorrhoids. During that hospitalization, received 4 units pRBC and underwent banding of internal hemorrhoids by anoscopy--banded x 2 (left posterior and anterior midline). In the ED, initial VS were 96.4 116 104/52 16 100% RA. Exam notable for pallor and guaiac positive stool on rectal. She also had bilateral lower extremity edema. Labs showed hemoglobin/hematocrit of 6.3/19.7 Chest X-ray showed small bilateral pleural effusions and mild interstitial edema. Received pantoprazole gtt. Transfer VS were 99/4, 118, 98/49, 26, 99% on RA GI was consulted in the ED and followed the patient through initial hospital course. Past Medical History: Medical History: -sCHF (EF=25%) -Mitral Valve replacement ___ Mitral regurgitation and prolapse -GI bleed (?upper vs. lower) -Polycythemia ___ -Basal Cell Carcinoma s/p Mohs Surgery of right cheek in ___ -DCIS s/p lumpectomy & radiation -Hyperlipidemia -Hypertension -Hypothyroidism -Osteoarthritis -Squamous Cell Carcinoma -Urinary Tract Infections, recurrent -Varicose Veins s/p venous stripping b/L ___ Surgical History: -Lumpectomy for DCIS -___ surgery, right cheek (___) -Prolapsed bladder surgery, failed -Rotator cuff surgery (___) -Salpingo-oophorectomy for dermoid cyst in ___, right -Total abdominal hysterectomy w/ removal of left ovary (___) -Vein stripping bilateral legs Social History: ___ Family History: Positive for lung cancer in one sister. Another sister died of cardiac disease. Physical Exam: =================== ADMISSION PHYSICAL: ------------------- Vitals: 97.8, 99/69, 118, 24, 97% on RA. General: Elderly appearing, pale appearing female, laying in bed, dry cough. HEENT: Sclera anicteric, PERRL, EOMI, pale conjunctiva. Neck: Supple, elevated JVD. CV: Irregularly irregular rhythm, S1 and S2, prominent prosthetic sound in apex. Lungs: Minimal bibasilar crackles, no wheezes. Abdomen: soft, non-tender, non-distended, no rebound or guarding, normoactive bowel sounds. Ext: 1+ pitting edema in bilateral lower extremities. Varociose veins appreciated in bilateral lower extremities. Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation. =================== DISCHARGE PHYSICAL: ------------------- VS- Tm 98.6 Tc 98.6 HR 110-113 BP 110/69 RR ___ 02 97% RA ___ over last 8h Weight: 69.3kg (from 70.8kg standing on ___ General: Elderly female, NAD. Less pallid compared to admission. HEENT: MMM. PERRLA. EOMI. Neck: Supple, JVP not appreciated. CV: Irregular rhythm, not tachycardic. +S1/S2, prominent prosthetic sound in apex with ___ systolic murmur. Lungs: +Rales b/L in lower to mid lung fields. No wheezes, no rhonchi. Lung sounds diminished in right base. Abdomen: Soft, non-tender, non-distended, no rebound or guarding. Normoactive bowel sounds. Ext: Minimal edema in bilateral lower extremities. Varociose veins appreciated in bilateral lower extremities. ___ stockings. Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation. Pertinent Results: =============== ADMISSION LABS: --------------- ___ 01:55PM BLOOD WBC-8.3# RBC-1.95* Hgb-6.3* Hct-19.7* MCV-101* MCH-32.3* MCHC-32.0 RDW-19.9* RDWSD-70.1* Plt ___ ___ 01:55PM BLOOD Neuts-75* Bands-2 Lymphs-15* Monos-2* Eos-0 Baso-3* Atyps-1* Metas-2* Myelos-0 AbsNeut-6.39* AbsLymp-1.33 AbsMono-0.17* AbsEos-0.00* AbsBaso-0.25* ___ 01:55PM BLOOD UreaN-28* Creat-0.8 Na-135 K-5.0 Cl-101 HCO3-23 AnGap-16 ___ 01:55PM BLOOD ALT-10 AST-13 AlkPhos-117* TotBili-0.4 DirBili-0.2 IndBili-0.2 ___ 01:55PM BLOOD TotProt-7.2 Albumin-3.9 Globuln-3.3 Calcium-9.0 Phos-4.3 Mg-2.6 =============== KEY LABS: --------------- ___ 05:25PM BLOOD WBC-7.2 RBC-1.85* Hgb-6.1* Hct-18.7* MCV-101* MCH-33.0* MCHC-32.6 RDW-20.1* RDWSD-68.9* Plt ___ ___ 07:00AM BLOOD ___ PTT-28.3 ___ ___ 07:00AM BLOOD Glucose-104* UreaN-22* Creat-1.0 Na-139 K-3.7 Cl-104 HCO3-19* AnGap-20 ___ 06:40AM BLOOD Glucose-107* UreaN-17 Creat-1.0 Na-137 K-4.4 Cl-105 HCO3-21* AnGap-15 =============== DISCHARGE LABS: --------------- ___ 07:00AM BLOOD WBC-5.9 RBC-2.62* Hgb-8.1* Hct-25.2* MCV-96 MCH-30.9 MCHC-32.1 RDW-17.6* RDWSD-59.0* Plt ___ ___ 07:00AM BLOOD Glucose-96 UreaN-19 Creat-0.8 Na-139 K-4.2 Cl-102 HCO3-27 AnGap-14 ___ 07:00AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.3 =============== IMAGING: --------------- ___ CHEST XR: IMPRESSION: 1. Small bilateral pleural effusions with bibasilar atelectasis. 2. Mild interstitial pulmonary edema. ___ CHEST XR: IMPRESSION: Heart size and mediastinum are stable including cardiomegaly. Mild vascular enlargement is demonstrated but no overt pulmonary edema is seen. Bilateral pleural effusions are most likely present, small to moderate. ___ CHEST XR: IMPRESSION: In comparison with the study of ___, there is continued enlargement of the cardiac silhouette with only minimal elevation of pulmonary venous pressure that is unchanged from previous studies. No acute focal pneumonia. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen ___ mg PO Q6H:PRN pain/temp 2. Docusate Sodium 100 mg PO BID 3. Levothyroxine Sodium 75 mcg PO DAILY 4. Metoprolol Succinate XL 25 mg PO BID 5. Ranitidine 150 mg PO BID 6. Aspirin EC 81 mg PO DAILY 7. Miconazole Nitrate Vag Cream 2% 1 Appl VG QHS Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN pain/temp 2. Aspirin EC 81 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Levothyroxine Sodium 75 mcg PO DAILY 5. Metoprolol Succinate XL 50 mg PO DAILY RX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 6. Furosemide 40 mg PO BID RX *furosemide 40 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 7. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*60 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY: ---------------- # GI BLEED # Acute anemia # Acute on chronic systolic congestive heart failure SECONDARY: ---------------- # Polycythemia ___ ___ Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with h/o recent vavle/heart surgery and more recent bleed; now w incr dyspnea/cough eval for evid of congestion /aspiration or pul etiology to cough // ___ year old woman with h/o recent vavle/heart surgery and more recent bleed; now w incr dyspnea/cough eval for evid of congestion /aspiration or pul etiology to cough TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph dated ___. FINDINGS: The sternotomy wires appear intact and appropriately aligned. There are small bilateral pleural effusions with bibasilar atelectasis, worse on the left. Mild interstitial pulmonary edema. The lungs are otherwise clear. Heart size is stable. The mediastinal and hilar contours are stable. No pneumothorax is seen. There are no acute osseous abnormalities. IMPRESSION: 1. Small bilateral pleural effusions with bibasilar atelectasis. 2. Mild interstitial pulmonary edema. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with CHF, with intermittent dyspnea // Evaluate for edema, infection TECHNIQUE: CHEST (PORTABLE AP) COMPARISON: ___ IMPRESSION: Heart size and mediastinum are stable including cardiomegaly. Mild vascular enlargement is demonstrated but no overt pulmonary edema is seen. Bilateral pleural effusions are most likely present, small to moderate Old first rib fracture is re- demonstrated on the left Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with worsening dyspnea // worsening pulmonary edema? worsening pulmonary edema? IMPRESSION: In comparison with the study of ___, there is continued enlargement of the cardiac silhouette with only minimal elevation of pulmonary venous pressure that is unchanged from previous studies. No acute focal pneumonia. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Dyspnea on exertion, Anemia Diagnosed with GASTROINTEST HEMORR NOS, ANEMIA NOS temperature: 96.4 heartrate: 116.0 resprate: 16.0 o2sat: 100.0 sbp: 104.0 dbp: 52.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, Thank you for choosing to get your care at ___! You were admitted with anemia ("low blood counts") and dark stools, which were concerning for GI bleeding. The GI specialists were consulted and perfermed endoscopic studies including an EGD and a colonoscopy. Your EGD was unrevealing, and the colonoscopy showed some possible sources of bleeding but no active bleeds. A capsule study was performed but was incomplete because the capsule never left your stomach. This test can be performed again outside the hospital. You have a scheduled ___ appointment with the GI doctors to discuss this further. During your hospitalization, you were found to be having some problems with the amount of water in your body because of your Congestive Heart Failure (CHF). This had caused some problems with your breathing as is typical for this condition. You were treated with diuretics to remove the extra water. As we did this, your breathing was better and your kidney function improved. You will be discharged on a new dose of the diuretic furosemide. You should follow up with your cardiologist as an outpatient to make sure this is the right dose for you. In the meantime, you should weigh yourself every morning and call your doctor if weight goes up more than 3 lbs. Also let your doctor know if you are having difficulty breathing, especially when you are lying down or in the middle of the night. You were not treated for your polycythemia ___ during this hospitalization because your blood counts were low and Dr. ___ ___ already been holding your hydroxyurea. You have a follow up appointment with your hematologists scheduled, at which point you can discuss this further. We wish you the best of future health! Sincerely, Your ___ care team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Phenothiazines / piperacillin-tazobactam / Thorazine Attending: ___. Chief Complaint: hypoxia Major Surgical or Invasive Procedure: None. History of Present Illness: ___ yo female with PMH significant for DM, COPD chronically on 2L home O2, developmental delay and numerous psychiatric diagnoses who is sent in from her nursing home after she complained of back pain and was found to have O2 sats in the ___ on her home oxygen. Per EMS report, nursing home called requesting transport to hospital for evaluation of back pain this morning. EMS found sats to be 97% on home O2 and lung exam was notable for rhonchi on auscultation of all lung fields and productive cough. Vitals on arrival to the ED: T 98.5 P 96 BP 94/58 RR 16 O2 97% 4L Nasal Cannula. Labs notable for: D-Dimer of 543, UA with + nitrite, large leuks, WBC 37 and 0 Epis. WBC 10.8 (83.4%N). Cr 1.0 with baseline closer to 0.5-0.6. Patient given Duonebs x6, Levofloxacin 750mg x1, Flagyl 500mg IV, Ceftriaxone 1gram, Methylprednisolone 125mg, 2L NS and 1gr of Acetaminophen. CXR showed bibasilar opacities and there was concern for PNA. The patient initially had high O2 requirement and was on a NRB at one point in the ED. Bed request was for ICU given hypotension, tachycardia, tachypnea, hypoxia, then changed to medicine floor as patient improved with above therapy. Vitals prior to transfer: T 98.7 P ___ BP 111/63 RR 27 O2 98% Nasal Cannula. This morning, the patient notes her breathing feels improved, and notes that he cough and sputum is new, though is unclear about the timeline. Denies any chest pain, fevers/chills, coughing with eating, trouble swallowing, abdominal pain, N/V. Denies LH/dizziness. Tells me she walks without assistance without difficulty (notes report walks with a walker). Reports her BMs are at baseline. No urinary complaints, or blood in stool or urine. Per discussion with group home, patient is on 2L O2 at night, nothing during the daytime. Also on puree diet with honey thickened liquids. Past Medical History: 1. Mild intellectual disability 2. Dementia 3. COPD, on 2L NC 4. h/o Multiple falls 5. bronchiectasis 6. lumbar stenosis 7. L chronic rotator cuff tear, followed by orthopedics, h/o past steroid injection 8. osteoporosis 9. DJD 10. GERD 11. Hypercholesterolemia 12. B12 deficiency 13. MRSA PNA in ___ and ___ 14. Cellulitis in ___, MRSA + per wound swab Past Psychiatric History (per OMR): 1. Anxiety 2. Depression 3. Psychotic disorder/schizophrenia 4. Bipolar disorder Social History: ___ Family History: (Per OMR) Mother lived to her mid-___ then suffered an MI. Father lived to his mid-___ before dying of natural causes. Pt is unable to state her family history. Physical Exam: ADMISSION PHYSICAL EXAM: ==================== Vitals - T: 98.8 BP: 95/57 HR: 102 RR: 20 02 sat: 97% 4L NC GENERAL: NAD, frail appearing elderly woman with red hair. Occasionally shouts out in pain. HEENT: AT/NC, EOMI, PERRL, anicteric sclera, MMM, edentulous NECK: nontender supple neck, no JVD appreciated CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: Overall clear, difficult to appreciate good lung sounds given patient difficulty cooperating and moaning, no overt rhonchi/wheezes ABDOMEN: nondistended, +BS, mild tenderness to deep palpation throughout but no rebound or guarding EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, alert and oriented to self, knows she is in a hospital. Guesses the day is ___ and year is ___. ___ strength bilateral lower extremities. SKIN: warm and well perfused, multiple ecchymoses on arms bilaterally DISCHARGE PHYSICAL EXAM: ==================== Vitals - Tm 98.1, Tc 97.6, HR 106 (88-106), BP 110/74 (97-120/55-83), RR ___, O2 Sat 93-100% on 2L GENERAL: NAD, frail appearing elderly woman with red hair, sleeping this morning. HEENT: AT/NC, PRRL, some mild 1.5mm anisocoria L>R, EOMI, dry MM, tongue midline CARDIAC: RRR, distant S1/ normal S2, no murmurs, gallops, or rubs LUNG: More clear lung exam this morning, with intermittent minimal expiratory rhonchi, decreased air movement on sides anteriorly, no wheezes. ABDOMEN: nondistended, +BS, completely nontender, no rebound or guarding. EXTREMITIES: no cyanosis, clubbing or edema, 2+ DP pulses bilaterally. SKIN: warm and well perfused, multiple ecchymoses on arms bilaterally. Pertinent Results: ==== ADMISSION LABS ==== ___ 07:15AM BLOOD WBC-10.8# RBC-4.00*# Hgb-11.5*# Hct-35.3*# MCV-88 MCH-28.6 MCHC-32.5 RDW-16.1* Plt ___ ___ 07:15AM BLOOD Neuts-83.4* Lymphs-11.2* Monos-4.8 Eos-0.5 Baso-0.1 ___ 07:15AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL ___ 07:15AM BLOOD ___ PTT-42.3* ___ ___ 07:15AM BLOOD Glucose-127* UreaN-19 Creat-1.0 Na-137 K-4.3 Cl-95* HCO3-32 AnGap-14 ___ 07:15AM BLOOD D-Dimer-543* ___ 11:04AM BLOOD ___ pO2-49* pCO2-52* pH-7.37 calTCO2-31* Base XS-2 ___ 07:23AM BLOOD Lactate-2.0 ___ 11:04AM BLOOD O2 Sat-80 ___ 11:00AM URINE Color-Yellow Appear-Hazy Sp ___ ___ 11:00AM URINE Blood-NEG Nitrite-POS Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-LG ___ 11:00AM URINE RBC-0 WBC-37* Bacteri-FEW Yeast-NONE Epi-0 ___ 11:00AM URINE 3PhosX-RARE ___ 11:00AM URINE Mucous-RARE ==== DISCHARGE LABS ==== ___ 10:40AM BLOOD WBC-20.2*# RBC-4.18* Hgb-11.5* Hct-37.1 MCV-89 MCH-27.6 MCHC-31.1 RDW-16.2* Plt ___ ==== MICROBIOLOGY ==== ___ BLOOD CULTURES X2: No growth. ___ 11:00 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. ___ URINE CULTURE: No growth. ___ 1:07 am SPUTUM Site: EXPECTORATED **FINAL REPORT ___ GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final ___: SPARSE GROWTH Commensal Respiratory Flora. STAPH AUREUS COAG +. MODERATE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S ==== IMAGING ==== ___ ECG: EKG: poor R wave progression, normal axis. Earlier EKGs with poor baseline, showing mild ST segment depressions in lateral leads. ___ CXR (PA AND LAT) FINDINGS: AP upright and lateral views of the chest provided. Bibasilar streaky opacities are again seen which may represent scarring/atelectasis. Difficult to exclude a component of aspiration/ pneumonia. A tiny right effusion is likely present. Cardiomediastinal silhouette is stable. No pneumothorax. No convincing signs of edema. Severe degenerative disease at bilateral shoulders again noted. There is a mild dextroscoliosis centered in the lumbar spine. IMPRESSION: Bibasilar opacities likely due to a combination of atelectasis, scarring, difficult to exclude a component of aspiration/pneumonia. ___ CXR (PORTABLE) AP portable upright view of the chest. Patient is rotated to her right. Bibasilar opacities with small right pleural effusion re- demonstrated without significant interval change from prior exam performed 3 hr earlier. No overt edema is seen. ___ CXR (PORTABLE) There is right lower lobe consolidation, which could be pneumonia. Left lung base atelectasis is similar to prior. There is small bilateral pleural effusions. Cardiomediastinal silhouette is unchanged. IMPRESSION: No notable interval change. Possible pneumonia at right lower lobe. ___ VIDEO OROPHARYNGEAL SWALLOW Barium passes freely through the oropharynx and esophagus without evidence of obstruction. There was significant aspiration of honey and puree consistencies, with penetration of nectar thick consistencies. Due to aspiration risk, this swallow study was terminated early. IMPRESSION: Significant aspiration of honey NP ray consistencies, with penetration of nectar-thick consistency. Please refer to the speech and swallow division note in OMR for full details, assessment, and recommendations. ___ PORTABLE ABDOMINAL 1. Oral contrast and air seen in multiple loops of nondilated bowel, without evidence of obstruction. 2. Lucency in the right lower quadrant is likely air in the ascending colon. However, upright/lateral radiographs could be obtained to assess for free intraperitoneal air. ___ ABD SUPINE AND LAT DECUBITUS Oral contrast again seen in multiple loops of large bowel. On decubitus views, no evidence of free intraperitoneal air or obstruction. Previously identified right lower quadrant bowel loops containing air and contrast no longer identified. Unchanged dextroscoliosis of bilateral degenerative changes of the hips. IMPRESSION: No evidence of free intraperitoneal air or obstruction. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 2. Docusate Sodium 100 mg PO BID 3. Artificial Tears 1 DROP BOTH EYES QID 4. Calcium Carbonate 600 mg PO BID 5. Divalproex Sod. Sprinkles 250 mg PO TID 6. ClonazePAM 0.5 mg PO BID 7. Lidocaine 5% Patch 1 PTCH TD QAM 8. Atorvastatin 10 mg PO QPM 9. Multivitamins 1 TAB PO DAILY 10. Senna 8.6 mg PO BID 11. Tiotropium Bromide 1 CAP IH DAILY 12. Acetaminophen 650 mg PO TID 13. Ascorbic Acid ___ mg PO BID 14. Vitamin D ___ UNIT PO DAILY 15. Sertraline 150 mg PO DAILY 16. OLANZapine 10 mg PO QHS 17. Bisacodyl 10 mg PO DAILY:PRN constipation 18. Bacitracin Ointment 1 Appl TP BID:PRN cuts/scrapes 19. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheeze/sob 20. Guaifenesin ER 600 mg PO Q12H 21. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN heartburn 22. Milk of Magnesia 30 mL PO Q24H:PRN constipation 23. Fluticasone Propionate NASAL 1 SPRY NU BID Discharge Medications: 1. Artificial Tears 1 DROP BOTH EYES QID 2. Bisacodyl 10 mg PO DAILY:PRN constipation 3. Calcium Carbonate 600 mg PO BID 4. ClonazePAM 0.5 mg PO BID 5. Divalproex Sod. Sprinkles 250 mg PO TID 6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 7. Guaifenesin ER 600 mg PO Q12H 8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheeze/sob 9. Lidocaine 5% Patch 1 PTCH TD QAM 10. OLANZapine 10 mg PO QHS 11. Sertraline 150 mg PO DAILY 12. Tiotropium Bromide 1 CAP IH DAILY 13. Acetaminophen 650 mg PO TID 14. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN heartburn 15. Bacitracin Ointment 1 Appl TP BID:PRN cuts/scrapes 16. Fluticasone Propionate NASAL 1 SPRY NU BID 17. Milk of Magnesia 30 mL PO Q24H:PRN constipation Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnoses: - Methicillin resistant Staph aureus pneumonia - Urinary tract infection - Aspiration - COPD exacerbation 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 (AP AND LAT) INDICATION: ___ with dyspnea, tachypnic // evidence of pneumonia COMPARISON: Chest radiograph ___ FINDINGS: AP upright and lateral views of the chest provided. Bibasilar streaky opacities are again seen which may represent scarring/atelectasis. Difficult to exclude a component of aspiration/ pneumonia. A tiny right effusion is likely present. Cardiomediastinal silhouette is stable. No pneumothorax. No convincing signs of edema. Severe degenerative disease at bilateral shoulders again noted. There is a mild dextroscoliosis centered in the lumbar spine. IMPRESSION: Bibasilar opacities likely due to a combination of atelectasis, scarring, difficult to exclude a component of aspiration/pneumonia. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ with dyspnea // evidence of fluid overload COMPARISON: Prior exam performed 3 hr earlier. FINDINGS: AP portable upright view of the chest. Patient is rotated to her right. Bibasilar opacities with small right pleural effusion re- demonstrated without significant interval change from prior exam performed 3 hr earlier. No overt edema is seen. IMPRESSION: No change. Radiology Report INDICATION: ___ yo female with PMH significant for DM, COPD chronically on 2L home O2, developmental delay and numerous psychiatric diagnoses who presents with hypoxia at her nursing home, found to have possible PNA on CXR, likely UTI, meeting SIRS criteria. // Please assess for interval change. EXAMINATION: CHEST (PORTABLE AP) TECHNIQUE: Portable Chest radiograph, AP view COMPARISON: Chest radiograph ___ FINDINGS: There is right lower lobe consolidation, which could be pneumonia. Left lung base atelectasis is similar to prior. There is small bilateral pleural effusions. Cardiomediastinal silhouette is unchanged. IMPRESSION: No notable interval change. Possible pneumonia at right lower lobe. Radiology Report EXAMINATION: VIDEO OROPHARYNGEAL SWALLOW INDICATION: ___ yo female with PMH significant for DM, COPD chronically on 2L home O2, developmental delay and numerous psychiatric diagnoses who presents with hypoxia at her nursing home, found to have possible PNA on CXR, likely UTI, meeting SIRS criteria. Please assess for evidence of aspiration. TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in conjunction with the speech and swallow division. Multiple consistencies of barium were administered. DOSE: Fluoro time: 2 min 13 seconds. COMPARISON: None available. FINDINGS: Barium passes freely through the oropharynx and esophagus without evidence of obstruction. There was significant aspiration of honey and puree consistencies, with penetration of nectar thick consistencies. Due to aspiration risk, this swallow study was terminated early. IMPRESSION: Significant aspiration of honey NP ray consistencies, with penetration of nectar-thick consistency. Please refer to the speech and swallow division note in OMR for full details, assessment, and recommendations. Radiology Report EXAMINATION: PORTABLE ABDOMEN INDICATION: ___ yo female with PMH significant for DM, COPD chronically on 2L home O2, developmental delay and numerous psychiatric diagnoses who presents with hypoxia at her nursing home, found to have MRSA PNA likely UTI, meeting SIRS criteria. Please assess for acute intraabdominal process. TECHNIQUE: Supine portable views of the abdomen. COMPARISON: Abdominal radiograph from ___ and video swallow from ___. FINDINGS: Oral contrast from the recent video swallow is present within the descending and sigmoid colon. Air is present multiple loops of nondilated bowel. Right lower quadrant lucency is likely air and contrast in the ascending colon, which could be within the pannus or possibly in a hernia. However, free air cannot be excluded on this single supine view. Dextroscoliosis of the lumbar spine and bilateral degenerative hip changes are also noted. IMPRESSION: 1. Oral contrast and air seen in multiple loops of nondilated bowel, without evidence of obstruction. 2. Lucency in the right lower quadrant is likely air in the ascending colon. However, upright/lateral radiographs could be obtained to assess for free intraperitoneal air. Radiology Report EXAMINATION: ABD SUPINE AND LAT DECUB INDICATION: ___ yo female with PMH significant for DM, COPD chronically on 2L home O2, developmental delay and numerous psychiatric diagnoses who presents with hypoxia at her nursing home, found to have MRSA PNA likely UTI, meeting SIRS criteria. Evaluate for obstruction, free air. TECHNIQUE: Supine and decubitus views of the abdomen. COMPARISON: Abdominal x-ray from earlier on the same date. FINDINGS: Oral contrast again seen in multiple loops of large bowel. On decubitus views, no evidence of free intraperitoneal air or obstruction. Previously identified right lower quadrant bowel loops containing air and contrast no longer identified. Unchanged dextroscoliosis of bilateral degenerative changes of the hips. IMPRESSION: No evidence of free intraperitoneal air or obstruction. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Back pain, Productive cough Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION, HYPOXEMIA temperature: 98.5 heartrate: 96.0 resprate: 16.0 o2sat: 97.0 sbp: 94.0 dbp: 58.0 level of pain: 13 level of acuity: 2.0

Dear Ms. ___, It was a pleasure taking care of you during your recent hospital stay at the ___. You were admitted for back pain with low oxygen levels and a new productive cough consistent with a lung infection called pneumonia. You also had your urine tested and you also had evidence of a urinary tract infection. You were treated with intravenous antibiotics, and your symptoms improved. Because you had some difficulty with breathing, you were also treated with steroids to treat a COPD exacerbation in the setting of your infections, and your breathing improved. While you were here, you were also noticed to have some difficulty with swallowing, so our speech and swallow specialists evaluated you, and recommended you have someone with you to help feed you your meals to prevent food going into your lungs, to help prevent future lung infections. Your medications and future medical appointments are listed below for you. We wish you the best with your health. Sincerely, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Dilaudid Attending: ___. Chief Complaint: Dyspnea And Edema Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old lady with history of Mitral valve prolapse ___ bioprosthetic MVR, atrial flutter (on coumadin) morbid obesity, sleep apnea who presents with 2 days of worsening dyspnea, orthopnea, peripheral edema. At baseline she is able to walk ___ blocks before feeling short of breath. Recently she was becoming short of breath with minimal exertion. No shortness of breath at rest. Additionally she normally sleeps on three pillows but recently was using four pillows. Per records patient's dry weight is 180lbs however in the past 2 weeks patient reports ___ lb weight gain. She usually tries to limit her salt intake but at times family makes food with salt in it including canned soup. Her lasix dose was halved to 20mg daily in ___ by Dr. ___ increased back to 40mg daily by PCP 2 weeks ago. She reports mild dry cough worse with lying flat but denies any fevers, chills, night sweats, chest pain, lightheadedness, palpitations. She was seen by PCP yesterday who noted 15lb weight gain and asked patient to go to ED for diuresis. Initial VS in the ED: 97.3 75 124/97 20 95%. Exam notable for ___ edema, weight gain, and crackles. Labs notable for BUN 27, INR 2.5, and a negative pregnancy test. CXR showed pulmonary congestion. Patient was not given any medications while in the ER. Overnight she received 40mg IV lasix and had 1L urine ouptut. Past Medical History: MVP/MR ___ bioprosthetic mitral valve in ___. Moderate MR ___ MVR. Depression, Diverticulosis Atrial Flutter on coumadin Social History: ___ Family History: FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory Physical Exam: Admission Physical Exam: Vitals: Tc 97.5 BP 117/70 HR 78 RR 20 97% RA General: NAD HEENT: EOMI Neck: Supple CV: RRR, nl S1/S2, no murmur appreciated Lungs: Crackles at the bilateral bases Abdomen: S/NT/ND Ext: 2+ Pitting edema bilaterally Neuro: AAOx3 Pertinent Results: Pertinent Labs: ___ 06:11PM BLOOD WBC-9.1 RBC-4.41 Hgb-13.6 Hct-40.4 MCV-92 MCH-30.8 MCHC-33.6 RDW-16.6* Plt ___ ___ 06:11PM BLOOD ___ PTT-34.1 ___ ___ 06:11PM BLOOD Glucose-118* UreaN-27* Creat-1.0 Na-139 K-4.1 Cl-102 HCO3-26 AnGap-15 ___ 07:55AM BLOOD ALT-24 AST-33 AlkPhos-79 TotBili-0.9 ___ 06:11PM BLOOD ___ ___ 06:11PM BLOOD Calcium-8.7 Phos-4.1 Mg-2.0 ___ 08:19AM BLOOD %HbA1c-5.7 eAG-117 ___ 11:01AM URINE Color-Straw Appear-Clear Sp ___ ___ 11:01AM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR ___ 11:01AM URINE RBC-1 WBC-3 Bacteri-FEW Yeast-NONE Epi-1 ___ 11:01AM URINE UCG-NEGATIVE . CXR: ___ FINDINGS: The patient is status post median sternotomy and mitral valve replacement. The cardiac silhouette is moderate to severely enlarged but unchanged. The mediastinal contours are stable with continued dilatation of the azygos vein. There is mild pulmonary edema, slightly improved compared to the previous exam. No pleural effusion or pneumothorax is clearly identified. There are no acute osseous abnormalities. . IMPRESSION: Mild congestive heart failure. . TTE: ___ The left atrium is moderately dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is unusually small. Overall left ventricular systolic function is mildly depressed (LVEF= 40%) secondary to markedly abnormal systolic septal motion/position (the latter consistent with right ventricular pressure overload) . The right ventricular cavity is markedly dilated with severe global free wall hypokinesis. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. Trace aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present. The prosthetic mitral valve leaflets are thickened. Motion of the mitral annulus is abnormal and suggestive of partial dehiscence. The gradients are higher than expected for this type of prosthesis. Moderate (2+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of ___, gradients across the mitral valve bioprosthesis and the degree of mitral regurgitation are similar (severely increased). Again slight abnormal motion of the mitral prosthesis is noted in the absence of a paravalvular leak. The right ventricle appears now severely dilated with worse systolic function and worse functional tricuspid regurgitation. Pulmonary pressures are higher. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amiodarone 200 mg PO DAILY 2. FoLIC Acid 1 mg PO DAILY 3. Warfarin 5 mg PO 4X/WEEK (___) 4. Warfarin 6 mg PO 3X/WEEK (___) 5. Furosemide 40 mg PO DAILY 6. Metoprolol Succinate XL 50 mg PO DAILY Discharge Medications: 1. Amiodarone 200 mg PO DAILY 2. FoLIC Acid 1 mg PO DAILY 3. Warfarin 5 mg PO 4X/WEEK (___) 4. Warfarin 6 mg PO 3X/WEEK (___) 5. Metoprolol Succinate XL 50 mg PO DAILY 6. Torsemide 20 mg PO DAILY RX *torsemide [Demadex] 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 7. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours RX *potassium chloride [Klor-Con M20] 20 mEq 20 mEq by mouth daily Disp #*30 Packet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Partial Dehiscence of Mitral valve replacement RV dilation w/RV failure CHF exacerbation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Congestive heart failure. TECHNIQUE: PA and lateral views of the chest. COMPARISON: ___. FINDINGS: The patient is status post median sternotomy and mitral valve replacement. The cardiac silhouette is moderate to severely enlarged but unchanged. The mediastinal contours are stable with continued dilatation of the azygos vein. There is mild pulmonary edema, slightly improved compared to the previous exam. No pleural effusion or pneumothorax is clearly identified. There are no acute osseous abnormalities. IMPRESSION: Mild congestive heart failure. Gender: F Race: HISPANIC/LATINO - PUERTO RICAN Arrive by WALK IN Chief complaint: DYSPNEA AND BLE EDEMA Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, HYPERTENSION NOS, MITRAL VALVE DISORDER, ATRIAL FIBRILLATION temperature: 97.3 heartrate: 75.0 resprate: 20.0 o2sat: 95.0 sbp: 124.0 dbp: 97.0 level of pain: 2 level of acuity: 2.0

Ms. ___, you were admitted to the ___ after gaining weight despite your water pills at home. You were given strong medications through an IV to get water out of your body. It was also noted that there was a leak around your mitral valve and unfortunately, this valve needs to be replaced. The plan is for you to go home for several days to take care of your mother and then come back to the Hospital on ___ to have the special catheter placed to measure the pressures in your heart prior to going to surgery for a valve replacement. In preparation for your procedure, your last dose of coumadin (warfarin) should be on ___. You will be contacted with a time to come back to the Hospital on ___ with the plan to stay and have your valve replaced. 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: chlorthalidone / lisinopril / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Low hemoglobin Major Surgical or Invasive Procedure: Colonoscopy EGD History of Present Illness: This is a ___ yo M with HFpEF, Afib on Apixaban, RCC with right nephrectomy ___, and CKD stage III who was getting outpatient labs in preparation for outpatient catheterization when he was found to have Hct of 21, and he was told to go to the emergency room, where his Hb was 5.7. He has had progressive dyspnea and dizziness and difficulty walking longer distances over the past few days and c/o lightheadedness worse with exertion/standing up. He says this issue has gotten progressively worse since he had his cardioversion in ___. He reports multiple family members and his cardiologist told him his color did not look good in the past month or so. Last known value was Hgb 12 in ___, with Hb ___ of 15.7. He also endorses increasing lower extremity and abdominal swelling of the last month, with noticeable worsening also after his recent cardio version. Notes pain in calves bilaterally which he has never had before. Denies any chest pain, abdominal pain, nausea, vomiting, diarrhea. No black or bloody stools, palpitations, tachycardia, irregular heart beat, chest pain, exertional chest pain or pressure. He has never had a colonoscopy, has a history of IBS. In the ED, initial VS were: 98.6 70 137/72 20 98% RA Labs showed: Heme negative rectal exam. Hgb 5.7 Imaging showed: Received: 1U PRBCs, 100 IV Lasix Transfer VS were: 97.8 71 118/64 16 100% RA On arrival to the floor, patient reports the findings noted in HPI above. He feels MUCH better after the unit of blood. Has not noticed any black or bloody stools. REVIEW OF SYSTEMS: (+)PER HPI Past Medical History: -HF with preserved EF * dry weight: 300, dry BNP: < 200 * Hospitalization: ___ in setting of AFib with RVR with BNP 400, weight 315 on admit and assume 300 on d/c, he also had concomitant transaminitis with hypocoagulopathy with the heart failure - anemia: mild anemia unknown etiology - atrial fibrillation: CHADSVASC score 4, on apixban *failed DCCV ___, then started on amio *successful DCCV mid ___ Hypertension [I10] Obesity [E66.9] GERD Hyperlipidemia [E78.5] Erectile dysfunction [N52.9] Testicular hypogonadism [E29.1] Nuclear cataract [H25.10] Pseudophakia [Z96.1] PCO (posterior capsular opacification) [H26.499] BPH (benign prostatic hyperplasia) [N40.0] Midline low back pain without sciatica [M54.5] Liver failure [K72.90] Rhabdomyolysis [M62.82] Thyroid nodule [E04.1] Left adrenal mass [E27.9] Coagulopathy [D68.9] Testicular hypogonadism [E29.1] R nephrectomy for malignancy Social History: ___ Family History: Family History: per chart review includes Anemia in his son (likely due to ulcer); Asthma in his daughter; CAD/PVD in his father; Cancer - ___ in his mother; Cancer - ___ in his father; ___ in his mother; ___ in his maternal grandmother. Physical Exam: ADMISSION PHYSICAL EXAM: GENERAL: NAD HEENT: Pale conjunctiva, PERRL, anicteric sclera, MMM NECK: supple, no LAD, mildly elevated JVD HEART: RRR, S1/S2 with possible S4 gallop heard but difficult to tell LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: Distended, tense, but no pain to palpation. EXTREMITIES: Has fingernail bed scooping. ___ 3+ pitting edema to mid thigh. 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: Vitals: 98.0 133 / 69 71 18 96 RA GENERAL: NAD HEENT: Pale conjunctiva, PERRL, anicteric sclera, MMM NECK: supple, no LAD, JVD remains elevated HEART: RRR, S1/S2, no mgr LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: Distended, tense, but no pain to palpation. EXTREMITIES: Has fingernail bed scooping. ___ 1+ pitting edema up to knee, shins erythematous 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 Pertinent Results: ADMISSION LABS: =============== ___ 10:30PM BLOOD WBC-7.3 RBC-3.14* Hgb-5.7* Hct-22.8* MCV-73* MCH-18.2* MCHC-25.0* RDW-19.9* RDWSD-51.3* Plt ___ ___ 10:30PM BLOOD Neuts-82.0* Lymphs-7.9* Monos-8.5 Eos-0.7* Baso-0.5 NRBC-0.3* Im ___ AbsNeut-5.99 AbsLymp-0.58* AbsMono-0.62 AbsEos-0.05 AbsBaso-0.04 ___ 07:30AM BLOOD Hypochr-1+* Anisocy-1+* Poiklo-1+* Macrocy-NORMAL Microcy-1+* Polychr-OCCASIONAL Ovalocy-1+* Tear Dr-1+* Bite-OCCASIONAL Ellipto-OCCASIONAL ___ 02:02AM BLOOD ___ PTT-48.5* ___ ___ 10:30PM BLOOD Glucose-105* UreaN-25* Creat-1.8* Na-133 K-3.9 Cl-90* HCO3-29 AnGap-14 ___ 10:30PM BLOOD LD(LDH)-178 TotBili-0.8 ___ 10:30PM BLOOD cTropnT-0.01 proBNP-5137* ___ 10:30PM BLOOD Iron-23* ___ 10:30PM BLOOD calTIBC-450 ___ Ferritn-12* TRF-346 ___ 10:39AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG ___ 10:39AM BLOOD PEP-AWAITING F IgG-1150 IgA-253 IgM-87 IFE-PND ___ 10:30PM BLOOD GreenHd-HOLD ___ 07:07PM BLOOD HCV Ab-NEG DISCHARGE LABS: =============== ___ 07:55AM BLOOD WBC-5.2 RBC-3.80* Hgb-7.8* Hct-29.6* MCV-78* MCH-20.5* MCHC-26.4* RDW-20.9* RDWSD-58.9* Plt ___ ___ 07:55AM BLOOD Glucose-89 UreaN-13 Creat-1.4* Na-142 K-4.1 Cl-97 HCO3-27 AnGap-18* ___ 07:55AM BLOOD Calcium-9.2 Phos-3.3 Mg-2.0 MICRO: ====== ___ 11:45 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: < 10,000 CFU/mL. IMAGING: ======== ___ CXR PA/LAT FINDINGS: Lung volumes are low. No definite focal consolidation is seen. There is mild distinctness of pulmonary vessels, which may reflect pulmonary vascular congestion, but no frank pulmonary edema. The heart is mildly enlarged. No pleural effusion or pneumothorax. IMPRESSION: Mild pulmonary vascular congestion without pulmonary edema. ___ CT Ab/pelvis IMPRESSION: 1. Small to moderate volume simple density ascites and small right-sided pleural effusion with mild diffuse superficial soft tissue stranding of unclear source, is most likely secondary to volume overload. Though the contour of the liver remains smooth, there is moderate splenomegaly. Cirrhosis with portal hypertension is a possibility despite the relative smooth contour of the liver and relative lack of volume redistribution. Hematologic dyscrasias are also within the differential. Correlate with lab values. 2. No retroperitoneal hemorrhage, or other definite source of hemorrhage. 3. 19 mm high density left renal lesion is likely a proteinaceous or hemorrhagic cyst. Confirmation with renal ultrasound is recommended. 4. Post right nephrectomy. Otherwise no definite evidence of malignancy or metastatic disease within the abdomen or pelvis given the confines of a noncontrast examination. 5. Probable left adrenal myelolipoma. 6. Anemia. 7. Diffuse diverticulosis. ___ ABD US FINDINGS: LIVER: Views of the liver are technically limited due to body habitus and noise. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is small volume ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 4 mm. GALLBLADDER: There is no evidence of stones or gallbladder wall thickening. PANCREAS: The pancreas is completely obscured by overlying bowel gas. SPLEEN: Normal echogenicity, measuring 16.4 cm. KIDNEYS: The right kidney is surgically absent. The left kidney measures 14.9 cm. Normal cortical echogenicity and corticomedullary differentiation is seen bilaterally. There is no evidence of masses, stones, or hydronephrosis in the kidneys. 2 cysts are identified ranging from 2.4-3.3 cm in size. The smaller cyst has a thin septation but no other concerning features. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: Moderate splenomegaly and small volume ascites. Limited views of the liver show no focal lesions. Portal vein is patent with hepatopetal flow. 2 left kidney cysts are noted with no other concerning lesions. Status post right nephrectomy. ___ ___ DUPLEX IMPRESSION: No evidence of deep venous thrombosis in the right or left lower extremity veins. ___ ECHO The left atrium is mildly dilated. The right atrium is moderately dilated. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Right ventricular cavity dilation with free wall hypokinesis. Moderate PA systolic hypertension. Mild symmetric left ventricular hypertrophy with preserved global systolic function. Mildly dilated ascending aorta. These findings are suggestive of a primary pulmonary process (e.g., sleep apnea, pulmonary embolism, COPD, etc.). ___ EGD Normal esophagus. Normal stomach. Normal duodenum. ___ Colonoscopy Diverticulosis of the both left and right colon. Due to redundant colon, we were unable to reach the cecum to assess for mass or source of bleed. Otherwise normal colonoscopy to distal ascending colon Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. HydrOXYzine 25 mg PO QHS 2. Apixaban 5 mg PO BID 3. Metolazone 5 mg PO 1X/WEEK (MO) 4. Amiodarone 200 mg PO DAILY 5. Bumetanide 3 mg PO BID 6. Metoprolol Succinate XL 200 mg PO QHS 7. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild 8. Tamsulosin 0.4 mg PO QHS Discharge Medications: 1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild 2. Amiodarone 200 mg PO DAILY 3. Apixaban 5 mg PO BID 4. Bumetanide 3 mg PO BID 5. HydrOXYzine 25 mg PO QHS 6. Metolazone 5 mg PO 1X/WEEK (MO) 7. Tamsulosin 0.4 mg PO QHS 8. HELD- Metoprolol Succinate XL 200 mg PO QHS This medication was held. Do not restart Metoprolol Succinate XL until you discuss with your cardiologist. Discharge Disposition: Home Discharge Diagnosis: Severe anemia secondary to chronic blood loss Acute on Chronic diastolic CHF CKD stage III Atrial Fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: AP and lateral chest radiographs INDICATION: History: ___ with SOB// evaluate for pulmonary edema TECHNIQUE: Chest PA and lateral COMPARISON: None. FINDINGS: Lung volumes are low. No definite focal consolidation is seen. There is mild distinctness of pulmonary vessels, which may reflect pulmonary vascular congestion, but no frank pulmonary edema. The heart is mildly enlarged. No pleural effusion or pneumothorax. IMPRESSION: Mild pulmonary vascular congestion without pulmonary edema. Radiology Report EXAMINATION: CT abdomen and pelvis without contrast INDICATION: ___ year old man with symptomatic anemia on abixiban, presented with Hb 5.7. initially responsive to transfusion but Hb 7.5-> 6.7 over 12 hours.// Retroperitoneal bleeding, signs of malignancy 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 3.8 s, 59.7 cm; CTDIvol = 6.6 mGy (Body) DLP = 392.0 mGy-cm. Total DLP (Body) = 392 mGy-cm. COMPARISON: None. FINDINGS: LOWER CHEST: Heart size is mildly enlarged without significant pericardial effusion. There is a small right-sided pleural effusion with mild adjacent compressive atelectasis. The imaged lung bases are otherwise grossly clear. There is relative hypoattenuation of the blood pool compared to the cardiac musculature. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout. There is no evidence of focal lesions within the limitations of an unenhanced scan. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. There is small to moderate volume simple density ascites. PANCREAS: There is diffuse fatty atrophy of the pancreas without definite focal mass given the confines of a noncontrast examination and no main pancreatic duct dilatation. There is no pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen is enlarged measuring 17.5 cm in maximal axis. No gross splenic lesion is identified. ADRENALS: The right adrenal gland is unremarkable. There is some expansion of the left adrenal gland with areas of fatty attenuation, suggestive of a 32 mm left adrenal myelolipoma. URINARY: Patient is status post right nephrectomy. There is a 35 mm simple cyst in the right interpolar kidney. There is a somewhat heterogeneous, high density exophytic lesion off the left lower pole kidney measuring 19 mm (02:45). Otherwise, there is no left-sided renal calculus or hydronephrosis. There is no frank left perinephric abnormality. GASTROINTESTINAL: The stomach is collapsed and grossly unremarkable. The duodenum and distal small bowel loops are normal caliber without evidence of obstruction. There is diffuse, extensive sigmoid predominant diverticulosis without secondary evidence for diverticulitis. Otherwise the large bowel is thin-walled without gross pericolonic fat stranding or organizing fluid collection given the fact that there is pre-existing ascites. The appendix is not definitively visualized though there is no secondary evidence for appendicitis. The rectum is grossly unremarkable. 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 grossly unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. There are moderate lumbar degenerative changes, focally severe at the L5-S1 level. There is moderate bilateral hip osteoarthritis. SOFT TISSUES: There are changes from prior abdominal surgery. There is mild diffuse superficial soft tissue stranding suggestive of fluid overload. The abdominal and pelvic wall is otherwise within normal limits. No organizing fluid collection or hematoma is visualized. IMPRESSION: 1. Small to moderate volume simple density ascites and small right-sided pleural effusion with mild diffuse superficial soft tissue stranding of unclear source, is most likely secondary to volume overload. Though the contour of the liver remains smooth, there is moderate splenomegaly. Cirrhosis with portal hypertension is a possibility despite the relative smooth contour of the liver and relative lack of volume redistribution. Hematologic dyscrasias are also within the differential. Correlate with lab values. 2. No retroperitoneal hemorrhage, or other definite source of hemorrhage. 3. 19 mm high density left renal lesion is likely a proteinaceous or hemorrhagic cyst. Confirmation with renal ultrasound is recommended. 4. Post right nephrectomy. Otherwise no definite evidence of malignancy or metastatic disease within the abdomen or pelvis given the confines of a noncontrast examination. 5. Probable left adrenal myelolipoma. 6. Anemia. 7. Diffuse diverticulosis. RECOMMENDATION(S): 1. Correlate with lab values and serology use for the possibility of cirrhosis or hematologic dyscrasia. 2. Renal ultrasound. Radiology Report EXAMINATION: ABDOMEN US (COMPLETE STUDY) INDICATION: ___ year old man with HFpEF, admitted in volume overload with significant anemia of Hb 5.7. CT abd/pelvis showed ?L renal lesion, possible cirrhosis of the liver.// Evidence of cirrhosis, portal vein thrombosis, characterize L renal lesion TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: CT ___. FINDINGS: LIVER: Views of the liver are technically limited due to body habitus and noise. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is small volume ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 4 mm. GALLBLADDER: There is no evidence of stones or gallbladder wall thickening. PANCREAS: The pancreas is completely obscured by overlying bowel gas. SPLEEN: Normal echogenicity, measuring 16.4 cm. KIDNEYS: The right kidney is surgically absent. The left kidney measures 14.9 cm. Normal cortical echogenicity and corticomedullary differentiation is seen bilaterally. There is no evidence of masses, stones, or hydronephrosis in the kidneys. 2 cysts are identified ranging from 2.4-3.3 cm in size. The smaller cyst has a thin septation but no other concerning features. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: Moderate splenomegaly and small volume ascites. Limited views of the liver show no focal lesions. Portal vein is patent with hepatopetal flow. 2 left kidney cysts are noted with no other concerning lesions. Status post right nephrectomy. Radiology Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ year old man with bilateral leg pain, HFpEF,+lupus anticoagulant// 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 is demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: No evidence of deep venous thrombosis in the right or left lower extremity veins. Gender: M Race: WHITE - OTHER EUROPEAN Arrive by WALK IN Chief complaint: Anemia, Dyspnea Diagnosed with Anemia, unspecified temperature: 98.6 heartrate: 70.0 resprate: 20.0 o2sat: 98.0 sbp: 137.0 dbp: 72.0 level of pain: 0 level of acuity: 2.0

Hi Mr. ___, It was a pleasure to take care of you at ___. WHY WAS I HERE? You were admitted to the hospital because you had very low blood counts (anemia) and had a lot of fluid on your body due to your heart failure. WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL - You received multiple blood transfusions to help with your anemia - You had a colonoscopy and upper endoscopy to look for a cause of your anemia and showed no source of bleeding - You received diuretics to help remove the extra fluid from your body. WHAT SHOULD I DO WHEN I GET HOME? You are leaving the hospital against medical advice. Please be sure to follow up with your doctors as below. 1) Follow up with your Primary Care Doctor. 2) Follow up with a Hematologist, Cardiologist, and Primary Care Physician 3) Take all your medications as prescribed by your doctors. 4) Return to the emergency room if you see black tarry or blood in your stool or if you develop new shortness of breath or dizziness. Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Geodon / Toradol / Penicillins / Maalox Total Relief (bismuth) / sticky tape Attending: ___. Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr ___ is a ___ year old man with PMHx notable for DM2, HTN, HLD bipolar disorder, s/p CCY who presents with abdominal pain and testicular pain. The patietn reports that he had onset of epigastric and ___ pain at 1800 on the day prior to admission. He reports that he had nausea and diarrhea associated with it. He reports that the pain was different than the pain that he was seen in the ___ ED for on ___. Work up at that time consisted of labs and CT scan which did not show an acute process. Patient was discharged and was doing well until the day of admission. He reports that he developed the ___ abdominal pain at the ___ game. Abdominal pain in the epigastric region, RUQ, RLQ. He reports that he had intercourse for the first time yesterday but that he used a condom. He denies dysuria or penile discharge. He also denies fevers, chills, vomiting. In the ED, initial vitals were: 98.9 96 134/72 20 97% RA Labs were notable for Lip: 165, WBC 11.8 with 70.8% Neuts and a negative U/A. Imaging was notable for unremarkable RUQ US and negative scrotal U/S. He recieved dilaudid 0.5mg IV x2, tylenol ___ PO x1, and 2L of IVF. He is being admitted for pancreatitis per the ED. Vitals on transfer are: 97.9 78 133/91 16 95% RA. On the floor, the patient reports the pain that had been periumbilical is now in the RLQ. He reports that the pain is a ___. He reports that he is unable to recount more of his medical history but his mother ___ is able to give his medication list. On speakign with his mother she reports that hs has a history of abdominal pain daiting back to the age of ___. She reports that her husband and the ___ father passed away recently and since then ___ has been depressed. She reports that the patient feels that his brothers do not have time for him. She reports that he often "runs away" to ___ and gets seen for abdminal pain and she does nto know what is causing it. She reports that he does nto drink but that he has not been taking any medication. She reports that he saw a provider on ___ prior to admission for the first time and that he was started on a number of medications but the patient did not like the provider ans she reports that he is not going back to them. Past Medical History: Bipolar disorder DM2 HLD HTN Fatty Liver s/p Lab Chole Social History: ___ Family History: Father HTN No family History of IBD. Paternal Uncle with ___ cancer. Physical Exam: >> Admission Phyiscal Exam: Vital Signs: 98, 110/71, 87, 18, 99%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, tender to palpation in the RLQ. Non-distended, +BS, + rebound. RLQ pain with straight leg raise and internal/external rotation of the right leg. Guiac negative. 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 normal. . >> Discharge Physical Exam: Vital Signs: 98, 90-110s/70s, 80s , 18, 99%RA General: NAD. No acute distress. HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI. PERRL. Neck supple. CV: RRR, S1, S2. No extra sounds heard Abdomen: Soft, mildly tender in the lower region. +BS. No rebound/guarding. Extremities: well perfused, 2+ pulses, no clubbing, cyanosis/edema. Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait normal. Pertinent Results: >> Admission Labs: ___ 12:31AM BLOOD WBC-11.8* RBC-4.39* Hgb-13.0* Hct-37.0* MCV-84 MCH-29.6 MCHC-35.2* RDW-14.0 Plt ___ ___ 07:10AM BLOOD Calcium-9.1 Phos-5.1* Mg-2.3 . >> Discharge Labs: ___ 07:10AM BLOOD WBC-9.5 RBC-4.30* Hgb-12.8* Hct-36.9* MCV-86 MCH-29.8 MCHC-34.8 RDW-14.0 Plt ___ ___ 07:10AM BLOOD Glucose-116* UreaN-15 Creat-0.9 Na-139 K-4.6 Cl-99 HCO3-29 AnGap-16 ___ 12:31AM BLOOD ALT-21 AST-19 AlkPhos-53 TotBili-0.1 ___ 12:31AM BLOOD Lipase-165* . >> Pertinent Reports: ___ Imaging CT PELVIS W/CONTRAST: The visualized large and small bowel loops are normal. The appendix is normal in appearance. Prostate and seminal vesicles are grossly unremarkable allowing for the limitations of CT assessment. The urinary bladder and distal ureters are unremarkable. There is no evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. BONES AND SOFT TISSUES: There is no evidence of worrisome lesions. Abdominal and pelvic wall is within normal limits. IMPRESSION: Normal appendix . ___ Imaging LIVER OR GALLBLADDER US Markedly limited right upper quadrant ultrasound due to bowel gas and body habitus. The patient is status post cholecystectomy. No fluid seen within the gallbladder fossa. There is no ascites identified. The portal vein is patent. Common bile duct not visualized. The liver appears echogenic but may be exaggerated due to body habitus. . IMPRESSION: 1. Markedly limited right upper quadrant, the liver appears echogenic but this may be exaggerated due to body habitus. Echogenic liver may be seen in setting of hepatic steatosis. 2. Common bile duct not visualized. . ___ Imaging SCROTAL U.S. : The right testicle measures: 2.7 x 3.4 x 2.1 cm. The left testicle measures: 2.8 x 4.0 x 1.9 cm. The testicular echogenicity is normal, without focal abnormalities. The epididymis is normal bilaterally. Vascularity is normal and symmetric in the testes and epididymis. . ___BD & PELVIS WITH CO: 1. Likely old L2 superior endplate compression fracture. Clinical correlation is recommended to assess for focal tenderness. 2. Normal appendix. 3. Hepatic steatosis. . >> MICROBIOLOGY : __________________________________________________________ ___ 7:10 am BLOOD CULTURE Blood Culture, Routine (Pending): __________________________________________________________ ___ 10:30 am BLOOD CULTURE Blood Culture, Routine (Pending): __________________________________________________________ ___ 12:47 am URINE Source: Unknown. Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Pending): NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Pending): __________________________________________________________ ___ 11:06 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetFORMIN (Glucophage) 500 mg PO BID 2. Gabapentin 300 mg PO BID 3. GlyBURIDE 5 mg PO DAILY 4. Ibuprofen 600 mg PO Q8H:PRN pain 5. Levothyroxine Sodium 100 mcg PO DAILY 6. Atenolol 50 mg PO DAILY 7. Fenofibrate 160 mg PO DAILY 8. Atorvastatin 20 mg PO QPM 9. DiCYCLOmine 20 mg PO QID Discharge Medications: 1. Atorvastatin 20 mg PO QPM 2. DiCYCLOmine 20 mg PO QID 3. Fenofibrate 160 mg PO DAILY 4. Gabapentin 300 mg PO BID 5. Ibuprofen 600 mg PO Q8H:PRN pain 6. Levothyroxine Sodium 100 mcg PO DAILY 7. GlyBURIDE 5 mg PO DAILY 8. MetFORMIN (Glucophage) 500 mg PO BID Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Abdominal Pain SECONDARY DIAGNOSES: 2. Bipolar Disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: SCROTAL U.S. INDICATION: ___ male with right testicular pain, tender on exam, evaluate for torsion. TECHNIQUE: Grey scale with color and spectral Doppler ultrasound of the scrotum was performed with linear transducer. COMPARISON: None. FINDINGS: The right testicle measures: 2.7 x 3.4 x 2.1 cm. The left testicle measures: 2.8 x 4.0 x 1.9 cm. The testicular echogenicity is normal, without focal abnormalities. The epididymis is normal bilaterally. Vascularity is normal and symmetric in the testes and epididymis. IMPRESSION: Normal scrotal ultrasound. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ s/p CCY, here with abdominal pain, lipase elevation, evaluate for stones TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: Comparison is made to abdominal and pelvic CT from ___. FINDINGS: Markedly limited right upper quadrant ultrasound due to bowel gas and body habitus. The patient is status post cholecystectomy. No fluid seen within the gallbladder fossa. There is no ascites identified. The portal vein is patent. Common bile duct not visualized. The liver appears echogenic but may be exaggerated due to body habitus. IMPRESSION: 1. Markedly limited right upper quadrant, the liver appears echogenic but this may be exaggerated due to body habitus. Echogenic liver may be seen in setting of hepatic steatosis. 2. Common bile duct not visualized. Radiology Report INDICATION: ___ year old man with RLQ abdominal pain, diarrhea, N/V // ? appendicitis. TECHNIQUE: MDCT axial images were acquired through pelvis following intravenous contrast administration with split bolus technique. Coronal and sagittal reformations were performed and submitted to PACS for review. No oral contrast was administered. DOSE: DLP: 538.74 mGy-cm (pelvis) IV Contrast: 130 mL Omnipaque injected at a rate of 2 cc/sec COMPARISON: None. FINDINGS: PELVIS: The visualized large and small bowel loops are normal. The appendix is normal in appearance. Prostate and seminal vesicles are grossly unremarkable allowing for the limitations of CT assessment. The urinary bladder and distal ureters are unremarkable. There is no evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. BONES AND SOFT TISSUES: There is no evidence of worrisome lesions. Abdominal and pelvic wall is within normal limits. IMPRESSION: Normal appendix. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abd pain, Testicular pain Diagnosed with ACUTE PANCREATITIS temperature: 98.9 heartrate: 96.0 resprate: 20.0 o2sat: 97.0 sbp: 134.0 dbp: 72.0 level of pain: 10 level of acuity: 3.0

Dear Mr. ___, It was a pleasure taking care of you during your hospital stay at ___. You were admitted to the hospital with abdominal pain, and underwent a workup including a CT scan, and an ultrasound which did not show any cause of this abdominal pain. Unfortunately we were unable to find a specific cause for your pain, and after treating you conservatively you started to improve. Please follow up with your primary care physician this week, and continue to take all of your medications as prescribed. Before you left, you met with our social work team here to help provide you transportation home. Take Care, Your ___ Team.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: Lipitor / Decadron Attending: ___. Chief Complaint: Altered mental status, fever Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old male known to the Neurosurgery service following recent admission and diagnosis of a ___ mass in the setting of a lung mass, now s/p left occipital craniotomy for tumor resection on ___ re-presents with fever and altered mental status. He was recently discharged on ___. Past Medical History: - PVD - Angioplasty x 3 - HTN - Hyperlipidemia - Gout - Solidtary kidney by birth - CKD stage III - Appenectomy - Tonsillegtomy - Left cataract surgery Social History: ___ Family History: Mother deceased: ___ disease Father deceased: CHF Sister alive ___, unknown history No additional family history known Physical Exam: ON ADMISSION ============ O: T: 98.4 HR 74 BP 153/73 RR20 Sat 96% 3L NC Gen: lethargic HEENT: soft fluctuat fluid collection at the incision site. Incision is healed well without erythema Extrem: right knee and right leg edema. Neuro: Mental status: lethargic, minimally verbal, opens eyes to voice Orientation: Oriented to person only Language: minimally verbal Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields unable to test III, IV, VI: Extraocular movements appear intact but unable to test V, VII: Facial strength appears intact. unable to test sensation VIII: Hearing intact to voice. IX, X: Palatal elevation unable to test. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. mild tremor in bilat UE, right greater than left Grips full bilaterally but pt does not follow a full motor exam. Grips billet to command, shows 2 fingers bilaterally Wiggles toes bilaterally Does not lift legs off bed to command Sensation: unable to test but responds to light touch bilaterally Coordination: unable to test ON DISCHARGE ============ Gen: awake HEENT: soft fluctuant fluid collection at the incision site. Incision is well healed without erythema Extrem: right knee and right leg edema. Neuro: Mental status: opens eyes to voice, confused Orientation: Oriented to person only Language: expressive dysphasia, perseverating, hallucinating Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. RIGHT hemianopsia III, IV, VI: Extraocular movements appear intact but unable to test V, VII: Facial strength appears intact. unable to test sensation VIII: Hearing intact to voice. IX, X: Palatal elevation unable to test. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. mild tremor in bilat UE, right greater than left Grips full bilaterally but pt does not follow a full motor exam. Grips billet to command, shows 2 fingers bilaterally Wiggles toes bilaterally At least antigravity in all 4 extremities Sensation: responds to light touch bilaterally Coordination: unable to test Pertinent Results: Please see OMR for pertinent imaging & labs ___ 06:00AM BLOOD WBC-12.3* RBC-3.36* Hgb-10.2* Hct-31.6* MCV-94 MCH-30.4 MCHC-32.3 RDW-13.2 RDWSD-44.9 Plt ___ ___ 06:00AM BLOOD Neuts-74.3* Lymphs-8.7* Monos-10.1 Eos-1.5 Baso-0.9 Im ___ AbsNeut-9.16* AbsLymp-1.07* AbsMono-1.25* AbsEos-0.19 AbsBaso-0.11* ___ 06:00AM BLOOD Plt ___ ___ 06:00AM BLOOD Glucose-95 UreaN-26* Creat-0.7 Na-146 K-3.8 Cl-104 HCO3-27 AnGap-15 CFS ------------- TUBE #2 CSF Chemistry Protein 111 Glucose 38 TUBE #1 CSF WBC 1265 RBC 5 Poly 78 Lymph 4 Mono 18 EOs Comments: CSF TNC: Hazy And Colorless CSF TNC: Clear Supernatent CSF TNC: Reported To And Read Back By ___ TNC: ___ ___ On ___ ___ 2:15 am CSF;SPINAL FLUID TUBE #3. **FINAL REPORT ___ GRAM STAIN (Final ___: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final ___: NO GROWTH. --------------- ___ 5:52 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 6:15 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ----------- GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ---------------- ___ 6:10 am URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. --------------- Medications on Admission: Acetaminophen 325-650 mg PO Q6H:PRN fever or pain, Allopurinol 50 mg PO DAILY, Colchicine 0.3 mg PO DAILY, Docusate Sodium 100 mg PO BID, Heparin 5000 UNIT SC BID, Ramelteon 8 mg PO QHS Should be given 30 minutes before bedtime, Senna 17.2 mg PO QHS, Valproic Acid ___ mg PO Q8H, amLODIPine 10 mg PO DAILY, Aspirin 81 mg PO DAILY Discharge Medications: 1. Acetaminophen 325-650 mg PO/PR Q6H:PRN Pain - Mild RX *acetaminophen 325 mg ___ tablet(s) by mouth every 6h Disp #*20 Tablet Refills:*0 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation RX *bisacodyl 10 mg 1 suppository(s) rectally daily Disp #*3 Suppository Refills:*0 3. Gabapentin 100 mg PO DAILY RX *gabapentin 100 mg 1 capsule(s) by mouth daily Disp #*3 Capsule Refills:*0 4. Haloperidol 0.5 mg PO Q6H:PRN agitation RX *haloperidol 0.5 mg 1 tablet(s) by mouth every 6h Disp #*12 Tablet Refills:*0 5. Ondansetron ODT 4 mg PO Q8H:PRN nausea RX *ondansetron 4 mg 1 tablet(s) by mouth every 8h as needed Disp #*9 Tablet Refills:*0 6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN BREAKTHROUGH PAIN RX *oxycodone 5 mg ___ tablet(s) by mouth every 4h Disp #*22 Tablet Refills:*0 7. Rivaroxaban 20 mg PO ONCE Duration: 1 Dose RX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth daily Disp #*3 Tablet Refills:*0 8. Senna 8.6 mg PO BID:PRN Constipation - First Line RX *sennosides 8.6 mg 1 tab by mouth twice daily Disp #*6 Tablet Refills:*0 9. Colchicine 0.6 mg PO DAILY RX *colchicine [Colcrys] 0.6 mg 1 tablet(s) by mouth daily Disp #*3 Tablet Refills:*0 10. Allopurinol 50 mg PO DAILY RX *allopurinol ___ mg 0.5 (One half) tablet(s) by mouth daily Disp #*3 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Metastatic neuroendocrine tumor to the ___ Lung lesion Fever, resolved Altered mental status Aseptic meningitis Toxic-metabolic encephalopathy Bilateral lower extremity DVT Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD INDICATION: ___ yo M hx left occipital craniotomy for mass resection discharged ___ presents with fever and AMS// ? abscess. Please perform with DWI sequences as well TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: Prior CT brain done ___ and pre discharge CT done ___ FINDINGS: Motion artifact degrades the diagnostic quality of the imaging. The patient is status post resection of a left occipital tumor. There is prominent peripheral restricted diffusion and enhancement in relation to the surgical bed. Centrally there is no restricted diffusion. The enhancement appears slightly more confluent along the lateral edges of the resection margin, with peripheral enhancement involving the posterior margins. Given that the region of peripheral enhancement along the posterior edge of the resection margin appears to correspond to the parenchyma, this is felt to be less likely abscess formation and rather represent a combination of postoperative change, ischemia/devitalized tissue, hemorrhage product and possible residual lesion. In the occipital horn of the right lateral ventricle there is soft tissue material which demonstrates restricted diffusion, and isointense T1 signal without evidence gradient echo susceptibility artifact. Although there is suggestion of mildly increased enhancement on motion degraded postcontrast sequence of series 19, image 13, no definite enhancement is seen on postcontrast image of series 20, image 13 series 21, image 15. Given lack of gradient echo susceptibility artifact, this raises concern for possible purulent material given the patient's clinical presentation, however hemorrhage product is a differential consideration. There is interval increase in size of the ventricular system suggesting communicating hydrocephalus. Fluid overlying the left occipital parietal bone measures 5 mm in sagittal diameter demonstrates mild rim enhancement and appears to communicate with the subarachnoid space immediately deep to the left occipital parietal bone and this most likely represents a CSF leak/pseudomeningocele. This is similar compared to most recent CT, but increased compared to pre discharge CT done ___. There is small 1.1 cm peripherally enhancing fluid collection inferior to the left mastoid tip (series 19, image 1) likely a postoperative seroma. Area of blooming and subtle T1 intrinsic hyperintensity in the left frontal lobe measuring 10 x 7 mm in the axial plane appear similar compared to prior. This lesion demonstrates avid postcontrast enhancement and on T2, the lesion does not demonstrate peripheral rim of hypointensity and central hyperintensity. There is mild FLAIR edema pattern surrounding the lesion. The pituitary appears normal. The craniocervical junction appears normal. The orbits appear normal. Mild mucosal thickening involving the paranasal sinuses. Moderate severe periventricular and deep white matter T2 and FLAIR hyperintense changes are most likely sequela of microangiopathy. IMPRESSION: 1. There is prominent diffusion-weighted hyperintense signal along the left occipital resection margins with regions of confluent enhancement along the lateral margins and regions of rim enhancement along the posterior inferior margins demonstrating central hypoenhancement. The regions of rim enhancement with central hypoenhancement appear to correspond to brain parenchyma on FLAIR and T1 precontrast sequences and therefore is felt to be unlikely abscess, but rather a combination of devitalized tissue, postsurgical ischemia/inflammatory changes, residual hemorrhage product and possible residual lesion. 2. Soft tissue material in the occipital horn of the right lateral ventricle demonstrates restricted diffusion and is without gradient echo susceptibility blooming artifact. Lack of blooming artifact does raise possibility of purulent material. However, there is no definitive associated enhancement. The lesion does appear to demonstrate mild postcontrast enhancement on 1 motion degraded postcontrast sequence, but not on subsequent postcontrast images and therefore hemorrhage product remains a differential consideration. 3. Interval increase in size of the ventricle suggest communicating hydrocephalus. 4. Interval increase in size of the fluid/CSF signal intensity collection overlying the left occipital parietal bone which appears to communicate with the subarachnoid space most likely represents a pseudomeningocele. There does appear to be a 1.1 cm peripherally enhancing fluid collection inferior to the left mastoid tip, likely a seroma however close attention is recommended to exclude infectious process. 5. Left frontal lesion demonstrating prominent gradient echo susceptibility artifact is unchanged. The lesion does not demonstrate of T2 hypointensity and central T2 hyperintensity and demonstrates avid postcontrast enhancement. There is surrounding edema pattern. This is unchanged from outside hospital MRI head of ___ and are not features typical for cavernoma, unless there has been recent hemorrhage. This raises suspicion for additional site of metastatic disease. Of note, no lesion was noted on outside hospital CT head of ___. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the ___ ___ at 2:08 pm, 10 minutes after discovery of the findings. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old man with NGT// placement Contact name: ___: ___ placement IMPRESSION: Compared to chest radiographs ___. Nasogastric drainage tube ends in the upper portion of a mildly distended stomach. Right apical lung lesion is presumably still present, but difficult to assess on conventional radiographs. Heart size normal. Lungs elsewhere clear. No pleural abnormality. Normal mediastinal and hilar contours. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST ___ MR HEAD INDICATION: ___ year old man with L neuroendocrine tumor, metastatic to the brain// worsening dysphasia, AMS, please include DWI studies also TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: MR head with and without contrast ___ FINDINGS: Patient is post left occipital craniotomy and mass resection. Small amount of subdural and subgaleal fluid collection surrounding the left occipital craniotomy is slightly increased from ___. Subdural component measures 7 mm in thickness, increased from 6 mm before. Sub glial component measures 8 mm in thickness, increased from 7 mm before. Ischemic changes surrounding the resection margin is similar to before. The enhancement at the resection margin and overlying dural enhancement appears more conspicuous than before. 9 mm lesion in the right occipital horn demonstrates T1 hyperintensity, restricted diffusion, and lack of susceptibility artifact, unchanged compared to ___. 9 mm enhancing lesion in the left frontal lobe with susceptibility artifact is again demonstrated. Previously noted small fluid collection inferior to the left mastoid tip is not demonstrated on this exam. Marked periventricular and subcortical white matter FLAIR hyperintensities are similar to before and consistent with chronic small vessel disease. There is no evidence of new hemorrhage, acute infarct, or midline shift. The ventricles and sulci are stable in caliber and configuration. IMPRESSION: 1. Subdural and subgaleal fluid collection surrounding the left craniotomy is larger compared to ___. No restricted diffusion is seen within this collection. However, possibility of superimposed infection cannot be excluded on MRI appearances. 2. Enhancement at the resection margin and overlying dural enhancement appears more conspicuous than before. Findings may reflect evolution of postoperative changes or differences in study techniques/artifact. 3. Ischemic changes at the resection margin appears similar to before. No new acute infarct is identified. 4. 9 mm left frontal lobe enhancing lesion is again demonstrated. Finding remains suspicious for metastatic lesion. 5. 9 mm lesion in the right occipital horn is unchanged . Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with fever and elevated WBC.// Evaluation of elevating WBC with fever. IMPRESSION: In comparison with study of ___, the opacification in the right apical region is again seen, though difficult to assess on plain radiographs. This was well demonstrated on the CT study of ___. The cardiomediastinal silhouette is stable and there is no evidence of vascular congestion or pleural effusion. Radiology Report EXAMINATION: MR ___ SPINE W/O CONTRAST ___ MR SPINE INDICATION: ___ year old man with history of neuroendocrine tumor. Evaluate for lumbar spinal metastatic disease. TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique, followed by axial T2 imaging. COMPARISON: ___ contrast abdomen and pelvis CT. FINDINGS: Study is severely degraded by motion, especially on fat-suppressed and axial imaging. Within these confines: For the purposes of numbering, the lowest rib bearing vertebral body was designated the T12 level. There is levoscoliosis of the lumbar spine. There is transitional anatomy with partial sacralization of L5. Approximately 30% L1 anterior compression deformities again noted. L1-2 and L4-5 probable type ___ ___ changes without definite epidural collection are noted. L2-3 type ___ ___ changes are noted. The visualized portion of the spinal cord is grossly preserved in signal and caliber. There is loss of intervertebral disc height and signal throughout the lumbar spine. At T12-L1 there is no vertebral canal or neural foraminal stenosis. At L1-2 there is disc bulge,mild vertebral canal and no neural foraminal narrowing. At L2-3 there is disc bulge,mild vertebral canal and no neural foraminal narrowing. Nonspecific left facet joint fluid is noted. At L3-4 there disc bulge,mild vertebral canal and moderate bilateral neural foraminal narrowing. Nonspecific left facet joint fluid is noted. At L4-5 there is disc bulge,mild vertebral canal and moderate left neural foraminal narrowing. Nonspecific bilateral facet joint fluid is noted. At L5-S1 there is disc bulge,mild vertebral canal and mild bilateral neural foraminal narrowing.bilateral facet joint probable synovial cysts are noted. Nonspecific bilateral facet joint fluid is noted. OTHER: Nonspecific bilateral L3 through L5 dorsal soft tissue T2 and STIR hyperintensity is noted. Mild STIR hyperintensity in bilateral psoas muscle and paraspinal muscles at L3-4 levels are noted. Patient's left atrophic partially cystic kidneys again noted (see 6:9). Right kidney probable extrarenal pelvis is again noted. Nonspecific fluid surrounding the right kidney is noted, not definitely seen on prior abdomen pelvis CT. Within limits of this motion degraded, noncontrast study, no definite evidence of paraspinal, paravertebral, or epidural mass identified. IMPRESSION: 1. Study is severely degraded by motion. 2. Additionally, evaluation for metastatic disease is limited due to lack administration of contrast, which was not administered due to patient inability to tolerate examination. If clinically indicated, consider repeat exam when patient can tolerate study. 3. Within limits of study, no definite evidence of lumbar spinal mass identified. 4. Extremely atrophic a partially cystic left kidney again noted. 5. Nonspecific right perinephric fluid not definitely seen on prior abdomen pelvis CT. If clinically indicated, consider renal ultrasound for further evaluation. 6. Nonspecific lower lumbar dorsal soft tissue and psoas muscle probable edema as described. 7. Approximately 30% L1 chronic anterior compression deformity. 8. Multilevel lumbar spondylosis as described, most pronounced at L3-4, where there is mild vertebral canal and moderate bilateral neural foraminal narrowing. 9. L4-5 moderate left neural foraminal narrowing. Radiology Report INDICATION: ___ with NG tube placed// Position TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: The tip of the Dobhoff projects over the stomach. There is no new focal consolidation, pleural effusion or pneumothorax identified. Unchanged opacification at the right lung apex. The size of the cardiac silhouette is within normal limits. IMPRESSION: The tip of the Dobhoff projects over the stomach. Otherwise no significant interval change. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Fever Diagnosed with Altered mental status, unspecified temperature: 98.4 heartrate: 76.0 resprate: 20.0 o2sat: 96.0 sbp: 153.0 dbp: 76.0 level of pain: ua level of acuity: 2.0

Activity • We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise. • 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. Medications • Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) other than what is being prescribed for you at discharge. • 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: • 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: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending: ___ Chief Complaint: syncope, bradycardia Major Surgical or Invasive Procedure: Single Chamber PPM placed ___ History of Present Illness: ___ with history of atrial fibrillation on Coumadin, severe AS s/p bioprosthetic AVR/CABG in ___, hypoparathyroidism, and hypothyroidism, transferred from ___ with ICH. The patient has dementia and is unable to provide much history. Per records from the outside hospital, the nursing home and found that the patient was increasingly bradycardic over the last 2 days. She also has had multiple falls. CT scan of the head performed at the outside hospital shows an intraparenchymal hemorrhage. The patient is awake and alert and oriented x2 which is baseline per the daughter's report. She denies any weakness, numbness, tingling. She denies any chest or abdominal pain. She denies any headache. She denies any vision changes. Her INR was 4.58 at the outside hospital. She has a known history of bradycardia and had discussions as an outpatient regarding a pacemaker placement. In the ED, initial VS were 97.2 40 190/80 20 98% RA. The patient was alert and oriented x1-2. She was having trouble finding the right words and was not always answering the question asked. Labs were notable for INR: 5.4 that went down to 1.3 after reversal with vitamin K and K-centra. She was also noted to have elevated creatinine to 2.3 from a baseline of 1.5 and anemia to 9.4 ECG: Irregular rhythm , absence of P waves, wide QRS 160 ms suggestive of LBBB, PVC, as well as prolonged QTc. CT A/P ___: showed 1. No acute fracture. 2. 3.5 cm infrarenal abdominal aortic aneurysm. 3. Small amount of pericholecystic fluid is likely secondary to third spacing. If there is clinical concern for acute cholecystitis, abdominal ultrasound ___ Knee XR: No acute fracture or dislocation. Moderate tricompartmental degenerative changes of both knees. CT Head ___: 1. No intracranial hemorrhage or mass effect. 2. 6 mm linear calcification in the right posterior parietal lobe is likely dystrophic in etiology and has been present since at least ___. This may have been the finding thought to reflect intracranial hemorrhage on the outside head CT. Received VitaminK, Kcentra, Hydral x2, 2L NS, Keppra 500, Synthroid 75mcg, and IM olanzapine x2. Neurosurgery and trauma were consulted. Per NSG, no intracranial bleed. Trauma did not identify any acute injuries. Decision was made to admit to medicine for further management. On arrival to the floor, patient notably obtunded with alternating cycles of tachypnea and apnea. She did not verbalize. She did follow commands. Per discussion with HCP, she was last seen in her alert, occasionally confused state 1 week ago. Yesterday, she was noted to be far more confused but alert. Today, she was nonverbal, agitated until olanzapine. Past Medical History: Atrial Fibrillation CAD (s/p CABG with SVG to OM1) Chronic sinusitis Hypoparathyroidism Hypothyroidism Aortic Stenosis s/p AVR in ___ Restless leg syndrome Hypertension Hyperlipidemia Scoliosis Kyphosis PVD AAA carotid stenosis 6 mm linear calcification in the right posterior parietal lobe Social History: ___ Family History: Brother died of heart attack at ___, father passed at ___ from a heart condition, but patient is unsure of what type. Mother also died of unclear heart condition at ___ Physical Exam: ADMISSION PHYSICAL EXAM: VS - 97.8 150/82 55 16 97%RA GENERAL: lethargic in bed, difficult to arouse HEENT: NC/AT. PERRL. Mild conjunctival pallor. No scleral icterus. PERRLA/EOMI. Dry mucous membranes. OP clear. +thyromegaly. No elevated JVP. CARDIAC: Irregularly irregular. nl s1/s2, III/VI systolic murmur best appreciated at ___. LUNGS: Loud upper airway sounds. Pt with mixed episodes of tachypnea and apnea. ABDOMEN: Soft, NTND, +BS. EXT: Trace edema, 2+ ___. SKIN: No rashes/lesions, ecchymoses. NEURO: Oriented x0, did not verbalize. CN II-XII unable to assess accurately but grossly normal. No pronator drift. Moving extremities, following commands for brief period when awakened DISCHARGE PHYSICAL EXAM: PHYSICIAL EXAM VS - 97.8 154/68 83 16 100RA GENERAL: alert laying in bed, NAD HEENT: NC/AT. PERRL. Mild conjunctival pallor. No scleral icterus. PERRLA/EOMI. More moist mucous membranes. OP clear. +thyromegaly. No elevated JVP. CARDIAC: Irregularly irregular. nl s1/s2, III/VI systolic murmur best appreciated at ___. LUNGS: CTAB, no w/r/r ABDOMEN: Soft, NTND, +BS. EXT: Trace edema, 2+ ___. SKIN: No rashes/lesions, ecchymoses. NEURO: Oriented x2 (___, ___, ___, mild confusion. CN II-XII intact. Baseline slightly droopier R side. No pronator drift. Moving all extremities. Pertinent Results: ADMISSION LABS ___ 05:35AM BLOOD WBC-5.5 RBC-3.40* Hgb-9.4* Hct-30.8* MCV-91 MCH-27.6 MCHC-30.5* RDW-16.3* RDWSD-54.4* Plt ___ ___ 05:35AM BLOOD Neuts-53.1 ___ Monos-12.3 Eos-6.0 Baso-0.7 Im ___ AbsNeut-2.94 AbsLymp-1.53 AbsMono-0.68 AbsEos-0.33 AbsBaso-0.04 ___ 05:35AM BLOOD ___ PTT-50.4* ___ ___ 05:35AM BLOOD Glucose-105* UreaN-38* Creat-2.3* Na-139 K-3.4 Cl-103 HCO3-27 AnGap-12 ___ 05:50AM BLOOD ALT-27 AST-35 LD(LDH)-222 AlkPhos-295* TotBili-0.7 ___ 05:35AM BLOOD Calcium-13.7* Phos-4.7* Mg-2.6 ___ 05:50AM BLOOD PTH-5* ___ 08:20PM BLOOD Lactate-1.3 ___ 06:15AM URINE Color-Straw Appear-Hazy Sp ___ ___ 06:15AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR ___ 06:15AM URINE RBC-1 WBC-4 Bacteri-MOD Yeast-NONE Epi-<1 TransE-<1 ___ 06:15AM URINE Hours-RANDOM UreaN-288 Creat-34 Na-35 URINE CULTURE (Final ___: NO GROWTH. DISCHARGE LABS ___ 06:20AM BLOOD WBC-5.7 RBC-3.09* Hgb-9.0* Hct-28.4* MCV-92 MCH-29.1 MCHC-31.7* RDW-17.0* RDWSD-57.0* Plt ___ ___ 06:20AM BLOOD ___ PTT-39.9* ___ ___ 06:20AM BLOOD Glucose-85 UreaN-28* Creat-1.7* Na-138 K-3.9 Cl-107 HCO3-22 AnGap-13 ___ 06:20AM BLOOD Calcium-9.2 Phos-3.0 Mg-1.8 IMAGING CT Head ___ 1. No intracranial hemorrhage or mass effect. 2. 6 mm linear calcification in the right posterior parietal lobe is likely dystrophic in etiology and has been present since at least ___. This may have been the finding thought to reflect intracranial hemorrhage on the outside head CT. KNEE XR ___ No acute fracture or dislocation. Moderate tricompartmental degenerative changes of both knees. CT A/P without contrast ___ 1. No acute fracture. 2. 3.5 cm infrarenal abdominal aortic aneurysm. 3. Small amount of pericholecystic fluid is likely secondary to third spacing. If there is clinical concern for acute cholecystitis, abdominal ultrasound could be obtained for further evaluation. CXR ___ Compared to chest radiographs since ___, most recently ___. Moderate cardiomegaly has worsened. Lungs are grossly clear. No pleural abnormality. CXR ___ New cardiac pacemaker lead terminates the right ventricle. No pneumothorax. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen 650 mg PO Q6H:PRN pain, ___ 2. Aspirin EC 81 mg PO DAILY 3. Calcitriol 0.25 mcg PO BID 4. Docusate Sodium 100 mg PO BID:PRN constipation 5. Furosemide 20 mg PO DAILY 6. Levothyroxine Sodium 50 mcg PO DAILY 7. Polyethylene Glycol 17 g PO DAILY:PRN constipation 8. Ranitidine 150 mg PO DAILY 9. Warfarin 3 mg PO DAILY16 10. Nystatin-Triamcinolone Cream 1 Appl TP BID:PRN rash 11. Vitamin D ___ UNIT PO 1X/WEEK (___) 12. Atorvastatin 40 mg PO DAILY 13. mometasone 50 mcg/actuation nasal DAILY 14. Potassium Chloride 10 mEq PO DAILY 15. Bisacodyl ___AILY:PRN constipation 16. Baclofen 10 mg PO QHS:PRN restless leg Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain, ___ 2. Aspirin EC 81 mg PO DAILY 3. Atorvastatin 40 mg PO DAILY 4. Bisacodyl ___AILY:PRN constipation 5. Docusate Sodium 100 mg PO BID:PRN constipation 6. Furosemide 20 mg PO DAILY 7. Levothyroxine Sodium 75 mcg PO DAILY 8. Polyethylene Glycol 17 g PO DAILY:PRN constipation 9. Ranitidine 150 mg PO DAILY 10. Warfarin 3 mg PO DAILY16 11. amLODIPine 10 mg PO DAILY 12. Baclofen 10 mg PO QHS:PRN restless leg 13. mometasone 50 mcg/actuation nasal DAILY 14. Nystatin-Triamcinolone Cream 1 Appl TP BID:PRN rash 15. Potassium Chloride 10 mEq PO DAILY 16. Vitamin D ___ UNIT PO 1X/WEEK (___) 17. Calcium Carbonate 1250 mg PO BID 18. Calcitriol 0.25 mcg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Toxic-Metabolic Encephalopathy Hypercalcemia Sick Sinus Syndrome Hypoparathyroidism Hypothyroidism Afib ___ Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: History: ___ with intracranial hemorrhage// please repeat CT head at 930 AM to 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 1.0 s, 4.2 cm; CTDIvol = 48.2 mGy (Head) DLP = 200.7 mGy-cm. 2) Sequenced Acquisition 4.5 s, 18.7 cm; CTDIvol = 48.2 mGy (Head) DLP = 903.1 mGy-cm. 3) Sequenced Acquisition 0.5 s, 2.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 100.3 mGy-cm. Total DLP (Head) = 1,204 mGy-cm. COMPARISON: CT head ___ at 03:38 from outside institution, CT head ___ and ___ FINDINGS: There is no evidence of acute large infarction, hemorrhage, edema, or mass. Linear hyperdensity measuring 6 mm within the right parietal lobe is unchanged from at least ___, and likely reflects dystrophic calcification. There is prominence of the ventricles and sulci suggestive of involutional changes. Periventricular, subcortical, and deep white matter hypodensities are nonspecific, but likely the sequela of chronic microvascular infarction. There is no evidence of fracture. Small mucous retention cyst is seen within the right maxillary sinus. The visualized portion of the remaining paranasal sinuses, mastoid air cells, and middle ear cavities are clear. Patient is status post bilateral lens replacement. Dense atherosclerotic calcifications are noted in the cavernous carotid arteries and distal left vertebral artery. IMPRESSION: 1. No intracranial hemorrhage or mass effect. 2. 6 mm linear calcification in the right posterior parietal lobe is likely dystrophic in etiology and has been present since at least ___. This may have been the finding thought to reflect intracranial hemorrhage on the outside head CT. Radiology Report INDICATION: History: ___ with falls, lumbar -spine/sacral tenderness, knee swelling // Eval for injuries TECHNIQUE: Bilateral knees, three views each COMPARISON: None. FINDINGS: No acute fracture or dislocation is identified within either knee. Moderate tricompartmental degenerative changes are most pronounced involving the patellofemoral compartments bilaterally with loss of joint space, subchondral sclerosis, and osteophyte formation. A small joint effusion is present in both knees. There are prominent superior patellar enthesophytes bilaterally. Diffuse vascular calcifications are noted in both knees. There are no concerning lytic or sclerotic osseous abnormalities. IMPRESSION: No acute fracture or dislocation. Moderate tricompartmental degenerative changes of both knees. Radiology Report EXAMINATION: CT abdomen and pelvis without contrast. INDICATION: ___ woman status post fall, now with lumbar spine and sacral tenderness. Evaluate for evidence of traumatic injury. TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired without intravenous contrast. Non-contrast scan has several limitations in detecting vascular and parenchymal organ abnormalities, including tumor detection. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.2 s, 46.0 cm; CTDIvol = 10.5 mGy (Body) DLP = 483.3 mGy-cm. Total DLP (Body) = 483 mGy-cm. COMPARISON: None. FINDINGS: LOWER CHEST: Smooth, septal thickening at the lung bases is consistent with mild pulmonary edema. There is no evidence of pleural or pericardial effusion. There is coronary artery calcification. There is mitral annular and aortic valve calcification. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout. There is no evidence of focal lesions within the limitations of an unenhanced scan. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is mildly distended with a small amount of pericholecystic fluid, most likely secondary to third spacing. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions within the limitations of an unenhanced scan. There is no pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size. There is no evidence of focal renal lesions within the limitations of an unenhanced scan. There is no hydronephrosis. There is no nephrolithiasis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber and wall thickness throughout. The colon and rectum are within normal limits. The appendix is normal. PELVIS: The distal ureters are unremarkable. A Foley catheter seen within the bladder. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is an infrarenal abdominal aortic aneurysm measuring up to 3.5 cm. Extensive atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. There is right convex lumbar scoliosis. There are severe degenerative changes throughout with bony vertebral canal stenosis. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. No acute fracture. 2. 3.5 cm infrarenal abdominal aortic aneurysm. 3. Small amount of pericholecystic fluid is likely secondary to third spacing. If there is clinical concern for acute cholecystitis, abdominal ultrasound could be obtained for further evaluation. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with AMS. hx of CAD, EF40% with dyspnea // evidence of infiltrate/pulm edema evidence of infiltrate/pulm edema IMPRESSION: Compared to chest radiographs since ___, most recently ___. Moderate cardiomegaly has worsened. Lungs are grossly clear. No pleural abnormality. Radiology Report EXAMINATION: PA and lateral chest radiographs INDICATION: ___ year old woman s/p single chamber PPM. // Assess lead placement and r/o PTx. TECHNIQUE: Chest PA and lateral COMPARISON: ___ portable chest radiograph FINDINGS: Interval placement of a single lead left pectoralis cardiac pacemaker with a lead that terminates in the right ventricle. No pneumothorax or pleural effusion. Lungs are fully expanded and clear. Mild cardiomegaly. Cardiomediastinal and hilar silhouettes are unremarkable. Median sternotomy wires are midline and intact. IMPRESSION: New cardiac pacemaker lead terminates the right ventricle. No pneumothorax. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: ICH, s/p Fall, Transfer Diagnosed with Unspecified atrial fibrillation, Long term (current) use of anticoagulants temperature: 97.2 heartrate: 40.0 resprate: 20.0 o2sat: 98.0 sbp: 190.0 dbp: 80.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, You were admitted to ___ for repeated falls and a change in your mental status. WHAT WAS DONE ============== -You were found to have high calcium levels that made you confused and damaged your kidneys. This was treated with fluids and other medications -You had a pacemaker placed for a slow heart rate that was thought to be the cause of your falls -You did not have a bleed in your brain, which was a concern at an outside hospital WHAT TO DO NEXT =============== -Take your medications as prescribed -Follow up with your doctors, including device clinic in ___ for your pacemaker. You should also follow up with an endocrinologist -Call your doctors ___ develop chest pain, fevers, chills, or worsening confusion Wishing you the best of health moving forward, Your ___ team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Unsteady gait and confusion Major Surgical or Invasive Procedure: ___ - Left Craniotomy for Subdural hematoma evacuation History of Present Illness: ___ yo M hx Afib known to Neurosurgery for bilat SDH Right > Left and s/p right burr hole evacuation of ___ on ___ presented with worsening unsteady gait over the past week and fall, no headstrike, 4 days prior. Coumadin was stopped at his last hospitalization. He complains also of general weakness. He denies numbness, vision changes, nausea, vomiting. Past Medical History: -Afib on Coumadin -Hypertension -Hyperlipidemia -h/p prostate CA s/p prostatectomy in ___ Social History: ___ Family History: NC Physical Exam: ON ADMISSION: O: T:98.3 BP: 126/95 HR:88 R20 O2Sats97% Gen: WD/WN, comfortable, NAD. HEENT: right burr hole incision well healed Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date, difficulty with month. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout with the exception of right tricep 4+/5 Bilateral upward drift Sensation: Intact to light touch bilaterally. Toes downgoing bilaterally Coordination: normal on finger-nose-finger ======================================== ON DISCHARGE: Pertinent Results: Please refer to ___ for pertinent imaging and lab results. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 25 mg PO DAILY 2. Omeprazole 20 mg PO DAILY 3. Simvastatin 10 mg PO QPM 4. Timolol Maleate 0.25% 1 DROP BOTH EYES BID 5. Loratadine 10 mg PO DAILY 6. TraZODone 25 mg PO QHS:PRN sleep Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN mild pain 2. LevETIRAcetam 500 mg PO BID RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a day Disp #*10 Tablet Refills:*0 3. Loratadine 10 mg PO DAILY 4. Metoprolol Succinate XL 25 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Simvastatin 10 mg PO QPM 7. Timolol Maleate 0.25% 1 DROP BOTH EYES BID 8. TraZODone 25 mg PO QHS:PRN sleep Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Bilateral subdural hematomas Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old man s/p left burr hole x 2 for ___ evacuation// postop eval, please perform at 2:30pm TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Total DLP (Head) = 1,339 mGy-cm. COMPARISON: CT head from ___ FINDINGS: Interval placement of a left frontal approach subdural drain is visualized and terminates in the left subdural space with interval decrease in subdural fluid collections now measuring 13 mm, previously measuring 21 mm. There is postoperative pneumocephalus, and a small amount of dense material is visualized adjacent to the drain site likely representing acute blood products (03:35). There is re-demonstration of a left convexity layering acute on chronic subdural collection that is grossly unchanged in appearance measuring up to 1.8 cm (03:34), unchanged in size from prior. There is no evidence of infarction or mass. The ventricles and sulci are stable in size and configuration. Periventricular and subcortical white matter hypodensities are nonspecific, but likely reflect sequelae of chronic small vessel ischemic disease. A left frontal burr hole and right posterior parietal burr hole are unchanged in appearance. There is no evidence of fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. Status post placement of left frontal approach subdural drain with interval decrease in size of subdural collection though high-density products are visualized adjacent to drain terminus. 2. Grossly unchanged left convexity acute on chronic subdural hematoma. NOTIFICATION: The findings were discussed with ___, N.P. by ___, M.D. on the telephone on ___ at 3:38 pm. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old man with left SDH now s/p crani/evac// eval for interval change- please ob tain @ 0500 on ___ TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained without intravenous contrast. Coronal and sagittal reformations and bone algorithms reconstructions were also performed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 747.3 mGy-cm. Total DLP (Head) = 747 mGy-cm. COMPARISON: Noncontrast head CT ___. FINDINGS: There is interval evolution of postoperative changes status post left craniotomy and multi compartment intracranial hemorrhages/subdural fluid collections. Similar volume/degree of bilateral mixed density subdural hematomas and left superior frontal subarachnoid hemorrhage, without evidence of new hemorrhage. A left frontal subdural drain is again visualized. There is no evidence of infarction or new hemorrhage. The ventricles and sulci are unchanged configuration. The paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: Expected evolution of postoperative changes status post left craniotomy and multi compartment intracranial hemorrhages, without significant change. No evidence of new hemorrhage or mass effect. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: SDH, Transfer Diagnosed with Nontraumatic subdural hemorrhage, unspecified temperature: 98.3 heartrate: 88.0 resprate: 20.0 o2sat: 97.0 sbp: 126.0 dbp: 95.0 level of pain: 0 level of acuity: 2.0

Surgery - You underwent a surgery called burr holes to have blood removed from your brain. - Please keep your staples along your incision dry until they are removed. - It is best to keep your incision open to air but it is ok to cover it when outside. - Call your surgeon if there are any signs of infection like redness, fever, or drainage. 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. - You may also experience some post-operative swelling around your face and eyes. This is normal after surgery and most noticeable on the second and third day of surgery. You apply ice or a cool or warm washcloth to your eyes to help with the swelling. The swelling will be its worse in the morning after laying flat from sleeping but decrease when up. - You may experience soreness with chewing. This is normal from the surgery and will improve with time. Softer foods may be easier during this time. - 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 symptoms 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: MEDICINE Allergies: Codeine Attending: ___. Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ female with history of Factor V Leiden, tobacco abuse, and chronic LBP, known herniated discs at L4-L5 and L5-S1, who was recently admitted to ___ for back pain, now presents after multiple reported falls with diffuse pain. At ___, she was treated for acute gouty arthritis with prednisone and colchicine, the latter of which she continued at discharge. She was seen by neurosurgery and nuerology, who opted for conservative management, ordered an outpatient EMG for a ___ sign, increased her gabapentin, and planned for her to be seen in the pain clinic for outpatient steroid injections. She reports a fall on ___ when she was walking in her yard and then fell because her body gave out. It was reportedly witnessed by her neighbor. She denies seizure like activity, CP, SOB, dizziness or LH prior to the fall. She denies mechanical fall. She then reports putting the dishes away ___ night when she fell from standing into her wheelchair, again because her body gave out on her. She then was going to bed and reports falling on to her bed. Her nephew found her and she reports that she looked unconscious. She notes that she couldn't see him (because of her baseline blindness) but could hear what he was saying. She reports being unable to move or keep her eyes open. She woke up in bed, not remembering what happened after her nephew found her. She was then sitting at her table outside with her family when she couldn't move or talk. She denies urinary or bowel incontinence or retention with last BM this morning. She denies any fevers or chills at home. Her son called ___ who brought her to ___, where she was transferred to ___ for MRI evaluation of the lower ___. In the ED, initial VS: 98.0 82 123/73 16 98% 2L pain 10. -exam with diminished rectal tone, no saddle anesthesia -given 15mg morphine, last 9pm -INR >7, no signs of bleeding, had been escalating coumadin as an outpt -cord consult: Discussed with Dr. ___ resident. Patient is a poor historian. Difficult to distinguish between giveway weakness and true weakness on her, generally effort is quite poor and pain limited examination. No sensory level with intact reflexes. Proximal > distal weakness in lower extremities as well as some weakness in upper extremities (full note to follow). Given her coumadin use, prior history of inflammatory disease (gout), degenerative joing disease of ___ (prior L5/S1 disc prolapse and S1 foraminal stenosis), I am concerned for cord and root pathology. Please image with MRI: C/T and L ___, with and without contrast MRI ___ imaging seems unremarkable save some cervical discs not causing any cord immpingement. Motion limited axials. -MRI ___ done without acute pathology -was asleep for the past two hours Most Recent Vitals: 98.2 79 117/78 16 96% 2L. Currently, the patient reports diffuse body pain and is thirsty. ROS: +Per HPI, occaisional chest heaviness that lasts for hours, vomiting and dizziness with every vertigo spell, dysuria. -fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, nausea, diarrhea, constipation, BRBPR, melena, hematochezia, hematuria. PHYSICAL EXAM: VS - 98.0 141/83 82 18 97% on RA 105.7kg GENERAL - well-appearing female in NAD, sleeping when I walked in, speaking softly and slowly HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MM dry, OP clear NECK - supple, no JVD LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - +BS, soft/ND, diffusely tender, not tender with deep auscultation, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) NEURO - awake, A&Ox3, CNs II-XII grossly intact, exam limited by patient effort, reports trouble moving but when distracted full ROM intact, no clonus, neg Babinski's, able to support extremities when lifted LABS: 139 97 18 125 AGap=15 estGFR: 65 / >75 4.2 31 0.9 Ca: 9.6 Mg: 2.4 P: 4.0 12.8 14.4 242 MCV 84 41.9 N:78.8 L:17.0 M:2.6 E:0.9 Bas:0.6 ___: 72.7 PTT: 42.8 INR: 7.3 MICROBIOLOGY: ___ urine culture pending STUDIES: ___ MR ___: no evidence of cord compression. mild disc bulge at L4-L5 and L5-S1. ASSESSMENT & PLAN: ___ yo female with history of Factor V Leiden, tobacco abuse, and chronic LBP, known herniated discs at L4-L5 and L5-S1 who presents after multiple falls at home. # Falls: Patient reports diffuse body pain after multiple falls. She is vague about the descriptions of each fall and describes no prior events. Her exam is limited by her efforts, and she is quite distractable. She will perform a movement she says she cannot perform when she thinks the examiner is not currently watching - for instance grapping a cup of soda or the remote when MD and RN are outside the door. -monitor on telemetry -continue home pain regimen with percocet -continue neurotin, changed to tid dosing for convenience -check ESR in setting of blindness and reported weakness -consider neurology consult -check orthostatics -outpatient ___ for vertigo -continue meclizine -home ___ for med administration -tox screens -touch base with PCP -___ cord team recs # Back Pain: She does not describe any bowel or bladder involvement with her back pain and MRI is also reassuring that there is no evidence of cord compresson. No evidence of hematoma in light of elevated INR. Could consider RP bleed but hematocrit is 41. -___ consult -follow up final read of MRI -trend hct # Elevated INR: Currently 7.4, when patient reports that outpatient providers were ___. Likely medication administration error. No evidence of bleeding. -trend coags -evaluate other options for anticoagulation as an outpatient # Depression and Anxiety: Appears dysthmic. -consider psych evaluation -continue ___ need to decrease in setting of multiple falls -continue citalopram, wellbutrin # HTN: Stable. -continue doxepin, lasix, inderal -may want to readdress BP regimen # Gout: No current pain in right podagra. -continue colchicine -consider transitioning to allopurinol # Med rec: -continue nicoderm at lower dose based on reported smoking history -continue hydroxyzine, omeprazole -hold potassium replacements # FEN: no IVFs / replete lytes prn / regular diet # PPX: heparin SQ, bowel regimen # ACCESS: PIV # CODE: DNR/DNI confirmed # CONTACT: son ___ ___ # DISPO: floor for now ___, MD PGY-2 ___ Past Medical History: Asthma/Bronchitis Obesity Factor V Leiden Legal Blindness Learning Problem GERD Migraine Headaches HL Social History: ___ Family History: Brother: ___ - Type II; Factor V ___ Sister: ___ - Type I; Factor V ___ Physical Exam: On Admission: VS - 98.0 141/83 82 18 97% on RA 105.7kg GENERAL - well-appearing female in NAD, sleeping when I walked in, speaking softly and slowly HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MM dry, OP clear NECK - supple, no JVD LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - +BS, soft/ND, diffusely tender, not tender with deep auscultation, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) NEURO - awake, A&Ox3, CNs II-XII grossly intact, exam limited by patient effort, reports trouble moving but when distracted full ROM intact, no clonus, neg Babinski's, able to support extremities when lifted On Discharge: VS - 97.6, 134/85, 20, 95% RA GENERAL - alert, pleasant, talkative HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MM dry, OP clear NECK - supple, no JVD LUNGS - CTAB HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - +BS, soft/ND, diffusely tender, not tender with deep auscultation, no masses or HSM, no rebound/guarding, obese EXTREMITIES - WWP, no edema b/l, 2+ peripheral pulses (radials, DPs) NEURO - awake, A&Ox3, CNs II-XII grossly intact, motor strength ___ upper and lower extremities, sensation intact, no asterixis Pertinent Results: Admission Labs: 139 97 18 125 AGap=15 estGFR: 65 / >75 4.2 31 0.9 Ca: 9.6 Mg: 2.4 P: 4.0 12.8 14.4 242 MCV 84 41.9 N:78.8 L:17.0 M:2.6 E:0.9 Bas:0.6 ___: 72.7 PTT: 42.8 INR: 7.3 Interim Labs: ___ 07:10 ALT155* AST64* LDH 237 ALKPHOS121* TBILI 0.2 ___ 07:00AM ALT(SGPT)-267* AST(SGOT)-249* LD(LDH)-307* CK(CPK)-33 ALK PHOS-132* TOT BILI-0.4 ___ 07:00AM CK-MB-<1 cTropnT-<0.01 ___ 07:00AM VIT B12-761 ___ 07:00AM ETHANOL-NEG ACETMNPHN-NEG ___ 07:00AM HCV Ab-NEGATIVE ___ 07:00AM WBC-10.6 RBC-4.88 HGB-13.7 HCT-41.3 MCV-85 MCH-28.2 MCHC-33.3 RDW-14.5 ___ 07:00AM PLT COUNT-227 ___ 07:00AM ___ PTT-42.8* ___ ___ 07:00AM SED RATE-9 ___ 06:40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG ___ 06:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 06:40PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 05:00PM CK-MB-<1 cTropnT-<0.01 ___ 05:00PM CK(CPK)-53 MICROBIOLOGY: ___ urine culture pending STUDIES: MR ___ W/O CONTRAST Study Date of ___. Final Report EXAM: MRI of the cervical, thoracic, and lumbar ___. CLINICAL INFORMATION: Patient with lower extremity and upper extremity weakness, history of L4-L5 disc herniation, for further evaluation. TECHNIQUE: T1, T2, and inversion recovery sagittal and T2 axial images of cervical, thoracic, and lumbar ___ were acquired. FINDINGS: Mild degenerative changes are seen in the cervical and thoracic region. There is no significant disc bulge, herniation, compression fracture, or marrow edema identified. There is no evidence of cord compression seen or intrinsic spinal cord signal abnormalities identified. Mild atelectatic changes are seen at the right lung base. In the lumbar region, mild degenerative disc disease identified. There is no evidence of spinal stenosis, disc herniation, or high-grade thecal sac compression seen. Slightly increased signal in the posterior subcutaneous fat in the upper lumbar region appears to be due to a mild degree of soft tissue edema. There is no fluid collection. No compression fracture is seen. IMPRESSION: No evidence of cord compression, spinal stenosis, or acute compression fracture. No spinal stenosis seen. No abnormal signal within the spinal cord. Multilevel mild degenerative changes without spinal stenosis. MR THORACIC ___ W/O CONTRAST Study Date of ___ EXAM: MRI of the cervical, thoracic, and lumbar ___. CLINICAL INFORMATION: Patient with lower extremity and upper extremity weakness, history of L4-L5 disc herniation, for further evaluation. TECHNIQUE: T1, T2, and inversion recovery sagittal and T2 axial images of cervical, thoracic, and lumbar ___ were acquired. FINDINGS: Mild degenerative changes are seen in the cervical and thoracic region. There is no significant disc bulge, herniation, compression fracture, or marrow edema identified. There is no evidence of cord compression seen or intrinsic spinal cord signal abnormalities identified. Mild atelectatic changes are seen at the right lung base. In the lumbar region, mild degenerative disc disease identified. There is no evidence of spinal stenosis, disc herniation, or high-grade thecal sac compression seen. Slightly increased signal in the posterior subcutaneous fat in the upper lumbar region appears to be due to a mild degree of soft tissue edema. There is no fluid collection. No compression fracture is seen. IMPRESSION: No evidence of cord compression, spinal stenosis, or acute compression fracture. No spinal stenosis seen. No abnormal signal within the spinal cord. Multilevel mild degenerative changes without spinal stenosis. CT HEAD W/O CONTRAST Study Date of ___ INDICATION: Elevated INR and chronic falls. Evaluate for subdural hematoma. COMPARISONS: None. TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without the administration of intravenous contrast. FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or infarction. The ventricles and sulci are mildly prominent, consistent with age-related atrophy. The basal cisterns are patent. Mild periventricular confluent white matter hypodensities are consistent with chronic small vessel ischemic disease. Calcifications are noted in the internal carotid arteries. There is preservation of gray-white matter differentiation. No fracture is identified. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. There is rightward deviation of the nasal septum. The soft tissues are unremarkable. IMPRESSION: 1. No acute intracranial abnormality. 2. Mild age-related atrophy and chronic small vessel ischemic disease. CHEST (PORTABLE AP) Study Date of ___ IMPRESSION: AP chest reviewed in the absence of prior chest radiographs: Lung volumes are quite low with crowding of vessels. Nevertheless, there is suggestion of several small nodules in the right mid and lower lung zone. Patient is rotated to the right exaggerating the caliber of the mediastinum in the region of the ascending aorta and obscuring the right hilus. Radiodensity in that region could be due to large hilar lymph node calcifications or additional nodules. In any case prior chest CT should be consulted, and if unavailable, should be supplemented by a chest CT performed here. Heart is normal size. Pleural effusion is small if any on the right. No pneumothorax. DUPLEX DOPP ABD/PEL Study Date of ___ ABDOMINAL ULTRASOUND AND LIVER DOPPLER CLINICAL INDICATION: Patient with complex medical history, elevated liver function tests, to assess for portal vein abnormalities or any liver or biliary abnormalities. The patient relates having had a prior cholecystectomy. There is no evidence of any intra- or extra-hepatic biliary dilatation. The head and body of the pancreas are normal in appearance but the tail is partially obscured by bowel gas. The abdominal aorta and inferior vena cava are unremarkable. The liver is diffusely increased in echogenicity, consistent with hepatic steatosis. There are no focal liver lesions seen and there is no evidence of ascites. The spleen is mildly enlarged, however, to 13.8 cm length. The kidneys show no evidence of hydronephrosis, stones or masses. The right kidney is 11.2 cm in length, while the left kidney appears smaller, measuring only 9.4 cm in length. Color flow and pulse Doppler waveform analysis was performed. The portal vein is patent with normal forward flow and slightly flattened pulse Doppler waveforms. Left and right portal veins are fully patent, as are the hepatic veins. Arterial signals within the liver are normal. Splenic vein was also seen to be patent with normal direction and flow, but the SMV could not be imaged due to overlying gas. CONCLUSION: 1. Fatty liver and mild splenomegaly. The possibility of more significant underlying liver disease, including fibrosis and cirrhosis, should be considered, particularly in view of the flattened portal venous waveforms. 2. Status post cholecystectomy with no biliary dilatation. 3. Slightly small left kidney compared to the right, of uncertain clinical significance. Portable TTE (Complete) Done ___ The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is 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 aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. CT CHEST W/CONTRAST Study Date of ___ HISTORY: Incidental lung nodules found on chest radiograph. The patient has chest pain and smokes tobacco. TECHNIQUE: Multidetector helical scanning with intravenous infusion of 75 mL Omnipaque nonionic iodinated contrast agent reconstructed as contiguous 5- and 1.25-mm thick axial and 5-mm thick coronal and parasagittal images reviewed in the absence of prior chest CT scans. FINDINGS: Fine detail in the lungs is degraded by respiratory motion, but is sufficient to show that there is no consolidation or nodulation, and only mild heterogeneity, reflected in ground-glass infiltration surrounding the bronchus to the anterior segment of the right upper lobe, 4:79, and nodular looking subpleural edema in the posterior segment, extending to the major fissure. A 6-mm wide oval nodule in the right lower lobe, 4:100, and 4-mm right middle lobe nodule, 4:106, in combination with what was probably mild pulmonary edema, may account for the interpretation of the conventional radiograph on ___ that the lungs were full of nodules. A nodular opacity where two bands of atelectasis originate in the right lower lobe, 4:157 should not be mistaken for a third lung nodule. Central lymph nodes are not pathologically enlarged, ranging in diameter up to 8 mm in the prevascular aortopulmonic windows station of the mediastinum. There is no pleural or pericardial effusion. This study is not designed for subdiaphragmatic diagnosis, but shows there is no adrenal mass, while the patient has had a cholecystectomy. IMPRESSION: 1. Resolving pulmonary edema. 2. Two subcentimeter lung nodules should be followed with repeat CT scanning in six months. HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) RIGHT Study Date of ___ HISTORY: Anterior hip pain. FINDINGS: Three views show the bony structures and joint spaces to be within normal limits and symmetric with the opposite side. There is contrast material in the bladder from recent CT scan. Contrast material in the bladder from recent CT. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient OSH d/c summary. 1. Nicotine Patch 21 mg TD DAILY 2. Warfarin 10 mg PO DAILY16 3. Clonazepam 0.5 mg PO QID:PRN anxiety 4. HydrOXYzine 50 mg PO Q6H:PRN pruritis 5. Meclizine 50 mg PO Q6H:PRN vertigo 6. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO Q8H:PRN severe pain 7. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN mild to moderate pain 8. Citalopram 20 mg PO DAILY 9. Doxepin HCl 150 mg PO DAILY 10. Furosemide 20 mg PO BID 11. Gabapentin 400 mg PO QID 12. Omeprazole 20 mg PO DAILY 13. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours 14. Propranolol 60 mg PO BID 15. BuPROPion 150 mg PO BID 16. Colchicine 0.6 mg PO DAILY Discharge Medications: 1. BuPROPion 150 mg PO BID 2. Citalopram 20 mg PO DAILY 3. Clonazepam 0.5 mg PO QID:PRN anxiety 4. Colchicine 0.6 mg PO DAILY 5. Doxepin HCl 150 mg PO DAILY 6. Furosemide 20 mg PO BID 7. HydrOXYzine 50 mg PO Q6H:PRN pruritis 8. Meclizine 50 mg PO Q6H:PRN vertigo 9. Nicotine Patch 21 mg TD DAILY 10. Omeprazole 20 mg PO DAILY 11. Propranolol 60 mg PO BID 12. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain hold for sedation, RR < 10 RX *oxycodone 10 mg 1 Tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*0 13. Warfarin 5 mg PO DAILY16 14. Outpatient Lab Work - Please draw INR on ___ for warfarin monitoring. ICD-9 289.81 - Fax result or notify primary care doctor: Name: ___ ___ Address: ___, ___ Phone: ___ Fax: ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnosis: acute encephalopathy secondary to medication side effect, chronic back pain, transaminitis, atypical chest pain 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: Elevated INR and chronic falls. Evaluate for subdural hematoma. COMPARISONS: None. TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without the administration of intravenous contrast. FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or infarction. The ventricles and sulci are mildly prominent, consistent with age-related atrophy. The basal cisterns are patent. Mild periventricular confluent white matter hypodensities are consistent with chronic small vessel ischemic disease. Calcifications are noted in the internal carotid arteries. There is preservation of gray-white matter differentiation. No fracture is identified. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. There is rightward deviation of the nasal septum. The soft tissues are unremarkable. IMPRESSION: 1. No acute intracranial abnormality. 2. Mild age-related atrophy and chronic small vessel ischemic disease. Results were discussed with Dr. ___ at 9:50 a.m. on ___ via telephone by Dr. ___. Radiology Report AP CHEST 10:50 A.M., ___ HISTORY: ___ woman with ill-defined chest pain, ruled out for MI. Evaluate other causes. IMPRESSION: AP chest reviewed in the absence of prior chest radiographs: Lung volumes are quite low with crowding of vessels. Nevertheless, there is suggestion of several small nodules in the right mid and lower lung zone. Patient is rotated to the right exaggerating the caliber of the mediastinum in the region of the ascending aorta and obscuring the right hilus. Radiodensity in that region could be due to large hilar lymph node calcifications or additional nodules. In any case prior chest CT should be consulted, and if unavailable, should be supplemented by a chest CT performed here. Heart is normal size. Pleural effusion is small if any on the right. No pneumothorax. Findings were posted to the online record of critical radiology findings, for notification of the referring physician, at 12:23 p.m. Radiology Report ABDOMINAL ULTRASOUND AND LIVER DOPPLER CLINICAL INDICATION: Patient with complex medical history, elevated liver function tests, to assess for portal vein abnormalities or any liver or biliary abnormalities. The patient relates having had a prior cholecystectomy. There is no evidence of any intra- or extra-hepatic biliary dilatation. The head and body of the pancreas are normal in appearance but the tail is partially obscured by bowel gas. The abdominal aorta and inferior vena cava are unremarkable. The liver is diffusely increased in echogenicity, consistent with hepatic steatosis. There are no focal liver lesions seen and there is no evidence of ascites. The spleen is mildly enlarged, however, to 13.8 cm length. The kidneys show no evidence of hydronephrosis, stones or masses. The right kidney is 11.2 cm in length, while the left kidney appears smaller, measuring only 9.4 cm in length. Color flow and pulse Doppler waveform analysis was performed. The portal vein is patent with normal forward flow and slightly flattened pulse Doppler waveforms. Left and right portal veins are fully patent, as are the hepatic veins. Arterial signals within the liver are normal. Splenic vein was also seen to be patent with normal direction and flow, but the SMV could not be imaged due to overlying gas. CONCLUSION: 1. Fatty liver and mild splenomegaly. The possibility of more significant underlying liver disease, including fibrosis and cirrhosis, should be considered, particularly in view of the flattened portal venous waveforms. 2. Status post cholecystectomy with no biliary dilatation. 3. Slightly small left kidney compared to the right, of uncertain clinical significance. Radiology Report CHEST CT, ___ HISTORY: Incidental lung nodules found on chest radiograph. The patient has chest pain and smokes tobacco. TECHNIQUE: Multidetector helical scanning with intravenous infusion of 75 mL Omnipaque nonionic iodinated contrast agent reconstructed as contiguous 5- and 1.25-mm thick axial and 5-mm thick coronal and parasagittal images reviewed in the absence of prior chest CT scans. FINDINGS: Fine detail in the lungs is degraded by respiratory motion, but is sufficient to show that there is no consolidation or nodulation, and only mild heterogeneity, reflected in ground-glass infiltration surrounding the bronchus to the anterior segment of the right upper lobe, 4:79, and nodular looking subpleural edema in the posterior segment, extending to the major fissure. A 6-mm wide oval nodule in the right lower lobe, 4:100, and 4-mm right middle lobe nodule, 4:106, in combination with what was probably mild pulmonary edema, may account for the interpretation of the conventional radiograph on ___ that the lungs were full of nodules. A nodular opacity where two bands of atelectasis originate in the right lower lobe, 4:157 should not be mistaken for a third lung nodule. Central lymph nodes are not pathologically enlarged, ranging in diameter up to 8 mm in the prevascular aortopulmonic windows station of the mediastinum. There is no pleural or pericardial effusion. This study is not designed for subdiaphragmatic diagnosis, but shows there is no adrenal mass, while the patient has had a cholecystectomy. IMPRESSION: 1. Resolving pulmonary edema. 2. Two subcentimeter lung nodules should be followed with repeat CT scanning in six months. Radiology Report HISTORY: Anterior hip pain. FINDINGS: Three views show the bony structures and joint spaces to be within normal limits and symmetric with the opposite side. There is contrast material in the bladder from recent CT scan. Contrast material in the bladder from recent CT. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: BACK PAIN Diagnosed with LUMBAGO, OTHER MALAISE AND FATIGUE, DIFFICULTY WALKING temperature: 98.0 heartrate: 82.0 resprate: 16.0 o2sat: 98.0 sbp: 123.0 dbp: 73.0 level of pain: 10 level of acuity: 2.0

It was a pleasure taking care of you at ___ ___. You came in with difficulty moving your limbs and falling. Your MRI and CT imaging did not show any concerning pathology. This was likely due to medications you were taking (oxycodone with gabapentin). We have changed your medications and discontinued gabapentin. You also complained of chest pain and there was no evidence of damage to your heart. You had normal imaging of your heart. You also had elevated liver tests. The pictures of your liver were normal except for some fatty changes. The numbers decreased and you will need to follow up with your primary care doctor and avoid any medications toxic to the liver such as tylenol. You came in with back pain and had an MRI of you ___ done that showed only mild degenerative changes seen with age. You also complained of hip pain and an x-ray of your hip did not show any breaks or fractures.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fall Major Surgical or Invasive Procedure: None History of Present Illness: Per Intitial ED Note: This patient is a ___ year old female who BIBEMS complains of fall. History is per EMS this patient is altered. She was found at the bottom of her stairs with obvious facial trauma. She has started to open her eyes spontaneously on arrival. Past Medical History: Depression Social History: ___ Family History: non-contributory Physical Exam: Constitutional: lying comfortable in bed HEENT: Pupils equal, round and reactive to light, Extraocular muscles intact, left periorbital ecchymoses improved over hospital course, repaired L temporal laceration Chest: Clear to auscultation, no chest wall tenderness Cardiovascular: Regular Rate Abdominal: Soft, non-tender, non-distended Extr/Back: No cyanosis, clubbing or edema, no pelvic tenderness Skin: Warm and dry Neuro; alert and oriented x 3. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: ___ s/p fall w/ AMS // eval for trauma TECHNIQUE: Contiguous axial images obtained through the cervical spine without intravenous contrast. Coronal and sagittal reformats were reviewed. DOSE: DLP: 798 mGy-cm CTDI: 37 mGy COMPARISON: None FINDINGS: Cervical vertebral bodies are maintained in height and alignment. There is no fracture. There is preservation of the normal cervical lordosis. Prevertebral soft tissues are unremarkable. Multilevel degenerative changes are seen with disc height loss and posterior osteophytes and uncovertebral joint hypertrophy most extensively at C5-C6. There secondary likely moderate canal, modearte right and mild left foraminal narrowing. Disk bulges are also identified at C3-4, C5-6 and C6-7 causing some degree of canal narrowing. 1 cm left thyroid nodule is identified. Included lung apices are unremarkable. Please see dedicated CT facial bones for description of facial fractures. IMPRESSION: Degenerative changes without fracture or malalignment. Radiology Report EXAMINATION: CTA HEAD AND CTA NECK INDICATION: History: ___ s/p fall down stairs // eval for vascualr injury TECHNIQUE: Rapid axial imaging was performed from the aortic arch through the brain during infusion of 70 cc of Omnipaque intravenous contrast material. Images were processed on a separate workstation with display of curved reformats, 3D volume redendered images, and maximum intensity projection images. DOSE: DLP: 1426.95 mGy-cm; CTDI: 79.02 mGy COMPARISON: CTA head without contrast ___, CT sinus of ___, CT C-spine of ___. FINDINGS: Head and neck CTA: There is a normal 3 vessel arch. The carotid and vertebral arteries and their major branches are patent with no evidence of stenoses. There is no extracranial internal carotid artery stenosis by NASCET criteria. The the cervical vertebral arteries are codominant. The intracranial internal carotid arteries, middle cerebral arteries, anterior cerebral arteries and their major branches are unremarkable. The posterior circulation is also unremarkable. There is no evidence of aneurysm larger than 3 mm or other vascular abnormality. Other: The left lobe of thyroid demonstrates a hypoattenuating 8 mm nodule. The remainder the thyroid gland is unremarkable. Lung apices are clear. The aerodigestive tract is unremarkable. There is no cervical lymphadenopathy by CT size criteria. Unchanged appearance of a left zygomaticomaxillary complex fracture. Layering fluid level within the right maxillary sinus is again seen as well as subcutaneous emphysema overlying the subcutaneous soft tissues anteriorly. Although the exam is not optimized for evaluation of brain parenchyma, the visualized brain is unremarkable. IMPRESSION: 1. Unremarkable CTA of the head and neck. No evidence of vascular injury or aneurysm. 2. The left lobe of the thyroid gland demonstrates a hypoattenuating 8 mm nodule. This may be further evaluated with ultrasound if clinically indicated. 3. Unchanged appearance of a left zygomaticomaxillary complex fracture. Radiology Report EXAMINATION: FOREARM (AP AND LAT) LEFT INDICATION: ___ with fall, left wrist pain. Assess for fracture. TECHNIQUE: Three views of the left wrist, two views of the left forearm. COMPARISON: None. FINDINGS: Comminuted distal radius fracture with mild impaction and extension of fracture line to the articular surface. No dislocation. Scapholunate interval is preserved. No additional fracture. No soft tissue calcification or radiopaque foreign body. Moderate soft tissue swelling is noted at site of fracture. No proximal radius or ulnar fracture. Limited assessment of the elbow is grossly unremarkable. Mild ulnar positive variance may be as result of fracture fragment impaction. IMPRESSION: 1. Comminuted distal radius fracture with mild impaction and intra-articular extension. 2. Moderate soft tissue swelling. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ who fell down stairs, +EtOH, does not remember event; has lateral ventricle hemorrhages, L zygomaticomaxillary fracture, and L sphenoid sinus wall fracture // interval changes in intraventricular bleeding. now w bradycardia, fixed L pupil compared to right 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 acquired. DOSE: DLP: 891 mGy-cm CTDI: 49 mGy COMPARISON: CT head ___ and CTA head/neck ___ FINDINGS: There is blood noted within the occipital horns of the lateral ventricles, slightly more and denser without significant change in appearance compared to the initial CT on ___. There is no new hemorrhage. No evidence of cerebral edema or major vascular territory infarction. There is persistent bi-frontal extra-axial hypodensities, which may be due to atrophy or possibly old subdural hematomas, unchanged from yesterday. Prominent ventricles and sulci are consistent with age-related atrophy. Periventricular hypodensities suggest chronic small vessel ischemic disease. Gray-white matter differentiation is preserved. There are multiple facial fractures, as described in the dedicated CT performed ___, partly imaged now. With the exception of the right maxillary sinus being relatively clear, there is fluid/secretions within all other visualized paranasal sinuses. Bilateral mastoid air cells and middle ear canals are clear. A superficial contusion is noted over the left zygomatic arch. IMPRESSION: 1. Stable intraventricular hemorrhage-slightly more and denser without significant change in appearance compared to the initial CT on ___. No new hemorrhage. 2. Multiple facial fractures as previously described on ___, incompletely imaged as not targeted . 3. Bi-frontal extra-axial hypodensities may be related to atrophy or chronic subdural hematomas. Radiology Report EXAMINATION: WRIST(3 + VIEWS) LEFT INDICATION: ___ year old woman with distal radius fx s/p reduction splinting // eval reduction TECHNIQUE: Three views left wrist COMPARISON: Earlier same day. FINDINGS: Intra-articular distal radial fracture, with impaction. There is dorsal angulation of the distal fracture fragments which appears slightly worse than previous. Mild ulnar positive variance may be as result of fracture fragment impaction. Incidental mild from interphalangeal joint degenerative change. IMPRESSION: Increased dorsal angulation of intra-articular impacted comminuted distal radial fracture. Radiology Report INDICATION: ___ s/p fall w/ AMS // eval for trauma TECHNIQUE: Supine views of the chest and pelvis. COMPARISON: None. FINDINGS: Within the limitation given overlying trauma board and external equipment, the following is noted: Chest: The lungs are clear. The cardiomediastinal silhouette is within normal limits. No displaced fractures identified. Pelvis: There is no fracture. Pubic symphysis and SI joints are preserved. Degenerative changes are noted in the lower lumbar spine. Phleboliths identified in the pelvis. IMPRESSION: No acute cardiopulmonary process. No pelvic fracture. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: History: ___ s/p fall w/ AMS // eval for trauma TECHNIQUE: Contiguous axial images images of the brain were obtained without contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed images were obtained. DOSE: DLP: 1003 mGy-cm CTDI: 52 mGy COMPARISON: None available FINDINGS: There is minimal amount of hemorrhage in the lateral ventricles in the body of the right and layering dependently in the occipital horns bilaterally. No other intracranial hemorrhage is detected. The ventricles and sulci are mildly prominent suggesting age-related atrophy. Prominent bifrontal extra-axial CSF density could be due to volume loss or low-density subdural fluid collections. The basal cisterns are patent. Gray-white matter differentiation is preserved. Left facial and skullbase fractures are better depicted on concurrent CT of the face. There is hemorrhagic opacification of the left maxillary sinus and sphenoids. The mastoid air cells and middle ear cavities are clear. IMPRESSION: 1. Minimal amount of hemorrhage in the lateral ventricles as detailed above. 2. Left facial and skullbase fractures better depicted on concurrent CT of the face. 3. Prominent bifrontal extra-axial CSF potentially due to volume loss and prominent subarachnoid space although low-density subdural fluid is also possible. This can be further assessed at time of CTA. Radiology Report EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST INDICATION: ___ s/p fall w/ AMS // eval for trauma TECHNIQUE: Helical axial images were acquired through the paranasal sinuses. Coronal reformatted images were also obtained DOSE: DLP: 541 mGy-cm; CTDI: 26 mGy COMPARISON: None available FINDINGS: Left lateral orbital fracture is medially displaced into the orbit approximately 5 mm. There is comminuted fracture of the left zygomatic arch. Fracture fragments of the zygomatic arch are seen approximately 3 mm from coronoid process. There is comminuted fracture of the anterior and lateral left maxillary walls. Left orbital floor fracture is seen to traverse the inferior orbital canal. The inferior left orbital rim is fractured. The globe is unremarkable. There is no CT evidence of extraocular muscle entrapment. Small amount of extraconal hematoma seen adjacent left lateral rectus muscle. There is fracture of the left sphenoid sinus walls extending to the left carotid canal (02:55). Fractures are also seen involving the posterior wall the pterygopalatine fossa (02:53). Hemorrhage seen layering within the left maxillary sinus and sphenoid sinuses. There is partial opacification of the ethmoid air cells. The mandible is intact. The temporomandibular joints are anatomically aligned. Pterygoid plates are also intact. IMPRESSION: Left zygomaticomaxillary complex fracture. Left sphenoid sinus wall fracture involving the left carotid canal should be further evaluated with CTA of the head and neck to exclude vascular injury. Left zygomatic arch fracture fragments seen approximately 3 mm from the coronoid process. Gender: F Race: UNKNOWN Arrive by AMBULANCE Chief complaint: FALL Diagnosed with CL SKUL BASE FX-COMA NOS, FX MALAR/MAXILLARY-CLOSE, FX ORBITAL FLOOR-CLOSED, OPEN WOUND OF FOREHEAD, OPEN WOUND OF AURICLE, ALCOHOL ABUSE-UNSPEC, FALL ON STAIR/STEP NEC temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: nan

You were evaluated in the Emergency Room following a fall down a flight of stairs. You were found to have a small bleed in your brain, facial fractures (maxillary and zygomatic fractures), Left hand fractures for which you were evaluated by Neurosurgery, Plastic Surgery, and Hand Surgery. FACIAL FRACTURES INFORMATION You were diagnosed with a facial fracture. Some facial fractures require an operation, others do not and heal on their own. Until you can be further evaluated, you do need to take some precautions: - Sleep with the head of your bed elevated about 45 degrees (prop yourself up with some pillows) - Do not do anything to increase pressure in your face: Do not use straws to drink, do not blow your nose, if you have to sneeze do so with an open mouth, and do not strain with bowel movements. - Avoid contact sports or strenuous physical activity - Take an over-the-counter stool softener, such as Colace, for the next 2 weeks to prevent straining with bowel movements. This is especially important if you have been prescribed narcotic pain medications, because all narcotics are constipating. - If an antibiotic was prescribed, please take it as directed. Call your doctor or return to the emergency room for: - Fevers or chills - Worsening headaches - Purulent or foul smelling drainage from one or both nostrils - Worsening tenderness in your face - Pain with ___ movement or difficulty moving eyes - Blurry vision - Nausea or vomiting - Any other concerns HAND/WRIST FRACTURES Many hand and wrist injuries are simple sprains or strains that will resolve over ___ weeks. Some types of ligament tears can take longer or require surgery. Fractures will require follow-up care for casting. The severity of some injuries can be difficult to determine at the time of an emergency visit. Certain types of injuries are always treated with a plaster splint since some fractures can take more than a week to show up on X-Rays. If X-Rays were taken: they were reviewed by physicians in the Emergency Department today, and will also be reviewed by a radiologist within 24 hours. We will call you if there are any questions, or if more x-rays are needed. <B>Treatment:</B> * Rest the affected area. If a splint was applied, be sure to wear it and use a sling. As much as possible, you should keep your arm elevated above the level of your heart. * For the first 2 days, apply ice packs for 15 minutes at a time. You can do this as frequently as possible, up to once every hour if there is a lot of swelling. Be sure to always place a towel between the ice pack and your skin. * After 2 days you can switch to heat if it is more comfortable, or continue using the ice. * Unless told otherwise by your doctor, you can use over the counter pain relievers such as acetaminophen (Tylenol) or ibuprofen (Advil, Motrin). If you were given a prescription for strong pain medications you should not drive, operate machinery or drink alcohol while taking them. * Be sure to follow up with your doctor or the specialist as instructed. <B>Warning Signs:</B> Call your doctor or return to the Emergency Department right away if any of the following problems develop: * Your pain or swelling gets much worse * Your arm or hand is cold or numb HEAD INJURY You have been diagnosed as having sustained an injury to your head. Most head injuries are not serious and get better over a few days. However in rare cases, further problems develop, so it is important that you, and a friend or relative monitor your condition and seek immediate help if you notice any of the warning signs below. If X-Rays were taken: they were reviewed by physicians in the Emergency Department today, and will also be reviewed by a radiologist within 24 hours. We will call you if there are any questions, or if more x-rays are needed. <B>Treatment:</B> * It is important that you stay with a friend or relative for at least 24 hours so they can help you watch for the warning signs below. * You should rest, and avoid exertion or heavy lifting for ___ days or until you feel completely well again. Do not drive, operate machinery or perform other tasks that require strict concentration until you are well. * Avoid alcohol, sedatives and any other substances that will make you sleepy. * Mild nausea is normal for a few hours after an injury. If you have severe nausea or if you are vomiting, seek medical attention. * A mild to moderate headache is to be expected. For the first 24 hours take only Tylenol (acetaminophen) for headache. <B>Warning Signs:</B> Call your doctor or return to the Emergency Department right away if any of the following problems develop: * Prolonged nausea * Vomiting * Confusion, drowsiness, change in normal behavior * Trouble walking, or speaking (slurred speech) * Numbness or weakness of an arm or leg. * Severe headache * Convulsions or seizures Dizziness, changes in sleep, forgetfulness and difficulty concentrating are not uncommon after a head injury. These symptoms will usually clear over a few days, but if they persist or become worrisome, you may benefit from following up with a Neurologist specializing in head injuries. Please call ___ to schedule an appointment at the Concussion Clinic. Indicate that you were recently seen in the ___ Emergency Room and you will generally be seen within 1 to 2 weeks.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: latex / Haldol / gabapentin Attending: ___. Chief Complaint: seizures Major Surgical or Invasive Procedure: none History of Present Illness: ___ with PMHx of bipolar disorder, anxiety, IVDU, chronic HCV, and seizure disorder presents to the ED with c/o increasing frequency of seizures. Pt reports that she has had more frequent seizures lately including several in the last week and one on ___ where she was admitted to ___. She reports not taking Keppra for the last 6 days because her PCP "told her to stop," given that her "Keppra levels were always low" despite taking the medication. She has not seen a neurologist for over ___ years and is managed by her PCP. In the ED: - Initial vital signs: 96.6 118 140/89 18 96% RA - Exam notable for: WNL - Labs were notable for: CBC WNL, Bicarb 19, lactate 7.0 -> 1.1 - Studies performed include: CT Head w/o Contrast: No acute intracranial abnormality - Meds: ___ 20:15 IM LORazepam 2 mg ___ ___ 23:56 IV Gentamicin 80 mg ___ - Consults: None - ED Course: Pt had witnessed GTC seizure in ED with lactatemia, s/p IM lorazepam with resolution. Given c/f endocarditis, pt given gentamicin. Upon arrival to the floor, pt endorsed the history above. In addition, she states she last used IV heroin 6 days ago. She does endorse one isolated fever at home of ___ F a few days ago and redness on her right hand. She denies CP, palpitations, dyspnea, cough, ___ edema. She reports a history of endocarditis approximately ___ year ago with no recent issues with her heart. ROS: Complete ROS obtained and is otherwise negative. Past Medical History: - Seizure disorder - Bipolar dz - Anxiety - Attention deficit syndrome and - ___ abuse, IV drug user, heroin. Per patient last used ___. Cocaine, sober for one-year. - History of heavy alcohol abuse with first detoxification ___ years ago. She reports no current alcohol use for more than one year. - Endocarditis Social History: ___ Family History: - Mother has ___ use. - Does not know her father. - 4 children who are alive and healthy Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: ___ 0135 Temp: 98.7 PO BP: 118/86 HR: 119 RR: 18 O2 sat: 94% O2 delivery: ra GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. Extremely poor dentition. Tachy MM NECK: No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, borderline tachycardia. No murmurs/rubs/gallops. LUNGS: CTAB. No wheezes, rhonchi or rales. ABDOMEN: Soft, NT, ND EXTREMITIES: No clubbing, cyanosis, or edema. SKIN: WWP. Area of 4 cm area of erythema, warmth over dorsum of Rt hand. In setting of IVDU. Multiple sites of previous injection b/l including 2 cm nodules in b/l brachial fossas. No ___ lesions, ___ nodes, or splinter hemorrhages NEUROLOGIC: AOx3. CN2-12 intact. ___ strength throughout. Normal sensation. DISCHARGE PHYSICAL EXAM: Vitals:24 HR Data (last updated ___ @ 926) Temp: 98.1 (Tm 98.3), BP: 99/63 (83-110/53-77), HR: 84 (75-93), RR: 16 (___), O2 sat: 93% (91-95) GEN: young woman lying in bed, NAD HEENT: EEG leads in place CV: well perfused RESP: normal WOB on RA EXTR track marks on arms bilaterally NEURO: mental status: awake, alert, oriented to medical situation. Provides linear and logical history. Speech fluent without paraphasic errors. Normal grammar and syntax. Pupils 5->3mm and brisk. EOMI with fatiguable, horizontal endgaze nystagmus. Facial activation symmetric. No dysarthria. Moves all extremities briskly. FNF without dysmetria. Pertinent Results: ADMISSION LABS --------------- ___ 08:42PM BLOOD WBC-6.6 RBC-4.66 Hgb-12.0 Hct-36.9 MCV-79* MCH-25.8* MCHC-32.5 RDW-17.3* RDWSD-49.1* Plt ___ ___ 08:42PM BLOOD Neuts-41.3 ___ Monos-5.8 Eos-4.3 Baso-0.8 Im ___ AbsNeut-2.71 AbsLymp-3.09 AbsMono-0.38 AbsEos-0.28 AbsBaso-0.05 ___ 08:42PM BLOOD Glucose-98 UreaN-9 Creat-1.1 Na-139 K-3.9 Cl-98 HCO3-19* AnGap-22* ___ 08:42PM BLOOD Calcium-9.9 Phos-4.1 Mg-1.6 ___ 04:50PM BLOOD HIV Ab-NEG ___ 08:42PM BLOOD ASA-NEG Acetmnp-NEG Tricycl-NEG ___ 08:52PM BLOOD Lactate-7.0* ___ 11:59PM BLOOD Lactate-1.1 DISCHARGE LABS ----------------- ___ 05:00AM BLOOD WBC-6.8 RBC-4.55 Hgb-11.6 Hct-37.7 MCV-83 MCH-25.5* MCHC-30.8* RDW-17.6* RDWSD-53.1* Plt ___ ___ 06:08AM BLOOD Glucose-105* UreaN-19 Creat-1.0 Na-139 K-4.5 Cl-101 HCO3-24 AnGap-14 ___ 05:00AM BLOOD Glucose-75 UreaN-21* Creat-1.0 Na-141 K-5.5* Cl-105 HCO3-18* AnGap-18 ___ 05:00AM BLOOD ALT-9 AST-27 AlkPhos-109* TotBili-<0.2 ___ 05:00AM BLOOD Albumin-3.8 Calcium-9.5 Phos-4.0 Mg-2.1 ___ 04:50PM BLOOD HIV Ab-NEG ___ 12:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG CT HEAD No acute intracranial abnormality. CXR Patchy opacification at the left lung base, concerning for infection. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Cetirizine 10 mg PO DAILY 2. CloNIDine 0.1 mg PO TID 3. Prazosin 2 mg PO QHS 4. Mirtazapine 30 mg PO QHS 5. Pregabalin 150 mg PO BID 6. TraZODone 100 mg PO QHS 7. linaCLOtide 145 mcg oral DAILY 8. Ranitidine 150 mg PO BID:PRN GERD 9. QUEtiapine Fumarate 100 mg PO BID 10. QUEtiapine Fumarate 200 mg PO QAM 11. Sertraline 200 mg PO BID 12. BusPIRone 15 mg PO QID 13. Methadone 150 mg PO DAILY 14. QUEtiapine Fumarate 400 mg PO QHS Discharge Medications: 1. DICYCLOMine 20 mg PO TID RX *dicyclomine 20 mg 1 tablet(s) by mouth three times a day as needed Disp #*21 Tablet Refills:*0 2. LOPERamide ___ mg PO QID:PRN loose stools RX *loperamide 2 mg ___ tablet(s) by mouth every six hours as needed Disp #*28 Tablet Refills:*0 3. Naloxone Nasal Spray 4 mg IH ONCE MR1 Duration: 1 Dose RX *naloxone [Narcan] 4 mg/actuation ___ spray intranasally as needed for opiate overdose Disp #*2 Spray Refills:*0 4. Simethicone 40-80 mg PO TID RX *simethicone 80 mg 1 tablet(s) by mouth three times a day as needed for stomach cramps Disp #*21 Tablet Refills:*0 5. Zonisamide 400 mg PO QHS RX *zonisamide 100 mg 4 capsule(s) by mouth at bedtime Disp #*120 Capsule Refills:*3 6. BusPIRone 15 mg PO QID 7. Cetirizine 10 mg PO DAILY 8. CloNIDine 0.1 mg PO TID 9. linaCLOtide 145 mcg oral DAILY 10. Methadone 150 mg PO DAILY Consider prescribing naloxone at discharge 11. Mirtazapine 30 mg PO QHS 12. Prazosin 2 mg PO QHS 13. Pregabalin 150 mg PO BID 14. QUEtiapine Fumarate 200 mg PO QAM 15. QUEtiapine Fumarate 400 mg PO QHS 16. QUEtiapine Fumarate 100 mg PO BID 17. Ranitidine 150 mg PO BID:PRN GERD 18. Sertraline 200 mg PO BID 19. TraZODone 100 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: epilepsy history of traumatic brain injury homelessness ___ abuse bipolar disorder chronic hepatitis C Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: History: ___ with fall and head strike// Please evaluate for large infarct, mass, bleed TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: DLP: 759 MGy-cm COMPARISON: CT dated ___ FINDINGS: There is no evidence of acute large territorial 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 paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: No acute intracranial abnormality. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with seizure, c/f endocarditis// Please evaluate for PNA or effusion TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph dated ___. FINDINGS: Patchy opacities at the left lung base, concerning for infection. The right lung is clear. No pulmonary edema. Normal cardiomediastinal silhouette. No pleural effusion. No pneumothorax. IMPRESSION: Patchy opacification at the left lung base, concerning for infection. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Abnormal labs Diagnosed with Epilepsy, unsp, not intractable, without status epilepticus temperature: 96.6 heartrate: 118.0 resprate: 18.0 o2sat: 96.0 sbp: 140.0 dbp: 89.0 level of pain: 0 level of acuity: 3.0

Dear Ms ___, You presented to ___ hospital because of concern that you had a seizure. While in the hospital, you were monitored on EEG. You also received antibiotics for a possible skin infection. You were seen by our addiction psychiatry team. After leaving the hospital, make sure you take your medications as prescribed. We wish you the best, Your ___ team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins Attending: ___ Chief Complaint: Syncope Major Surgical or Invasive Procedure: ___: Placement of IVC filter History of Present Illness: Ms. ___ is a ___ y/o F with history of duodenal ulcers and dementia who presented as a transfer from ___ for management of pulmonary embolism, arrived on heparin gtt. Per reports, she is a resident of ___, and had a syncopal episode lasting 30 seconds to 1 minute, prompting her to be taken to the ED. At ___, she was found to have extensive bilateral pulmonary emboli with right heart strain and elevated troponins. She was transferred to ___ on heparin gtt which was started around 1440 on ___. MASCOT was consulted and recommended remaining on heparin gtt at this time, and recommended further workup with lower extremity dopplers and formal TTE. After discussion with the family and patient, they clearly expressed not wanting to pursue aggressive measures at this time, including IVC filter. However, should further complications develop, they are willing to discuss more advanced therapies at this time. On the floor, she had two further syncopal episodes with BP dropping as low as SBP ___, requiring up to 2L O2 via NC, prompting transfer to the MICU. She was started on 1 L NS with SBP increasing to ___. On arrival to the MICU, patient reports feeling well without complaints. Alert, awake, interactive. Breathing comfortably. Past Medical History: Anemia Esophagitis Peptic ulcer disease on PPI/sucralfate Bullous pemphigoid on prednisone Alzheimer's dementia on donepezil Social History: ___ Family History: n/c Physical Exam: ======================= ADMISSION PHYSICAL EXAM ======================= VITALS: BP 95/56 HR 93 RR 19 O2 100% GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, oropharynx clear NECK: supple LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding EXT: Extensive bruising on left arm and right hand. Large fluid filled bullae on right foot. No edema. WArm SKIN: No rashes, bruising as above NEURO: Moving all extremities ============================ DISCHARGE PHYSICAL EXAM ============================ Vitals: 97.4 106/67 81 20 94 Ra General: bedbound, comfortable, AO x 1 (said she was in a ___ hospital and the month/year was ___, speaking in ___ word sentences answering "I don't know" and "everything hurts". Neck: supple Lungs: breathing comfortably, CTAB, good respiratory effort CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic murmur Abdomen: soft, non-tender, non-distended, no suprapubic tenderness or fullness Ext: 2+ painful non pitting edema of the bilateral lower extremities to level of knees, some associated erythema, non-tender to palpation. No further edema of upper extremities. GU: Foley in place Skin: Diffuse ecchymoses, dry dressing on bulla of R foot Neuro: Alert and fully oriented Pertinent Results: ============================= ADMISSION LABS ============================= ___ 06:56PM BLOOD WBC-20.1* RBC-4.31 Hgb-12.5 Hct-39.5 MCV-92 MCH-29.0 MCHC-31.6* RDW-16.4* RDWSD-55.3* Plt ___ ___ 06:56PM BLOOD Neuts-89.7* Lymphs-4.9* Monos-4.0* Eos-0.0* Baso-0.2 Im ___ AbsNeut-18.03* AbsLymp-0.98* AbsMono-0.81* AbsEos-0.00* AbsBaso-0.04 ___ 06:56PM BLOOD ___ PTT-150* ___ ___ 06:56PM BLOOD Glucose-156* UreaN-57* Creat-1.7* Na-138 K-4.6 Cl-92* HCO3-27 AnGap-19* ___ 06:56PM BLOOD CK-MB-8 proBNP-6954* ___ 06:56PM BLOOD cTropnT-0.30* ___ 12:15PM BLOOD Calcium-8.0* Phos-4.4 Mg-1.7 ___ 03:50AM BLOOD ___ pO2-29* pCO2-54* pH-7.42 calTCO2-36* Base XS-7 ___ 03:50AM BLOOD Lactate-4.4* Na-138 K-3.8 Cl-88* ___ 10:40PM URINE Color-Straw Appear-Clear Sp ___ ___ 10:40PM URINE Blood-MOD* Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 10:40PM URINE RBC-116* WBC-1 Bacteri-NONE Yeast-NONE Epi-0 ============================= DISCHARGE LABS ============================= ___ 05:30AM BLOOD WBC-8.5 RBC-2.42* Hgb-7.2* Hct-23.2* MCV-96 MCH-29.8 MCHC-31.0* RDW-17.2* RDWSD-58.4* Plt ___ ___ 05:30AM BLOOD Glucose-82 UreaN-19 Creat-0.7 Na-140 K-3.8 Cl-102 HCO3-28 AnGap-10 ___ 05:30AM BLOOD Calcium-8.3* Phos-2.5* Mg-1.7 ============================= INTERVAL LABS ============================= ___ 10:28AM BLOOD CK-MB-4 cTropnT-0.15* ___ 06:05AM BLOOD CK-MB-3 cTropnT-0.16* proBNP-5272* ___ 12:15PM BLOOD CK-MB-8 cTropnT-0.23* proBNP-6919* ___ 06:56PM BLOOD cTropnT-0.30* ___ 06:56PM BLOOD CK-MB-8 proBNP-6954* ___ 10:28AM BLOOD Cortsol-15.3 ___ 05:26AM BLOOD calTIBC-225* VitB12-592 Ferritn-394* TRF-173* ___ 05:26AM BLOOD TSH-8.7* ___ 05:26AM BLOOD Free T4-0.6* ___ 12:33PM BLOOD ___ pO2-33* pCO2-43 pH-7.46* calTCO2-32* Base XS-5 ___ 12:33PM BLOOD Lactate-1.0 ============================= IMAGING ============================= ___ ___ 1. Deep venous thrombosis of the right femoral and popliteal veins. 2. Nonvisualization of posterior tibial and peroneal veins bilaterally. Within these limits, no evidence of deep venous thrombosis in the leftlower extremity veins. ___ ECHO The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Left ventricular systolic function is hyperdynamic (EF = 75%). There is AT LEAST a mild resting left ventricular outflow tract obstruction (with premature closure of the aortic valve) due to the hyperdynamic and underfilled nature of the left ventricle. The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal with normal free wall contractility. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. ___ CXR Cardiac size is top-normal. Patient has a large hiatal hernia. Enlargement of the pulmonary arteries is again noted. There is no pneumonia, pulmonary edema, evident pneumothorax or pleural effusions. ___ CXR Right internal jugular line tip is in the proximal right atrium. Heart size and mediastinum are unchanged including cardiac enlargement. Left retrocardiac opacities concerning for infectious process. No appreciable pleural effusion. Hiatal hernia is large, re-demonstrated. ***Incidental radiology findings from ___ scan*** -complete intrathoracic stomach with organoaxial rotation, without ___ volvulus. -dilatation of the esophagus with air-fluid levels identified. -cholelithiasis -Colonic diverticula -5 mm left lower lobe pulmonary nodule. -Enlarged thyroid gland with heterogeneous parenchyma and densely calcified bilateral nodules ============================= PROCEDURES ============================= ___ IVC FILTER PLACEMENT 1. Patent normal sized, non-duplicated IVC with single bilateral renal veins and no evidence of a clot. 2. Successful deployment of an infra-renal retrievable IVC filter. ============================= MICRO ============================= __________________________________________________________ ___ 5:50 pm BLOOD CULTURE #1. Blood Culture, Routine (Pending): __________________________________________________________ ___ 3:53 pm URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. __________________________________________________________ ___ 3:54 pm BLOOD CULTURE Source: Line-R IJ #2. Blood Culture, Routine (Pending): __________________________________________________________ ___ 10:28 am URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. __________________________________________________________ ___ 10:28 am BLOOD CULTURE Source: Line-R IJ #2. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 6:10 pm BLOOD CULTURE Source: Line-CL. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 6:10 pm BLOOD CULTURE Source: Line-CL. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 10:40 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Citalopram 10 mg PO DAILY 2. Donepezil 5 mg PO QHS 3. PredniSONE 5 mg PO DAILY Discharge Medications: 1. Apixaban 5 mg PO BID 2. Levofloxacin 500 mg PO Q24H Duration: 1 Day last dose: ___ on ___, to complete a ___. Pantoprazole 40 mg PO BID prior to meals 4. Sucralfate 1 gm PO QID 5. PredniSONE 10 mg PO DAILY 6. Citalopram 10 mg PO DAILY 7. Donepezil 5 mg PO QHS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: =========================== Primary: =========================== Syncope secondary to massive pulmonary embolism Catheter-associated urinary tract infection ============================= Secondary: ============================= Anemia Esophagitis Peptic ulcer disease Bullous pemphigoid Alzheimer's dementia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Followup Instructions: ___ Radiology Report INDICATION: ___ year old woman with massive PE, now with regression of mental status// evaluate previously described infiltrate TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: The tip of the right internal jugular central venous catheter projects over the right atrium, unchanged. Increasing retrocardiac opacities may reflect atelectasis and/or consolidation. There is no pneumothorax or large pleural effusion. The size of the cardiac silhouette is enlarged but unchanged. Calcification of the aortic arch again noted. IMPRESSION: Increased retrocardiac opacities may reflect atelectasis or consolidation. Radiology Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: History: ___ with pe, eval for dvt// pe, eval for dvt TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, flow and augmentation of the right common femoral vein. However, there is expansile, echogenic thrombus in the right femoral and popliteal veins with no color flow or compressibility. There is normal compressibility, flow, and augmentation of the left common femoral, femoral, and popliteal veins. The posterior tibial and peroneal veins were not clearly seen on either side. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: 1. Deep venous thrombosis of the right femoral and popliteal veins. 2. Nonvisualization of posterior tibial and peroneal veins bilaterally. Within these limits, no evidence of deep venous thrombosis in the leftlower extremity veins. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with new PE hypoxemia// Assess for infiltrate or cause of hypoxemia TECHNIQUE: Single frontal view of the chest COMPARISON: Chest CT ___ IMPRESSION: Cardiac size is top-normal. Patient has a large hiatal hernia. Enlargement of the pulmonary arteries is again noted. There is no pneumonia, pulmonary edema, evident pneumothorax or pleural effusions. Radiology Report INDICATION: ___ year old woman with submassive PE and large RLE DVT// Please place IVC filter COMPARISON: None. TECHNIQUE: OPERATORS: Dr. ___ and Dr. ___ radiologist performed the procedure. Dr. ___ supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings. ANESTHESIA: Local anesthesia was utilized with 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: None. CONTRAST: 30 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 5 min, 76 mGy PROCEDURE: 1. Left iliac vein and IVC venogram. 2. Infrarenal retrievable IVC filter deployment. 3. Post-filter placement venogram. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the healthcare proxy. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. Both groins were prepped and draped in the usual sterile fashion. Under ultrasound and fluoroscopic guidance, the patent and compressible right common femoral vein was punctured using a 21G micropuncture needle. Ultrasound images of the access was stored on PACS. A ___ wire was advanced through the micropuncture sheath into the inferior vena cava. A 5 ___ sheath was exchanged for the micropuncture sheath. After the inner dilator was removed, an Omniflush catheter was advanced over the wire into the IVC. The ___ wire was exchanged for an angled Glidewire, which was advanced into the left common iliac vein and the catheter tip was advanced into the left common iliac vein. A left common iliac and inferior vena cava venogram was performed. Based on the results of the venogram, detailed below, a decision was made to place a retrievable, infrarenal IVC filter. The catheter and sheath were removed over the wire and the sheath of the retrievable filter was advanced over the wire into the IVC past the take-off of the renal vessels. An inferior vena cava filter was advanced over the wire until the cranial tip was at the level of the inferior margin of the lower renal vein. The sheath was then withdrawn until the filter was deployed. The wire and loading device were then removed through the sheath and a repeat contrast injection was performed, confirming appropriate filter positioning. The final image was stored on PACS. The sheath was removed and pressure was held for 10 minutes, at which point hemostasis was achieved. A sterile dressing was applied. The patient tolerated the procedure well and there were no immediate post procedure complications. FINDINGS: 1. Patent normal sized, non-duplicated IVC with single bilateral renal veins and no evidence of a clot. 2. Successful deployment of an infra-renal retrievable IVC filter. IMPRESSION: Successful deployment of an infrarenal retrievable IVC filter. RECOMMENDATION(S): Please contact the department of Interventional Radiology with questions or concerns about the retrievable filter and for follow-up for retrieval if clinically feasible. Radiology Report EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM INDICATION: ___ year old woman with PE s/p RIJ CVL// CVL placement, ?interval changes COMPARISON: Chest radiographs from ___ through ___ FINDINGS: Semi-erect portable AP view of the chest provided. The right IJ central venous catheter tip is in the right atrium, approximately 1.5 cm below the estimated location of the superior cavoatrial junction. A large hiatal hernia is again seen and is unchanged. Enlargement of the pulmonary artery is stable, and there is no pleural effusion or pulmonary edema. There is no focal consolidation. No pneumothorax. The cardiac size is top normal, unchanged. IMPRESSION: 1. The right IJ central venous catheter tip is in the right atrium, approximately 1.5 cm below the estimated location of the superior cavoatrial junction. 2. Enlargement of the pulmonary artery is stable. No evidence of pulmonary vascular congestion or pulmonary edema. 3. Large hiatal hernia, unchanged. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with massive PE (stabilized on heparin gtt with VC filter in place) but with ongoing hypotension// evaluate for infiltrate (?hospital-acquired pneumonia) evaluate for infiltrate (?hospital-acquired pneumonia) IMPRESSION: Right internal jugular line tip is in the proximal right atrium. Heart size and mediastinum are unchanged including cardiac enlargement. Left retrocardiac opacities concerning for infectious process. No appreciable pleural effusion. Hiatal hernia is large, re-demonstrated. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: PE, Transfer Diagnosed with Other pulmonary embolism without acute cor pulmonale, Syncope and collapse temperature: 98.4 heartrate: 97.0 resprate: 18.0 o2sat: 97.0 sbp: 140.0 dbp: 91.0 level of pain: 0 level of acuity: 2.0

Dear ___, ___ were admitted to the hospital with a pulmonary embolism, which is a large blood clot in your lungs. ============================================= What happened while ___ were in the hospital? ============================================= - ___ received heparin, a blood thinning medicine, through your IV. The day before ___ were discharged, this was switched to a tablet called apixaban. - Because of the large blood clot in your lungs, the interventional radiologists put a filter to prevent other clots in your legs from traveling to your lungs. - ___ had low blood pressures and signs of an infection. This made ___ somewhat confused. We think the infection may have been from your urinary catheter, but we cannot say for sure. ___ were given antibiotics and fluids through the IV, which led to improvement. - ___ also had low blood counts and required a few blood transfusions. =============================================== What should ___ do when ___ leave the hospital? =============================================== - Make sure to work hard at rehab to rebuild strength and follow up with the gastroenterology team. - ___ should continue taking the new blood thinner medicine, apixaban (Eliquis), 5mg twice a day, for at least 3 months to treat the blood clot. It was a pleasure taking care of ___! Congratulations on your 90th birthday! Sincerely, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Lithium Attending: ___. Chief Complaint: EtOH withdrawal Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ male with bipolar disorder and alcohol use disorder who presented to the ED with alcohol intoxication and withdrawal. He drinks more than a quart of hard liquor per day. His last drink was the day before he came to the ED. He estimates it was about 4 hours before he presented to the ED in the early morning of ___. He usually starts withdrawing after he has gone without alcohol for about 4 hours. His most bothersome withdrawal symptom has been tremors. He has a mild headache as well. He has some mild anxiety. He does not feel like eating but is not nauseated. No vomiting. No diaphoresis. He feels better after receiving phenobarbital PO x2. He has not been hallucinating. He has a history of withdrawal seizures. He thinks the last one was about ___ years ago. He has been admitted to the ICU almost every time he has been hospitalized for alcohol withdrawal. He has never been intubated. He had been sober for over a year until this past ___. He was living in a nursing home and the nursing home closed. He had an option to move to a different nursing home, but he did not want to and decided to live on the streets instead. He started drinking again when he left the nursing home. He has been drinking since the age of ___. The longest he has been sober has been for about ___ years. Keeping busy/working/exercising has been helpful to maintain sobriety in the past. He hears himself wheezing but does not feel short of breath. He occasionally coughs, but it is not productive. No fevers/chills. He has not vomited. He has never smoked. ED COURSE: VS: Tmax 98.3, HR ___, BP 120s-140s/60s-80s, RR ___, SpO2 96-98% on RA Exam: "On exam, he is initially sleeping comfortably, however when aroused, is immediately profoundly tremulous, including arms, legs, and face/head. He is not hallucinating or otherwise confused, although doesn't know exactly where he is or what led to him coming here" Labs: Mag 1.4, serum EtOH 104, urine tox positive for benzos, barbiturates, and opiates, AST 59, LDH 606 Imaging: CXR clear Interventions/Meds: Diazepam 20 mg PO x1 Duoneb x1 Levofloxacin 750 mg IV x1 LR 1L x1 Diazepam 20 mg IV x1 Diazepam 20 mg PO x1 Thiamine 100 mg PO x1 Multivitamin 1 tab PO x1 Phenobarbital 259.2 mg PO x1 Magnesium sulfate 4 grams IV x1 ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: Psych: -Bipolar disorder: Over 10+ hospitalizations since ___. Multiple suicide attempts via overdose and wrist cutting. History of ECT. History of manic episodes. -Depression: history of multiple medication trials including Trileptal, Seorquel, and Wellbutrin. -Alcohol Abuse: Long history of abuse with 2 ICU stays for withdrawal as well as multiple seizures. Notes family history of alcoholism. Has had trouble with alcohol for around ___ years. - Hep A: +HAVAb but -HAV IgM ___. -Hep B: VL not detected ___ -Hep C: HCV VL 3,460,000 IU/mL, HBV not detected on ___. -likely cirrhosis with evidence of portal hypertension and thrombocytopenia; patient self-reports a history of cirrhosis, not followed yet by hepatology -COPD: 20 pack year smoking history. Quit in ___. -GERD -Chronic lower back pain - received 3 steroid injections. PAST SURGICAL HISTORY: -Cholecystectomy - ___ -Urethral stent placement - ___ Social History: ___ Family History: - FATHER: alcoholism, died of esophageal cancer - MOTHER: alcoholism, died of esophageal cancer - SISTER: fibromyalgia - BROTHER: diabetes ___ Physical Exam: ADMISSION: ========== VITALS: 24 HR Data (last updated ___ @ 1804) Temp: 97.7 (Tm 97.7), BP: 147/80, HR: 97, RR: 18, O2 sat: 96%, O2 delivery: RA, Wt: 180.6 lb/81.92 kg GENERAL: Alert, NAD, somnolent but easily arousable EYES: Anicteric, PERRL, no nystagmus ENT: mmm, OP clear CV: NR/RR, no m/r/g RESP: Diffuse expiratory wheezing ABD/GI: Soft, ND, NTTP, normoactive bowel sounds GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs VASC/EXT: No ___ edema, 2+ DP pulses SKIN: No rashes or lesions noted on visible skin NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, bilateral coarse resting tremor in hands/arms, mouth, tongue PSYCH: pleasant, appropriate affect Discharge exam: =============== 98.7 PO 117 / 68 62 18 97 Ra General: Pleasant, comfortable HEENT: Anicteric, eyes conjugate, MMM, no JVD Cardiovascular: RRR no MRG, nl. S1 and S2 Pulmonary: Lung fields clear to auscultation throughout Gastroinestinal: Soft, non-tender, non-distended, bowel sounds present, no HSM MSK: No edema Skin: No rashes or ulcerations evident Neurological: Alert, interactive, speech fluent, face symmetric, moving all extremities. Essential tremor (rest and movement) of bilateral upper extremities Psychiatric: pleasant, appropriate affect Pertinent Results: ADMISSION/SIGNIFICANT LABS: ========================== ___ 06:15AM BLOOD WBC-5.2 RBC-4.48* Hgb-13.7 Hct-39.4* MCV-88 MCH-30.6 MCHC-34.8 RDW-13.3 RDWSD-42.7 Plt ___ ___ 06:15AM BLOOD Glucose-107* UreaN-10 Creat-0.7 Na-146 K-4.5 Cl-105 HCO3-21* AnGap-20* ___ 06:55AM BLOOD ALT-19 AST-20 LD(LDH)-187 AlkPhos-50 TotBili-1.1 MICRO: ===== Cdiff Positive PCR, Cdiff toxin positive IMAGING/OTHER: ============== ___ CXR No pneumonia or evidence of cardiac decompensation. LABS ON DISCHARGE: ================== ___ 07:20AM BLOOD WBC-4.8 RBC-4.40* Hgb-13.7 Hct-40.8 MCV-93 MCH-31.1 MCHC-33.6 RDW-13.9 RDWSD-46.5* Plt ___ ___ 07:20AM BLOOD Glucose-121* UreaN-14 Creat-0.7 Na-142 K-4.1 Cl-103 HCO3-26 AnGap-13 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN mild to severe 2. FoLIC Acid 1 mg PO DAILY 3. Lidocaine 5% Patch 1 PTCH TD QPM 4. Multivitamins 1 TAB PO DAILY 5. Pantoprazole 40 mg PO Q24H 6. Propranolol 20 mg PO TID 7. Thiamine 100 mg PO DAILY Discharge Disposition: Extended Care Discharge Diagnosis: # Alcohol Withdrawal # Alcohol Use Disorder # Clostridium difficile infection # Bipolar Disorder with depressive symptoms 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 wheezing/cough. Evaluate for pneumonia. TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph performed ___. FINDINGS: Lungs are well inflated and clear. No pleural effusion or pneumothorax. The cardiomediastinal silhouette is within normal limits. Healed left rib fractures are long-standing. IMPRESSION: No pneumonia or evidence of cardiac decompensation. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: ETOH Diagnosed with Pneumonia, unspecified organism temperature: 98.2 heartrate: 92.0 resprate: 16.0 o2sat: 98.0 sbp: 142.0 dbp: 76.0 level of pain: 0 level of acuity: 3.0

Dear Mr. ___, It was a privilege to care for you at the ___ ___. You were admitted for alcohol detox. You were also noted to have poorly controlled Bipolar Disorder with depressive symptoms requiring inpatient psychiatric therapy. While you were here, you were diagnosed with an infection called C. Difficile which causes diarrhea. You were treated with antibiotics for this with improvement in your symptoms. You were also started on propranolol for your tremor. Now that you have completed treatment for your infection, you are ready for transfer to ___ at ___ for ongoing ECT treatments and management of your depression. We wish you the best in your recovery. Sincerely, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine / Bactrim / Penicillins Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: ___ woman with history of CAD (70% mid LAD, 80% Diagonal, 100% occlusion of the LCx, mid RC 50-60%), PVD, T2DM, peripheral neuropathy, CKD who presents with complaint of wheezing and shortness of breath. Evening of ___ she woke up in the middle of the night to urinate and noted shortness of breath and wheezing which resolved on its own. Evening of ___ she again noted shortness of breath with wheezing which she stated was ___. She also noted a chest flutter sensation, denies any chest pain or palpitations. She took a nitro SL but it did not change her symptoms. Her symptoms started acutely. She denied any nausea, vomiting, chest pain, abdoinal pain, palpitations, fevers, chills, diarrhea, constipation, orthopnea, ___ edema. She denies any recent travel or surgeries. - In the ED, patient was afebrile, hypertensive to 160s-190s/50s-70s, HR ___, SpO2 high ___ on 3L. - Exam was notable for: tachypnea, decreased breath sounds at bases - Labs were notable for: normal WBC, Cr 1.2, trop 0.02, BNP 2176, VBG 7.39/47 - EKG: NSR, normal axis, normal intervals, STD V2-V4 <1mm - CXR: no edema, effusions, or consolidations - Bedside echo with normal EF. B-lines appreciated bilaterally. - The patient was given: ___ 00:36SLNitroglycerin SL .4 mg ___ 02:39IHIpratropium-Albuterol Neb 1 NEB ___ 02:39IVFurosemide 40 mg ___:38IV DRIPNitroglycerin Started 0.1 mcg/kg/min ___ 03:38PO/NGAspirin 325 mg ___ 04:13IV DRIPNitroglycerin Rate Changed to 0.5 mcg/kg/min ___ 04:16IV DRIPNitroglycerin Rate Changed to 1 mcg/kg/min ___ 04:42IV DRIPNitroglycerin Rate Changed to 1.5 mcg/kg/min ___ 04:57IV DRIPNitroglycerin Rate Changed to 2 mcg/kg/min ___ 06:34IV DRIPNitroglycerin Rate Changed to 2.5 mcg/kg/min ___ 09:04IV DRIPNitroglycerinConfirmed Rate Changed to 3 mcg/kg/min ___ 09:50PO/NGAspirin 325 ___ 09:50SC Insulin 4 Units ___ 11:19PO/NGOxyCODONE--Acetaminophen (5mg-325mg) 1 ___ 11:19PO/NGGabapentin 600 mg ___ 12:35IV DRIPNitroglycerinConfirmed No Change in Rate, rate continued at 3 mcg/kg/min ___ 14:30SCInsulin 10 Units ___ 18:32IV DRIPNitroglycerinConfirmed Rate Changed to 2 mcg/kg/min ___ 20:00SCInsulin 8 Units ___ 20:20PO/NGAtorvastatin 80 mg ___ 20:20PO/NGOxyCODONE--Acetaminophen (5mg-325mg) 1 TAB ___ 20:20PO/NGHydrALAZINE 25 mg ___ 20:20POIsosorbide Mononitrate (Extended Release) 120 mg ___ 20:20POMetoprolol Succinate XL 100 mg ___ 20:25IV DRIPNitroglycerinConfirmed Rate Changed to 1 mcg/kg/min ___ 20:54IV DRIPNitroglycerinConfirmed Rate Changed to 0.5 mcg/kg/min ___ 21:18IV DRIPNitroglycerinConfirmed Rate Changed to 0 mcg/kg/min ___ 21:30IV DRIPNitroglycerinStopped in Other Location On arrival to the floor, the patient states she is feeling well with no symptoms. She denies any chest pain or shortness of breath. She is unclear at which point her symptoms improved. Past Medical History: CAD Carotid stenosis status post CEA on the left Significant PVD s/p multiple interventions DMII Back Pain Depression Hypercholesterolemia HTN PAST SURGICAL HISTORY: ___: Right external iliac artery to profunda femoral artery bypass graft with 6 mm ringed PTFE. ___: Right ___ toe debridement of skin, subcutaneous tissue and nail. Second toe debridement of skin, subcutaneous tissue and bone. ___: Ileofemoral/profunda femoral endarterectomy with Saphenous vein patch angioplasty. Right profunda femoral to peroneal artery bypass graft using non reverse greater saphenous vein ___: Revision of left femoral to peroneal artery bypass graft with jump graft using reversed left arm cephalic vein. ___: Left common femoral to peroneal artery bypass with non reversed saphenous vein graft ___: Left carotid endarterectomy Social History: ___ Family History: Mother deceased at ___. Father deceased at ___ of myocardial infarction. Sister deceased at ___, pancreatic cancer. Brother deceased at ___, GI tract cancer. All other siblings are deceased secondary to complications of diabetes and high blood pressure. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== ___ 0048 BP: 152/68 HR: 79 ___ 0022 Temp: 97.4 PO BP: 173/59 HR: 64 RR: 18 O2 sat: 95% O2 delivery: RA GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: No cervical lymphadenopathy. JVD to mid neck at 45 degrees. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. ___ SEM best heard at ___ LUNGS: Faint crackles at lung bases 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: trace pedal edema bilaterally, 1+ DP pulses b/l, s/p toe amputations, no visible ulcers 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 ___ @ 1127) Temp: 98.3 (Tm 98.4), BP: 116/60 (116-179/59-74), HR: 74 (65-77), RR: 20 (___), O2 sat: 94% (92-94), O2 delivery: RA, Wt: 177.47 lb/80.5 kg GENERAL: In NAD HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM NECK: JVP ~10 cm CARDIAC: RRR, ___ systolic murmur best heard at ___ LUNGS: CTAB EXTREMITIES: Warm, no ___ edema bilaterally, s/p toe amputations, no visible ulcers SKIN: No visible rashes NEUROLOGIC: A&Ox3, motor and sensation grossly intact. Pertinent Results: ___ 01:22AM BLOOD WBC-9.0 RBC-3.44* Hgb-10.2* Hct-33.3* MCV-97 MCH-29.7 MCHC-30.6* RDW-13.1 RDWSD-46.1 Plt ___ ___ 01:22AM BLOOD ___ PTT-32.8 ___ ___ 01:22AM BLOOD Glucose-208* UreaN-31* Creat-1.2* Na-140 K-4.7 Cl-104 HCO3-25 AnGap-11 ___ 01:22AM BLOOD CK(CPK)-388* ___ 01:22AM BLOOD CK-MB-11* MB Indx-2.8 proBNP-2176* ___ 01:22AM BLOOD cTropnT-0.02* ___ 06:55AM BLOOD cTropnT-0.05* ___ 03:53PM BLOOD cTropnT-0.05* ___ 07:45AM BLOOD CK-MB-4 cTropnT-0.02* ___ 10:21AM BLOOD CK-MB-9 cTropnT-0.07* ___ 05:11PM BLOOD cTropnT-0.87* ___ 11:10PM BLOOD cTropnT-1.16* ___ 07:15AM BLOOD cTropnT-1.30* ___ 07:45AM BLOOD Calcium-9.4 Phos-2.5* Mg-1.6 ___ 03:22PM BLOOD %HbA1c-7.9* eAG-180* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 300 mg PO DAILY 2. Gabapentin 600 mg PO QPM 3. Gabapentin 900 mg PO QHS 4. Albuterol Inhaler 2 PUFF IH Q4H:PRN cough, chest tightness 5. amLODIPine 10 mg PO DAILY 6. Atorvastatin 80 mg PO QPM 7. BuPROPion 75 mg PO BID 8. Fluticasone Propionate NASAL 2 SPRY NU DAILY 9. HydrALAZINE 25 mg PO TID 10. NPH 28 Units Breakfast NPH 5 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 11. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY 12. Lidocaine 5% Patch 1 PTCH TD QAM back pain 13. Metoprolol Succinate XL 100 mg PO DAILY 14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 15. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN Pain - Moderate 16. Rivaroxaban 2.5 mg PO BID 17. Aspirin 81 mg PO DAILY 18. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. CARVedilol 12.5 mg PO BID RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. Losartan Potassium 50 mg PO DAILY RX *losartan 50 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. HydrALAZINE 50 mg PO TID RX *hydralazine 50 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 4. NPH 28 Units Breakfast NPH 5 Units Bedtime 5. Albuterol Inhaler 2 PUFF IH Q4H:PRN cough, chest tightness 6. amLODIPine 10 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Atorvastatin 80 mg PO QPM 9. BuPROPion 75 mg PO BID 10. Fluticasone Propionate NASAL 2 SPRY NU DAILY 11. Gabapentin 300 mg PO DAILY 12. Gabapentin 900 mg PO QHS 13. Gabapentin 600 mg PO QPM 14. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY 15. Lidocaine 5% Patch 1 PTCH TD QAM back pain 16. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 17. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN Pain - Moderate 18. Rivaroxaban 2.5 mg PO BID 19. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Hypertensive Emergency Secondary: CAD, DM2, CKD, PVD 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 possible flash pulmonary edema// eval for pulmonary edema TECHNIQUE: Portable AP chest COMPARISON: Chest radiograph from ___ FINDINGS: There is no focal consolidation, pleural effusion, or pneumothorax. Compared to the prior chest radiograph right basilar atelectasis has mildly improved. Heart size is top-normal. Chronic elevation of the right hemidiaphragm, unchanged, accounts for vascular crowding and mild atelectasis at the right lung base. Aorta, with dense degenerative calcifications in the knob, has an otherwise normal contour. IMPRESSION: No acute cardiopulmonary process, specifically no pulmonary edema. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with CAD w/ new onset CP, dyspnea// ? pulm edema TECHNIQUE: Chest AP COMPARISON: ___ IMPRESSION: Lungs are low volume with subsegmental atelectasis in the right lung base. The patient is rotated to the left. Cardiomediastinal silhouette is stable. There is no pleural effusion. No pneumothorax is seen. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Chest pain, Dyspnea Diagnosed with Chest pain, unspecified temperature: 97.5 heartrate: 66.0 resprate: 16.0 o2sat: 97.0 sbp: 185.0 dbp: 59.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, You were admitted to the hospital because you could not breath and had chest pain. These symptoms were due to an extremely high blood pressure, which we have treated by increasing your blood pressure medications. When you leave the hospital, please follow up with any doctor appointments listed below and make a note of any medication changes below. It was a pleasure caring for you! Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Major Surgical or Invasive Procedure: PICC insertion, left upper extremity attach Pertinent Results: DISCHARGE LABS: ___ 06:57AM BLOOD WBC-2.7* RBC-3.51* Hgb-11.1* Hct-33.5* MCV-95 MCH-31.6 MCHC-33.1 RDW-13.1 RDWSD-45.2 Plt ___ ___ 06:57AM BLOOD Neuts-45.0 ___ Monos-13.1* Eos-4.1 Baso-0.7 Im ___ AbsNeut-1.20* AbsLymp-0.98* AbsMono-0.35 AbsEos-0.11 AbsBaso-0.02 ___ 06:57AM BLOOD Glucose-102* UreaN-11 Creat-0.8 Na-143 K-3.3* Cl-105 HCO3-26 AnGap-12 ___ 06:57AM BLOOD ALT-5 AST-12 LD(LDH)-146 AlkPhos-59 TotBili-0.2 ___ 06:57AM BLOOD Mg-1.7 MICRO: ___: ___ MSSA, ___ Acenitobacter radioresistens ___: NGTD ___: NGTD ___: NGTD MRI: 1. Unchanged configuration of a T12 compression fracture, with persistent high signal on water ideal images. Retropulsion results in mild canal narrowing, but no cord compression or signal abnormality. 2. There is no evidence of vertebral discitis/osteomyelitis, or epidural abscess. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Diphenoxylate-Atropine 1 TAB PO Q6H 2. Dolutegravir 50 mg PO DAILY 3. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB PO DAILY 4. Escitalopram Oxalate 30 mg PO DAILY 5. Fludrocortisone Acetate 0.2 mg PO DAILY 6. FoLIC Acid 1 mg PO DAILY 7. LevETIRAcetam 1000 mg PO BID 8. LOPERamide 4 mg PO QID diarrhea 9. Midodrine 2.5 mg PO TID 10. Montelukast 10 mg PO DAILY 11. Multivitamins W/minerals 1 TAB PO DAILY 12. Rivaroxaban 20 mg PO QPM 13. Simvastatin 20 mg PO QPM 14. Thiamine 100 mg PO DAILY 15. Omeprazole 40 mg PO BID 16. Potassium Chloride 20 mEq PO DAILY 17. Prochlorperazine 5 mg IV Q8H:PRN Nausea/Vomiting - First Line Reason for PRN duplicate override: Not tolerating PO 18. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever 19. dutasteride 0.5 mg oral QHS 20. LORazepam 0.5 mg PO Q6H:PRN nausea 21. Promethazine 25 mg PO Q6H:PRN nausea 22. Niacin SR 1000 mg PO BID Discharge Medications: 1. CeFAZolin 2 g IV Q8H Duration: 23 Days last day ___ (4 weeks from first negative culture, ___ RX *cefazolin in dextrose (iso-os) 2 gram/50 mL 2 g IV every eight (8) hours Disp #*60 Intravenous Bag Refills:*0 2. Ciprofloxacin HCl 500 mg PO BID Duration: 8 Days RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice a day Disp #*17 Tablet Refills:*0 3. Lidocaine Jelly 2% 1 Appl TP ONCE Duration: 1 Dose apply to lower back for back pain RX *lidocaine 5 % apply thin film twice daily as needed Refills:*0 4. sodium chloride 0.9 % injection 6X/WEEK for orthostatic hypotension NS 1L IV with MVI-13 added, 6 days per week PRN RX *sodium chloride 0.9 % 1 Liter IV 6 days per week, PRN Disp #*24 Cartridge Refills:*0 5. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever 6. Diphenoxylate-Atropine 1 TAB PO Q6H 7. Dolutegravir 50 mg PO DAILY 8. dutasteride 0.5 mg oral QHS 9. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB PO DAILY 10. Escitalopram Oxalate 30 mg PO DAILY 11. Fludrocortisone Acetate 0.2 mg PO DAILY 12. FoLIC Acid 1 mg PO DAILY 13. LevETIRAcetam 1000 mg PO BID 14. LOPERamide 4 mg PO QID diarrhea 15. LORazepam 0.5 mg PO Q6H:PRN nausea 16. Midodrine 2.5 mg PO TID 17. Montelukast 10 mg PO DAILY 18. Multivitamins W/minerals 1 TAB PO DAILY 19. Niacin SR 1000 mg PO BID 20. Omeprazole 40 mg PO BID 21. Potassium Chloride 20 mEq PO DAILY 22. Prochlorperazine 5 mg IV Q8H:PRN Nausea/Vomiting - First Line Reason for PRN duplicate override: Not tolerating PO 23. Promethazine 25 mg PO Q6H:PRN nausea 24. Rivaroxaban 20 mg PO QPM 25. Simvastatin 20 mg PO QPM 26. Thiamine 100 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Staph aureus (methicillin-susceptible) bacteremia Acenitobacter bacteremia Acute right upper extremity Deep vein thrombosis associated with PICC line 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 PICC // PICC position TECHNIQUE: Chest: Frontal and Lateral COMPARISON: ___ FINDINGS: Right-sided PICC terminates in the low SVC, without evidence of pneumothorax. 1.3 cm nodular opacity projects over the right upper chest with associated fiducial marker, similar to prior, compared to today's measurement of the prior study measuring the same size. No new focal consolidation is seen. There is no pleural effusion or pneumothorax. Cardiac silhouette size is borderline to mildly enlarged. Mediastinal contours are unremarkable.. IMPRESSION: Right-sided PICC terminates in the low SVC. Redemonstrated right upper lung nodular opacity with fiducial marker, similar to prior. No new focal consolidation. Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: NO_PO contrast; History: ___ with diarrhea, now no BM. n/v. Hx of anal Ca s/p radiationNO_PO contrast // bowel obstruction TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 24.1 mGy (Body) DLP = 12.0 mGy-cm. 2) Spiral Acquisition 6.4 s, 50.6 cm; CTDIvol = 13.4 mGy (Body) DLP = 678.8 mGy-cm. Total DLP (Body) = 691 mGy-cm. COMPARISON: CT abdomen pelvis ___ FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. Calcification is noted of the mitral annulus. 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 not visualized. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of solid renal lesions or hydronephrosis. Left renal cysts measure up to 2.5 cm. There left cortical and parapelvic cysts. There is no perinephric abnormality. GASTROINTESTINAL: Moderate hiatal hernia. The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. Diverticulosis of the sigmoid colon is noted, without evidence of wall thickening or fat stranding. The appendix is normal. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. BONES: Severe T12 compression deformity appears increased when compared to the study from ___, but similar compared to ___. There is no significant change in alignment. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. No acute intra-abdominal process. Diverticulosis without evidence of acute diverticulitis. 2. Moderate hiatal hernia. 3. Severe T12 compression deformity appears increased when compared to the study from ___, but similar compared to ___. There is no significant change in alignment. Radiology Report EXAMINATION: UNILAT UP EXT VEINS US RIGHT INDICATION: ___ w/ PICC in right UE, now with staph bacteremia, eval for clot // please include RUE and right neck for evidence of thrombus TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper extremity veins. COMPARISON: None. FINDINGS: There is normal flow with respiratory variation in the bilateral subclavian veins. There is a nonocclusive DVT in the right axillary vein. Also seen is a nonocclusive thrombus in the right basilic vein. The right internal jugular and brachial veins are patent, show normal color flow, spectral doppler, and compressibility. The right cephalic vein is patent, compressible and show normal color flow. IMPRESSION: Nonocclusive DVT in the right axillary vein and basilic vein. NOTIFICATION: Findings were communicated via telephone with ___, MD on ___ at 15:20, 15 minutes after discovery of findings. Radiology Report EXAMINATION: MRI THORACIC AND LUMBAR PT6 MR SPINE INDICATION: ___ w/ MSSA bacteremia, back pain // ?vertebral osteo ?vertebral osteo please include T and L-spine, eval for osteo/abscess TECHNIQUE: Sagittal imaging was performed with T2, T1, and IDEAL technique. Axial T2 imaging was performed. Axial GRE images of the cervical spine were performed. After the uneventful administration of Gadavist contrast agent, additional axial and sagittal T1 images were obtained. COMPARISON: CT abdomen and pelvis dated ___ and ___. FINDINGS: THORACIC: There is exaggerated thoracic kyphosis centered at T9. Alignment is otherwise normal. There is a compression fracture of the T12 vertebral body with increased STIR and decreased T1 signal. The vertebral body enhances after contrast administration. Overall the degree of compression is more severe in comparison with ___, but comparable to the ___ suggesting that this is subacute. Vertebral body signal intensity is otherwise preserved. There is loss of disc height and disc desiccation signal throughout the thoracic spine. There is no canal or neural foraminal narrowing from T1-T2 through T9-10. Ligamentum flavum thickening/facet osteophytes at T9-10 results in mild canal narrowing. At T11-12, there is mild canal narrowing due to retropulsion of the superior T12 vertebral body. There is also mild bilateral neural foraminal narrowing. At T12-L1, there is no canal narrowing. Mild bilateral neural foraminal narrowing is noted. LUMBAR: Alignment is normal.Vertebral body signal intensity is normal. There is mild disc desiccation signal throughout the lumbar spine.The conus medullaris terminates at L1.There is no evidence of infection or neoplasm. There is no abnormal enhancement after contrast administration. At L1-2 and L2-3, there is no canal or neural foraminal narrowing. At L3-4, small broad disc bulge in combination with facet hypertrophy and ligamentum flavum thickening results in mild canal narrowing. There is mild left greater than right neural foraminal narrowing. At L4-5, a disc bulge with superimposed central protrusion in combination with mild facet hypertrophy and ligamentum flavum thickening results in mild canal narrowing. No neural foraminal narrowing. At L5-S1, minimal disc bulge is present without canal narrowing. No neural foraminal narrowing. OTHER: Numerous left peripelvic T2 hyperintense renal cysts and a cortical cysts are noted. IMPRESSION: 1. Unchanged configuration of a T12 compression fracture, with persistent high signal on water ideal images. Retropulsion results in mild canal narrowing, but no cord compression or signal abnormality. 2. There is no evidence of vertebral discitis/osteomyelitis, or epidural abscess. PREVALENCE: Prevalence of lumbar degenerative disk disease in subjects without low back pain: Overall evidence of disk degeneration 91% (decreased T2 signal, height loss, bulge) T2 signal loss 83% Disk height loss 58% Disk protrusion 32% Annular fissure 38% Jarvik, et all. Spine ___ 26(10):___ Lumbar spinal stenosis prevalence- present in approximately 20% of asymptomatic adults over ___ years old ___, et al, Spine Journal ___ 9 (7):545-550 These findings are so common in asymptomatic persons that they must be interpreted with caution and in context of the clinical situation. Gender: M Race: WHITE - OTHER EUROPEAN Arrive by AMBULANCE Chief complaint: n/v/d Diagnosed with Vomiting, unspecified, Diarrhea, unspecified, Left upper quadrant pain, Tachycardia, unspecified temperature: 98.4 heartrate: 124.0 resprate: 24.0 o2sat: 100.0 sbp: 163.0 dbp: 99.0 level of pain: 0 level of acuity: 2.0

You were admitted for an infection of your bloodstream associated with your PICC line. This has been treated with antibiotics, which will continue for 4 weeks total. The last day of your IV antibiotics will be ___. You will also complete 2 weeks of an antibiotic, Ciprofloxacin, by mouth. The first dose will be tonight. I have included prescription for lidocaine cream to apply to your low back for pain, as needed. It was also found while in the hospital that you had a new rash reaction to your niacin. You may continue to use it at home as previously directed, though if there is a repeat of this reaction, you should stop and discuss future use with your outpatient doctor.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: L arm and chest pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ gentleman with a history of IDDM, HTN, and asthma but no known history of CAD or chest pain who presented to ___ with L arm and chest pain and was found to have lateral TWI and trop-I 0.33 concerning for NSTEMI. He was transferred to ___ for further management. Patient reports he was in his usual state of health until ~9pm evening before presentation, when he noticed dull left arm pain. He works as a ___, often lifting, and didn't think much of the pain. He did check his blood pressure and noted it to be 220/100. His wife suggested he go to the ED but he declined. Around ___ pain woke him up and he took an extra dose of clonidine and returned to bed. He woke up again at 0500 with dizziness. He called out of work. He was able to sleep until 0900 when he awoke with persistent L arm pain that now extended into L lateral chest. Pain is dull, pressure like, and got worse with exertion. At ___, patient received SLNTG with improvement in pain. He was started on a heparin gtt and received a full-strength ASA. He was noted to be hyperglycemic, with f/s 400. Cr was 1.7 (denies known history of kidney disease, though has had refractory HTN and baseline Cr 1.1-1.3). He was transferred to our ED, where initial vitals were 6 98.4 85 141/95 18 98% . Trop-T was 0.08 --> 0.10 and Cr had improved to 1.4. EKG showed LVH, TWI in V4-V6 and II, III, and aVF, and J-point elevation in V1-V2. He was continued on a heparin gtt, which was decreased from 1090 units/hr to 590 units/hr for unknown reason (possibly high PTT at OSH? First PTT here 86). He had returning CP and was put on NTG gtt starting at 0.14mcg; this was briefly increased to 0.44 for ongoing CP. He was admitted to the ___ service for medical management and consideration of catheterization. Vitals prior to transfer were 5 98.7 70 158/93 18 99% RA. On arrival to the floor, patient is sitting comfortably in bed. He reports ongoing ___ CP that is dull and constant, radiating down L arm. No associated SOB, dizziness, lightheadedness, abdominal pain, tearing pain. Morphine was ordered but when RN went to administer, patient had fallen asleep. Of note, patient's wife reports that his HTN is refractory and he has been seen by a HTN specialist, who told them patient's kidneys are fine. He underwent ETT in ___ that was negative for ischemia. She reports he is so used to running high that he feels dizzy with SBP's in 120's. He recently ran out of amlodipine due to a refill problem and has been off of that for several days. She also reports his blood sugars are poorly controlled. Also of note, patient is on furosemide for an unclear indication. He says it is to "help me pee," and denies a history of CHF or edema. He denies CAD, prior MI's, prior CP, orthopnea, PND, or palpitations. His mother died suddenly at age ___ of unknown causes but there is no known family history of early CAD. On reassessment, patient continues to sleep comfortably. Past Medical History: - IDDM: poorly controlled per report - Asthma - HTN: poorly controlled ___ medication non-compliance - HL - Seasonal allergies Social History: ___ Family History: - Mother died suddenly at age ___ (cause unknown) - Father died of old age at ___ - No family history of CAD, MI, or CVA Physical Exam: ADMISSION PHYSICAL EXAM: ============================ Vitals: 98 160/104 66 16 100 RA 91.4 kg GENERAL: NAD, very comfortable-appearing HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, patent nares, MMM, nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs. PMI nondisplaced. Chest wall non-tender. LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: No cyanosis, clubbing or edema PULSES: 2+ ___ pulses bilaterally NEURO: CN II-XII intact, A+O x 3 SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: =========================== Vitals: 98.1, 140/80, 72, 18, 98% on RA GENERAL: NAD, very comfortable-appearing HEENT: NCAT, EOMI, injected conjunctiva, patent nares, MMM NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs. PMI nondisplaced. Chest wall non-tender. LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: No cyanosis, clubbing or edema PULSES: 2+ ___ pulses bilaterally Pertinent Results: ADMISSION LABS ================= ___ 04:10PM BLOOD WBC-4.4 RBC-3.32* Hgb-10.8* Hct-31.3* MCV-94 MCH-32.6* MCHC-34.6 RDW-12.1 Plt ___ ___ 04:10PM BLOOD Neuts-40.4* Lymphs-46.2* Monos-8.2 Eos-4.6* Baso-0.6 ___ 04:10PM BLOOD ___ PTT-86.6* ___ ___ 04:10PM BLOOD Glucose-300* UreaN-22* Creat-1.4* Na-138 K-3.9 Cl-103 HCO3-33* AnGap-6* ___ 10:57PM BLOOD Calcium-9.0 Phos-3.9 Mg-2.1 NOTABLE LABS =============== ___ 08:00AM BLOOD Glucose-123* UreaN-16 Creat-1.4* Na-138 K-3.9 Cl-102 HCO3-31 AnGap-9 ___ 07:10AM BLOOD Glucose-130* UreaN-19 Creat-1.5* Na-140 K-3.9 Cl-101 HCO3-30 AnGap-13 ___ 04:10PM BLOOD CK-MB-6 ___ 04:10PM BLOOD cTropnT-0.08* ___ 10:45PM BLOOD cTropnT-0.10* ___ 10:57PM BLOOD CK-MB-7 ___ 08:00AM BLOOD CK-MB-11* cTropnT-0.30* ___ 06:46PM BLOOD CK-MB-7 cTropnT-0.24* ___ 10:57PM BLOOD ___ PTT-34.0 ___ ___ 08:00AM BLOOD ___ PTT-49.0* ___ ___ 09:45AM BLOOD ___ PTT-72.9* ___ ___ 04:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG ___ 02:21PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG ___ 04:30PM URINE Color-Straw Appear-Clear Sp ___ ___ 02:21PM URINE Color-Straw Appear-Clear Sp ___ ___ 04:56AM URINE Hours-RANDOM UreaN-304 Creat-43 Na-113 K-10 Cl-95 ___ 04:56AM URINE Osmolal-347 DISCHARGE LABS ================ ___ 07:55AM BLOOD WBC-3.8* RBC-3.37* Hgb-10.8* Hct-32.0* MCV-95 MCH-32.1* MCHC-33.9 RDW-12.2 Plt ___ ___ 07:55AM BLOOD Glucose-148* UreaN-23* Creat-1.5* Na-138 K-3.8 Cl-100 HCO3-28 AnGap-14 ___ 07:55AM BLOOD Calcium-9.1 Phos-4.7* Mg-2.0 STUDIES =========== ECG (___): Sinus rhythm with marked first degree A-V delay. Left ventricular hypertrophy. Secondary ST-T wave inversions in the lateral leads, probably due to left ventricular hypertrophy. Cannot exclude ischemia. No significant change compared to three previous tracings of ___. CT HEAD W/O CONTRAST (___): IMPRESSION: No acute intracranial process RENAL ULTRASOUND WITH DOPPLERS (___): The right kidney measures 10.7 cm and is normal morphology. The cortex is normal in thickness and echogenicity. There is no hydronephrosis or perinephric fluid collection. The left kidney measures 9.9 cm with normal echotexture, no perinephric fluid collections, and normal morphology. There is no hydronephrosis. In the right kidney, the resistive indices of the intrarenal arteries ranges from 0.66 is 0.7, within the normal range. In the left kidney, the resistive indices of the intrarenal arteries ranges from 0.64-0.73, within the normal range. Acceleration times and peak systolic velocities of the main renal artery are normal. Appropriate flow and waveforms are seen in the main renal veins bilaterally. No evidence of tardus parvus waveforms. The bladder is filled with fluid and is normal. IMPRESSION: Normal bilateral renal ultrasound with appropriate arterial resistive indices. STRESS TEST (___): RESTING DATA EKG: NSR, 1ST DEGREE AVD, LVH W/ REPOL ABN HEART RATE: ___ PRESSURE: 170/98 PROTOCOL ___ - TREADMILL STAGETIMESPEEDELEVATIONHEARTBLOODRPP (MIN)(MPH)(%)RATEPRESSURE ___ ___ ___ TOTAL EXERCISE TIME: 9.5% MAX HRT RATE ACHIEVED: 81 SYMPTOMS:NONE INTERPRETATION: This was an active ___ year old DM2 man with HTN and HLD, who was referred to the lab from the inpatient floor for an evaluation of chest discomfort in the setting of recent NSTEMI (___). He exercised for 9.5 minutes of ___ protocol ___ METs) and stopped due to fatigue. This represents an average functional capacity for his age. He denied any chest, arm, neck or back discomforts, inappropriate shortness of breath, palpitations or symptoms of exercise intolerance throughout the study. In the setting of diffuse ST T wave abnormalities on baseline ECG due to LVH with strain, the ECG was uninterpretable for evaluating ischemic changes. However, the ST segment and T wave morphologies did not change from baseline during exercise or in recovery. The rhythm was sinus with rare isolated APB's seen during exercise. There was marked hypertension at rest with an exaggerated hypertensive blood pressure response to exercise. The heart rate responded appropriately to both exercise and recovery. IMPRESSION: ECG uninterpretable for ischemia evaluation in the setting of LVH w/ strain. No anginal type symptoms. Resting hypertension with exaggerated hypertensive response to exercise. Average functional capacity demonstrated. Echo report sent separately. STRESS TTE (___): LVEF >55%. The patient exercised for 9 minutes30 seconds according to ___ treadmill protocol (10.6 METS) reaching a peak heart rate of 130 bpm and a peak blood pressure of 220/90 mmHg. The test was stopped because of fatigue. This level of exercise represents an average exercise tolerance for age. The exercise ECG was uninterpretable due to resting ST-T wave changes (see exercise report for details). The blood pressure response to stress was abnormal/mildly hypertensive. Resting images were acquired at a heart rate of 62 bpm and a blood pressure of 170/98 mmHg. These demonstrated normal regional and global left ventricular systolic function. Echo images were acquired within 98 seconds after peak stress at heart rates of 120 - 85 bpm. These demonstrated appropriate augmentation of all left ventricular segments with slight decrease in cavity size. IMPRESSION: Average functional exercise capacity with baseline hypertension and hypertensive BP response to exercise. ECG not interpretable for ischemia in the presence of baseline abnormalities. No 2D echocardiographic evidence of inducible ischemia to achieved workload. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Glargine 34 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 2. Amlodipine 10 mg PO DAILY 3. Furosemide 20 mg PO DAILY 4. Simvastatin 20 mg PO DAILY 5. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation q4-6h prn SOB, wheezing 6. Metoprolol Succinate XL 200 mg PO DAILY 7. CloniDINE 0.3 mg PO BID Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Glargine 34 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO DAILY RX *atorvastatin 80 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 5. Carvedilol 25 mg PO BID RX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 6. Chlorthalidone 25 mg PO DAILY RX *chlorthalidone 25 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 7. Lisinopril 40 mg PO DAILY RX *lisinopril 40 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation q4-6h prn SOB, wheezing 9. Outpatient Lab Work Please have chemistry-10 panel drawn on ___ DX: Unspecified essential hypertension ICD-9 Code: ___. Please Fax Results To: ___. Fax ___ Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES ==================== # Type II Non-ST Elevation Myocardial Infarction # Hypertensive Emergency # Acute Kidney Injury CHRONIC ISSUES =============== # Insulin Dependent Diabetes Mellitus # Asthma # Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old man with headaches, hypertensive urgency // bleed or mass, mass effect TECHNIQUE: Contiguous axial images CT images were obtained through the brain without administration of IV contrast. Reformatted coronal and sagittal and thin section bone algorithm-reconstructed images were acquired. DOSE: DLP: 891.93 mGy-cm CTDI: 54.63 mGy COMPARISON: None. FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or infarction. The ventricles and sulci are normal in size and configuration. The basal cisterns appear patent and there is preservation of gray-white matter differentiation. No fracture is identified. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The globes are unremarkable. IMPRESSION: No acute intracranial process. Radiology Report HISTORY: Uncontrolled hypertension, elevated creatinine and elevated microalbumin to creatinine ratio. Technique: Grayscale, color, and spectral Doppler evaluation of the kidneys. COMPARISON: None FINDINGS: The right kidney measures 10.7 cm and is normal morphology. The cortex is normal in thickness and echogenicity. There is no hydronephrosis or perinephric fluid collection. The left kidney measures 9.9 cm with normal echotexture, no perinephric fluid collections, and normal morphology. There is no hydronephrosis. In the right kidney, the resistive indices of the intrarenal arteries ranges from 0.66 is 0.7, within the normal range. In the left kidney, the resistive indices of the intrarenal arteries ranges from 0.64-0.73, within the normal range. Acceleration times and peak systolic velocities of the main renal artery are normal. Appropriate flow and waveforms are seen in the main renal veins bilaterally. No evidence of tardus parvus waveforms. The bladder is filled with fluid and is normal. IMPRESSION: Normal bilateral renal ultrasound with appropriate arterial resistive indices. Gender: M Race: BLACK/CAPE VERDEAN Arrive by WALK IN Chief complaint: NSTEMI Diagnosed with MYOCARDIAL INFARCTION NOS, INIT EPISODE OF CARE temperature: 98.4 heartrate: 85.0 resprate: 18.0 o2sat: 98.0 sbp: 141.0 dbp: 95.0 level of pain: 6 level of acuity: 2.0

Mr. ___, It was a pleasure meeting and caring for you during your hospitalization at ___. You were admitted with chest pain and arm pain. We found that you had a small heart attack. Your heart attack was probably not from a blockage in the heart artery (coronary artery) but because of very elevated blood pressures. We performed a stress test on your heart which returned normal which makes a blockage in a heart artery even less likely. We changed your blood pressure medication regimen which is expalined below. Please continue to take your blood pressure pills as they are prescribed at the same time each day. Also, please record your blood pressures in a journal. Bring the journal and your blood pressure cuff to your next primary care appointment. We wish you a speedy recovery. All the best, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Cefepime / Ragweed Attending: ___. Chief Complaint: cough, congestion Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ woman with a history of lymphoblastic blast crisis of CML day ___ after a double cord transplant who presented to the ED with productive cough, headache, sinus and ear congestion. Patient reports acute onset of symptoms x4 d ago, since then little relief with flonase, sudafed 30mg bid, allegra. Patient has a history of sinus infections in the past, previously seen by ENT, intermittently treated with Augmentin. Pt went to ENT today for appt, but was told that her insurance expired, and was referred here to the ER for eval. In the ED, initial vitals were: 96.5 118 115/68 20 95%. Labs were significant for WBC 17, Cr 1.7 (baseline 1.3-1.5), lactate 2.1. CXR was concerning for multifocal PNA. Patient was given 750mg po levoflox, Zofran, 650mg acetaminophen, an albuterol neb, and Tesselon pearles as well as 1L NS. Case was discussed with Dr. ___ recommended admission. Vitals prior to transfer were 98.1 104 134/69 18 97% Review of Systems: (+) Endorses congestion, nose bleeds, nausea, and vomiting (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies blurry vision, diplopia, loss of vision, photophobia. Denies chest pain or tightness, palpitations, lower extremity edema. Denies dysuria, stool or urine incontinence. Denies arthralgias or myalgias. Denies rashes or skin breakdown. No numbness/tingling in extremities. All other systems negative. Past Medical History: BREAST CANCER ___: L infiltrating ductal ca dx ___ and tx lumpectomy, axillary node dissection, chemo and XRT. Followed by ___. Has declined Tamoxifen. s/p prophylactic BSO in ___. . CML 1. CML diagnosed ___, started on imatinib on ___, went into CHR and had a partial cytogenetic and major molecular response. 2. Noticed to have blasts on peripheral blood smear on ___ - bone marrow biopsy ___ showed lymphoblastic blast phase of chronic myelogenous leukemia. The blast count was 43% on the aspirate and 60-70% on the core biopsy. 3. Part A of hyper-CVAD from ___, part B of hyper-CVAD on ___. 4. Bone marrow biopsy on ___ showed no evidence of leukemia involvement. Cytogenetics were negative for ___ chromosome. 5. High dose cyclophosphamide on ___ as conditioning for allogenic bone marrow transplant, transplant aborted because her stem cell donor refused to have his stem cell collected. She was discharged home and restarted on dasatinib. 6. Allogenic double cord HSCT on ___, conditioning with Cyclophosphamide/TBI/Fludarabine. Hospitalized ___. Her hospital stay was complicated by fever on day -5 and, in the post-transplant setting by HHV-6 viremia and BK viruria. HHV-6 viremia cleared. 7. Hospitalization with severe sinusitis ___. 8. Hospitalization for shortness of breath ___. 9. Hospitalization after a seizure episode between ___ and ___. 10. Maintenance Dasatinib started end ___ - stopped ___. Other PMH: CERVICAL SPONDYLOSIS CHRONIC RENAL FAILURE (baseline Cr ~1.5) GLAUCOMA INSOMNIA OSTEOPOROSIS EAR, NOSE & THROAT SEIZURES BASAL CELL CARCINOMA SINUSITIS, chronic rhinitis Social History: ___ Family History: Patient's mother died ___ years old, had a history of melanoma. Patient's father is alive. A maternal grandmother died from ovarian cancer at the age of ___. ___ had 2 brothers and one died in a car accident. One brother is alive and well. She has a son and a daughter. Physical Exam: ADMISSION EXAM PHYSICAL EXAM: VS: 98.6, 131/77, 106, 18, 97% on RA GENERAL: NAD HEENT: Mucous membranes moist NECK: No cervical, submandibular, or supraclavicular LAD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTA bilaterally, dullness at bases ABDOMEN: +BS, non-tender, non-distended, no rebounding or guarding EXTREMITIES: Moving all extremities well, no cyanosis, clubbing or edema, no obvious deformities PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: Warm and well perfused, no excoriations or lesions, no rashes DISCHARGE EXAM VS: 98.4 114/62 105 18 100RA GENERAL: NAD HEENT: Mucous membranes moist NECK: No cervical, submandibular, or supraclavicular LAD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTA bilaterally, dullness at bases ABDOMEN: +BS, non-tender, non-distended, no rebounding or guarding EXTREMITIES: Moving all extremities well, no cyanosis, clubbing or edema, no obvious deformities PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: Warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS: ___ 02:45PM BLOOD WBC-17.0*# RBC-3.37* Hgb-10.1* Hct-31.4* MCV-93 MCH-29.9 MCHC-32.1 RDW-13.9 Plt ___ ___ 04:18PM BLOOD Glucose-125* UreaN-29* Creat-1.7* Na-133 K-4.1 Cl-97 HCO3-25 AnGap-15 ___ 04:23PM BLOOD Lactate-2.1* DISCHARGE LABS: ___ 07:55AM BLOOD WBC-12.9* RBC-3.09* Hgb-9.3* Hct-28.6* MCV-93 MCH-30.2 MCHC-32.6 RDW-13.8 Plt ___ ___ 07:55AM BLOOD Neuts-82.6* Lymphs-10.6* Monos-6.2 Eos-0.5 Baso-0.1 ___ 07:55AM BLOOD Calcium-7.9* Phos-2.2* Mg-1.9 CXR ___ FINDINGS: Patchy bilateral lower lobe opacities are seen, worrisome for multifocal pneumonia. No pleural effusion is seen. The cardiac and mediastinal silhouettes are unremarkable. No evidence of pneumothorax is seen. IMPRESSION: Patchy bilateral lower lobe opacities worrisome for multifocal pneumonia. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Alendronate Sodium 70 mg PO Frequency is Unknown 2. Astelin *NF* (azelastine) 137 mcg NU QD 3. Estring *NF* (estradiol) 2mg Vaginal Every 3 months 4. Fluticasone Propionate NASAL 2 SPRY NU DAILY 5. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE HS 6. Venlafaxine XR 150 mg PO DAILY 7. Calcium Carbonate 500 mg PO QID 8. Vitamin D 800 UNIT PO DAILY Discharge Medications: 1. Astelin *NF* (azelastine) 137 mcg NU QD 2. Calcium Carbonate 500 mg PO QID 3. Fluticasone Propionate NASAL 2 SPRY NU DAILY 4. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE HS 5. Venlafaxine XR 150 mg PO DAILY 6. Vitamin D 800 UNIT PO DAILY 7. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN Cough RX *codeine-guaifenesin 100 mg-10 mg/5 mL ___ ml by mouth q6 Disp #*200 Milliliter Refills:*0 8. Levofloxacin 250 mg PO Q24H Duration: 5 Days RX *levofloxacin 250 mg 1 tablet(s) by mouth daily Disp #*5 Tablet Refills:*0 9. Alendronate Sodium 70 mg PO QMON 10. Estring *NF* (estradiol) 2mg Vaginal Every 3 months 11. Oseltamivir 75 mg PO Q12H RX *oseltamivir [Tamiflu] 75 mg 1 capsule(s) by mouth twice a day Disp #*6 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Community Acquired Pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Productive cough with sputum, chills. TECHNIQUE: Frontal and lateral views of the chest. COMPARISON: ___. FINDINGS: Patchy bilateral lower lobe opacities are seen, worrisome for multifocal pneumonia. No pleural effusion is seen. The cardiac and mediastinal silhouettes are unremarkable. No evidence of pneumothorax is seen. IMPRESSION: Patchy bilateral lower lobe opacities worrisome for multifocal pneumonia. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: SINUS INFECTION Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED temperature: 96.5 heartrate: 118.0 resprate: 20.0 o2sat: 95.0 sbp: 115.0 dbp: 68.0 level of pain: 4 level of acuity: 3.0

Dear Ms. ___, You were admitted to ___ for pneumonia. You were given Levofloxacin and your symptoms improved, and your white count went down. Please continue to take Levofloxacin for 5 more days. Return to the hospital or clinic if you develop fevers, worsening of your symptoms, trouble breathing, or diarrhea.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ___ Attending: ___. Chief Complaint: Jaundice, confusion Major Surgical or Invasive Procedure: ERCP History of Present Illness: This is an ___ gentleman with a pmhx. significant for DM II, HTN, AAA repair, and ?TIAs who is admitted from ___ ___ with elevated LFTs, jaundice, and change in mental status. History is obtained from patient's wife and HCP as patient is confused and unable to details events leading up to admission. Apparently patient was in his usual state of health until about 2 weeks ago when he began feeling unwell and with decreased appetite. He also noticed darkened urine around that time. However, about 3 days prior to admission, urine became much darker and patient's wife noticed that the whites of his eyes were turning yellow. Patient's family brought him to ___ ___ on ___ where he was found to have elevated LFTs and a RUQ concerning for biliary dilation and ?pancreatic mass. Patient was transferred to ___ for ERCP and further work-up. In the ___ ED, initial vitals were: 87 181/66 16 99%. Patient was not given any medications. RUQ ultrasound showed: "comparison OSH ultrasound performed earlier today. s/p cholecystectomy. Intrahepatic biliary dilatation, no prior s/p ccy for comparison. distal CBD/panc duct dilated to 1 cm. ? echogenic mass measuring 3.5 cm along panc head. rec further eval with CTA panc/MRCP and/or ERCP. AAA s/p repair." Upon transfer to the floor, vitals were: 88 160/57 18 98%. A full review of systems is unable to be obtained due to patient delirium. Past Medical History: --DM II --TIAs --Hypertension --BPH --AAA repair Social History: ___ Family History: Patient's mother had DM. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.7, 146/91, 85, 18, 99% on RA GENERAL: Lying in bed, no acute distress, foley in place, knows name and that he is in the hospital, thinks there is another person at foot of the bed when there is not HEENT: Mucous membranes very dry CHEST: Patient does not cooperate with exam, no obvious wheezes or rhonchi CARDIAC: Irregularly irregular, no MRG ABDOMEN: +BS, soft, non-tender, non-distended EXTREMITIES: No edema bilaterally NEURO: Patient is moving all 4 extremities, but a thorough neurologic exam is difficult due to confusional state DISCHARGE EXAM: GENERAL: Alert, NAD CV: RRR, no m/r/g RESP: CTA bilaterally ABD: S/NT/ND, BS present NEURO: non-focal, oriented x 3 Pertinent Results: Admission Labs: ___ 06:45PM BLOOD WBC-8.3 RBC-4.41* Hgb-14.4 Hct-41.3 MCV-94# MCH-32.6* MCHC-34.8 RDW-14.7 Plt ___ ___ 06:45PM BLOOD Neuts-80.8* Lymphs-11.5* Monos-5.0 Eos-1.8 Baso-0.8 ___ 06:45PM BLOOD ___ PTT-30.9 ___ ___ 06:45PM BLOOD Glucose-91 UreaN-12 Creat-0.8 Na-141 K-3.6 Cl-105 HCO3-23 AnGap-17 ___ 06:45PM BLOOD ALT-423* AST-270* AlkPhos-538* TotBili-8.4* DirBili-6.7* IndBili-1.7 ___ 06:45PM BLOOD Albumin-3.5 Calcium-9.1 Phos-2.6* Mg-1.9 Discharge Labs: ___ 06:40AM BLOOD WBC-7.6 RBC-3.93* Hgb-12.3* Hct-37.4* MCV-95 MCH-31.3 MCHC-32.9 RDW-15.6* Plt ___ ___ 06:40AM BLOOD Glucose-127* UreaN-12 Creat-0.6 Na-137 K-3.6 Cl-106 HCO3-19* AnGap-16 ___ 06:40AM BLOOD ALT-195* AST-87* AlkPhos-435* TotBili-6.4* ___ 07:05AM BLOOD Calcium-8.5 Phos-2.6* Mg-1.7 ___ 08:24PM URINE Color-Yellow Appear-Clear Sp ___ ___ 08:24PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-10 Bilirub-MOD Urobiln-4* pH-6.5 Leuks-SM ___ 08:24PM URINE RBC-1 WBC-9* Bacteri-NONE Yeast-NONE Epi-0 ___ 08:24PM URINE Mucous-RARE RUQ US - FINDINGS: There is intrahepatic biliary dilatation. No discrete intrahepatic lesion is seen. The patient is status post cholecystectomy. The main portal vein is patent with hepatopetal flow. The common bile duct measures 0.8 cm in its mid portion and up to 1 cm distally. The distal CBD versus the pancreatic duct measures 1.0 cm. In the region of the pancreatic head, there is an echogenic area measuring 3.0 x 3.5 cm, which could represent a mass. Recommend further evaluation with CTA pancreas, MRC, and/or ERCP. Patient is status post AAA repair with the full size of the mid aorta measuring 7.3 x 8.4 x 7.3 cm and with the lumen of the stent patent. IMPRESSION: Intra- and extra-hepatic biliary dilatation. Status post cholecystectomy without prior imaging since the cholecystectomy prior to today. Query echogenic lesion in the region of the pancreatic head. Recommend further evaluation with CTA pancreas, MRCP, and/or ERCP. ERCP - Normal major papilla - Cannulation of the biliary duct was successful and deep with a sphincterotome - A 1 cm stricture was seen in the mid-CBD. The proximal CBD was dilated. - A sphincterotomy was performed - Cytology samples were obtained using a brush from the CBD stricture - A 7cm by ___ plastic biliary stent was placed successfully across the CBD stricture - Otherwise normal ercp to third part of the duodenum CTA Abdomen - FINDINGS: FINDINGS: The visualized lung bases show trace bilateral pleural fluid on the left greater than the right. There is mild associated compressive atelectasis of the left lung base. Subtle air trapping is noted in the left lung base. Limited imaging of the heart shows extensive coronary calcifications. No pericardial effusion is present. The distal esophagus shows circumferential thickening of the wall, which is a nonspecific finding but may represent esophagitis in the appropriate clinical setting. The liver demonstrates several hypo enhancing areas in the right posterior segment measuring 1.0 cm (6: 142), 1.5 cm (series 6: 128), 1.5 cm (6: 125) compatible with hepatic metastases. There is moderate intrahepatic biliary dilation in the right posterior segment, which may be related to local obstruction from hepatic metastases. There is centralized pneumobilia predominantly in the left lobe of the liver, which is an expected finding after ERCP. Small amount ___ hepatic ascites is present. A biliary stent is in place extending from the proximal common bile duct into the ___ portion of the duodenum. Gallbladder is surgically absent. The pancreas is heterogeneously enhancing with multiple hypoattenuating areas in the body and tail and extensive dilatation of the pancreatic duct and most prominent upstream measuring up to 12 mm in the head of the pancreas. There is an abrupt cut off of the pancreatic duct within the head of the pancreas at the level of a large hypo attenuating mass measuring 2.9 x 2.8 cm on coronal imaging series 109, image 24. There is stranding about the head of the pancreas. The adjacent abdominal vasculature is patent with no apparent encasement of the vessels. There are multiple enhancing peripancreatic lymph nodes measuring up to 10 mm in short axis (6: 47). Both kidneys enhance symmetrically and excrete contrast normally. There are multiple subcentimeter hypodensities in the bilateral kidneys which are too small to fully characterize but most likely represent renal cysts. The right adrenal gland is unremarkable. The left adrenal gland shows nodular contours. The stomach demonstrates an enhancing exophytic soft tissue mass measuring 2.5 x 1.9 cm (6b:119), which is concerning for a gastrointestinal stromal tumor. The intra-abdominal loops of small and large bowel are normal in caliber. There is a soft tissue nodule adjacent to the transverse colon (6b: 174), which is concerning for spread of disease. A few colonic diverticula are noted without inflammatory changes to suggest diverticulitis. No free air or ascites is present. There are extensive vascular calcifications. The patient is status post endovascular repair of a large infrarenal abdominal aortic aneurysm measuring 8.0 x 7.7 x 7.8 cm with a stent extending from chest below the level of the renal veins to the bilateral common iliac arteries. OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions are detected. Multilevel degenerative changes are noted throughout the visualized thoracolumbar spine. IMPRESSION: 1. Metastatic pancreatic neoplasm: Hypo attenuating 2.9 cm mass in the head of the pancreas at the level of abrupt cutoff of the dilated pancreatic duct concerning for primary pancreatic neoplasm with hypoattenuating lesions in the right posterior segment of the liver concerning for hepatic metastases. Prominent peripancreatic lymph nodes and multiple hypoattenuating, likely cystic lesions throughout the body and tail of the pancreas. 2. Biliary: Moderate intrahepatic biliary dilation in the right posterior segment may be related to local obstruction from hepatic metastases. Mild centralized intrahepatic biliary dilation status post ERCP with biliary stent in appropriate position. 3. Patent vasculature with conventional anatomy. 4. Exophytic gastric mass: Enhancing 2.5 cm mass from the gastric fundus concerning for gastrointestinal stromal tumor. Endoscopic ultrasound could be considered for further evaluation. 5. Circumferential thickening of the distal esophageal wall may represent esophagitis in the appropriate clinical setting. 6. Large infrarenal abdominal aortic aneurysm status post endovascular aortic repair. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetFORMIN (Glucophage) 500 mg PO BID 2. Atenolol 50 mg PO DAILY Please hold for SBP <100 or HR <55. 3. Cyanocobalamin 1000 mcg PO DAILY 4. Lisinopril 20 mg PO DAILY Please hold for SBP <100. 5. Aspirin 81 mg PO DAILY 6. Glargine 14 Units Dinner Discharge Medications: 1. Atenolol 50 mg PO DAILY Please hold for SBP <100 or HR <55. 2. Cyanocobalamin 1000 mcg PO DAILY 3. Glargine 14 Units Dinner 4. Lisinopril 20 mg PO DAILY Please hold for SBP <100. 5. MetFORMIN (Glucophage) 500 mg PO BID 6. Magnesium Oxide 0 PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Metastatic Pancreatic Neoplasm Stomach Mass Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAM: Right upper quadrant ultrasound. CLINICAL INFORMATION: ___ male with jaundice. COMPARISON: Outside hospital ultrasound performed earlier the same date, ___. FINDINGS: There is intrahepatic biliary dilatation. No discrete intrahepatic lesion is seen. The patient is status post cholecystectomy. The main portal vein is patent with hepatopetal flow. The common bile duct measures 0.8 cm in its mid portion and up to 1 cm distally. The distal CBD versus the pancreatic duct measures 1.0 cm. In the region of the pancreatic head, there is an echogenic area measuring 3.0 x 3.5 cm, which could represent a mass. Recommend further evaluation with CTA pancreas, MRC, and/or ERCP. Patient is status post AAA repair with the full size of the mid aorta measuring 7.3 x 8.4 x 7.3 cm and with the lumen of the stent patent. IMPRESSION: Intra- and extra-hepatic biliary dilatation. Status post cholecystectomy without prior imaging since the cholecystectomy prior to today. Query echogenic lesion in the region of the pancreatic head. Recommend further evaluation with CTA pancreas, MRCP, and/or ERCP. Radiology Report HISTORY: Elevated liver enzymes and recent ultrasound concerning for pancreatic mass, here to evaluate for pancreatic and hepatobiliary pathology. TECHNIQUE: Multi detector CT imaging was performed of the abdomen prior to and during the dynamic injection of 200 cc Omnipaque intravenous contrast per CTA pancreas protocol. The initial scan was suboptimal due to failure of the patient's IV. A repeat scan was performed after the IV was replaced. Multiplanar reformats were generated and reviewed. DLP: ___ mGy-cm. COMPARISON: Right upper quadrant sonogram dated ___. FINDINGS: The visualized lung bases show trace bilateral pleural fluid on the left greater than the right. There is mild associated compressive atelectasis of the left lung base. Subtle air trapping is noted in the left lung base. Limited imaging of the heart shows extensive coronary calcifications. No pericardial effusion is present. The distal esophagus shows circumferential thickening of the wall, which is a nonspecific finding but may represent esophagitis in the appropriate clinical setting. The liver demonstrates several hypo enhancing areas in the right posterior segment measuring 1.0 cm (6: 142), 1.5 cm (series 6: 128), 1.5 cm (6: 125) compatible with hepatic metastases. There is moderate intrahepatic biliary dilation in the right posterior segment, which may be related to local obstruction from hepatic metastases. There is centralized pneumobilia predominantly in the left lobe of the liver, which is an expected finding after ERCP. Small amount ___ hepatic ascites is present. A biliary stent is in place extending from the proximal common bile duct into the ___ portion of the duodenum. Gallbladder is surgically absent. The pancreas is heterogeneously enhancing with multiple hypoattenuating areas in the body and tail and extensive dilatation of the pancreatic duct and most prominent upstream measuring up to 12 mm in the head of the pancreas. There is an abrupt cut off of the pancreatic duct within the head of the pancreas at the level of a large hypo attenuating mass measuring 2.9 x 2.8 cm on coronal imaging series 109, image 24. There is stranding about the head of the pancreas. The adjacent abdominal vasculature is patent with no apparent encasement of the vessels. There are multiple enhancing peripancreatic lymph nodes measuring up to 10 mm in short axis (6: 47). Both kidneys enhance symmetrically and excrete contrast normally. There are multiple subcentimeter hypodensities in the bilateral kidneys which are too small to fully characterize but most likely represent renal cysts. The right adrenal gland is unremarkable. The left adrenal gland shows nodular contours. The stomach demonstrates an enhancing exophytic soft tissue mass measuring 2.5 x 1.9 cm (6b:119), which is concerning for a gastrointestinal stromal tumor. The intra-abdominal loops of small and large bowel are normal in caliber. There is a soft tissue nodule adjacent to the transverse colon (6b: 174), which is concerning for spread of disease. A few colonic diverticula are noted without inflammatory changes to suggest diverticulitis. No free air or ascites is present. There are extensive vascular calcifications. The patient is status post endovascular repair of a large infrarenal abdominal aortic aneurysm measuring 8.0 x 7.7 x 7.8 cm with a stent extending from chest below the level of the renal veins to the bilateral common iliac arteries. OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions are detected. Multilevel degenerative changes are noted throughout the visualized thoracolumbar spine. IMPRESSION: 1. Metastatic pancreatic neoplasm: Hypo attenuating 2.9 cm mass in the head of the pancreas at the level of abrupt cutoff of the dilated pancreatic duct concerning for primary pancreatic neoplasm with hypoattenuating lesions in the right posterior segment of the liver concerning for hepatic metastases. Prominent peripancreatic lymph nodes and multiple hypoattenuating, likely cystic lesions throughout the body and tail of the pancreas. 2. Biliary: Moderate intrahepatic biliary dilation in the right posterior segment may be related to local obstruction from hepatic metastases. Mild centralized intrahepatic biliary dilation status post ERCP with biliary stent in appropriate position. 3. Patent vasculature with conventional anatomy. 4. Exophytic gastric mass: Enhancing 2.5 cm mass from the gastric fundus concerning for gastrointestinal stromal tumor. Endoscopic ultrasound could be considered for further evaluation. 5. Circumferential thickening of the distal esophageal wall may represent esophagitis in the appropriate clinical setting. 6. Large infrarenal abdominal aortic aneurysm status post endovascular aortic repair. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: JAUNDICE Diagnosed with OBSTRUCTION OF BILE DUCT, JAUNDICE NOS, HYPERTENSION NOS temperature: 97.6 heartrate: 87.0 resprate: 16.0 o2sat: 100.0 sbp: 172.0 dbp: 52.0 level of pain: 13 level of acuity: 2.0

You were admitted to ___ with an obstruction in your bile ducts. You had an ultrasound that was concerning for a mass in your pancreas. You had a stent placed to keep your bile ducts open, and you had biopsies taken which were still pending at the time of discharge. Finally, you also had a CT scan, which showed a pancreatic malignancy, with concern for metastases to the liver. The CT scan also showed a mass in your stomach. You are being discharged to a rehab facility. You will need to follow-up with an oncologist to further discuss your results and treatment options. You will also need to discuss potential additional evaluation of the mass in your stomach. You should discuss this further with your primary care physician. You will need a repeat ERCP in approximately 6 weeks to have your stent replaced for a metal one. Our ERCP office will be in contact to schedule this. You can contact them at ___ if you have any questions. It was a pleasure taking part in your medical care.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: L sided weakness/numbness Major Surgical or Invasive Procedure: none History of Present Illness: The pt is a ___ year-old R-handed F w/o significant PMH who presents with L sided weakness and numbness. Hx obtained from pt and family at bedside. Pt reports that early this morning, she woke up with excruciating pain in her L calf. She later went to her mom's house and at approximately 8:30am acutely developed numbness in her LUE/LLE in a downward spreading fashion. Denies associated burning, tingling, headache or back pain. Around the same time, she also noted weakness in L hemibody, typified by feeling herself slouch in kitchen chair. She also endorses proceeding "fogginess" and breathing difficulties, with her family reporting she seemed confused. They also said she displayed some slurred speech. Pt reports she had difficulty "getting her words out", although denied any clear word finding difficulties. Due to this constellation of sx, she was urgently brought to ___ for evaluation. Within an hour at OSH ED, mental status and language improved. Since that time, numbness and weakness have been improving in gradual fashion. Continues to have sharp pain in L calf, which with palpation radiates up to proximal thigh. She states she has had this intermittently over the last 3 weeks and for which she was planning to undergo ___ Dopplers per her PCP. Of note, pt reports taking one line of cocaine last night (she says she has taken a few times in past without issues). Denies prior hx of migraines, sz, or strokes. On neuro ROS, the pt endorses headache in posterior occiput over last hour, pressure-like in quality and mild in severity. Otherwise ROS negative except as noted above. Past Medical History: None Social History: ___ Family History: PGF-stroke in ___ Physical Exam: ADMISSION PHYSICAL EXAM Physical Exam: Vitals: T: 98 P: 69 BP: 121/67 RR: 16 O2sat: 99% RA 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: Discomfort to palpation over L calf, 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. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt was able to register 3 objects and recall ___ at 5 minutes. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 2 to 1.5mm 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 and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 3 ___ ___ 2 5- 4+ 4+ 5- 5- 5- R 5 ___ ___ 5 5 5 5 5 5 5 *pt displayed giveway throughout LUE/LLE during confrontational exam -Sensory: Decreased LT over LUE/LLE 9(70-80% of normal). Initially endorsed decreased PP over L hemibody but later stated normal and then hyperesthesias. Intact to temperature sensation b/l. Proprioception intact at great toes b/l. 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 dysdiadochokinesia noted. No dysmetria on FNF on R, none on HKS bilaterally. -Gait: Deferred ======================================= DISCHARCHE PHYSICAL EXAM L deltoid ___ and pain limited, otherwise exam is non focal. Sensation and strength intact. Able to ambulate on her own without assistance. Pertinent Results: LABS ___ 07:20AM BLOOD WBC-6.5# RBC-3.99 Hgb-13.0 Hct-38.4 MCV-96 MCH-32.6* MCHC-33.9 RDW-12.3 RDWSD-43.3 Plt ___ ___ 04:10PM BLOOD WBC-14.0* RBC-4.17 Hgb-13.5 Hct-39.5 MCV-95 MCH-32.4* MCHC-34.2 RDW-12.3 RDWSD-43.0 Plt ___ ___ 04:10PM BLOOD Neuts-61.6 ___ Monos-7.7 Eos-0.9* Baso-0.4 Im ___ AbsNeut-8.64* AbsLymp-4.07* AbsMono-1.08* AbsEos-0.13 AbsBaso-0.05 ___ 07:20AM BLOOD Plt ___ ___ 07:20AM BLOOD ___ PTT-32.1 ___ ___ 04:10PM BLOOD Plt ___ ___ 04:10PM BLOOD ___ PTT-29.8 ___ ___ 07:20AM BLOOD Glucose-81 UreaN-10 Creat-0.7 Na-137 K-3.8 Cl-103 HCO3-22 AnGap-16 ___ 04:10PM BLOOD Glucose-93 UreaN-8 Creat-0.7 Na-137 K-3.4 Cl-101 HCO3-19* AnGap-20 ___ 07:20AM BLOOD CK(CPK)-38 ___ 12:45PM BLOOD cTropnT-<0.01 ___ 07:20AM BLOOD CK-MB-<1 cTropnT-<0.01 ___ 07:20AM BLOOD Calcium-9.1 Phos-4.3 Mg-2.0 Cholest-142 ___ 04:10PM BLOOD Albumin-4.4 Calcium-9.2 Phos-3.8 Mg-1.8 ___ 07:20AM BLOOD %HbA1c-4.8 eAG-91 ___ 07:20AM BLOOD Triglyc-111 HDL-65 CHOL/HD-2.2 LDLcalc-55 ___ 07:20AM BLOOD TSH-1.7 ___ 07:20AM BLOOD CRP-3.1 ___ 04:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 07:20AM BLOOD SED RATE-PND IMAGING MRI BRAIN: No evidence of acute territorial infarction, intracranial hemorrhage, mass, or abnormal enhancement. Medications on Admission: NONE Discharge Medications: NONE Discharge Disposition: Home Discharge Diagnosis: Transient headache, confusion, LT sided weakness, and chest tightness in the setting of severe anxiety after cocaine use. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (upright AP AND LAT) INDICATION: ___ with Left sided weakness// PNA? Consolidation? COMPARISON: None FINDINGS: AP upright and lateral views of the chest provided. Hyperdense nodule projecting over the left apex could represent a calcified granuloma. AAThere 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: MR HEAD W AND W/O CONTRAST T9112 MR HEAD. INDICATION: ___ year old woman with hx of recent cocaine use who presented with left-sided weakness and numbness, resolving. Evaluate for intracranial pathology. 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: Prior outside CT head dated ___. FINDINGS: There is no evidence of acute infarction or intracranial hemorrhage. The ventricles are normal in size without mass effect or midline shift. The visualized arterial vascular flow voids are preserved. There is no enhancing mass or abnormal enhancement. The dural venous sinuses appear patent on the postcontrast images. There is mild mucosal thickening of the bilateral ethmoid and maxillary sinuses. There is trace nonspecific opacification of the bilateral mastoid air cells. The orbits appear unremarkable. IMPRESSION: 1. No evidence of acute territorial infarction, intracranial hemorrhage, mass, or abnormal enhancement. Radiology Report EXAMINATION: UNILAT LOWER EXT VEINS LEFT INDICATION: History: ___ with left calf pain// DVT? TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the left lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, flow, and augmentation of the left common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: No evidence of deep venous thrombosis in the left lower extremity veins. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: L Calf pain, L Weakness, Transfer Diagnosed with Weakness temperature: 98.0 heartrate: 69.0 resprate: 16.0 o2sat: 99.0 sbp: 121.0 dbp: 67.0 level of pain: 8 level of acuity: 2.0

Dear ___, You were admitted to the hospital with left arm and leg weakness and confusion. Initial concerns were for a stroke or a seizure. We obtained imaging of your brain with MRI, as well as vessels with CTA head and neck which did not show any evidence of stroke or vessel spasm. We sent a Lyme blood test which is still pending. We also monitored your cardiac enzymes as you had symptoms of chest tightness and these were stable. You complained of leg pain and swelling so we checked your veins for clots and this was also negative. Your gait and strength slowly improved back to baseline. At this point we recommend close follow up with your PCP and one follow up appointment with us here in Neurology. We think that this episode was likely a physical manifestation of the severe stress you have been undergoing as well as possible transient small vasospasm due to cocaine use. We strongly urge you to NOT use cocaine in the future. Please have an ultrasound of your heart done in the outpatient setting. It was a pleasure caring for you and we are glad that you are on your way to recovery. It was a pleasure taking care of you, Your ___ 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: Rash, abnormal labs Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ y/o man with a history of rheumatoid arthiritis (previously on anti-TNF; stopped ___, prior alcohol abuse complicated by chronic portal vein thrombosis in the setting of pancreatitis, portal hypertension with varices s/p band ligation presenting for evaluation of rash and abnormal labs. The patient reports that he had a mechanical fall on ___. He presented to ___, and was found to have traumatic right humeral fracture and rib fractures requiring chest tube placements c/b Infuenza Pneumonia and MSSA bacteremia/empyema s/p thoracocentesis and decortication. He was discharged on IV cefazolin for an intended 4-week course, but subsequently developed a purpuric rash on his knees, per notes around ___. He was seen by ID, and his antibiotics were switched from cefazolin to vancomycin. He subsequently presented to ___ in ___ for persistent rash, and vancomycin was switched to Linezolid, although vancomycin was not thought to be the cause of his rash. He underwent skin biopsy on ___, with pathology consistent with leukocytoclastic vasculitis, although numerous eosinophils in the biopsy raises consideration for a hypersensitivity etiology. The differential diagnosis includes vasculitis associated with autoimmune disease (rheumatoid arthritis). Overall, the thinking was that this rash was possibly triggered by an infection, and was thought to be less likely secondary to his rheumatoid arthritis or an antibiotic or drug exposure. Immunosuppression and prednisone was considered but was not initiated. Per ___ notes, it appears that the plan was for the patient to see rheumatology as an outpatient to discuss re-initiating Humira. In the interim, the patient reports that the rash has progressed, and spread to his arms just recently. The rash is not pruritic or painful. He saw his gastroenterologist on the day of admission, who referred him to the hospital for further evaluation. On arrival to the floor, patient reports that he has severe pain in his right shoulder, which has been present since his accident in ___. No other joint pain or swelling. He denies any other complaints. No fever/chills, weight loss. No cough, shortness of breath, chest pain, palpitations. He has been told that he has hematuria, but he has not noticed this himself. No melena or hematochezia. No nausea, vomiting, diarrhea. No unintentional weight loss. Of note, the patient localizing the worsening of his symptoms to the same time that he started iron supplementation. Past Medical History: - Alcohol abuse - Pancreatitis - Pancreatic pseudocyst x2 - Chronic cholecystitis - Hepatic, portal and splenic vein thromboses; not on anticoagulation due to hemorrhagic pancreatic pseudocyts - Portal hypertension - Esophageal varices s/p banding - HLD - Rheumatoid arthritis, previously on anti-TNF - s/p bilateral hernia repair in ___ - left eye strabismus, s/p corrective surgery good success without complication in ___ Social History: ___ Family History: Mother w/ emphysema. Father w/ CAD. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.2 145/73 81 18 98 Ra GENERAL: Lying in bed, in NAD HEENT: EOMI, PERRL, anicteric sclera, MMM, no oral lesions NECK: No JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi ABDOMEN: BS+, soft, NTND EXTREMITIES: No peripheral edema; TTP over right glenuohumeral joint PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: Nonblanching purpuric rash on bilateral lower extremities with blistering of bilateral heels; rash also present on dorsum of hands up to mid-arm bilaterally; sparing of trunk and face DISCHARGE PHYSICAL EXAM VS: 97.9F, 112/59, HR 81, RR 16, 98% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: CTAB, no wheezes, rales, rhonchi CV: rrr, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: trace edema ___, non-tender Skin: dozens of erythematous macules on legs and arms, sparing chest/abdomen/back/face. Rash improving. Left heel bulla. Neuro: A&Ox3, moving all extremities with purpose Pertinent Results: ADMISSION LABS ___ 09:30AM BLOOD WBC-10.0 RBC-2.84* Hgb-8.2* Hct-26.6* MCV-94 MCH-28.9 MCHC-30.8* RDW-15.7* RDWSD-53.9* Plt ___ ___ 09:30AM BLOOD Neuts-82.8* Lymphs-8.7* Monos-4.6* Eos-3.2 Baso-0.4 Im ___ AbsNeut-8.24* AbsLymp-0.87* AbsMono-0.46 AbsEos-0.32 AbsBaso-0.04 ___ 09:30AM BLOOD ___ PTT-36.2 ___ ___ 09:30AM BLOOD Plt ___ ___ 05:30AM BLOOD Ret Aut-1.9 Abs Ret-0.04 ___ 05:30AM BLOOD ___ Thrombn-18.6* ___ 05:30AM BLOOD FactVII-93 ___ 09:30AM BLOOD TotProt-7.6 Albumin-2.6* Globuln-5.0* Phos-2.9 Mg-2.0 Iron-31* ___ 09:30AM BLOOD calTIBC-176* VitB12-1256* Folate-15 Ferritn-699* TRF-135* ___ 05:30AM BLOOD Hapto-171 ___ 09:30AM BLOOD TSH-0.93 ___ 05:30AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-POS* ___ 05:30AM BLOOD ANCA-NEGATIVE B ___ 05:30AM BLOOD CRP-94.6* dsDNA-NEGATIVE ___ 09:30AM BLOOD RheuFac-18* ___ ___ 09:30AM BLOOD PEP-NO MONOCLO FreeKap-239.5* FreeLam-314.8* Fr K/L-0.76 IgG-2368* IgA-1347* IFE-NO MONOCLO ___ 05:30AM BLOOD C3-102 C4-14 ___ 07:20PM BLOOD HBV VL-NOT DETECT ___ 05:30AM BLOOD HCV Ab-NEG DISCHARGE LABS ___ 01:00PM BLOOD WBC-5.0 RBC-2.54* Hgb-7.3* Hct-23.7* MCV-93 MCH-28.7 MCHC-30.8* RDW-15.9* RDWSD-54.4* Plt ___ ___ 01:00PM BLOOD Plt ___ ___ 07:21AM BLOOD ___ PTT-32.9 ___ ___ 07:21AM BLOOD Glucose-82 UreaN-27* Creat-1.7* Na-140 K-5.0 Cl-104 HCO3-24 AnGap-12 ___ 07:21AM BLOOD Calcium-8.3* Phos-3.9 Mg-1.9 ___ 01:00PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-POS* IMAGING Renal US ___ 1. Cavernous transformation of the main portal vein consistent with chronic portal vein thrombosis. A small amount of hepatopetal flow was identified within the right portal vein. 2. No hydronephrosis identified. CXR ___ No previous images. The cardiac silhouette is at the upper limits of normal. Indistinctness of pulmonary vessels suggests some elevated pulmonary venous pressure. Opacification at the left base silhouetting hemidiaphragm most likely represents a combination of atelectasis and pleural fluid. However, there is suggestion of mild coalescence of opacification just above and lateral to the lower cardiac border. In the appropriate clinical setting, this would be worrisome for superimposed aspiration/pneumonia. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Zolpidem Tartrate 10 mg PO QHS 2. LORazepam 1 mg PO Q8H:PRN Anxiety 3. Nadolol 20 mg PO DAILY 4. Lovastatin 20 mg oral QHS 5. Ferrous Sulfate 325 mg PO DAILY 6. Magnesium Oxide 280 mg PO DAILY 7. Tamsulosin 0.4 mg PO QHS 8. Levothyroxine Sodium 25 mcg PO DAILY 9. Vitamin B Complex 1 CAP PO DAILY 10. OxyCODONE (Immediate Release) ___ mg PO QHS:PRN Pain - Severe Discharge Medications: 1. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe RX *oxycodone 5 mg 1 tablet(s) by mouth q6h PRN Disp #*28 Tablet Refills:*0 3. Thiamine 100 mg PO DAILY RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Levothyroxine Sodium 25 mcg PO DAILY 5. LORazepam 1 mg PO Q8H:PRN Anxiety 6. Lovastatin 20 mg oral QHS 7. Magnesium Oxide 280 mg PO DAILY 8. Tamsulosin 0.4 mg PO QHS 9. Vitamin B Complex 1 CAP PO DAILY 10. Zolpidem Tartrate 10 mg PO QHS 11. HELD- Nadolol 20 mg PO DAILY This medication was held. Do not restart Nadolol until you follow up with your PCP 12.Outpatient Lab Work Lab: Na,K,Cl,HCO3,BUN,Cr,Glu Date: ___ Dx: Acute kidney failure (ICD9:___.9) ___: ___ (Dr. ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Leukocytoclastic Vasculitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (SINGLE VIEW) INDICATION: ___ year old man with recent pneumonia presenting with leukocytoclastic vasculitis// Pneumonia? Pulmonary edema? Pulmonary hemorrhage? IMPRESSION: No previous images. The cardiac silhouette is at the upper limits of normal. Indistinctness of pulmonary vessels suggests some elevated pulmonary venous pressure. Opacification at the left base silhouetting hemidiaphragm most likely represents a combination of atelectasis and pleural fluid. However, there is suggestion of mild coalescence of opacification just above and lateral to the lower cardiac border. In the appropriate clinical setting, this would be worrisome for superimposed aspiration/pneumonia. Radiology Report EXAMINATION: ABDOMEN US (COMPLETE STUDY) INDICATION: ___ year old man with history of portal vein thrombosis, here with ___ and leukocytoclastic vasculitis// Doppler evaluation of portal vein; hydronephrosis? TECHNIQUE: Grey scale, color and spectral doppler ultrasound images of the abdomen were obtained. COMPARISON: CT abdomen and pelvis ___ FINDINGS: LIVER: Note is made the left hepatic lobe could not be identified due to overlying bowel gas and limited sonographic windows. Within that limitation the hepatic parenchyma appears within normal limits. The contour of the liver is smooth. There is no focal liver mass. The region of the main portal vein was evaluated with color and spectral Doppler imaging. The region where the main portal vein usually lies is replaced with multiple tortuous vessels which demonstrate arterial flow on spectral Doppler imaging, consistent with cavernous transformation and chronic portal vein thrombosis. Within the region of the right portal vein, a small amount of hepatopetal portal venous flow is identified. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 5 mm. GALLBLADDER: There is no evidence of stones or gallbladder wall thickening. PANCREAS: The pancreas is not well visualized, largely obscured by overlying bowel gas. SPLEEN: Normal echogenicity, measuring 12.4 cm. KIDNEYS: The right kidney measures 10.4 cm. The left kidney measures 12.9 cm. Views of the bilateral kidneys show no hydronephrosis. A simple cyst is seen arising from the lower pole of the left kidney measuring 1.1 cm RETROPERITONEUM: Visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. Cavernous transformation of the main portal vein consistent with chronic portal vein thrombosis. A small amount of hepatopetal flow was identified within the right portal vein. 2. No hydronephrosis identified. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abnormal labs Diagnosed with Encntr for obs for oth suspected diseases and cond ruled out temperature: 97.2 heartrate: 76.0 resprate: 16.0 o2sat: 97.0 sbp: 150.0 dbp: 69.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, It was a pleasure caring for you at ___ ___! WHY WERE YOU ADMITTED? -You were admitted for a rash and worsening kidney function. WHAT HAPPENED IN THE HOSPITAL? -Your rash and kidney function remained stable. You were evaluated by the rheumatologists, nephrologists and dermatologists who did not feel you needed immediate treatment. -You received a transfusion for anemia, which has likely been chronic. You were evaluated by hematology who did not find abnormalities on your blood smear. Please have your PCP continue to monitor your anemia. WHAT SHOULD YOU DO AT HOME? -You should take your medications as prescribed. -You should follow-up with your physicians based on the appointments listed below. Thank you for allowing us be involved in your care, we wish you all the best! Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Macrodantin / hydrochlorothiazide / Reglan / cephalexin / rifampin / nitrofurantoin Attending: ___ Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old woman w/hx AS s/p TAVR (___), afib on coumadin, HFpEF (EF 60-65%), BiV ICD (___), TIA presenting with subacute dyspnea on exertion and chest pain. Patient presented to the ___ ED as she noted chest pressure at rest as well as ongoing dyspnea on exertion. There was no associated nausea or diaphoresis. At ___, patient had negative troponin, normal BNP. CXR was without abnormality and EKG was without ischemic changes. Patient was transferred here for further evaluation. Patient has noted ongoing dyspnea on exertion which did not improve after her TAVR in ___. She states that her shortness of breath on exertion has been subjectively worsening over the past 3 weeks though has been stably present since prior to TAVR. She has not been able to walk more than a few steps without significant dyspnea for at least ___ year. She uses a walker at home and notes that knee and back pain are the first limiting factor for exertion though dyspnea has been an issue as well. No chest pain or tightness with activity. Notes intermittent substernal sensation of tightness at rest that resolves spontaneously and has no associated triggers. No concurrent nausea or dyspnea. The sensation of chest tightness is new over the past few weeks and remains stable. She has had gradual weight gain over the past few years given significant back and knee pain and DOE. No ___ swelling. No new PND or orthopnea though hard to assess as sleeps in recliner at baseline over the past ___ years for back pain. Uses CPAP at night for OSA. She otherwise denies any fevers, nausea, vomiting, diarrhea, dysuria, hematuria. Of note, she did sustain a fall a few days prior to presentation with residual pain in her neck and bilateral shoulders. She notes falling while playing with her grandchildren without any prodromal symptoms. She reported to an urgent care after the fall with normal x-ray. In the ED initial vitals were: T 97 HR 88 BP 121/78 RR 16 SpO2 94% RA Labs/studies notable for: WBC 12.5 Hgb 14.3 Plt ___ ------------- 4.9/24/1.0 INR 3.4 pBNP 355, trop <0.01 x2 UA: neg nit, 123 WBC, 6 RBC, 30 prot, 10 epi Patient was given: ___ 81mg Lisinopril 5mg Spirolocatone 75mg Metoprolol succinate 75mg Insulin 80 Oxycodone 2.5mg Insulin 160mg Warfarin 13mg Atorvastatin 40mg Oxycodone 2.5mg Vitals on transfer: T 98.5 HR 75 BP 149/52 RR 18 SpO2 92% RA EKG: paced rhythm, biventricular pacing, underlying Afib, no new ST changes CXR: Left chest wall dual lead pacing device as well as a replaced valve are again noted. The lungs are clear without focal consolidation. No pleural effusion or pneumothorax is seen. Enlarged cardiomediastinal silhouette is unchanged. On the floor, patient confirms the history above and denies chest pain or shortness of breath. She has very limited mobility with transfer from bed to chair due to pain. Past Medical History: 1. CARDIAC RISK FACTORS - Diabetes mellitus type II - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - ___ LMCA clear, LAD with mild plaquing. LCx with mild plaquing, RCA with 40% stenosis at origin. - HFpEF (EF 60%) - Aortic stenosis s/p TAVR ___ - Recurrent Atrial Fibrillation, S/P multiple cardioversions and ultimately AVJ ablation ___ - S/p biventricular pacer/ICD implant ___ at ___ 3. OTHER PAST MEDICAL HISTORY - Amaurosis fugax while on xarelto - Obesity - Cervical plate surgery - Torn meniscus bilateral knee - OSA - CPAP - Chronic back pain - S/p failed left total knee replacement - Right anterior mid-calf ulcer, followed by ___ for dressing changes Social History: ___ Family History: Mother- atrial fibrillation Father - MI at age ___. Sons: 3 with mitochondrial disease of varying degrees Physical Exam: ADMISSION PHYSICAL EXAM ============================= T 98.4 BP 140/60 HR 81 RR 17 Sat 93% RA Gen: Sitting up in chair comfortably, significant pain with movement from bed to chair, gait appears unstable without cane HEENT: No icterus. MMM. OP clear. NECK: Supple, unable to assess JVP with body habitus. CV: RRR. no m/r/g LUNGS: CTAB though very distant breath sounds No wheezes, rales, or rhonchi. ABD: NABS. Obese Soft, NT, ND. EXT/skin: significant bilateral venous stasis changes shins down to feet, no evidence of cellulitis or warmth, feet warm though unable to palpate pulses. NEURO: A&Ox3. CN ___ grossly intact. Preserved sensation throughout. ___ strength throughout. Gait assessment deferred DISCHARGE PHYSICAL EXAM ============================== 24 HR Data (last updated ___ @ 512) Temp: 97.9 (Tm 98.4), BP: 138/84 (111-154/53-84), HR: 75 (75-78), RR: 18 (___), O2 sat: 96% (93-96), O2 delivery: Ra, Wt: 364.42 lb/165.3 kg Fluid Balance (last updated ___ @ 244) Last 8 hours Total cumulative -1400ml IN: Total 0ml OUT: Total 1400ml, Urine Amt 1400ml Last 24 hours Total cumulative -1640ml IN: Total 1260ml, PO Amt 1260ml OUT: Total 2900ml, Urine Amt 2900ml Gen: Morbidly obese woman sitting up in chair comfortably HEENT: No icterus. MMM. OP clear. NECK: Supple, unable to assess JVP with body habitus. CV: RRR. no m/r/g LUNGS: CTAB though very distant breath sounds, expiratory wheezes, rales, or rhonchi. ABD: NABS. Obese Soft, NT, ND. EXT/skin: significant bilateral venous stasis changes shins down to feet, no evidence of cellulitis or warmth, feet warm though unable to palpate pulses. Raised dermatomal rash on L back with vesicle formation. Intertrigo of the breasts NEURO: A&Ox3. CN ___ grossly intact. Preserved sensation throughout. ___ strength throughout. Unsteady gait Pertinent Results: ADMISSION LABS =================== ___ 02:45AM BLOOD WBC-12.5* RBC-4.58 Hgb-14.3 Hct-44.9 MCV-98 MCH-31.2 MCHC-31.8* RDW-14.6 RDWSD-52.9* Plt ___ ___ 02:45AM BLOOD Neuts-72.8* Lymphs-15.0* Monos-8.9 Eos-2.2 Baso-0.6 Im ___ AbsNeut-9.13* AbsLymp-1.88 AbsMono-1.11* AbsEos-0.27 AbsBaso-0.08 ___ 02:45AM BLOOD ___ PTT-36.6* ___ ___ 02:45AM BLOOD Glucose-85 UreaN-23* Creat-1.0 Na-138 K-4.9 Cl-100 HCO3-24 AnGap-14 ___ 06:54AM BLOOD ALT-26 AST-23 AlkPhos-82 TotBili-0.7 ___ 02:45AM BLOOD proBNP-355 ___ 02:45AM BLOOD cTropnT-0.01 ___ 09:45AM BLOOD cTropnT-<0.01 ___ 06:54AM BLOOD Calcium-9.3 Phos-4.8* Mg-1.8 PERTINENT LABS ==================== ___ 05:43AM BLOOD WBC-14.0* RBC-4.39 Hgb-13.5 Hct-42.9 MCV-98 MCH-30.8 MCHC-31.5* RDW-14.2 RDWSD-50.9* Plt ___ ___ 06:05AM BLOOD WBC-12.7* RBC-4.53 Hgb-14.1 Hct-43.8 MCV-97 MCH-31.1 MCHC-32.2 RDW-14.0 RDWSD-49.7* Plt ___ ___ 06:05AM BLOOD Glucose-58* UreaN-26* Creat-0.8 Na-137 K-4.1 Cl-97 HCO3-26 AnGap-14 ___ 06:05AM BLOOD Calcium-9.5 Phos-3.3 Mg-2.0 IMAGING ====================== TTE ___ The left atrial volume index is mildly increased. The right atrium is mildly enlarged. The estimated right atrial pressure is ___ mmHg. The left ventricle has a normal cavity size. There is suboptimal image quality to assess regional left ventricular function. The visually estimated left ventricular ejection fraction is >=60%. There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Tissue Doppler suggests a normal left ventricular filling pressure (PCWP less than 12mmHg). The right ventricle was not well seen with uninterpretable free wall motion assessment. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal with a normal descending aorta diameter. A ___ 3 aortic valve bioprosthesis is present. The prosthesis is well seated with normal gradient. There is no aortic valve stenosis. There is an eccentric, anterior mitral leaflet directed jet of trace aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is moderate mitral annular calcification. There is trivial mitral regurgitation. Due to acoustic shadowing, the severity of mitral regurgitation could be UNDERestimated. The pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Likely preserved global left ventricular systolic function. Cannot comment on right ventricular function. Well-seated, normally functioning aortic valve ___ ___ortic regurgitation (no paravalvular leak). Mild pulmonary hypertension. Compared with the prior TTE ___, suboptimal image quality precludes definititve comparison CTA CORONARY ARTERIES ___ FINDINGS: Image Quality: The overall quality of the CT angiographic examination is poor and is limited by poor arterial opacification and patient motion. AGATSTON SCORE: The total (aggregate) calcium score using the AJ 130 method is 1476. Total volume score is 1352. 90% of similar patients have less coronary artery calcium. Individual major vessel AJ 130 scores are: LM: 117; LAD: 572; LCX: 320; RCA: 467. CORONARY CTA: Dominance of the coronary artery system: right with normal origins and course. There is atherosclerotic disease noted in the LAD, LCx and RCA. No major plaques are seen, though evaluation is very limited and narrowing within 50% cannot be excluded. CARDIAC MORPHOLOGY: The right atrium is normal. The right ventricle is normal. The left atrium is normal. The left ventricle is normal. The pericardium is normal and there is no pericardial effusion. The patient is status post aortic valve replacement. No plaques are seen associated with the replaced aortic valve. There are mitral annular calcifications. A biventricular pacing devices is seen. EXTRACARDIAC FINDINGS: No suspicious pulmonary nodules. There is mild left basilar atelectasis and mild bilateral dependent atelectasis. There are moderate multilevel degenerative changes of the thoracic spine. IMPRESSION AND RECOMMENDATIONS: Very limited study due to patient body habitus, motion artifact, poor arterial opacification. Please note coronary CTA is not the preferred modality due to patient body habitus. Total calcium score of 1476. CAC-DRS ___ A3/N3 CAC Score risk: CAC-DRS 3 (>300): moderately to severely increased risk- high intensity statin + 81mg ___ recommended (A - risk category based on Agatston score / N - number of coronary arteries containing calcifications) CAD-RADS N- Non-diagnostic study, obstructive CAD cannot be excluded. Additional or alternative evaluation may be needed. There is disease noted in the LAD, LCx and RCA, and while no major plaques are seen, evaluation is very limited and narrowing within 50% cannot be excluded. CT CHEST ___ No evidence of pulmonary edema or pneumonia. ANKLE XRAY ___ FINDINGS: No acute fractures or dislocations are seen.There is mild periosteal reaction about the medial and inferior medial aspect of the medial malleolus with subtle lucency of the medial malleolus tip. There is moderate soft tissue edema about the ankle most pronounced medially.There is a healed distal fibular fracture. Prominent plantar and Achilles related enthesophytes. There are vascular calcifications. There are mild degenerative changes about the tibiotalar joint. Possible small ankle joint effusion. IMPRESSION: Mild periosteal reaction about the medial aspect of the ankle with questionable small osseous erosion of the distal tip of the medial malleolus, may represent early osteomyelitis in the correct clinical context, with other etiologies including inflammatory arthropathy not excluded. Note that MRI is more sensitive for detection of osteomyelitis. Moderate soft tissue edema about the ankle, most pronounced medially. MRI ___ IMPRESSION: 1. No bone marrow signal abnormality to suggest osteomyelitis. 2. Diffuse subcutaneous edema of the left ankle without rim enhancing fluid collection. 3. Mid substance Achilles tendinopathy with edema in ___ fat pad. No Achilles tendon tear. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. Lisinopril 5 mg PO DAILY 4. Metoprolol Succinate XL 75 mg PO DAILY 5. Venlafaxine XR 225 mg PO DAILY 6. Vitamin D ___ UNIT PO DAILY 7. Spironolactone 25 mg PO DAILY 8. Warfarin 13 mg PO DAILY16 9. ClonazePAM 2 mg PO QHS:PRN sleep 10. U-500 Conc 160 Units Breakfast U-500 Conc 160 Units Bedtime Discharge Medications: 1. Advair HFA (fluticasone propion-salmeterol) 115-21 mcg/actuation inhalation BID 2 puffs twice a day RX *fluticasone propion-salmeterol [Advair HFA] 115 mcg-21 mcg/actuation 2 puffs IH twice a day Disp #*1 Inhaler Refills:*0 2. Albuterol Inhaler ___ PUFF IH Q6H cough, wheeze, shortness of breath RX *albuterol sulfate [ProAir HFA] 90 mcg ___ puffs IH every six (6) hours Disp #*1 Inhaler Refills:*0 3. Cephalexin 500 mg PO QID Duration: 7 Days RX *cephalexin 500 mg 1 tablet(s) by mouth four times a day Disp #*28 Tablet Refills:*0 4. Lidocaine 5% Patch 1 PTCH TD QAM 5. Spiriva Respimat (tiotropium bromide) 2.5 mcg/actuation inhalation DAILY 2 puffs daily RX *tiotropium bromide [Spiriva Respimat] 2.5 mcg/actuation 2 puffs IH once a day Disp #*1 Inhaler Refills:*0 6. TraMADol 25 mg PO Q6H:PRN BREAKTHROUGH PAIN Duration: 2 Days RX *tramadol [Ultram] 50 mg 0.5 (One half) tablet(s) by mouth every six (6) hours Disp #*6 Tablet Refills:*0 7. ValACYclovir 1000 mg PO TID Duration: 7 Days RX *valacyclovir 1,000 mg 1 tablet(s) by mouth three times a day Disp #*4 Tablet Refills:*0 8. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth nightly Disp #*30 Tablet Refills:*0 9. U-500 Conc 160 Units Breakfast U-500 Conc 160 Units Bedtime 10. Lisinopril 10 mg PO DAILY RX *lisinopril 10 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 11. Metoprolol Succinate XL 100 mg PO DAILY RX *metoprolol succinate 100 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 12. Aspirin 81 mg PO DAILY 13. ClonazePAM 2 mg PO QHS:PRN sleep 14. Spironolactone 25 mg PO DAILY 15. Venlafaxine XR 225 mg PO DAILY 16. Vitamin D ___ UNIT PO DAILY 17. Warfarin 13 mg PO DAILY16 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS ====================== COPD Cellulitis of Left Lower Extremity Varicella Zoster SECONDARY DIAGNOSIS ======================== ATRIAL FIBRILLATION HEART FAILURE WITH PRESERVED EJECTION FRACTION 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 shortness of breath// pneumonia, pulmonary edema TECHNIQUE: Chest: Frontal and Lateral COMPARISON: Chest radiograph ___ FINDINGS: Left chest wall dual lead pacing device as well as a replaced valve are again noted.The lungs are clear without focal consolidation. No pleural effusion or pneumothorax is seen. Enlarged cardiomediastinal silhouette is unchanged. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: CTA CORONARY ARTERIES W/3D W/FUNCTION INDICATION: ___ is a ___ year old woman w/hx AS s/p ___, afib, HFpEF (EF 60-65%), BiV ICD (___), TIApresenting with subacute dyspnea on exertion and chest pain.// eval for coronary artery stenosis TECHNIQUE: A 320-slice multidetector CTA ___) of the coronary arteries was obtained using prospective ECG gating with Omnipaque contrast administered intravenously. To provide better evaluation of the anatomy and disease process, advanced 3D post-processing techniques, including multiplanar reconstruction, maximal intensity projections, curved reconstructions, and volume rendering were performed on a separate workstation. Calcium score was calculated using Vitrea V-Score software. No intravenous contrast material was administered for this portion of the exam. Medications: None. Nitroglycerin could not be given due to patient's aortic stenosis. Vital Signs: The patient's heart rate was continuously monitored by a nurse. Prior to this study, the heart rate was 80 beats per min and the blood pressure was 134/48 mm Hg. Procedure complications/allergic reactions: none DOSE: Acquisition sequence: 1) Sequenced Acquisition 0.6 s, 23.5 cm; CTDIvol = 7.3 mGy (Body) DLP = 170.7 mGy-cm. 2) Stationary Acquisition 0.5 s, 14.0 cm; CTDIvol = 12.5 mGy (Body) DLP = 175.1 mGy-cm. 3) Stationary Acquisition 0.3 s, 0.5 cm; CTDIvol = 1.6 mGy (Body) DLP = 0.8 mGy-cm. 4) Stationary Acquisition 3.7 s, 0.5 cm; CTDIvol = 20.3 mGy (Body) DLP = 10.1 mGy-cm. Total DLP (Body) = 357 mGy-cm. COMPARISON: None available. FINDINGS: Image Quality: The overall quality of the CT angiographic examination is poor and is limited by poor arterial opacification and patient motion. AGATSTON SCORE: The total (aggregate) calcium score using the AJ 130 method is 1476. Total volume score is 1352. 90% of similar patients have less coronary artery calcium. Individual major vessel AJ 130 scores are: LM: 117; LAD: 572; LCX: 320; RCA: 467. CORONARY CTA: Dominance of the coronary artery system: right with normal origins and course. There is atherosclerotic disease noted in the LAD, LCx and RCA. No major plaques are seen, though evaluation is very limited and narrowing within 50% cannot be excluded. CARDIAC MORPHOLOGY: The right atrium is normal. The right ventricle is normal. The left atrium is normal. The left ventricle is normal. The pericardium is normal and there is no pericardial effusion. The patient is status post aortic valve replacement. No plaques are seen associated with the replaced aortic valve. There are mitral annular calcifications. A biventricular pacing devices is seen. EXTRACARDIAC FINDINGS: No suspicious pulmonary nodules. There is mild left basilar atelectasis and mild bilateral dependent atelectasis. There are moderate multilevel degenerative changes of the thoracic spine. IMPRESSION AND RECOMMENDATIONS: Very limited study due to patient body habitus, motion artifact, poor arterial opacification. Please note coronary CTA is not the preferred modality due to patient body habitus. Total calcium score of 1476. CAC-DRS ___ A3/N3 CAC Score risk: CAC-DRS 3 (>300): moderately to severely increased risk- high intensity statin + 81mg ASA recommended (A - risk category based on Agatston score / N - number of coronary arteries containing calcifications) CAD-RADS N- Non-diagnostic study, obstructive CAD cannot be excluded. Additional or alternative evaluation may be needed. There is disease noted in the LAD, LCx and RCA, and while no major plaques are seen, evaluation is very limited and narrowing within 50% cannot be excluded. REFERENCES: Calcium Scoring is reported using the interactive ___ form (___) and graded using the CAC-DRS ___ (J Cardiovasc Comput Tomogr ___. CAC-DRS 0 (A0) - Agaston score 0: Very low risk (statin generally not recommended) CAC-DRS 1 (A1) - Agaston score between ___: Mildly increased risk (moderate intensity statin recommended) CAC-DRS 2 (A2) - Agaston score between 100-299: Moderately increased risk (moderate to high intensity statin + 81 mg ASA recommended) CAC-DRS 3 (A3) - Agaston score between >300: Moderately to severely increased risk (high intensity statin + 81 mg ASA recommended) Coronary stenoses are reported as maximum percentage diameter stenosis and graded using the CAD-RADS classification (___ Cardiovasc Imaging ___ Sep;9(9):1099-113). CAD-RADS 0: 0%, no stenosis CAD-RADS 1: ___, minimal stenosis or plaque with no stenosis CAD-RADS 2: ___, mild stenosis CAD-RADS 3: 50-69%, moderate stenosis CAD-RADS 4A: 70-99%, severe stenosis CAD-RADS 4B: >50% stenosis of the left main or >=70% stenosis of the left anterior descending, the left circumflex, and the right coronary, severe stenosis CAD-RADS 5: 100%, total occlusion CAD-RADS N: Non-diagnostic study, obstructive CAD cannot be excluded NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 2:08 pm, 50 minutes after discovery of the findings. Radiology Report EXAMINATION: CT CHEST WITHOUT CONTRAST INDICATION: ___ year old woman with significant dyspnea on exertion// eval lung parenchyma TECHNIQUE: Multi detector helical scanning of the chest was reconstructed as 5 and 1.25 mm thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP axial images. Contrast agent was not administered. All images were reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 8.6 s, 33.1 cm; CTDIvol = 22.9 mGy (Body) DLP = 720.9 mGy-cm. Total DLP (Body) = 735 mGy-cm. COMPARISON: CTA torso from ___. FINDINGS: NECK, THORACIC INLET, AXILLAE AND CHEST WALL: The thyroid is unremarkable. No enlarged lymph nodes in either axilla or thoracic inlet. No abnormalities on the chest wall. Mild atherosclerotic calcifications in the head and neck arteries. Left anterior wall AICD with leads in the right atrium and right ventricle. HEART AND VASCULATURE: The heart is enlarged with a dilated right atrium. Status post aortic valve replacement. Coarse calcifications are noted surrounding the mitral annulus.. No pericardial effusion. Moderate atherosclerotic calcifications in the aorta and in the coronary arteries. The aorta and pulmonary arteries are normal in caliber throughout. MEDIASTINUM AND HILA: The esophagus is unremarkable. Small mediastinal lymph nodes, none pathologically enlarged by CT size criteria. No hilar lymphadenopathy. PLEURA: No pleural effusions. Mild bilateral apical scarring. LUNGS: Respiratory motion artifacts limits evaluation of the lung parenchyma. The airways are patent to the subsegmental levels. No bronchial wall thickening, bronchiectasis or mucus plugging. No grossly large suspicious lung nodules. Small linear consolidation in the left lower lobe, likely atelectasis. CHEST CAGE: No acute fractures. Moderate thoracic spondylosis. No suspicious lytic or sclerotic lesions. Anterior cervical fusion hardware. Healed fracture through the posterior aspect of the left fifth rib. UPPER ABDOMEN: Limited evaluation of the upper abdomen show mild diffuse low-attenuation of the liver, likely representing hepatic steatosis. Unchanged thickened left adrenal gland with no evident nodules. IMPRESSION: No evidence of pulmonary edema or pneumonia. Radiology Report EXAMINATION: ANKLE (AP, MORTISE AND LAT) LEFT INDICATION: ___ year old woman with significant pain to palpation of L ankle with overlying cellulitis// eval for osteo TECHNIQUE: Three views of the left ankle. COMPARISON: None available. FINDINGS: No acute fractures or dislocations are seen.There is mild periosteal reaction about the medial and inferior medial aspect of the medial malleolus with subtle lucency of the medial malleolus tip. There is moderate soft tissue edema about the ankle most pronounced medially.There is a healed distal fibular fracture. Prominent plantar and Achilles related enthesophytes. There are vascular calcifications. There are mild degenerative changes about the tibiotalar joint. Possible small ankle joint effusion. IMPRESSION: Mild periosteal reaction about the medial aspect of the ankle with questionable small osseous erosion of the distal tip of the medial malleolus, may represent early osteomyelitis in the correct clinical context, with other etiologies including inflammatory arthropathy not excluded. Note that MRI is more sensitive for detection of osteomyelitis. Moderate soft tissue edema about the ankle, most pronounced medially. NOTIFICATION: The impression above was entered by Dr. ___ on ___ at 11:48 into the Department of Radiology critical communications system for direct communication to the referring provider. Radiology Report EXAMINATION: MR ANKLE ___ LEFT INDICATION: ___ F with HFpEF, Afib s/p AVJ ablation with biV pacemaker presenting with cellulitis and erosive changes on xray c/f osteo. Patient with clearance for MRI as per OMR.// eval for osteo TECHNIQUE: Multiplanar images of the left ankle were performed with and without intravenous contrast using a routine MR ankle protocol. COMPARISON: Left ankle radiograph dated ___. FINDINGS: Achilles tendon: There is mid substance tendinopathy of the Achilles tendon without discrete tear. There is edema in the ___ fat pat. Posterior tibial tendon: Normal. Flexor digitorum tendon: Normal. Flexor hallucis tendon: Normal. Peroneal tendons: Normal. Anterior tibialis tendon: Normal. Extensor digitorum tendon: Normal. Extensor hallucis longus: Normal. The study is not tailored for evaluation ligamentous injury in the ankle. Given the limitation the syndesmotic ligaments, lateral collateral ligament, and medial collateral ligament are grossly intact. Sinus tarsi: Normal. Plantar fascia: Normal. Tibiotalar joint space: There is no joint effusion or osteochondral lesions. Marrow signal: There is no bone marrow signal abnormality to suggest osteomyelitis.. Other findings: There is diffuse subcutaneous edema. No rim enhancing fluid collection identified. IMPRESSION: 1. No bone marrow signal abnormality to suggest osteomyelitis. 2. Diffuse subcutaneous edema of the left ankle without rim enhancing fluid collection. 3. Mid substance Achilles tendinopathy with edema in ___ fat pad. No Achilles tendon tear. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Chest pain, Dyspnea on exertion Diagnosed with Dyspnea, unspecified temperature: 97.0 heartrate: 88.0 resprate: 16.0 o2sat: 94.0 sbp: 121.0 dbp: 78.0 level of pain: 3 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 admitted to the hospital because you were short of breath. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? - You had a lot of tests to determine the cause of your shortness of breath. - The pulmologists (lung doctors) saw you and think it was due to COPD so we treated you with nebulizers and prednisone. - You also developed shingles in the hospital and were given a medicine to treat this. - You had cellulitis (an infection of your skin) on your left leg and you were given antibiotics for this. You had an MRI to make sure the infection wasn't in the bone. WHAT SHOULD I DO WHEN I GO HOME? - You should continue to take your medications as prescribed. - You should attend the appointments listed below. - Weigh yourself every morning, call your doctor (___) at ___ if your weight goes up more than 3 lbs. - Seek medical attention if you have new or concerning symptoms or you develop swelling in your legs, abdominal distention, or shortness of breath at night. - Your discharge weight: 365 lbs. You should use this as your baseline after you leave the hospital. We wish you the best! Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: opioids Attending: ___. Chief Complaint: Fever Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old man with stage IIB Hodgkin lymphoma s/p 2 cycles of ABVD c/b pneumonitis with subsequent PET-CT ___ showing progression of disease who is now C3D6 ICE chemotherapy and recently D/C on ___ (stayed for 3 days) who developed fever to 102.2 at home, with fatigue and new cough. Pt received his first dose of neuopogen ___ morning prior to presentation to ED but pt denies previous febrile reaction. Pt states that he usually feels the peak effects of ICE chemo on day 5. He has been laying in bed since his discharge, recovering from the chemo. He states that on ___ ___, he began to experience fevers/chills (denies rigors) and his T was checked which was 102.2. He states that he has developed a mild cough, productive but unable to describe color, that started that day as well. No SOB, CP, palpitations. He denies other infectious ROS including HA, neck pain, nasal congestion, sore throat, odynophagia, ear pain, n/v, abd pain, d/c, dysuria, rashes, or any other pains. . In the ED, initial VS were 98.2 104 107/65 16 99%. Labs notable for WBC of 33 (up from 8; neupogen x1). UA unrevealing. Lactate 1.7. CXR did not show PNA. No antibiotics given. At time of transfer to the ___ floors, VS were 97.9 91 109/65 16 97%. No fever while in the ED. . Review of Systems: Per HPI Past Medical History: PAST ONCOLOGIC HISTORY ___ presented to PCP with week of fevers to 102, drenching night sweats, cough and enlarged lymph node of the neck. CXR was performed that was concerning for lymphoma ___ CXR: bilateral mediastinal masses with marked enlargement of the mid and superior mediastinal structures surrounding the lower portion of the trachea without evidence of significant constriction ___iopsy consistent with classic HL ___ C1D1 ABVD ___ C2D1 ABVD ___ Repeat PFT showed drop in DLCO and started on low dose prednisone at 20mg ___ PET scan showed marked regression in mediastinal mass, but some progression in some areas and one new area of avidity, but in setting of possible lung inflammation was difficult to interpret and plan to continue ABVD and repeat ___ C3D1 ABVD ___ Repeat PFT on prednisone showed resolution of DLCO ___ Repeat PET scan showed clear progression of his disease ___ After meeting with Dr. ___ for elective admission on ___ for salvage ICE therapy. ___ ICE cycle 1 ___ ICE cycle 2 ___ ICE cycle 3 . PAST MEDICAL HISTORY: Depression/anxiety GERD superficial venous thrombosis: L Cephalic vein in forearm . PAST SURGICAL HISTORY: Vasectomy in ___ Social History: ___ Family History: Mother died of breast cancer at age ___ in ___. Maternal grandmother w/ breast cancer. Father w/ blood DO, but was a heavy drinker and died @ age ___. No family history lymphomas or leukemias in his family. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: 99 124/54 91 18 96%RA General: NAD, comfortable, no signs of resp distress HEENT: NCAT, MMM, pink conj, anicteric, no thrush or oral lesions Neck: Supple, no JVD CV: S1S2 RRR no m/g/c/r Lungs: CTAB Abdomen: NABS soft, NT/ND, no organomegaly, no r/g GU: No foley Ext: 2+ pulses, no c/c/e Neuro: CN ___ intact, motor/sensation in tact, normal ambulation Skin: No rash, salmon colored patch on occiput . DISCHARGE PHYSICAL EXAM: similar to admission. Pertinent Results: ADMISSION LABS: ___ 11:55PM BLOOD WBC-33.1*# RBC-3.47* Hgb-10.8* Hct-31.5* MCV-91 MCH-31.3 MCHC-34.4 RDW-16.9* Plt ___ ___ 11:55PM BLOOD Neuts-96.1* Lymphs-3.0* Monos-0.4* Eos-0.5 Baso-0 ___ 11:55PM BLOOD Glucose-108* UreaN-14 Creat-0.8 Na-132* K-3.7 Cl-96 HCO3-22 AnGap-18 ___ 11:55PM BLOOD ALT-26 AST-17 AlkPhos-114 TotBili-1.1 ___ 11:55PM BLOOD LD(LDH)-223 ___ 11:55PM BLOOD Albumin-4.1 ___ 12:09AM BLOOD Lactate-1.7 ___ 12:57AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG ___ 12:57AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 . DISCHARGE LABS: . MICRO: Blood and Urine Cxs Pending . IMAGING: CXR ___ IMPRESSION: Hyperinflated but clear lungs. Mediastinal and hilar enlargement consistent with the patient's lymphoma. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO TID 2. Escitalopram Oxalate 20 mg PO DAILY 3. Lorazepam 0.5-1 mg PO Q6H:PRN nausea 4. Ondansetron ___ mg PO Q8H:PRN nausea 5. Prochlorperazine ___ mg PO Q8H:PRN nausea 6. Ranitidine 150 mg PO DAILY 7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 8. Zolpidem Tartrate 10 mg PO HS:PRN insomnia 9. Filgrastim 480 mcg SC Q24H Please resume on ___ and use as directed Discharge Medications: 1. Acyclovir 400 mg PO TID 2. Escitalopram Oxalate 20 mg PO DAILY 3. Lorazepam 0.5-1 mg PO Q6H:PRN nausea 4. Ondansetron ___ mg PO Q8H:PRN nausea 5. Prochlorperazine ___ mg PO Q8H:PRN nausea 6. Ranitidine 150 mg PO DAILY 7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 8. Zolpidem Tartrate 10 mg PO HS:PRN insomnia 9. Filgrastim 480 mcg SC Q24H 10. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*14 Tablet Refills:*0 11. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*21 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary: Fever Secondary: Hodgkin's Lymphoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report REASON FOR EXAMINATION: Refractory Hodgkin's lymphoma and ongoing fever. COMPARISON: ___. Mediastinal bulky mass is unchanged, bilateral. Lungs are clear. There is no pleural effusion or pneumothorax. The Port-A-Cath catheter tip terminates at the level of low SVC. Gender: M Race: UNKNOWN Arrive by WALK IN Chief complaint: FEVER Diagnosed with FEVER, UNSPECIFIED, HODGKINS DIS NOS UNSPEC temperature: 98.2 heartrate: 104.0 resprate: 16.0 o2sat: 99.0 sbp: 107.0 dbp: 65.0 level of pain: 2 level of acuity: 2.0

Dear Mr. ___, It was a pleasure taking care of you during your stay at ___. You were admitted for a fever. We did not think you had an obvious infection but are sending you home on antibiotics to cover for possible infection. We think that the fever is most likely likely due to Neupogen and/or chemotherapy. Please talk to your outpatient hem/onc doctor about how long to continue the antibiotics. Please keep the follow-up appointments made for you. ___ MDs

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Toradol / Wellbutrin / Ambien / Benadryl / Celebrex / Zyprexa / torsemide / BuSpar / clonidine Attending: ___. Chief Complaint: chest pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ with PMH of systolic CHF, etoh abuse, b/l ___ edema, personality disorder, HL, and history of TBI who presents with shortness of breath and lower extremity pain and swelling. Says that he has been at rehab for the past four weeks and that he's being "neglected and abused" by staff. He has multiple rambling complaints and is at times difficult to redirect. His biggest complaint is his leg, his right leg has a new ulcer and he believes the legs are not being dressed properly. His shortness of breath feels worse. He refused in the ED to take Lasix, and also refuses on the floor. He states that Lasix cause his body to shut down. On previous admissions he has been found cutting the IV on a Lasix drip. He has vague complaints of chest pain, and is unable, or unwilling, to describe his symptoms, but does not have chest pain currently. Of note he is poorly compliant with diuretics and diet. In the ED initial vitals were: 98.1 ___ 18 96% RA EKG: sinus rate of 98, prolonged QTC, otherwise normal intervals, poor R wave progression with q-waves in V1-V3, diffuse ST flattening Labs/studies notable for: WBC 8.1 with 79% PMNs, H/H 9.8/32.2, normal Chem7, BNP 2796, troponin < 0.01. UA with large leuks, many WBCs, moderate bacteria, 19 RBCs. Chest xray showed stable cardiomegaly and mild hilar congestion. Patient was given: PO cipro Vitals on transfer: 98.1 95 104/60 18 99% RA On the floor, patient refused Lasix, he states he will improve his volume overload by taking "his own nutrients". He was screaming at staff. He was demanding pain medications. ROS: On 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. 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: - sHF (EF 20%) - Hyponatremia - MI at age ___, states he "lost 15% of his heart muscle" and had an "enlarged heart" thereafter. Formerly followed by a cardiologist at ___ - "internal bleeding" several months ago, with hematuria, resolved - Ortho-spine issues after being attacked (several times) in muggings; s/p anterior fusion of C3-C7. Followed by orthopedic surgery and neurosurgery at ___ - DJD - PTSD after being attacked - Anxiety - Personality or mood disorder (schizoid), he has been hospitalized at ___ at least once within the past year, for two months, states this was for "exhaustion and depression." Pt refers team to Dr. ___ at ___ ___ - Alcohol abuse - Tobacco abuse - Homelessness (recently housed) Social History: - Born/raised, childhood: Grew up in ___, with mother, father, and 4 siblings. - Education: Completed high school, took some college courses - Employment/Source of income: Worked many jobs in the past, including ___, worked at a ___ clinic, and several volunteer jobs. Currently unemployed, on ___ - Housing: lives alone, in current apartment x 6 months, prior to that was homeless - Exposure to violence: attacked and mugged many times SUBSTANCE ABUSE HISTORY: As per Dr. ___ ___ note: "- EtOH: ___ year of sobriety with AA meetings. Denies history of WD. Review of OMR reveals ___ detox program. EtOH levels as high as 340 previously. Past three EtOH levels ___, and ___ were negative." - Tobacco: 1.5 ppd - Marijuana: denies - Opiates, including heroin: only opioid use is morphine prescribed for back pain - Benzodiazepines: denies - Cocaine/Crack: denies (although has admitted to use per the record) - Amphetamines: denies - LSD/PCP/Ecstasy/Mushrooms: denies" Family History: Mother died of breast CA Father and brother died of ___ disease Physical Exam: =================== Admission Exam: =================== GENERAL - NAD HEENT - no scleral icterus, OP clear, poor dentition NECK - supple, JVP elevated CARDIAC - regular, pronounced PMI, no m/r/g appreciated PULMONARY - bilateral crackles ABDOMEN - +BS, soft, non-distended, non-tender EXTREMITIES - edematous, 2+ pitting edema, bilateral erythema but no warmth, superficial ulcers on right leg, wrapped left leg, refuse taking off bandage, NEUROLOGIC - Moves all 4 extremities LABS: reviewed, see below MICRO: reviewed, see below EKG: sinus rate of 98, prolonged QTC, otherwise normal intervals, poor R wave progression with q-waves in V1-V3, diffuse ST flattening ====================== Discharge Exam: ***LEFT AMA*** ====================== VS: T=98.0 BP=113/65 HR=83 (running high 90's, low 100's) RR=18 O2 sat=96RA I/O: 24hr: 1480/3700 8hr: ___ Wt: 8 3 . 1 k g - > 8 2 . 4 kg->82.5->81.6->79.3->79.2->76.7->76.0->73.3kg->74.4->73.3->71.8 GENERAL: disheveled, poorly shaven, NAD HEENT: EOMI, no scleral icterus NECK: Supple with JVP of 3cm above collarbone at 45 degrees CARDIAC: RRR, no MRG LUNGS: On RA, good air exchange, no increased work of breathing, mild crackles at bases standing up, no rales or ronchi. ABDOMEN: Soft, NTND. +BS EXTREMITIES: 2+ edema to knees b/l with 2cm round ulceration on ventral aspect of R shin, about 5cm above the ankle, can see fatty tissue but no purulence SKIN: chronic skin changes of b/l shins/calves Pertinent Results: ================= Admission Labs: ================== ___ 07:09PM BLOOD WBC-8.1 RBC-3.80* Hgb-9.8* Hct-32.2* MCV-85 MCH-25.8* MCHC-30.4* RDW-19.5* RDWSD-60.1* Plt ___ ___ 04:54AM BLOOD ___ PTT-32.9 ___ ___ 07:09PM BLOOD Glucose-112* UreaN-17 Creat-1.0 Na-133 K-5.1 Cl-98 HCO3-23 AnGap-17 ___ 04:54AM BLOOD ALT-14 AST-23 AlkPhos-253* TotBili-1.0 ___ 07:09PM BLOOD proBNP-2796* ___ 07:09PM BLOOD cTropnT-<0.01 ___ 04:54AM BLOOD cTropnT-<0.01 ___ 04:54AM BLOOD Calcium-8.7 Phos-3.9 Mg-1.9 ============== CARDIAC LABS: ============== ___ 07:09PM BLOOD proBNP-2796* ___ 07:09PM BLOOD cTropnT-<0.01 ___ 04:54AM BLOOD cTropnT-<0.01 ========================= PERTINENT IMAGING/STUDIES ========================= CT HEAD W/O CONTRAST (___): Chronic findings as discussed above. No evidence of fracture, hemorrhage or infarction CT C- SPINE (___): No evidence of fracture. Minimal anterior subluxation of C7 on T1 due to degenerative disease. Anterior fusion of C3 through C7 appears intact with no evidence of hardware failure. Degenerative disc disease with canal and foraminal narrowing at multiple levels. CXR PA/LAT (___) FINDINGS: AP upright and lateral views of the chest provided. The heart remains mildly enlarged. Lung volumes are low limiting assessment. No convincing signs of pneumonia or edema. There may be mild hilar congestion. No large effusion or pneumothorax. Mediastinal contour is normal. Bony structures are intact. Bilateral AC joint arthropathy noted. Fusion hardware projects over the C-spine. IMPRESSION: Stable mild cardiomegaly with mild hilar congestion. ====== MICRO: ====== Urine Culture: URINE CULTURE (Final ___: ___ MD (___) REQUESTS FOSFOMYCIN SENSITIVITIES ___. ENTEROCOCCUS FAECIUM. >100,000 ORGANISMS/ML.. Sensitivity testing per ___ ___. ZONE SIZE FOR FOSFOMYCIN IS 15 MM. Zone size determined using a method that has not been standardized for this drug- organism combination and for which no CLSI or FDA-approved interpretative standards exist. Interpret results with caution. Fosfomycin sensitivity testing performed by ___ ___. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECIUM | AMPICILLIN------------ =>64 R LINEZOLID------------- 2 S NITROFURANTOIN-------- 64 I TETRACYCLINE---------- =>16 R VANCOMYCIN------------ =>32 R =============== Discharge Labs: ***LEFT AMA*** =============== ___ 07:00AM BLOOD WBC-5.1 RBC-3.86* Hgb-9.8* Hct-31.2* MCV-81* MCH-25.4* MCHC-31.4* RDW-18.0* RDWSD-52.9* Plt ___ ___ 07:00AM BLOOD Plt ___ ___ 03:04PM BLOOD Glucose-157* UreaN-22* Creat-1.2 Na-130* K-3.6 Cl-86* HCO3-31 AnGap-17 ___ 03:04PM BLOOD Calcium-10.3 Phos-3.9 Mg-2.1 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q8H 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Bengay Cream 1 Appl TP TID:PRN pain 5. FoLIC Acid 1 mg PO DAILY 6. Gabapentin 300 mg PO TID 7. Metoprolol Succinate XL 25 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. QUEtiapine Fumarate 200 mg PO QHS 10. QUEtiapine Fumarate 50 mg PO QAM 11. QUEtiapine Fumarate ___ mg PO Q6H:PRN anxiety, agitation, insomnia 12. Thiamine 250 mg PO DAILY 13. Furosemide 100 mg PO BID Discharge Medications: 1. Acetaminophen 650 mg PO Q8H RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by mouth every eight (8) hours Disp #*90 Tablet Refills:*0 2. Aspirin 81 mg PO DAILY RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet Refills:*0 4. Bengay Cream 1 Appl TP TID:PRN pain RX *menthol [BenGay Vanishing Scent] 2.5 % apply three times a day Refills:*0 5. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 6. Gabapentin 300 mg PO TID RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day Disp #*90 Capsule Refills:*0 7. Metoprolol Succinate XL 25 mg PO DAILY RX *metoprolol succinate 25 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 8. Multivitamins 1 TAB PO DAILY RX *multivitamin [Daily Multi-Vitamin] 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 9. QUEtiapine Fumarate 200 mg PO QHS RX *quetiapine 200 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 10. QUEtiapine Fumarate 50 mg PO QAM RX *quetiapine 50 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 11. Thiamine 250 mg PO DAILY RX *thiamine HCl (vitamin B1) 250 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 12. Furosemide 100 mg PO BID RX *furosemide [Lasix] 80 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 RX *furosemide [Lasix] 20 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 RX *furosemide 20 mg 5 tablet(s) by mouth twice a day Disp #*300 Tablet Refills:*0 13. QUEtiapine Fumarate ___ mg PO Q6H:PRN anxiety, agitation, insomnia 14. Potassium Chloride (Powder) 40 mEq PO DAILY RX *potassium chloride 20 mEq 2 packet(s) by mouth daily Disp #*100 Packet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: acute on chronic systolic heart failure Urinary tract infection Secondary diagnoses: Leg ulcers Mood disorder 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 cough sob COMPARISON: ___ FINDINGS: AP upright and lateral views of the chest provided. The heart remains mildly enlarged. Lung volumes are low limiting assessment. No convincing signs of pneumonia or edema. There may be mild hilar congestion. No large effusion or pneumothorax. Mediastinal contour is normal. Bony structures are intact. Bilateral AC joint arthropathy noted. Fusion hardware projects over the C-spine. IMPRESSION: Stable mild cardiomegaly with mild hilar congestion. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old man who fell and hit hit, no LOC. // eval for hemorrhage after headstrike TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained without intravenous contrast. Coronal and sagittal reformations and bone algorithms reconstructions were also performed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 17.1 cm; CTDIvol = 47.0 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: CT head ___ FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. Prominence of the ventricles and sulci is suggestive of atrophy. No fracture seen. There is moderate mucosal thickening in the ethmoid air cells. The imaged portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are otherwise clear. The imaged portion of the orbits are unremarkable. IMPRESSION: Chronic findings as discussed above. No evidence of fracture, hemorrhage or infarction. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: ___ year old man who fell and hit hit, no LOC. eval for hemorrhage. cervical spine tenderness // eval for cervical spine tenderness TECHNIQUE: Contiguous axial images obtained through the cervical spine without intravenous contrast. Coronal and sagittal reformats were reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 6.4 s, 24.8 cm; CTDIvol = 37.3 mGy (Body) DLP = 926.2 mGy-cm. Total DLP (Body) = 926 mGy-cm. COMPARISON: CT C-spine ___ FINDINGS: Evaluation at the level of the dental hardware is somewhat limited due to artifact. Anterior fusion hardware from C3-C7 appears similar to prior. There is no perihardware lucency or other complication identified. Alignment is not significantly changed since prior, with minimal C7 on T1 anterolisthesis similar to prior. No fractures are identified. There are changes of degenerative disc disease with a small bulge of the disc at C2-3 narrowing the spinal canal but not contacting the spinal cord. The neural foramina appear normal. At C3-4, prominent intervertebral osteophytes encroach on the spinal canal, greater on the left than right. These appear to flatten the anterior surface of the spinal cord. In addition, uncovertebral and facet osteophytes produce moderate -severe left neural foraminal narrowing. At C4-5, intervertebral osteophytes narrow the spinal canal and flatten the anterior surface of the spinal cord. Facet and uncovertebral osteophytes produce moderate right neural foraminal narrowing. At C5-6, small intervertebral osteophytes narrow the spinal canal and contact the anterior surface of the spinal cord. The neural foramen appears normal. At C6-7, intervertebral osteophytes narrow the spinal canal and slightly flatten the anterior surface of the spinal cord. Uncovertebral osteophytes produce mild right and moderate left neural foraminal narrowing. There is mild canal narrowing at C7-T1 due to subluxation. However, this does not appear sufficient to contact the spinal cord. The neural foramina appear normal. There is no prevertebral edema. The thyroid and included lung apices are unremarkable. IMPRESSION: No evidence of fracture. Minimal anterior subluxation of C7 on T1 due to degenerative disease. Anterior fusion of C3 through C7 appears intact with no evidence of hardware failure. Degenerative disc disease with canal and foraminal narrowing at multiple levels. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Leg swelling, Dyspnea Diagnosed with Heart failure, unspecified temperature: 98.1 heartrate: 104.0 resprate: 18.0 o2sat: 96.0 sbp: 98.0 dbp: 71.0 level of pain: 10 level of acuity: 3.0

Mr. ___, You were admitted to the hospital because you had gained a lot of weight because you were refusing your diuretic medicine at your rehab. This weight was all fluid. As well, we found that you had a urinary tract infection that we treated with antibiotics. The wound on your leg was treated with dressings but we did not think it was infected. At home you should check your weight every day and if you gain more than 3 pounds you should call your doctor right away. You decided to leave AGAINST MEDICAL ADVICE on ___. We strongly encourage you to seek care at a hospital after leaving because you still have a lot of extra fluid causing strain on your heart and you need ongoing treatment with IV medication to remove fluid. However, you understand the risks of leaving the hospital, including the risks of serious illness and death. Be well, your ___ team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Beta-Blockers (Beta-Adrenergic Blocking Agts) / Tetanus / Tuberculin,Purif.Prot.Deriv. / metoprolol Attending: ___ Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: ___ with hx cirrhosis (NASH + ETOH), IDDM, COPD, CVA (L hemiplegia), and schizophrenia, now presenting with altered mental status. He was noted by ___ to have confusion and disorientation, which appeared to be new as of ___. He was unable to provide further history given altered mental status. Per outpatient notes, he has been gaining weight due to dietary indiscretion. In the ED, initial VS notable for 97.8 88 136/51 18 100% RA Exam was notable for soft abdomen, 2+ bilateral pitting edema, guaiac positive stool, mild asterixis, no accessible ascites seen on ultrasound. He was given: ___ 18:44 IV Dextrose 50% 12.5 gm ___ 19:01 IVF 1000 mL NS 1000 mL ___ 21:55 PO/NG Lactulose 30 mL ___ 00:09 PO/NG Lactulose 30 mL He was admitted to medicine for further management. On arrival he had large bowel movement. Denies pain or discomfort. Past Medical History: - EtOH abuse - EtOH cirrhosis - Variceal bleeds - Erosive esophagitis and gastic varicies - CVA and left hemiplegia - IDDM - Schizophrenia - Anemia - Hypothyroidism - Obesity - HTN - HL - Migranes - COPD Social History: ___ Family History: No family history of liver disease Physical Exam: ADMISSION VS: 98.3 123/56 97 22 100RA General: Obese man in NAD HEENT: NCAT, pupils equal, MMM Neck: Supple CV: RRR, S1/S2 no m/r/g Lungs: CTAB anterior fields Abdomen: Soft, nontender, nondistended NABS GU: Incontinent of urine. Ext: Tender ___ pitting edema bilaterally to knees Neuro: A/O to name only, not to location or year. Skin: No rashes noted. DISCHARGE VS: 98.9 120s/50-70s 80-90s ___ 100RA General: Obese man in NAD HEENT: NCAT, pupils equal, MMM Neck: Supple CV: RRR, S1/S2 no m/r/g Lungs: CTAB anterior fields Abdomen: Soft, nontender, nondistended NABS GU: Incontinent of urine. Ext: Tender ___ pitting edema bilaterally to knees Neuro: A/O x 3, no asterixis Skin: No rashes noted. Pertinent Results: ADMISSION LABS ___ 06:48PM BLOOD WBC-4.7 RBC-3.65* Hgb-11.7* Hct-33.5* MCV-92 MCH-32.1* MCHC-34.9 RDW-13.0 RDWSD-43.6 Plt Ct-53* ___ 06:48PM BLOOD Neuts-77.3* Lymphs-9.0* Monos-10.5 Eos-2.6 Baso-0.2 Im ___ AbsNeut-3.60# AbsLymp-0.42* AbsMono-0.49 AbsEos-0.12 AbsBaso-0.01 ___ 06:48PM BLOOD ___ PTT-36.4 ___ ___ 06:48PM BLOOD Plt Ct-53* ___ 06:48PM BLOOD Glucose-74 UreaN-22* Creat-0.9 Na-136 K-3.8 Cl-102 HCO3-22 AnGap-16 ___ 06:48PM BLOOD ALT-28 AST-54* AlkPhos-77 TotBili-1.1 ___ 05:00AM BLOOD Albumin-3.2* Calcium-8.7 Phos-4.2 Mg-2.3 ___ 02:02AM URINE Color-Yellow Appear-Hazy Sp ___ ___ 02:02AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG ___ 02:02AM URINE RBC-3* WBC-3 Bacteri-MOD Yeast-NONE Epi-<1 ___ 02:02AM URINE CastHy-5* DISCHARGE LABS ___ 05:00AM BLOOD WBC-1.8* RBC-3.23* Hgb-10.1* Hct-30.2* MCV-94 MCH-31.3 MCHC-33.4 RDW-12.9 RDWSD-43.9 Plt Ct-48* ___ 05:00AM BLOOD Plt Ct-48* ___ 05:00AM BLOOD Glucose-143* UreaN-20 Creat-0.8 Na-138 K-3.6 Cl-107 HCO3-21* AnGap-14 ___ 05:00AM BLOOD ALT-30 AST-51* AlkPhos-76 TotBili-0.7 ___ 05:00AM BLOOD Albumin-3.3* Calcium-8.9 Phos-4.1 Mg-2.0 MICROBIOLOGY ___ BLOOD CULTURE, URINE CULTURE NEGATIVE IMAGING -Chest x-ray ___: Mild pulmonary vascular congestion. No focal consolidation to suggest pneumonia. -RUQUS ___: 1. Cirrhotic liver with no focal hepatic lesions identified in this limited examination. 2. Patent main portal vein. 3. Splenomegaly. Radiology Report EXAMINATION: CHEST (AP AND LAT) INDICATION: History: ___ with altered mental status TECHNIQUE: Upright AP and lateral views of the chest COMPARISON: Chest radiograph ___ FINDINGS: Cardiac silhouette size remains mildly enlarged. The aorta is unfolded. There is mild pulmonary vascular congestion. No focal consolidation, pleural effusion or pneumothorax is present. Mild multilevel degenerative changes are seen in the thoracic spine. IMPRESSION: Mild pulmonary vascular congestion. No focal consolidation to suggest pneumonia. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: History: ___ with cirrhosis and altered mental status TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: Abdominal CT from ___. FINDINGS: Study is slightly limited due to patient's inability to comply with breathing instructions. LIVER: The liver is coarsened and nodular in echotexture. The contour of the liver is nodular, consistent with cirrhosis. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 4 mm. GALLBLADDER: There is no evidence of stones or gallbladder wall thickening. PANCREAS: Imaged portion of the pancreas appears within normal limits, without masses or pancreatic ductal dilation, with portions of the pancreatic tail obscured by overlying bowel gas. SPLEEN: Normal echogenicity, measuring 18.4 cm. RETROPERITONEUM: Visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. Cirrhotic liver with no focal hepatic lesions identified in this limited examination. 2. Patent main portal vein. 3. Splenomegaly. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: History: ___ with altered mental status, question of fall today, tenderness to palpation within the midline cervical spine 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, 16.3 cm; CTDIvol = 49.3 mGy (Head) DLP = 802.7 mGy-cm. 2) Sequenced Acquisition 6.4 s, 16.3 cm; CTDIvol = 49.3 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 1,605 mGy-cm. COMPARISON: None. FINDINGS: The exam is somewhat limited by motion despite attempts to repeat sequences. There is no evidence of infarction, hemorrhage, edema, or mass. There is prominence of the ventricles and sulci suggestive of involutional changes. There is slight leftward angulation of the nasal bone, likely chronic. 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: No acute intracranial process Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE INDICATION: History: ___ M with altered mental status, possible fall today, tenderness to palpation within the midline cervical spine. TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue and bone algorithm images were generated. Coronal and sagittal reformations were then constructed. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.9 s, 22.8 cm; CTDIvol = 37.2 mGy (Body) DLP = 850.4 mGy-cm. Total DLP (Body) = 850 mGy-cm. COMPARISON: None. FINDINGS: Alignment is normal. No fractures are identified.Multilevel mild degenerative changes are noted with loss of disc height and anterior and posterior osteophytes, worse at C3-4 C5-6 and C6-7. A disc bulge and posterior osteophytes at C3-4 and C6-7 indent the thecal sac anteriorly. Mild multilevel neural foraminal narrowing is most pronounced bilaterally at C5-6 and C6-7. There is no prevertebral soft tissue swelling. There is no evidence of infection or neoplasm. IMPRESSION: No evidence of fracture or traumatic malalignment. Gender: M Race: HISPANIC/LATINO - PUERTO RICAN Arrive by AMBULANCE Chief complaint: Altered mental status Diagnosed with Altered mental status, unspecified temperature: 97.8 heartrate: 88.0 resprate: 18.0 o2sat: 100.0 sbp: 136.0 dbp: 51.0 level of pain: unable level of acuity: 2.0

Dear Mr. ___, You were admitted to ___ with concern for worsening confusion. This is due to your liver disease. There was no evidence of infection. We increased your lactulose and your mental status improved. Please follow up with your appointments and continue to take your lactulose. Please increase your lactulose to every 2 hours if you notice worsening confusion. Best of luck, it was a pleasure taking care of you. Your ___ medical team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: Bactrim / Sulfa(Sulfonamide Antibiotics) Attending: ___. Chief Complaint: increasing h/a's and lower extremity weakness (L>R) Major Surgical or Invasive Procedure: ___: Right craniotomy and evacuation of subdural hematoma History of Present Illness: This is a ___ y.o. female known to service with chronic R SDH after a syncopal fall. She was followed by Dr. ___ in the ___ clinic. She reports that for the past ___ days she has had increasing headaches and gait instability. She has tried OTC without much relief. She went to the ED and after evaluation surgical planning was initiated. Past Medical History: asymptomatic PE and DVT off coumadin since ___ CAD s/p stent ___ HTN thoracic aneurysm, with mural thrombus in the descending aortic artery ___ lupus anticoagulant upper limit normal diverticular disease hyperlipidemia GERD anxiety osteoarthritis s/p total-knee replacement carpal tunnel s/p release surgeries and prior hysterectomy 3 lumbar spine surgeries Social History: ___ Family History: No FH of clotting, PE, stroke, or known autoimmune illness. Positive FH of CABG in 6 siblings, M/I in father. Physical Exam: On admission: Mental status: Awake and alert x2.5 knew day and year cofused with month, cooperative with examination; normal affect. Speech fluent with good comprehension and repetition. No dysarthria or paraphasic errors. Cranial Nerves: II-XII intact, pupils ___ b/l, EOM intact, no nystagmus Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ in UEs, slight generalized weakness in LLE ___. + slight left pronator drift; no clonus, toes upgoing on left, downgoing on right PHYSICAL EXAM UPON DISCHARGE: Alert and Oriented x2, somewhat confused about place on and off CN ___ grossly intact L grip 5-, LLE IP 5-, Q5, H4, AT5, EHL3, G5 Pertinent Results: ___ CT Head: IMPRESSION: 1. Interval increase in size of right hemispheric convexity subdural hematoma with associated increase in leftward shift of the normally midline structures. 2. No acute large vascular territorial infarction. ___ CXR: IMPRESSION: No acute cardiopulmonary process. CT HEAD W/O CONTRAST Study Date of ___ 7:46 ___ IMPRESSION: Interval right craniotomy and placement of a right subdural drain with decrease in size of the right subdural fluid collection, which now measures 14-mm, but persistent right sulcal and lateral ventricle effacement and 8 mm leftward shift of normally midline structures. Large right subdural air, likely post-procedural. CT HEAD W/O CONTRAST Study Date of ___ 7:46 AM IMPRESSION: Expected post-surgical changes in right subdural hematoma drain with decrease in pneumocephalus. Stable 8 mm leftward shift of midline structures. CT Head ___: Since the previous CT examination, the subdural drain has been removed. The size of the residual subdural has not significantly changed. No definite new hemorrhage seen LENS ___: No evidence of deep vein thrombosis in either leg Medications on Admission: Atenolol; Fluoxetine; Nifedipine; Nitroglycerine; Omeprazole. Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain, HA, fever 2. Atenolol 50 mg PO DAILY 3. Codeine Sulfate ___ mg PO Q4H:PRN pain RX *codeine sulfate 15 mg ___ tablet(s) by mouth Q4hrs Disp #*60 Tablet Refills:*0 4. Fluoxetine 20 mg PO DAILY 5. Heparin 5000 UNIT SC TID may start at 2200 ___ 6. LeVETiracetam 1000 mg PO BID Duration: 6 Days Last dose on ___ 7. NIFEdipine CR 60 mg PO DAILY 8. Omeprazole 20 mg PO DAILY 9. Simvastatin 20 mg PO DAILY 10. Xopenex Neb *NF* 1 NEB IH Q6H wheezing Reason for Ordering: Wheezing, albuterol may induce A. Fib 11. Docusate Sodium 100 mg PO BID 12. Senna 1 TAB PO BID constipation 13. Bisacodyl 10 mg PO/PR DAILY constipation 14. Nitroglycerin SL 0.4 mg SL PRN chest pain Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Right Subdural Hematoma Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report INDICATION: Known subdural hematoma, now with worsening lower extremity weakness over the past three days. Evaluate for progression of subdural hematoma. TECHNIQUE: Sequential axial images were acquired through the head without administration of intravenous contrast material. Multiplanar reformats were performed. COMPARISON: CT head from ___. FINDINGS: There has been an interval increase in size of the known subdural hematoma overlying the right cerebral hemisphere, with the maximal width of the extra-axial collection now measuring 2.4 cm compared to 1.7 cm previously (2:17). The degree of associated leftward shift of the normally midline structures is also increased, now measuring 11 mm compared to 8 mm previously (2:13). Marked sulcal effacement throughout the right hemisphere is redemonstrated, as is marked compression of the right lateral ventricle. There is no entrapment of the left lateral ventricle or transtentorial herniation. There is no acute large vascular territorial infarction. Calcifications are seen of the bilateral cavernous carotid arteries. The imaged portions of the orbits are unremarkable. The visualized portions of the paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: 1. Interval increase in size of right hemispheric convexity subdural hematoma with associated increase in leftward shift of the normally midline structures. 2. No acute large vascular territorial infarction. Radiology Report CHEST, TWO VIEWS: ___ HISTORY: ___ female with subdural hematoma which is worsening. Preop chest x-ray. FINDINGS: Frontal and lateral views of the chest are compared to previous exam from ___. The lungs remain clear of focal consolidation or effusion. Cardiac silhouette is slightly enlarged and there is a tortuous aorta, unchanged from prior. The descending thoracic aorta is enlarged, aneurysmal, measuring 5.8 cm AP and lateral view. Osseous structures notable for left shoulder arthroplasty. IMPRESSION: No acute cardiopulmonary process. Radiology Report INDICATION: ___ female with coronary artery disease and history of pulmonary embolus, now with subdural hematoma. ___. TECHNIQUE: Axial CT images through the head were acquired without intravenous contrast. Coronal, sagittal, and thin slice bone reconstructed images were reviewed. FINDINGS: There has been interval right frontal craniotomy with placement of a subdural catheter. Large right frontal subdural air is likely post-procedural. There has been interval decrease in size of the right subdural collection, which now measures 14 mm in greatest width. There is decreased but persistent leftward shift of normally midline structures, now measuring 8 mm. The basal cisterns appear patent. There is persistent effacement of the sulci along the right cerebral convexity and of the right lateral ventricle. Soft tissue swelling and subgaleal air overlie the craniotomy site. Craniotomy hardware and scalp surgical staples are seen. The visualized portions of the paranasal sinuses and mastoid air cells appear well aerated. IMPRESSION: Interval right craniotomy and placement of a right subdural drain with decrease in size of the right subdural fluid collection, which now measures 14-mm, but persistent right sulcal and lateral ventricle effacement and 8 mm leftward shift of normally midline structures. Large right subdural air, likely post-procedural. Radiology Report INDICATION: Chronic subdural hematoma with craniotomy performed. Evaluation for interval changes after evacuation. TECHNIQUE: Contiguous axial images were obtained through the brain without IV contrast. COMPARISON: Multiple prior NECTs of the head from ___ to ___. FINDINGS: Comparison to NECT of the head from ___, there is little interval change. Again noted is a large right frontoparietal fluid collection with recent evacuation and external drain in place. There is unchanged 8 mm leftward subfalcine herniation. The basal cisterns are patent, however. Pneumocephalus has decreased. The subdural fluid collection is unchanged in size. Persistent effacement of the right lateral ventricle and right frontoparietal cerebral convexities is unchanged. Post-surgical changes from craniotomy are noted. There is no new area of hemorrhage. The visualized paranasal sinuses, mastoid air cells, middle ear cavities are clear. IMPRESSION: Expected post-surgical changes in right subdural hematoma drain with decrease in pneumocephalus. Stable 8 mm leftward shift of midline structures. Radiology Report EXAM: CT of the head. CLINICAL INFORMATION: Patient with subdural hematoma status post evacuation. TECHNIQUE: Axial images of the head were obtained without contrast and compared with prior CT of ___. FINDINGS: Since the previous study, the subdural drain has been removed. Residual subdural with high and low density measuring approximately 14 mm is again identified, not significantly changed since the prior study. Mild indentation on the adjacent sulci and slight indentation on the right lateral ventricle are again noted without significant midline shift. Basal cisterns remain patent. IMPRESSION: Since the previous CT examination, the subdural drain has been removed. The size of the residual subdural has not significantly changed. No definite new hemorrhage seen. Radiology Report HISTORY: ___ female with extended bed rest, evaluate legs for DVT. COMPARISON: No previous exam for comparison. FINDINGS: Grayscale, color and Doppler images were obtained of bilateral common femoral, femoral, popliteal and tibial veins. Normal flow, compression and augmentation is seen in all of the vessels. IMPRESSION: No evidence of deep vein thrombosis in either leg. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: LOWER EXTREMITY WEAKNESS Diagnosed with INTRACEREBRAL HEMORRHAGE temperature: 97.6 heartrate: 61.0 resprate: 18.0 o2sat: 96.0 sbp: 99.0 dbp: 53.0 level of pain: 0 level of acuity: 2.0

Craniotomy for Hemorrhage •Have a friend/family member check your incision daily for signs of infection. •Take your pain medicine as prescribed. •Exercise should be limited to walking; no lifting, straining, or excessive bending. •**Your wound was closed with staples. You may wash your hair only after sutures and/or staples have been removed on ___ •You may shower before this time using a shower cap to cover your head. •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, and Ibuprofen etc. •**You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. •Clearance to drive and return to work will be addressed at your post-operative office visit. •Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Headache, back pain Major Surgical or Invasive Procedure: Lumbar Puncture ___ History of Present Illness: ___ yo. w/history of severe migraines, now here with 2 weeks of headache and 1 week of low back pain. First symptom was headache similar to previous migraines but unrelenting for the last couple of weeks, which she has not had since high school. It is left-sided, frontal, throbbing, associated with phonophobia, nausea, and extreme light sensitivity: she wears her sunglasses at night. Also has sensation of floaters or tracers in eyes, and pain on eye movements when looking to the side of the headache. She thinks these visual symptoms may be related to her extreme photophobia as they are improved with the sunglasses. She has been taking ibuprofen 600 ___ x daily as well as Fioricet, without relief, and just got prescriptions for tramadol and sumatriptan as well but was unable to tolerate these as they made her feel trippy and woozy. Over the last week, she also developed low back pain that radiates down her entire right leg. The last couple of days has had neck stiffness on the left side. No history of neck trauma At the time of evaluation, pt had received morphine 5 mg IV twice and ondansetron, without relief. ROS: Complains of urinary frequency but not urgency or incontinence, and has good bowel control. Feels unable to ambulate due to severe pain. On neurologic ROS, no lightheadedness/confusion/syncope/seizures/difficulty with producing or comprehending speech/amnesia/concentration problems; no loss of vision/amaurosis/diplopia/vertigo, tinnitus, hearing difficulty, dysarthria, or dysphagia. On general ROS, no fevers/chills/rigors/night sweats/anorexia/weight loss. No chest pain/palpitations/dyspnea/exercise intolerance/cough. No vomiting/diarrhea/constipation/abdominal pain. No dysuria/hematuria. Past Medical History: - Migraine without aura, with previous ED visits and hospitalizations as teenager - ruptured ovarian cyst - lactose intolerance Social History: ___ Family History: Parents: mother with migraines ___: grandmother with ___ Uncle with epilepsy Physical Exam: Admission exam: VS T:97.6 HR:75 BP:102/66 RR:18 SaO2:99%RA General: NAD, lying in bed in moderate distress due to headache, back pain and photophobia, wearing dark sunglasses - Head: NC/AT, no conjunctival pallor or icterus, no oropharyngeal lesions - Neck: Negative Brudzinski and Kernig signs but has paracervical muscle spasm on left. No lymphadenopathy or thyromegaly. - Neurovascular: No carotid, vertebral or subclavian bruits. - Cardiovascular: carotids with normal volume & upstroke; RRR, no M/R/G - Respiratory: Nonlabored, clear to auscultation with good air movement bilaterally - Abdomen: nondistended, normal bowel sounds, no tenderness/rigidity/guarding, no hepatosplenomegaly to palpation and percussion - Extremities: Warm, no cyanosis/clubbing/edema. - Back: no tenderness to percussion of spine. Negative straight leg raise when sitting on edge of bed, although pt was unable to tolerate it lying flat; negative crossed straight leg raise. Internal rotation of hip elicits pain, as does compression of pelvis. Neurologic Examination: Mental Status: Awake, alert, oriented x 3. Attention: Recalls a coherent history; thought process coherent and linear without circumstantiality and tangentiality. Concentration maintained when recalling months backwards. Language: fluent without dysarthria and with intact repetition and verbal comprehension. No paraphasic errors. Follows two-step commands, midline and appendicular and crossing the midline. High- and low-frequency naming intact. Normal reading. Normal prosody. Memory: Registration ___ and recall ___, improving to ___ with category cueing. Praxis: No ideomotor apraxia or neglect w/o bodypart-as-object or spacing errors. Executive function tests: Luria hand sequencing learned without verbal reinforcement. Cranial Nerves: [II] Pupils: equal in size, small ~ 1 mm and reactive on taking off sunglasse, unable to tolerate flashlight or fundoscopic exam. [III, IV, VI] EOM intact, only physiologic end-gaze nystagmus. [V] V1-V3 with symmetrical sensation to light touch/pin/cold. Pterygoids contract normally. [VII] No facial asymmetry. [VIII] Hearing grossly intact. [IX, X] Palate elevation symmetric. [XI] SCM strength ___ bilaterally. [XII] Tongue shows no atrophy, emerges in midline and moves facilely. Motor: Normal bulk and tone. No pronation or drift. No tremor or asterixis. [ Direct Confrontational Strength Testing ] Arm Deltoids [R 5] [L 5] Biceps [R 5] [L 5] Triceps [R 5] [L 5] Extensor Carpi Radialis [R 5] [L 5] Finger Extensors [R 5] [L 5] Finger Flexors [R 5] [L 5] Leg Iliopsoas [R 5] [L 5] Quadriceps [R 5] [L 5] Hamstrings [R 5] [L 5] Tibialis Anterior [R 5] [L 5] Gastrocnemius [R 5] [L 5] Extensor Hallucis Longus [R 5] [L 5] Extensor Digitorum Brevis [R 5] [L 5] Flexor Digitorum Brevis [R 5] [L 5] Sensory: Intact proprioception at halluces bilaterally. No deficits to pinprick testing on extremities and trunk. Has patches of hypersensitivity on left face & neck & shoulder, low back pain, stretch over right groin, inside of left thigh, entire right leg. Cortical sensation: No extinction to double simultaneous stimulation. Graphesthesia intact. Reflexes [Bic] [Tri] [___] [Quad] [Ankle] L ___ 2 2 R ___ 2 2 Babinski testing impossible due to withdrawal. Coordination: No rebound. No past-pointing when touching own nose with finger, with eyes closed. No dysmetria on finger-to-nose and heel-knee-shin testing. No dysdiadochokinesia. Forearm orbiting symmetric. Finger tapping on crease of thumb symmetric. Gait& station: Antalgic gait. . . DISCHARGE EXAM: Unchanged. Pertinent Results: ___ 08:28PM BLOOD WBC-5.1 RBC-4.55 Hgb-13.4 Hct-40.0 MCV-88 MCH-29.5 MCHC-33.6 RDW-12.5 Plt ___ ___ 08:28PM BLOOD Neuts-59.0 ___ Monos-5.1 Eos-0.4 Baso-0.9 ___ 08:28PM BLOOD Glucose-85 UreaN-7 Creat-0.6 Na-139 K-4.3 Cl-100 HCO3-25 AnGap-18 ___ 11:55AM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-1* Polys-8 ___ ___ 11:55AM CEREBROSPINAL FLUID (CSF) TotProt-26 Glucose-62 ___ 11:55 am CSF;SPINAL FLUID Source: LP #3. **FINAL REPORT ___ GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ___ 9:20 am SEROLOGY/BLOOD **FINAL REPORT ___ LYME SEROLOGY (Final ___: NO ANTIBODY TO B. BURG___ DETECTED BY EIA. Reference Range: No antibody detected. Negative results do not rule out B. burg___ infection. Patients in early stages of infection or on antibiotic therapy may not produce detectable levels of antibody. Patients with clinical history and/or symptoms suggestive of lyme disease should be retested in ___ weeks. . . CT HEAD NON-CONTRAST IMPRESSION: No evidence of an acute intracranial process. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ibuprofen 600 mg PO Q8H:PRN headache 2. TraMADOL (Ultram) 50 mg PO Q6H:PRN headache 3. Sumatriptan Succinate 50 mg PO DAILY:PRN headache Discharge Medications: 1. Ibuprofen 600 mg PO Q8H:PRN headache 2. Sumatriptan Succinate 50 mg PO DAILY:PRN headache 3. TraMADOL (Ultram) 50 mg PO Q6H:PRN headache Discharge Disposition: Home Discharge Diagnosis: Migraine Headaches Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Neurological Exam: Non-focal Followup Instructions: ___ Radiology Report HISTORY: Two weeks of headaches and neck pain. TECHNIQUE: Continuous axial sections were acquired through the brain without the administration of IV contrast. Coronal and sagittal reformations were provided and reviewed. DLP: 897.50 mGy/cm. COMPARISON: None. FINDINGS: There is no acute intracranial hemorrhage, edema or mass effect. The ventricles, cisterns and sulci are normal in size and configuration. The gray-white matter differentiation is preserved. The imaged paranasal sinuses and mastoid air cells are well aerated. The bones are unremarkable. IMPRESSION: No evidence of an acute intracranial process. Gender: F Race: HISPANIC/LATINO - PUERTO RICAN Arrive by WALK IN Chief complaint: Neck pain, Back pain Diagnosed with HEADACHE, LUMBAGO temperature: nan heartrate: 75.0 resprate: 18.0 o2sat: 99.0 sbp: 102.0 dbp: 66.0 level of pain: 9 level of acuity: 3.0

Dear Ms. ___, You were admitted with a headache and back pain. We were concerned that the two symptoms together may have indicated meningitis so we performed a lumbar puncture, which returned as normal. Therefore, we feel that your symptoms were related to a migraine headache. We made no following changes to your medications. Please continue to take your other medications as previously prescribed. If you experience any of the below listed Danger Signs, please contact your doctor or go to the nearest Emergency Room. It was a pleasure taking care of you on this hospitalization.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Multiple complaints Major Surgical or Invasive Procedure: None History of Present Illness: History is somewhat hampered by the patient's inability to relate a coherent history. Mr ___ is a ___ with Hodgkin lymphoma s/p chemo and mantle-XRT ___, thymic carcinoma s/p resection ___ with recurrence ___, stable until ___ when lost to followup in our center, CAD s/p IPMI and PCI with "3 stents", HTN, HL, COPD, active smoking, BPH, GERD, depression/anxiety, chronic left shoulder pain, who presents with fairly nebulous complaints. He relates a history that has no particular start point and no obvious milestones. - He says that over the past year he has noticed a clicking sensation, not really a pain, that occurs when he breathes. It comes and goes, but it has been more frequent recently and he has started to worry about it. He thinks it could represent progression/recurrence of his cancer. - He says that he has had shoulder issues for years. He was enrolled in a pain clinic for ___ years, trial of injections and Percocet, but was unhappy because they "didn't try to find the answer" and so he stopped going. He was referred to orthopedist Dr ___ performed MRI that showed "tears" and reportedly performed a procedure on his shoulder, that didn't work. Dr ___ told him "there wasn't anything more he could do for him." Over the past few weeks, he has noted increasing pain in the shoulder, some in his neck on that side, with radiation down his arm. Pain is sharp, worsened with ROM, but it is present all the time. - He has had fluctuations in his blood pressure, at times as high as high 180s/110s. This has been happening for the past few weeks. He denies symptoms, but said his daughter checks his BP frequently. - He is anxious and feels he needs a PET scan to determine the source of his underlying issues. According to Mr ___, his daughter became concerned about his shoulder pain with the radiation down the arm, along with the higher blood pressure. She brought him into ___ ___. He endorses a negative experience, where they "focused only on my heart and said things were fine." We do not have those records. His PCP apparently recommended he go back to see Dr ___ from Thoracics given his concerns. For unclear reasons, they decided to come to our ED rather than making an appointment. In the ED here, he had stable vital signs, mild tachycardia. Labs were performed and were unremarkable. Imaging was uploaded but there is no comment on the reads and he was not sent to us with copies of records. Admission was requested. He currently complains only of shoulder pain. It is as described above. He notably denies any increase in pain with ambulation. He tells me he is able to walk to the store and back without dyspnea and has continued to be able to do. He experiences chronic dyspnea with exertion when going up 1 flight of stairs, but denies chest pain. He endorsed sweats, but no f/c, n/v/d/c, cough, leg swelling, rashes. ROS is negative in 10 points except as noted above Past Medical History: Hodgkin lymphoma s/p chemo and mantle-XRT ___, thymic carcinoma s/p resection ___ with recurrence ___, stable until ___ when lost to followup in our center, CAD s/p IPMI and PCI with "3 stents", HTN, HL, COPD, active smoking, BPH, GERD, depression/anxiety, chronic left shoulder pain Social History: ___ Family History: Mother died in ___ of pancreatic cancer Father died in ___ of COPD and prostate cancer Sister died in ___ of cancer (cannot remember type) Physical Exam: Vitals AVSS Gen NAD, pleasant Abd soft, NT, ND, bs+ CV RRR, soft systolic murmur, no rubs ___ Lungs CTA ___, few rhonchi at bases Ext WWP, no edema Skin no rash, anicteric GU no foley Eyes EOMI HENT MMM, OP clear Neuro nonfocal, moves all extremities, steady gait MSK pain with flexion, abduction, and internal and external rotations of the left shoulder Psych flat affect Discharge Physical Exam: Exam: Vitals AVSS, SBP 100s-130s. Gen NAD, pleasant, sitting up in bed eating lunch. Abd soft, NT, ND, bs+ CV RRR, soft systolic murmur Lungs CTA ___, few rhonchi at bases Ext WWP, no edema Skin no rash, anicteric Neuro nonfocal, moves all extremities, steady gait MSK pain with flexion, abduction, and internal and external rotations of the left shoulder Psych flat affect Pertinent Results: Labs on admission: Heme ___ 08:10PM BLOOD WBC-7.5 RBC-4.82 Hgb-14.3 Hct-42.0 MCV-87 MCH-29.7 MCHC-34.0 RDW-14.6 RDWSD-46.8* Plt ___ ___ 08:10PM BLOOD Neuts-72.1* ___ Monos-5.5 Eos-1.1 Baso-0.4 Im ___ AbsNeut-5.43 AbsLymp-1.55 AbsMono-0.41 AbsEos-0.08 AbsBaso-0.03 ___ 08:10PM BLOOD ___ PTT-31.7 ___ Chem ___ 08:10PM BLOOD Glucose-122* UreaN-13 Creat-0.8 Na-139 K-3.9 Cl-102 HCO3-24 AnGap-17 ___ 08:10PM BLOOD ALT-20 AST-25 CK(CPK)-57 AlkPhos-94 TotBili-0.2 ___ 08:10PM BLOOD Lipase-22 ___ 08:10PM BLOOD cTropnT-<0.01 proBNP-116 ___ 08:10PM BLOOD Albumin-4.5 Calcium-9.9 Phos-2.8 Mg-2.2 Imaging: CT Chest: New 2.5 cm paramediastinal mass, adjacent to the aortic arch. Recurrence of disease is likely. Severe pulmonary emphysema with multiple small areas of nodularity and scarring, with a morphology unlikely to reflect metastatic disease. Ultrasound Sniff Test: There is normal, expected downward movement of the diaphragm upon rapid nasal inspiration bilaterally. Discharge Labs: ___ 07:49AM BLOOD WBC-7.7 RBC-4.73 Hgb-14.1 Hct-43.0 MCV-91 MCH-29.8 MCHC-32.8 RDW-15.4 RDWSD-50.6* Plt ___ ___ 07:49AM BLOOD Glucose-100 UreaN-15 Creat-0.9 Na-142 K-4.2 Cl-102 HCO3-26 AnGap-18 Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. meloxicam 15 mg oral DAILY 2. Citalopram 20 mg PO DAILY 3. Tamsulosin 0.4 mg PO QHS 4. TraMADol 50 mg PO BID:PRN Pain - Moderate 5. Omeprazole 20 mg PO DAILY 6. Metoprolol Tartrate 50 mg PO BID 7. Cyclobenzaprine 5 mg PO TID 8. HydrALAZINE 50 mg PO DAILY 9. amLODIPine 10 mg PO DAILY 10. Aspirin 325 mg PO DAILY 11. Tiotropium Bromide 1 CAP IH DAILY 12. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 13. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H RX *acetaminophen 500 mg 2 tablet(s) by mouth Every 6 hours Disp #*90 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 #*60 Capsule Refills:*0 3. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 4. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity Please take for the next ___ days then stop. RX *ibuprofen 600 mg 1 tablet(s) by mouth Every 8 hours Disp #*20 Tablet Refills:*0 5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Severe Duration: 5 Days Reason for PRN duplicate override: Alternating agents for similar severity Please taper off this medication over the next 5 days. RX *oxycodone 5 mg ___ tablet(s) by mouth Every 4 hours Disp #*25 Tablet Refills:*0 6. Senna 17.2 mg PO BID RX *sennosides [Senexon] 8.6 mg 2 Tablet by mouth twice a day Disp #*60 Tablet Refills:*0 7. Thiamine 100 mg PO DAILY RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 8. Vitamin D 800 UNIT PO DAILY RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth Daily Disp #*60 Tablet Refills:*0 9. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath 10. amLODIPine 10 mg PO DAILY 11. Aspirin 81 mg PO DAILY 12. Citalopram 20 mg PO DAILY 13. Cyclobenzaprine 5 mg PO TID 14. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 15. Furosemide 20 mg PO DAILY 16. HydrALAZINE 50 mg PO DAILY 17. Loratadine 10 mg PO DAILY 18. LORazepam 1 mg PO QHS:PRN extreem anxiety 19. Metoprolol Tartrate 50 mg PO BID 20. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 21. Omeprazole 20 mg PO DAILY 22. Tamsulosin 0.4 mg PO QHS 23. Tiotropium Bromide 1 CAP IH DAILY 24. TraMADol 50 mg PO TID:PRN Pain - Moderate Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Arthritis pain Likely recurrence of Thymic cancer 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/CONTRAST INDICATION: ___ year old man with history of Hodgkin's lymphoma status post chemotherapy and mantle field distribution radiotherapy in ___ with interval development of a mediastinal mass consistent with thymic carcinoma. Thepatient is status post resection in ___ and a biopsy of a recurrence in ___. Lost to follow up for ___ years now with left shoulder pain.// ? Recurrance of cancer TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration, administration of intravenous contrast material, multiplanar reconstructions. DOSE: DLP: 219 mGy-cm COMPARISON: ___. FINDINGS: Status post sternotomy. No abnormalities at the level of the thyroid. Saber sheath trachea. 25 x 20 mm soft tissue density mass in the anterior mediastinum, adjacent to the aortic arch (3, 15). No hilar lymphadenopathy. Borderline sized lymph nodes in the posterior mediastinum (3, 25). No incidental pulmonary embolism. No pericardial effusion. Right kidney cyst (3, 57). Mild degenerative vertebral disease. No vertebral compression fractures. No osteolytic lesions at the level of the ribs, the sternum, or the vertebral bodies. Mild bilateral apical scarring. Moderate respiratory motion. Severe pulmonary emphysema. The masslike lesion in the mediastinum shows extension into the lung parenchyma, with accompanying interstitial thickening (5, 78). Several mostly subpleural micronodules and areas of parenchymal scarring (5, 139). Mild atelectasis at the left lung basis. Mild mucous plugging. No pleural effusions. IMPRESSION: New 2.5 cm paramediastinal mass, adjacent to the aortic arch. Recurrence of disease is likely. Severe pulmonary emphysema with multiple small areas of nodularity and scarring, with a morphology unlikely to reflect metastatic disease. Radiology Report EXAMINATION: Ultrasound sniff test INDICATION: ___ year old man with PMHx Hodgkin lymphoma s/p chemo and mantle-XRT ___, thymic carcinoma s/p resection ___ with recurrence ___, stable until ___ when lost to follow-up in our center. CT scan now with 2-3cm anterior mediastinal mass likely near the vagus nerve. Discussed with Thoracic surgery who requests sniff test to check diaphragm function (U/S)// sniff test to check diaphragm function (U/S) TECHNIQUE: Grey scale Doppler ultrasound images of the abdomen were obtained of the right and left hemidiaphragm while at skin the patient to rapidly inspired through the nose. COMPARISON: CT chest ___ FINDINGS: There is normal, expected downward movement of the diaphragm upon rapid nasal inspiration bilaterally. IMPRESSION: No paradoxical diaphragmatic motion with rapid nasal inspiration. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abnormal CT, L Shoulder pain Diagnosed with Adult failure to thrive, Weakness temperature: 97.3 heartrate: 108.0 resprate: 16.0 o2sat: 99.0 sbp: 142.0 dbp: 94.0 level of pain: 10 level of acuity: 3.0

Mr ___, You were admitted for control of your blood pressure, evaluation of your shoulder pain, and follow up of your recurrent thymic cancer. You were continued on your home medications and placed on pain control with improvement in your symptoms. You had a CT scan that showed likely recurrence of your thymic cancer. We discussed a biopsy of the site but your declined an inpatient and requested this be worked up as an outpatient instead. As we discussed arthritis pain is not well treated with narcotic pain medication and you will have a short course but the intention is to taper off of this over the upcoming week. Please follow up as noted below.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: propranolol Attending: ___. Chief Complaint: right stump infection Major Surgical or Invasive Procedure: none History of Present Illness: Mr ___ is a ___ year old male patient with uncontrolled DM type 2 who is status post right below knee amputation with c/b surgical site infection and bone cyst, who presets to the ED after having discharge from surgical site associated with subjective fever and chills. condition started approximately last ___ after visiting Dr. ___ in the clinic and sutures were removed at that time. over the week, he experienced mild shooting pain that comes and goes associated with some malodorous discharge. He states that these are similar symptoms as when he had wound infection. He endorsed chills and subjective fever, but no anorexia, nausea/vomiting, chest pain, shortness of breath or any other complaints. Past Medical History: PMH: DM1, HTN, HLD, CKD stage 3 (Baseline Cr 1.9), PVD, R heel osteomyelitis PSH: - Right L4-5 discectomy ___ ___ - R THR - RLE angiogram for nonhealing heel ulcer - single vessel ___ runoff to foot ___ ___ - Split-thickness skin graft to the right heel ___ ___ - Right BKA ___ ___ - Left AT and peroneal angioplasty ___ ___ - Left below knee popliteal to anterior tibial arterial bypass Social History: ___ Family History: Non-contributory Physical Exam: Vitals: afebrile, GEN: AOx3, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses Ext: no Right stump erythema, hotness. mild tenderness at the distal anterior part of the stump, open wound at the tip of the stump, with malodorous discharge. Pulses: R: P/D/BKA L: P/D/D/D Pertinent Results: ___ 07:10AM BLOOD WBC-4.7 RBC-3.40* Hgb-9.2* Hct-29.3* MCV-86 MCH-27.1 MCHC-31.4* RDW-13.8 RDWSD-43.1 Plt ___ ___ 11:45PM BLOOD Neuts-85.9* Lymphs-6.0* Monos-5.9 Eos-1.4 Baso-0.4 Im ___ AbsNeut-13.80* AbsLymp-0.96* AbsMono-0.94* AbsEos-0.22 AbsBaso-0.06 ___ 01:05PM BLOOD Glucose-149* UreaN-35* Creat-2.3* Na-135 K-5.0 Cl-103 HCO3-24 AnGap-13 ___ 01:05PM BLOOD Calcium-8.1* Phos-4.1 Mg-2.4 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amitriptyline 25 mg PO QHS 2. Atorvastatin 10 mg PO QPM 3. CloNIDine 0.2 mg PO TID 4. Gabapentin 800 mg PO TID 5. Lisinopril 10 mg PO DAILY 6. Metoprolol Tartrate 50 mg PO DAILY 7. amLODIPine 10 mg PO DAILY 8. Senna 8.6 mg PO BID:PRN constipation 9. Glargine 45 Units Bedtime Humalog 10 Units Breakfast Humalog 10 Units Lunch Humalog 10 Units Dinner Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. Docusate Sodium 100 mg PO BID hold for ___ stool 3. Metoprolol Succinate XL 50 mg PO DAILY 4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe RX *oxycodone 5 mg 1 tablet(s) by mouth Q4H PRN Disp #*18 Tablet Refills:*0 5. Sulfameth/Trimethoprim DS 1 TAB PO BID RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 6. Glargine 45 Units Bedtime Humalog 10 Units Breakfast Humalog 10 Units Lunch Humalog 10 Units Dinner 7. Amitriptyline 25 mg PO QHS 8. amLODIPine 10 mg PO DAILY 9. Atorvastatin 10 mg PO QPM 10. CloNIDine 0.2 mg PO TID 11. Gabapentin 800 mg PO TID 12. Lisinopril 10 mg PO DAILY 13. Senna 8.6 mg PO BID:PRN constipation Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Rt Bellow Knee stump infection 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: KNEE (AP, LAT AND OBLIQUE) RIGHT INDICATION: ___ with BKA with concern for wound infection. Assess for subcutaneous gas. TECHNIQUE: Frontal and cross-table lateral radiographs of the right knee. COMPARISON: None. FINDINGS: Status post below right knee amputation. Of note distal most aspect of tibia and fibula was not fully evaluated. No acute fracture or dislocation. No joint effusion. Subtle rounded lucency seen along the edge of film may represent a locule of gas projecting over the mid tibia/fibula. Mild degenerative changes of the right knee predominantly involve the medial compartment. No periosteal reaction or cortical irregularity. No suspicious lytic or sclerotic lesion is identified. No soft tissue calcification or radio-opaque foreign body is detected. IMPRESSION: 1. Status post below right knee amputation. Of note distal most aspect of tibia and fibula WAS EVALUATED ON A SUBSEQUENT STUDY. 2. Subtle rounded lucency along the distal tibia may represent a locule of gas projecting over the mid tibia/ fibula, suspicious for infectious subcutaneous emphysema. RECOMMENDATION(S): Clinical correlation recommended to assess for infection and necrotizing fasciitis. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 1:32 AM, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: Chest radiograph. INDICATION: ___ with cough and fever. Assess for pneumonia. TECHNIQUE: Single portable upright frontal chest radiograph. COMPARISON: Chest radiograph ___. FINDINGS: The lungs are well inflated and clear. No pleural effusion or pneumothorax. Heart size, mediastinal contour, and hila are unremarkable. IMPRESSION: No acute cardiopulmonary process. Specifically, no pneumonia. Radiology Report EXAMINATION: TIB/FIB (AP AND LAT) RIGHT INDICATION: ___ with right BKA stump site inefection. Assess distal stump for subcutaneous emphysema. TECHNIQUE: Frontal and lateral view radiographs of right knee. COMPARISON: Right knee radiograph ___. FINDINGS: Patient is status post below right knee amputation with associated postsurgical changes. Subtle rounded radiolucencies within the distal lateral posterior stump may represent subcutaneous emphysema. No cortical irregularity or periosteal new bone formation. Scattered soft tissue calcifications are likely postsurgical. No right knee joint effusion. Mild degenerative changes of the medial right knee with subchondral sclerosis and small osteophytes. IMPRESSION: 1. Subtle rounded radiolucencies along distal lateral posterior stump may be subcutaneous emphysema. 2. No radiographic evidence of osteomyelitis. 3. Status post right below-knee amputation with associated postsurgical changes. RECOMMENDATION(S): If persistent concern for osteomyelitis consider MR for further evaluation. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with fevers // ___ year old man with fevers ___ year old man with fevers IMPRESSION: COMPARED TO CHEST RADIOGRAPHS SINCE ___, MOST RECENTLY ___ AND ___ AT 00:44. LUNGS CLEAR. HEART SIZE NORMAL. NO PLEURAL ABNORMALITY. CONFIGURATION TO THE UPPER MEDIASTINUM, WIDENED TO THE LEFT, COULD BE DUE TO FAT DEPOSITION OR THE CONGENITAL ANATOMIC ANOMALY, PERSISTENT LEFT SUPERIOR VENA CAVA. Radiology Report INDICATION: ___ year old man with nausea, vomiting // ___ year old man with nausea, vomiting TECHNIQUE: Portable supine abdominal radiograph was obtained. COMPARISON: None FINDINGS: There are no abnormally dilated loops of large or small bowel. Supine assessment limits detection for free air; there is no gross pneumoperitoneum. Osseous structures are notable for degenerative changes in the lumbar spine and left hip. There is a right-sided total hip arthroplasty. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: No evidence of bowel obstruction. Radiology Report EXAMINATION: CT LOWER EXT W/C RIGHT INDICATION: ___ year old man with febrile illness susp. bacteremia with Rt BKA stump wound ulcer. His Cr is ___ since ___. we hydrated him before an will hydrate after the CT will be done. Thank you. Evaluate for source of infection in RLE. TECHNIQUE: ___ MD CT images of the right lower extremity were obtained after the administration of IV contrast and reformatted in bone and soft tissue algorithm. Coronal and sagittal reformations were also obtained and used in evaluation. DOSE: Acquisition sequence: 1) Spiral Acquisition 24.8 s, 75.9 cm; CTDIvol = 34.6 mGy (Body) DLP = 2,585.9 mGy-cm. Total DLP (Body) = 2,603 mGy-cm. COMPARISON: Right tib-fib radiograph of ___. FINDINGS: There is diffuse soft tissue swelling and edema at the right below-the-knee amputation stump, extending up to the tibial tuberosity. Of note, there is an irregular 2.7 x 1.6 x 0.9 cm fluid collection in the soft tissues of the stump (4:351, 603A:66). Multiple small calcifications are identified in the soft tissues at the stump, likely postsurgical in nature. There is no subcutaneous emphysema. No evidence of cortical irregularity or periosteal reaction involving the underlying tibia and fibula. Of note, multiple enlarged, likely reactive, right inguinal lymph nodes are present (4:93, 604A:22). Incidental note is made of extensive atherosclerotic disease involving the right common, superficial, and deep formal artery, extending into the right popliteal artery. There also small bilateral fat containing inguinal hernias. There is no joint effusion. Patient is post right will hip arthroplasty. Degenerative changes of the medial patellofemoral compartment are mild. IMPRESSION: 1. Soft tissue swelling and edema involving the right below-the-knee amputation distal tissues, extending up to the level of the tibial tuberosity. Multiple enlarged, reactive right inguinal lymph nodes. 2. There is a 2.7 x 1.6 x 0.9 cm peripherally enhancing fluid collection in the soft tissues at the stump, concerning for a small abscess. 3. No evidence of underlying tibial or fibular cortical irregularity or periosteal reaction. However, as noted on the prior radiograph, MRI is more sensitive for evaluation of osteomyelitis. 4. There is no subcutaneous emphysema. This preliminary report was reviewed with Dr. ___ radiologist. NOTIFICATION: The above findings were communicated via telephone by Dr. ___ to Dr. ___ at 17:15 on ___, 5 min after discovery. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Wound eval, Fever, Hyperglycemia Diagnosed with Infection of amputation stump, right lower extremity, Amputation of limb(s) cause abn react/compl, w/o misadvnt temperature: 98.1 heartrate: 99.0 resprate: 16.0 o2sat: 99.0 sbp: 158.0 dbp: 85.0 level of pain: 8 level of acuity: 2.0

Dear Mr ___, It was a pleasure talking care of you at ___ ___. You were admitted to the vascular surgery service with an infection iof your Rt bellow knee amputation stump. You were admitted with febrile illness and a CT scan of your lower extremities showed a collection at the distal part of your stump. which later drained spont. You were treated conservatively with intravenous antibiotics. You tolerated the treatment well and got better. you were admitted with a Cr of 1.9 ( your lowest levels recently were 1.6) which during your stay went up as high as 2.8 and now trending down. On your day of discharge you are afebrile and feel well. What to expect: You should get stronger every day and the fever should nor return. Your stump should be getting better as well with no erythema or pain. If your fever returns and /or the stump starts to be painful red, warm or develop ulcer and/or a discharge you should be reffered to the ED or call your surgeon. ACTIVITY: - please do not use a prosthesis at least until your visit with Dr ___ a new prosthesis was contumed for you by this time please bring it with you to your visit. - Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. - You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. 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 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 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 fluids and see if it goes away. If it does not go away, or is severe and you feel ill, please call your surgeon. MEDICATIONS: - Take all the medicines you were on before the admission 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: M Service: PODIATRY Allergies: Latex / Penicillins / Bactrim Attending: ___ Chief Complaint: Right Foot Infection Major Surgical or Invasive Procedure: 1. Excisional debridement of bone, ___ metatarsal, right foot. 2. Ulcer excision with primary closure, right foot. History of Present Illness: Mr. ___ is a ___ with PMHx significant for CMT, COPD, HTN. He underwent a reconstruction of the R foot ___. He has had a lateral foot ulcer on the right foot since surgery. The size of the ulcer improved after the surgery. He also has a L ___ toe amputation at ___ last month and is still healing from that. He reports over the last 5 days he was having fevers / chills and also decreased appetite. He then noticed increased redness and swelling to the Right Foot with increased bloody and clear drainage from the lateral foot ulcer. He has been doing daily dressing changes. Per the patient Dr. ___ has been treating him, mentioned that he might need to go back to the OR to take some bone out around the ulcer which could be causing the wound to remain open. He then decided to present to the ED for further evaluation. He denies any recent chest pain, shortness of breath, nausea, diarrhea, constipation. He has not noticed any purulent drainage coming from the R foot wound. He does not have sensation to the ___ and does not report any pain ___ either foot. Past Medical History: PMH: Charcot ___ disease, COPD, HTN PSH: R triple arthrodesis, TAL (___), L tibial and fibular sesamoidectomy (___), L ___ MTC and hallux IPJ fusion (___), R ___, midfoot osteotomy, TAL (___), L Pan met, Keller, TAL (___), L hallux amp (___) Right Foot cavus Recon (___) Social History: ___ Family History: n/c Physical Exam: Discharge Physical Exam: AVSS Gen - NAD Cardiac - RRR Pulm - no respiratory distress Abd - soft, nontender VASC: ___ pulses palpable bilaterally, cap refill < 3 sec to the digits. Right Lower extremity - ___ normal and palpable b/l. Lateral and plantar midfoot T incision sutures intact, incision well copated, no signs of dehisence, mild serous drainage. No surrounding erythema or edema. No TTP Left Lower Extremity - s/p hallux amputation and recent ___ toe amputation. The second toe amputation site that has completely healed. Neuro: light touch sensation absent to the ___ bilaterally. Pertinent Results: MICRO: GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CLUSTERS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. TISSUE (Final ___: STAPH AUREUS COAG +. SPARSE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. MIXED BACTERIAL FLORA. This culture contains mixed bacterial types (>=3) so an abbreviated workup is performed. Any growth of P.aeruginosa, S.aureus and beta hemolytic streptococci will be reported. IF THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT ___ this culture. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. ___ 06:09AM BLOOD WBC-8.0 RBC-4.72 Hgb-14.8 Hct-43.8 MCV-93 MCH-31.4 MCHC-33.8 RDW-14.1 RDWSD-47.8* Plt ___ ___ 07:10AM BLOOD WBC-6.0 RBC-4.65 Hgb-14.5 Hct-42.8 MCV-92 MCH-31.2 MCHC-33.9 RDW-14.4 RDWSD-48.4* Plt ___ ___ 07:00AM BLOOD WBC-6.2 RBC-4.77 Hgb-14.9 Hct-44.3 MCV-93 MCH-31.2 MCHC-33.6 RDW-13.9 RDWSD-47.7* Plt ___ ___ 08:10AM BLOOD WBC-6.8 RBC-4.50* Hgb-14.2 Hct-41.8 MCV-93 MCH-31.6 MCHC-34.0 RDW-13.9 RDWSD-47.8* Plt ___ ___ 06:04AM BLOOD WBC-8.1 RBC-4.60 Hgb-14.2 Hct-42.6 MCV-93 MCH-30.9 MCHC-33.3 RDW-14.0 RDWSD-47.8* Plt ___ ___ 06:09AM BLOOD Neuts-83.5* Lymphs-5.8* Monos-9.2 Eos-0.1* Baso-0.4 Im ___ AbsNeut-6.71* AbsLymp-0.47* AbsMono-0.74 AbsEos-0.01* AbsBaso-0.03 ___ 06:09AM BLOOD Plt ___ ___ 07:10AM BLOOD Plt ___ ___ 07:00AM BLOOD ___ PTT-30.1 ___ ___ 07:00AM BLOOD Plt ___ ___ 08:10AM BLOOD Plt ___ ___ 06:04AM BLOOD Plt ___ ___ 06:09AM BLOOD Glucose-169* UreaN-21* Creat-1.5* Na-130* K-3.9 Cl-95* HCO3-21* AnGap-18 ___ 07:10AM BLOOD Glucose-139* UreaN-18 Creat-0.9 Na-136 K-3.8 Cl-101 HCO3-21* AnGap-18 ___ 07:00AM BLOOD Glucose-103* UreaN-13 Creat-0.7 Na-140 K-3.8 Cl-103 HCO3-24 AnGap-17 ___ 08:10AM BLOOD Glucose-160* UreaN-14 Creat-0.7 Na-138 K-3.7 Cl-103 HCO3-26 AnGap-13 ___ 06:04AM BLOOD Glucose-98 UreaN-18 Creat-0.8 Na-141 K-3.8 Cl-105 HCO3-25 AnGap-15 ___ 07:10AM BLOOD Calcium-8.5 Phos-2.4* Mg-1.9 ___ 07:00AM BLOOD Calcium-8.4 Phos-2.5* Mg-1.9 ___ 08:10AM BLOOD Calcium-8.3* Phos-2.7 Mg-1.6 ___ 06:04AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.9 ___ 07:10AM BLOOD CRP-172.2* ___ 06:51AM BLOOD Vanco-15.9 ___ 04:18PM BLOOD Lactate-2.5* Medications on Admission: sotalol 80", diltiazem 240', ASA 81', lisinopril 20' Discharge Medications: 1. CeFAZolin 2 g IV Q8H Duration: 6 Weeks RX *cefazolin ___ dextrose (iso-os) 2 gram/50 mL 2 Grams IV every eight (8) hours Disp #*126 Intravenous Bag Refills:*0 2. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*84 Tablet Refills:*0 3. MetroNIDAZOLE 500 mg PO TID RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day Disp #*126 Tablet Refills:*0 4. Aspirin 81 mg PO DAILY 5. Diltiazem Extended-Release 240 mg PO DAILY 6. Lisinopril 20 mg PO DAILY 7. Sotalol 80 mg PO BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Right Foot Infection with osteomyelitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Non-weightbearing to right foot Followup Instructions: ___ Radiology Report EXAMINATION: FOOT AP,LAT AND OBL RIGHT INDICATION: History: ___ with CMT and extensive podiatric history presents with redness, swelling and worsening plantar ulcer// evaluate for fracture, osteo TECHNIQUE: Non-weightbearing frontal, oblique, and lateral view radiographs of right foot COMPARISON: Right foot radiographs from ___ FINDINGS: Calcaneal osteotomy and screw fixation appears unchanged. Postoperative changes with resection of the fourth and fifth metatarsals appears stable. Foci of subcutaneous emphysema are present along the lateral soft tissues adjacent to the fifth metatarsal base. There is no definite underlying osteolysis. Soft tissue edema noted. Linear radiopaque 8mm structure seen on the lateral view plantar to the proximal to the metatarsals may represent a foreign body. IMPRESSION: 1. Foci of subcutaneous emphysema along the lateral soft tissues adjacent to the fifth metatarsal base which are concerning for infection and/or ulceration. No definite underlying osteolysis to suggest acute osteomyelitis radiographically. 2. Stable post operative changes. 3. Possible plantar foreign body. Radiology Report EXAMINATION: FOOT AP,LAT AND OBL RIGHT INDICATION: ___ year old man s/p right foot bony debridement lateral midfoot// post op eval TECHNIQUE: Right foot three views COMPARISON: ___ FINDINGS: There has been interval debridement of lateral midfoot. Previously seen soft tissue gas is decreased, remaining components may be postsurgical or from infection. More prominent plantar surface soft tissue swelling. Postoperative changes resection of distal fourth, fifth metatarsals. Calcaneal osteotomy. Hindfoot fusion with 2 screws in place. Advanced degenerative, hypertrophic changes midfoot, with abundant hypertrophic changes, subchondral cystic changes, are stable, may be degenerative, or from neuropathic arthropathy. Normal midfoot alignment. Stable lucency at the proximal first metatarsal. Degenerative changes interphalangeal joint great toe, first MTP joint, stable. Distal phalanx of second toe is suboptimally seen, may be secondary to its position, or postoperative, resorptive change, stable. Calcaneal plantar, Achilles bone spurs. IMPRESSION: Interval postoperative changes, more prominent plantar surface soft tissue swelling. Residual soft tissue air the surgical bed, may be postoperative or from infection.. Otherwise as above Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old man with new R PICC// R SL Power PICC 44cm ___ ___ Contact name: ___: ___ TECHNIQUE: Chest single view COMPARISON: ___ FINDINGS: Right PICC line tip is difficult to see, is likely in the low SVC, it overlies spine. Shallow inspiration. Normal heart size, pulmonary vascularity. Linear atelectasis at the left base. Right lung is clear. No sizable effusion. No pneumothorax. IMPRESSION: Right PICC line Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Fever, Wound eval Diagnosed with Cellulitis of left lower limb temperature: 101.7 heartrate: 86.0 resprate: 18.0 o2sat: 96.0 sbp: 135.0 dbp: 75.0 level of pain: 4 level of acuity: 3.0

Dear ___ ___ was a pleasure taking care of you at ___. You were admitted to the Podiatric Surgery service for your right foot infection which also required surgery. You were given IV antibiotics while here. You are being discharged home with the following instructions: ACTIVITY: There are restrictions on activity. Please remain non weight bearing to your R foot until your follow up appointment. You should keep this site elevated when ever possible (above the level of the heart!) No driving until cleared by your Surgeon. PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: Redness ___ or drainage from your leg wound(s). New pain, numbness or discoloration of your foot or toes. Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. Exercise: Limit strenuous activity for 6 weeks. No heavy lifting greater than 20 pounds for the next ___ days. Try to keep leg elevated when able. BATHING/SHOWERING: You may shower immediately upon coming home, but you must keep your dressing CLEAN, DRY and INTACT. You can use a shower bag taped around your ankle/leg or hang your foot/leg outside of the bathtub. Avoid taking a tub bath, swimming, or soaking ___ a hot tub for 4 weeks after surgery or until cleared by your physician. Your dressing should be changed daily with betadine soaked gauze and a gauze wrap. MEDICATIONS: Unless told otherwise you should resume taking all of the medications you were taking before surgery. Remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods ___ your diet. (Check with your physician if you have fluid restrictions.) If you feel that you are constipated, do not strain at the toilet. You may use over the counter Metamucil or Milk of Magnesia. Appetite suppression may occur; this will improve with time. Eat small balanced meals throughout the day. DIET: There are no special restrictions on your diet postoperatively. Poor appetite is not unusual for several weeks and small, frequent meals may be preferred. FOLLOW-UP APPOINTMENT: Be sure to keep your medical appointments. If a follow up appointment was not made prior to your discharge, please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. This should be scheduled on the calendar for seven to fourteen days after discharge. Normal office hours are ___ through ___. PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR QUESTIONS THAT MIGHT ARISE.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: aspirin Attending: ___ Chief Complaint: Fall Major Surgical or Invasive Procedure: - Orthopedic surgery to repair R femur fracture on ___ History of Present Illness: ___ y/o demented F presenting from nursing home where she had is thought to have had a mechanical fall. Fall was unwitnessed, was found down in bathroom. Sent to ___ for initial evaluation with subsequent transfer to ___. Head CT and CT cervical spine at ___ negative. No PNA was seen there. although rib fracture noted. ___. . In the ED, initial VS: Tc: 98.2 HR: 106 BP: 122/80 02 sat 99% RA. In the ED she became hypotensive to 74/50 with altered mental status, had elevated white count, thus she received empiric antibiotic coverage with IV ceftriaxone and vancomycin. No clear source was noted. An XR and CT showed fracture right femur. She was found to be hypokalemic. . She received morphine 4mg IV, zofran 2mg, ceftriaxone 1g, vancomycin 1g, potassium IV. . REVIEW OF SYSTEMS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: Dementia Hyperlipidemia Urinary incontenence Depression Anemia Social History: ___ Family History: Unable to obtain from patient due to dementia Physical Exam: ADMISSION PHYSICAL EXAM: VS - Temp: 96.9 HR: 95% BP:142/78 02: 96% 4LNC ___ - unable to follow commands, responds to voice, touch 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 - PMI non-displaced, RRR, holosystolic murmur, 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), external rotation right hip. SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, CNs II-XII grossly intact, muscle strength ___ throughout. DISCHARGE PHYSICAL EXAM: VSS WNL GEN: Resting in bed in NAD. HEENT: NCAT, MMM. COR: +S1S2, RRR, ___ SEM heard throughout precordium PULM: Bibasilar crackles, no coarse breath sounds. ___: +NABS in 4Q. Soft, NTND. EXT: WWP, edema improved in R ___. 1+ hand edema. NEURO: Oriented to "hospital". Pertinent Results: ADMISSION LAB RESULTS: ___ 09:45PM BLOOD WBC-13.8* RBC-3.96* Hgb-11.6* Hct-33.8* MCV-85 MCH-29.2 MCHC-34.2 RDW-14.3 Plt ___ ___ 09:45PM BLOOD Neuts-88.3* Lymphs-8.7* Monos-2.6 Eos-0.1 Baso-0.4 ___ 09:45PM BLOOD Glucose-181* UreaN-31* Creat-1.3* Na-139 K-4.0 Cl-93* HCO3-33* AnGap-17 ___ 04:45PM BLOOD CK(CPK)-272* ___ 01:00AM BLOOD cTropnT-<0.01 ___ 01:00AM BLOOD Albumin-2.8* Calcium-6.8* Phos-4.9* Mg-1.7 ___ 01:24AM BLOOD Lactate-3.4* PLAN FILMS OF R LEG: FINDINGS: There is complete fracture through the distal shaft of the femur with displacement of the distal fragment by a full shaft width with foreshortening and there is also a comminution fragment. The bones appear demineralized. Patchy vascular calcifications are present. The fracture approaches the metaphysis but does not appear to enter the knee joint itself. . IMPRESSION: Complete oblique displaced distal right femur fracture. . DISCHARGE LABS: . ___ 06:45AM BLOOD WBC-9.2 RBC-3.60* Hgb-10.9* Hct-31.6* MCV-88 MCH-30.2 MCHC-34.3 RDW-15.6* Plt ___ ___ 06:45AM BLOOD Glucose-104* UreaN-36* Creat-0.7 Na-138 K-3.2* Cl-104 HCO3-21* AnGap-16 CT Abdomen, Chest, Pelvis with Contrast (___): FINDINGS: A calcified thyroid nodule is noted within the right lobe of the thyroid gland (series 2, image 30) measuring 20 x 16 mm. This can be further evaluated with a thyroid ultrasound on a non-emergent basis. A 16-mm nodule is noted within the right upper lobe of the lung (series 2, image 22) which is suspicious for malignancy. Bibasilar atelectasis is noted. Mediastinal, axillary and hilar lymph nodes do not meet size criteria for pathologic enlargement. The ascending aorta measures 5.5 cm consistent with ascending aortic aneurysm. . Complex mixed fusiform abdominal aneurysm is noted with a suprarenal component measuring 6.3cm and component at and below the level of the renal arteries measuring 6cm in max diameter. There is an aortobifemoral graft with occluded native common iliac arteries. Extensive atherosclerotic calcifications are noted throughout the abdominal aorta. . Two hyperdense foci may be due to enhancing polyps or potentially stones, although the former is more likely. Particularly regarding the fundal lesion, focal adenomyomatosis could also be considered. A 19 x 12 mm hypodensity at the head of the pancreas may represent IPMN and may be further evaluated with MRCP. . The liver, spleen, bilateral adrenal glands appear unremarkable. Both kidneys appear mildly lobulated with minimal scarring of the cortex, particularly in the left kidney, but there is no evidence of hydronephrosis or renal calculi. There is no free air or free fluid within the abdomen. Retroperitoneal and mesenteric lymph nodes do not meet size criteria for pathologic enlargement. Intra-abdominal loops of large and small bowel are unremarkable. . There is a Foley catheter within the bladder. Pelvic lymph nodes do not meet size criteria for pathologic enlargement. The uterus appears unremarkable. The rectum and sigmoid colon are within normal limits. . There is extensive demineralization of the bones. A right sixth rib deformity is of indeterminate chronicity, correlate with point tenderness (2,35). . Multilevel degenerative changes are noted within the thoracolumbar spine. . IMPRESSION: 1. 16 mm right upper ___ pulmonary nodule, suspicious for malignancy. 2. Ascending aorta aneurysm measuring 5.5cm in max diameter. Complex mixed fusiform abdominal aneurysm with a suprarenal component measuring 6.3cm and component at and below the level of the renal arteries measuring 6cm in max diameter. Aortic bifem with occluded native common iliac arteries. 3. Right 6th rib deformity is of indeterminate chronicity, correlate with point tenderness. 4. Calcified thyroid nodule measuring 20 mm, may be further evaluated with an US on a nonemergent basis. 5. Hyperdense foci in the gallbladder suggesting polyps or potentially stones, probably less likely; unless MRCP is pursued, gallbladder ultrasound could be considered clinically indicated to evaluate further. 6. Sigmoid diverticulosis. 7. A 19 x 12 mm hypodensity at the head of the pancreas may represent IPMN and may be further evaluated with MRCP. . CXR (___): FINDINGS: The mediastinum is widened secondary to known ascending aortic aneurysm, but is unchanged from prior exams. There is no new mediastinal widening. The cardiac silhouette is stably enlarged. Bilateral moderate pleural effusions are unchanged with associated bibasilar atelectasis. There are no new consolidations. There is no pneumothorax. . IMPRESSION: 1. Unchanged appearance of the mediastinum. 2. Bilateral moderate pleural effusions. 3. Bibasilar atelectasis. Medications on Admission: Lovastatin 20mg daily Paxil 20mg daily HCTZ 25mg daily potassium chloride 20mEQ BID Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for Pain. 2. enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg Subcutaneous Q12H (every 12 hours) for 1 months. 3. lovastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. Paxil 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. potassium chloride 20 mEq Packet Sig: One (1) PO twice a day. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES: - R Distal Femur fracture s/p fall - Delirium SECONDARY DIAGNOSES: - Dementia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Followup Instructions: ___ Radiology Report INDICATION: ___ female with new hypotension and tachypnea status post trauma. COMPARISON: Outside hospital chest radiograph dated ___ at approximately 5 p.m. and CT chest dated ___ at approximately 9:00 p.m. TECHNIQUE: Single frontal chest radiograph was obtained portably. Per technologist's report, the patient was unable to cooperate for the exam and was stabilized by the ED resident, who approved the image. FINDINGS: Very limited view of the chest without obvious pneumothorax or edema. The patient is rotated, limiting evaluation of the cardiomediastinal silhouette, but an enlarged calcified aorta is again noted. Right lower lung nodule is obscured. Note is made of a large right calcified thyroid nodule. IMPRESSION: Very limited study due to patient rotation without evidence for large pneumothorax. Radiology Report REASON FOR EXAMINATION: Open reduction and internal fixation of the femur. Note is made that the radiologist was not attending the procedure. Total fluoroscopy time of 169.4 seconds was documented. The eleven fluoroscopic spot images were brought to our review and demonstrate the process of open reduction and internal fixation. For precise details, please review procedure report. Radiology Report REASON FOR EXAMINATION: Evaluation of the patient after femur fracture, with pulmonary edema. AP radiograph of the chest was compared to ___. Bilateral consolidations appear to be increased as well as there is increase in bilateral pleural effusion. On the other hand, there is no evidence of pulmonary edema on the current examination. Enlarged aorta is consistent with thoracic ascending aortic aneurysm, better appreciated on the CT chest from ___. No pneumothorax is seen. The right upper lobe nodule is better appreciated on the CT torso not well seen on the chest radiograph. Radiology Report INDICATION: Postoperative hypotension with thoracic aneurysm on Lovenox. Evaluate for mediastinal changes. COMPARISONS: Chest radiograph ___. Chest radiograph ___. FINDINGS: The mediastinum is widened secondary to known ascending aortic aneurysm, but is unchanged from prior exams. There is no new mediastinal widening. The cardiac silhouette is stably enlarged. Bilateral moderate pleural effusions are unchanged with associated bibasilar atelectasis. There are no new consolidations. There is no pneumothorax. IMPRESSION: 1. Unchanged appearance of the mediastinum. 2. Bilateral moderate pleural effusions. 3. Bibasilar atelectasis. Gender: F Race: HISPANIC OR LATINO Arrive by AMBULANCE Chief complaint: FEMUR FX Diagnosed with FX FEMUR SHAFT-CLOSED, UNSPECIFIED FALL, DEMENTIA, UNSPECIFIED, WITHOUT BEHAVIORAL DISTURBANCE temperature: 98.2 heartrate: 106.0 resprate: 16.0 o2sat: 99.0 sbp: 122.0 dbp: 280.0 level of pain: 13 level of acuity: 2.0

Ms. ___, it was a pleasure to participate in your care while you were at ___. You came to the hospital after you feel and fractured your right leg. You were taken to the operating room on ___ to repair your fracture. You had some low blood counts after your surgery so you were given som blood prodcuts. During your hospitalization you became delirious, but this improved. MEDICATION CHANGES: - Medications ADDED: ----> Please start taking lovenox as prescribed for 1 month to prevent blood clots - Medications STOPPED: ----> Hydrochlorothiazide 25 mg daily: While you were in the hospital you did not require this medication. You may not need to be on this medication in the future. Please talk to your primary care doctor about restarting this medication. - Medications CHANGED: None.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Laparoscopic appendectomy History of Present Illness: ___ year old year old male with no significant PMHx, p/w RLQ pain starting ___ after lunch, associated w/ mild nausea, no emesis. Patient reports anorexia but otherwise denies fevers/chills. Patient denies migration or radiation of pain anywhere. Upon evaluation in ED, patient appeared comfortable. Abdomen significant for focal RLQ TTP, no rebound/guarding. Past Medical History: Anxiety Social History: ___ Family History: Father with hematologic malignancy Physical Exam: Physical Exam on admission ___: Vitals - T 98.3 / HR 68 / BP 118/74 / RR 16 / O2sat 100% RA General - comfortable, NAD HEENT - moist mucous membranes, PERRLA, EOMI Cardiac - RRR, no M/R/G Chest - CTAB Abdomen - soft, nondistended, focal TTP in RLQ, no rebound/guarding Extremities - warm and well-perfused Neuro - A&OX3 Physical Exam on discharge ___: Vitals - T 98.2 HR 74 BP 119/75, RR 16 O2 sat 97% on RA. General: NAD Neuro: Alert and oriented x 3, follows commands Cardiac: Regular rate and rhythm Pulmonary: Lung sounds clear bil Abdomen: +bs, soft, non-distended, slightly tender to touch, no erythema or exudate at port sites. Extremities: No edema, no calf pain Skin: Warm, dry Pertinent Results: ___ 11:30AM BLOOD WBC-7.4 RBC-4.65 Hgb-14.2 Hct-41.5 MCV-89 MCH-30.5 MCHC-34.2 RDW-12.3 RDWSD-39.6 Plt ___ ___ 11:30AM BLOOD Neuts-69.6 Lymphs-16.1* Monos-13.5* Eos-0.1* Baso-0.3 Im ___ AbsNeut-5.16 AbsLymp-1.19* AbsMono-1.00* AbsEos-0.01* AbsBaso-0.02 ___ 04:00PM BLOOD ___ PTT-29.1 ___ ___ 11:30AM BLOOD Glucose-118* UreaN-10 Creat-0.7 Na-139 K-4.2 Cl-101 HCO3-25 AnGap-13 ___ 11:30AM BLOOD ALT-22 AST-17 AlkPhos-61 TotBili-0.3 ___ 11:30AM BLOOD Albumin-4.4 ___ 11:56AM BLOOD Lactate-1.2 Abd/Pelvis CT with contrast on ___: IMPRESSION: Early acute uncomplicated appendicitis. Medications on Admission: Sertraline 50mg PO twice daily Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 2. Docusate Sodium 100 mg PO BID constipation 3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate do not drive while on this medication, may cause drowsiness RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills:*0 4. Polyethylene Glycol 17 g PO DAILY:PRN constipation 5. Senna 8.6 mg PO BID:PRN constipation 6. Sertraline 50 mg PO BID 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: ___ with right lower quadrant abdominal pain// ? appendicitis TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 21.7 mGy (Body) DLP = 10.8 mGy-cm. 2) Spiral Acquisition 5.3 s, 57.9 cm; CTDIvol = 16.4 mGy (Body) DLP = 949.5 mGy-cm. Total DLP (Body) = 960 mGy-cm. COMPARISON: None. FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. Portal venous system is patent. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The 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. Colon and rectum are within normal limits. The base of the appendix is mildly enlarged, measuring up to 8 mm, with thickened walls. Together with mucosal hyperemia and periappendiceal fat stranding, findings are compatible with early acute appendicitis. No abscess or perforation. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The prostate and seminal vesicles are normal. LYMPH NODES: There is no retroperitoneal lymphadenopathy. A few prominent mesenteric lymph nodes measuring up to 9 mm in the right lower quadrant are likely reactive. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: Early aacute uncomplicated appendicitis. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: RLQ abdominal pain Diagnosed with Unspecified acute appendicitis temperature: 99.3 heartrate: 92.0 resprate: 16.0 o2sat: 99.0 sbp: 133.0 dbp: 84.0 level of pain: 4 level of acuity: 3.0

You came to the hospital with abdominal pain. Your abdominal imaging showed acute appendicitis. You were brought to the operating room and had your appendix removed. There were no complications. Your pain is being controlled and you are tolerating your diet. You are ready for discharge home. Please continue your recovery at home by following the instructions below: ACTIVITY: o Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. o You may climb stairs. o You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. o Don't lift more than ___ lbs for 4 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. o You may start some light exercise when you feel comfortable. o You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. HOW YOU MAY FEEL: o You may feel weak or "washed out" for a couple of weeks. You might want to nap often. Simple tasks may exhaust you. o You may have a sore throat because of a tube that was in your throat during surgery. o You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. o You could have a poor appetite for a while. Food may seem unappealing. o 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: o Tomorrow you may shower and remove the gauzes over your incisions. Under these dressing you have small plastic bandages called steri-strips. Do not remove steri-strips for 2 weeks. (These are the thin paper strips that might be on your incision.) But if they fall off before that that's okay). o Your incisions may be slightly red around the stitches. This is normal. o You may gently wash away dried material around your incision. o Avoid direct sun exposure to the incision area. o Do not use any ointments on the incision unless you were told otherwise. o 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. o You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. YOUR BOWELS: o Constipation is a common side effect of narcotic pain medications. 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. o If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. PAIN MANAGEMENT: o It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". o Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. o You will receive a prescription for pain medicine to take by mouth. It is important to take this medicine as directed. o Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. o Your pain medicine will work better if you take it before your pain gets too severe. o 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. o If you are experiencing no pain, it is okay to skip a dose of pain medicine. o 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 following, 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: MEDICINE Allergies: ciprofloxacin Attending: ___. Chief Complaint: PCP: ___. ___ CC: Leg pain and swelling Major Surgical or Invasive Procedure: None History of Present Illness: ___ woman with a history of HTN who presented to the ED with LLE swelling and pain for a few weeks. She reports that about 3 weeks prior to admission she was at her daughter's house when she tripped over the threshold entering her house and she fell to the ground landing on both her knees. She developed a laceration and presented to ___ for evaluation. Per ___ records x-rays were negative and no evidence of infection so she was discharged home. Approximately one week prior to admit, two weeks after initial fall, she was walking off the T in the ___ station when her foot caught a "spike" sticking up out of the bricks, she tripped and landed on her left knee. The wound reopened and it started bleeding a lot. She again presented to ___ where x-rays were negative and she was discharged without antibiotics given no concern for infection. Over the next week, several days prior to presentation to the ED she reports increased redness, swelling and pain of LLE. She reports ongoing bleeding from wound with severe pain, she has been applying bacitracin to the wound and she has not seen any purulence or other drainage from the wound. More recently she developed tingling sensation in 3 of her toes. She saw her PCP for evaluation this morning who referred her to the ED for work up. In the ED, initial vitals were: ___ pain 97.8 87 136/88 18 100% RA. Labs were notable for leukocytosis. Because extent of swelling, pain and new paresthesias ortho was consulted for potential compartment syndrome. Ortho was less concerned for compartment syndrome or necrotizing fasciitis after evaluation, they recommend plain films and ultrasound. ___ was negative for DVT, x-ray negative for fracture and soft tissue US showing edema consistent with cellulitis without abscess. Ortho final evaluation was consistent with severe cellulitis and recommended conservative therapy and strict LLE elevation at all times. She was started on IV Vancomycin and admitted to medicine. On the floor, she appears well and is in no acute distress. Her pain is well controlled, currently ___ in severity and she denies fevers. She reports subjective chills but otherwise feels well. Incidentally, her daughter presented to ___ ED at the same time as her index ED visit and remains hospitalized for "kidney problems" Review of systems: (+) Per HPI (-) Denies fever, 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. Otherwise ROS is negative. I reviewed records from ___ which arrived with the patient Past Medical History: Hypertension Gout Hyperlipidemia Glaucoma Morbid Obesity BMI >40 Social History: ___ Family History: Daughter with "kidney problems" Son with MI at ___ Physical Exam: PHYSICAL EXAM: Vitals: 98.1 PO 148 / 80 104 18 94 RA Pain Scale: ___ General: Patient appears well, she is awake, interactive, pleasant, fully alert, oriented and linear. She appears in no acute distress HEENT: Sclera anicteric, MMM Neck: supple, JVP low, no LAD appreciated Lungs: Clear to auscultation bilaterally, moving air well and symmetrically, no wheezes, rales or rhonchi appreciated CV: Regular rate and rhythm, S1 and S2 clear and of good quality, no murmurs, rubs or gallops appreciated Abdomen: Obese abdomen, soft, non-tender, non-distended, normoactive bowel sounds throughout, no rebound or guarding Ext: Her LLE is warm to touch, predominantly around wound which is marked, the skin is mildly erythematous and blanched with palpation. Anteriorly there is a There is also a 2cm, oval shaped, open wound overlying tibial head inferior to patella. The sounds is actively bleeding with dark red blood, there is no purulent drainage even with massaging wound. There is a soft, fluctuant, pocket inferor to the wound with surrounding induration more distally, superiorly and lateral to wound. There is no pain with active or passive range of motion of foot or ankle. 2+ DP pulses and her foot is warm. There is preserved sensation. Calf is swollen on left compared to right but is soft and compressible, not tense. Neuro: CN2-12 grossly in tact, motor and sensory function grossly intact in bilateral UE and ___, symmetric Exam on discharge: 97.6 BP:111/69 HR: 86 R: 18 98 Ra Gen: NAD, lying in bed, well appearing Eyes: EOMI, sclerae anicteric ENT: MMM, OP clear Cardiovasc: RRR, no MRG, full pulses, no edema Resp: normal effort, no accessory muscle use, lungs CTA ___. GI: soft, NT, ND, BS+ MSK: No significant kyphosis. No palpable synovitis. Skin: No visible rash. No jaundice. Ext: Anterior L shin with oval shaped 3x3cm wound with packing in place. Laterally- 2x3cm wound also with packing. +sanguenous drainage Neuro: AAOx3. No facial droop. Psych: Full range of affect Pertinent Results: Admission Labs: ___ 04:30PM BLOOD WBC-10.5* RBC-3.99 Hgb-11.4 Hct-36.6 MCV-92 MCH-28.6 MCHC-31.1* RDW-15.5 RDWSD-51.4* Plt ___ ___ 04:30PM BLOOD Neuts-72.0* ___ Monos-5.6 Eos-1.7 Baso-0.5 Im ___ AbsNeut-7.53* AbsLymp-2.06 AbsMono-0.59 AbsEos-0.18 AbsBaso-0.05 ___ 04:30PM BLOOD ___ PTT-31.3 ___ ___ 04:30PM BLOOD Glucose-95 UreaN-12 Creat-0.7 Na-139 K-3.5 Cl-101 HCO3-25 AnGap-17 ___ 05:04PM BLOOD Lactate-1.2 Imaging: Knee Tib/Fib: No fracture. No focal erosion. ___: No evidence of deep venous thrombosis in the left lower extremity veins. Soft Tissue US of leg: IMPRESSION: Edema and complex fluid collection fluid is seen in the subcutaneous tissues of the left shin, with some extension into the adjacent musculature. Infection could certainly be possible in the proper clinical setting. MRI Leg: ___ IMPRESSION: 8.5 x 1.8 x 7 collection within the subcutaneous tissue of the anterior aspect of the left leg could represent an organized hematoma, however superimposed infection cannot be excluded. No evidence of muscle or bony involvement. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Simvastatin 10 mg PO QPM 3. Hydrochlorothiazide 12.5 mg PO DAILY 4. Lisinopril 5 mg PO DAILY 5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 6. clotrimazole-betamethasone ___ % topical BID:PRN 7. Aspirin 81 mg PO DAILY 8. Glucosamine Chondroitin PLUS (gluc-condr-om3-dha-epa-___-st) 375-100-36-54 mg oral DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO TID 2. Cephalexin 500 mg PO Q6H RX *cephalexin 500 mg 1 capsule(s) by mouth Q6hrs Disp #*18 Capsule Refills:*0 3. Sulfameth/Trimethoprim DS 2 TAB PO BID RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by mouth twice a day Disp #*9 Tablet Refills:*0 4. Allopurinol ___ mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. clotrimazole-betamethasone ___ % topical BID:PRN 7. Glucosamine Chondroitin PLUS (gluc-condr-om3-dha-epa-___-st) 375-100-36-54 mg oral DAILY 8. Hydrochlorothiazide 12.5 mg PO DAILY 9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 10. Lisinopril 5 mg PO DAILY 11. Simvastatin 10 mg PO QPM Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Hematoma with concern for infection Cellulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: UNILAT LOWER EXT VEINS LEFT INDICATION: ___ with left leg lesion, swelling// dvt TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the left lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, flow, and augmentation of the left common femoral, femoral, and popliteal veins. Normal color flow is demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: No evidence of deep venous thrombosis in the left lower extremity veins. Radiology Report EXAMINATION: US LOWER EXTREMITY, SOFT TISSUE LEFT INDICATION: ___ year old woman with wound// please evaluate marked area for abscess TECHNIQUE: Grayscale ultrasound images were obtained of the superficial tissues of the left shin. COMPARISON: None FINDINGS: Transverse and sagittal images were obtained of the superficial tissues of the left shin. There is edema and a well-defined complex fluid collection seen in the subcutaneous tissues of the left shin, with some extension into the adjacent musculature. The discrete area of complex fluid measures approximately 4.8 cm cc by 4.1 cm TRV by 2.3 cm deep. IMPRESSION: Edema and complex fluid collection fluid is seen in the subcutaneous tissues of the left shin, with some extension into the adjacent musculature. Infection could certainly be possible in the proper clinical setting. NOTIFICATION: Updated wording of wet read was discussed by ___ with Dr. ___. Radiology Report EXAMINATION: MRI of the left calf. INDICATION: ___ year old woman with history of repeat trauma to her left shin with open wound and ultrasound showing fluid collection. Orthopedics requesting MRI to better evaluate abscess vs. hematoma and extent of muscle involvement// ? hematoma vs. abscess, question muscle involvement. Wound is anterior shin/tibia TECHNIQUE: Multiplanar images of the left calf was performed with the administration of 10 CC of Gadavist using a routine MR calf protocol. COMPARISON: Ultrasound from ___. FINDINGS: Soft tissue: There is a mildly T1 hyperintense STIR hyperintense rim enhancing collection within the anterior aspect of the left leg measuring approximately 8.5 x 1.8 x 7.7 cm within its maximal dimension that could represent an organized hematoma, however superimposed infection cannot be excluded. A skin defect is noted within the anterior aspect of the midportion of the leg, which is contiguous with the collection. Muscles: Fatty atrophy of the medial gastrocnemius muscle is likely from old injury. Otherwise, normal signal intensity. Bone marrow: No signal abnormality to suggest osteomyelitis. Mild subchondral edema is noted within the bilateral tibial plateau secondary to degenerative changes. IMPRESSION: 8.5 x 1.8 x 7 collection within the subcutaneous tissue of the anterior aspect of the left leg could represent an organized hematoma, however superimposed infection cannot be excluded. No evidence of muscle or bony involvement. Radiology Report INDICATION: ___ with recent fall, concern for infection of left calf/knee// soft tissue, fracture TECHNIQUE: Three views of the left knee. Two views of the left tibia and fibula. COMPARISON: None. FINDINGS: Tricompartmental degenerative changes are noted with joint space loss, particularly at the medial femorotibial compartment, and spurring. There is no fracture. There is no suprapatellar effusion. Distally, the left tibia and fibula are intact without fracture or focal osseous abnormality. Plantar and posterior calcaneal spurs are noted. IMPRESSION: No fracture. No focal erosion. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: L Leg swelling, Wound eval Diagnosed with Cellulitis of left lower limb temperature: 97.8 heartrate: 87.0 resprate: 18.0 o2sat: 100.0 sbp: 136.0 dbp: 88.0 level of pain: 4 level of acuity: 3.0

Ms. ___, It was a pleasure taking care of you during your recent admission to ___. You were admitted with an open leg wound. You were seen by both orthopedic surgery and plastic surgery. Plastic surgery performed bedside drainage of the wound which was likely a hematoma (clotted blood). You were treated with antibiotics and you will be discharged on oral antibiotics. You should continue to change your dressing once per day. You have been scheduled for follow up with your primary care physician. Please discuss returning to work with your primary care doctor. We wish you the best, Your ___ Care team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fall, LLE fracture Major Surgical or Invasive Procedure: Left lower leg ORIF History of Present Illness: ___ y.o. M with myotonic dystrophy and mild mental ___ transferred from ___ s/p fall presents with L lower extremity fracture. The patient's guardian reports that the patient was walking from the bathroom when he felt sudden onset weakness of his L leg. The patient reportedly tripped over a rug and subsequently fell scraping his head and landing on his shoulder. There were no reported prodromal symptoms (syncope, changes in vision, palpitations, convulsions) or lost of consciousness. After his fall, the patient denied any headaches, mental status changes, nausea, or vomiting. The patient initially presented to ___ where initial head/spine CT was unremarkable. Radiographs of the LLE revealed comminuted fractures of the distal tibia and fibula. The patient was subsequently transferred to the ___ for further evaluation and management. In the ED, his initial vitals were: 98.4 92 141/91 24 100%. He received 10 mg IV morphine and IV Cefazolin. Ortho was consulted and recommended ORIF today. His vitals prior to transfer to the floor were 90 137/83 20 100%. Initial labs were most notable for Na 148. The patient and his guardian denies any recent illnesses but does endorse cough and diarrhea for the past several months. Currently, the patient is anxious but overall denies any headaches, pain, nausea, vomiting, or confusion. Past Medical History: 1. Myotonic dysptrophy since birth 2. Oropharyngeal dysphagia 3. Left bundle branch block (LBBB) 4. Blepharitis Social History: ___ Family History: Mother and brother had myotonic dystrophy. Father died of cancer. Physical Exam: Admission Physical Exam: PHYSICAL EXAM: VS: 98.1, 82, 135/71, 24, 99% RA ___: NAD. HEENT:Head: Superfical scalp laceration on anterior surface. No active bleeding, no hematomas. No tenderness on palpation of sinuses. No periorbital or mastoid ecchymoses. Sclera appear slightly injected. Tympanic membranes clear on otoscopy. Mild erythema of ear canal bilaterally. Moist mucous membranes with white material. No pharyngeal lesions. Neck: Poor control. No lymphadenopathy. CV: Marked pectus excavatum. RRR, normal S1 and S2. No m,r,g Lungs: CTAB Abdomen: Soft, NT, ND. +BS. No masses or hepatosplenomegaly. No rebound or guarding. Back: Marked GU: Exam deferred. MSK: Flaccid muscle tone throughout. No focal tenderness at shoulder joints bilaterally. Left leg in cast. Ext: Full lower extremity pulses, no cyanosis or clubbing. No appreciate edema. Neuro: AOx3. CN II-XII grossly intact. No focal deficits. Discharge Physical Exam: VS: 98.6 98.5 61-108 (118/43- 157/75) ___ 95-100% RA I/O: MN: NR/700, 24h: 1450/600 BMx3 ___: NAD. HEENT: Superfical scalp laceration on anterior surface. No active bleeding, no hematomas. No tenderness on palpation of sinuses. No periorbital or mastoid ecchymoses. Sclera appear slightly injected. Tympanic membranes clear on otoscopy. Moist mucous membranes with white material. No pharyngeal lesions. Neck: Poor control. No lymphadenopathy. CV: Marked pectus excavatum. RRR, normal S1 and S2. No m,r,g Lungs: CTAB Abdomen: Soft, NT, ND. +BS. No masses or hepatosplenomegaly. No rebound or guarding. Back: Marked GU: Exam deferred. MSK: Flaccid muscle tone throughout. No focal tenderness at shoulder joints bilaterally. Left leg stabilized with splint. Ext: Full lower extremity pulses, no cyanosis or clubbing. No appreciate edema. Neuro: AOx3. CN II-XII grossly intact. No focal deficits. Labs: Reviewed, please see below Pertinent Results: Admission Labs ---------------- ___ 07:00AM BLOOD WBC-9.3 RBC-4.69 Hgb-15.2 Hct-43.1 MCV-92 MCH-32.4* MCHC-35.3* RDW-12.6 Plt ___ ___ 07:00AM BLOOD Neuts-79.2* Lymphs-14.0* Monos-5.4 Eos-0.4 Baso-1.1 ___ 07:00AM BLOOD ___ PTT-20.9* ___ ___ 07:00AM BLOOD Glucose-95 UreaN-17 Creat-0.5 Na-148* K-4.1 Cl-113* HCO3-18* AnGap-21* ___ 08:00AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG ___ 08:00AM URINE Color-Straw Appear-Clear Sp ___ Discharge Labs ---------------- ___ 07:25AM BLOOD WBC-7.3 RBC-3.99* Hgb-12.6* Hct-37.5* MCV-94 MCH-31.6 MCHC-33.6 RDW-13.0 Plt ___ ___ 07:25AM BLOOD Plt ___ ___ 07:25AM BLOOD Glucose-113* UreaN-7 Creat-0.4* Na-146* K-4.0 Cl-113* HCO3-23 AnGap-14 Imaging ---------------- CXR ___: A semi-erect frontal view of the chest shows no displaced rib fracture. There is a marked dextroscoliosis of the thoracic spine. There is no pleural effusion, pneumothorax focal airspace consolidation. The cardiac silhouette is difficult to assess given the spinal abnormality. However, mild cardiomegaly is present. Air-filled loops of large bowel are seen. CT C-SPINE W/O CONTRAST ___: No C-spine fracture. CT HEAD W/O CONTRAST ___: No acute intracranial process. ANKLE (AP, MORTISE & LA) ___: 3 views of the knee demonstrate normal alignment without fracture or dislocation. There are mild degenerative changes. 3 views of the left ankle demonstrate a comminuted distal tibial and fibular fractures overlying plaster which somewhat limits evaluation . There is a minimal impaction and angulation at the fracture site, with the largest area of distration measuring 5 mm in the anterior cortex of the tibia with posterior angulation at the fracture site. Microbiology ---------------- Blood cultures ___ pending Medications on Admission: This patient is not taking any preadmission medications Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC DAILY Duration: 2 Weeks 4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain 5. Senna 2 TAB PO HS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: L Comminuted Tib-Fib Fracture Hypernatremia Discharge Condition: Mental Status: Clear and coherent (at baseline mental status) Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report HISTORY: Myotonic dystrophy after fall this morning. Evaluate for fracture. COMPARISON: None. FINDINGS: A semi-erect frontal view of the chest shows no displaced rib fracture. There is a marked dextroscoliosis of the thoracic spine. There is no pleural effusion, pneumothorax focal airspace consolidation. The cardiac silhouette is difficult to assess given the spinal abnormality. However, mild cardiomegaly is present. Air-filled loops of large bowel are seen. Radiology Report INDICATION: Myotonic dystrophy, status post fall this morning with head trauma. Evaluate for head bleed. COMPARISON: None. TECHNIQUE: Contiguous axial slices were acquired through the brain without administration of IV contrast. Coronal and sagittal reformations were provided and reviewed. DLP: 1025.72 mGy-cm. FINDINGS: There is no evidence of infarction, hemorrhage, edema, or shift of the normally midline structures. The ventricles and sulci are of normal size and configuration for age. There is periventricular white matter hypodensity suggesting chronic small vessel ischemia. The basal cisterns remain patent. A small osteoma is seen along the right parietal bone. The imaged paranasal sinuses and mastoid air cells are well aerated. There is no fracture. IMPRESSION: No acute intracranial process. Radiology Report INDICATION: Myotonic dystrophy with fall this morning and head trauma. Evaluate for spinal fracture. COMPARISON: None. TECHNIQUE: MDCT axial images were acquired through the cervical spine without administration of IV contrast. Coronal and sagittal reformations were provided and reviewed. DLP: 804.82 mGy-cm. FINDINGS: There is no evidence of fracture or subluxation. There is no prevertebral soft tissue swelling. Minimal degenerative changes are seen at C5-C6 with anterior osteophytes. Small posterior osteophytes at this location minimally encroach on the spinal canal, but do not appear to contact the spinal cord. Soft tissues of the neck and lung apices are unremarkable. The thyroid is normal. Small amount of debris is seen within the trachea. IMPRESSION: No evidence of fracture or subluxation. Radiology Report HISTORY: Status post fall with open left ankle fracture. COMPARISON: Outside films from ___ at 0 200. FINDINGS: 3 views of the knee demonstrate normal alignment without fracture or dislocation. There are mild degenerative changes. 3 views of the left ankle demonstrate a comminuted distal tibial and fibular fractures overlying plaster which somewhat limits evaluation . There is a minimal impaction and angulation at the fracture site, with the largest area of distration measuring 5 mm in the anterior cortex of the tibia with posterior angulation at the fracture site.. Radiology Report HISTORY: ORIF. Fluoroscopic assistance provided to surgeon in the O.R. without the radiologist present. Four spot views obtained. Fluoro time recorded as 19.3 seconds on the electronic requisition. Correlation with real-time findings and when appropriate conventional radiographs are recommended for full assessment. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: S/P FALL Diagnosed with FX ANKLE NOS-OPEN, UNSPECIFIED FALL, MYOTONIC MUSCULAR DYSTROPHY temperature: 98.4 heartrate: 92.0 resprate: 24.0 o2sat: 100.0 sbp: 141.0 dbp: 91.0 level of pain: 6 level of acuity: 2.0

Dear Mr. ___, You were admitted to the ___ because you broke your bones in the left leg after falling down. Your broken bones were fixed by the orthopedic surgeons and you tolerated the procedure very well. The surgeons placed a splint to keep you leg stabilized and allow it to heal. Your pain was treated with Tylenol. When you were admitted, your sodium was high and you were treated with fluids. Your sodium levels returned to normal at the time of discharge. Please follow your discharge instructions for the care of your left leg splint. Please take your medications as instructed. Please take Lovenox 40mg daily for 2 weeks after discharge for prophylaxis against blood clots. You are nonweightbearing in your left lower extremity until follow-up. Please followup with orthopedics as directed. It was a pleasure taking care of you. 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 can get the wound wet/take a shower starting 3 days after your surgery. You may wash gently with soap and water, and pat the incision dry after showering. - 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. ACTIVITY AND WEIGHT BEARING: - Nonweightbearing left lower extremity

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: fatigue and new PE/port-associated right atrial clot on CT Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ yo woman with history of metastatic bladder cancer with no evidence of disease after 9 cycles of pembrolizumab, pembro-induced COOP and atrial thrombus on apixaban, who presents with increased fatigue and new PE + port-associated right atrial clot noted on CT Torso. Ms ___ states she has been generally well, apart from 2 weeks of worsening fatigue, where she notices decreased energy by the end of the day after going about her daily activities. She saw Dr ___ in follow up today and after the appointment, her routine CT Torso incidentally noted segmental LLL PE and port-associated RA thrombus, for which she was referred to ED. She states that she otherwise is completely asymptomatic. Denies chest pain, palpitations, extremity edema. She has had ongoing dyspnea on exertion for months with the diagnosis of her pembro pneumonitis, which is unchanged. She estimates she can walk about ___ minutes before stopping for dyspnea. She has not had headache, dizziness, subjective fevers, night sweats, change in appetite, bleeding in stool or urine, abd discomfort, N/V. She has not missed any doses of apixaban. Past Medical History: PAST MEDICAL HISTORY: -Asymptomatic sinus bradycardia, Adapta pacemaker placed in ___ -bilateral intraocular lens replaced in ___. -Single oophorectomy in the ___. -TURBT ___ -Radical cystectomy and urostomy ___. Social History: ___ Family History: Mother deceased at ___, had diabetes. Father deceased at ___, had history of kidney cancer. One sister had colon cancer and another sister had breast cancer. Physical Exam: VITALS: ___ 1335 Temp: 98.5 PO BP: 154/71 R Sitting HR: 64 RR: 16 O2 sat: 97% O2 delivery: RA EXAMINATION General: Well appearing pleasant elderly woman, ambulating from bed to chair. In no acute distress. Not dyspneic on short ambulation. Neuro: Alert, oriented, provides clear history, PERRL, moving all four extremities. HEENT: No scleral icterus. Oropharynx moist without lesions. Cardiovascular: Regular rate and rhythm without murmur. Radial and DP pulses present. Chest/Pulmonary: Clear to auscultation bilaterally Abdomen: Soft, nontender, nondistended. Bowel sounds present. Surgical deformity and umbilical hernia that is reducible. Urostomy in RLQ is c/d/i with clear yellow urine with some sediment. Extr/MSK: Thin, no peripheral edema Skin: No acute rashes noted, but areas of ecchymosis related to venipuncture. Access: PIV. POC not accessed. Pertinent Results: ___ 06:50AM BLOOD WBC-7.2 RBC-2.90* Hgb-8.3* Hct-28.3* MCV-98 MCH-28.6 MCHC-29.3* RDW-20.4* RDWSD-73.6* Plt ___ ___ 11:35AM BLOOD WBC-8.1 RBC-2.94* Hgb-8.5* Hct-28.6* MCV-97 MCH-28.9 MCHC-29.7* RDW-20.6* RDWSD-73.0* Plt ___ ___ 06:50PM BLOOD Neuts-76.2* Lymphs-14.0* Monos-8.8 Eos-0.2* Baso-0.6 Im ___ AbsNeut-6.61* AbsLymp-1.21 AbsMono-0.76 AbsEos-0.02* AbsBaso-0.05 ___ 06:50PM BLOOD ___ PTT-27.9 ___ ___ 06:50AM BLOOD Creat-0.8 Na-145 K-4.4 Cl-111* HCO3-25 AnGap-9* ___ 11:35AM BLOOD UreaN-23* Creat-0.9 Na-142 K-4.3 Cl-106 HCO3-25 AnGap-11 ___ 10:15AM BLOOD ALT-10 AST-16 AlkPhos-48 TotBili-<0.2 ___ 06:50PM BLOOD cTropnT-<0.01 proBNP-181 ___ 06:50AM BLOOD Phos-3.7 Mg-2.3 ___ 06:50AM BLOOD TSH-40* ___ 10:15AM BLOOD TSH-38* ___ 06:50AM BLOOD T3-80 Free T4-0.4* ECHOCARDIOGRAM ___ IMPRESSION: Small, ill-defined, probable, mass attached to the right atrial catheter (better visualized by transesophageal echocardiography). Mild symmetric left ventricular hypertrophy with normal cavity size and hyperdynamic regional/global systolic function. Mild to moderate tricuspid regurgitation. Normal estimated pulmonary artery systolic pressure. Right upper extremity ultrasound ___ IMPRESSION: No evidence of deep vein thrombosis in the right upper extremity. CT Chest ___ IMPRESSION: Filling defect in the left posterior basal segmental branch of the left lower lobe pulmonary artery concerning for pulmonary embolism. Additional filling defect in the distal SVC surrounding the distal tip of the Port-A-Cath and within the right atrium also most likely represents thrombus. Correlation with echocardiography is recommended. No evidence of infarction. Stable right middle lobe pulmonary nodule measuring 2 mm. No new pulmonary nodules. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PredniSONE 5 mg PO DAILY 2. Ranitidine 150 mg PO BID 3. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 4. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500 mg(1,250mg) -125 unit oral DAILY 5. Gabapentin 100 mg PO TID 6. Apixaban 5 mg PO BID 7. Denosumab (Prolia) 60 mg SC EVERY 6 MONTHS 8. Lidocaine 5% Patch 1 PTCH TD QAM knee pain 9. Docusate Sodium 240 mg PO BID 10. Ferrous Sulfate 325 mg PO EVERY OTHER DAY Discharge Medications: 1. Enoxaparin Sodium 60 mg SC Q12H RX *enoxaparin [Lovenox] 60 mg/0.6 mL 60 mg Subcutaneous every twelve (12) hours Disp #*60 Syringe Refills:*0 2. Levothyroxine Sodium 12.5 mcg PO DAILY RX *levothyroxine 125 mcg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500 mg(1,250mg) -125 unit oral DAILY 4. Denosumab (Prolia) 60 mg SC EVERY 6 MONTHS 5. Docusate Sodium 240 mg PO BID 6. Ferrous Sulfate 325 mg PO EVERY OTHER DAY 7. Gabapentin 100 mg PO TID 8. Lidocaine 5% Patch 1 PTCH TD QAM knee pain 9. PredniSONE 5 mg PO DAILY 10. Ranitidine 150 mg PO BID 11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: Pulmonary embolism and port-associated RA thrombus Constipation Metastatic bladder cancer Pembrolizumab associated COOP Fatigue Hypothyroidism Normocytic anemia L3 compression fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: UNILAT UP EXT VEINS US RIGHT INDICATION: ___ with history of metastatic bladder cancer with no evidence of disease after 9 cycles of pembrolizumab, pembro-induced COOP and atrial thrombus on apixaban, who presents with increased fatigue and new PE + port-associated right atrial clot noted on CT Torso.// evaluate for RUE port associated clot burden TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper extremity veins. COMPARISON: CT chest from ___ FINDINGS: There is normal flow with respiratory variation in the bilateral subclavian veins. The right internal jugular, axillary, and brachial veins are patent, show normal color flow, spectral doppler, and compressibility. The right basilic, and cephalic veins are patent, compressible and show normal color flow. IMPRESSION: No evidence of deep vein thrombosis in the right upper extremity. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: PE, Transfer Diagnosed with Other pulmonary embolism without acute cor pulmonale, Intracardiac thrombosis, not elsewhere classified, Dyspnea, unspecified temperature: 97.3 heartrate: 69.0 resprate: 18.0 o2sat: 99.0 sbp: 147.0 dbp: 56.0 level of pain: 0 level of acuity: 2.0

You were admitted with a blood clot associated with your port and pacemaker wire. Your blood thinner was switched from Apixaban to Enoxaparin (Lovenox), which you have used before. Please follow with your hematologist-oncologist in about 1 months. You will have a repeat ultrasound of the heart around the time of that visit. Additionally, your thyroid tests were abnormal. It seems like your thyroid is not producing enough hormone. After conversation with your outpatient provider, we have decided to start you on a thyroid hormone replacement and they will recheck values in about 1 month. 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: Syncope Major Surgical or Invasive Procedure: None. History of Present Illness: History of Present Illness: ___ is a ___ year-old woman with recent history of copious diarrhea presented to OSH with right sided numbness and paresthesia, and is transferred after syncope, bradycardia, hypotension for further evaluation Patient endorses chronic diarrhea since ___ (constant since ___, notable for watery diarrhea ___. Outpatient workup in ___ negative C diff, and upcoming colonoscopy scheduled ___. She recently went to ___ for LUE numbness and paresthesia on ___. She had LUE numbness and heaviness of the entirety of her LUE lasting for ___ hours. She was admitted for workup. Per OSH records, her workup included negative MRI, CTA/MRA, TTE with bubble. A1c 5.3%, LDL 114. She initially received ASA 81 mg and Lipitor 10 mg while awaiting results of her hypercoagulable workup, but these were held due to concern for overtreatment. B12 was 305, and B12 supplementation was recommended. She was discharged home. ___ as she worked out she became lightheaded and nauseous, and was generally fatigued for the following days. She woke from sleep at 4 am on ___. with right arm numbness / heaviness and tingling in fingers and hand heaviness. She also experienced "head heaviness" and trouble finding words. In the ED, she had jaw tightness and a syncopal event. Per OSH report, her HR dropped to 32 and BP 52/40. Her BG was 67. She was given atropine and D50. The patient was lying down at the time, reports her "head felt heavy" and "jaw felt tight," and she was nauseated with a headache. She did not feel the room spinning or darkness closing in. Reportedly she passed out for 10 seconds, no head strike, and awoke feeling sick, nauseous and still with a HA. Her EKG was concerning for TWI, so OSH ED referred her to ___ for further evaluation In the ED, initial vital signs were: T 98.6 P 64 BP 99/62 R 18 O2 sat. 100 on RA - Exam unremarkable - Studies performed include CXR - Vitals on transfer: T 98.2 P 59 BP 98/57 R 17 O2 sat. 100 on RA Upon arrival to the floor, the patient in no acute distress. The numbness and tingling she reported earlier has resolved. She feels intermittently lightheaded and dizzy but only when she stands up, no further syncope episodes. She does report a ___ bilateral frontal squeezing headache without radiation similar in character to previous headaches. Notably, the patient reports dyspnea and chest tightness after ___ crossfit workout, resolved with rest, slight recurrence while walking on ___ but otherwise has not recurred. ROS otherwise negative in remaining systems. Past Medical History: None. Social History: ___ Family History: Notable for MI at age ___ in grandfather and in ___ in maternal aunt. ___ and HTN on mother's side but not in mother. Sister with ___ disease and ___ cousin with UC. No history sudden cardiac death or unexplained death. Physical Exam: ADMISSION PHYSICAL EXAM ======================= Vitals- 98.6PO 98/54 56 18 99 RA GENERAL: AOx3, NAD 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, good dentition. Oropharynx is clear. NECK: Thyroid is normal in size and texture, no nodules. No cervical lymphadenopathy. 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. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. 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 throughout. Normal sensation. No dysmetria, disdiadochokinesia. Gait is normal. DISCHARGE PHYSICAL EXAM ======================= Vitals: Tm: 98.6 Tc: 97.9 BP: 95-106/52-66 HR: 56-64 RR: ___ O2%: 99-100 GENERAL: AOx3, NAD 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, good dentition. Oropharynx is clear. NECK: Thyroid is normal in size and texture, no nodules. No cervical lymphadenopathy. 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. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. 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 throughout. Normal sensation. No dysmetria, disdiadochokinesia. Gait is normal. Pertinent Results: ADMISSION LABS ============== ___ 11:30AM BLOOD WBC-5.1 RBC-3.89* Hgb-12.1 Hct-36.9 MCV-95 MCH-31.1 MCHC-32.8 RDW-12.3 RDWSD-42.7 Plt ___ ___ 11:30AM BLOOD Neuts-71.1* ___ Monos-6.5 Eos-0.8* Baso-0.6 Im ___ AbsNeut-3.62 AbsLymp-1.05* AbsMono-0.33 AbsEos-0.04 AbsBaso-0.03 ___ 11:30AM BLOOD ___ PTT-25.6 ___ ___ 11:30AM BLOOD Plt ___ ___ 11:30AM BLOOD Glucose-88 UreaN-12 Creat-0.8 Na-141 K-4.0 Cl-110* HCO3-20* AnGap-15 ___ 11:30AM BLOOD cTropnT-<0.01 ___ 11:30AM BLOOD Calcium-8.5 Phos-2.7 Mg-1.9 ___ 11:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 11:47AM BLOOD Lactate-1.3 MICROBIOLOGY ============== ___ CULTURE-FINALEMERGENCY WARD IMAGING/STUDIES ============== ___ EKG Sinus bradycardia. Compared to the previous tracing of ___ there are no significant changes. ___ CXR IMPRESSION: No evidence of acute cardiopulmonary process. DISCHARGE LABS ============== ___ 07:40AM BLOOD WBC-4.5 RBC-3.70* Hgb-11.4 Hct-34.7 MCV-94 MCH-30.8 MCHC-32.9 RDW-12.4 RDWSD-43.0 Plt ___ ___ 07:40AM BLOOD Plt ___ ___ 07:40AM BLOOD Glucose-81 UreaN-12 Creat-0.8 Na-137 K-4.0 Cl-105 HCO3-21* AnGap-15 ___ 07:40AM BLOOD ALT-11 AST-16 AlkPhos-38 TotBili-0.3 ___ 07:40AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.9 ___ 07:40AM BLOOD Cortsol-10.4 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Cyanocobalamin 1000 mcg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Cyanocobalamin 1000 mcg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis -Vasovagal syncope Secondary diagnosis -Diarrhea, unexplained etiology -Unspecified disturbances of skin sensation 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 no sig PMHx syncopal episode given atropine doing an infectious work up. // Eval for PNA TECHNIQUE: Chest PA and lateral COMPARISON: Outside facility Chest radiograph ___ at 07:46 FINDINGS: Lung volumes are normal. There is no consolidation, pleural effusion or pneumothorax. Cardiomediastinal contours are normal. There is no subdiaphragmatic free air. No acute osseous abnormalities are identified. IMPRESSION: No evidence of acute cardiopulmonary process. Gender: F Race: UNKNOWN Arrive by UNKNOWN Chief complaint: Syncope, Transfer Diagnosed with Syncope and collapse temperature: 98.6 heartrate: 64.0 resprate: 18.0 o2sat: 100.0 sbp: 99.0 dbp: 62.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, You were admitted to the hospital from ___ because you had a syncopal episode in the ER, with low heart rate and blood pressure. When you came here your vital signs were stable, and the enzyme we check for people with heart attacks (troponin) were negative. You had some changes in your EKG, but since we didn't have a comparison, we didn't know if they were new. While in the hospital we watched your heart rate on telemetry and you didn't have any unusual rhythms or more syncopal episodes. We felt the episode was likely due to a vasovagal response, which can occur in times of emotional or physiologic stress such as your recent diarrhea. We feel it's important to diagnose what's causing your diarrhea, and feel it's safe for you to be discharged home to complete the colonoscopy on ___. Please follow up with your primary care physician on your appointment ___ they may recommend additional follow-up with cardiology, but we didn't feel the need to run additional cardiac tests during your admission. Please do not drive until you feel well again. Thank you for letting take part in your medical care. Sincerely, Your ___ Health Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine / Percocet / Ultram / tramadol / Oxycodone / Alleve / chlorine / bee venom (honey bee) / bee pollen Attending: ___. Chief Complaint: Low Back Pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ w/ long hx of spinal fractures and pelvic instability/dislocations, who now p/w lower back/R hip pain w/ sudden onset 2 days ago. Crossed legs while sitting, then pain began when she tried to stand. Since then has been unable to put pressure on R side, has vomited once ___ pain. Denies numbness/weakness/paresthesias. Called orthopedist/PCP who told her to come to ED for evaluation. In the ED, imaging was obtained: - Pelvic/R hip x-ray: Degenerative disease at the hips is mild. No acute fracture or dislocation. - LS spine x-ray: No fracture or malalignment - CT pelvis: No acute fracture or dislocation - CT L spine: No acute fracture or spinal subluxation Pr was seen by ___ in ED whose report is below: Pt is limited by pain. She is able to ambulate short distances independently with RW and perform basic bed mobility independently. She was not able to progress to stairs assessment on 2 attempts ___ pain. Pt was provided ice which she reports subjectively improved the pain. Anticipate once pain control is optimized she will be able to functionally return home and should f/u with her outpatient ___. RN is going to medicate pt and assess ambulation and will page ___ if there are any additional issues. Also pt has RW and B AC's at home already. Also seen by orthopedics whose report is below: Patient seen and examined with Dr ___. Patient well known to Dr ___ several joint related issues. After discussion w patient and her husband, we recommend: 1) Warm and form back brace. Nopco paged by ___ 2) ___ for mobility/stair training. Has walker at home 3) DC on short course of po dilaudid and valium 4) Dr ___ to arrange injection with Dr ___ for patient On the floor, before the physician has seen the patient, nursing reports that the patient has been very difficult to manage due to certain requests. Patient would like to stay in the stretcher while in room because she needs a hard mattress. She refuses to transfer to the hospital bed, which is against hospital policy because of lack of safety features on the stretcher. Finally a compromise is reached where the stretcher mattress is placed on the bed. Husband was also caught taking pictures of staff for litigous purposes, which is also against policy. security alerted and husband confronted that if he does takes another picture of staff he will be escorted from the hospital. Throughout this situration, there multiple threats to leave AMA. Once Examining the patient, she is very pleasant and recounts the history of her illness. She is currently not in pain while immobile and seated in the decubitus position. She will not however allow me to do a full exam due to pain. Past Medical History: 1.Spinal Problems 2.vaginal lichen planus 3.hypertension 4.osteopenia ___ BMD) 5.GERD 6. Mitral Valve Prolapse 7. C. Diff colitis 8. Raynaud's 9. Tibial Plateau Fracture 10. Right meniscal tear s/p meniscectemy 11. Uterine fibroid Social History: ___ Family History: Hypertension (Mother) ___ (Father) Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 97 167/67 63 18 100%RA General: Alert, oriented, no acute distress, lying comfortably in lateral decubitus position HEENT: NC/AT Neck: supple Lungs: No respiratory distress, no increased work of breathing CV: No pedal edema Abdomen: non-distended, soft Ext: TTP right sacroilliac joint; rest of joint and leg exam is limited by pain Neuro: AO x 3 DISCHARGE PHYSICAL EXAM Vitals: Refused morning vital signs General: Alert, oriented, no acute distress; lying supine initially; she is able to sit up to side of bed without assistance. No distress while performing these maneuvers. Lungs: No respiratory distress, no increased work of breathing CV: No pedal edema Abdomen: non-distended, soft Ext: TTP right sacroilliac joint; did not allow physician to move the lower extremities in order to perform a full joint exam. Neuro: AO x 3; moves all extremities without difficulty Pertinent Results: CT L-SPINE: No acute fracture or malalignment in the lumbar spine CT PELVIS: 1. No acute fracture or dislocation. 2. Trace amount of simple pelvic free fluid, which is not a normal finding in a postmenopausal patient though nonspecific. PELVIS PLAIN FILM Degenerative disease at the hips is mild. No acute fracture or dislocation. LUMBAR PLAIN FILM: No fracture or malalignment in the lumbar spine. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Enalapril Maleate 5 mg PO DAILY 2. Hydrochlorothiazide 25 mg PO DAILY 3. Estradiol 1 mg PO DAILY Discharge Medications: 1. Enalapril Maleate 5 mg PO DAILY 2. Estradiol 1 mg PO DAILY 3. Hydrochlorothiazide 25 mg PO DAILY 4. Outpatient Physical Therapy Please evaluate and provide home physical therapy. Discharge Disposition: Home Discharge Diagnosis: Primary: Acute Low Back Pain Secondary: 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 INDICATION: ___ with hx of pelvic instability now w/ new R hip pain // eval for new lower back/hip pain COMPARISON: Prior CT abdomen pelvis from ___. FINDINGS: AP pelvis and two views of the right hip were provided. The bony pelvic ring is intact. SI joints are symmetric and normal. Both hips align normally with mild loss of joint space and mild subchondral sclerosis. The femoral heads maintain their normal rounded contour. No soft tissue abnormalities. Mild spurring is seen along the inferior femoral acetabular joint. IMPRESSION: Degenerative disease at the hips is mild. No acute fracture or dislocation. Radiology Report INDICATION: ___ with hx of pelvic instability now w/ new R hip pain // eval for new lower back/hip pain COMPARISON: ___, CT abdomen pelvis from ___. FINDINGS: AP and lateral views of lumbar spine were provided. There are 5 non-rib-bearing lumbar type vertebral bodies. Rudimentary ribs are noted at T12. There is no compression fracture or malalignment. Disc spaces are preserved. No significant spur formation. SI joints appear normal. Hip joints align normally with mild subchondral sclerosis noted. The imaged bowel gas pattern is unremarkable. IMPRESSION: No fracture or malalignment in the lumbar spine. Radiology Report INDICATION: ___ female with history of pelvic instability and spinal fractures now with lumbosacral pain. Evaluate for fracture. TECHNIQUE: Helical axial MDCT sections through the lumbar spine. Reformatted images in sagittal and coronal axis were obtained. No IV contrast was administered. DOSE: DLP: 882 mGy-cm. CTDIvol: 31 mGy. COMPARISON: Radiographs from ___ and CT from ___. FINDINGS: There are 5 lumbar-type vertebral bodies with preserved vertebral body height. No acute fracture or malalignment is seen, and there is no prevertebral soft tissue swelling or hematoma. Mild facet arthropathy is noted throughout the lumbar spine. Mild disc height loss is seen at L5-S1. While CT is unable to provide intrathecal detail compared with MRI, the visualized outline of the thecal sac is normal. The visualized small and large bowel loops are normal without signs of obstruction or wall thickening. Parapelvic cysts are noted in the left kidney. The other visualized abdominal organs are within normal limits. IMPRESSION: No acute fracture or malalignment in the lumbar spine. Radiology Report INDICATION: ___ female with history of pelvic instability and spinal fractures, now with new pain in the lumbosacral spine, right hip and pelvis. TECHNIQUE: Axial MDCT images were obtained through pelvis without IV contrast material or oral contrast material. Sagittal and coronal reformatted images were obtained. DOSE DLP: 745 mGy-cm. COMPARISON: Radiograph from ___ and ___. FINDINGS: OSSEOUS STRUCTURES: The bony pelvic ring is intact. SI joints are symmetric without significant degenerative disease. Both hips align normally with mild degenerative disease including small marginal osteophytosis and mild loss of joint space noted at both hips. The imaged small and large bowel loops appear normal without wall thickening or signs of obstruction. The appendix is normal. Uterus and adnexal regions appear grossly unremarkable. The urinary bladder is partially distended. Trace free pelvic fluid is noted of unclear etiology. IMPRESSION: 1. No acute fracture or dislocation. 2. Mild degenerative disease at both hips. 3. Trace amount of simple pelvic free fluid. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Back pain Diagnosed with LUMBAGO, FEM GENITAL SYMPTOMS NOS temperature: 98.9 heartrate: 72.0 resprate: 18.0 o2sat: 98.0 sbp: 170.0 dbp: 75.0 level of pain: 7 level of acuity: 3.0

Dear ___, It was a pleasure taking care of you. You were admitted to the hospital for low back pain. We treated you with medications to control your pain and nausea. You will follow up with your orthopedist for further management of this issue. Please do not drive or operate machinery for the rest of the day or in the future if you have used sedating medications (eg oxycodone, valium) Sincerely, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: adhesive tape / Lactulose Attending: ___. Chief Complaint: S/p seizure Major Surgical or Invasive Procedure: None History of Present Illness: This is a ___ woman with a pmhx. significant for metastatic RCC with mets to skull on pazopanib, HTN, hyperlipidemia and depression, who is admitted from the ED with change in mental status and ___ activity. Patient states that for the last 3 days she has felt slightly off: she has noticed ___ difficulty and that sometimes she "moves her lips and no words come out." She also reports myoclonic jerkings in her extremities, which subside on their own. On day of admission to the hospital, patient's social worker was visitng. Ms. ___ lost consciousness and apparently had a seizure (unknown duration or clinical manifestations). Social worker called ___, and the next thing patient remembers was waking up in the back of an ambulance. She was taken to ___ where a CT scan showed: in comparison to study in ___, stable L craiotomy changes presnet w/ underlying encephalomalacia of the L frontal and parietal lobe. inc CSF is noted at the surgical site. no evidence of acute ICH. no midline shift. no masses. no evidence of acute territorial infarct. bony calvarium is otherwise intact." Patient was transferred to ___ for further evaluation. In ___ ED, initial vitals were: 98.1 68 109/66 21 96%. Neuro oncology was contacted who recommended Keppra load of 1000mg and admit to OMED. On admission, vitals were: 68 108/68 20 97%. ROS: Patient endorses ___ difficulties. Says memory has gotten worse over the past ___ days. Has chills but no documented fevers. Nausea, which she relates to anxiety. Denies vision change, shortness of breath, chest pain, change in stools, dysuria, or other concerning signs or symptoms. Past Medical History: --Metastatic renal cancer --Hypertension --Hyperlipidemia --Ostomy for incontinence --Depression --COPD Social History: ___ Family History: No family history of malignancies. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 68 108/68 20 97% GENERAL: No acute distress, lying in bed, pale HEENT: Mucous membranes slightly dry NECK: No cervical, submandibular, or supraclavicular LAD CHEST: CTA bilaterally, no wheezes, rales, or rhonchi CARDIAC: RRR, no MRG ABDOMEN: +BS, soft, light brown stool in ostomy, ___, ___ EXTREMITIES: No edema bilaterally NEURO: Alert and oriented, forgetful about some parts of her medical history (she says this is not normal), CN ___ grossly intact, strength ___ in upper and lower extremities, cerebellar signs not done, gait deferred Pertinent Results: ___ 05:45PM ___ UREA ___ ___ TOTAL ___ ANION ___ ___ 05:45PM ___ this ___ 05:45PM ALT(SGPT)-23 AST(SGOT)-36 ALK ___ TOT ___ ___ 05:45PM ___ ___ 05:45PM ___ ___ ___ 05:45PM ___ ___ ___ 05:45PM ___ ___ ___ 05:45PM ___ ___ ___ 05:45PM PLT ___ ___ 05:45PM ___ ___ CXR ___: FINDINGS: Frontal and lateral views of the chest were obtained. There is persistent blunting of the costophrenic angles and possible minimal pleural thickening bilaterally, which is unchanged in appearance since the prior study. Chain sutures are again seen overlying the right ___ hemithorax. Slight upper lobe patchy opacity are seen which could be due to aspiration or infection and are of indeterminate acuity. No pleural effusion is seen. There is no evidence of pneumothorax. The cardiac and mediastinal silhouettes are stable. Surgical clips are partially seen in the upper abdomen. . ___ read: Preliminary ReportNo infarct or hemorrhage. No evidence of abnormal enhancement or masses Preliminary Reportwithin the confines of the study. . Head CT: IMPRESSION: Interval development of a small ___ hemorrhage at the cranioplasty site, without mass effect on the adjacent brain. . Micro ___ flora Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Albuterol Inhaler ___ PUFF IH Q6H:PRN Shortness of breath 2. Atenolol 100 mg PO DAILY 3. Chlorthalidone 25 mg PO DAILY Please hold for SBP <100. 4. Fludrocortisone Acetate 0.1 mg PO DAILY 5. Hydrocortisone 15 mg PO BID 6. Mirtazapine 15 mg PO HS 7. Sertraline 200 mg PO DAILY 8. Simvastatin 20 mg PO DAILY 9. pazopanib *NF* 400 mg Oral QD 10. TraMADOL (Ultram) 50 mg PO Q8H:PRN Headache Discharge Medications: 1. Atenolol 50 mg PO DAILY 2. Chlorthalidone 25 mg PO DAILY 3. Fludrocortisone Acetate 0.05 mg PO DAILY 4. Hydrocortisone 15 mg PO QAM 5. Hydrocortisone 10 mg PO QPM 6. Lorazepam 0.5 mg PO Q8H:PRN anxiety 7. Mirtazapine 15 mg PO HS 8. Sertraline 200 mg PO DAILY 9. Simvastatin 20 mg PO DAILY 10. pazopanib *NF* 400 mg Oral QD 11. Prochlorperazine 10 mg PO Q6H:PRN nausea 12. Acetaminophen 1000 mg PO Q8H:PRN headache available over the counter 13. Divalproex (DELayed Release) 750 mg PO BID RX *divalproex [Depakote] 250 mg 3 tablet(s) by mouth twice a day Disp #*90 Tablet Refills:*0 14. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN severe pain RX *oxycodone 5 mg ___ to1 tablet(s) by mouth q6hr; prn Disp #*60 Tablet Refills:*0 15. Outpatient Lab Work Dx = Convulsive Seizure ICD 345.10. Please draw "depakote" level on ___ and fax result to Dr. ___ and Dr. ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: seizure w/ fall, small head bleed metastatic renal cell carcinoma depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Followup Instructions: ___ Radiology Report EXAM: Chest frontal and lateral views. CLINICAL INFORMATION: For seizure. ___. FINDINGS: Frontal and lateral views of the chest were obtained. There is persistent blunting of the costophrenic angles and possible minimal pleural thickening bilaterally, which is unchanged in appearance since the prior study. Chain sutures are again seen overlying the right mid-to-lower hemithorax. Slight upper lobe patchy opacity are seen which could be due to aspiration or infection and are of indeterminate acuity. No pleural effusion is seen. There is no evidence of pneumothorax. The cardiac and mediastinal silhouettes are stable. Surgical clips are partially seen in the upper abdomen. Radiology Report HISTORY: Metastatic renal cell carcinoma, now with new onset of seizures. TECHNIQUE: Multiplanar multisequence MRI of the brain was obtained before and after the administration of IV gadolinium. The patient became agitated and a code purple was called. The patient was sedated and brought back to the MRI, however he continued to move, and the scan was aborted as the MPRAGE images were non diagnostic due to motion, and the T2 and FLAIR sequences were not completed. COMPARISON: CT head noncontrast of ___ and MRI of ___. FINDINGS: Please note that the T2, FLAIR and MPRAGE sequences were not acquired and the axial T1 post-contrast is limited due to motion, therefore the sensitivity of this study is decreased. There is no infarct or hemorrhage. There is no midline shift, masses, or abnormal enhancement. There is mild mucosal thickening of the ethmoid air cells. There is a left frontal cranioplasty. IMPRESSION: No infarct or hemorrhage. No evidence of abnormal enhancement or masses within the confines of the study. Radiology Report HISTORY: ___ woman with metastatic renal cell carcinoma, history of left frontal bone metastasis resection and cranioplasty, now status post fall and seizure, with progressive worsening left frontal headache. COMPARISON: CT from ___ dated ___, and multiple prior head CTs and MRIs performed here. TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without administration of IV contrast. Coronal, sagittal, and thin-section bone-algorithm reconstructed images were obtained. DLP: 1040 mGy-cm CTDIvol: 64 mGy FINDINGS: Left frontal cranioplasty is again seen. There is interval development of a small extra-axial hemorrhage overlying the brain at the cranioplasty site, not seen on the ___ CT one day earlier. There is no associated mass effect on the adjacent brain parenchyma. There is no parenchymal hemorrhage or edema. A small rounded hypodensity in the region of the right lentiform nucleus corresponds to a prominent perivascular space seen on prior MRIs. The ventricles and sulci are unchanged in size, within normal limits for age. Basal cisterns are patent. There is preservation of gray-white matter differentiation. No acute fracture is identified. Partial opacification of bilateral mastoid air cells and mild mucosal thickening within the right sphenoid sinus are unchanged from one day earlier. IMPRESSION: Interval development of a small extra-axial hemorrhage at the cranioplasty site, without mass effect on the adjacent brain. NOTIFICATION: Findings were discussed with Dr. ___ by Dr. ___ at 15:50 on ___ via telephone, 5 minutes following discovery. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: NEW SEIZURE Diagnosed with SEC MAL NEO BRAIN/SPINE temperature: 97.5 heartrate: 62.0 resprate: 18.0 o2sat: 100.0 sbp: 126.0 dbp: 78.0 level of pain: 3 level of acuity: 2.0

You were admitted for evaluation of a seizure. For this, you were started on a new medication called depakote to help prevent further seizures. In addition, you had a head imaging (CT scan) that showed concern for a possible small bleed and you were evaluated by the neurosurgical service. In addition, you underwent an MRI that showed which did not show anyhing further though was limited by motion artifact. You were evaluated by the physical therapists as well as occupational therapists who felt that you wouild be ideally served in rehab. You declined to go to rehab so services are being increased for you at home. Please take acetaminophen and oxycodone for any residual headache. Please follow up with your physicians.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Sulfa (Sulfonamide Antibiotics) / aspirin Attending: ___. Chief Complaint: foul smelling drainage from umbilicus Major Surgical or Invasive Procedure: none History of Present Illness: ___ with extensive PMH, hospitalized ___ for sepsis and RP hematoma after a fall, course complicated by acute cholecystitis managed with percutaneous cholecystostomy, also c/b acute-on-chronic renal failure and acute-on-chronic CHF. He was discharged to an extended care facility, and was again hospitalized ___ due to concern for stroke. He has been recovering well at rehab, though his cholecystostomy tube did fall out on ___, without recurrence of his RUQ pain. He presented to the ED tonight after noticing foul-smelling brown fluid coming from his umbilicus. He has not been having pain or obstructive symptoms, and has no history of abdominal surgery. He denies fever, chills, nausea, vomiting, diarrhea, or constipation. Past Medical History: Atrial fibrillation Chronic Kidney Disease Morbid obesity Sleep apnea Nephrolithiasis s/p extended hospitalization for pneumonia s/p removal of right arm benign tumor one year ago Diabetes Mellitus Type 2 Hypothyroidism Diastolic CHF Hypertension Hyperlipidemia s/p lithotripsy Ulcer -- many years ago Social History: ___ Family History: Non-contributory Physical Exam: On admission: Vitals: T 99.1, HR 97, BP 126/79, RR 24, O2 96ra Gen: a&o x3, nad, morbidly obese CV: rrr, no murmur Resp: decreased at bilateral bases Abd: morbidly obese, mild erythema of lower pannus, ostomy appliance over umbilicus with stool in bag Extr: chronic venous stasis changes, warm DRE: unable to perform due to patient habitus . On discharge: Vitals: T 98.1, HR 91, BP 106/59, RR 2, O2 97% ra Gen: a&o x3, nad, morbidly obese CV: rrr, no murmur Resp: decreased at bilateral bases Abd: morbidly obese, mild erythema of lower pannus improved from prior assessment, ostomy appliance over umbilicus with formed light brown stool in bag, abdomen nontender, no rebound/guarding Extr: chronic venous stasis changes, warm Pertinent Results: ___ Ultrasound of abdomen: No drainable fluid collections identified ___ 03:30AM WBC-8.1 RBC-3.21* HGB-8.7* HCT-26.7* MCV-83 MCH-27.1 MCHC-32.5 RDW-16.5* ___ 03:30AM NEUTS-70.1* ___ MONOS-7.7 EOS-2.6 BASOS-0.4 ___ 03:30AM PLT COUNT-322 ___ 03:30AM ___ PTT-33.4 ___ ___ 03:30AM GLUCOSE-121* UREA N-22* CREAT-1.0 SODIUM-136 POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-24 ANION GAP-15 ___ 03:30AM CALCIUM-8.3* PHOSPHATE-2.7 MAGNESIUM-1.6 . Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct ___ 06:45 6.2 3.26* 8.9* 27.5* 84 27.1 32.2 16.5* 320 DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas ___ 03:30 70.1* 19.1 7.7 2.6 0.4 BASIC COAGULATION ___, PTT, PLT, INR) ___ PTT Plt Ct ___ ___ 07:35 23.0*1 2.2* Medications on Admission: tylenol prn, milk of mag prn, ___ prn, dulcolax prn, lasix 60", KCl 40", toprol 100', folic acid, synthroid ___, zocor 20', omeprazole 20', multivitamin, advair 250-50", augmentin 500-125" through ___, guaifenesin 100 prn, coumadin Discharge Medications: 1. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 2. furosemide 40 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 3. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. simvastatin 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation BID (2 times a day). 7. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 14 days. 8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. insulin regular human 100 unit/mL Solution Sig: One (1) inj Injection ASDIR (AS DIRECTED): per attached sliding scale. 11. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: Start ___. Adjust for goal INR ___. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: 1. colocutaneous fistula 2. cellulitis 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: Colocutaneous fistula through an umbilical hernia with possible associated abscess. Assess for drainable collection. COMPARISON: Reference CT available from ___. TECHNIQUE: Ultrasonography of the umbilical region. FINDINGS: Mixed echogenic material is seen within the paraumbilical region, subjacent to a stoma bag filled with colonic fluid and stool. No drainable fluid collections are seen. An area of nonvascular echogenic material may represent phlegmon; however, this is difficult to distinguish from neighboring tissues, which includes mental fat within a known paraumbilical hernia, better seen on the reference CT examination. IMPRESSION: No drainable collection seen. Mixed echogenic material subjacent to the stoma bag may represent phlegmonous material; however, it is difficult to distinguish this from neighboring omental fat from known paraumbilical hernia. Infection cannot be excluded by US. This area is better visualized on the reference CT examination from ___. Radiology Report LIMITED ABDOMINAL ULTRASOUND CLINICAL INDICATION: Erythema and query fluctuance on left pannus, evaluate for fluid collections. Scanning was performed over the area of skin erythema in the left lower abdomen pannus. No fluid collections could be identified in any portion of this region. CONCLUSION: No drainable fluid collections identified. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: SURGICAL EVAL Diagnosed with INTESTINAL FISTULA temperature: 99.1 heartrate: 97.0 resprate: 24.0 o2sat: 96.0 sbp: 126.0 dbp: 79.0 level of pain: 3 level of acuity: 2.0

You came to the hospital because you noted fluid draining from your an area in your abdomen. You were found to have a colocutaneous fistula. It has been determined that it is not safe to surgically fix the draining fistula at this time. You have been seen by the ostomy nurse who has placed an appliance to collect the drainage. You were also noted to have an area of redness around the fistula, likely related to the drainage. A CT scan was done to ensure that there is no drainable collection of fluid under your skin. You are being treated with antibiotics for the infection of you skin in that area. You will be on antibiotics for 2 weeks. Please follow up at the appointment listed below in the ___ clinic. If you have any questions/concerns prior to your follow up appointment you can call the clinic at ___. Your coumadin has been held for short time because of the interaction it has with one of the antibiotics you were on initially. You are no longer on this antibiotic and can resume taking your coumadin on ___. 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. *If you have increase abdominal distention, abdominal pain or nausea. *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.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Neck/Back pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ w HTN s/p TEVAR & L renal artery stent ___ for type B aortic dissection, discharged 2 days prior to presentation, returns w focal neck pain. Pt has focal, non-radiating, midline lower neck pain that began 2 days ago on the morning of discharge. Was felt to be musculoskeletal at that time due to the presence of tenderness and improvement with tylenol and heat packs. Pt states that after he went home it persisted. Last night it increased in severity and kept him up most of the night. Early this AM it became so unbearable that he could not move his neck so he went to ___ ___. Since receiving IV pain meds, pt's pain has improved. On arrival to ___ pt has full range of motion of his neck and ___ pain. He is admitted for further evaluation given resent TEVAR. Past Medical History: PMH: type B aortic dissection diagnosed ___, HTN PSH: back surgery x2, L wrist surgery Physical Exam: Alert and oriented x 3. His neurological exam normal, upper back is now ony slightly tender to palpation. VS:BP 118/71 HR 70 RR 18 Resp: Lungs clear Abd: Soft, non tender Ext: Pulses: all palp. Feet warm, well perfused. No open areas. Pertinent Results: ___ 05:01AM BLOOD WBC-12.2* RBC-4.37* Hgb-12.8* Hct-37.9* MCV-87 MCH-29.3 MCHC-33.8 RDW-13.0 RDWSD-41.2 Plt ___ ___ 06:55AM BLOOD Glucose-123* UreaN-16 Creat-1.3* Na-136 K-4.2 Cl-100 HCO3-24 AnGap-16 ___ 06:55AM BLOOD Calcium-9.6 Phos-4.4 Mg-2.0 CT cervical spine 1. No evidence of epidural collection. 2. Multilevel degenerative changes most pronounced at C5-C6 and C6-C7 where there is cord remodeling without abnormal cord signal. Medications on Admission: -Amlodipine 10 mg daily -Diltiazem 90 mg QID -Hydralazine 100 mg Q6H -Lisinopril 40 mg daily -Carvedilol 25 mg BID -Chlorthalidone 50 mg daily -Spironolactone 50 mg daily -Aspirin 81 mg daily -Acetaminophen ___ mg Q8H Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H pain 2. Amlodipine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Carvedilol 25 mg PO BID 5. Chlorthalidone 50 mg PO DAILY 6. Cyclobenzaprine 10 mg PO QID:PRN muscle spasm RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth every 6 hours as needed Disp #*30 Tablet Refills:*0 7. Diltiazem 90 mg PO QID 8. HydrALAzine 100 mg PO Q6H 9. Lisinopril 40 mg PO DAILY 10. Ibuprofen 600 mg PO Q8H:PRN pain 11. Spironolactone 50 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Back/Neck Pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CTA CHEST WANDW/O CANDRECONS, NON-CORONARY INDICATION: History: ___ with neck pain with recent dissection // eval for dissection TECHNIQUE: Contiguous helical MDCT images were obtained through the chest, abdomen and pelvis after administration of 100 cc of Omnipaque IV contrast. Reformatted coronal, sagittal, thin slice axial images, and oblique maximal intensity projection images were submitted to PACS and reviewed. DOSE: DLP: 1798 mGy-cm COMPARISON: CTA torso ___ FINDINGS: CTA TORSO: Patient is status post type B aortic dissection repair with endovascular graft extending from just proximal to the left subclavian artery to the distal thoracic aorta. The left subclavian artery is excluded and not opacified proximally but reconstitutes approximately 3 cm distal with the remainder of the subclavian artery appearing opacified. Beyond the stent the dissection flap remains visible with grossly stable size of the false and true lumens. The celiac trunk, right and left renal arteries originating from the true lumen and are patent. There has been interval placement of a left proximal renal artery stent which appears patent (2:161). The patent ___ from the true lumen. The dissection flap ends approximately 8 cm from the aortic bifurcation. Tiny amount of thrombus adherent to the wall of the right jugular and brachiocephalic vein is noted not extending to the SVC (02:39). CT CHEST WITH CONTRAST: Thyroid is unremarkable. No lymphadenopathy. Scattered mediastinal lymph nodes are similar to prior not pathologically enlarged by CT size criteria. Heart size is normal without pericardial effusion. The main pulmonary arteries are enlarged up to 4.3 cm as before. There is atherosclerotic calcification of the coronary arteries most notably the LAD. The tracheobronchial tree is patent to the subsegmental level. There is no bronchial wall thickening. Lungs are clear without pleural effusion or pneumothorax. There is no worrisome pulmonary nodule or opacity. CT ABDOMEN WITH CONTRAST: The liver enhances normally without focal lesions. The gallbladder, spleen and pancreas are unremarkable. 1.2 cm hypodense nodule in the right adrenal gland is incompletely characterize but is statistically most likely a benign adrenal adenoma, unchanged since the prior study. The stomach, small and large bowel are normal in caliber without obstruction. There is no mesenteric retroperitoneal lymphadenopathy. There is no free air or free fluid. There is a small fat containing paraumbilical hernia. CT PELVIS WITH CONTRAST: Small fat containing bilateral inguinal hernias. The urinary bladder, seminal vesicles and prostate are unremarkable. There is no pelvic wall or inguinal lymphadenopathy. OSSEOUS STRUCTURES: No worrisome blastic or lytic lesions. IMPRESSION: 1. Expected postoperative appearance following repair of type B aortic dissection. 2. The proximal neck vessels appear normal without evidence of dissection. The excluded left subclavian artery is occluded proximally but reconstitutes after approximately 3 cm. 3. The main arterial structures of the abdomen and pelvis are patent. Notably, the left renal stent is patent and both kidneys enhance symmetrically. 4. Tiny amount of thrombus adherent to the wall of the right brachiocephalic and jugular veins is noted (02:39) but does not extend to the SVC possibly secondary to previous central venous catheter. 5. Stable enlargement of the main pulmonary artery suggesting component of pulmonary hypertension. 6. 1.2 cm hypodense nodule in the right adrenal gland is incompletely characterized but is statistically most likely an adrenal adenoma. Attention can be paid on follow up imaging. Radiology Report EXAMINATION: MR CERVICAL SPINE W/O CONTRAST INDICATION: ___ w HTN s/p TEVAR L renal artery stent ___ for type B aortic dissection, discharged 2 days ago, returns w focal neck pain. // focal tenderness focal tenderness TECHNIQUE: Patient was unable to tolerate a full examination examination. Only sagittal images of the cervical spine without contrast could be obtained COMPARISON: None FINDINGS: Limited exam as patient could not tolerate the full exam. Only sagittal sequences could be obtained. Alignment is normal. Vertebral body marrow signal is mildly heterogeneous likely reflecting degenerative change. There is mild loss of normal intervertebral disc signal. There is loss of normal intervertebral disc height at C6-C7. The spinal cord appears normal in caliber and configuration. There is a broad-based disc protrusion at C3-C4 with resulting mild spinal canal narrowing and broad-based disc protrusions at C5-C6 and C6-C7 with resulting moderate spinal canal narrowing. There is no abnormal cord signal detected but evaluation on inversion recovery images is limited due to artifacts. Increased signal in the interspinous region in the C7-T1 level appears artifactual. Mild increased signal between the spinous processes of C1 and C2 on inversion recovery images are nonspecific and may indicate mild ligamentous injury without disruption. . IMPRESSION: Limited examination. Multilevel degenerative changes most pronounced at C5-C6 and C6-C7. No abnormal cord signal detected. Increased signal between the spinous processes of C1 and C2 on inversion recovery images is nonspecific and may indicate mild ligamentous injury without disruption. Given the limited nature of examination, this could not be fully evaluated. Radiology Report EXAMINATION: MR ___ WAND W/O CONTRAST INDICATION: ___ w HTN s/p TEVAR L renal artery stent ___ for type B aortic dissection, discharged 2 days ago, returns w focal neck pain. // Please evaluate for focal tenderness, needs gadolinium TECHNIQUE: Routine MRI of the cervical spine using sagittal and axial T1, T2 and STIR images. Postcontrast imaging was performed. COMPARISON: Prior limited MRI of the cervical spine dated ___. FINDINGS: Examination limited by artifact from aortic stent as well as motion. On the sagittal images, there is no malalignment or loss of vertebral body height. No suspect marrow lesions are seen. There is mild diffuse loss of normal intervertebral disc signal and loss of normal intervertebral disc height at C6-C7. The craniovertebral junction is unremarkable. The cord is normal in signal intensity and morphology. At C1-C2, there is no significant disc herniation or spinal canal stenosis. There is right greater than left uncovertebral facet joint arthropathy resulting in mild right neural foraminal narrowing. At C3-C4, there is no significant disc herniation or spinal canal stenosis. There is right greater than left uncovertebral facet joint arthropathy resulting in moderate to severe right neural foraminal narrowing and mild left neural foraminal narrowing. At C4-C5, there is no disc herniation or spinal canal stenosis. There is bilateral uncovertebral facet joint arthropathy resulting in moderate left and mild right neural foraminal narrowing. At C5-C6, there is a left paracentral/foraminal disc protrusion which is moderately narrowing the spinal canal and remodeling the cord without resulting in abnormal cord signal. There is bilateral uncovertebral facet joint arthropathy resulting in mild right and moderate to severe left neural foraminal narrowing. At C6-C7, there is a broad-based disc protrusion moderately narrowing the spinal canal and flattening the ventral aspect of the cord. There is bilateral uncovertebral facet joint arthropathy resulting in moderate to severe bilateral neural foraminal narrowing. At C7-T1, there is no significant disc herniation, spinal canal stenosis or neural foraminal narrowing. There is no abnormal enhancement on post-contrast images. The visualized soft tissues of the neck are unremarkable. IMPRESSION: 1. No evidence of epidural collection. 2. Multilevel degenerative changes as detailed above most pronounced at C5-C6 and C6-C7 where there is cord remodeling without abnormal cord signal. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Abd pain, Transfer Diagnosed with CERVICALGIA, POSTSURGICAL STATES NEC temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: 13 level of acuity: 1.0

Mr. ___, You were admitted to the hosptial with severe upper back/neck pain. We were concern that this could be a sign of a problem with your thoracic artery stent. You were treated with muscle relaxers and pain medications. The neurology team evaluated you and did an MRI of the cervical spine. We did not see any abnormalities. THe pain improved and we have arranged for you to follow up with your PCP to discuss ___ or other therapies for your discomfort. Duing your hopitalization, your BP control was excellent on your new medication regiment. 130-110/80s. Please continue all the medications you were taking before you were admitted. You were given a prescription for a muscle relaxer to take if needed.

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Lipitor / lisinopril / Pravachol / Indocin / Zocor Attending: ___ Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo M with history of CAD s/p attempted PCI of CTO of RCA ___ with plan for recanalization ___ who presented ___ with CP this evening. The patient reports central chest pressure last evening at 7pm that occurred when he was watching TV. It was ___ non-radiating sharp pain. It lasted 45 minutes; resolved 30 minutes after taking nitroglycerin x2 by EMS. He was also given a full dose aspirin. He denies nausea, vomiting, diaphoresis, ripping or tearing pain. Prior episodes of chest pain occurred with exertion. He was brought to ___ troponin x1 was <0.015. EKG was unchanged without any signs of ischemia. He was given 1 inch of nitropaste. Reports that the chest pain that started overnight was different than previous episodes. This pain was described as chest pain that was substernal and came on with rest. Previous episodes were associated with chest pressure. Yesterday's chest pain resolved 40 minute after taking sublingual nitro. Other labs were unremarkable. He was then transferred to ___ for further care. In the ED initial vitals were: 98.0 70 162/66 16 95% RA - Labs in the ED unremarkable. No cardiac enzymes were drawn. - EKG: NSR, nl axis, early R wave progression, LVH, STD/E/I - Patient was given: nothing On the floor the patient denies chest pain. He is feeling well. Past Medical History: - CAD w/attempted RCA with attempted PCI of CTO in ___ - Paroxysmal atrial fibrillation - Hypertension - Hyperlipidemia - Peripheral vascular disease s/p bilateral iliac and femoral artery stents - Gout - BPH - HLD Social History: ___ Family History: Mother with angina in her ___, a paternal uncle who underwent coronary bypass at age ___, and a paternal grandmother with a CVA in her ___. There is no family history of sudden cardiac death or arrhythmia. Physical Exam: PHYSICAL EXAM ON ADMISSION ===================================== VS: 97.8 157/52 58 16 95% RA wt 68.8kg GENERAL: Well appearing gentleman HEENT: Drooping of right eyelid. PERRL. MMM NECK: Supple, no JVD CARDIAC: Bradycardic, no m/r/g LUNGS: CTAB ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: +1 pitting edema b/l SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PHYSICAL EXAM ON DISCHARGE ====================================== T= 97.8 BP= 140/54 HR= 57 RR=16 O2 sat= 95% RA Wt: 68.8 kg GENERAL: In NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: No elevated JVP LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: + 1 pitting edema up to mid shin bilaterally. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Radial 2+ Left: Radial 2+ Pertinent Results: LABS ON ADMISSION =================================== ___ 06:45AM GLUCOSE-89 UREA N-26* CREAT-1.1 SODIUM-142 POTASSIUM-4.5 CHLORIDE-108 TOTAL CO2-25 ANION GAP-14 ___ 06:45AM CALCIUM-9.5 PHOSPHATE-3.4 MAGNESIUM-2.2 ___ 06:45AM WBC-6.7 RBC-3.32* HGB-11.4* HCT-33.8* MCV-102* MCH-34.3* MCHC-33.7 RDW-12.3 RDWSD-45.9 ___ 02:25AM NEUTS-73.0* LYMPHS-16.4* MONOS-7.7 EOS-2.1 BASOS-0.5 IM ___ AbsNeut-4.54 AbsLymp-1.02* AbsMono-0.48 AbsEos-0.13 AbsBaso-0.03 ___ 03:37AM ___ PTT-25.1 ___ ___ 01:25PM CK-MB-5 cTropnT-<0.01 ___ 01:25PM BLOOD CK-MB-5 cTropnT-<0.01 LABS ON DISHCARGE =================================== ___ 06:45AM BLOOD WBC-6.7 RBC-3.32* Hgb-11.4* Hct-33.8* MCV-102* MCH-34.3* MCHC-33.7 RDW-12.3 RDWSD-45.9 Plt ___ ___ 06:45AM PLT COUNT-127* ___ 06:45AM BLOOD Plt ___ ___ 06:45AM BLOOD Glucose-89 UreaN-26* Creat-1.1 Na-142 K-4.5 Cl-108 HCO3-25 AnGap-14 ___ 06:45AM BLOOD Calcium-9.5 Phos-3.4 Mg-2.2 ___ 06:45AM CK(CPK)-237 ___ 06:45AM ___ PTT-29.2 ___ ___ 06:45AM BLOOD CK-MB-5 cTropnT-<0.01 EKG ___: Sinus bradycardia. Vent rate: 56 bpm. PR interval: 172 ms. ___: 82 ms QTc: 425. No signs of ST segment elevation or depression. No TWI. ADMISSION EKG ___: Sinus rate 55, normal axis and intervals, LVH, no TWI or ST changes STRESS TEST ___: He exercised for 9 mins and achieved 10.1 METS with evidence of inducible ischemia with the development of 2mm downsloping ST depressions in V4-6 during the recovery phase. CARDIAC CATH ___: Single vessel CAD of the RCA with attempted PCI of CTO of RCA, unable to pass wire, plan to return in late ___ for planned CTO recanalization. CXR ___: No acute cardiopulmonary processes Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Pravastatin 20 mg PO QPM 2. Multivitamins 1 TAB PO DAILY 3. Fish Oil (Omega 3) 2400 mg PO BID 4. Niacin SR 1000 mg PO DAILY 5. Clopidogrel 75 mg PO DAILY 6. Losartan Potassium 100 mg PO DAILY 7. Aspirin 325 mg PO DAILY 8. Allopurinol ___ mg PO DAILY 9. Metoprolol Succinate XL 25 mg PO DAILY 10. Amlodipine 5 mg PO DAILY 11. Doxazosin 2 mg PO HS 12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain Discharge Medications: 1. Allopurinol ___ mg PO DAILY 2. Amlodipine 5 mg PO DAILY 3. Clopidogrel 75 mg PO DAILY 4. Doxazosin 2 mg PO HS 5. Fish Oil (Omega 3) 2400 mg PO BID 6. Losartan Potassium 100 mg PO DAILY 7. Metoprolol Succinate XL 25 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Pravastatin 20 mg PO QPM 10. Niacin SR 1000 mg PO DAILY 11. Aspirin 325 mg PO DAILY 12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain Discharge Disposition: Home Discharge Diagnosis: Primary: Chest Pain Secondary: CAD s/p attempted PCI of RCA ___ with plan re-canalization on ___ Paroxysmal Atrial Fibrillation Hypertension Hyperlipidemia PVD s/p ___ iliac and femoral stents. Gout BPH HLD 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 chest pain // eval for pna TECHNIQUE: Chest PA and lateral COMPARISON: None FINDINGS: The cardiomediastinal silhouette and pulmonary vasculature are unremarkable. The lungs are clear aside from volume loss in the right lower lobe. There is no pleural effusion or pneumothorax. IMPRESSION: No acute abnormality. Gender: M Race: WHITE - OTHER EUROPEAN Arrive by AMBULANCE Chief complaint: Transfer Diagnosed with Cardiomyopathy, unspecified temperature: 98.0 heartrate: 70.0 resprate: 16.0 o2sat: 95.0 sbp: 162.0 dbp: 66.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, You came to the hospital with chest pain. You were found to have no signs of worsening cardiac disease. Your chest pain resolved by the time you got to the hospital. If your pain is not responsive to nitroglycerin you should go to the emergency room. You are scheduled for your cardiac catheterization with Rotoblader treatment on ___. Dr. ___ is aware of your hospitalization. It was a pleasure meeting you. Sincerely, 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: altered mental status, fall Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year old man w/ PMH anemia, DVT/PE on Coumadin, glaucoma, CKD, NSTEMI ___, depression, thrombocytopenia who presented with confusion and left shoulder pain s/p fall. Per ED note: Patient has 3 days of progressive weakness and altered mental status, followed by unwitnessed fall last night. Patient's son heard him fall, immediately entered room, denies that he had loss of consciousness. Approximately 1 week ago he began having cough with yellow/brown sputum production, started by PCP on azithromycin following CXR without focal pneumonia. Interval improvement in cough. No hemoptysis. Exam noted right pupil larger than left s/p cataract surgery. AAOX3, with ___ strength in upper and lower extremities. DTRs intact. Gait testing was deferred. Per PCP note the day prior, the patient started having delirium ___. He developed a "cold" ___ days ago and has had a cough of thick yellow-green sputum. Some dyspnea on exertion but no SOB at rest. Had no fevers but did not have chills and sweats. Had been exposed to sick contacts with flu and URIs. On the ___ he started hearing people and seeing people that weren't there. At that time a CXR was done which was felt to show increased interstitial markings and the PCP diagnosed the patient with bronchitis and started him on Azithromycin. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: Anemia, B12 deficiency BPH Bladder cancer hx Carpal tunnel syndrome Cataract Chronic low back pain DVT/PE on Coumadin Glaucoma HLD OA CKD Vocal cord polyps Eczematous dermatitis NSTEMI ___ Depression Thrombocytopenia Social History: ___ Family History: Reviewed and found to be not relevant to this illness/reason for hospitalization. Physical Exam: Admission Physical: ==================== VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Discharge physical ==================== General: Well appearing, comfortable, NAD, hoarse voice HEENT: Anicteric, eyes conjugate, MM dry, no JVD, right pupil dilated from prior surgery Cardiovascular: RRR no MRG, nl. S1 and S2 Pulmonary: Lung fields with some rhonchi at bases otherwise clear Gastroinestinal: Soft, non-tender, non-distended, bowel sounds present, no HSM MSK: No edema Skin: No rashes or ulcerations evident Neurological: Alert, interactive, speech fluent, oriented to place and year as ___ Psychiatric: pleasant, appropriate affect Pertinent Results: Admission Labs: ================ ___ 12:32PM BLOOD WBC-6.7 RBC-3.20* Hgb-10.2* Hct-31.4* MCV-98 MCH-31.9 MCHC-32.5 RDW-14.2 RDWSD-50.9* Plt ___ ___ 12:32PM BLOOD Neuts-52.8 ___ Monos-10.2 Eos-3.3 Baso-0.8 Im ___ AbsNeut-3.52 AbsLymp-2.16 AbsMono-0.68 AbsEos-0.22 AbsBaso-0.05 ___ 09:17AM BLOOD ___ PTT-44.4* ___ ___ 12:32PM BLOOD UreaN-33* Creat-2.0* Na-142 K-5.0 Cl-107 HCO3-25 AnGap-10 ___ 09:17AM BLOOD ALT-28 AST-37 AlkPhos-133* TotBili-0.6 ___ 12:32PM BLOOD Calcium-8.3* Phos-2.7 Mg-2.1 Discharge Creatinine 2.1 Hgb 9.5, platelet 116 INR 4.2-->3.9-->4.1-->2.5 CXR ___ IMPRESSION: 1. No evidence of pneumonia. 2. Unchanged diffuse interstitial disease, better described on prior CT. XR hip ___ IMPRESSION: No fracture or dislocation. CT c-spine ___ IMPRESSION: Study is moderately limited due to motion. No evidence of traumatic malalignment. No acute fracture. CT head ___ IMPRESSION: The study is severely limited due to patient motion. Within the limitations, there is no evidence of large intracranial hemorrhage, no evidence of midline shift. There is no evidence of acute large territory infarction, however detection is significantly limited due to motion. EKG NSR 62, QT 487 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Finasteride 5 mg PO DAILY 2. Terazosin 2 mg PO QHS 3. Acetaminophen 1000 mg PO Q8H 4. QUEtiapine Fumarate 25 mg PO QHS 5. ammonium lactate ___ % topical BID:PRN 6. Timolol Maleate 0.5% 1 DROP BOTH EYES BID 7. Docusate Sodium 100 mg PO BID 8. Warfarin 7.5 mg PO DAILY16 9. Atorvastatin 40 mg PO QPM 10. Multivitamins 1 TAB PO DAILY 11. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 12. melatonin 6 mg oral QHS 13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 14. Aspirin 81 mg PO DAILY 15. FLUoxetine 40 mg PO DAILY 16. Cyanocobalamin 1000 mcg IM/SC MONTHLY 17. Vitamin E 400 UNIT PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. ammonium lactate ___ % topical BID:PRN 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Cyanocobalamin 1000 mcg IM/SC MONTHLY 6. Docusate Sodium 100 mg PO BID 7. Finasteride 5 mg PO DAILY 8. FLUoxetine 40 mg PO DAILY 9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 10. melatonin 6 mg oral QHS 11. Multivitamins 1 TAB PO DAILY 12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 13. QUEtiapine Fumarate 25 mg PO QHS 14. Terazosin 2 mg PO QHS 15. Timolol Maleate 0.5% 1 DROP BOTH EYES BID 16. Vitamin E 400 UNIT PO DAILY 17. Warfarin 7.5 mg PO DAILY16 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: metabolic encephalopathy fall weakness supratherapeutic INR Discharge Condition: fair Ambulatory with 1 person assist Followup Instructions: ___ Radiology Report INDICATION: ___ with AMS// eval for pneumonia TECHNIQUE: Single supine view of the chest. COMPARISON: Chest x-rays from ___ and ___. FINDINGS: The lungs are clear. There is no consolidation. No obvious effusion or pneumothorax based on a supine film. The cardiomediastinal silhouette is stable. No displaced fractures identified. IMPRESSION: No acute cardiopulmonary process. Radiology Report INDICATION: ___ s/p fall with weakness and right hip tenderness.// Fracture? Dislocation TECHNIQUE: AP view of the pelvis. AP and frogleg lateral views of the right hip. COMPARISON: Correlation made to CT abdomen pelvis from ___. FINDINGS: There is no fracture. No focal osseous abnormality. Mild degenerative changes noted at the femoroacetabular joints bilaterally. There is no dislocation. Surgical material projects over the right pelvis as well as an IVC filter partially visualized over the lower abdomen. IMPRESSION: No fracture or dislocation. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ with closed head inj// eval for bleed/fx 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 2.0 s, 2.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 100.3 mGy-cm. 2) Sequenced Acquisition 6.0 s, 6.6 cm; CTDIvol = 45.7 mGy (Head) DLP = 301.0 mGy-cm. 3) Sequenced Acquisition 8.0 s, 16.8 cm; CTDIvol = 74.4 mGy (Head) DLP = 1,248.7 mGy-cm. Total DLP (Head) = 1,650 mGy-cm. COMPARISON: ___ CT head FINDINGS: The study is severely limited due to patient motion, despite repeat imaging. Within the limitations, there is no evidence of large intracranial hemorrhage, no evidence of midline shift. There is no evidence of acute large territory infarction, however detection is significantly limited due to motion. There is prominence of the ventricles and sulci suggestive of involutional changes. Periventricular white matter hypodensities are nonspecific, but likely reflect sequelae of chronic small vessel ischemic disease. There is no evidence of fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: The study is severely limited due to patient motion. Within the limitations, there is no evidence of large intracranial hemorrhage, no evidence of midline shift. There is no evidence of acute large territory infarction, however detection is significantly limited due to motion. RECOMMENDATION(S): If there is deterioration in exam or other concern, repeat imaging may be obtained as clinically indicated. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 11:05 am, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: ___ with closed head inj// eval for bleed/fx TECHNIQUE: Contiguous axial images obtained through the cervical spine without intravenous contrast. Coronal and sagittal reformats were reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.8 s, 22.8 cm; CTDIvol = 22.7 mGy (Body) DLP = 518.1 mGy-cm. Total DLP (Body) = 518 mGy-cm. COMPARISON: ___ CT cervical spine FINDINGS: Study is limited due to motion at the C3-C4 level and at C7. There no malalignment. No fractures are identified. There is multilevel scratch uncovertebral hypertrophy and facet osteophytes with resulting multilevel mild-to-moderate neural foraminal stenosis, most significant at C3-C4. There are posterior vertebral body osteophytes with resulting mild spinal canal narrowing most significant at C3-C4 and C5-C6. There is no prevertebral edema. The thyroid and included lung apices are unremarkable. IMPRESSION: Study is moderately limited due to motion. No evidence of traumatic malalignment. No acute fracture. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Confusion, L Shoulder pain, s/p Fall Diagnosed with Altered mental status, unspecified, Weakness, Abnormal coagulation profile, Long QT syndrome temperature: 98.9 heartrate: 72.0 resprate: 18.0 o2sat: 96.0 sbp: 144.0 dbp: 75.0 level of pain: 5 level of acuity: 2.0

Mr. ___, You were admitted after a fall and had some confusion/hallucinations. We think the confusion might have been related to a viral illness, which resolved promptly without intervention. Your INR was high which was likely from the antibiotics you received outpatient. We held a few doses of warfarin, but you may resume your normal dose after discharge. Our physical therapist evaluated you and think you will benefit from rehab. Please follow up with your primary care doctor in 2 weeks. It was a pleasure caring for you in ___!

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Erythromycin Base / Oxycodone Attending: ___. Chief Complaint: fever Major Surgical or Invasive Procedure: ___ placement History of Present Illness: ___ w/Necrotizing gallstone pancreatitis requiring multiple hospitalizations (most recently dc ___. Pt presents with fever to 101.4. She denies localizing symptoms, specifically denies abdominal pain, nausea, vomiting, shortness of breath, chest pain, open wounds. In ED pt had CT scan, unchanged from prior. GI notified. Given vanc/cipro/flagyl and zofran. Bolused 2L and blood cultures drawn. On arrival to floor pt reports that she currently has no pain or nausea. +Cough for 3 days, spitting up clear sputum with associated nausea. Also with left ear pain. No hearing loss. No history of recurrent ear infections. ROS: +as above, otherwise reviewed and negative Past Medical History: Hyperlipidemia Necrotizing gallstone pancreatitis; hospitalization ___ Pleural effusion, d/t pancreatitis Hyperglycemia, d/t pancreatitis Pancreatic insufficiency, d/t pancreatitis Anemia, chronic disease Social History: ___ Family History: Unknown. Pt adopted. Physical Exam: Vitals: T:100.1 BP:130/74 P:110 R:18 O2:96%ra PAIN: 0 General: nad HEENT: DBT in place with bridle, op clear, unable to visualize posterior pharynx Lungs: clear CV: rrr no m/r/g Abdomen: bowel sounds present, soft, nt/nd Ext: no e/c/c Skin: no rash Neuro: alert, follows commands Physical exam on discharge: Vitals: 98.7 BP: 126/75 P: 90 R: 18 O2: 98% RA Pain: O Laying in bed in NAD HEENT: NGT in place with bridle, op clear, unable to visualize posterior pharynx Lungs: decreased air entry at left base CV:RRR, no m/r/g Abdomen: Soft, non tender, non distended bowel sounds present Ext: no e/c/c Skin: no rash Neuro: alert, follows commands Pertinent Results: ___ 09:45PM GLUCOSE-132* UREA N-14 CREAT-0.4 SODIUM-135 POTASSIUM-4.9 CHLORIDE-96 TOTAL CO2-26 ANION GAP-18 ___ 09:45PM ALT(SGPT)-59* AST(SGOT)-47* ALK PHOS-503* TOT BILI-0.3 ___ 09:45PM LIPASE-62* ___ 09:45PM ALBUMIN-3.4* ___ 09:45PM WBC-24.3*# RBC-3.57* HGB-9.7* HCT-31.2* MCV-87 MCH-27.3 MCHC-31.2 RDW-14.2 ___ 09:45PM NEUTS-81.7* LYMPHS-11.5* MONOS-5.5 EOS-0.6 BASOS-0.7 ___ 09:45PM PLT COUNT-1099* ___ 12:20AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 12:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-7.0 LEUK-MOD ___ 12:20AM URINE RBC-3* WBC-15* BACTERIA-FEW YEAST-NONE EPI-<1 ___ 12:20AM URINE MUCOUS-OCC Pleural fluid: ATYPICAL. Atypical cells - favor reactive mesothelial cells; inflammatory cells and histiocytes. CT ABD/PEL ___ Wetread: Moderate-sized left pleural effusion is relatively unchanged since ___. Multiple multiloculated pseudocysts are decreased in size since ___. No ascites. CXR ___ Preliminary Report IMPRESSION: A moderate-sized left pleural effusion with underlying atelectasis has decreased since ___. No focal opacity suggestive of pneumonia is seen. CT abd/chest ___ IMPRESSION: 1. Roughly 20 cm stretch of transverse colon beginning at the hepatic flexure with prominent wall thickening, edema and surrounding marked inflammatory change. This degree of findings with phlegmonous change with decreased size of an uncinate pancreatic pseudocyst is most suggestive of partial cyst rupture with leak of pancreatic enzyme contents across the mesocolon causing secondary inflammation. No frank abscess. Diverticulitis is hard to exclude but seems much likely as the etiology to describe the overall findings. 2. Transgastric catheter continues to drain the pancreatic tail pseudocyst, which is decreased in size compared to prior examination; a superior subphrenic extension, including an air-fluid level, persists but has also decreased. An uncinate process pseudocyst is also decreased in size; however, the now largest pancreatic head pseudocyst has intervally increased in size, and it may exert focal mass effect on the adjacent traversing duodenum. 3. Trace ascites likely secondary to inflammation. 4. Simple renal cyst. CT chest ___ Left greater than right bibasilar consolidations are similar to prior examination and could represent atelectasis; however, their pattern of hypoenhancement particularly at the left base is worrisome for pneumonia. A small to moderate left sided simple density pleural effusion has decreased in volume compared to prior study. CT abdomen: ___ IMPRESSION: 1. Increased organization of a phlegmon surrounding the proximal tranverse colon consistent with walled off fat necrosis. No discrete drainable abscess in this region. Known transverse colitis within this fat necrosis is unchanged. No free intraperitoneal air or pneumotosis. 2. Mild decrease in a subdiaphragmatic abcess. Drainage of this abscess would be difficult given its location and risk of infecting overlying pleural effusion. 3. Mild increase in a nonhemorragic left pleural effusion. 4. Mild decrease in size of the pancreatic head and uncinate pseudocysts. Increase in pancreatic body pseudocyst and stable pancreatic tail pseudocyst with a drainage catheter. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Docusate Sodium 100 mg PO BID:PRN constipation 2. FoLIC Acid 1 mg PO DAILY 3. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain 4. Lorazepam 0.5 mg PO Q8H:PRN nausea/anxiety 5. Senna 1 TAB PO BID 6. Ondansetron 4 mg PO Q8H:PRN nausea 7. Glargine 18 Units Breakfast Discharge Medications: 1. Aztreonam ___ mg IV Q8H Last day ___ RX *aztreonam in dextrose(iso-osm) [Azactam in dextrose (iso-osm)] 2 gram/50 mL 2 gm IV Q8hrs Disp #*240 Vial Refills:*0 2. Docusate Sodium 100 mg PO BID:PRN constipation 3. FoLIC Acid 1 mg PO DAILY 4. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain 5. Glargine 12 Units Bedtime 6. Lorazepam 0.5 mg PO Q8H:PRN nausea/anxiety 7. Ondansetron 4 mg PO Q8H:PRN nausea 8. Senna 1 TAB PO BID 9. Famotidine 20 mg PO Q12H RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 10. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Take until ___ RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth Q8hrs Disp #*90 Tablet Refills:*0 11. Outpatient Lab Work Please check weekly CBC, Chem 7, BUN/CR and AST/ALT and have results faxed to ___ R.N.s at ___. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Diverticulitis/Transverse Colitis Pleural effusion Secondary: Pancreatitis with pseudocysts Secondary diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Fever and recent pseudocyst drainage. Evaluation of pseudocyst size. TECHNIQUE: Multi detector CT scan through the abdomen and pelvis was performed after the administration of 130 cc Omnipaque IV contrast. Coronal and sagittal reformatted images were obtained. DLP: 480.31 mGy-cm. COMPARISON: CT abdomen and pelvis ___ at ___. FINDINGS: There is bibasilar, left greater than right atelectasis. A moderate-sized left pleural effusion is relatively unchanged since ___. The liver enhances homogeneously without focal lesions. The portal vein is patent. There are multiple calcified gallstones within the gallbladder. The previously seen multiloculated pancreatic pseudocyst in the body and tail continues to decrease in size now measuring 4.1 x 5.4 cm (02:24) and previously measuring 5. 6 x 7.2 cm. The cyst contains air and multiple pigtail catheters are seen within the cyst communicating with the stomach. An additional portion of the pseudocyst located superior to the spleen has also has decreased in size, now measuring 1.1 x 5.4 cm (601B: 50) and previously measuring 3 x 7.8 cm. A bilobed pseudocyst adjacent to the pancreatic head is stable in size measuring 4.2 x 2.8 cm (02:31) and previously measured 4.3 x 3 cm. The smaller component of this pseudocyst measures 2.3 x 3 .8 cm (02:40) and previously measured 2.8 x 3.9 cm. These two cysts do not contain catheters. The remainder of the pancreas enhances homogeneously without focal areas of necrosis. The spleen appears normal. The the adrenal glands are unremarkable. A 2.6 cm left renal cyst (02:31) is unchanged. The kidneys demonstrate symmetric nephrograms and excretion of contrast. There is no hydronephrosis. The stomach contains multiple pigtail catheters. An upper enteric tube terminates in the small bowel. The small and large bowel are normal without evidence of wall thickening or obstruction. The appendix appears normal. The bladder, uterus and adnexa appear normal. There is no free fluid, free air or lymphadenopathy. The aorta is normal in caliber. Osseous structures: No concerning osteoblastic or osteolytic lesions. IMPRESSION: 1. Moderate-sized left pleural effusion is relatively unchanged since ___. 2. Multiple multiloculated pseudocysts in the left upper quadrant with drains in place are decreased in size since ___ however, a collection within the head of the pancreas is not significantly changed and does not contain a drainage catheter. 3. No free fluid or signs of pancreatitis or pancreatic necrosis. Radiology Report HISTORY: Patient with prolonged dobhoff tube due to pancreatitis now with fever, left sided neck and ear pain, please eval for abscess, mastoiditis. COMPARISON: None available. TECHNIQUE: MDCT all of the neck was performed with 2.5 mm axial sections obtained from the aorticopulmonary window through the orbital level, during the dynamic administration of IV contrast. Reformatted coronal and sagittal images were generated and reviewed. CTDIvol: 111.70mGy. DLP: 1317.10 mGy-cm FINDINGS: Visualized portions of the intracranial structures are unremarkable. The paranasal sinuses, mastoid air cells, and middle ear cavities are clear. A nasal gastric tube is seen within the left nasal cavity. Evaluation of the aerodigestive tract demonstrates no exophytic mucosal mass, nor areas of focal mass-effect. Evaluation of the cervical lymph node chains demonstrate no pathologic lymphadenopathy by imaging criteria. The thyroid gland is normal. The salivary glands are unremarkable in appearance. The neck vessels enhance bilaterally without significant stenosis. No abnormal fluid collections or mass is identified in the neck. Partially visualized lung apices demonstrate a large left-sided pleural effusion with adjacent compressive atelectasis. IMPRESSION: 1. No evidence of abnormal fluid collection or mass seen in the neck. The mastoid air cells are clear. 2. Partially visualized large left-sided pleural effusion with compressive atelectasis. Radiology Report REASON FOR EXAMINATION: Evaluation of the patient with pleural effusion after chest tube placement. AP radiograph of the chest was compared to ___. The left pigtail catheter is in place. There is a substantial interval decrease in pleural effusion. Heart size and mediastinum are stable. Upper lungs are clear. Right lung is unremarkable. Radiology Report REASON FOR EXAMINATION: Evaluation of the patient with left pleural effusion. AP radiograph of the chest was reviewed in comparison to ___. The Dobbhoff tube passes below the diaphragm with its tip not included in the field of view. Left pigtail catheter is in place. There is interval decrease in left pleural effusion. Still present right pleural effusion are most likely small to moderate. There is no pneumothorax. No pulmonary edema demonstrated. Radiology Report REASON FOR EXAMINATION: Evaluation of the patient after chest tube removal. AP radiograph of the chest was reviewed in comparison to ___ obtained at 09:37 a.m. The left pigtail catheter has been removed. There is no interval development of pneumothorax and there is no interval increase in pleural effusion. Basal consolidation and atelectasis are noted. The heart size and mediastinum are stable. Lungs are essentially clear with only mild vascular congestion. Radiology Report HISTORY: Pancreatitis, rising white count with concern for abscess. COMPARISON: CT abdomen and pelvis ___. TECHNIQUE: Axial helical MDCT images were obtained of the chest, abdomen and pelvis after the administration of IV and oral contrast. Additional images through the abdomen were obtained prior to contrast. Chest images were archived to a separate clip. Multiplanar reformatted images were generated in the coronal and sagittal planes. DLP: 1756.00 mGy-cm. FINDINGS: CT ABDOMEN WITH CONTRAST: The liver enhances homogeneously without focal lesion, intra- or extra-hepatic biliary ductal dilatation. The portal vein is patent. Numerous gallstones are contained within an otherwise thin-walled gallbladder. The spleen and adrenal glands are grossly unremarkable in appearance. There is a simple density 2.6 cm left interpolar renal cyst. The kidneys otherwise present symmetric nephrograms and excretion of contrast without focal solid lesion, pelvicaliceal dilatation or perinephric abnormality. There remains mild peripancreatic fat stranding with numerous pseudocysts. Transgastric drainage catheters remain in the collection adjacent to the pancreatic tail with only a minimal amount of fluid with locules of gas, appearing mildly improved compared to prior examination, at the site of catheter placements. A air-fluid containing left subphrenic extension of the collection persists but also appears somewhat decreased. The largest remaining collection is within the pancreatic head and measures 5.3 x 3.7 cm (3:60), mildly increased in size compared to prior study where it measured 4.2 x 2.9 cm. An additional cystic collection suggesting a pseudocyst adjacent to the uncinate process measures 2.7 x 2.1 cm, decreased in size compared to a prior study (3:70), where it measured 3.2 x 2.8 cm. The remainder of the pancreatic parenchyma enhances homogeneously without evidence of necrosis. The mid splenic vein is again probably occluded or at least with markedly attenuated flow as it passes through a region of severe inflammatory changees, also noting omental collateral flow pathways. The IMV is minimally attenuated adjacent to the large pancreatic head pseudocyst, but appears patent. There is a roughly 20 cm stretch of transverse colon beginning at the hepatic flexure demonstrating prominent wall thickening with mural edema and diffuse surrounding area of marked expansile fat stranding measuring roughly 14.9 x 9.5 cm without distinct fluid collection. Fat stranding extends superiorly up to a suspected pseudocyst that has decreased in size over the short interval. There are a few colonic diverticula including in the region of affected mid transverse colon. A small portion of an adjacent ileal loop is mildly thickened, likely reactive. The distal large bowel is grossly unremarkable. There is no evidence of bowel obstruction. An upper enteric post-pyloric tube terminates in the proximal jejunum. The abdominal aorta is normal in caliber with grossly patent celiac axis, SMA, bilateral renal arteries and ___. There is no mesenteric or retroperitoneal lymphadenopathy. There is a small fat-containing umbilical hernia. CT PELVIS WITH CONTRAST: A small amount of fluid layering within the pelvis likely is tracking from above. The uterus, adnexa, bladder and rectum are grossly unremarkable. There is no inguinal or pelvic wall lymphadenopathy by CT size criterion. BONE WINDOWS: There are no suspicious focal blastic or lytic lesions. IMPRESSION: 1. Roughly 20 cm stretch of transverse colon beginning at the hepatic flexure with prominent wall thickening, edema and surrounding marked inflammatory change. This degree of findings with phlegmonous change with decreased size of an uncinate pancreatic pseudocyst is most suggestive of partial cyst rupture with leak of pancreatic enzyme contents across the mesocolon causing secondary inflammation. No frank abscess. Diverticulitis is hard to exclude but seems much likely as the etiology to describe the overall findings. 2. Transgastric catheter continues to drain the pancreatic tail pseudocyst, which is decreased in size compared to prior examination; a superior subphrenic extension, including an air-fluid level, persists but has also decreased. An uncinate process pseudocyst is also decreased in size; however, the now largest pancreatic head pseudocyst has intervally increased in size, and it may exert focal mass effect on the adjacent traversing duodenum. 3. Trace ascites likely secondary to inflammation. 4. Simple renal cyst. Results were discussed over the telephone with Dr. ___ by Dr. ___ ___ at 3:20 p.m. on ___, five minutes after discovery. Radiology Report HISTORY: Pancreatitis with rising leukocytosis and cough with suspicion for abscess. COMPARISON: Numerous CT abdomen and pelvis studies dating from ___ through ___. TECHNIQUE: Axial helical MDCT images were obtained of the chest, abdomen and pelvis after the administration of IV and oral contrast. Abdomen and pelvis images were archived to a separate clip. Multiplanar reformatted images were generated in the coronal and sagittal planes as well as axial maximum intensity projection images. DLP for the total of chest, abdomen and pelvis acquisition is recorded on the separate abdomen and pelvis report. FINDINGS: CT CHEST WITH CONTRAST: The thyroid gland is unremarkable. The trachea is midline, and the airways are patent to the subsegmental level. Heart size is normal without significant pericardial effusion. The thoracic aortic arch and main pulmonary artery are normal in caliber. There is no central pulmonary embolus. There are no pathologically enlarged supraclavicular, axillary, hilar or mediastinal lymph nodes. Bibasilar left greater than right basal consolidations are similar compared to ___ however, the pattern of relative ___ is concerning for pneumonia. The small layering left-sided simple density pleural effusion has improved compared to a prior study. Motion artifact limits evaluation for a small nodularity. A 3 mm nodule in the lingula is unchanged compared to prior examination (4:126). This nodule has no concerning features and does not require further surveillance. No new nodule is identified. There is no pneumothorax. BONE WINDOWS: The thoracic cage is unremarkable without suspicious blastic or lytic lesion. IMPRESSION: 1. Left greater than right bibasilar consolidations are similar to prior examination and could represent atelectasis; however, their pattern of ___ particularly at the left base is worrisome for pneumonia. A small to moderate left sided simple density pleural effusion has decreased in volume compared to prior study. 2. Abdomen and pelvis findings are included on a separate report. Results were discussed over the telephone with Dr. ___ by Dr. ___ ___ at 3:20 p.m. on ___, five minutes after discovery. Radiology Report CHEST RADIOGRAPH HISTORY: PICC line placement. COMPARISONS: ___ radiograph and CT from ___. TECHNIQUE: Chest, semi-upright AP portable. FINDINGS: A new left-sided PICC line terminates in the mid superior vena cava. A feeding tube courses into the stomach. There are at least three double pigtail catheters in the left upper quadrant. A moderate left-sided pleural effusion is probably unchanged in size with patchy associated opacity suggesting minor atelectasis. There is no pneumothorax. IMPRESSION: New PICC line terminating in the superior vena cava. Radiology Report HISTORY: Pancreatitis and pseudocyst presents with fever found to have transverse colitis. Assess for developing abscess. COMPARISON: CT abdomen/ pelvis ___. ___ TECHNIQUE: Axial helical MDCT images were obtained from the suprasternal notch to the pubic symphysis after administration of IV and oral contrast. Multiplanar reformatted images in coronal and sagittal axis were generated FINDINGS: Heart and lungs: Limited assessment of the lung bases demonstrate no focal opacity. Again seen is a large nonhemorrhagic left pleural effusion which has mildly increased in size. Mild decrease in the subdiaphragmatic fluid collection with a peripheral enhancing irregular rim and locules of air which is consistent for an abscess. No pericardial effusion. Liver: The liver is homogeneous without focal opacity. No portal venous air or pneumobilia. No intrahepatic biliary duct dilatation. The gallbladder is thin walled with multiple calcified gallstones which are unchanged from prior study. The main portal vein and its major branches are patent. Pancreas: Again seen are multiple pseudocysts. There has been interval decrease in the pancreatic head pseudocyst which now measures 4.1 x 3.4 cm (previously 5.3 x 3.7 cm)(4:33) as well as a 2.5 x 2.1 cm (previously 2.7 x 2.1 cm) (4: 42) pseudocyst in the uncinate. The pseudocyst in the pancreatic body has slightly increased in size now measuring 1.8 x 1.0 cm (previously 1.3 x 0.5cm. Again seen is a drainage ___ is seen is tail pseudocyst which is unchanged in size and measures 2.7 x 1.2 cm (previously 2.9 x 1.2 cm)(4:27). No new focal solid or cystic lesions. No peripancreatic fat stranding. Adrenal gland: The adrenal glands are unremarkable. Spleen: The spleen is homogeneous and normal in size. The subdiaphragmatic abscess is superior and distinct from the spleen. Kidney: Again seen is a 2.7 x 2.3 cm (previously 2.8 x 2.3 when measured in a similar fashion) lobulated cyst in the left mid kidney. No additional focal cystic or solid lesions. Symmetric nephrograms and excretion of contrast. The proximal ureters are normal in caliber. No pelvocaliceal dilatation or perinephric stranding. GI: A feeding tube courses through the esophagus with the tip in the mid jejunum. The stomach is non distended. The duodenum, small bowel are normal in caliber without focal wall thickening or obstruction. Few diverticula without diverticulitis are noted in the sigmoid colon. The rectum, descending and distal transverse colon are normal in caliber without focal wall thickening, fat stranding, or mass lesion. Again seen is thickening of the proximal transverse colon bowel wall which is unchanged from prior study with preserved passage of contrast distally. Previously identified inflammation surrounding the proximal transverse colon is now more organized with enhancing internal vessels suggestive of walled off fat necrosis. No pneumatosis. Vascular: The descending aorta and its major branches are normal in caliber and patent. No aneurysmal dilatation of the descending aorta. The IVC, hepatic veins, splenic vein, SMV and renal veins are patent. Retroperitoneum and abdomen: No retroperitoneal or mesenteric lymph node enlargement by CT criteria. No ascites, free intraperitoneal air or abdominal wall hernia. Osseous structures: Mild degenerative changes of the lumbar spine is noted. No focal lytic or blastic lesions suspicious for malignancy. CT pelvis: Air is seen in the vagina. The bladder is decompressed and the terminal ureters are not visualized. No inguinal or pelvic wall lymph node enlargement. No pelvic free fluid. IMPRESSION: 1. Increased organization of a phlegmon surrounding the proximal tranverse colon consistent with walled off fat necrosis. No discrete drainable abscess in this region. Known transverse colitis within this fat necrosis is unchanged. No free intraperitoneal air or pneumotosis. 2. Mild decrease in a subdiaphragmatic abcess. Drainage of this abscess would be difficult given its location and risk of infecting overlying pleural effusion. 3. Mild increase in a nonhemorragic left pleural effusion. 4. Mild decrease in size of the pancreatic head and uncinate pseudocysts. Increase in pancreatic body pseudocyst and stable pancreatic tail pseudocyst with a drainage catheter. Results were conveyed via telephone by Dr. ___ to ___ at 16:00 on ___ within 10 minutes of observation of findings. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Fever Diagnosed with FEVER, UNSPECIFIED, HYPERLIPIDEMIA NEC/NOS temperature: 99.4 heartrate: 126.0 resprate: 18.0 o2sat: 94.0 sbp: 128.0 dbp: 83.0 level of pain: 7 level of acuity: 3.0

Ms. ___, It was a pleasure taking care of you during your recent admission to ___. You were admitted with fevers and found to have inflammation surrounding your colon. You were followed by the surgical teams, and infectious diseases. A repeat CT scan showed fluid collections which are not able to be drained. You will need to continue antibiotics until you see the infectious disease doctors at which time they will discuss with you further work up and treatment. If you develop, fever, nausea/vomiting or worsening abdominal pain or other symptoms which concern you, please return to the hospital. . You were also noted to have fluid surrounding your lung. This fluid was removed and did not show an infection. . For your pancreatitis, you were continued on tube feeds and clear liquids. You will need to follow up with Dr. ___.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: adhesive / Plaquenil / omeprazole / Prozac / quinacrine / metformin / varenicline / vancomycin Attending: ___ Chief Complaint: Fevers Major Surgical or Invasive Procedure: Hepatic abscess aspiration Bilateral percutaneous transhepatic biliary srain placement R chest tube placement History of Present Illness: Ms. ___ is a pleasant ___ w/ Stage IV adenocarcinoma of the appendix on cetuximab, s/p R hemicolectomy with diverting ileostomy, complicated by chronic partial SBO on TPN, bilateral hydronephrosis s/p b/l ureteral stents and percutaneous nephrostomy tubes, recent polymicrobial bacteremia and liver abscesses s/p 6 weeks of IV antibiotics, who presents with fevers of ___. She states she saw her oncologist on ___. She had a CT done which revealed possible reaccumulation of her hepatic abscess. The plan was to continue monitor and have it drained. ___ the weekend she felt fatigued, with nausea, no vomiting and decreased appetite (albeit she does not eat). She has also been having decreased output from her ostomy bag. She also had a fever of ___. She called ___. She went to ___ where she had a CT scan which revealed concern for recurrent hepatic abscess. She is actually already scheduled for a transhepatic cholangiogram for possible drainage of the abscess. Images were uploaded. Pt oncologist at ___ recommended transfer to ___ for further management due to concern for possible recurrent infection. Pt received IV Zozyn PTA at 7pm this evening. She also received Dilaudid for pain. She was AF in ED and mildy tachy in ___ with otherwise stable VS. Past Medical History: Oncologic History and Complications: -Stage 4 adenocarcinoma of the appendix (peritoneal implants, pulmonary nodules) s/p: - R hemicolectomy w/end ileostomy (___) - debulking surgery with hyperthermic intraperitoneal mitomycin-C chemo ___, ___ - Neoadjuvant and adjuvant FOLFOX chemo (? to ___ ___ - ?) - Currently on cetuximab (___) -Chronic partial SBO on TPN -Bilateral hydronephrosis s/p b/l ureteral stents and percutaneous nephrostomy tubes (s/p multiple exchanges) -Biliary obstruction s/p stents & drains -GERD Other Medical History: -SLE -HTN -Dyslipidemia -Fibromyalgia ___ procedures: ___: R PCN exchange ___: bilateral PCN exchange ___: bilateral PCN exchange ___: biliary drain removal. ___: cholangiogram with tri-lateral stent placement. ___: PTBD placement ___: PCN placement Social History: ___ Family History: Father with multiple MIs, first in ___. Multiple cancers. Mother with lung cancer. Counsin with leukemia. Physical Exam: ========================== ADMISSION PHYSICAL EXAM ========================== VITAL SIGNS: ___ 130/78 91 93% RA General: NAD, Resting in bed comfortably, chronically ill, fatigued HEENT: MM very dry CV: RR, NL S1S2 no S3S4 No MRG PULM: CTAB, No C/W/R, No respiratory distress ABD: BS+, soft, tender to deep palpation, ostomy bag w/ liquid brown stool, b/l PCN dressings c/d/i w/ clear yellow urine draining. LIMBS: WWP, no ___, no tremors SKIN: No rashes on the extremities NEURO: Grossly normal =========================== DISCHARGE PHYSICAL EXAM =========================== VS: 98.4 140/70 99 18 95%RA GEN: NAD, lying in bed HEENT: scleral icterus, scar on R cheek and forehead that patient reports are from lupus Cards: RRR no murmurs/gallops/rubs. Pulm: diffuse rhonchorous breath sounds throughout GU: nephrostomies draining clear yellow urine Abd: erythema around ostomy site, colostomy draining brown liquid with blood tinged stool; no melena; +BS, soft, PTBDs capped, no rebound or guarding, distended but not firm Neuro: AOx3, moving all 4 extremities Pertinent Results: ========================= ADMISSION LABS ========================= ___ 12:00AM BLOOD WBC-11.2*# RBC-3.23* Hgb-8.4* Hct-26.9* MCV-83 MCH-26.0 MCHC-31.2* RDW-16.2* RDWSD-49.1* Plt ___ ___ 12:00AM BLOOD Neuts-85.2* Lymphs-7.0* Monos-5.7 Eos-1.6 Baso-0.2 Im ___ AbsNeut-9.52* AbsLymp-0.78* AbsMono-0.64 AbsEos-0.18 AbsBaso-0.02 ___ 12:00AM BLOOD Plt ___ ___ 06:32AM BLOOD ___ PTT-28.6 ___ ___ 12:00AM BLOOD Glucose-80 UreaN-16 Creat-0.7 Na-134 K-3.5 Cl-101 HCO3-22 AnGap-15 ___ 12:00AM BLOOD ALT-114* AST-110* AlkPhos-457* TotBili-5.2* DirBili-4.3* IndBili-0.9 ___ 12:00AM BLOOD Albumin-2.7* ___ 06:32AM BLOOD Albumin-2.4* Calcium-8.2* Phos-3.3 Mg-1.4* ___ 12:25AM BLOOD Lactate-0.9 ==================== MICRO ==================== ___ 12:00 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 2:11 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000 CFU/mL. YEAST. 10,000-100,000 CFU/mL. ___ 6:32 am BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) Source: Line-PORT. BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. ___ 3:15 pm ABSCESS Source: Liver Abscess. **FINAL REPORT ___ GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: Reported to and read back by ___ ___ 2:40PM. ___ ALBICANS. SPARSE GROWTH. Yeast Susceptibility:. Fluconazole = 0.5 MCG/ML = SUSCEPTIBLE. Antifungal agents reported without interpretation lack established CLSI guidelines. Results were read after 24 hours of incubation. Sensitivity testing performed by Sensititre. KLEBSIELLA PNEUMONIAE. RARE GROWTH. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. CEFTAZIDIME AND Piperacillin/Tazobactam sensitivity testing performed by ___. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- 1 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. ___ 4:21 pm PLEURAL FLUID **FINAL REPORT ___ GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. ___ 7:33 pm BLOOD CULTURE Source: Line-port. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 10:41 pm URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 5:04 pm URINE Source: Kidney. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ========================= IMAGING ========================= ___ HEPATIC ABSCESS ASPIRATION Successful US-guided aspiration of a right hepatic lobe fluid collection. Sample was sent for microbiology evaluation. ___ CXR Interval placement of a right chest tube which projects over the right mid to lower hemithorax. No significant interval change in the moderate right pleural effusion. ___ CT A/P 1. Again seen are four common bile duct metal stents. Compared to ___, there is decreased intrahepatic biliary ductal dilatation in the portion of the hepatic parenchyma drained by the left biliary stent. There is also new pneumobilia in this region. Mild hyperenhancement of the hepatic parenchymal in this region is favored to represent either cholestatic hepatitis or cholangitis. 2. There is persistent intrahepatic biliary ductal dilatation in the segments drained by the right anterior stent. Again seen in this region is a resolving biloma/abscess which is similar in size compared to ___. 3. No significant intrahepatic biliary ductal dilatation is noted in the areas drained by the other 2 right-sided biliary stents. 4. Similar to mildly decreased size of a segment 8 hypodensity, compatible with resolving abscess. No new hepatic lesion is seen. 5. Mild persistent right hydronephrosis is slightly decreased compared to prior studies. There is no left hydronephrosis. The bilateral percutaneous nephrostomy tubes are in appropriate position. 6. Similar appearance of multiple splenic hypodensities, compatible with infarcts. 7. Diffusely thickened bladder wall may be related to under distension and tumor involvement, however clinical correlation to exclude cystitis is recommended. 8. Similar appearance of persistent posterior bladder mass with loss of rectal fat plane worrisome for metastatic involvement. 9. Similar appearance of retroperitoneal lymphadenopathy. 10. Bilateral pleural effusions and patchy nodular airspace opacity in the lung bases, right middle lobe, and lingula were better evaluated on the dedicated CT of the chest from ___. Please see that report for further details. ___ PTBD 1) Successful balloon sweeps of the right anterior metallic stent 2) Successful ___ PTBD placement through the right anterior stent 3) Successful balloon sweeps of the left biliary stent 4) Successful placement of a left 10 ___ internal external biliary drain through the interstices of the existing left internal metal stent. ___ CXR In comparison with study of ___, there is little overall change. Again there is a small apical pneumothorax. Little change in the atelectatic streaks at the right base with residual effusion. Mild atelectatic changes are seen at the left base and the central catheters are stable. ================ DISCHARGE LABS ================ ___ 06:00AM BLOOD WBC-11.3* RBC-3.12* Hgb-8.2* Hct-26.8* MCV-86 MCH-26.3 MCHC-30.6* RDW-16.8* RDWSD-51.8* Plt ___ ___ 06:00AM BLOOD Plt ___ ___ 06:00AM BLOOD Glucose-196* UreaN-19 Creat-0.5 Na-139 K-3.8 Cl-104 HCO3-25 AnGap-14 ___ 06:00AM BLOOD ALT-95* AST-92* AlkPhos-315* TotBili-4.8* ___ 06:00AM BLOOD Calcium-8.0* Phos-3.4 Mg-1.8 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fentanyl Patch 50 mcg/h TD Q72H 2. Ondansetron 8 mg IV BID n/v 3. Oxybutynin 10 mg PO QHS 4. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain 5. Thiamine 100 mg PO TID 6. LORazepam 1 mg PO Q4H:PRN anxiety 7. Famotidine 20 mg PO DAILY 8. Ondansetron 8 mg IV DAILY:PRN nausea 9. Prochlorperazine 10 mg PO Q6H:PRN nausea 10. Pantoprazole 40 mg PO Q12H Discharge Medications: 1. CefTRIAXone 2 gm IV Q24H RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 gm IV every 24 hours Disp #*18 Intravenous Bag Refills:*0 2. Fluconazole 400 mg PO Q24H RX *fluconazole [Diflucan] 200 mg 2 tablet(s) by mouth daily Disp #*36 Tablet Refills:*0 3. Fentanyl Patch 100 mcg/h TD Q72H RX *fentanyl 100 mcg/hour 1 patch every 72 hours Disp #*5 Patch Refills:*0 4. OxyCODONE (Immediate Release) 15 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 15 mg 1 tablet(s) by mouth every four hours Disp #*60 Tablet Refills:*0 5. Famotidine 20 mg PO DAILY 6. LORazepam 1 mg PO Q4H:PRN anxiety 7. Ondansetron 8 mg IV BID n/v RX *ondansetron HCl 2 mg/mL 8 mg IV twice a day Disp #*28 Vial Refills:*0 8. Ondansetron 8 mg IV DAILY:PRN nausea RX *ondansetron HCl 2 mg/mL 8 mg IV daily Disp #*14 Vial Refills:*0 9. Oxybutynin 10 mg PO QHS 10. Pantoprazole 40 mg PO Q12H 11. Prochlorperazine 10 mg PO Q6H:PRN nausea 12. Thiamine 100 mg PO TID 13.Normal Saline 0.9% Solution Sig: Please infuse 1L of IV Normal Saline over ___ hours daily. Disp: 14 Bags of IVF Refills: 0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Cholangitis Hepatic abscess R pleural effusion Secondary: Metastatic appendiceal carcinoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old woman with port and power picc // evaluate position of picc evaluate position of picc IMPRESSION: In comparison with the study of ___, the monitoring and support devices are unchanged. There is increasing right pleural effusion with volume loss in the right lower lobe. No evidence of vascular congestion or acute focal pneumonia, though in the appropriate clinical setting it would be impossible to exclude consolidation at the right base, especially in the absence of a lateral view. Radiology Report INDICATION: ___ year old woman with ? recurrent hepatic abscess // please review ___ ct scan and evaluate for recurrent hepatic abscess, fluid will need to be sent for cultures COMPARISON: Outside hospital CT torso from ___. PROCEDURE: Ultrasound-guided drainage of a right hepatic lobe collection. OPERATORS: Dr. ___ resident, Dr. ___ fellow, and Dr. ___ radiologist. Dr. ___ supervised the trainee during the key components of the procedure and reviewed and agree with the trainee's findings. TECHNIQUE: The risks, benefits, and alternatives of the procedure were explained to the patient. After a detailed discussion, informed written consent was obtained. A pre-procedure timeout using three patient identifiers was performed per ___ protocol. The patient was placed in a supine position on the table. Limited preprocedure ultrasound was performed to localize the collection. Based on the ultrasound findings an appropriate skin entry site for the aspiration was chosen. The site was marked. Local anesthesia was administered with 1% Lidocaine solution. Using continuous sonographic guidance, 18G ___ needle was advanced via trocar technique into the collection. Approximately 4 cc of thick clear yellow fluid was aspirated and sent for microbiology evaluation. The needle was then removed and a sterile dressing applied. The procedure was tolerated well, and there were no immediate post-procedural complications. SEDATION: Monitored anesthesia care with an anesthesiologist present, per the patient's request. FINDINGS: Septated fluid collection in the inferior right hepatic lobe. IMPRESSION: Successful US-guided aspiration of a right hepatic lobe fluid collection. Sample was sent for microbiology evaluation. Radiology Report INDICATION: ___ year old woman with pleural effusion s/p chest tube insertion // assess chest tube location TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: Right chest wall power injectable Port-A-Cath is present as well as a left PICC line, both tips, projecting over the right atrium. A right pleural catheter projects over the right mid/lower hemithorax. There is no significant interval change in the moderate right pleural effusion with adjacent atelectasis. No pneumothorax identified. The left lung is clear. This size appearance of the cardiac silhouette is unchanged. IMPRESSION: Interval placement of a right chest tube which projects over the right mid to lower hemithorax. No significant interval change in the moderate right pleural effusion. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: new chest tube placed ___ // evaluate position of chest tube on morning of ___. please obtain this CXR between 5:00 and 5:45 am TECHNIQUE: Single frontal view of the chest COMPARISON: ___. IMPRESSION: Right base pigtail catheter is in place. There is no evident pneumothorax. Now small right effusion has markedly decreased. No other interval change from prior study. Radiology Report INDICATION: ___ year old woman with dark brown vomiting // concern for small bowel obstruction TECHNIQUE: Upright and supine radiograph view of the abdomen. The upright image does not include portions of the lower abdomen or the pelvis. COMPARISON: Abdominal radiograph dated ___. CT torso dated ___ from an outside facility and uploaded onto PACS. FINDINGS: Mildly dilated air-filled loops of small bowel in the left lower and mid abdomen persist and are similar to the prior radiograph and CT. No evidence of pneumatosis or free air. No air fluid levels identified on limited upper abdomen upright view. There is a right lower quadrant ileostomy. There is moderate stool in the descending colon. Bilateral percutaneous nephrostomy tubes appear in place. 4 biliary stents appear unchanged. Surgical clips from cholecystectomy are unchanged. No unexplained soft tissue calcifications or radiopaque foreign bodies. An 1.8-cm round, sclerotic lesion appears benign, unchanged. A right pigtail drain projects over the right lower hemithorax. Opacity and silhouetting of the right hemidiaphragm is likely residual effusion and atelectasis seen on prior CT. Opacities in the left lung base may be atelectasis. A central line in the SVC probably ending near the SVC-RA junction is partially imaged. IMPRESSION: Mildly dilated air-filled small bowel loops in the mid-left lower quadrant, similar to prior CT and radiograph could be early small bowel obstruction. Close attention on follow-up. Radiology Report EXAMINATION: CT CHEST W/O CONTRAST INDICATION: ___ year old woman with metastatic appendiceal cancer and recurrent R pleural effusion // assess for trapped lung/impaired expansion after chest tube placement TECHNIQUE: Multi detector helical scanning of the chest was reconstructed as 5 and 1.25 mm thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP axial images. Contrast agent was not administered. All images were reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 6.3 s, 33.6 cm; CTDIvol = 6.5 mGy (Body) DLP = 221.2 mGy-cm. Total DLP (Body) = 221 mGy-cm. COMPARISON: Chest CT ___. FINDINGS: Right pleural drainage tube inserted low laterally is largely curled in the major fissure. Residual right pleural fluid volume is small, generally dependent, some fissural. Parietal pleural thickening of the right lower posterior pleura is smooth, slightly greater than it was on ___ when a small nonhemorrhagic pleural effusion layered posteriorly. Pleural thickening along the lateral costal surface, 03:25, is greater than it was previously, associated with a loculation of non serous pleural fluid. Supraclavicular and axillary lymph nodes are not enlarged. Specifically excluding the breasts which require mammography for evaluation, there is no soft tissue abnormality in the chest wall suspicious for malignancy. Edema in the right posterior thoracoabdominal chest wall is new. Small left pleural effusion and small pericardial effusion have also developed. Volume of the right pneumothorax is small. Emphysema is moderately severe. Several small regions of lung abnormality have developed since ___, most of which are probably atelectasis, most notably at the right lung base, but a region of peribronchial opacification in the anterior segment of the right upper lobe, 5:157, and a smaller region in the anterior segment of the left upper lobe, 5:143 could be pneumonia. Nearly the entire esophagus is severely distended with fluid to the level of the gastroesophageal junction. Assessment of swallowing function her and exclusion of stricture or subtle mass would require fluoroscopic observation of a contrast swallow or direct inspection. In any case, the condition puts the patient at risk for aspiration. CHEST CAGE, ESPECIALLY THE THORACIC SPINE, IS SEVERELY OSTEOPENIC, BUT THERE IS NO COMPRESSION FRACTURE, PATHOLOGIC FRACTURE, OR CLEARLY DESTRUCTIVE BONE METASTASIS. IMPRESSION: PERSISTENT SMALL POSSIBLY LOCULATED RIGHT PLEURAL EFFUSION SMALL PNEUMOTHORAX, FOLLOWING INSERTION OF RIGHT PLEURAL DRAINAGE CATHETER, LARGELY FISSURAL. MODERATE VOLUME OF RIGHT LOWER LOBE ATELECTASIS IS NEW SINCE ___. SEVERE DISTENTION AND RETENTION OF FLUID IN OF THE ESOPHAGUS PUTS THE PATIENT AT RISK FOR ASPIRATION. SMALL AREAS OF LIKELY NEW PNEUMONIA. NEW MILD ANASARCA. EMPHYSEMA. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 5:20 ___, 1 minutes after discovery of the findings. Radiology Report INDICATION: ___ year old woman with metastatic appendiceal carcinoma // concern for aspiration pneumonia TECHNIQUE: AP portable chest radiograph COMPARISON: Chest radiograph and CT scan of the chest dated ___ from earlier in the day FINDINGS: Right chest wall power injectable Port-A-Cath tip and left PICC line tip project over the right atrium. A right pleural drainage tube is present. Unchanged atelectasis at the right lung base as well as patchy airspace opacities predominantly involving the right lung. A small right pleural effusion is present. Trace right pneumothorax which is better evaluated on today's CT scan of the chest. The size the cardiomediastinal silhouette is within normal limits. IMPRESSION: Trace right pneumothorax ; however this was better evaluated on today's CT scan of the chest. Otherwise there is no significant interval change since the prior examination. . Radiology Report EXAMINATION: CT abdomen pelvis with contrast INDICATION: ___ year old woman with cholangitis // ___ request for planning placement of PTBD history of appendiceal cancer, metastatic. TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 1.5 mGy-cm. 2) Stationary Acquisition 14.9 s, 0.2 cm; CTDIvol = 253.7 mGy (Body) DLP = 50.7 mGy-cm. 3) Spiral Acquisition 7.5 s, 48.9 cm; CTDIvol = 15.8 mGy (Body) DLP = 760.8 mGy-cm. Total DLP (Body) = 813 mGy-cm. COMPARISON: CT abdomen pelvis with contrast ___ and ___. Chest CT ___. FINDINGS: LOWER CHEST: There are bilateral pleural effusions, small, right greater than left, and patchy nodular airspace opacity in the lung bases, right middle lobe, and lingula, better evaluated on the recent CT of the chest from ___. Again noted is opacification of the distal esophagus with fluid. ABDOMEN: HEPATOBILIARY: Again seen are 4 common bile duct stents. There has been an interval decrease in left sided intrahepatic biliary ductal dilatation compared to ___, now with pneumobilia. Mild hyper enhancement of the hepatic parenchymal in this region is favored to represent either cholestatic hepatitis or cholangitis. There is persistent intrahepatic biliary ductal dilatation in the area drained by the right anterior biliary drain. Again seen in this region is a fluid collection, compatible with resolving biloma/abscess. This fluid collection measures 1.2 x 1.3 cm, and is not significantly changed from the most recent prior studies but has decreased over serial examinations (02:28). There is a stable 9 mm hypodensity in segment IV compatible with a cyst. An ill-defined area of low density in hepatic segment VIII measuring 1.8 x 1.1 cm is slightly decreased in size from ___ at which time it measured 1.8 x 1.3 cm (04:15). No significant intrahepatic biliary ductal dilatation is noted in the areas drained by the other 2 right-sided biliary stents. No new focal lesions are seen. The gallbladder is surgically absent. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: There is similar appearance of numerous peripheral wedge shaped perfusion defects in the spleen, compatible with splenic infarcts. 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 focal renal lesions are seen. There is mild persistent right hydronephrosis which has decreased in time since ___. Bilateral percutaneous nephrostomy tubes are in appropriate positioning. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is collapsed. There are a few mildly dilated loops of small bowel in the midline which contain air and fluid measuring up to 4.8 cm, similar compared to prior studies. The patient is status post right colectomy with anastomosis in the right upper quadrant. There is a right lower quadrant colostomy. There is no evidence of obstruction or parastomal hernia. PELVIS: The bladder is thick walled which may be related to underdistention or tumor involvement. Again seen is a lobulated mass in the posterior aspect of the bladder with loss of the normal fat plane between the posterior bladder wall, vagina, and rectum. There is a trace amount of free fluid in the pelvis. REPRODUCTIVE ORGANS: No large adnexal mass is seen. LYMPH NODES: Again seen is prominent retroperitoneal adenopathy with a prominent left periaortic lymph node measuring 1.4 cm, previously 1.3 cm (04:34). There is no inguinal or pelvic lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Again seen are four common bile duct metal stents. Compared to ___, there is decreased intrahepatic biliary ductal dilatation in the portion of the hepatic parenchyma drained by the left biliary stent. There is also new pneumobilia in this region. Mild hyperenhancement of the hepatic parenchymal in this region is favored to represent either cholestatic hepatitis or cholangitis. 2. There is persistent intrahepatic biliary ductal dilatation in the segments drained by the right anterior stent. Again seen in this region is a resolving biloma/abscess which is similar in size compared to ___. 3. No significant intrahepatic biliary ductal dilatation is noted in the areas drained by the other 2 right-sided biliary stents. 4. Similar to mildly decreased size of a segment 8 hypodensity, compatible with resolving abscess. No new hepatic lesion is seen. 5. Mild persistent right hydronephrosis is slightly decreased compared to prior studies. There is no left hydronephrosis. The bilateral percutaneous nephrostomy tubes are in appropriate position. 6. Similar appearance of multiple splenic hypodensities, compatible with infarcts. 7. Diffusely thickened bladder wall may be related to under distension and tumor involvement, however clinical correlation to exclude cystitis is recommended. 8. Similar appearance of persistent posterior bladder mass with loss of rectal fat plane worrisome for metastatic involvement. 9. Similar appearance of retroperitoneal lymphadenopathy. 10. Bilateral pleural effusions and patchy nodular airspace opacity in the lung bases, right middle lobe, and lingula were better evaluated on the dedicated CT of the chest from ___. Please see that report for further details. Radiology Report INDICATION: ___ year old woman with adenocarcinoma and biliary obstruction // PTBD COMPARISON: CT abdomen pelvis on ___. TECHNIQUE: OPERATORS: Dr. ___ and Dr. ___ radiologist performed the procedure. Drs. ___ were present and personally supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings. ANESTHESIA: General anesthesia was administered by the anesthesiology department. MEDICATIONS: General anesthesia CONTRAST: 40 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 55.4 min, 171 mGy PROCEDURE: 1. Transabdominal ultrasound. 2. Ultrasound guided right anterior percutaneous transhepatic bile duct access. 3. Right anterior cholangiogram. 4. Balloon sweep of the right anterior internal metal stent. 5. Successful placement of a 8 ___ right anterior biliary drain through the pre-existing right anterior internal metal stent 6. Ultrasound guided left percutaneous transhepatic bile duct access. 7. Left cholangiogram. 8. Balloon sweep of the left internal metal stent. 9. Successful placement of a 10 ___ left biliary drain through the interstices of the pre existing left internal metal stent. 1. PROCEDURE DETAILS: Following the discussion of the risks, benefits, and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The right and mid abdomen was prepped and draped in the usual sterile fashion. Under Ultrasound and Fluoroscopic guidance, a 21G Cook needle was advanced into right anteriorbiliary system. Images of the access were stored on PACS. Once return of bilious fluid was identified, a Nitinol wire was advanced under fluoroscopic guidance into the peripheral right anterior duct. A skin ___ was made over the needle and the needle was removed over the wire. An Accustick set was advanced over the wire and the inner stiffener was withdrawn. A contrast injection was performed to confirm biliary anatomy. The Nitinol wire was exchanged for a Glidewire which was placed through the right anterior internal metal stent and into the duodenum using a MPA catheter. The glidewire was exchanged for ___ wire. A ___ sheath was advanced over the wire into the biliary system. Next, a 6 mm x 40 mm Mustang balloon was used to balloon sweep the right anterior internal metal stent. Cholangiogram was again performed. A 5 ___ balloon was also used a balloon sweep the right anterior internal metal stent. Attention was then turned to the left sided system. Under Ultrasound and Fluoroscopic guidance, a 21G Cook needle was advanced into the leftbiliary system. Images of the access were stored on PACS. Once return of bilious fluid was identified, a Nitinol wire was advanced under fluoroscopic guidance into a peripheral left bile duct. A skin ___ was made over the needle and the needle was removed over the wire. An Accustick set was advanced over the wire and the inner stiffener was withdrawn. A contrast injection was performed to confirm biliary anatomy. The Nitinol wire was exchanged for a stiff Glidewire.A ___ sheath was advanced over the wire into the biliary system. The stiff Glidewire was replaced with a Glidewire, and the Glidewire was placed through the the interstices of the left internal metal stent and into the duodenum using a Kumpe catheter. The glidewire was exchanged for an Amplatz wire. Next, a 6 mm x 40 mm Mustang balloon was used to dilate the interstices of the metal stent and balloon sweep the left internal metal stent. Cholangiogram was again performed. Cholangiogram was again performed on the right sided system. The ___ wire was replaced with an Amplatz wire. The catheters and sheath were removed. A ___ internal external biliary catheter was advanced, the wire and inner stiffener were removed and the pigtail was formed. Contrast injection confirmed appropriate position. The catheter was flushed with saline, secured with stay sutures to the skin and sterile dressings were applied. The catheter was attached to a bag. On the left, the catheters and sheath were removed. A ___ internal external biliary catheter was advanced, the wire and inner stiffener were removed and the pigtail was formed. Contrast injection confirmed appropriate position. The catheter was flushed with saline, secured with stay sutures to the skin and sterile dressings were applied. The catheter was attached to a bag. The patient tolerated the procedure well. There were no immediate complications. FINDINGS: 1. Right anterior cholangiogram demonstrates complete obstruction of the right anterior internal metal stent with moderate upstream biliary dilation. The known biloma/abscess in the right anterior liver was noted to be supplied by this liver segment. 2. Post balloon sweep of the right anterior internal metal stent demonstrates brisk flow through the stent. 3. Cholangiogram through the successfully placed 8 ___ internal external biliary drain demonstrates good flow and drainage of the right anterior bile ducts. 4. Left sided cholangiogram of an excluded duct which was utilized to access the left biliary stent demonstrates complete obstruction of the left internal metal stent and moderate upstream biliary dilation. Numerous excluded dilated ducts were noted on the left sided of the liver which were successfully drained with the new ___ internal external drain. 5. Post balloon sweep of the left internal metal stent demonstrates brisk flow through the stent. 6. Cholangiogram through the successfully placed 10 ___ internal external biliary drain demonstrates good flow and drainage of the left bile ducts. IMPRESSION: 1) Successful balloon sweeps of the right anterior metallic stent 2) Successful ___ PTBD placement through the right anterior stent 3) Successful balloon sweeps of the left biliary stent 4) Successful placement of a left 10 ___ internal external biliary drain through the interstices of the existing left internal metal stent. RECOMMENDATION(S): Patient can remain to bag while she defervesces. After this, she should return for a repeat cholangiogram to evaluate the stent patency and flow. The ___ team will follow the patient. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with metastatic appendiceal carcinoma with large right pleural effusion s/p chest tube // Any interval change? Any interval change? IMPRESSION: In comparison with study of ___, there is little overall change. Again there is a small apical pneumothorax. Little change in the atelectatic streaks at the right base with residual effusion. Mild atelectatic changes are seen at the left base and the central catheters are stable. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with Stage IV adenocarcinoma of the appendix with right pleural effusion s/p chest tube to suction // Image requested per IP. Any interval change?***Please perform at 3 pm on ___ Image requested per IP. Any interval change?***Please perform at 3 pm on ___ IMPRESSION: In comparison with the earlier study of this date, the apical pneumothorax on the right appears to have slightly decreased. Otherwise little change. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Transfer, Fever, Abscess Diagnosed with Unspecified abdominal pain, Fever, unspecified temperature: 97.7 heartrate: 95.0 resprate: 16.0 o2sat: 95.0 sbp: 127.0 dbp: 76.0 level of pain: 7 level of acuity: 2.0

Dear Ms. ___, You were admitted to ___ because you were having fevers. You were found to have an abscess in your liver and infection in your bile, called cholangitis. The liver abscess was aspirated, and you had two drains placed to drain your bile. You were also given antibiotics to treat your infection. Please continue to take the ceftriaxone and fluconazole until ___ and when you are seen by the infectious disease doctors. ___ will tell you when to stop taking these. You were also experiencing some shortness of breath and had fluid drained from your lung which helped this. Physical therapy also worked with you to help you get stronger. Thank you for choosing ___ for your health care. Sincerely, 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: abdominal distension Major Surgical or Invasive Procedure: EGD with banding ___ Large volume paracentesis ___ History of Present Illness: ___ year-old gentleman with alcoholic cirrhosis decompensated by refractory ascites and encephalopathy who has been referred in for evaluation of worsening renal function. He was seen in ___ clinic yesterday and told to come into the ER for admission, however he left without being seen due to the long wait time. Hepatology would like his diuretics held and IV albumin for the renal function. For the last 2 weeks he has been having intermittent hematuria which he says he has never had before. No other new urinary symptoms (he is incontinent at baseline s/p prostatectomy and radiation therapy; however, this is unchanged). Does not think that he has been obstructed. No back or flank pain. No other infectious sx/sx. No abdominal pain. No lightheadedness / dizziness. No f/c. No confusion. No other bleeding that he has noticed. In the ED: - Initial vital signs were notable for: T 97.0, HR 66, BP 96/68, RR 15, O2 100% RA - Exam notable for: Moderately distended abdomen, soft, nontender, AOx3 - Labs were notable for: Chem 10: Na 139, Cr 2.3 CBC: WBC 6.9, Hgb 11.7, Plt 132 coags: INR 1.2 - Studies performed include: Diagnostic tap: TNC 258 - Patient was given: Albumin 75g - Consults: Hepatology "Pt with etoh cirrhosis, portal htn, ascites with new ___ in the setting of worsening refractory ascites. Will need: 1. Full labs 2. Infectious rule out 3. Dx paracentesis 4. 1gm/kg of 25% IV albumin 5. Admit to the Liver service (attending ___ Vitals on transfer: T 98.1, HR 70, BP 97/68, RR 18, O2 100% RA REVIEW OF SYSTEMS: Complete ROS obtained. Positive per HPI. Also positive for R small toe pain 1 day ago that has since resolved. Otherwise negative. Past Medical History: alcoholic cirrhosis, prostate cancer s/p prostatectomy and radiation in ___, depression s/o ECT in ___, GERD, radiation proctitis, hearing loss from aminoglycosides, essential tremor Social History: ___ Family History: Denies family history of liver disease or liver cancer. Physical Exam: ADMISSION PHYSICAL EXAM: ============================ VITALS: T 98.8 PO BP 93/58 HR 71 RR 18O2 94 RA Gen: alert, NAD HEENT: no scleral icterus, pupils equally round, OP clear, no JVD Lungs: CTAB Heart: RRR, soft systolic murmur Abdomen: soft, non-tender, quite distended with medium reducible umbilical hernia Ext: WWP, no edema, no toe lesions appreciated, no swelling / erythema / warmth Skin: no rashes noted Neuro: Face symmetric, no dysarthria, moving all extremities with purpose. DISCHARGE PHYSICAL EXAM: ========================== VITALS: ___ 0720 Temp: 98.0 PO BP: 109/71 HR: 66 RR: 18 O2 sat: 96% O2 delivery: RA HEENT: no scleral icterus, pupils equally round, MMM Lungs: CTAB, no adventitious sounds Heart: RRR, soft systolic murmur, no rubs/gallops Abdomen: soft, BS+, non-tender, abd distention, reducible umbilical hernias x2 Ext: WWP, no ___ edema Neuro: A&Ox3, moving all extremities with purpose, no asterixis Pertinent Results: ADMISSION LABS ================ ___ 08:53PM BLOOD WBC-7.6 RBC-3.67* Hgb-11.8* Hct-36.1* MCV-98 MCH-32.2* MCHC-32.7 RDW-14.0 RDWSD-50.9* Plt ___ ___ 08:53PM BLOOD Neuts-72.3* Lymphs-13.1* Monos-11.5 Eos-2.2 Baso-0.5 Im ___ AbsNeut-5.46 AbsLymp-0.99* AbsMono-0.87* AbsEos-0.17 AbsBaso-0.04 ___ 08:53PM BLOOD Plt ___ ___ 06:19PM BLOOD ___ PTT-29.9 ___ ___ 08:53PM BLOOD Glucose-130* UreaN-36* Creat-2.2* Na-133* K-4.5 Cl-94* HCO3-25 AnGap-14 ___ 08:53PM BLOOD ALT-7 AST-22 AlkPhos-61 TotBili-1.3 ___ 03:55PM BLOOD Lipase-54 ___ 03:55PM BLOOD Albumin-3.9 Calcium-10.1 Phos-4.2 Mg-2.4 DISCHARGE LABS =============== ___ 06:40AM BLOOD WBC-5.2 RBC-3.02* Hgb-9.7* Hct-29.4* MCV-97 MCH-32.1* MCHC-33.0 RDW-13.8 RDWSD-49.4* Plt Ct-84* ___ 06:40AM BLOOD ___ PTT-30.4 ___ ___ 06:40AM BLOOD Glucose-94 UreaN-21* Creat-1.6* Na-135 K-3.9 Cl-98 HCO3-21* AnGap-16 ___ 06:40AM BLOOD ALT-<5 AST-15 AlkPhos-42 TotBili-1.9* ___ 06:40AM BLOOD Calcium-9.6 Phos-3.3 Mg-1.9 Other Pertinent Labs/Micro ============================ ___ 08:37AM BLOOD ANCA-NEGATIVE ___ 08:37AM BLOOD ___ ___ 07:00AM BLOOD C3-75* C4-10 ___ 01:28AM URINE Color-Yellow Appear-Clear Sp ___ ___ 01:28AM URINE Blood-MOD* Nitrite-NEG Protein-TR* Glucose-NEG Ketone-TR* Bilirub-NEG Urobiln-4* pH-6.0 Leuks-NEG ___ 01:28AM URINE RBC-8* WBC-3 Bacteri-FEW* Yeast-NONE Epi-1 ___ 01:28AM URINE CastHy-5* ___ 01:28AM URINE Mucous-RARE* ___ 11:18PM URINE Hours-RANDOM Creat-208 TotProt-29 Prot/Cr-0.1 ___ 05:30PM ASCITES TNC-258* RBC-65* Polys-6* Lymphs-4* Monos-61* Mesothe-16* Macroph-13* Other-0 ___ 05:30PM ASCITES TotPro-3.3 Glucose-114 ___ 10:15AM ASCITES TNC-120* RBC-203* Polys-5* Lymphs-42* Monos-20* Mesothe-1* Macroph-32* ___ 5:30 pm PERITONEAL FLUID GRAM STAIN (Final ___: 2+ ___ 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, if applicable. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ___ 10:15 am PERITONEAL FLUID 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, if applicable. FLUID CULTURE (Preliminary): ANAEROBIC CULTURE (Preliminary): ___ 10:15 am FLUID RECEIVED IN BLOOD CULTURE BOTTLES PERITONEAL FLUID. Fluid Culture in Bottles (Pending): Pertinent Imaging/Studies ========================== Renal U/S (___) IMPRESSION: 1. No evidence of hydronephrosis. 2. Cirrhotic liver, with large volume ascites. EGD (___) Findings: -Esophagus: Normal mucosa was noted in the whole esophagus. 3 cords of large varices were seen in the distal esophagus. The varices were not bleeding. 3 bands were applied for variceal eradication successfully. -Stomach: Diffuse continuous erythema and edema of the mucosa with no bleeding was noted in the stomach body. These findings are compatible with gastritis. Several mixed non-bleeding polyps of benign appearance were found in the stomach body. The polyps were inflammatory-appearing. Impressions: –Varices in the distal esophagus (ligation) –Normal mucosa in the whole esophagus. –Inflammatory polyps in the stomach body. –Erythema and edema in the stomach body compatible with gastritis. Recommendations: -Omeprazole 20 mg twice daily, Carafate 2 g twice daily for 2 weeks. Soft diet for 24 hours and then advance diet as tolerated to regular diet. Paracentesis (___): 6L ascitic fluid was drained Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fluticasone Propionate NASAL 1 SPRY NU Frequency is Unknown 2. rifAXIMin 550 mg PO BID 3. BuPROPion XL (Once Daily) 300 mg PO DAILY 4. BuPROPion XL (Once Daily) 150 mg PO DAILY 5. Escitalopram Oxalate 10 mg PO DAILY 6. Furosemide 80 mg PO DAILY 7. Lactulose 30 mL PO QHS 8. Midodrine 5 mg PO TID 9. Propranolol 10 mg PO QHS 10. Pantoprazole 40 mg PO Q24H 11. Spironolactone 200 mg PO DAILY Discharge Medications: 1. Sucralfate 1 gm PO QID Duration: 2 Weeks RX *sucralfate 1 gram/10 mL 1 mL by mouth four times a day Disp #*1 Bottle Refills:*0 2. Fluticasone Propionate NASAL 1 SPRY NU DAILY 3. Lactulose 30 mL PO TID 4. Midodrine 10 mg PO TID RX *midodrine 10 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*3 5. BuPROPion XL (Once Daily) 150 mg PO DAILY 6. BuPROPion XL (Once Daily) 300 mg PO DAILY 7. Escitalopram Oxalate 10 mg PO DAILY 8. Pantoprazole 40 mg PO Q24H 9. rifAXIMin 550 mg PO BID 10.Outpatient Lab Work ICD-9 571.5 Please collect chem 10 weekly Fax results to Dr. ___ at ___. Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ================= Acute kidney injury SECONDARY DIAGNOSES =================== Decompensated alcoholic cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: RENAL U.S. INDICATION: ___ year old man with decompensated cirrhosis, new ___, and new hematuria // hydronephrosis TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: No relevant prior studies available for comparison. FINDINGS: There is no hydronephrosis, stones, or masses bilaterally. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. Right kidney: 11.3 cm Left kidney: 11.5 cm The bladder is moderately well distended and normal in appearance. The liver demonstrates a nodular contour, compatible with known cirrhosis. Large volume ascites is partially imaged. IMPRESSION: 1. No evidence of hydronephrosis. 2. Cirrhotic liver, with large volume ascites. Gender: M Race: WHITE Arrive by WALK IN WALK IN Chief complaint: Abdominal distention, Abnormal labs Abdominal distention Diagnosed with Abdominal distension (gaseous) Alcoholic cirrhosis of liver with ascites temperature: 97.9 97.0 heartrate: 72.0 66.0 resprate: 16.0 15.0 o2sat: 100.0 100.0 sbp: 124.0 96.0 dbp: 74.0 68.0 level of pain: 0 0 level of acuity: 3.0 2.0

Dear Dr. ___, ___ were hospitalized at ___ from ___. WHY WERE ___ ADMITTED? - ___ were admitted because your kidney function had declined. WHAT HAPPENED WHILE ___ WERE ADMITTED? - We stopped your diuretics, which was likely contributing to your kidney injury. - We gave ___ IV fluids and medicine that helped your kidney function to improve. - We did an endoscopy and banded three swollen blood vessels in your throat to prevent them from bleeding in the future. WHAT SHOULD ___ DO AFTER ___ LEAVE THE HOSPITAL? - Follow up with your doctors as listed in this paperwork. - Take all of your medications. - Refrain from drinking any amount of alcohol as it will damage your already unhealthy liver. It was a pleasure caring for ___. Sincerely, 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: Nausea/vomiting Major Surgical or Invasive Procedure: Endoscopic retrograde cholangiopancreatography Magnetic resonance elastography History of Present Illness: ___ with localized unresectable neuroendocrine tumor encasing the mesentery who developed nausea yesterday evening and was transferred with a diagnosis of SBO from OSH. The patient has had upset stomach off and on with gas sounds for the past few weeks, but there was a change with nausea developing yesterday. This morning he couldn't eat cereal because of nausea and vomiting which was not controlled by Compazine and Zofran. He felt weak and also couldn't tolerate oral nutritional supplement, so wife called ambulance who took him to a local hospital. There he had CT scan that showed SBO with dilated proximal small bowel loops with air-fluid levels and a transition at the level of the ileum. NGT was placed but how much was suctioned up was not documented. He was transferred to ___ for surgical eval. Here surgery saw patient and he had KUB that confirmed NGT location and signs of SBO. Vitals 98.6 80 119/65. Surgery recommended ___ medical management. Past Medical History: #localized unresectable neuroendocrine tumor encasing the mesentery --followed by Dr. ___ with octreotide every 28d, last on ___ #Ascites requiring weekly paracentesis #Malnutrition, weight loss No longer requires medication for HTN, HL Social History: ___ Family History: Esophageal cancer and alcoholism in his father MI in his mother Physical ___: ADMISSION: ___ 1127 Temp: 98.0 PO BP: 131/78 R Lying HR: 93 RR: 16 O2 sat: 94% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___ thin male with some temporal wasting non toxic, aox3 fluent speech NGT in place, capped CTAB RRR NMRG soft abdomen, trace bulging flanks, hypoactive bowel sounds, no tenderness to palpation, percussion, no appreciable organomegaly no suprapubic tenderness no peripheral edema no confusion no signs of bleeding no asterexis DISCHARGE 98.0 PO 125/75 78 16 95% 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, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, mildly 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: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Pertinent Results: ADMISSION ___ 03:56AM BLOOD WBC-10.9*# RBC-4.73 Hgb-13.1* Hct-40.4 MCV-85 MCH-27.7 MCHC-32.4 RDW-14.3 RDWSD-44.4 Plt ___ ___ 03:56AM BLOOD Neuts-87.9* Lymphs-4.1* Monos-6.3 Eos-0.2* Baso-0.5 Im ___ AbsNeut-9.59*# AbsLymp-0.45* AbsMono-0.69 AbsEos-0.02* AbsBaso-0.05 ___ 03:56AM BLOOD Glucose-130* UreaN-25* Creat-1.1 Na-130* K-7.2* Cl-95* HCO3-24 AnGap-11 ___ 05:33AM BLOOD Albumin-2.7* Calcium-8.5 Phos-4.8* Mg-2.1 DISCHARGE ___ 06:50AM BLOOD WBC-5.6 RBC-4.45* Hgb-12.1* Hct-38.9* MCV-87 MCH-27.2 MCHC-31.1* RDW-14.3 RDWSD-45.7 Plt ___ ___ 06:50AM BLOOD Glucose-84 UreaN-16 Creat-0.9 Na-140 K-4.4 Cl-100 HCO3-25 AnGap-15 ___ 06:50AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.0 CT abdomen/pelvis performed ___ at ___ moderate bilateral pleural effusions slight decrease in mod-significant ascites stable lobulated mass lesion near root of mesentery, 8.5x5.3x5.5cm, unchanged since ___ proximal small bowel loops with air-fluid levels and a transition at the level of the ileum KUB ___ Small-bowel obstruction, likely distal Upper endoscopy Normal mucosa in esophagus, stomach and duodenum MRE IMPRESSION: 1. Evidence of unchanged distal small-bowel obstruction secondary to the central mesenteric mass as described above. 2. Unchanged edema and mucosal hypoenhancement of the most distal dilated small bowel loops proximal to the transition point concerning for vascular compromise. Evidence of marked luminal narrowing of the SMV and SMA. 3. Moderate amount pleural effusions and large amount of intra-abdominal ascites. 4. Unchanged central mesenteric mass biopsy-proven neuroendocrine tumor with associated mesenteric adenopathy. 5. 8 mm hypoenhancing right hepatic lobe lesion, incompletely evaluated and remains indeterminate. This can be followed on subsequent imaging. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Furosemide 10 mg PO DAILY 2. Creon 12 1 CAP PO TID W/MEALS 3. Pantoprazole 40 mg PO Q24H 4. Vitamin D ___ UNIT PO 1X/WEEK (FR) Discharge Disposition: Home Discharge Diagnosis: Small bowel obstruction Pancreatic neuroendocrine tumor Ascites Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: History: ___ with ___ w/ NGT eval for position// ___ w/ NGT eval for position TECHNIQUE: Supine and upright abdominal radiographs were obtained. COMPARISON: Outside hospital CT from ___. FINDINGS: Multiple air-fluid flow loops of small bowel are seen to the level of the pelvis measuring up to 4.7 cm. The large bowel is decompressed. There is large volume ascites. There is no free intraperitoneal air. Osseous structures are unremarkable. Previously administered contrast is seen within the bladder. An enteric tube is visualized terminating in the proximal stomach. IMPRESSION: Small-bowel obstruction, likely distal as dilated loops of bowel are seen to the level of the pelvis. Radiology Report EXAMINATION: MR ___ INDICATION: ___ w/ unresectable neuroendocrine tumor in the mesentery who presented to OSH with complaints nausea and vomiting thought to be ___ to a SBO.// Please evaluate for bowel obstruction TECHNIQUE: T1 and T2-weighted multiplanar images of the abdomen and pelvis were acquired within a 1.5 T magnet, including 3D dynamic sequences performed prior to, during, and following the administration of 0.1 mmol/kg of Gadavist intravenous contrast (6 cc). Oral contrast consisted of 900 mL of VoLumen. 1.0 mg of Glucagon was administered IM to reduce bowel peristalsis. COMPARISON: CT abdomen/pelvis ___. FINDINGS: MR ENTEROGRAPHY: Small bowel motility appears unremarkable. There is re-demonstration of proximally dilated small bowel loops measuring up to 4.3 cm in caliber. The distal small bowel loops are under distended in a similar fashion when compared to the ___ with a transition point in the right lower quadrant (series 13, image 65) where the small-bowel loops are tethered to the mesenteric mass. The degree of dilatation has not significantly changed. There is mild submucosal edema of the distal most dilated small bowel loops just proximal to the transition point, the degree of which is not changed from the CT examination. There is also mild mucosal hypoenhancement when compared to the remaining small bowel loops, which may indicate vascular compromise. The draining veins of these bowel loops appear mildly engorged when compared to the rest of the mesenteric veins. These findings are secondary to the spiculated homogeneously enhancing mass centered around the root of the small bowel mesentery inferior to the pancreatic head and encircling the SMA and SMV where it causes marked luminal narrowing. This mass collectively measures 5.9 x 7 x 9.6 cm. There are associated enlarged mesenteric lymph nodes that have not changed in size. MRI OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: There is moderate amount of ascites that has not changed. There is an 8 mm hypoenhancing lesion along the dome of the right hepatic lobe, incompletely evaluated. This is too small to be seen on the previous CT. Gallbladder appears unremarkable. Portal vein is patent. There is no splenomegaly. There is no pancreatic ductal dilatation. The mass is inferior to the pancreatic head. There is no hydronephrosis. Left adrenal gland appears unremarkable. There are moderate size bilateral pleural effusions. IMPRESSION: 1. Evidence of unchanged distal small-bowel obstruction secondary to the central mesenteric mass as described above. 2. Unchanged edema and mucosal hypoenhancement of the most distal dilated small bowel loops proximal to the transition point concerning for vascular compromise. Evidence of marked luminal narrowing of the SMV and SMA. 3. Moderate amount pleural effusions and large amount of intra-abdominal ascites. 4. Unchanged central mesenteric mass biopsy-proven neuroendocrine tumor with associated mesenteric adenopathy. 5. 8 mm hypoenhancing right hepatic lobe lesion, incompletely evaluated and remains indeterminate. This can be followed on subsequent imaging. Radiology Report EXAMINATION: ULTRASOUND-GUIDED PARACENTESIS INDICATION: ___ w/ unresectable neuroendocrine tumor in the mesentery who presented to OSH with complaints nausea and vomiting thought to be ___ to a SBO. Has had refractory ascites since cancer diagnosis requiring weekly paracentesis, due tomorrow.// Therapeutic paracentesis. Diagnostic to determine if truly chylous ascites (concern per pt's description). Also serum-to-ascites albumin gradient, cell count and differential, culture, total protein and cytology. TECHNIQUE: Ultrasound guided diagnostic and therapeutic paracentesis COMPARISON: Outside facility CT abdomen and pelvis ___ FINDINGS: Limited grayscale ultrasound imaging of the abdomen demonstrated a large amount of ascites. A suitable target in the deepest pocket in the right lower quadrant was selected for paracentesis. PROCEDURE: The procedure, risks, benefits and alternatives were discussed with the patient and written informed consent was obtained. A preprocedure time-out was performed discussing the planned procedure, confirming the patient's identity with 3 identifiers, and reviewing a checklist per ___ protocol. Under ultrasound guidance, an entrance site was selected and the skin was prepped and draped in the usual sterile fashion. 1% lidocaine was instilled for local anesthesia. A 5 ___ catheter was advanced into the largest fluid pocket in the right lower quadrant and 3.5 L of blood-tinged, slightly cloudy fluid were removed. Fluid samples were submitted to the laboratory for cell count, differential, culture, and cytology. Please note that according to patient, the previously drained fluid looked very 'milky or milk-shake like' and different in appearance compared to fluid retrieved on this paracentesis. 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. 3.5 L of thin milky pink fluid were removed. Fluid samples were submitted to the laboratory for cell count, differential, culture, and cytology. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Abd pain, SBO, Transfer Diagnosed with Unsp intestnl obst, unsp as to partial versus complete obst temperature: 98.6 heartrate: 94.0 resprate: 16.0 o2sat: 96.0 sbp: 140.0 dbp: 79.0 level of pain: 0 level of acuity: 3.0

Dear Mr. ___, You were admitted to the hospital with nausea/vomiting and found to have a small bowel obstruction due to your pancreatic neuroendocrine tumor. In addition to your primary medicine team, the surgery, hepatology and gastroenterology teams also evaluated you. For the small bowel obstruction, your symptoms improved, and surgery decided based on the imaging and your symptoms that it is reasonable to wait to do a bypass. Please go to the follow up appointment with them. For your ascites, the hepatology team evaluated and felt that it was unlikely due to underlying cirrhosis and more likely due to portal hypertension as well as lymph node system obstruction. We did a paracentesis and will notify you of the results. In addition to your surgery follow up appointment, we also scheduled a follow up appointment with your oncologist and primary care doctor. It was a pleasure taking care of you! Sincerely, Your ___ 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: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms ___ is an ___ female patient with history of hypertension, diabetes, arthritis, on steroids, dementia presenting with her son for evaluation of ongoing weakness. The patient was seen in the ED on ___ for abdominal pain and shortness of breath and had a negative CT scan at that time. She was diagnosed with a UTI and discharged home. Today she returns with worsening pain weakness and shortness of breath. The shortness of breath is worse with exertion. She is now also requiring oxygen as she desats to 88 or 89% on room air. Her son is also noticed that she has had new bilateral lower extremity swelling. She has no history of heart failure. Son denies any nausea vomiting or diarrhea. No black or bloody stools. However he does note that she has been having poor p.o. intake. In the ED, initial vital signs were: T 97.7, HR 105, BP 128/55, RR 18, 92% Ra Exam notable for: on 3L NC, guiac negative Labs were notable for: CBC: WBC 11.2, Hgb 9.8, platelets 208 Chemistry: Na 140, K 4.5, CL 99, HCO3 25, BUN, Cr 0.8 Lactate 2.2 UA: Leuk Lg, nitrates positive, WBC 97, many bacteria proBNP 547 troponins pending Normal LFTs Studies performed include: CTA Chest: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Elevated right hemidiaphragm is similar to before. 3. Trace left pleural effusion. CXR: FINDINGS: Lung volumes are relatively low as seen previously. Elevation the right hemidiaphragm is unchanged. Linear opacity on the lateral view, likely localizing to the left on the frontal view is likely atelectasis. No definite focal consolidation. No edema or effusion. Cardiomediastinal silhouette is stable. IMPRESSION: No definite acute cardiopulmonary process. Patient was given: Ceftriaxone 1 g Insulin 2 units Haldol 2 mg Consults: none Vitals on transfer: HR 104, BP 106/60, RR 18, 94% 3 L NC Upon arrival to the floor, the patient was found sleeping. History was obtained by the family. The daughter and son who take care of her note that she is verbal, but does not respond to direct questioning. The family noted that their mom began grabbing her stomach earlier in the month. That is when they first presented to the ED. The patient was diagnosed with a UTI and was discharged with a 10 day course of antibiotics. She took all of the antibiotics as scheduled, but the abdominal pain never abided. She initially had only been grabbing her left lower abdomen and is now grabbing her right lower abdomen as well. The family reports she did not tolerate the antibiotics well and was extremely awake and active during treatment. She denies fevers, chills. Her appetite has been decreased. She has intermittently having some looser stools (last on ___. She has had no vomiting. She has had increased wet diapers. Of note she has also been placing her hand over her chest at times. She is currently short of breath. This has only started in the past week. She was not short of breath when she came to the ED several weeks ago. The son reports she had a similar episode of shortness of breath some time ago and was started on an incentive spirometer by her PCP. The family notes that she always reports she has a headache. She is always cold even on warm summer nights. ROS otherwise limited as patient does not respond to direct questioning. Past Medical History: Stroke Diabetes Dementia Osteoarthritis (RT hip pain) Hypertension Osteoporosis Lower Extremity Edema Rheumatoid arthritis Social History: ___ Family History: Grandmother had stomach cancer Physical Exam: ADMISSION PHYSICAL EXAM: ======================== Vitals- T97.8, BP 172/67, HR 113, RR 18, 93% Ra General: Well appearing, NAD, sleeping comfortably HEENT: atraumatic, PERRLA, no pallor, unable to assess mouth, neck soft, no lymphadenopathy Cardiac: Normal S1, S2, RRR, no murmur, rubs, gallops Abdomen: normal bowel sounds, soft, non-tender, non-distended Extremities: warm to palpation, 1+ peripheral edema, 2+ DP pulses Pysch: Not responding to any questioning, not following commands DISCHARGE PHYSICAL EXAM: ======================== General: NAD, pleasant HEENT: MMM PULM: Decreased breath sounds at bases of lungs bilaterally with faint crackles CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops GI: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: warm, well perfused, 2+ DP pulses, no ___ edema Pertinent Results: ADMISSION LABS: =============== ___ 10:12AM BLOOD WBC-11.2* RBC-3.90 Hgb-9.8* Hct-32.6* MCV-84 MCH-25.1* MCHC-30.1* RDW-17.1* RDWSD-50.9* Plt ___ ___ 10:12AM BLOOD Glucose-171* UreaN-18 Creat-0.8 Na-140 K-4.5 Cl-99 HCO3-25 AnGap-16 ___ 10:12AM BLOOD ALT-7 AST-12 AlkPhos-80 TotBili-0.3 ___ 10:12AM BLOOD proBNP-547 ___ 10:12AM BLOOD cTropnT-<0.01 ___ 10:12AM BLOOD Lipase-30 MICROBIOLOGY: ============= ___ 11:20 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: THIS IS A CORRECTED REPORT ___. Reported to and read back by ___ (MD) (___) ___. ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION OF TWO COLONIAL MORPHOLOGIES. . PREVIOUSLY REPORTED AS ___. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S DISCHARGE LABS: =============== ___ 06:55AM BLOOD WBC-8.4 RBC-3.59* Hgb-8.9* Hct-29.8* MCV-83 MCH-24.8* MCHC-29.9* RDW-17.1* RDWSD-51.6* Plt ___ ___ 05:50AM BLOOD Glucose-93 UreaN-14 Creat-0.8 Na-141 K-4.1 Cl-99 HCO3-28 AnGap-14 IMAGING/STUDIES: ================ CTA CHEST ___: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Elevated right hemidiaphragm is similar to before. 3. Trace left pleural effusion. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PredniSONE 5 mg PO DAILY 2. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild 3. Lisinopril 10 mg PO DAILY 4. Mirtazapine 7.5 mg PO QHS:PRN insomnia 5. RisperiDONE 0.25 mg PO BID 6. MetFORMIN (Glucophage) 500 mg PO BID 7. Glargine 24 Units Breakfast Humalog 14 Units Lunch Humalog 6 Units Dinner Insulin SC Sliding Scale using HUM Insulin 8. Clopidogrel 75 mg PO DAILY 9. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral BID 10. Cyanocobalamin 100 mcg PO DAILY 11. Citalopram 20 mg PO DAILY Discharge Medications: 1. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild 2. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral BID 3. Citalopram 20 mg PO DAILY 4. Clopidogrel 75 mg PO DAILY 5. Cyanocobalamin 100 mcg PO DAILY 6. Glargine 24 Units Breakfast Humalog 14 Units Lunch Humalog 6 Units Dinner Insulin SC Sliding Scale using HUM Insulin 7. Lisinopril 10 mg PO DAILY 8. MetFORMIN (Glucophage) 500 mg PO BID 9. Mirtazapine 7.5 mg PO QHS:PRN insomnia 10. PredniSONE 5 mg PO DAILY 11. RisperiDONE 0.25 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Urinary tract infection Hypoxia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report INDICATION: ___ with SOB, hypoxia// r/o PTX PNA TECHNIQUE: Two portable AP views of the chest. COMPARISON: Chest x-ray from ___. FINDINGS: Lung volumes are relatively low as seen previously. Elevation the right hemidiaphragm is unchanged. Linear opacity on the lateral view, likely localizing to the left on the frontal view is likely atelectasis. No definite focal consolidation. No edema or effusion. Cardiomediastinal silhouette is stable. IMPRESSION: No definite acute cardiopulmonary process. Radiology Report EXAMINATION: CTA CHEST WITH CONTRAST INDICATION: ___ with ___ edema dyspnea, hypoxia// r//o PE TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of intravenous contrast. Reformatted coronal, sagittal, thin slice axial images, and oblique maximal intensity projection images were submitted to PACS and reviewed. DOSE: Acquisition sequence: 1) Stationary Acquisition 1.5 s, 0.5 cm; CTDIvol = 4.6 mGy (Body) DLP = 2.3 mGy-cm. 2) Spiral Acquisition 3.0 s, 23.3 cm; CTDIvol = 13.8 mGy (Body) DLP = 322.1 mGy-cm. Total DLP (Body) = 324 mGy-cm. COMPARISON: CT abdomen and pelvis ___ FINDINGS: HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the subsegmental level without filling defect to indicate a pulmonary embolus. The thoracic aorta is normal in caliber without evidence of dissection or intramural hematoma. The heart, pericardium, and great vessels are within normal limits. No pericardial effusion is seen. AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar lymphadenopathy is present. No mediastinal mass. PLEURAL SPACES: Trace left pleural effusion is noted. LUNGS/AIRWAYS: Atelectasis is mild at the bilateral lung bases. Elevation of the right hemidiaphragm is similar to before. 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 notable for partially imaged 0.8 cm hypodense lesion in the spleen, unchanged compared to ___ and statistically likely a cyst or hemangioma. BONES: No suspicious osseous abnormality is seen.? There is no acute fracture. IMPRESSION: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Elevated right hemidiaphragm is similar to before. 3. Trace left pleural effusion. Gender: F Race: HISPANIC/LATINO - COLUMBIAN Arrive by WALK IN Chief complaint: Abd pain, Dyspnea on exertion, Leg swelling Diagnosed with Dyspnea, unspecified temperature: 97.7 heartrate: 105.0 resprate: 18.0 o2sat: 92.0 sbp: 128.0 dbp: 55.0 level of pain: 4 level of acuity: 3.0

Dear Ms. ___, It was a pleasure caring for you at ___ ___! WHY YOU WERE ADMITTED: -You were having difficulty breathing and we were concerned you had a urinary infection WHAT HAPPENED IN THE HOSPITAL: -You were treated with antibiotics for the infection in your urine -Imaging of your lungs showed the right side of your diaphragm is higher than usual. There is nothing that needs to be done about this -An echocardiogram of your heart was normal -Your breathing improved with treating your infection WHAT YOU SHOULD DO AT HOME: -It is very important to be cleaned well after any incontinence to prevent future infections -Follow-up with your doctors as ___ below. We wish you all the best! Your ___ Team

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Ketorolac / Nalbuphine / Simvastatin / Atorvastatin / Crestor / adhesive tape / Erythromycin Base / Green Pepper / Macrobid / Tizanidine Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: ___ female with history of sarcoidosis presents with worsening shortness of breath, back pain, and dehydration. Patient is ___ days post left pharngoplasty, arytenoid adduction, and medialization laryngoplasty and since then she reports she has not fully recovered, with poor ability to tolerate p.o. and worsening back pain, which is chronic for her. Denies any fever or chills at home. Has a chronic cough, which is nonproductive. She denies any N/V/D orthopnea, PND or sputum production. In the ED, initial vitals were: 97.6 107 111/71 22 97% ra Labs were significant for CBC: 8.8 > 12.5 < 309 CHEM 7 131 95 23 -------------<355 5.2 24 0.7 Lactate:3.6 Ca: 11.0 Mg: 1.9 P: 2.3 Imaging revealed - T spine X ray: Limited evaluation of the vertebral bodies at the upper thoracic spine. If This remains of clinical concern, CT is more sensitive and should be considered. Query pulmonary nodule projecting over the right mid lung appear recommend dedicated chest x-ray for further evaluation. - CXR: No acute findings The patient was given 2 L IVF 1 mg IV dilaudid x2 and tessalon perels x1 Vitals prior to transfer were: T 97.5 82 129/69 20 98% RA Upon arrival to the floor, Vitals were T 98.1 BP 155/80 p 96 R 20 99% on RA REVIEW OF SYSTEMS: (+) Per HPI On interview on the floor she reports cough is worse after eating and she now has worsening SOB on exertion which is worse since her surgery on ___. She also reprots subacute gait insability requiring a walker for ambulation x several months as well as urinary incontinece requiring depends x ___ months. (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History: TBM - (Aspiration of foreign object ___ s/p intubation) 1. Sarcoidosis 2. Diabetes 3. Hypertension 4. Hyperlipidemia 5. Pancreatic disease - s/p cholecystectomy, ___ - s/p sphincterotomy, ___ - numerous ERCP 6. Chronic abdominal/back pain with history of detox 7. Osteoarthritis 8. Osteoporosis with compression fractures 9. Peptic ulcer disease 10. Gastroesophageal reflux disease 11. Depression . PAST SURGICAL HISTORY: 1. Appendectomy. ___ 2. Right ankle pinning, 1970s 3. Total abdominal hysterectomy, ___ 4. Kyphoplasy, ___ 5. Rib fracture, thought secondary to coughing (___) 6. Inguinal hernia repair 7. Left pharngoplasty, arytenoid adduction, and medialization laryngoplasty (___) Social History: ___ Family History: Father: died of CVA Mother: died of MI/COPD Brother: died of MI (age ___ Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T 98.1 BP 155/80 HR 96 R 20 99% on RA General: Alert, oriented, no acute distress, initially able to speak full sentenced but became staccato during interview with rare transmitted upper airway wheeze HEENT: ruddy complexion Sclera anicteric, MMM, oropharynx clear Neck: thick neck, CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: rare expiratory wheeze Abdomen: Obese, nontender Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, gait deferred. DISCHARGE PHYSICAL EXAM: Vitals: Tm 98.9, 108/65, 76, 18, 97%RA General: Alert, oriented, NAD HEENT: Oropharynx clear CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Occasional transmission of upper airway sounds, otherwise clear to auscultation, no wheezes. Pertinent Results: ==== ADMISSION LABS ==== ___ 06:10PM BLOOD WBC-8.8 RBC-4.24 Hgb-12.5 Hct-34.9* MCV-82 MCH-29.4 MCHC-35.8* RDW-16.1* Plt ___ ___ 06:10PM BLOOD Neuts-76.9* ___ Monos-4.4 Eos-0.4 Baso-0.3 ___ 01:18AM BLOOD Glucose-215* UreaN-17 Creat-0.6 Na-136 K-4.5 Cl-103 HCO3-23 AnGap-15 ___ 06:10PM BLOOD Calcium-11.0* Phos-2.3* Mg-1.9 ==== PERTINENT LABS ==== ___ 01:18AM BLOOD PTH-51 ___ 01:18AM BLOOD 25VitD-21* ___ 01:18AM BLOOD VITAMIN D ___ DIHYDROXY-PND ==== IMAGING ==== CXR (___): PA and lateral views of the chest provided. Lungs appear grossly clear. Subtle areas of scarring in the right mid lung not significantly changed from recent CT. No focal consolidation concerning for pneumonia. No effusion or pneumothorax. Cardiomediastinal silhouette is stable. Vertebroplasty changes at the lower thoracic spine noted. Chronic right fourth rib resection noted. IMPRESSION: No acute findings. T-SPINE PLAIN FILM (___): Limited evaluation of the vertebral bodies at the upper thoracic spine. This remains of clinical concern, CT is more sensitive and should be considered. Query pulmonary nodule projecting over the right mid lung appear recommend dedicated chest x-ray for further evaluation. VIDEO SWALLOW (___): FINDINGS: Barium passes freely through the oropharynx and esophagus without evidence of obstruction. There is trace penetration with thin liquids, but no gross aspiration. IMPRESSION: Penetration with thin liquids, but no aspiration. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze 2. Amlodipine 5 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Fluticasone Propionate 110mcg 2 PUFF IH BID 5. Lisinopril 10 mg PO DAILY 6. MetFORMIN (Glucophage) 500 mg PO BID 7. Omeprazole 20 mg PO DAILY 8. Tricor (fenofibrate nanocrystallized) 145 mg ORAL QAM 9. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain 10. Pravastatin 40 mg PO QPM 11. PredniSONE 20 mg PO DAILY 12. Glargine 10 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 13. Ibuprofen 400 mg PO Q8H:PRN pain 14. Nortriptyline 75 mg PO QHS 15. Lorazepam 1 mg PO Q8H:PRN anxiety 16. Metoclopramide 10 mg PO QIDACHS 17. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___) Discharge Medications: 1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze 2. Amlodipine 5 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Fluticasone Propionate 110mcg 2 PUFF IH BID 5. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain 6. Lisinopril 10 mg PO DAILY 7. Lorazepam 1 mg PO Q8H:PRN anxiety 8. Metoclopramide 10 mg PO QIDACHS 9. Nortriptyline 75 mg PO QHS 10. Omeprazole 40 mg PO BID 11. Pravastatin 40 mg PO QPM 12. PredniSONE 20 mg PO DAILY 13. Fenofibrate (fenofibrate nanocrystallized) 145 mg ORAL QAM 14. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet by mouth every twelve (12) hours Disp #*14 Tablet Refills:*0 15. Magnesium Oxide 400 mg PO BID RX *magnesium oxide 400 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 16. Nystatin Cream 1 Appl TP BID Duration: 5 Days RX *nystatin 100,000 unit/gram Apply to affected area. twice a day Refills:*0 17. Oxybutynin 5 mg PO TID RX *oxybutynin chloride [Ditropan XL] 5 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 18. Phosphorus 500 mg PO TID RX *sod phos,di & mono-K phos mono [Phospha 250 Neutral] 250 mg 2 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 19. Potassium Chloride 20 mEq PO DAILY RX *potassium chloride 20 mEq 1 tablet(s) by mouth qday Disp #*30 Tablet Refills:*0 20. MetFORMIN (Glucophage) 500 mg PO BID 21. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___) 22. Ibuprofen 400 mg PO Q8H:PRN pain 23. Outpatient Lab Work Please draw Chem-10 panel on ___ Indication: ICD-9-CM ___ Fax results to Dr. ___ (FAX: ___ 24. Glargine 14 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 25. Outpatient Physical Therapy Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: - Paradoxical vocal cord dysfunction Secondary Diagnoses: - Urinary tract infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ with increased sob/doe // ?pna COMPARISON: CT trachea dated ___. FINDINGS: PA and lateral views of the chest provided. Lungs appear grossly clear. Subtle areas of scarring in the right mid lung not significantly changed from recent CT. No focal consolidation concerning for pneumonia. No effusion or pneumothorax. Cardiomediastinal silhouette is stable. Vertebroplasty changes at the lower thoracic spine noted. Chronic right fourth rib resection noted. IMPRESSION: No acute findings. Radiology Report INDICATION: History: ___ with upper thoracic spine pain // Eval for fx/injury TECHNIQUE: AP and lateral views of thoracic spine COMPARISON: None. FINDINGS: The superior thoracic spine vertebral bodies are not well assessed on the lateral view. The patient is status post vertebroplasty/ kyphoplasty at the thoracolumbar junction, not well assessed on the study. Vertebral body heights and alignment are maintained in the mid to lower thoracic spine. Chronic appearing rib deformity involving the right fourth rib. Query pulmonary nodule projecting over the right mid lung appear recommend dedicated chest x-ray for further evaluation. IMPRESSION: Limited evaluation of the vertebral bodies at the upper thoracic spine. This remains of clinical concern, CT is more sensitive and should be considered. Query pulmonary nodule projecting over the right mid lung appear recommend dedicated chest x-ray for further evaluation. Radiology Report EXAMINATION: VIDEO SWALLOW STUDY INDICATION: ___ year old woman with hx of sarcoidosis, ENT surgery 1 month ago for vocal cord paralysis, p/w worsening SOB/cough/dysphagia since operation. // ? leak contributing to aspiration TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in conjunction with the speech and swallow division. Multiple consistencies of barium were administered. DOSE: Fluoro time: 2.4 min. COMPARISON: ___ FINDINGS: Barium passes freely through the oropharynx and esophagus without evidence of obstruction. There is trace penetration with thin liquids, but no gross aspiration. IMPRESSION: Penetration with thin liquids, but no aspiration. Please refer to the speech and swallow division note in OMR for full details, assessment, and recommendations. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Dyspnea Diagnosed with SHORTNESS OF BREATH, HYPERCALCEMIA, DIABETES UNCOMPL JUVEN temperature: 97.6 heartrate: 107.0 resprate: 22.0 o2sat: 97.0 sbp: 111.0 dbp: 71.0 level of pain: 8 level of acuity: 2.0

Dear ___, ___ were admitted to ___ on ___ with worsening shortness of breath, cough, weakness and urinary incontinence. ___ were seen by our ENT, Neurology, and Pulmonary specialists and we had further discussions with our Interventional Pulmonary team who recommended that there was no acute intervention that could be offered at this time. ___ were found to have a urinary tract infection and have been prescribed antibiotics to continue taking for several days after hospital discharge. ___ also had some mild electrolyte abnormalities which were corrected with oral supplementation and we have prescribed ongoing oral supplementation for ___ to take at home on an ongoing basis. Regarding your ongoing urinary incontinence, we are in the process of setting up a follow up appointment for ___ with neurology. ___ will be called regarding scheduling this appointment. We also highly recommend that ___ follow up with your outpatient urologist for further management of this issue. Regarding your ongoing cough and shortness of breath, ___ have been scheduled follow up with your pulmonologist. It was a pleasure to take care of ___ during your hospital stay. Sincerely, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / Cephalosporins / Quinolones / Bactrim / Oxycodone Attending: ___. Chief Complaint: intertrochanteric hip fracture Major Surgical or Invasive Procedure: ORIF of hip History of Present Illness: ___ y/o F with hx of ESRD on HD ___, HTN, moderate AS, and bifasicular block who presents with a fall leading to R intertrochanteric hip fracture and is transferred to the MICU for respiratory status monitoring after general anesthesia. Patient was home after HD and fell face forward after getting up from the chair due to hx of imbalance and lightheadedness after HD. No LOC, +head strike, remembers event of the fall. Family denies any chest pain, shortness of breath, or any other recent complaints. She was brought to OSH where she was found to have R intertrochanteric hip fracture. CT head and c-spine were negative. She was transferred to BI for orthopedic intervention. She reportedly had palpitations and progressive dyspnea, and a pre-operative TTE on ___ revealed mild/moderate aortic stenosis with a valve area of 1.7, elevated PASP around 60mmHg, mild mitral stenosis. She subsequently went to the OR for ORIF. She received 1U PRBCs intraoperatively. She did not tolerate spinal block thus the procedure was done under general anesthesia. She was hypotensive during the case to 70/30 and was transfused 1U PRBCs, given 1300mL IVF, and started on phenylephrine. She remained intubated given general anesthesia and intraoperative fluid shifts, so she is transferred to the care of the MICU team post-op. On arrival to the MICU, patient is intubated and sedated but hemodynamically stable. Past Medical History: stage V CKD ___ htn and ischemic nephropathy HTN gout osteoarthritis sensori-neural hearing loss mod aortic stenosis mitral annular calcification tricuspid regurgitation diverticulitis s/p colostomy and subsequent takedown, ileostomy h/o GI obstruction vitamin D deficiency h/o obesity abdominal fistula hip fracture Social History: ___ Family History: Father passed at ___ from MI, mother passed at ___ from "old age." Multiple siblings passed from cancer including brother from colon ca in ___, sister with stomach cancer, sister with throat cancer. Another brother currently has ___ and another sister passed from unknown causes. Physical Exam: Physical Exam on Admission: GENERAL: intubated and sedated HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, no LAD LUNGS: Clear to auscultation bilaterally, CV: distant heart sounds no murmurs appreciated ABD: soft, non-distended, bowel sounds present EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, right hip dressing clean with incision clean, dry, and intact SKIN: multiple small areas of eccymoses NEURO: intubated and sedated, does not open eyes to voice or noxious stimuli Discharge Physical Exam: Vitals: T: 98.1 BP: 101/46 P: 77 R: 18 O2: 95% RA General: Alert, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: JVP normal Lungs: Clear to auscultation bilaterally with good air movement CV: Regular rate and rhythm, normal S1 + S2, mid peaking II/VI SEM Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema. Patient states she has chronic decreased right foot sensation which is stable. Moves R toes to command. Incision has surrounding ecchymosis but is c/d/i. The right hip is moderately larger than the left hip but is not firm. Pertinent Results: ___ 09:42PM GLUCOSE-128* UREA N-36* CREAT-4.0* SODIUM-138 POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-30 ANION GAP-11 ___ 09:42PM estGFR-Using this ___ 09:42PM CALCIUM-8.7 PHOSPHATE-3.6 MAGNESIUM-2.1 ___ 09:42PM WBC-16.4* RBC-3.45* HGB-10.6* HCT-34.0* MCV-99* MCH-30.6 MCHC-31.1 RDW-17.7* ___ 09:42PM NEUTS-81.3* LYMPHS-10.2* MONOS-7.0 EOS-1.0 BASOS-0.4 ___ 09:42PM PLT COUNT-256 ___ 09:42PM ___ PTT-29.3 ___ Discharge Labs: ___ 05:40AM BLOOD WBC-12.1* RBC-2.89* Hgb-9.1* Hct-28.2* MCV-98 MCH-31.5 MCHC-32.2 RDW-17.4* Plt ___ ___ 05:40AM BLOOD Glucose-86 UreaN-32* Creat-3.7*# Na-131* K-3.8 Cl-93* HCO3-29 AnGap-13 ___ 05:40AM BLOOD Calcium-7.6* Phos-3.4 Mg-2.1 CXR: FINDINGS: In comparison with study of ___, what appears to be the right-sided PICC line has its tip just outside the rib cage. Obliquity of the patient somewhat obscures detail, though the overall appearance of the heart and lungs is quite similar to the prior examination. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Citalopram 20 mg PO DAILY 2. Nephrocaps 1 CAP PO DAILY Discharge Medications: 1. Citalopram 20 mg PO DAILY 2. Nephrocaps 1 CAP PO DAILY 3. Acetaminophen 1000 mg PO Q8H 4. Heparin 5000 UNIT SC TID 5. Lidocaine 5% Patch 1 PTCH TD QAM 6. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth q6hrs prn Disp #*30 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis: Right Hip fracture s/p ORIF Secondary Diagnosis: Heart failure with preserved EF HTN Gout CKD stage V on Hemodyalisis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: PICC line pulled by the patient. FINDINGS: In comparison with study of ___, what appears to be the right-sided PICC line has its tip just outside the rib cage. Obliquity of the patient somewhat obscures detail, though the overall appearance of the heart and lungs is quite similar to the prior examination. Radiology Report EXAMINATION: HIP UNILAT MIN 2 VIEWS RIGHT IN O.R. INDICATION: ORIF right hip. TECHNIQUE: 51 spot fluoroscopic images obtained in the OR without radiologist present, 134.1 seconds fluoroscopy time. COMPARISON: Right femur radiographs ___. FINDINGS: The available images show open reduction internal fixation of a proximal femoral fracture with placement of an IM nail. A dynamic hip screw is placed through the femoral neck. Please see the operative report for further details. IMPRESSION: Intraoperative images from open reduction internal fixation of a right proximal femur fracture Radiology Report PORTABLE CHEST ___ WITH COMPARISON ___ RADIOGRAPH FINDINGS: Interval placement of endotracheal tube, with tip terminating 3 cm above the carina. Cardiomediastinal contours are stable. Interval development of bibasilar atelectasis, left greater than right, as well as a small left pleural effusion. No definite pneumothorax. Radiology Report INDICATION: ___ year old woman with 45cm right PICC out 1 cm. TECHNIQUE: Single portable AP view of the chest was obtained. COMPARISON: Multiple prior chest radiographs, most recently ___ 14:22 FINDINGS: Endotracheal tube has been removed. There is interval placement of a right-sided PICC line. The tip projects over the right paraspinal line and is somewhat difficult to see, but likely terminates in the lower SVC. Enlargement of the cardiac silhouette is likely in part due to technique, but remains stable. Lungs are clear. Bibasilar atelectasis noted. There is no large effusion or pneumothorax. IMPRESSION: Interval removal of endotracheal tube and placement of a right PICC with tip likely in the lower SVC. No substantial change otherwise. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: s/p Fall, RIGHT HIP FX, Transfer Diagnosed with INTERTROCHANTERIC FX-CL, UNSPECIFIED FALL temperature: nan heartrate: nan resprate: nan o2sat: 98.0 sbp: 127.0 dbp: 84.0 level of pain: 6 level of acuity: 3.0

Dear Ms. ___, It was a pleasure taking care of ___ at ___. ___ broke your left hip and our orthopedic surgions successfully repaired it. We observed ___ for several days and ___ have remained stable after requiring a brief stay in the ICU following your surgery. ___ will continue to work on regaining your strength at rehab.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ___ Attending: ___. Chief Complaint: left upper extremity paresthesias and weakness Major Surgical or Invasive Procedure: Core needle biopsy of the thoracic spinal mass ___ History of Present Illness: ___ year old man with history of C4-C5 cervical fusion ___ years ago), L2-L5 stenosis, DM2 and HTN, presents with left upper extremity paresthesias and weakness. Symptoms began two months ago. He has pain that starts in his left shoulder blade and radiates down arm to level of elbow. From his elbow to his hand he has paresthesias. He has lost his fine dexterity in his left hand which feels weak. He has been using oxycodone for the pain which helps, but recently needed to increase the dose because of worsening symptoms. No aggravating factors. He has cervical neck pain when flexing his chin to his chest, but not with head rotation. He lost 20lb unintentionally over the past year. Denies fever, chills, night sweats, blood in stool/urine. He has recently developed a sore throat and cough, but no SOB. He smokes ___ cig/day for the past ___ years. His PCP ordered an MRI of the cervical spine which showed a mass around the cervical cord. His neurosurgeon subsequently referred him to the ED. In the ED, initial vitals: 99.2 91 165/72 16 100% RA. He received his home meformin 100mg, oxycodone/acetaminophen ___ x2, gabapentin 20mg. Images were uploaded into PACS. No labs were obtained. Upon arrival to the floor, he has mild pain in his arm and shoulder. Feels anxious and scared. He has a supportive wife and brother with him at the bedside. ROS: per HPI, headache, vision changes, rhinorrhea, congestion, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: cervical fusion by Dr ___ at ___ ___ years ago cervical fusion by Dr ___ at ___ ___ years ago glaucoma Type II diabetes ? HTN severe DJD with L2-L5 lumbar stenosis arthritis psoriasis right knee meniscus repair ___ years ago at ___ orthopedics lymph node/left enlarged salivary gland resection ___ yrs ago (benign) Social History: ___ Family History: father w/ psoriasis and CABG age ___, mother with OA, maternal uncle with lung CA (smoker), no other malignancies. Physical Exam: ADMISSION PHYSICAL EXAMINATION (___): VS - 97 136/64 78 18 100%RA GENERAL - NAD, comfortable, appropriate HEENT - PERRLA, EOMI, sclera anicteric, MMM, OP clear NECK - supple, no LAD HEART - RRR, nl S1-S2, no MRG LUNGS - wheezing at bases b/l, no rhonchi or crackles ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs), no axillary or inguinal LAD SKIN - psoriatic plaques on UE b/l NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ with exception of 4+/5 with hand flexion, sensation intact to dull and sharp touch in UE b/l DISCHARGE PHYSICAL EXAMINATION (___): GENERAL - NAD, comfortable, appropriate HEENT - PERRLA, EOMI, sclera anicteric, MMM, OP clear NECK - supple, no LAD HEART - RRR, nl S1-S2, no MRG LUNGS - CTAB, no wheezes/rales/rhonchi ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - psoriatic plaques on UE b/l NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ grossly in UE and ___, sensation intact grossly in UE and ___ Pertinent Results: ADMISSION LABS: ___ 09:05PM BLOOD WBC-5.9 RBC-3.28* Hgb-11.4* Hct-33.6* MCV-102* MCH-34.8* MCHC-34.0 RDW-13.9 Plt Ct-71* ___ 09:05PM BLOOD Neuts-55 Bands-0 ___ Monos-7 Eos-5* Baso-0 ___ Myelos-0 ___ 09:05PM BLOOD Hypochr-OCCASIONAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL ___ 09:05PM BLOOD ___ PTT-33.4 ___ ___ 07:25AM BLOOD Ret Aut-1.6 ___ 09:05PM BLOOD Glucose-105* UreaN-10 Creat-0.9 Na-137 K-4.4 Cl-102 HCO3-29 AnGap-10 ___ 09:05PM BLOOD ALT-30 AST-33 LD(LDH)-128 AlkPhos-64 TotBili-0.4 ___ 09:05PM BLOOD Calcium-10.0 Phos-3.0 Mg-2.1 UricAcd-3.6 ___ 07:25AM BLOOD TotProt-6.8 Albumin-3.7 Globuln-3.1 Iron-76 ___ 07:25AM BLOOD calTIBC-337 ___ Ferritn-95 TRF-259 ___ 07:50AM BLOOD VitB12-431 ___ 07:25AM BLOOD TSH-1.7 ___ 07:25AM BLOOD HBsAb-NEGATIVE ___ 07:25AM BLOOD PEP-NO SPECIFI ___ 07:25AM BLOOD HCV Ab-NEGATIVE ___ 07:25AM BLOOD METHYLMALONIC ACID-PND ___ 02:00AM URINE U-PEP-NO PROTEIN DISCHARGE LABS: ___ 07:20AM BLOOD WBC-5.4 RBC-3.48* Hgb-12.1* Hct-36.8* MCV-106* MCH-34.6* MCHC-32.8 RDW-14.1 Plt Ct-73* ___ 07:20AM BLOOD Glucose-117* UreaN-11 Creat-1.0 Na-138 K-4.2 Cl-101 HCO3-28 AnGap-13 IMAGING STUDIES: CXR (___): Hardware overlies the lower cervical spine consistent with previous cervical fusion. Lungs are relatively well inflated without evidence of focal airspace consolidation, pleural effusions, or pneumothorax. The interstitium is slightly prominent, but this may reflect small airways disease, age related changes or smoking-related changes. Clinical correlation is advised. Overall cardiac and mediastinal contours are within normal limits. No acute bony abnormality is seen. Depending upon the etiology of the patient's cervical mass, additional imaging with CT could be undertaken. Minimal degenerative changes in the thoracic spine with no obvious vertebral compression fractures. CT CHEST/ABDOMEN/PELVIS with CONTRAST (___): 1. 5.6 x 6.2 cm enhancing mass arising from the upper pole of the right kidney suspicious for renal cell carcinoma with large mass involving T1-T3 likely representing a metastatic focus as well as a concerning lesion in the spleen. 2. Enlarged left subclavian lymph node may also represent metastatic involvement. 3. Thicking of the bilateral adrenal glands without discrete nodule or mass may represent hyperplasia, but metastases not excluded. 4. Cirrhosis with evidence of portal hypertension and esophageal varices. 5. Cholelithiasis. ___ RADIOLOGY READ OF OSH C-SPINE MRI (___) 1. Large expansile mass lesion involving the posterior left paramedial vertebral bodies from T1 through T3 levels as described in detail above, causing left-sided neural foraminal narrowing at T1/T2, T2/T3 levels and also left paracentral canal narrowing and impinging the thecal sac posteriorly, no frank evidence of spinal cord edema is demonstrated. 2. The differential diagnosis for this lesion includes metastatic disease, myeloma may have similar appearance. 3. Small cystic-appearing formation noted in the posterior lobe of the thyroid gland on the right, there is also a small area of cystic signal on the posterior aspect of the right parotid gland, possibly consistent with a small intraparotid lymph node or cystic formation. 4. The patient is status post anterior fusion and discectomy at C5/C6 level. PATHOLOGY: Spinal mass cytology (___): POSITIVE FOR MALIGNANT CELLS, consistent with metastatic carcinoma, Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientFamily/Caregiver. 1. Infliximab 800 mg IV Q5WEEKS 2. MetFORMIN (Glucophage) 1000 mg PO BID 3. Gabapentin 300 mg PO HS 4. Gabapentin 200 mg PO TID 5. OxycoDONE (Immediate Release) 10 mg PO TID:PRN pain 6. Duloxetine 90 mg PO DAILY 7. Simvastatin 20 mg PO DAILY 8. Lisinopril 10 mg PO DAILY 9. Timolol Maleate 0.5% 1 DROP BOTH EYES QAM 10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 11. Ranitidine 150 mg PO BID 12. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Duloxetine 90 mg PO DAILY 2. Gabapentin 300 mg PO HS 3. Gabapentin 200 mg PO TID 4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 5. Lisinopril 10 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain hold for RR <12 or sedation RX *oxycodone 10 mg 1 tablet(s) by mouth q4H PRN Disp #*80 Tablet Refills:*0 8. Ranitidine 150 mg PO BID 9. Simvastatin 20 mg PO DAILY 10. Timolol Maleate 0.5% 1 DROP BOTH EYES QAM 11. Acetaminophen 650 mg PO Q6H:PRN pain 12. Docusate Sodium 100 mg PO BID constipation RX *Colace 100 mg 1 capsule(s) by mouth BID PRN Disp #*30 Tablet Refills:*0 13. Nicotine Patch 14 mg TD DAILY nicotine craving RX *nicotine 14 mg/24 hour 1 patch daily Disp #*28 Transdermal Patch Refills:*0 14. Oxycodone SR (OxyconTIN) 20 mg PO Q12H hold for RR <12 or sedation RX *OxyContin 20 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*30 Tablet Refills:*0 15. Senna 1 TAB PO BID constipation RX *senna 8.6 mg 1 tab by mouth BID PRN Disp #*60 Tablet Refills:*0 16. Infliximab 800 mg IV Q5WEEKS 17. MetFORMIN (Glucophage) 1000 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Metastatic malignancy, suspected renal origin with metastases to thoracic spine, adrenal and spleen Thrombocytopenia Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report PA AND LATERAL CHEST FILM ___ AT 2138 CLINICAL INDICATION: ___ with new cervical mass. Evaluate for intrathoracic malignancy. No comparison studies. Please note that comparison to old films can be helpful to detect subtle interval change. PA and lateral views of the chest ___ at 2138 are submitted. IMPRESSION: 1. Hardware overlies the lower cervical spine consistent with previous cervical fusion. Lungs are relatively well inflated without evidence of focal airspace consolidation, pleural effusions, or pneumothorax. The interstitium is slightly prominent, but this may reflect small airways disease, age related changes or smoking-related changes. Clinical correlation is advised. Overall cardiac and mediastinal contours are within normal limits. No acute bony abnormality is seen. Depending upon the etiology of the patient's cervical mass, additional imaging with CT could be undertaken. Minimal degenerative changes in the thoracic spine with no obvious vertebral compression fractures. Radiology Report EXAM: CT torso with contrast. INDICATION: ___ man with new T1-T3 mass with left-handed weakness and shoulder pain. Please evaluate for other primary malignancy. COMPARISON: MRI cervical spine from outside institution ___. TECHNIQUE: 5-mm axial series through the chest, abdomen, and pelvis after uneventful administration of 75 cc Omnipaque IV contrast and 900 cc Redicat p.o. contrast. Coronal and sagittal reformats provided by technologist. DLP: 816.97 mGy-cm. FINDINGS: CHEST: In the left supraclavicular fossa, there is a 1.3-cm lymph node. No other lower cervical or supraclavicular adenopathy is seen. Normal appearance of the visualized thyroid. Heart size within normal limits. Atherosclerotic coronary artery calcifications are noted. There is a 5-mm prevascular lymph node as well as a 10-mm subcarinal lymph node. Normal overall lung parenchymal pattern without suspicious nodule or mass arising from the lung parenchyma. Extending from T1 to T4, there is a large soft tissue mass which measures 5.4 x 5.8 cm in greatest axial dimension, with cortical destruction involving the posterior and left paramedial aspect of the vertebral bodies, the costovertebral junction, and short segments of the left first-third ribs. The mass measures 6.3 cm in craniocaudal dimension and involves only the superior T4 facet on the left. There is encroachment on the spinal canal, best seen on series 2, image 9, with abutment against the spinal cord at the T2 and T3 levels. No other thoracic lesions are identified. ABDOMEN/PELVIS: Cirrhotic morphology of the liver with hypertrophied caudate lobe, recanalization of the umbilical vein, esophageal varices and gastrohepatic varices. No hepatic lesions are identified. There is a small amount of perihepatic fluid. There is cholelithiasis without evidence of acute cholecystitis. The spleen contains a 14-mm ill-defined hypoenhancing lesion (2:54) which is suspicious for metastasis. In the right kidney, there is a 5.6 x 6.2 cm heterogeneously enhancing mass arising from the upper pole which may represent the primary tumor. There is also a cortical defect of the right inferior renal pole which could be post-infectious or related to prior procedure or infarct. Left kidney contains a simple-appearing 9-mm cyst which is too small to accurately characterize with CT. There is thickening of the medial limb of the right adrenal gland as well as slight thickening of the left adrenal gland which could represent hyperplasia versus less likely, metastatic involvement. Small and large bowel are unobstructed. There is colonic diverticulosis without evidence of acute diverticulitis. Normal appearance of the bladder. Hepatic arterial anatomy is standard. Portal vein and splenic veins are patent. There are prominent peripancreatic and periportal lymph nodes measuring up to 1.5 cm in short axis, which are most likely related to cirrhosis, however, metastasis is not excluded. Degenerative changes of the lower lumbar spine. No additional suspicious bone lesions are identified. IMPRESSION: 1. 5.6 x 6.2 cm enhancing mass arising from the upper pole of the right kidney suspicious for renal cell carcinoma with large mass involving T1-T3 likely representing a metastatic focus as well as a concerning lesion in the spleen. 2. Enlarged left subclavian lymph node may also represent metastatic involvement. 3. Thicking of the bilateral adrenal glands without discrete nodule or mass may represent hyperplasia, but metastases not excluded. 4. Cirrhosis with evidence of portal hypertension and esophageal varices. 5. Cholelithiasis. Radiology Report INDICATION: Left hand weakness and paresthesias. COMPARISON: MR ___ reference examination available from ___. TECHNIQUE: MDCT-acquired 2.5-mm axial images of the neck were obtained following the uneventful administration of 70 cc of Omnipaque intravenous contrast. Coronal and sagittal reformations were performed at 2-mm slice thickness. FINDINGS: The patient is post anterior fusion of C5/6 (301B:55). Vertebral disc spacer prosthesis is present. There is no acute fracture or traumatic malalignment of the cervical spine. No prevertebral soft tissue abnormalities are seen. Centered about the left T2 lamina is a large heterogeneously enhancing soft tissue mass measuring up to 5.9 x 5.3 cm, better appreciated on the CT torso examination performed on the same day (2:70), demonstrating extensive cortical destruction of the posterior left paramedial T1, T2, and T3 vertebral bodies, with involvement of the costovertebral junction, short segments of the left first through third ribs, the left T2 and T3 lamina and spinous processes, and the left T1 through 3 neural foramen. There is encroachment of the spinal canal with abutment against the cord at the T2 and T3 levels (2:70).There is about 50% narrowing of the spinal canal and displacement of the thecal sac to the right. Included views of the brain parenchyma are unremarkable. Aerosolized secretions are seen within the maxillary sinuses, worse on the right (2:15). The middle ear cavities and mastoid air cells are clear. The parotid and submandibular glands are symmetric in size and appear normal. No cervical lymphadenopathy is seen. The thyroid is normal. There are moderate atherosclerotic calcifications at the carotid bifurcations (2:46). Prominent prevascular lymph nodes and an enlarged subcarinal node (2:90) are incompletely seen, better appreciated on the CT torso examination. IMPRESSION: 1. Destructive soft tissue mass arising from the T2 left lamina extending to the T1 through T3 posterior left paramedial vertebral bodies, with involvement of the T1 through T3 costovertebral junction, towards segments of the left first through third ribs, and left T1 through T3 neural foramen. 2. Encroachment of the mass into the spinal cord at the T2 and T3 levels, with abutment against the cord. 3. No cervical lymphadenopathy. 4. Moderate maxillary sinusitis with acute features. 5. Post C5/6 anterior cervical fusion. Radiology Report EXAM: CT-guided soft tissue biopsy. COMPARISON: CT Torso, ___. MEDICATIONS: Fentanyl 100 mcg, Versed 2 mg, 10ml 1% Lidocaine. Moderate sedation was provided by administering divided doses of fentanyl and Versed throughout the total intraservice time of 20 minutes during which the patient's hemodynamic parameters were continuously monitored. PHYSICIANS: Dr. ___ Dr. ___. TECHNIQUE: Informed consent was obtained. A final timeout was performed. The patient was scanned in prone position in the area of interest. The area over the planned tract was prepped and draped. The skin and tract were anesthetized using 1% lidocaine. An 18-gauge ___ needle was advanced to the lesion, and using a 17-gauge Bard biopsy device, two samples were obtained. These were deemed adequate by cytology onsite. The needle and trocar were removed. Manual pressure was used for hemostasis. The patient tolerated the procedure well without complication. Complications: None Sample: Core Biopsy (2) IMPRESSION: Successful thoracic mass biopsy. Radiology Report STUDY: MRI of the cervical spine, second opinion readout. CLINICAL INDICATION: ___ man with history of low back pain, presurgical evaluation. COMPARISON: Prior CT of the neck and torso dated ___. TECHNIQUE: This examination was performed on ___ at an outside institution (Shields MRI, ___ MRI and CT Center). Sagittal T1, T2 and proton density images were submitted for interpretation and also axial 3D T2, axial T2-weighted images. FINDINGS: The left parotid gland is not clearly identified, however, appears present in the CT of the neck dated ___. The visualized elements of the posterior fossa and the craniocervical junction are grossly unremarkable. Small rounded hyperintense area is noted in the posterior aspect of the right parotid gland, likely consistent with a small intraparotid nodule (image #23, series #8). The signal intensity throughout the cervical and upper thoracic spinal cord appears normal with no evidence of focal or diffuse lesions to indicate the spinal cord edema. The patient is status post anterior fusion from C4/C5 through C6/C7 levels. The fixation hardware is causing significant susceptibility artifacts, however, there is no evidence of significant spinal canal stenosis at the surgical site. At C2/C3 level, both neural foramina are patent and there is no evidence of spinal canal stenosis. At C3/C4, there is a mild posterior osteophytic disc bulge complex formation, causing minimal anterior thecal sac deformity as well as mild bilateral neural foraminal narrowing (image #28, series #7). At C4/C5, there is mild posterior disc bulging and bilateral uncinate process hypertrophy, causing mild bilateral neural foraminal narrowing, there is no evidence of central spinal canal stenosis. At C5/C6 level, the patient is status post fusion and discectomy, significant metallic artifact obscures the anatomical details, there is mild left and moderate right neural foraminal narrowing, and there is no evidence of significant spinal canal stenosis. At C6/C7 level, the patient is status post anterior fusion, metal artifact also obscures the anatomical details, however, it is possible to identify mild bilateral uncovertebral hypertrophy, causing mild bilateral neural foraminal narrowing (image #13, series #7). At C7/T1 level, there is no evidence of neural foraminal narrowing or spinal canal stenosis. There is mild-to-moderate posterior epidural lipomatosis visualized from C7 throughout the upper thoracic spine. In comparison with the CT of the neck dated ___, again a large expansile mass lesion arising from the T2 left lamina and extending to T1 through T3 levels is identified. This lesion demonstrates an intermediate T1 and T2 isointense signal with some areas with heterogeneous signal and is causing significant narrowing of the left T1, T2, and T2/T3 neural foramina. This lesion is also causing canal compromise and is displacing the thecal sac towards the right (image #1, series #8). No frank evidence of edema is noted within the cervical or thoracic spinal cord. There is no evidence of lymphadenopathy or enlarged lymph nodes by radiological criteria. A small T2 hyperintense focus is demonstrated in the posterior margin of the right thyroid lobe (image #12, series #8), measuring approximately 5 x 4 mm in size. IMPRESSION: 1. Large expansile mass lesion involving the posterior left paramedial vertebral bodies from T1 through T3 levels as described in detail above, causing left-sided neural foraminal narrowing at T1/T2, T2/T3 levels and also left paracentral canal narrowing and impinging the thecal sac posteriorly, no frank evidence of spinal cord edema is demonstrated. 2. The differential diagnosis for this lesion includes metastatic disease, myeloma may have similar appearance. 2. Small cystic-appearing formation noted in the posterior lobe of the thyroid gland on the right, there is also a small area of cystic signal on the posterior aspect of the right parotid gland, possibly consistent with a small intraparotid lymph node or cystic formation. 3. The patient is status post anterior fusion and discectomy at C5/C6 level. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: ABNORMAL MRI Diagnosed with BONE & CARTILAGE DIS NOS, DIABETES UNCOMPL ADULT, HYPERTENSION NOS temperature: 99.2 heartrate: 91.0 resprate: 16.0 o2sat: 100.0 sbp: 165.0 dbp: 72.0 level of pain: 5 level of acuity: 3.0

Dear Mr. ___, You came to the hospital because of left hand weakness and numbness. Your MRI showed a new mass in the thoracic spine. A CT scan of your abdomen, pelvis and chest showed a mass on the kidney with spread to an adrenal gland and the spleen. Your underwent a biopsy of the spinal mass which showed that there are malignant (cancerous) cells present. We suspect you likely have a kidney cancer, but this needs to be finalized by the pathologist over the next few days. You were seen by oncology who is working on scheduling follow up for you (they will contact you with the appointment and time). Please follow up with your PCP and ___ liver doctor here at ___.